Lecture on pediatric surgery for the

5-th year students of medical

department
Theme:

Urgent surgical diseases of
the abdominal cavity in
children

Prof. O. Fofanov
Lecture structure:


1. Acquired Intestinal Obstruction. Bowel
Intussusception.
2. Inflammatory Diseases of the
Abdominal Cavity. Acute Appendicitis.
3. Gastrointestinal Bleeding.
4. Portal Hypertension.
5. Closed Abdominal Trauma.


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Classification of acquired intestinal obstruction
1) Based on morphofunctional features:

I. Mechanical
Strangulated Obturative Mixed

Volvulus Internal type Intussusception
Node formation External type Adhesive
Pinching
II. Dynamic intestinal obstruction

Spastic

Paralytic

1) small intestinal obstruction
A) High
B) Low

2) colon obstruction

3) Based on the course of disease:
1) acute
2) chronic
3) relapsing

4) The degree of obstruction:
A) complete B) partial
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2) By the level of obstruction:

There are 3 stages of intestinal
obstruction:
1 interruption in the passage of intestinal
contents

2 intestinal disorders of bowel
hemocirculation

3 - peritonitis
Causes of dynamic bowel obstruction:
Paralytic

Some medications
Infections of the abdominal
cavity
Mesenteric ischemia
Complications of abdominal
surgery
Diseases of kidney and
thoracic organs
Hypokalemia
Traumatic brain injury
Pneumonia, sepsis, meningitis


Spastic

Ascariasis
Hysteria
Poisoning by
heavy metal
compounds

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Causes of mechanical
bowel obstruction:
Obturative
Tumors
Lump of helminths
Adhesive obstruction
(plane reunions)
Koprostasis
Obturation by food
masses
Mixed
Intussusception
Adhesive obstruction


Strangulated

Volvulus of the
intestine
Pinched hernia
Node formation
Adhesive obstruction
(like-cord reunions)


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Immersion of one segment of
bowel into another
Frequency: 1-4 from 1000
babies
The majority (80-90%) of
cases is observed from 4 to
10 months
The most often localization is
in the region of the ileocecal
angle (about 92-94%)

Intussusception
Hystory
For the first time the disease was
documented by Paul Barbet from
Amsterdam in 1674.
The first successful surgery on
intussusception in a 2-year child was
performed by Jonathan Hitchynson in
1871.
In 1871 Hirschsprung described
conservative treatment of intussusception
by applying hydrostatic pressure on the
intestine.


Classification by H.I.Feldman:

Small intestine intussusception - occurs in 3.5% of
patients.
Large intestine intussusception - 2.8% of patients.
Ileocecal intussusception - 94% of patients.
A) ileum-colon immersion of ileum into ileum and then
into the colon with frequency rate of about 41%-with
strangulation prevailing.
B) cecum-colon - cecum is involved in colon and iliac
colon and appendix stretch for it - found in 53% of
patients.
Rare forms of intussusception: isolated intussusception
of the appendix, retrograde intussusception and multiple.
By the course of intussusception: acute, chronic and
relapsing.
By the structure: simple and complex


Aetiology and pathogenesis
Anatomical and physiological features in infants:
1) mutual long mesentery of small and large intestine and
therefore increased mobility of the intestine;
2) unequal development of the longitudinal and circular
layers of muscles of the intestinal wall with a
predominance of circulatory muscles
3) non-differentiated nervous apparatus of the intestine,
non-coordinated peristalsis.
Changing of the regime and the nature of feeding
gradual weaning (which occurs in 4-5 months) and
especially its improper administration.
Some anatomical formations: Meckel`s diverticulum,
polyps, tumors of intestinal wall, enlarged mesenteric
lymph nodes, bowel wall hematoma (e.g., disease
Schonlein - Henoch), hyperplasia of Peyer patches and
helminthes.
Enterocolitis - due to a significant increase peristalsis.


