2. Paediatric Surgical Emergencies
Presented by
Dr Ayman A A Albatanony
Associate Professor of Surgery

3. Don't forget:
Trauma: (RTA, Burn,…..)
Urinary emergencies
ENT emergencies
Ophthalmic emergencies
Orthopaedic emergencies
Cardiothoracic emergencies

4. Neonatal Surgical Emergencies 3 Paediatric Surgical Emergencies 1
The subject is divided into 2 main topics:
Neonatal Surgical Emergencies 3 Paediatric Surgical Emergencies 1

5. Neonatal Surgical Emergencies
1. Neonatal intestinal obstruction 2. Neonatal major abdominal wall defects 3. Neonatal obstructive jaundice
Neonatal Surgical Emergencies

6. Neonatal intestinal obstruction
Necrotizing enterocolitis
Atresia, stenosis
Small Bowel Atresia
Malrotation
Hirschsprung’s
Annular pancreas
Antral web
Meconium ileus
Imperforate anus
Complicated inguinal hernia
Congenital Hypertrophic pyloric stenosis

7. In physical Exam, remember to:
Remove diaper

8. Physical Exam
Must perform rectal exam, not just look!

9. Initial Management NG or OG (NPO!!) Hydrate and replace losses
Antibiotics if suspect perforation or necrosis
Consult surgeon and/or transfer to appropriate facility

10. Bowel Obstruction Diagnosis is often age specific
Bilious vomiting in the infant and child is a surgical emergency until proven otherwise
Child may look surprisingly good until it’s too late

11. Atresia Usually presents the first few days of life
Child may feed well for a day or two with distal atresia
Duodenal atresia often diagnosed on antenatal U/S
Atresias can occur anywhere in GI tract from pharynx to anus

12. Atresias
Esophageal: aspirate feeds immediately, OG tube won’t pass (non-bilious, but still bad)
Duodenal: bilious vomiting immediately, “double bubble” on KUB with absence of distal gas, Down’s Syndrome
Jejunal: usually present 1st 24 hours, large dilated proximal loop or loops

13. Atresias Ileal: may take 24-48 hours before bilious emesis
Colonic: rare, may present with bilious emesis after 2-3 days
Anal: should be diagnosed at birth, often a perineal fistula is labeled normal

15. Atresias may be multiple

16. Jejunal Atresia

17. Apple Peel Deformity (IIIb)

18. Imperforate Anus: Anal atresia

19. Hirschsprung’s Disease
Congenital colonic aganglionosis
Physiologic obstruction
May present first few days to weeks of life
Starts at anus and extends proximally a variable distance

20. Hirschsprung’s Delayed passage of meconium at birth:
Meconium plug syndrome, small left colon syndrome, Down’s syndrome
Often present with distension
Profoundly distended abdomen with dilated bowel
Fever and WBC’s with colitis

21. Hirschsprung’s Rectal exam may seem normal until withdraw finger
“Explosive” release of liquid stool almost diagnostic
Barium enema while dilated
Irrigate and dilate until decompressed
Rectal biopsy

22. Hirschsprung’s Disease

24. Necrotising enterocolitis:
Aetiology:
Remains unknown
Ischemia and/or reperfusion injury may play a role
Translocation of intestinal flora across compromised mucosa may play a role
Incidence and age at onset
More common in premature infants
But can also be seen in term babies
Affected term neonates are usually systemically ill with other conditions such as birth asphyxia, respiratory distress or congenital heart disease
Babies who are breastfed have a lower incidence of NEC than formula-fed babies

25. Imaging findings
Plain film of the abdomen remains method in which disease is diagnosed most often
Findings include
Dilated loops of bowel
Thickened bowel walls
Fixed and dilated loop that persists is especially worrisome
Absence of bowel gas
Pneumatosis intestinalis
Pathognomonic of NEC in newborn
Linear radiolucency parallels bowel lumen within bowel wall
Represents air that has entered from the lumen

