nuggets in paediatric surgery · bilious vomiting 2 infant •malrotation •obstructed hernia...
TRANSCRIPT
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Practical Paediatrics
Paediatric Surgery
JI Curry
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Practical Paediatrics, June 2018
Objectives
• To review common paediatric surgical
emergencies
• Gain understanding of basic pathology
• Understand first/emergency treatment prior
to transfer
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Paediatric surgery
• Different diagnoses from adult surgery
• Diagnoses can present differently in
different age groups
• Normal physiology and response to disease
vary greatly across age ranges
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Practical Paediatrics, June 2018
Take home message
• Bile stained vomiting is a “surgical
emergency” until proven otherwise
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What colour is bile?
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Prophylaxis !
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Practical Paediatrics, June 2018
Infant with vomiting
consider obstruction/surgical causes
yes
consider mainly medical causes
except pyloric stenosis
no
is it bilious?
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Practical Paediatrics, June 2018
Pyloric stenosis
• Consider in well hungry infant
• Test feed positive
• USS
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Practical Paediatrics, June 2018
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Pyloric Stenosis
• Typical biochemistry
• NGT to drain stomach. IVI
• Transfer when surgical bed available
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Practical Paediatrics, June 2018
Bilious vomiting
Newborn
• NEC
• Hirschsprung’s disease
• ARA
• Meconium ileus
• Duodenal/jejuno-ileal atresia
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Bilious vomiting 2
Infant
• malrotation
• obstructed hernia
• intussusception
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Bilious vomiting 3
What should you do?
Discuss/refer
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Malrotation
Surgical emergency
• bilious vomiting
• scaphoid abdomen
• beware distended stomach and absence of distal gas on AXR
• UGI diagnostic
• Urgent surgical referral
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Inguinal hernias
• Lump in groin
• Parents point to external inguinal ring
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Hernias
Differential diagnoses
• UDT
• Hydrocoele
• Hydrocoele of the cord
• Hernias in females contain the ovary
– still a surgical emergency if acute
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Practical Paediatrics, June 2018
Hernias - acute
• Needs urgent attention
– damage to testicle more common than to gut
• ivi, ngt
• analgesia
• reduction by experienced practitioner
• referral to paediatric surgeon
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Practical Paediatrics, June 2018
Hernias do’s and don’ts
DO NOT
• Hope it will get better
• put in elevation
• apply ice
• attempt reduction if you don’t know how to do it
DO
• Send them on a trip in an ambulance!
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Intussusception
• Think of the diagnosis.
• USS (+’ve in 95%)
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Intussusception
• Fluid requirements persist until reduction
• NG tube to decompress
• Give antibiotics
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Practical Paediatrics, June 2018
Intussusception - tips
• Empty RIF more reliable than “sausage
mass” (Dance’s sign)
• “red current jelly stool” present in about
25%
• Colicky abdo pain and “drawing up legs”not specific to intussusception
• Often “white as a sheet” between colics
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Bilious vomiting 3
Child
• appendicitis
• obstructed hernia
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Appendicitis
• Varies with age
• >5 more typical presentation
– NB 5 to 10% negative appendicectomy rate
• 2-5
– often delayed diagnosis
– mimics D & V type illness
• under 2
– perforated with generalised peritonitis
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Why didn’t the other doctors
know it was appendicitis?
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Appendicitis - tips
• Mainly clinical diagnosis
– can they hop on right leg?
