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8/8/2019 Surgical Problems in Children
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Surgical Problems in Children
BY Ragheb Assaf ,MD
8/8/2019 Surgical Problems in Children
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ProblemsGASTROINTESTINAL- Pyloric stenosis- Malrotation
- Midgut volvulus- Duodenal atresia- Meconium ileus- Intussusception
- Meckel¶s diverticulum- appendicitis- Hirschsprung¶s disease
GENITOURINARY ± Inguinal hernia
± Umbilical hernia- Hypospadias- Phimosis/paraphimosis- Cryptorchidism- Hydrocele- Testicular torsion
OBJECTIVES
-Recognize-Diagnose-C onsult surgery
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Pyloric stenosisHypertrophy of the gastric outlet
1:150 males, 1:750 females2-12 weeks of age
Repetitive vomitingProjectileNon-bilious
DehydrationHypochloremic alkalosis
ExamVisible peristaltic wavePalpable ³olive´ to right of umbilicus
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Pyloric stenosis: DiagnosisUG I
Delayedpassage of barium throughthickened pyloricchannel
U ltrasound
Thickened,elongatedpyloricchannel
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Pyloric stenosis :treatment
Hypertrophy of pylorus
E ndoscopic balloon dilation
S urgical tx = pyloromyotomy
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Surgical treatment
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MalrotationFailure of midgut to rotateinto normal anatomic
position duringdevelopment - Colon and cecum in left - Duodenum on right side
- Bilious vomiting- Peritoneal (Ladd) bandscause partial bowel obstruction
- High risk for...
Duodenum toright of spine
C ecum in leftabdomen
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Midgut volvulus
Twisting of bowel around itsmesentery and vascular supply
Leads to ischemia, infarction, perforation, necrosisPresentation: lethargy, abdominal distention, bloody stools
!SURGICAL
EMERGENCY
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MALROTATION
M ust consider in every infantwith bilious emesis
30% present within first week of life50% within first monthM idgut volvulus with necrosisdisastrous
C an lead to SBS, death
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C LINI C AL P RE S ENTATION of
MALROTATION
Sudden onset of bilious emesis in 95 %
A bdominal distention common
Blood stool +
Bloody vomitus or diarrhea in 30%
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RADIOLOGI C DX of
MALROTATIONKU B:Gasless abdomen,SBO,
³double bubble´
C ontrast study: spiral or corkscrew appearanceU TS: reversed positionof S MA/ S MV
Study MUST beexpeditious
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P REO P ERATIVE P RE P ARATION:
MALROTATIONW
ITH VOLVULU
SL abs / unnecessaryM ortality remains as high
as 28 %P reoperative preparation?? N O N E !!
... GO TO OR« . QUICK LY
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O P ERATIVE C ORRE C TION of
MALROTATION
L add procedure
P osition of corrected malrotationSmall bowel descends on RightL arge bowel on L eft A ppendix potentially in L U Q p Removed
Role of second look operation
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Duodenal atresiaObliteration of lumen
Failure to recanalize
Neonatal bilious vomiting Associations
Prematurity Congenital heart defects
Trisomy 21C omplete
small bowelobstruction
Doubl ebubbl e sign
!SURGICAL
EMERGENCY
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Meconium ileusCYSTIC FIBROSIS
First manifestation in 15%of CF casesThick meconium impactsin ileum Abdominal distention
Bilious vomiting
Risk for VolvulusPerforation
M icrocolonwithmeconiumplugs
!SURGICAL
EMERGENCY
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I ntussusceptionM ost common cause of intestinal obstructionbetween 3 mo - 6 yrs2 /3 cases occur <2 yrsM ale /F emale=4:175-95 % Ileocolic>9 0% idiopathic;M eckel¶s, P eyer¶spatches, tumors, polyps Telescoping of proximal bowel
into distal (Terminal Ileum intoCecum depicted in diagram)
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IntussusceptionTelescoping of onesegment of bowel intoanother
Ileocolonic most common6 mos ± 3 years old
Progressive courseIntermittent acute abd. pain
VomitingBloody stools (currant jelly)Fever, lethargy Palpable sausage-shaped mass in upper abdomen
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I ntussusception : PresentationA bdominal pain,vomiting and rectalbleeding triad seen in <
1 /3 of cases .85 % display only colickyabdominal pain often 1-5minutes of crying andpain separated by 3 -30
minutes of nl behavior 75 % have vomiting(develops after 6-12 hrs)40% rectal bleedingU p to 1 0% : L ethargyonly
U/S demonstrating targetor donut sign
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I ntussusception : D iagnosisP hys Exam: 25-89 % may have variablytender sausage shapedmass; Dance¶s sign:empty R L QU /S: target,pseudokidney,
radiologist dependent; if high suspicion, order thebarium enema P lain films ±target sign,
crescent , and obstruction,30% may be normal
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I ntussusception : M anagementEnema: diagnostic & therapeutic, ³coiledspring´
Surgery must be consulted prior to study.
Barium vs . A ir- 80% correction if within first 12-24 hrs .
A ir Enema- safer if perforation
5-10%
recurrence rate in first 24-48h after barium enema reductionIf free air on films or signs of peritonitis, do notadminister barium, prepare child for surgery
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Intussusception Management
Ultrasound : Hydrostatic pressure reduces theintussusception
Surgeon must be involved directly If enema reduction failsSmall bowel intussusceptions requiresurgical reduction
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Intussusception
Terminal ileum telescopedinto cecum
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A ppendicitis80 ,000 cases in children /year /in U S A
Rare in children < 2years20 -4 0% misdiagnosed on initial exam50 -7 0% perforation rate in pre-schoolM ortality Rates of 5 % in perforated vs0 .1% in non-perforated appendicitis
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A ppendicitis
P athophysiology: obstruction of appendix by fecalith or lymphoidtissue causes congestion,
distention, ischemia, infection &perforation .
