Paediatric Surgical Problems Sept 2014 By Age 0-3/12: necrotising enterocolitis, malrotation, incarcerated hernia, testicular torsion 3/12 – 3yr: intussusception, testicular torsion, gastro, constipation, UTI, HSP, trauma, volvulus, appendicitis, toxic megacolon, vaso-occlusive crisis 3-15yrs: appendicitis, DKA, vaso-occlusive crisis, toxic ingestion, testicular torsion, ovarian torsion, ectopic preg, trauma, toxic megacolon, constipation, gastro, UTI, pneumonia, pancreatitis, cholecystitis, renal stones, HSP, IBD, mesenteric adenitis Necrotising enterocolitis Epidemiology: usually affects prems/LBW, but can also occur in full term Risk factors: congenital heart disease, sepsis, resp distress Sx: non-specific, abdo distension, tenderness, pneumoperitoneum, sepsis, feed intolerance, bloody stools Ix: septic screen; X-table AXR (dilated loops of bowel, abnormal gas pattern, pneumatosis intestinalis, hepatic portal air, perf air seen above liver) Management: bowel rest, aggressive IVF, broad spectrum Abx, ICU Appendicitis Epidemiology: most common surgical emergency in children; peak age 9-12yrs; M > F; less specific Sx in children; rapid progression in <2yrs; perf rate 80% if <4yrs, 10-20% in adolescents Sx: classical story present in only 50%; N+V+anorexia in >80%; V more common in younger children Ix: clinical diagnosis; 10% have normal WCC; WCC <10 has strong NPV; USS = 85% sens, >95% spec; CT = 94% sens, 95% spec Paediatric appendicitis score: migration of pain, anorexia, N/V, fever, cough/percussion/hopping pain, RIF tenderness, WCC >10; >6 = 93% sens, 70% spec; <2 = not appendicitis Mesenteric adenitis Assoc with URTI; constant and colicky abdo pain, high temp, localised tenderness, minimal peritoneal signs Malrotation/volvulus Epidemiology: <3/12, 2:1 M:F; malrotation 1:500; 75% volvulus present in 1st few months of life Pathology: irreversible ischaemia after a few hours Sx: sudden, constant pain, bilious vomiting, distension, shock, peritonitis Ix: AXR - double-bubble sign, paucity of gas with air bubbles in duodenum/stomach, loop of bowel overriding liver, obstruction; upper GI contrast series (narrowing at obstruction site = bird’s beak); USS Management: emergent OT Intussusception Epidemiology: most common cause of obstruction 3 months - 3 yrs, peak 5-10/12; 4:1 M:F; 1-4 per 1000, diagnosis delayed/missed in 60%; mortality 1-3% with trt, 100% without; peaks during GI illness seasons Pathology: small bowel segment invaginates into the lumen of more distal bowel - causes venous congestion (blood and mucus) - bowel ischaemia - wall necrosis - perforation; often assoc with adenovirus Causes: 90% idiopathic; some due to Meckel’s, polyps, lymphoma, HUS, CF Assessment: 4 classic symptoms: vomiting, abdo pain, abdominal mass, bloody stool Episodic severe distress, pale faced crying, palpable sausage-shaped mass (RIF/RUQ; in 2/3), red-currant jelly stool (50%; late sign), diarrhoea (30%); vomiting occurs late (after 6-12hrs, may be bilious) www.shakEM.co.nz 1 Ix: USS (sens 96%, spec 97%) – donut sign, target lesion AXR: 25% normal, maybe target sign (soft tissue mass RUQ), Dance sign (no air RLQ), meniscus sign (crescent gas in colon), perf, obstruction Positive FOB/fecal guaiac Indications for air enema: <24hrs duration, no peritonism/toxicity, no blood on PR Management: IVF; NG if vomiting; air enema works in 75% (5-10% recur, usually in 24-48hrs); if air enema not work, needs OT; air enema allows better control over colonic p, and avoids spillage of barium if perf; with Ba incr risk of perf but decr risk of recurrence Hirschprung’s disease Epidemiology: 1/5000; 4:1 M:F Pathology: absence of parasympathetic cells from myenteric plexus from anus proximally; prox bowel hypertrophies and distends Sx: acute obstruction in neonatal period, or chronic constipation in older; failure to pass meconium within 24hrs, bilious vomiting Management: OT Pyloric stenosis Epidemiology: 3/1000; 4:1 M:F; usually 2-8/52; most common in 1 st born males; 50% familial Pathology: marked hypertrophy and hyperplasia of pylorus - narrowing of gastric antrum Assessment: