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Common problems In Pediatric Surgery

• •1J'Yll1iiu~'YnJlhw'l 'Il1~'llmffllVftll'f~{ !l1Ull1hiA'~lv'l ~~ii

I. Respiratory Distress Syndrome

2. Acute Abdomen

3. GI bleeding

4. Mass (tumor)

5. Miscelleneous

r, rlf~ pa",n- '-\I(\-

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- eh<e

RespIratory distress in new born,d... d 'i.!

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Classification of neonatal respiratory distress

I. Medical condition - Pulmonary edema

CHF

Pnewnonia etc.

2. Surgical condition

2.1 Developmental anormalies of the oropharynx. b' dro . ~«\' .L~ '''\ I-- ~~- j\IIn\1.l t.~,:l v~(j~~h).- PIerre Ro 10Syn me Vl""";S,, 11""" ,.,Im ~"

- Retrognathia with, without cleft palate

- Malformation of cheek, tongue

- Hematoma of tongue("CtHtH'1M vf\.ll.../

- Haemangioma of tongue '\

• Nasopharyngeal tumor - i~"'\""''l"'I>~- Chaochal atresia' ~- {.;I"',<A1~lilu',

I'" \i h',jf, ,be ,1e,,1i~JMf""17'lO't.o <

1 ~i)l.:~li'lW Qt.,"dtteS1LtJ

2.2 Laryngeal and tracheal malformations

• congenital microlarynx

• congenital of the larynx

- Laryngeal web

- Haemangioma of the larynx

) "'.,,.

......-2-

- Tracheal stenosis

- Traeheolaryngeal malasia

2.3 Massive swelling of neck and floor of the mouth'.

2.4 Pleural conditions

- Empyema flllJl1lr~ infection ••• >yoJu;, for nl<l

- Haemothorax lltl~trauma ••

~Pneumothorax "Hr~resuscitation, on respira

2.5 The pulmonary condition

- congenital lung cyst •

- congenital lobar emphysema

- congenital cystic disease oflung - CCAM

2.6 Mediastinal condition

- Pneumothorax ••

- Mediastinal teratoma

- Duplication cysts - Esophageal duplication

2.7 Diaphragmatic hernia ••••

2.8 Tracheoesophageal malformation •••

2.9 Abdominal condition ••••

- Intestinal obstruction

- Abdominal distension due to

Ascitis, Bile, Chylous

Peritonitis

Intraabdominal mass

Principle of management

~ "...1 v Q; Yb1 ..J.""J'llJVYiUrespirat.ory failure lflfl'IJU~:::9mnUlLfll'IJfll ~111m9,J'l1lfl~'lJU

i~""""....Q; $I 1 ~11fl1'1U~IIIJ'l1lJflflV~ ~VVlrrV clinical sign Lm:::fl , investication

• 4 l . .•'" ~, i-Im1~11l Degree of respITatory 1L~:::l1H)metabolic ac doSlS lYimUlJILU1'l1Nfl1"fl~1~V 1J

1Mfl1' l'fl~ll'1 NflMfln lJ~ llJ11111191,Clinical groups of degree of respiratory distress

2.2

3

I. Severe respiratory failure in present

1.1 Endotracheal indubation & assisted ventilation

1 ';1' " ~.. 1" 1 ",.1 ,1.2 Tracheostomy U'llVl1 11'tube 111l11lJ'lf1VMM1V~~'lJU l'lfU tracheal stenosis

2. Mild to moderate respiratory distress in present (not treatening of life) 11ll:;lrl!JiJ~ll.jl1'll1.J

m'l1iJu~v

2.1 Investication MllY1LM'l1'lfUx-raylid ,,!'t1 ~1ll1Ylf1!J1m'l11l1~:;'l!J~llf1I'IJ'lllJ'IJ!J I

2.3 Resuscitation 'lllJfl11lJ~11tlulm:: 1 M'f1m.h.;~i'f11l1mlJr\'ULM'l

3. Resiration distress is not present, work for Diagnosis 111l:;i'mn911lJ.rULM'l~!Jill, "e:l •.•

Acute abdomen !J1m'l'l11~'lf!J~l1!J~UW1.J'YlllU

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- m'l91'l1u-il~mv m'jff~lf191~!Jlm'j

