Pediatric Emergencies

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Pediatric Emergencies

• Dr.Mohammad Saquib Mallick,FRCS
• Consultant Pediatric Surgeon.

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ACUTE ABDOMEN IN CHILDREN

• Surgical Causes
• Acute appendicitis 30
• Intussusception
• Meckels diverticulitis

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ACUTE ABDOMEN IN CHILDREN cont..

• Twisted ovarian cyst
• Primary peritonitis
• Malrotation of midgut
• Acute Cholecystitis (rare)
• Acute pancreatitis (rare)

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ACUTE ABDOMEN IN CHILDREN cont..

• Medical Causes
• Acute Non-specific abdominal pain (NSAP) 30-50
• Gastroenteritis
• Constipation
• Genito-urinary infection
• Mesenteric adenitis

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ACUTE ABDOMEN IN CHILDREN cont..

• Pelvic inflammatory disease
• Pneumonia
• Measles
• Sickle cell crisis
• Henoch-Schönlein purpura

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Intussusception

• Pathology
• Diagnosis
• Management

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Pathology

• Incidence 1.5-4/1000 live births
• Sex male predominance
• Peak Age 6-9 months
• Pathogenesis
• invagination of
  intestine
• mesentery with it
• venous obs - arterial obs

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Pathology cont..

• Site commonly - ileo-colic
• less commonly - ileo-ileal
• colo-colic
• Aetiology Idiopathic 90
• Adenovirus or Rotavirus
• (Marked lymphoid tissue in ileum may act as
  leading point)
• It may be associated with upper respiratory
  tract infection or gastroenteritis

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Pathology cont..

• Lead points(2-10)
• e.g. Meckels diverticulum
• Polyps
• Intestinal duplication
• Lymphomas
• Henochs purpura
• Haemangiomas

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DiagnosisHistory

• Pain - colic every 10-15 minutes
• healthy infant
• screaming suddenly
• pulls the legs up
• Stool - red mucoid, bleeding PR
• Vomiting - bilious
• History of viral gastroenteritis or URTI

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Diagnosis cont.. Examination

• Vital sign - stable initially
• dehydration, tachycardia,
• temperature,
• Abdomen - sausage shaped mass
• bowel sounds increased
• PR - blood stained stool
• (red current jelly)

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Diagnosis cont.. Investigations

• AXR supine and erect
• USG -target lesion
• - pseudo kidney sign

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Intussusceptions

• Contrast enema
• coiled spring sign

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Management

• Nasogastric tube
• Intravenous fluid therapy
• Antibiotics -
• Blood Work-up - CBC
• -electrolytes
• - cross-matching

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Management cont..

• Child - stable and no peritonitis
• treatment - hydrostatic reduction
  with barium/air enema
• Child - shock or peritonitis or perforation
• treatment - laparotomy

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Intussusceptions
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Management cont..

• Post operative
• 8-12 recurrence rate
• Discharge - hydrostatic 1 day
• laparotomy 4-7 days
• Reduction of recurrence
• hydrostatic / laparotomy

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Other causes of acute abdomen in children

• Intestinal obstructions
• Malrotation
• obstructed Inguinal hernia
• Adhesions (post operative)
• Meckels diverticulitis
• Same as acute appendicit

Cautions Bilious vomiting
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Malrotation Midgut volvulus

• Most common symptom of malrotation with volvulus
  is Vomiting.(95)
• Abdominal distention follows with bloody diarrhea
  (28)
• Children with volvulus appear severely ill
• Dehydration, lethargic, Peritonitis, shock

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Malrotation Midgut volvulus
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Malrotation Midgut volvulus

• Investigation
• Urgent Upper GI contrast Study.
• Corkscrew sign

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Malrotation Midgut volvulus
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Malrotation Midgut volvulus

• Management
• Urgent Laparotomy after Resuscitation
• Ladds procedure if bowels are alive.

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Obstructed Inguinal Hernia

• A 6 month old boy presented to your clinic with
  irritability, crying, vomiting, and painful
  swelling in right inguinal area.
• On examination
• 4 by 3 cm tender, nonreducible inguinal
  swelling, both testes are in scrotum.No other
  abnormalities detected.

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• DIAGNOSIS ?
• Incarcerated (irreducible) inguinal hernia
• Management
• Sedation and analgesia
• Reduction
• Admission and Herniotomy after24 to 48 hours

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Acute appendicitis

• Pathology
• Diagnosis
• Difficult and delayed
• Management
• Differences
• high rate perforation
• difficult to examine
• reduced immunity
• scanty omentum

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Appendectomy open or Laparoscopy
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Meckels diverticulitis
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Twisted Ovarian cyst
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Twisted Ovarian cyst
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Summary- Acute abdomen in children

• Acute appendicitis is an important surgical
  disease in children , 1 5 appendix will
  rupture prior to operation and cause serious
  illness
• All children with acute abdomen should have urine
  test
• Resuscitation of sick child must be done prior to
  operation
• Diagnosis is mainly clinical however,
  Investigations ( US, x-rays) may be helpful