• bloods and x-rays of little early use
• look for other causes esp. ENT
• BEWARE
– child with very high temp
– child who hasn’t vomited
– teenage females
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Appendicitis is NOT a surgical
emergency
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“We just got there in time”
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• Study from Royal London
• Historical comparison
• Delayed surgery until 2 doses of IV
antibiotics given
• Significant improvement in post-operative
complications– McCartan et al, increase in hospital stay NOT associated with
perforation or increased morbidity)
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Why
• ? Iv antibiotics
• ? Adequate resuscitation
• ? Seen by senior member of staff
• ? Operated by (or with) senior member of staff
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• Ingraham et all (Arch Surg, 2010)
• Nearly 33,000 patients
• No difference in 30 day outcomes when
surgery delayed for 12 hours
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Responsibility
• Ensure children are assessed by experienced member of staff
• Ensure adequate resuscitation and other urgent treatment
• Seriously question all out of hours operating on children when a consultant is not present
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Abdominal pain -
points to consider• If > than 1 month has <5% chance of being
surgical
• 50% of children admitted with abdo pain will have no definitive cause found
• Beware labels if you don’t know
• Tests frequently unhelpful
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Abdominal pain
• If in doubt admit
• Give analgesia if child in pain
• Actively observe
• If symptoms persist then FBC and CRP +/-
abdo x-ray
• USS in teenage girls
• Rectal exam usually not useful
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Analgesia
• For children being assessed for onset of acute abdominal
pain………………
• Yes please doctor!
– Kokki et al, Arch Pediatr Adolesc Med. 2005
– Bailey et al, Ann Emerg Med. 2007
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Abdominal pain
• Acute cholecystitis
• Acute pancreatitis (don’t forget the lipase)
• Acute diverticulitis (meckels)
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Please
Please
Please
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Mesenteric adenitis
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Mesenteric adenitis
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Mesenteric adenitis
Non specific viral
abdominal pain
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Abdominal pain• Pneumonia
• Sickle cell disease
• Keto-acidosis
• Hepatitis
• Henoch-schonlein purpura
• Poisoning (e.g.lead)
• Acute porphyria
• Migraine
• Psychological causes etc etc etc……………….
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Joe – don’t forget
to mention bilious
vomiting is bad
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Painful things - Testes
• Torsion usually obvious
• 2 peaks, neonatal and pubertal
• Infection and torted hydatids more common in under 5’s
– blue dot sign in torted hydatid
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Practical Paediatrics, June 2018
Painful things - Testes
• Torsion usually obvious
• 2 peaks, neonatal and pubertal
• Infection and torted hydatids more common in under 5’s
– blue dot sign in torted hydatid
• Don’t forget to check urine
• Don’t forget to examine for rashes
• Almost all should be referred
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Other painful things - penis
• Sore and no/mild swelling
– normal development. No treatment needed
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Practical Paediatrics, June 2018
Other painful things - penis
• Sore and no/mild swelling
– normal development. No treatment needed
• Sore and very swollen
– True balanoposthitis - rare (antibiotics)
• Poor stream and previously retractile
– Think BXO
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Paraphimosis?
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Practical Paediatrics, June 2018
Other painful things – penis 2
• Paraphimosis (ouch!!!)
– Analgesia (topical and oral)
– Refer
– Don’t always need circ
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Practical Paediatrics, June 2018
Caustic ingestion
• Find out what
• Poisons unit advice
• Paediatric surgeon/ENT
• Early endoscopy/gastrostomy
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Practical Paediatrics, June 2018
Foreign bodies
Sticks at
– Cricopharyngeus (not really)
– aortic arch
– GOJ
• if in stomach forget it
– Don’t give radiotherapy!!
– Simple advice
• sifting through stools only if they have
really p***ed you off!!
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Practical Paediatrics, June 2018
Foreign bodies - tips
Beware
• Watch (button)
batteries
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Practical Paediatrics, June 2018
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Practical Paediatrics, June 2018
Foreign bodies - tips
• Open points still in oesophagus
• Symptoms but nothing visible on xray
Lateral films can be useful
• Beware drooling child
• Did they wheeze or cough?
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Practical Paediatrics, June 2018
Objectives- review
• Reviewed common paediatric surgical
emergencies
• Gained understanding of basic pathology
• Understand first/emergency treatment prior to
transfer
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Practical Paediatrics, June 2018