27. Toxic Megacolon Severe enterocolitis
NG decompression, IV fluids, IV antibiotics
Mortality 20-30%

28. Toxic Megacolon

29. Malrotation
Normal

30. Malrotation Most often presents during the first few days of life
Infant with acute onset of bilious emesis
Malrotation is a surgical urgency due to the possibility of volvulus
VOLVULUS IS A SURGICAL EMERGENCY

31. Volvulus
Malrotation most common condition resulting in midgut volvulus
Can have volvulus with normal rotation
omphalomesenteric remnant
internal hernia
Duplication
Adhesive small bowel obstruction

32. Midgut Volvulus

33. Volvulus 75% First month of life Malrotation is the risk for volvulus
Small and large bowel are not fixed
Narrow mesentery
 more likely to turn around itself
Malrotation can cause or present with:
Volvulus is dangerous
Acute obstruction
Chronic intermittent obstruction

34. Volvulus is lethal
Malrotation  midgut volvulus  midgut intestinal death  surgery (resected)  short-gut syndrome  death
C/F
Bilious vomiting
+/- pain
if +pain (irritable)  likely volvulus +ischemia
- pain (calm)  malrotation+obstruction

35. Midgut volvulus Infant + Bilious vomiting is EMERGENCY
Investigate (if infant is not sick)
Upper GI series (look for malrotation)
No duodenal C-loop
Duodeno-jejunal junction (ligament of Treitz) to the right of Vertebral col.
Duodenal obstruction
Whirlpool or corkscrew sign (volvulus)
U/S
Can’t R/O volvulus
Can Dx volvulus

36. Midgut volvulus Pt should go directly for surgery if: Time = Bowel
If can’t do investigation immediately
Pt is sick + bilious vomiting
Time = Bowel
Surgery:
Untwist (counter clock wise)  assess viability
If extensive ischemia  close 2nd look hrs
Viable SB  close and observe
Ladd’s procedure

39. Meckel’s

40. Duplication

41. Intussusception
Inversion of the bowel upon itself secondary to a lead point
Juvenile intussusception most often idiopathic
Also secondary to Meckel’s
Presents 6 months to 2 years of age
As early as 1 month

42. Intussusception Acute painful episodes followed by periods of lethargy
When incarcerated progress to continuous lethargy
May have “currant-jelly” stool
But often stool is heme positive
Rule out with a left lateral decubitus film

43. Left-lateral Decubitus Film

44. Intussusception

45. Intussusception

47. Bad Intussusception

48. Intussusception 7% chance of recurrence after hydroststic reduction
May recur in 48 hours
Operative exploration warranted on second recurrence to R/O pathologic lead point
Recurrence after surgery rare but possible
Post-op intussusception can occur after any surgery

49. Congenital Hypertrophic Pyloric Stenosis

50. Pyloric stenosis
Presentation: vomiting occurs after all feeds copious, no bile in vomitus may be blood, initially child wants to feed again, later becomes weak, listless, metabolic alkalosis, failure to thrive
Signs-may palpate pyloric tumour 9 in epigastrium just above umbilicus or between liver edge and right rectus, may see peristalsis
presents in first few months of life-between 3-6 wks of age rare if <10days or older than 11 wks
Affects 1:450 children
Males ( 85%)more common than females
Tx: NG tube, Rehydration, electrolyte correction, Ramstedt procedure

52. Incarcerated Hernia

53. Incarcerated Inguinal Hernia

54. Hernia Reduction
From Surgery of Infants and Children, Oldham, et. al., 1997

55. Incarcerated Hernia Most can be reduced in clinic or ED
Bowel usually OK if able to reduce
Surgical consultation if reduction difficult
Repair with 1-2 days of incarceration
Beware the “inguinal node’ in females
incarcerated ovary

56. Incarcerated Hernia
If unable to reduce: urgent operative exploration (NPO)
If able to reduce without sedation: urgent surgical referral with repair soon
If extremely difficult (sedation, surgical referral): repair next day
Watch child for obstructive symptoms

57. Perforated Appendix
Children still die from complications of perforated appendicitis
Resuscitation is critical
Diagnosis difficult...Why??