Typical clinical picture :
Sudden onset of the background full health;
Strong pain with light intervals;
Symptom "monkey" ("ladder");
Vomiting;
Bloody discharge from the rectum
(symptom "raspberry jelly");
Definition invaginate palpation;
Symptom Dansye;
Symptom "Obukhov Hospital;
Palpation of the intussusceptum.
Diagnosis of intussusception
Sonography : symptoms of "target,
"pseudo kidney"
Colour Doppler : used to confirm the
viability of the intestine and as a prognostic
sign of the success of conservative
treatment
Pneumocolonography : symptoms of
shape of the sickle , a crab claw , bow
ULTRASOUND. Ileocecal intussusception
Symptom of "pseudo kidney"
ULTRASOUND. Ileocecal intussusception
symptom of "target"
X-ray examination

Pneumo-
colonography
Air comes to
the head of
intussuscep-
tum
Intussuscep-
tum shadow
Symptom of
the ``bow``.
X-ray symptoms:
shape of the sickle a crab
claw
Conservative treatment: the method of
throughout retrograde air insufflation
suggested by Gritsenko
Contraindications to conservative
disinvagination :
duration of the illness more than 24
hours;
signs of peritonitis;
recurrent intussusception;
loss invaginate through the rectum;
age of children - over 1 year.


Surgical treatment
Complications/duration of the illness
more than 24 hours;
signs of peritonitis;
recurrent intussusception;
loss invaginate through the
rectum;
age of children - over 1 year.

Letality
Adequate treatment recovery after 24 h.
Letality 1-3%. Without treatment disease is
fatal in 2-5 days.
Recurrent in 3-11% cases, mainly after
conservative treatment.

Complications
Intestinal bleeding
Necrosis and perforation of the colon
Sepsis, shock
Acute appendicitis
Hystory
In 1886, a Harvard pathologist Reginald Fitz
described the inflammation of the appendix with
perforation, its diagnosis and treatment. Fitz
proposed the term "appendicitis".
In 1887, Morton from Philadelphia conducted
the first successful appendectomy for
perforated appendix. Subsequently, the
operation of appendicitis became quite
common.
In 1889, Charles Mc-Burnham described the
place of greatest pain in acute appendicitis
Clinical anatomy

The average length of 10.8
cm (range 2-20 cm)
Appears on the 5-th month
of gestation
Bloodv supply: a. appendi-
cularis (from a. ileocolica)
Venous outflow: v.
mesenterica superior
Place ascent teniae coli
helps to determine the
base of the appendix
Anatomical and physiological features
Mobile ileocecal angle
The high placement of the cecum
Nerve plexus are embryonic in nature,
their differentiation ends up to 14 years
Newborn appendix has a conical shape
with no clear boundary of the cecum.
Appendiceal flap (flap Gerlach) are often
absent
Low plastic properties of the peritoneum
High suction capacity of the peritoneum



-High hydrophilicity of appendix tissue

- Intensive blood flow in the appendix

- Omentum majus in infants is short, thin and
of little barrier capacity.

Aetiology and pathogenesis.
Infectious theory. Most important in the
pathogenesis of appendicitis are: Bacteroides
fragilis, Escherichia coli, Streptococcus,
Pseudomonas, Klebsiella, Clostridium.
Chance of hematogenous and lymphogenous
pathways of infection.
Mechanical factors: obstruction of the appendix
lumen by fecal stones, worms, congenital
anomalies of the appendix (torsion, bends,
membranes).
Nutritional factors (promotes the use of meat and
fatty foods).
Hyperplasia of lymphoid follicles.
Clinical and morphological
classification (Sprengel).
Simple (catarrhal) appendicitis
Phlegmonous appendicitis
Gangrenous appendicitis
Perforative appendicitis

Appendicular infiltrate is often
identified as a separate form. Infiltrated
appendix, small bowel loops, omentum
and cecum form a dense, painful
conglomerate.


Simple (catarrhal) appendicitis
Appendix looks
normal or slightly
hyperemic and
swollen. The serous
membrane presents
no exudate. The
mucous membrane
may covered with be
focal hemorrhages
and ulcerations.
Phlegmonous appendicitis
Appendix, is swollen,
reddened, tense,
thickened, compacted,
sometimes covered with
fibre-like depositions.
Sometimes the appendix is
inflated, fluctuations are
observed, inside there may
be some pus (empyema of
the appendix). In the
abdominal cavity serous,
seropurulent or purulent
exudate is found.


Gangrenous appendicitis
Is characterized by
destructive changes of the
entire wall of the
appendix.
Appendix is thickened,
earthy-grey, with purulent
and fibre-like depositions.
Its wall is flabby and can
be easily perforated.
Parietal peritoneum is
often altered: edematous,
infiltrated, covered by
fibrin.