""" ,''' "I I• m'j91'l1~ViI!l1l (Investication) 1.J1HlVl~'l1~!J1~IlJ

h\'lu.r!J~m 1~ll1'lJ!Jill• CBC, Urine, stool exam

• Chest film PA,

• KUB

• (Ba. Enema)

• Upper GI series

• UlS of abdomen

• CT & etc.,'" ,!!10l'ln'Yl1J1J!!V1'IJM Acute Abdomen

I. Abdomen pain

2. Diarrhea

3. Vomiting nausea

4. Fever

5. Contipation,obtipation

Common causes of Acute Abdomen

I. Traumatic

Blunt trauma

- f'\l)l1o)\.", ~ndt'r. f" ~lJaitl

- "0>1",'-';,,'1' "",."n04"'01. t'1)~lSiJn- ,o'r,i un YY'.U'r-hJ ~.sn.

4

GSW

Stab wound /I'\~'"nl' '1'''01Blast injury

2. Non traumatic caused

With bowel obstruction

With out bowel obstruction

Adhesion

Infection

Congenital

Perforation

Vulumlus

Etc.

Intestinal obstruction" " ..!I d S1 ••• ~ '"I "I I I ••• ~

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I. Non biliary vomiting

Atresia & stenosis *.

1.1 Intrinsic caused

Esophageal atresia TB malformation 00

Chalasia

Hiatus hernia

Esophageal stenosis

Hypertrophic pyloric stenosis

1.2 Extrensic causes

vascular ring

Duplication

2. Biliary vomiting

2.1 Duodenal obstruction

,lJd1l.,kAnular of pancreas 000 dooU. 'ian.Duodenal Web an diaphragm 00 'l\o\h bw'o\. )

2.2 Malrotation 0

2.3 Jujunal, ileal atresia 000

L Terrie. ~,H'crvtJ.

.rt\~..,,-n ';-~Clr1'fl..l\ (tr.l,\ltnm1

H00.

5

2.4 Meconium ileus ~\1~>t\o('n

2.5 Meconium plug syndrome J2.6 Duplication

2.7 Hirschsprung's disease (Megacolon) ••••

2.8 Imperforate Anus (with or without fistula) ••••

2.9 Volvulus - mid gut

Non intestinal obstruction

I. PU Perforation, Gastric perforation •

2. Intestinal perforation - Typhoid perforation ••

3. Enderocolitis: Acute segmented ischemic jejunitis '1nm'D~u'1,],l

NEe (Neonatal necrotizing enterocolitis)"

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- ;J, ('c~ i r(.~ ~drl,-lC.lpaI1r1fc\hc.n'l1 ~1>') fV'\(",kd 1 ~~.

8. Liver abscess rupture •

9. Mesenteric lyphadinitis •

7. Intraperitonial hemorrhage

6. Bile peritonitis

5. Mechel's diverticulitis •• disease on S- 'ccl> U ""~ l.c,- nUlL,

Hirschsprung's disease ••••

4. Acute appendicitis •••• '\....(\~ I "."n, ~O, /0.0 ~nl,,;\l<Nv I r-h~'e",\\;)ryC n1Q 0nm

, ~l1ocl.\'l1'I 0~,e,,~.

