D R. H AT E M E L G O H A RYL E C T U R E R O F G E N E RA L S U R G E RY

COMMON PEDIATRIC SURGICAL CONDITIONS

INTUSSUSCEPTION

the invagination of one portion of the intestineinto an adjacent segment

causes a strangulating bowel obstruction, which can progress to gangrene and perforation

Intussusception is classified according to the site of the inner intussusceptum and outer intussuscipiens.

Most common is iliecolic.

AETIOLOGY

Causes:• Hyperplasia of gut lymphoid tissue, which may in

turn be secondary to viral infection.

• Pathological lead point such as a Meckel’s diverticulum, enteric duplication cyst or even small bowel lymphoma.

DIAGNOSIS

Symptoms:Colicky pain, vomiting.

Redcurrant jelly’ stool.

Signs:Dehydration, abdominal distension and a palpable sausage-shaped mass in the right upper quadrant.

DIAGNOSIS

Ultrasound:Diagnosis can be confirmed by an abdominal ultrasound scan (Target sign) or contrast enema.

MANAGEMENT

• Resuscitation with intravenous fluids, broad-spectrum antibiotics and nasogastric drainage.

• Non-operative reduction of the intussusceptioncan be attempted using an air or barium enema.

• Successful reduction can only be accepted if there is free reflux of barium or air into the small bowel, together with resolution of symptoms and signs in the patient.

• If non-operative reduction is contraindicated or unsuccessful, surgery is necessary.

• Right-sided transverse abdominal incision the intussusception is milked back by gentle compression from its apex. Both the intussusceptum

and the intussuscipiens must be carefully inspected for areas of non-viability.

ACUTE ABDOMEN

ACUTE APPENDICITIS

Inflammation of the vermiform appendix.

Causes:Obstruction of the lumen of the appendix due to lymphoid hyperplasia secondary to inflammatory bowel disease, infections, foreign bodies, fecolith and neoplasms.

Risk in pediatrics:Poor localization of infection and early perforation.

DIAGNOSIS (MAINLY CLINICAL)

Symptoms:• Abdominal pain in the right iliac fossa or

generalized in peritonitis.• Vomiting.• Loose stool.

Signs:• Fever and tachycardia.• Localized tenderness in the right iliac fossa.• Guarding rigidity.

Investigations:

CBC: Leukocytosis and neutrophila.CRP: HighU/S: Appendix, pelvic collection and to exclude other causes of pain .

MANAGEMENT

• Rehydration.• Broad spectrum Antibiotics.• Analgesics.• Appendectomy.• IF Appendicular Mass Interval Appendectomy

after 4- 6 weeks.• If Appendicular Abscess Drainage of abscess

then interval appendectomy 4-6 weeks.

OTHER CAUSES OF ABDOMINAL PAIN

• Intestinal obstruction. Consider intussusception, inguinal hernia, adhesions and Meckel’s diverticulum.• Constipation. Often overdiagnosed as a cause of

acute abdominal pain, particularly as the plain abdominal radiograph of a dehydrated ill child frequently shows faecal loading.• Constipation is more often a cause of acute

abdominal pain in a child who has been treated for Hirschsprung’s disease or an anorectal malformation.

OTHER CAUSES OF ABDOMINAL PAIN

• Urinary tract disorders. Urinary tract infection is a cause of acute abdominal pain. Urinary symptoms, fever and vomiting tend to predominate. Urinalysis, microscopy and culture are useful. Boys with pelviureteric junction obstruction can present with acute or recurrent abdominal pain and no urinary symptoms.

OTHER CAUSES OF ABDOMINAL PAIN

• Gastroenteritis. May cause colicky abdominal pain.

• testicular torsion.