58. Perforated Appendix
Suspect in children 3-5 years old with history suggestive of appendicitis
“Bowel obstruction” in a 3-5 year old without obvious etiology is perforated appendix until proven otherwise

59. Perforated Appendix

60. Resuscitation NG tube, NPO
20 cc/kg boluses until UOP > 1 cc/kg/hr and VS stable
1.5-2 times maintenance fluids
Broad Spectrum Antibiotics

62. Perforated Appendix

63. ? Summary Atresias Hirschsprung’s Malrotation Volvulus Intussusception
Incarcerated Hernia
Perforated Appendix ?

64. Neonatal major abdominal wall defects
Omphalocele
Gastroschisis

65. OMPHALOCOELE
Anterior abdominal wall defect at the base of the umbilical cord with herniation of the umbilical contents

66. Incidence Small omphalocoele 1:5000 Large omphalocoele 1:10000
Male to female ratio 1:1

67. Pathophysiology
Failure of the midgut to return to abdomen by the 10th week of gestation

68. Clinical Findings Covered clinical defect of the umbilical ring
Defect may vary from 2-10 cm
Sac is composed of amnion, Wharton’s jelly and peritoneum

69. 50% have accompanying liver, spleen, testes/ovary
Cord attachment is on the sac

71. Presentation :
AFP level at 12 wks is elevated
Detected at routine morphology USS

72. GASTROSCHISIS
herniation of bowel contents through a defect in the anterior abdominal wall,not related to the umbilicus, not in the midline and organs not confined to peritoneal sac

73. Incidence 1:20,000-30,000 Sex ratio 1:1
10-15% have associated anomalies
40% are premature

74. Pathophysiology Abnormal involution of right umbilical vein
Rupture of a small omphalocoele
Failure of migration and fusion of the lateral folds of the embryonic disc on the 3rd-4th week of gestation

75. Clinical Findings
Defect to the right of an intact umbilical cord allowing extrusion of abdominal content
No covering sac

76. Bowels often thickened, matted and edematous
10-15% with intestinal atresia

77. Management (both) ABC Heat Management Fluid Management
Sterile wrap or sterile bowel bag
Radiant warmer
Fluid Management
IV bolus 20 ml/kg LR/NS
D10¼NS 2-3 maintenance rate

78. Nutrition Gastric Distention Infection Control Associated Defects
NPO and TPN
Gastric Distention
OG/NG tube
Infection Control
Associated Defects

79. Conservative treatment
Reduction by squeezing the sac
Painting sac with escharotic agent
0.25% Silver nitrate
0.25% Merbromin (Mercurochrome)

81. Surgical Management Skin Flaps Primary Closure Staged Closure
Staged repair using silo pouch

82. Skin Flaps

83. Primary Closure

84. Staged Closure

85. Omphalocoele Gastroschisis
Incidence
1:6,000-10,000
1:20,000-30,000
Delivery
Vaginal or CS CS
Covering Sac
Present
Absent
Size of Defect
Small or large
Small
Cord Location
Onto the sac
On abdominal wall
Bowel
Normal
Edematous, matted

86. Omphalocoele Gastroschisis
Other Organs
Liver often out
Rare
Prematurity
10-20%
50-60%
IUGR
Less common
Common
NEC
If sac is ruptured
18%
Associated Anomalies
>50%
10-15%
Treatment
Often primary
Often staged
Prognosis
20%-70%
70-90%