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III Acute Scrotum

• Introduction
• Acutely painful or swollen scrotum
• A few real pediatric surgical emergency
• Causes
• Testicular Torsion
• Torsion of appendage
• Epididymo-orchitis
• Idiopathic scrotal edema
• Other conditions e.g. incarcerated hernia, acute
  hydrocele, HSP, truma

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III Acute Scrotum

• Testicular Torsion
• Incidence 14000
• Common in peripubertal and perinatal
• Symtoms
• Initially, it may be lower abdominal pain and
  vomiting
• Later localized to one side of scrotum
• Swollen, red scrotum
• Signs
• Tender
• Cremasteric reflux absent
• Lies higher than contalateral tesis
• Horizantal in position

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Testicular Torsion

• Investigations
• Colour Doppler US
• Radionuclide Scan
• Management
• Timing is critical 4-6 hrs
• Exploration if any doubt
• Untwist anticlockwise Putting the clock back
  if it viable
• Fix the other side
• If more than 10 hrs, it is likely to be
  non-vialable, needs excision

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Testicular Torsion
Extra-vaginal, neonatal
intra-vaginal, adolescent
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Torsion of appendage

• Introduction
• Embryological remnants of the mesonephric and
  mullerian duct system occur as tiny ( 2-10mm
  long) appendages of testis ( hydatid of
  Morgagani), epididymis and paradidymis
• Peak age 10-12 yrs
• Presentation
• pain more gradual onset
• Blue spot in the scrotum
• Swollen, red hemiscrotum
• Somtimes difficult to distinguish between two
  conditions
• Colour Doppler scan
• Management Conservative or operative if torsion
  cannot exclude

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Idiopathic scrotal edema

• Introduction
• Cause?
• Peak age 4-5 yrs
• Presentation
• Swollen, red hemiscrotum or bilateral
• Pain minimum
• Management Conservative, self limiting within
  1-2 days

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II Inguino-scrotal swellings

• Inguinal hernia
• Hydrocele
• Undescended testes
• Acute scrotum

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II Inguino-scrotal swellings

• Inguinal hernia
• 1-5 boys
• 91 male/female
• 99 indirect
• More in premature (up to 35)
• More in right side
• Congenital in origin

Inguinal hernia? or Hydrocele?
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Inguinal hernia

• Clinical History
• Intermittent groin swelling
• Asymptomatic until incarcerated
• In girls, lump in upper part of labia mojora
• Examination
• Examine the testes
• Cough impulse
• Reducibility

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Inguinal hernia and Hydrocele
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Inguinal hernia

• Management
• Herniotony
• Incarcerated hernia
• Sedation and analgesia
• Reduction
• Herniotomy as soon as possible

Age is not contraindicated for operation
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Hydrocele

• Clinical History
• Scrotal swelling
• Asymptomatic
• 1 over 1 years of age
• Examination
• Get above the swelling
• Not Reducible
• transilluminates
• Management
• Below Age 2 years surgery not advised
• Ligation of PPV

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Undescended testes
Palpable 80

• Definitions
• True undescended testes
• Ectopic
• Retractile
• Incidence
• At birth 3-4
• At one year 1
• Pre-term 30

Nonpalpable 20
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Undescended testes

• Diagnosis
• Parents/Doctors
• Clinical features
• Empty scrotum
• Palpable or not
• Milk it down to scrotum
• Ultrasound ?
• Laparoscopy
• Diagnostic
• Therapeutic

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Undescended testes

• Indication
• Abnormal fertility
• Testicular tumour
• Cosmetic/social
• Trauma/torsion
• Treatment at 1 yr
• Single stage
• Orchiodopexy
• Two stages
• laparoscopic

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Abdominal wall defect

• Omphalocele
• Gastroschisis
• Umbilical hernia

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Abdominal wall defect

• Omphalocele
• A birth defect in which part of the intestine,
  covered only by a thin transparent membrane,
  protrudes outside the abdomen at the umbilicus.

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Abdominal wall defect

• Omphalocele
• occurs due to a failure during embryonic
  development for a section of the intestines (the
  midgut) to return from outside the abdomen and
  reenter the abdomen as it should.

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Abdominal wall defect

• It may be associted with other congenital
  abnormalities.
• An omphalocele must be repaired with surgery.

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Abdominal wall defect

• Gastroschisis
• A birth defect in which there is a separation in
  the abdominal wall. Through this opening
  protrudes part of the intestines which are not
  covered by peritoneum.

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Abdominal wall defect

• Gastroschisis
• The opening in the abdominal wall in
  gastroschisis is never at the site of the
  umbilicus. Rather, the umbilicus is
  characteristically to the left of the
  gastroschisis and is separated from it by a
  bridge of skin.

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Abdominal wall defect

• Omphalocele and gastroschisis together make up
  most of the major defects of the abdominal wall.
• Omphalocele is more common and affects about 1
  in 5,000 newborn babies.
• Gastroschisis occurs in about 1 in 11,000 babies

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Abdominal wall defect

• Gastroschisis
• The treatment of gastroschisis is to carefully
  wrap it in pads soaked in saline (salt solution)
  so the herniated intestines do not dry out.

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Abdominal wall defect

• Nasogastric tube to remove air and decompress
  the intestines,
• Surgically repair the gastroschisis by returning
  the herniated intestines to the abdomen and then
  closing the abdominal wall.