non-bilious projectile vomiting of feeds; maybe small amount of blood; hungry - feeds after vomit; upper abdo distension with peristaltic wave (from L-R) and succussion splash after feeding; palpable olive shaped mass >1cm in RUQ; dehydration, failure to thrive, but infant appears well unless dehydrated Ix: hypochloraemic (Cl <100, Na <130) hypoK metabolic alkalosis (present in <10% if diagnosed <1/12); USS (sens 97%, spec 100%); Ba meal Management: IVF; trt electrolyte probs; OT - Ramstedt pyloromyotomy Meckel’s diverticulum Pathology: in terminal ileum; incidence 2%; 75% asymptomatic; 60% complications occur <2yrs May contain gastric mucosa and secrete acid Sx: pain, obstruction, GI bleed, perforation. Most common cause significant GI bleeding in kids. Complications: haemorrhage, perf, intussusception, malrotation, infection, Littre’s hernia Ix: Meckel’s scan (Tech99) Management: iv fluids, transfusion for massive bleed, laparoscopic excision Colic Definition: excessive unexplained paroxysms crying in healthy infant (cry >3hrs/day, >3 days/week, >3/52); starts in 1st week, peaks 2 nd month, resolves by 3-4 months Epidemiology: incidence 13% Sx: flushed face, circumoral pallor, clenched fists, tense abdo, draw up legs, cold feet Ix: examine baby; assess caretaker mental health (RF for NAI). Term babies regain birth weight by 1/52 Management: instruct in proper feeding practices; 1/52 trial of hypoallergic milk if severe; reassurance GORD Usually resolves by 1yr; may begin at 1/52; often resolves with solids foods and sitting position Ix: barium swallow (exclude hiatus hernia, webs, stenosis, stricture, vascular ring, gastric outlet obstruction, malrotation), pH monitoring Management: burping, small vol feeds, thicken feeds, gaviscon; ranitidine/omeprazole if oesophagitis; OT Complications: oesophagitis (irritability, loss of appetite, haematemesis, malaena, peptic stricture), FTT, resp probs (asthma, pneumonia, apnoea, ALTEs, recurrent cough, stridor), family dysfunction www.shakEM.co.nz 2 Incarcerated hernia st Epidemiology: hernias occur in up to 5%; more common in prems; incarceration in 1/3, usually in 1 yr. Most indirect - extend into scrotum/labia, particularly when crying (incr pressure). Differentiate from hydrocele by transillumination Management: reduce (may need sedation); needs FU with paeds surgeon in 24-48hrs; up to 1/3 recur Umbilical hernias almost never incarcerate, only repair if persist >5 years Cholecystitis Uncommon in children; more likely to be acalculous; stones secondary to haemolysis and TPN; causative organisms E coli and klebsiella; if cholecystitis, trt with ampicillin + gentamicin Pancreatitis Rare; 25% idiopathic; 35% systemic causes; 15% trauma; 10% structural abnormalities; 5% metabolic; 5% drugs; 2% hereditary; RF = recent chemo, trauma, CF, FH pancreatitis; lipase 100% spec, incr within hours, remains up 2/52, severity of rise doesn’t correlate with severity of disease. AXR may show sentinel loop; USS imaging of choice Vomiting in Infants Assessment: Age, colour of vomit Newborn with mucosy clear froth: oesophageal atresia Hx: polyhydramnios Ix: can’t pass 10F feeding tube beyond 10cm, gas-less abdomen Management: leave feeding tube in place for aspiration, nurse supine, stops feeds, refer to surgeon Newborn to 2 days with bilious vomiting: intestinal atresia or Hirschsprung’s disease Ix: rule out sepsis, AXR to exclude atresia Management: referral to neonatal Infant with bilious vomiting: malrotation Usually presents at 4/52, but can be any age Infant with green vomit = malrotation/potential volvulus until proven otherwise Surgical emergency - risk necrosis of small bowel Other causes of bilious vomiting: Intestinal atresia Anorectal anomalies Meconium ileus Hirschsprungs Malrotation with volvulus Irreducible inguinal hernia Intussusception Inflammatory (complicated appendicitis, Meckel’s diverticulitis, IBD) Meckel’s diverticulum Adhesions Infant with milk vomiting: pyloric stenosis or GOR Analgesia Morphine: 0.1mg/kg IV Q2-4hr (0.05-0.1mg/kg Q4hr in neonates) Fentanyl: 1-2mcg/kg IV Q30-60mins www.shakEM.co.nz 3 .