PEDIATRIC SURGICAL REVIEW Dr. M. Bettolli Department of General Pediatric Surgery Children’s Hospital of Eastern Ontario, Ottawa April 8th, 2011

Objectives Hernias obstruction • Acute abdomen/Bowel -Trauma -Appendicitis -Midgut volvulus -Intussusception Pyloric stenosis obstruction •

Inguinal Hernias Failure to obliterate: Embriology and anatomy: Testis descend into the scrotum during the 7th month in utero inside the procesus vaginalis (PV) The PV begins to obliterate after birth (close 1 yr of life) Failure to obliterate: Procesus Vaginalis Hydrocele Communicating hydrocele Inguinal hernia Complete inguinal hernia Cyst of the cord (encysted hydro.)

Inguinal Hernias Incidence: Entities associated w/ an ↑incidence: The commonest condition requiring Sx during childhood It varies directly w/ the degree of prematurity - Prematures 10-30% - Terms 3-5% Nearly all ing. hernias in children are indirect Entities associated w/ an ↑incidence: -Cryptorchidism -CF -Ascitis, VP shunts, PD catheters -Abd wall defects -Conective tissue disorders, congenital hip dislocation -Mucopolisacaridosis -Meningomyeolocele

Inguinal Hernias Clinical presentation: Most hernias are asymptomatic Inguinal bulging or swelling w/ straining Often found by parents or pediatritian on routine examination Phys. Ex.: - valsalva maneuvers - silk glove sign - always exam the opposite side - confirm position of both testes A common scenario: “Normal examination w/a suggestive Hx” Options? Return for a 2nd exam Digital photo

Inguinal Hernias • Hydrocele: cystic, irreducible, transiluminate, Diferential diagnosis: • Hydrocele: cystic, irreducible, transiluminate, painless, the upper limit is easily demonstrable • Retractile or undescended testis • Femoral hernias and direct hernias are rare • Inguinal lymph nodes

Inguinal Hernias Treatment: Surgery Ideally, repair hernia before Timing: bowel incarceration in prematures is significantly ↑(threefolds)* Ideally, repair hernia before discharge *Ein S.H. et al JPS 2006 May;41(5):980-6

Inguinal Hernias -fussy or inconsolable infant w/ Complications: Incarceration: -fussy or inconsolable infant w/ -intermittent abd pain -tense, tender sweeling at the -external ing. ring Strangulation: redness, induration overlying the lump, peritonitic signs Diferential diagnosis: Cyst of the cord: -may appear suddenly, not tenderness -happy infant -redness after manipulation Torsion of an undescended testis: absence of testis on the same side Lymphadenitis or local inguinal abscess “Overall 90-95% of incarcerated hernias can be successfully reduced” The incidence of testicular atrophy is to 2-3% in this patients

Acute abdomen & Bowel obstruction • Abdominal pain is one of the most common complaints in Acute abdomen & Bowel obstruction childhood Frequently requires urgent evaluation in the office or ER The challenge is to identify those pts w/ serious or potentially life- threatening conditions (e.g. appendicitis or bowel obstruction) The likely Dx is often suggested by the child's age and clinical features Signs of obstruction,Hx of prior abd. surgery, and peritoneal irritation are clinical features associated w/ serious intraabdominal conditions that require prompt Dx and Tt. • • •

Acute abdomen & Bowel obstruction Neonates 2mo – 2 yrs 2yrs – 5 yrs Causes of life threatening abd pain by age Acute abdomen & Bowel obstruction Neonates Volvulus NEC Adhesions 2mo – 2 Trauma Incarcerated hernia yrs 2yrs – 5 Trauma Appendicitis yrs >5 yrs Appendicitis Trauma Perforated ulcer Adhesions Hemolytic uremic syndr. Primary bacterial peritonitis Intussusception Foreign body ingestion Adhesions Hemolytic uremic syndr. Primary bacterial peritonitis Intussusception Foreign body ingestion HD Adhesions Hemolytic uremic Syndr.

