Paediatric surgical emergencies

Mani Thyagarajan

BWCH

General points

• Always discuss

• Call consultant for help ASAP

• CT scan is a bad modality in paediatrics

Ultrasound

• ? Intussusception

• ? Renal colic

• ? UTI

• Issues with Transplant Kidney

• ? Malrotation

• ? Appendicitis? Ovarian cause

• ? Intestinal obstruction

Ultrasound

• Full bladder for pelvis

• Fasted for hepato-bilairy system and pancreas

Fluoroscopy

• Bilious vomitters

• Failure to pass meconium

• Intussception reduction

• NJ tube insertion

CT scan

• Source of infection ???

• Post appendectomy

Pyloric stenosis

Appendicitis

Abdominal radiography

• Plain radiographs rarely add to the diagnosis because they are typically normal in appendicitis.

• Abdominal radiographs should be obtained in any patient with an examination concerning for intestinal obstruction or with peritoneal signs.

• The presence of a calcified appendiceal fecalith occurs in fewer than 10% of cases.

Literature

• What they did: – Meta-analysis – 26 studies involving children – 9,356 total patients

• Primary outcome: – Pooled sensitivity and specificity of CT and US in diagnosis of acute

appendicitis in children

• Results: – Pooled sensitivity and specificity for US in diagnosis of appendicitis in

children: 88% and 94% – Pooled sensitivity and specificity for CT in diagnosis of appendicitis in

children: 94% and 95%

• Conclusion: CT has a higher sensitivity than US for diagnosis of acute appendicitis in children.

Literature

• The decision to obtain an US vs CT for children with suspected appendicitis remains a challenge. On a case by case basis, one should consider the following 4 major goals in care:

• Minimize rates of missed appendicitis

• Minimize risk from radiation exposure

• Avoid misdiagnosis leading to negative appendectomy

• Properly identify appendicitis before perforation

Background

• Children have a higher risk/unit dose

• Why? – Growing tissue more susceptible

– Longer life span to develop malignancies

• For 600,000 CT-head/abdo’s performed in <15 yr olds2

~500 fatal cancers within their lifetime.

Background

• Corresponds to lifetime risk of fatal cancer of ~ 1 in 1000

– 0.18% for CT-abdomen

– 0.07% for CT-head

Concept or risk – keep in context!

– Lifetime risk of dying from cancer - 1:3

– Fatal slip in the bath/shower - 1:2500

• (~same as a 5yr old developing a fatal cancer from a CT-chest)

– Striking it rich on the antiques roadshow - 1:60,000

– Marrying a supermodel - 1:88,000

Results – Risk per investigation

For a 5yr old, what is the lifetime risk of developing a fatal cancer from each investigation?

<1 in 40,000

~1 in 20,000

~1 in 6000

~1 in 3000

~1 in 1500

CXR ✔

CT Head ✔ 6 44

CT Chest ✔ 5 44

CT A/P ✔ 5 44

MRI + Gad ✔ 65 31

Ba Swallow ✔ 27 48

MCUG ✔ 26 47

Ultrasound ✔ 76 24

Literature

Radiation Protection

• use of CT, thus

– Dose reduction

– Education and awareness

• Ionising Radiation (Medical Exposure) Regulations, 2000 – IRMER.

Appendicitis

Appendicitis

Unwell pyrexial vague abdominal pain

Right iliac fossa pain

Ovarian Torsion

• USS has a vital role in the examination of women with lower abdominal and pelvic pain

• Typically, the affected ovary is enlarged, with multiple immature or small follicles along its periphery

• Color Doppler sonography can help in determining whether blood flow is impaired

• MRI can serve as a secondary modality when ultrasonographic findings are nondiagnostic

Torsion Ovary

Normal left ovary

Ovarian cyst haemorrhagic

Meckel’s diverticulum

Intussusception

Role of plain film is controversial

• Not necessary

Role of ultrasound

• Diagnosis

• Looking for contraindications for pneumatic reduction

Pneumatic reduction

Intussception

Intussception

Torsion testis

• Role of Ultrasound

Torsion testis

Strangulated Hernia

Hernia Role of Ultrasound

Urinary tract infection

Role of Imaging

• Normal imaging does not rule out infection

• To look for conditions predisposing to infection

• Complications of infection

PUV

• Ultrasound – any male child with bilateral hydroneprosis with hydroureter with or without thick walled bladder is PUV unless proved otherwise by a MCUG

• MCUG

Caecal volvulus