10. Abdominal tumor, Wilm tumor. Neuroblastoma, Hepatoma ••., -"'"0fh.~hM~,rrd>l <: p-rfolak

11. G.U. tract, GU mfeclIon ',~. '-.l\ ',,'VfH ~v.- ? 00, \...., rp"ndi\

TorSion testis' - (Retractile testis)

PID

Epididymo~is ~,,,rrr.~~Ectopic pregnancy

12. Hernia

Management

o lI1fflll19j"hnflV::'hil1'm.luvu

o ~::il1'tmfn1Jl~1U1iifl~~~llfi

1. NPO, GI Decompression

2. Fluid electrolyte correction

6

3. Fluid I/O

4. GIM & blood transfusion mlJmllJ~ll1'Jw

5. Preoperative care

6. Antibiotic cover gram negative gram positive L111::Anaerotie \llllJt111lJ~111'JW

7. Temperature controlod..... .d jJ

Surgical treatment \lll1JfflLl1ijVl'VlU'I1l1~Resuscitation f1Utl1

Early diagnosis, and proper operation

1. Pre-operative care - Resuscitation hl'~~l1\ll

2. Operative care F.h.r\lli"n1Jl~WLl1ij'll!H1Hl

3. Postop care - wound care

Intake and output

Antibiotic

Prevent complication etc.

Prognosis.1 ~ 9. ~~ ~ 1 ,.. "" "o 'IIWnU011 ~'I10111w~n/J 1t1 mJn~HH11\ll111L1lJW/Jlll\ll'I1W

o hl'011i"mn~\1n~v~IY;IJ~1\ll

o n l1\llLll1rimJlll1::mi~Fh.r\ll~IY;/J~1'1•~J •• "o Complication 1O'I'IIW'I11VlJ

Gastrointestinal bleeding

11'Jwih\!m~ ~::'VlU' ~1iV/J'l 'I1l~fllJl1ftl1lJfllff\ll f lin mh~'I1i1~l~n m~ ~::1J1~11JmLIiIJWl1'J\lLftV\llci llJl1'lW•• ,"'.. • ok •• _I." .; Y •• '1 , ••~. ok • 9.mV\llmIJlUWlJfUl1V\llIl~~11::\ll1'lf~m~1Jm011u1\llVlV~ 'I11Vm011VW'l i'l1/J'I11V lJn ~'I 'lf~~::\llV~1'11011

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Gastrointestinal Bleeding,• ••Etiology Vl\llltJ~lfll'11~VVf1mlJVlqll'l"ltJ

1. New born

01\hl.ll1!~~

i.o.J"r~",,{,,{i I~'d"

\~h"\'\~J \f.1..r1o..1

o Swallowed matamal blood (most common) •••

o Primary coagulation defect (Common) ••

o NEC ••• lurol'\

o PU (stress ulcer, Drug induced) 'io As ~ I \I\Jcnvi\1~ '11'L

o Gastric erosion

o Anal fissure (common) •••

7

o Yovlus (Rare)

••2. Infancy (J-241'lfJU)

Most cOmmon

- Anal fissure

• Meckel's diverticulum

- Intussusception

• Polyps

- Duplication

3. Children (over 2 years)

• Polyps

- Meckel's diverticulum fl'qrri vtJ.

- Duplication

- Amebic colitis

• F.B.

oJ &!:I Q,oO I uClinical picture fJ1mn1l'l1JfJ1UlJllnlJru::911~'1 f1U9IllJl1'lll1~

Epistoxis Nasopharyngial bleeding

Bleeding Hematemisis upper GI

- upper GI

- Melena upper G.!. bleeding

- Hematochezia (Reddish brown) mid gut

- Fresh blood, Lower GI, Anus

Less COmmon

PU & Stress ulcer

Peptic esophagitis

Esophageal varices

Enterocolitis

FB trauma

Less cOmmon

Esophageal varices

Ulcerative colitis

Peptic esophagitis

Intussusception

Hemach-Schonlein purpora

Hemorrhage gastitis

- Bloodymucous or Gelationus, GI irritation

Volume of bleeding

1. Massive bleeding

• Meckel's diverticulum

- Esophageal varices

- Acute hemorrhagic gastritis

-PU

- Colonic polyp

- Leech in rectum

8

- Acute gangrenous jejunitis

2. Scanty

. Rectal polyp

. Amebiasis

. Intussusception

. Prolapse rectum

• Anal fissure .