87. Neonatal obstructive jaundice
Biliary atresia
Choledochal cyst
Inspissated bile syndrome
Sepsis

88. Biliary Atresia Incidence 1/20,000
Obliterative process of the extrahepatic bile ducts
Associated with hepatic fibrosis
Arrest of development during the solid stage of bile duct formation.
Aetiology unclear

89. Atretic ducts – solid fibrous cords that may contain occasional islands of biliary epithelium
Three patterns: minimal, partial complete
Over time the failure to excrete bile results in progressive periportal fibrosis and obstruction of the intrahepatic portal veins

90. Presentation & Diagnosis
Grey or acholic stools – secondary to obstructed bile flow
Failure to thrive
Liver failure and portal hypertension
Bilirubin > 3 mg/dl
Alk phos
GGT > 300

91. Technetiun-99m iminodiacetate (HIDA) after pretreatment with phenobarbital ( promotes tracer uptake)
If radionucleotide appears in the intestine then the biliary tree in presumed to be patent
Ultrasound can exclude choledochal cyst

92. Treatment
Excise scarred bile ducts and gall bladder and Portoenterostomy

93. Biliary atresia (60%)
Neonatal Hepatitis (35%)
hepatic inflammation that can be secondary to several different causes:
CMV, syphilis, herpes, toxoplasma
Metabolic defects : Alpha 1-antitrypsin deficiency, galactosemia
Choledochal cyst (5%)

94. Continued
Spontaneous perforation of extrahepatic bile ducts
Ascites, mild jaundice, failure to thrive
Usu occurs at the junction between the cystic and common bile ducts
Inspissated bile syndrome – bile plug syndrome
Extrrahepatic obstruction of the bile ducts by biliary sludge
Associated with massive hemolysis, hemorrhage, TPN,
cystic fibrosis and other intestinal diseases such as Hirchsprungs

95. Diaphragmatic hernia
Diaphragmatic hernia 95

98. Congenital diaphragmatic hernias occur in about 1 out of 2,500 live births with a 2 to 1 male to female ratio.
Herniation of abdominal viscera occurs through a defect in the diaphragm caused by failure of the pleural peritoneal canal to close completely during embryonic development.
Varying degrees of herniation can occur.
These patients will often have hypoplastic lungs due to crowding of the thoracic space.

99. They may show signs of severe respiratory distress such as dyspnea and cyanosis if herniation of abdominal contents is to such an extent as to cause hypoplastic lungs.
Signs and symptoms of acute intestinal obstruction can also occur.
The diagnosis is usually made by radiographic examination.
Emergency treatment: respiratory support, Nasogastric intubation with suction. Extracorporal membrane oxygenation (ECMO) may improve prognosis although mortality rate remains about 50%.

100. TracheoEsophageal Fistula

101. TracheoEsophageal Fistula
5 Types (Gross and Vogt)
7.7% % % % %

102. Tracheoesophageal Fistula
Incidence: 1:4000 live births
M > F (25:3)
10-40% are preterm
Antenatal history: polyhydramnios (60%)
Etiology: failure in mesenchymal separation of
upper foregut

103. Tracheoesophageal Fistula
Clinical Presentation
choking on 1st feed
coughing
cyanosis
excessive salivation
aspiration pneumonia

104. Tracheoesophageal Fistula
Diagnosis
inability to pass a suction catheter into the stomach
CXR: coiled orogastric tube in the cervical pouch; air in the stomach and intestine

105. Tracheoesophageal Fistula
Emergency management
NPO
head-up position
sump tube on low continuous suction
± gastrostomy under local anesthesia
Antibiotics
12-L ECG and Echocardiogram : mandatory???
IV access ± arterial line

106. Pediatric surgical emergency 1
Differential diagnosis of an acutely painful scrotal swelling in a 6 years old boy
Testicular torsion
Acute epididymitis (with or without orchitis)
Orchitis (e.g., mumps)
Trauma eg testicular haematoma
Testicular tumor (hemorrhage within tumor)
Incarcerated inguinal hernia

107. Thank you