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REVIEW
Dr. M.
Bettolli
Department of General Pediatric
April 8th,
2011 Surgery
Childrens Hospital of Eastern
Ontario, Ottawa
Objective
Hernias
s
Acute obstructio
abdomen/Bowel
n
-Trauma
-Appendicitis
-Midgut volvulus
-Intussusception
Pyloric stenosis
Inguinal
Hernias
Testis descend into the scrotum during the 7th month in
utero
The PV begins to obliterate after birth 1 yr of
Embriology and anatomy:
inside the procesus vaginalis (PV)
(close life)
Failure to
obliterate:
Procesus
Vaginalis
e g l inguinal (encysted
Inguinal
Incidence
The commonest condition requiring Sx during
:childhood Hernias
It varies directly w/ the degree of
prematurity
- Prematures 10-30%
- Terms 3-5%
Nearly
Entitiesall ing. hernias in children
associated w/ an are indirect
-Cryptorchidism
incidence:
-CF
-Ascitis, VP shunts, PD catheters
-Abd wall defects
-Conective tissue disorders, congenital hip
dislocation
-Mucopolisacaridosis
-Meningomyeolocele
Inguinal
Most hernias are asymptomatic
Hernias
Inguinal bulging or swelling w/ straining
Often found by parents or pediatritian on routine
Clinical
examination presentation:
Phys. Ex.: - valsalva maneuvers
- silk glove sign
- always exam the opposite side
- confrm position of both testes
Digital photo
Inguinal
Hernias
Hydrocele: cystic, irreducible,
Diferential diagnosis:
transiluminate,
Retractile or undescended
painless, the upper limit is easily
testis
Femoral hernias and direct hernias are
demonstrable
rare
Inguinal lymph
nodes
Inguina Hernia
Treatment
Surgery
:Timing: bowel l s
incarceration
in prematures is
signifcantly
(threefolds)*
before
discharge
:
Hernias
w/
Complications:
-intermittent abd pain
-tense, tender sweeling
Strangulation: redness, induration overlying the lump, peritonitic
at the
signs -external ing. ring
Diferential
Cyst of the cord: diagnosis:
-may appear suddenly, not tenderness
-happy infant
obstruction
childhood
Frequently requires urgent evaluation in the offce 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 abdome & Bowel
Causes of life threatening abd pain by age
n obstruction
Neonate 2mo 2 yrs 2yrs yrs >5
Trauma
s Incarcerat 5 yrs
Volvulus ed hernia Intussusception
Trauma Appendicitis
NEC Intussusception Trauma
Foreign body
Appendiciti
Adhesio Foreign body Perforated
ns ingestion
s ulcer
ingestion Adhesions
Adhesions
HD Hemolytic
Hemolytic uremic
Adhesions syndr.
uremic
Hemolytic Primary
syndr.
uremic bacterial
Primary
Syndr. peritonitis
bacterial
Acute abdomen & Bowel
Evaluation:
obstruction
The frst 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
Characteristics of abdominal pain:
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,
Specific Dx associated w/ characteristic patterns of
frequency, duration,
pain:
and location
Appendicitis of their symptoms
Periumbilical, migrating to the RLQ
focal
surgery
-Pts w/ Hirschsprung Disease can develop obstruction
and
fulminant
-Primary enterocolitis
bacterial peritonitis occurs w/ increased
frequency
among
-Diabeticchildren w/ nephrotic
pts, ketoacidosis w/abd syndrome
pain
Acute abdomen & Bowel
Imaging:
obstruction
-Essential component of the evaluation in children
w/
acute abdominal pain and concerning
Traum
clinical fetaures:
Masses a
Peritoneal
irritation
Distensio
Signs of
n
Focal obstruction
tenderne
ss
Acute abdomen: Abd.
-Children w/ abdominal pain who have sustained trauma must
Trauma
be carefully evaluated for intraabdominal
injuries
-MVA, MV pedestrian collisions, falls, and child abuse
are
mechanisms typically
-Although abdominal associated
injuries w/ common
are 30% more
significant injury
than
thoracic injuries,
-Historically, they areunfamiliar
adult surgeons 40% lessw/likely
the to be
fatal
nonoperative
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
-Anorexia andrisk
The lifetime vague periumbilical
of appendicitis is pain
8.7% for boys & 6.7% for
-Migration of periumbilical pain to the RLQ
girls
-Nausea leading to vomiting follows the onset of
pain
Perforation rates as high as 82% in children <5 yrs and nearly
-Diarrhea
100% more commonly seen w/ perf.
appendicitis, also more common in infants and
of 1-yr olds
toddlers
Clinical presentation:
Acute abdomen: Appendiciti
A.
