pediatric surgical emergencies division of pediatric surgery patty lange september 2005
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Pediatric Surgical Pediatric Surgical EmergenciesEmergencies
Division of Pediatric SurgeryDivision of Pediatric Surgery
Patty LangePatty Lange
September 2005September 2005
ObjectivesObjectives
Understand what constitutes an emergencyUnderstand what constitutes an emergency Understand the basic patholophysiology of Understand the basic patholophysiology of
pediatric surgical emergenciespediatric surgical emergencies Recognize signs and symptoms of intestinal Recognize signs and symptoms of intestinal
obstruction, peritonitis, sepsisobstruction, peritonitis, sepsis Learn the basic diagnostic techniques in surgical Learn the basic diagnostic techniques in surgical
emergenciesemergencies Learn management strategies for the various Learn management strategies for the various
surgical emergenciessurgical emergencies
OutlineOutline
AppendicitisAppendicitis IntussusceptionIntussusception Pyloric StenosisPyloric Stenosis Incarcerated Inguinal herniaIncarcerated Inguinal hernia Hirschsprung’s EnterocolitisHirschsprung’s Enterocolitis Malrotation with volvulusMalrotation with volvulus
Outline ContinuedOutline Continued
What are the important points about the What are the important points about the history?history?
What are the pertinent physical findings?What are the pertinent physical findings? What is the differential diagnosis?What is the differential diagnosis? What further workup is needed?What further workup is needed? How is the problem managed?How is the problem managed? When/if to do surgery?When/if to do surgery? Postop managementPostop management
Case 1Case 1
6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension
Case 1Case 1
6mo6mo infant with vomiting, poor po intake, infant with vomiting, poor po intake, abdominal distensionabdominal distension Previous 33wk gest agePrevious 33wk gest age Non-bilious emesisNon-bilious emesis Looks illLooks ill Some respiratory problems as neonateSome respiratory problems as neonate No history of surgeries, no medsNo history of surgeries, no meds Physical exam---Physical exam---
KUBKUB
Inguinal Hernias in childrenInguinal Hernias in children
Patent Processus VaginalisPatent Processus Vaginalis
Not so subtle SometimesNot so subtle Sometimes
High Ligation of SacHigh Ligation of Sac
Case 2Case 2
6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension
Case 2Case 2
6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension Otherwise healthy infant, no previous feeding Otherwise healthy infant, no previous feeding
intoleranceintolerance Looks Looks wellwell, mom says , mom says intermittentintermittent fussiness fussiness Mom says pt passed Mom says pt passed reddish, thick-mucousreddish, thick-mucous
stoolstool Physical exam--Physical exam--
IntussusceptionIntussusception
““Currant jelly stool”Currant jelly stool”
KUBKUB
KUBKUB
Intussusceptum
Contrast EnemaContrast Enema
Incomplete Air ReductionIncomplete Air Reduction
Perforation and NecrosisPerforation and Necrosis
Case 3Case 3
6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension
Case 3Case 3
6mo infant with vomiting, poor po intake, 6mo infant with vomiting, poor po intake, abdominal distensionabdominal distension Mom says not tolerating his bottle today. Mom says not tolerating his bottle today.