Investicatlon

• NG intubation and lavage

. PR 'lltnllJ ••

. Stool exam for occult blood

- Proctoscope and sigmoidoscope

• Colonoscope

. Gastro and esophagoscopy

. Baenema

- Upper GI series

T 99M •. x scannmg

• Serial Hb & Hct

. PT & PTI Coagulation study

Treatment

~ v'1. Medical treatment 1110fllJ'l'J0'1111J

- Emergency therapy - treat shock - IV fluid

. Blood transfusion

• Vit K I

• GI lavage & Decompression

. Specific treatment - Antacid, Histamine Iireceptor antagonist etc.. Depend upon etiology

• Follow up - observation

• • ••• InveslIcatlon l'l'lfll1ll'1'1lMfJ

9

2. Surgical treatment

.1 '~v 1 '" i d" v , " v- "U1Wfl1J~Um~"ll~ 1f1111ll Ufl1Oll'lconservative 11"1 lJ f1H"• •- Preop & postop care.; , i d .d""Incidence 'YI'111J1JlllJUlflfll'llJbleeding perrectum

Rectal polyp 36.31% .

Intussusception 17.58%

Amebiasis I 1.55%

Anal fissure 9.22%

Negative study 15.58%

Mass LtJUUfll'l'lm"ll1rl~~'I11J1hw1fIlJlJ1~i'1/Jl~ll~ihl'llUtJiI1w1iwl nu llWl'ltJ1" lJu~LiiI]j1l1lljjmfl11~'A'I. Swelling of the neck

- Nonspecific hyhperplesia, of corveral LN ••

- Acute lymphadenitis •

- Chronic specific lymphadenitis ••

- Lymphoma'

- Thyroglossal cyst ••

- Bronchial sinus or cyst'

- Cystic hygroma ••

- Epidermoid cyst

- Thyroid swallowing

- Neonatal coiter

- Colloid goiter'

- Thyrotoxicosis

- Adenoma

- Carcinoma

- Torticolis ••

~.1,~ ~,;<, ''''V ~ 1fl1nmn"Ull~fltJfl11m1~flmlluUll~ 1~~ l1fl1nflfllmlJl'I'lm>]"IH 1f1v i)l d _I 'j} <!t)1 ..; I

2. Abdominal mass flllU Ul'lll~m~lJmfll1u1f1'11ll~ 111llfl1IJlllfl11llU'l nlJ

55-60 % Medical problem

40-45 % Surgical problem, 50% GU tract

10

Age incidence

Neonate - congenital kidney inorigin

hypertrophicpyloric stenosis

Intussusception

Malignancy - Wilum's tumor

5iJ - Neuroblastoma

- Rhabdosarcoma

- Malignant lymphoma

\

Congenital Benign lesion - Hydronephrosis

8'"1] - Cyst

------Inflarnmatory - Appendicial abscess

Incidence Llti~mlJrrll11'l~""1J'jh'1'Ill1. Malignancy 20%

2. Congenital abnormality 20%

3. Inflammatory mass 20%

4. Spemomagaly 20%

5. Other mass 20%

Etiology ~""lJ~1'1ill1. Congenital

2. Inflammatory

3. Trauma

4. Tumor

5. Miscellunoma

Hydronephrisis

TB abscess

Hematoma

Malignancy, Benign

Intussusception

II

Sign & Symptom Imlillltll5111lJ hili 1l1~YlU"wu~lihy i.WlllJ 'I11lJll1Jll~'111~lJlJdilti'lJ1Jlld~u~nlll

1 'I Y ''1 Q Y ~ Y Q Q' Q d.. Y dIU' ,'I '\Jill:: 9llJlnUllUlll'l l1U 1111::lJ"'I1f111UIl1U1::'\JNll'lU~lYlU~'I 1l1~lJllltll5l51mll'lflf11~Il'lflJA. Acute on set- Intussusception