-Tenderness RLQ (McBurneys s
point)
Physical
-Guarding orfndings:
rigidity
-Rebound tenderness
Children often
Neutrophilia present w/
and lymphopenia wide deviations from
the
Acute abdomen: A.
Appendicitis
-X-rays: may demonstrate a fecalith in 5-15% of Pts
appendicolith
1-yo child
Appendicitis
Treatment:
Surgery
Medical management: -Delay presentation or Dx
(>5days)
-Pt clinically stable
-Mass
RLQ
-Percutaneous drain
Bowel
Neonatal bowel -abd. distension
obstruction obstruction
-failure to pass
-bile
thevomiting
meconium
Several congenital anomalies of gut can cause
neonatal
bowel obstruction:
- Hirschsprungs disease
Bowel
obstruction
Bile-stained vomiting in the neonatal period always is
signifcant
Clinical fndings
Must be evaluated carefully (is indicative of bowel
obstruction)
pellets)
Bowel
Imaging:
Plain x-ray is very useful: distension of the gut w/ fluid
levels obstruction
Level of the obstruction may be related to the number of fluid
levels
Meconium
ileus
Bowel
obstruction
Transport: is a particularly stressful time and the
metabolic
General treatment:
problems should be corrected before transfer
NG tube is mandatory
Resuscitation: -fluid replacement
-glucose replacement
-correction of acidosis
volvulus
The normal mesentery of
the small bowel has a wide
base from the angle of
Treitz to the cecum
Bowel Midgut
obstruction: volvulus
In malrotation, the angle of The narrow base of the
Treitz and the cecum lie side mesentery allows the gut to
by side twist around the superior
mesenteric vessels
Bowel obstruction: Midgut
volvulus
Healthy full term baby who is well for the first few days of
life,
Clinical features:
develop feeding diffculties w/ bile vomiting
Early stage, the abdomen is soft and not
distended
Blood per rectum and
The diagnosis should be made at this stage
abdominal
(Urgent UGI)
distension w/ tenderness are
late
gut
ischaemia
Bowel obstruction:
Intussusception
The incidence is highest in
Uncommon
the below 3 mo of age and
1st and 2nd yrs of life and
is after 3 yrs of
life
One of the most frequent causes of BO in infants & toddlers
Most patients are well nourished, healthy
infants
-Young child w/ intermittent, crampy abdominal pain
Clinical presentation:
associated w/ currant jelly stools
symptom
-As the obstruction worsens bilious emesis &
worsening abdo distention
Bowel obstruction:
Intussusception
Vital signs are usually normal in the early stage
During painless intervals, the child look
comfortable &
Physical examination:
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
Bowel obstruction:
Intussusception
Diagnosis:
-Abdominal X-rays: normal, non- specifc or reveal a
SBO w/ air-fluid levels in dilated small bowel
d usually is the
-U/S: confrmed Dx
1st
an
ussusception is
Investigation when
int
Bowel Intussusceptio
obstruction: n
Treatment:
Nonoperative management:
-Complete blood cell count and
-NG tube to decompress the
stomach
electrolytes
-NPO
-IV fluid resuscitation
Bowel Intussusceptio
obstruction:
Colon
n
Air reduction(1st line
Nonoperative
enema
of treatment) success
management:
rate
If successful admit
2.8%
24hs (recurrence
for
rate
10-12%)
Bowel Intussusceptio
obstruction:
Operative n
manageme
Open
nt:
approach
Lap
approach
PyloricStenosi
History:
s
4 weeks old male
Full term
3 days history of
vomiting
Pyloric
Non bilious vomiting
Stenosis
Progressive
..
Projectile
Pyloric
Stenosis
Pyloric stenosis
Feeding
Differential diagnosis:
intolerance
GER
Infections:
UTI
CN
S
GI
PyloricStenosi
Hydration: s
-Fontanels
-Eyes
-Mucous
membranes
-Skin turgor
-Urinary output
Pyloric
Stenosis
Gastric distention
Findings on abdominal
Gastric peristaltic
waves
exam:
Pyloric olive
PyloricStenosi
you
Priorities
-Correction of electrolyte & metabolic
abnormalities
-Rehydration
(metabolic alkalosis, Na, Cl, K)
-Confrm diagnosis
PyloricStenosi
Ultrasound
s
3mm
>15mm
>14mm
PyloricStenosi
Surgical s
Pyloromyotomy
correction
-Alkalosis
corrected
rehydrated
Preoperative
normal inform parents about
expected post op vomiting
electrolytes
O.
L.
pyloromyotomy
pyloromyotomy
END!