Began having Began having greengreen emesis, has not had a emesis, has not had a wet diaper todaywet diaper today
Baby looks ill, not very reactive on examBaby looks ill, not very reactive on exam PE--Abd distended, tense, tenderPE--Abd distended, tense, tender
Bilious Emesis is Bilious Emesis is BADBADBilious Emesis is Malrotation Bilious Emesis is Malrotation
with Volvulus Until Proven with Volvulus Until Proven Otherwise Otherwise
EmbryologyEmbryology
EmbryologyEmbryology
VolvulusVolvulus
UGIUGI
Duodenal-jejunaljunction
UGIUGI
“Bird’s beak”
Volvulus and IschemiaVolvulus and Ischemia
Dividing Ladd’s BandsDividing Ladd’s Bands
Widening the MesenteryWidening the Mesentery
Positioning the VisceraPositioning the Viscera
Case 4Case 4
5wk old male infant with persistent emesis 5wk old male infant with persistent emesis for 2 weeksfor 2 weeks
Case 4Case 4
5wk old male infant with persistent emesis 5wk old male infant with persistent emesis for 2 weeksfor 2 weeks Mom says baby throws up almost every feedMom says baby throws up almost every feed
—getting worse and more forceful, emesis —getting worse and more forceful, emesis looks like the formula she feeds himlooks like the formula she feeds him
On Prevacid for reflux diagnosed 1 wk agoOn Prevacid for reflux diagnosed 1 wk ago Using rice cereal to thicken feeds but no Using rice cereal to thicken feeds but no
improvementimprovement Not wetting as many diapersNot wetting as many diapers
Pyloric Stenosis--USPyloric Stenosis--US
UGIUGI
ResuscitationResuscitation
Electrolytes typically showElectrolytes typically show HypokalemiaHypokalemia HypochloremiaHypochloremia Elevated bicarbonateElevated bicarbonate Indirect hyperbilirubinemia (glucuronyl Indirect hyperbilirubinemia (glucuronyl
transferase deficiency)transferase deficiency) Importance of adequate resuscitationImportance of adequate resuscitation
Anesthetic implicationsAnesthetic implications
HPSHPS
Thickened PylorusThickened Pylorus
PyloromyotomyPyloromyotomy
Pyloromyotomy CompletedPyloromyotomy Completed
Case 5Case 5
4 day old female presents to ED with 4 day old female presents to ED with lethargy, abdominal distension, emesislethargy, abdominal distension, emesis
Case 5Case 5
4 day old female presents to ED with 4 day old female presents to ED with lethargy, abdominal distension, emesislethargy, abdominal distension, emesis 37 wk gestation, Twin A37 wk gestation, Twin A Small ASD, no other medical probsSmall ASD, no other medical probs Mom says pt not making as many diapers as Mom says pt not making as many diapers as
her twin sister and not eating as muchher twin sister and not eating as much PE—abd distension, rectal exam—(make sure PE—abd distension, rectal exam—(make sure
you stand to the side!)you stand to the side!)
Hirschsprung’s DiseaseHirschsprung’s Disease
KUBKUB
Hirschsprung’sHirschsprung’s
Contrast EnemaContrast Enema
Transition ZoneTransition Zone
Leveling ColostomyLeveling Colostomy
(-)
(+)
Case 6Case 6
6yo male, otherwise healthy, presents to 6yo male, otherwise healthy, presents to pediatrician with abdominal pain and pediatrician with abdominal pain and nauseanausea
Case 6Case 6
6yo male, otherwise healthy, presents to 6yo male, otherwise healthy, presents to pediatrician with abdominal pain and pediatrician with abdominal pain and nauseanausea Dad says pt started complaining about abd Dad says pt started complaining about abd
pain yesterday after school (1pain yesterday after school (1stst day of school) day of school) Ate dinner but then woke up around midnight Ate dinner but then woke up around midnight
c/o pain againc/o pain again Vomited once this amVomited once this am Walks hunched overWalks hunched over H/O occasional constipationH/O occasional constipation
KUBKUB
USUS
Abdominal CTAbdominal CT
Psoas signPsoas sign
Laparoscopic AppendectomyLaparoscopic Appendectomy
SummarySummary
Bilious Emesis is BAD!! Bilious emesis is Bilious Emesis is BAD!! Bilious emesis is malrotation with volvulus until proven malrotation with volvulus until proven otherwiseotherwise
Resuscitation prior to surgery is very Resuscitation prior to surgery is very importantimportant
Clinical “Gestalt” is often the best Clinical “Gestalt” is often the best diagnostic tooldiagnostic tool