Acute abdomen & Bowel obstruction Evaluation: Acute abdomen & Bowel obstruction The first goal is to identify life-threatening conditions that require emergent interventions History: -History of trauma -Prior abdominal surgery -Fever -Vomiting -Location of the abdominal pain -Pattern of symptoms -Last menstrual period & sexual activity (pubertal girls)

Acute abdomen & Bowel obstruction Characteristics of abdominal pain: Acute abdomen & Bowel obstruction -< 2 yrs, symptoms such us drawing the legs up or inconsolability -The preschool child may be able to describe pain & symptoms -> 5 yrs, can typically characterize the onset, frequency, duration, and location of their symptoms Specific Dx associated w/ characteristic patterns of pain: Appendicitis Periumbilical, migrating to the RLQ Appendiceal rupture (early), ovarian torsion  Acute, severe, focal Intussusception  Intermittent, colicky Gastroenteritis  Diffuse or vague Cholecystitis  Right upper quadrant Gastritis, gastric ulcer disease  Epigastric Pancreatitis Steady periumbilical pain, often radiating to the back

Acute abdomen & Bowel obstruction Associated symptoms: Acute abdomen & Bowel obstruction Fever, children w/ abdominal pain frequently have fever Vomiting, and abdominal pain (in the absence of diarrhea) should be carefully evaluated for life-threatening conditions… -Volvulus must be excluded when bilious emesis and apparent abdominal pain -Intussusception  vomiting (initially non-bilious ) may occur following episodes of pain -Small bowel obstruction result of postoperative or postinflammatory adhesions -Appendicitis nausea & vomiting are typically present Diarrhea, usually not a surgical abdomen, unless perf.appendix

Acute abdomen & Bowel obstruction Past medical history: Acute abdomen & Bowel obstruction -Bowel obstruction from adhesions due prior abdominal surgery -Pts w/ Hirschsprung Disease can develop obstruction and fulminant enterocolitis -Primary bacterial peritonitis occurs w/ increased frequency among children w/ nephrotic syndrome -Diabetic pts, ketoacidosis w/abd pain

Acute abdomen & Bowel obstruction Imaging: Acute abdomen & Bowel obstruction -Essential component of the evaluation in children w/ acute abdominal pain and concerning clinical fetaures: Trauma Masses Peritoneal irritation Distension Signs of obstruction Focal tenderness

Acute abdomen: Abd. Trauma -Children w/ abdominal pain who have sustained trauma must Acute abdomen: Abd. Trauma be carefully evaluated for intraabdominal injuries -MVA, MV pedestrian collisions, falls, and child abuse are mechanisms typically associated w/ significant injury -Although abdominal injuries are 30% more common than thoracic injuries, they are 40% less likely to be fatal -Historically, adult surgeons unfamiliar w/ the nonoperative management of solid organ injuries raised doubts about the wisdom of this approach

Acute abdomen: Abd. Trauma Most solid visceral injuries are successfully treated non operatively, kidneys (98%), spleen (95%), and liver (90%)

Acute abdomen: A. Appendicitis The most common acute surgical condition in children The lifetime risk of appendicitis is ≅8.7% for boys & 6.7% for girls Perforation rates as high as 82% in children <5 yrs and nearly 100% of 1-yr olds Clinical presentation: -Anorexia and vague periumbilical pain -Migration of periumbilical pain to the RLQ -Nausea leading to vomiting follows the onset of pain -Diarrhea more commonly seen w/ perf. appendicitis, also more common in infants and toddlers

Acute abdomen: A. Appendicitis Lab findings: Physical findings: Appendicitis -Tenderness RLQ (McBurney’s point) -Guarding or rigidity -Rebound tenderness -Palpable mass (delayed Dx) -Low grade fever -Urinary symptoms Lab findings: Mild elevation of the leukocyte count (11,000 to 16,000) Neutrophilia and lymphopenia “Children often present w/ wide deviations from the classic picture”

Acute abdomen: A. Appendicitis Radiologic imaging: -X-rays: may demonstrate a fecalith in 5-15% of Pts -US: fluid-filled, noncompressible appendix diameter > 6 mm appendicolith periappendiceal or pericecal fluid ↑periappendiceal echogenicity caused by inflammation Hyperhemia -CT: operator dependent, and extremely accurate (sen&esp 95%) lifetime risk of a fatal radiation-induced malignancy is 0.18% for a 1-yo child -MRI: extremely accurate, but impractical

Acute abdomen: A. Appendicitis Treatment: Surgery Medical management: -Delay presentation or Dx (>5days) -Pt clinically stable -Mass RLQ -Percutaneous drain

Bowel obstruction Neonatal bowel obstruction -abd. distension -bile vomiting Neonatal bowel obstruction -abd. distension -failure to pass meconium Several congenital anomalies of the gut can cause neonatal bowel obstruction: - Duodenal obstruction: Duodenal atresia/web, annular pancreas - Bowel atresia: most common Dtl ileum, rare in the colon - NEC - Malrotation w/ midgut volvulus - Hirschsprung’s disease - Meconium ileus, meconium plug - Bowel duplications - Imperforate anus

three exceptions: - HD (may pass stools w/stimulation) Bowel obstruction Clinical findings • Bile-stained vomiting in the neonatal period always is significant Must be evaluated carefully (is indicative of bowel obstruction) • Abdominal distension is less specific • Neonates with bowel obstruction do not pass meconium three exceptions: - HD (may pass stools w/stimulation) - Meconium ileus (pass some sticky pellets) - Malrotation w/ volvulus (delay ppt)