- Appendicial abscess

- Twisted cyst

B. Slow progressive

Malignancy - Wilm's tumor

- Neuroblastoma

- Rhabdosarcoma

Benign

- Malignant

- Congenital hydronephrosis

- Mesenteric & omental cyst.1 I ••••••• I ~ •••• • ..d. ~

lnvestlcation '\JlJlJ~f1Uflfl1111::151l1~Yl~nIll111lmlJl1~1IUlJ

- Routone lab

- KUB, chest film PA

- VIS 'lhU'lJtll51iJ~l1unllUlJ/h~lJlf1

- IVP, RP

- Angiogram, venogram

- CT

-Homonal study

- Bone, Liver scan

• Bone marrow study

Treatment

- Surgical treatment

- Merlocal treatment

- Total excision

- Radical surgery

- Internal drainage

. External drainage

• Partial excision

- Palliative or bypass procedure etc.

- Antibiotic

. Anti. T.B.

'. },d:I,'rl', (Ijljhn1~\..l~\.,.\

fO.$I-. of (tJte,

- vIr

- o~- ,;; ("I~' rI Po } v -,q

~ f5<-..('ldt.no ftJb~

- 11"'(1510\ f b{~,~ t;ta~. - M'LJ,irt,n,

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• ,"n"l.,--\-,..) I I, , j ."" ..•'Iv ~Od.""ll'.'\.1l4:U':il\It.jHf'lfQi.

f"'1"'rd"rl(.tI~R'lrfl~~iJ rl'"ll'" ~'lo~tAL..

Prt cfl:,ah ~

~ "'Po ~. ~-(. "r. ll.1~1l I$\,"l\ 'il \ ~l\';l(

- ,c\,.",c<'k \...•,'~sIC'CIt. qL\O~.

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,~rvl'UU'kQ.~f''ffI1''0krn'c~t ~fIlo"~O"I1.!flV.

12

- Surgery & Medical

- Chemotherapy

• Etc.

- Hydrocele •••

_Undescended testis" ~'''''''uS~tlV1

- Trauma *

- Gastroschesis ••

- Bum'

- Surgery & Radiation

• Surgery & Medical & radiation

- Omphaloce1 ••

- Hernia IIH ••••

- Medical & Radiation

.x '~Q 1';'" ' ~Prognosis 'lJ1J{)~n'lJ'lf1J~'lJtH~tlYll1J1JLLCl::m~response ~tlm~~n'lJl

Miscellenous htl~61~'Yl'lJumJ'1

"'!' "'f'lr<:lko"."\'. ''''.,,"k~,\A,hJ. • Radiotherapy

cO" : !-i1= ~In Ol-"'r l.~(ld.-Combined

""d'l ( ;rrohr-<' \f,u<.,,,

CN!i :(,f\ h:ll"Cil"1'11~Q I hNcn<lt I

r~r!'S v' trr-,bct'.ctY'(t, ..her.

- Torsion testis

- Obstruction jaundice - Biliary atresia ••

- Choleductal duct cyst •

.. ""'!. ,,,,,,,,,,l_ 0 '(\Ct\1Ci15

•.. <., I cl.,t,.(}'<,'l'fK>S\lC"f).

- J,ol)-V.C.

Nv~11-1,.JIJ(ubG.

,1if'l~"o,'"01~"_ f1~o ~~ I,l"l~Htl* parrnr cdurd~O(l

Etc.

"""'~"l "" eel",.c.- b~. r'\uh.,holl

~"Ju\.04'9. Q'ltT1(1do:J1'd .n f~';"..lO-':'

\0 ~"~rnorm,

••.• J""" •••fl'Cl(JfI'lffml~(J1..•... ~1(J•.•......~~~'1

(!> ~~r."r<:ll Co:. m,r1~'"'"hI r\

~ cll"tf pcJl.Jk "'f\f~o\.laHJ1

fr-:°FIl:1~~v.

ror->x

- {ll(" 1f'1'\\' {11< 1l\~fnhcl)

~ 1w{~l:)\<J1l~l

@ !\'W~hon.

@. P~i"'",hC:'"

G> 1""" opn<>h", C~lc.~ 1-~.

" PS'ljr-hC.\oBb' _ ~Uo)'1~,JI11ti1f')

- 'I1rlo lh~-r~