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H istoryM igration of pain from initial periumbilicalto R L Q was 64 % sensitive and 82 %
specificA norexia is the most common of associated symptoms
V omiting is more variable, occuring inabout ½ of patients
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Physical Ex amF indings depend on duration of illnessprior to exam .
Early on patients may not have localizedtendernessWith progression there is tenderness to
deep palpation over M cBurney¶s point
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Physical Ex amM cBurney¶s P oint: just below the middleof a line connecting the umbilicus and
the A S ISRovsing¶s: pain in R L Q with palpation toLL Q
Rectal exam: pain can be mostpronounced if the patient has pelvicappendix
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Physical Ex amF ever: another late finding .
A t the onset of pain fever is usually notfound . Temperatures > 3 9 C are uncommon infirst 24 h, but not uncommon after
rupture
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D iagnosisImaging studies: include X-rays, U S, C TXrays of abd are abnormal in 24-95 %
A bnormal findings include: fecalith,appendiceal gas, localized paralyticileus, blurred right psoas, and free air
A bdominal xrays have limited use b /c thefindings are seen in multiple other processes
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D iagnosisL imitations of U S:retrocecal appendixmay not bevisualized,perforations may bemissed due to returnto normal diameter
U/S demonstrating thickenednon-compressible, fluid filledappendix
U /S vs . C T: Sensitivityand Specificity are90%/ 97 % and94 %/ 94 % , respectively
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D iagnosisC T appears tochange management
decisions anddecreasesunnecessaryappendectomies ingirl, but it is not asuseful for changingmanagement in boy .
CT showing fluid filledappendix (diameter >6mm)with fat stranding
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T reatmentA ppendectomy is the standard of careP atients should be N P O, given IVF , andpreoperative antibioticsA ntibiotics are most effective when givenpreoperatively and they decrease post-
op infections and abscess formation
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Hirschsprung¶s diseaseCongenital absence of ganglioncells in distal rectum
- and varying distance proximally Lack of peristalsis causes colonic obstruction Abdominal distentionFailure to pass meconiumFever and diarrhea suggest ³toxic megacolon´ !
SURGICALEMERGENCY
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Hirschsprung¶s
AX R:obstructivepattern
B arium enema:Dilated proximalcolon witht ransi t i o n z o ne
S uction rectal bx
A b sence of g an gl i o n ce ll sin myentericplexus
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Hirschsprung¶s
Surgical treatment 1. Colostomy 2. Pull-through and removal of
aganglionic segment
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T ransanal pull-through
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Umbilical herniaIncomplete closure of umbilical ring fasciaMore common in prematureand African-AmericaninfantsUsually close by 2-4 yrsRefer to surgery if:
Larger than 1.5 cm at 2 yrsPresent after 4 yrs
Supraumbilical hernia :Refer to surgery
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Hypospadias Abnormal low position of urethral meatus
Absence of ventral foreskin Associations
Undescended testes
Urinary tract anomaliesManagement
Avoid circumcisionRefer to surgeon
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Phimosis vs. Paraphimosis
P himosis: inability toretract foreskinTx: dorsal slit or
circumcision
P araphimosis: foreskin retractedbehind coronal groove; tourniquet toglans
Tx: circumcision
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Scrotal swellingPAINLESS
Hydrocele
VaricoceleSpermatoceleInguinal hernia
PAINFULTesticular torsion
EpididymitisOrchitisIncarcerated hernia
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Hydrocele
M obileTransilluminatesSpontaneous resolution
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CryptorchidismUndescended testicle(s)
Spontaneous descent doesnot occur beyond age 1 yr
Bilateral in 1/3 of cases Associations
Inguinal herniaHypospadias
Higher incidence of Testicular torsionInfertility Cancer in cryptorchid testis
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CryptorchidismEndocrine eval.
Refer early: 6-12 mos of agehCG stimulation test
Can aid in descent
Karyotype if hypospadiasco-exists
Surgery Orchidopexy
Usually in1- 2 nd yr of life
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Testicular torsionTwisting of testis around spermatic cord
Caused by abnormal fixationof testis to scrotumVascular supply compromised
Acute painful scrotal swelling
Severe tendernessRedness or dusky color Testis elevated Cremasteric reflex absent
!SURGICALEMERGENCY
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management
In the patient with acute surgical scrotalpain ,immediate surgical consultation is
essential .
Surgical exploration , detorsion and
fixation .
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O utcome
Ischemic testicular damage related tothe number of turns of the spermatic
cord and the duration of torsion .A ll cases with a torsion > 3 60* and > 24h
duration will have testicular loss or severe
atrophy if the testis left in situ .
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What to do?A lways undress the childfor examDon¶t forget
Intussusception inlethargic childrenU tilize imaging liberallywhen child looks sickand know your
radiologist¶s expertise
A ny type of blood instool may be due toIntussusception (not only
currant jelly)V omiting in infantsshould not be takenseriouslyBe conservative with
children w/
unclear dxBe sure that the parent(s) understand return precautions . If
they do not, then observe child
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Q uestions or C omments