Bowel obstruction Imaging: Plain x-ray is very useful: distension of the gut w/ fluid levels Level of the obstruction may be related to the number of fluid levels Ileal atresia, HD Double buble Jejunal atresia

Bowel obstruction Imaging: high obstructions UGI are useful for incomplete high obstructions Contrast enema is a suitable for low obstructions Midgut volvulus Meconium ileus

Bowel obstruction General treatment: •Transport: is a particularly stressful time and the metabolic problems should be corrected before transfer •NG tube is mandatory •Resuscitation: -fluid replacement -glucose replacement -correction of acidosis •Hypothermia: is a major risk to the sick neonate •Sepsis: risk of sepsis w/ neonatal BO IV Abx are started after cultures are taken

Bowel obstruction: Midgut volvulus The normal mesentery of the small bowel has a wide base from the angle of Treitz to the cecum

Bowel obstruction: Midgut volvulus In malrotation, the angle of Treitz and the cecum lie side by side Midgut volvulus The narrow base of the mesentery allows the gut to twist around the superior mesenteric vessels

Bowel obstruction: Midgut volvulus Clinical features: Healthy full term baby who is well for the first few days of life, develop feeding difficulties w/ bile vomiting Early stage, the abdomen is soft and not distended The diagnosis should be made at this stage (Urgent UGI) Blood per rectum and abdominal distension w/ tenderness are late features and indicate major gut ischaemia Treatment: Urgent surgery is required (otherwise gangrene of the duodenum to the right colon)

Bowel obstruction: Intussusception One of the most frequent causes of BO in infants & toddlers The incidence is highest in the 1st and 2nd yrs of life and is Uncommon below 3 mo of age and after 3 yrs of life Most patients are well nourished, healthy infants Clinical presentation: -Young child w/ intermittent, crampy abdominal pain associated w/ “currant jelly” stools -Between the painful episodes, the child may appear comfortable or fall asleep -The child may stiffen and pull the legs up to the abdomen -Lethargy or altered consciousness can be the primary symptom -As the obstruction worsens bilious emesis & worsening abdo distention infants) minal

Bowel obstruction: Intussusception Physical examination: Vital signs are usually normal in the early stage During painless intervals, the child look comfortable & Phys. Ex. will be unremarkable The benign clinical appearance may lead to an erroneous Dx (constipation or gastroenteritis) A mass might be palpable anywhere in the abdomen or even visualized On rectal examination, blood-stained mucus or blood may be encountered Prolapse of the intussusceptum through the anus is a grave sign

Bowel obstruction: Intussusception Diagnosis: -Abdominal X-rays: normal, non- specific or reveal a SBO w/ air-fluid levels in dilated small bowel d usually is the 1st ussusception is -U/S: confirmed Dx an Investigation when int suspected

Bowel obstruction: Intussusception Treatment: Nonoperative management: -NG tube to decompress the stomach -NPO -IV fluid resuscitation Intussusception -Complete blood cell count and electrolytes

Bowel obstruction: Intussusception Colon enema • Air reduction (1st Nonoperative management: Intussusception Colon enema • Air reduction (1st line of treatment) success rate 75-94%, perf. rate 0.16- 2.8% • If successful admit for 24hs (recurrence rate 10-12%)

Bowel obstruction: Intussusception Operative Open approach management: • Open approach Lap approach

Pyloric Stenosis 4 weeks old male History: Full term 3 days history of vomiting

Non bilious vomiting Pyloric Stenosis Progressive….. Projectile

Pyloric Stenosis Pyloric stenosis Differential diagnosis: UTI • Feeding intolerance GER Infections: – UTI CNS GI

Pyloric Stenosis -Fontanels Hydration: -Eyes -Mucous membranes -Skin turgor -Urinary output

Pyloric Stenosis Gastric distention Findings on abdominal exam: • Gastric peristaltic waves Pyloric olive

Pyloric Stenosis What would you do now? Priorities -Rehydration do now? -Correction of electrolyte & metabolic abnormalities (metabolic alkalosis, ↓Na, ↓Cl, ↓K) -Confirm diagnosis

Ultrasound Pyloric Stenosis 3mm >15mm >14mm

Pyloric Stenosis Surgical correction Pyloromyotomy -Alkalosis corrected rehydrated normal electrolytes Preoperative inform parents about expected post op vomiting

O. pyloromyotomy L. pyloromyotomy

END!