Perforative appendicitis
The wall of the appendix is
perforated in place of necrosis.
Abdominal cavity contains
purulent exudate with fecal
odour.
Perforation hole is often
located near the top on the
side opposite to mesentery
where blood supply is scarce.
Perforation of the appendix in
young children causes
widespread peritonitis.
Parietal peritoneum is
edematous, hyperemic,
thickened and can be easily
torn.


Location of the
appendix:

Typical: point McBurney
(2/3 of the distance between
the navel and spina iliaca
anterior superior)
Atypical localization:
Retrocecal
Pelvic
Retroperitoneal
Subhepatic
Leftside
The classic clinical symptoms of
appendicitis (in older children)
Pain in the periumbilical or epigastric region,
which moves in the right iliac area
Nausea, vomiting (1-2 fold), anorexia
Delayed bowel movements or diarrhea
Low-grade fever
Symptom of "scissors"
Palpation: Filatov symptom, passive muscle
tension, Schetkin-Blumberg symptom
Reducing of bowel noises
Pain in the right side in rectal examination
Rectal digital examination
Performed in all cases, the most informative
is by pelvic placement process
Features of clinic in infants
Prevalence of common symptoms over the
local;
Worries of child, behavior change, anorexia;
Febrile body temperature;
Repeated vomiting, diarrhea;
Bloating;
Filatov Symptom, Shurynok symptom
Tensions of anterior abdominal wall muscles
expressed in all departments;
Requires review in a dream

Features of clinic in atypical
placement of appendix
Retroperitoneal - pain appeared in the right
lumbar region, may radiate to the genitals or the
course of the ureter, causing frequent and
painful urination. The abdomen is involved in
breathing, palpation soft, painless throughout,
Schetkin symptom is negative. There is a
positive Kocher symptom. Palpation in the right
lumbar region marked tenderness, muscle
tension, positive Pasternatsky symptom.

Pelvic - characterized by abdominal pain,
above the pubis, which irradiate the course of
the urethra, in the testis (right sexual lip),
rectum. In patients there diarrhea or frequent
painful urination. Palpation abdominal pain and
muscle tension showing above the pubis. Great
help in the diagnosis gives digital rectal
examination, which show a sharp pain, sagging
or infiltrate into the pelvis. In the urine sample is
often defined proteins, leukocytes, epithelium,
erythrocytes.
Subhepatic - the clinical picture resembles a
destructive cholecystitis: repeated vomiting, pain
in the right pidrebir'yi, local pain and muscle
tension here, positive symptom Ortner.
Sometimes there is a mild hysteria skin. The
lower abdomen is painful, soft on palpation.
Leftside - caused by mobile cecum, incomplete
rotation "midgut" reverse arrangement of internal
organs. Clinical manifestations localized left.
Retrocecal - severe intoxication with mild local
symptoms. Local pain and muscle tension of the
abdominal wall is much less pronounced. Later,
there are peritoneal signs.


Additional methods of research
Blood tests: leukocytosis (15 to 20 thousand)
and leukocyte shift to the left (to the young
forms and myelocytes)
Urinalysis
Thermometry aksillaris and rectal: the
difference is more than 0.6 C
Ultrasound: The diameter of the appendix over
6 mm; Infiltration of the appendix wall; absence
of peristalsis; presence of free fluid around
appendix
Laparoscopy
Differential diagnosis
Inflammatory and infectious diseases: acute nonspecific
mesadenitis, acute respiratory tract infection,
pneumonia, acute otitis; intestinal infection,
pseudotuberculosis, acute hepatitis, children's infectious
diseases (measles, scarlet fever, chickenpox, mumps)
Surgical diseases of the abdominal cavity: coprostasis,
functional spastic ileus (intestinal colic), obstructive ileus,
intussusception, acute cholecystitis, peptic ulcer, acute
pancreatitis, abdominal tumors, Crohn's disease,
incomplete turning of "midgut
Urologic Diseases: urolithiasis; nephroptosis,
hydronephrosis, acute pyelonephritis, acute cystitis
Gynecological diseases: primary pelviperitonitis; pre-
menstrual cramps; hematokolpos, hematosalpinx;
apoplexy of ovary, ovarian cysts
Systemic diseases: rheumatic fever, hemorrhagic
vasculitis, diabetes.


Treatment of appendicitis: "Open"
or laparoscopic appendectomy

Complications of acute appendicitis
Complications of abdominal cavity:
Preoperative complications: peritonitis,
periappendicular abscess.
Postoperative complications : adhesive
intestinal obstruction, paralytic ileus, failure
appendix stump, postoperative peritonitis,
intestinal fistula, postoperative infiltrates and
abscesses of the abdominal cavity.
Complications during surgery: bleeding,
perforation of the intestine.



Complications of wounds: bleeding,
suppuration, infiltration, fistula, failure of
stitches, bowel eventration, ventral hernia,
kelloid scars.
Complications of other organs and
systems: pneumonia, sepsis, liver failure,
renal failure, cerebral edema, toxic
encephalopathy.

Complications of acute appendicitis
Diseases which can cause bleeding
from the digestive tract:

I Somatic and infectious diseases:
salmonellosis, dysentery, hemorrhagic diathesis,
acute leukemia, intestinal parasites, metabolic
reticulosis, lymphogranulomatosis, intestinal
sepsis.
II Borderline disorders:
peptic ulcer and duodenal ulcer, ulcerative
colitis, thrombocytopenia, coagulopathy of
newborns, Turner syndrome, typhoid fever,
regional enteritis.



III Surgical diseases:
varicose veins of the esophagus and stomach
cardia, hernia of esophageal aperture of
diaphragm, intussusception, Meckel`s
diverticulum, intestinal duplication, Peytts-
Yehers syndrome, intestinal tumors, colon and
rectal polyps, fissures of anal ring, varicose
hemorrhoidal veins.
Diseases which can cause bleeding
from the digestive tract:

There is a link between age of children
and pathological processes
In newborns - coagulopathy of newborns
In infants - hernia of the esophageal aperture of
diaphragm, intussusception, intestinal
duplication, Meckel diverticulum ulcer
In children 3-7 years - esophageal varices due
to portal hypertension, colon polyps, fissures of
anal ring
In children 10-14 years - peptic stomach and
duodenal ulcer, gastrointestinal polyps,
hemorrhoids varicose veins, intestinal tumors
(lymphoma, hemangioma)

Portal hypertension
Classification
Prehepatic block (80% in children) - congenital
stenosis of the portal vein, portal vein
thrombosis, compression of the portal vein by
scars, infiltrates
Intrahepatic block (1-3% in children) - cirrhosis,
intrahepatic arteriovenous anastomoses
Posthepatic block - hepatic vein phlebitis
(syndrome Budd-Chiari)
Mixed (15-20% in children) - pre-and
intrahepatic block

Symptoms of portal
hypertension bleeding
Vomiting blood, often as "a coffee
grounds",rapidly progressing hemorrhagic
shock
After 6-8 hours a resin-like stool is present
Common symptoms of blood loss (pale skin,
hypotension, tachycardia, weakness, systolic
murmur over the apex of the heart)
Enlarged spleen
Sometimes ascitis

Diagnosis of portal hypertension
bleeding
General analysis of blood - signs of anemia
(decreased hematocrit, hemoglobin, erythrocyte
count)
Ultrasound examination reveals "cavity" in the
area of portal vein, slow and sometimes reverse
flow. In case of liver cirrhosis the structure of
the liver is changed. Enlarged spleen
Fibrogastroscopy shows varicose veins of the
esophagus and stomach cardia


Treatment of portal
hypertension bleeding
Conservative measures: bed rest, cold - locally,
medication hemostatic agents (cryoprecipitate,
etamzylat, vikasol, calcium chloride,
aminocaproic acid, fresh frozen plasma,
sandostatin), replacement therapy.
Probe - stoppers Blackmore.
Endoscopic sclerotherapy or klipsing veins of
the esophagus.
Surgery - gastrotomy, suturing veins.
Traumatic injury of the
abdomen

Among all types of damage abdominal trauma
is 20%. They cause disorders of vital functions
and high mortality ( 22%)
Damage to the abdominal cavity leads to post-
traumatic peritonitis. 75% of patients with
traumatic injury of the abdomen develop signs
of post-traumatic shock.
Closed abdominal trauma injuries are divided
into the trauma of hollow and parenchymatous
organs

Symptom "sickle"

Thank you!
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