Pediatric Surgical Emergencies

Robert W. Letton, Jr., MD

Associate Professor, Department of Surgery
Pediatric Surgery

Introduction

Bowel Obstruction
Atresias
Hirschsprungs
Malrotation
Volvulus
Intussusception

NEC
The Acute Groin
Bleeding Meckels
Foreign Bodies

Question 1?
Why do Pediatric Surgeons
always make such a big deal
out of a little yellow or
green emesis?

Answer
Because unlike when Stan
sees Wendy in Southpark,
it usually means
bowel obstruction or
necrosis in our
patients!

Bowel Obstruction
Diagnosis often age specific
Bilious vomiting in the infant and child is a
surgical emergency until proven otherwise
Difficult to tell when volvulus is present
Child may look surprisingly good until its
too late

Atresia
Usually presents the first few days of life
Child may feed well for a day or two with
distal atresia
Duodenal atresia often diagnosed on
antenatal U/S
Atresias can occur anywhere in GI tract
from pharynx to anus

Atresias
Esophageal: aspirate feeds immediately, OG
tube wont pass
Duodenal: bilious vomiting immediately,
double bubble on KUB with absence of
distal gas
Jejunal: usually present 1st 24 hours, large
dilated proximal loop or loops

Atresias
Ileal: may take 24-48 hours before bilious
emesis
Colonic: rare, may present with bilious
emesis after 2-3 days
Anal: should be diagnosed at birth, often a
perineal fistula is labeled normal

Atresias may be multiple

Jejunal Atresia

Imperforate Anus: Anal atresia

Hirschsprungs Disease
Congenital colonic aganglionosis
Physiologic obstruction
May present first few days to weeks of life
Short segment disease often tolerated for
months
Starts at anus and extends proximally a
variable distance

Hirschsprungs Disease

Hirschsprungs Disease

Toxic Megacolon
Severe enterocolitis
Very rare to get with idiopathic constipation
Usually only seen with Hirschsprungs
Disease or Ulcerative Colitis
NG decompression, IV fluids, IV antibiotics
Mortality 20-30% in some studies

Toxic Megacolon

Hirschsprungs in an 8 year old

Believe it or Not . . .

Malrotation

Normal

Malrotation
Most often presents during the first few
months of life
Infant with acute onset of bilious emesis
May be diagnosed on UGI for other reasons
Malrotation is a surgical urgency due to the
possibility of volvulus
VOLVULUS IS A SURGICAL
EMERGENCY

Malrotation

Malrotation

Volvulus

Volvulus
Malrotation most common condition
resulting in midgut volvulus
Can have volvulus with normal rotation
omphalomesenteric remnant
internal hernia
Duplication
Adhesive small bowel obstruction

Small Bowel Obstruction

Meckels

Intussusception
Inversion of the bowel upon itself
secondary to a lead point
Juvenile intussusception most often
idiopathic
Also secondary to Meckels
Presents 6 months to 2 years of age
As early as 1 month

Intussusception
Acute painful episodes followed by periods
of lethargy
When incarcerated progress to continuous
lethargy
May or may not have currant-jelly stool
But often stool is heme positive
Rule out with a left lateral decubitus film

Intussusception

Intussusception

Intussusception
7% chance of recurrence after ACE
reduction
Usually recur in 48 hours
Operative exploration warranted on second
recurrence to R/O pathologic lead point
Recurrence after surgery rare but possible
Post-op intussusception can occur after any
surgery

Bowel Obstruction

Bowel Obstruction: Initial

Management
NG or OG to low wall suction (NPO!!)
Hydrate and replace losses
10 cc/kg of crystalloid IS NOT AN
ADEQUATE BOLUS!!
Antibiotics if suspect perforation or necrosis
Acute Abdominal Series
Transfer to appropriate facility

Necrotizing Enterocolitis
Incidence: 25,000 per year; 10-70% mortality
Most common serious GI disease of low
birth-weight infants
Etiology is unknown
Most common in terminal ileum and colon
pan-necrosis involves >75% of gut and
occurs in 19% of patients; mortality
approaches 100%

Necrotizing Enterocolitis
Abdominal distention is most common
finding
Feeding intolerance with bilious NG
aspirate
Palpable bowel loops and crepitus
Edema and erythema of abdominal wall
peritonitis
Rectal bleeding is common: gross and/or
occult

NEC Abdominal Films

Necrotizing Enterocolitis
Initial medical management unless evidence
of necrosis/perforation
OG decompression
Broad spectrum antibiotics
NPO, TPN, fluid resuscitation
Abdominal film surveillance
Serial labs: CBC with platelets, ABG, CRP

NEC Abdomen

NEC Pneumoperitoneum

NEC Ileal Involvement

NEC Totalis

The Acute Groin

Testicular Torsion
Most important, not most common cause
Peak incidence 13 to 16 years of age
Before age 16
60% torsion testis appendix, 30%
testicular torsion, 10% epididymitis
Sudden testicular pain, nausea, palpation
exquisitely tender, horizontal lie,
hemiscrotum red, edematous

Testicular Torsion

Testicular Torsion
Loss of cremasteric reflex with torsion
Torsion of appendix testis similar: point
tender at upper pole, testicle less tender
Ultrasound and/or nuclear blood flow study
MAY be of benefit in adolescents
smaller children difficult to perform
and/or interpret
Do not delay surgical exploration for
studies

Testicular Torsion

Inguinal/Scrotal Anatomy

From Surgery of Infants and Children, Oldham, et. al., 1997

Inguinal Hernia

From Atlas of Pediatric Surgery, Ashcraft, 1994

Incarcerated Inguinal Hernia

Hernia Reduction

From Surgery of Infants and Children, Oldham, et. al., 1997

Incarcerated Hernia
If unable to reduce: urgent operative
exploration (NPO)
If able to reduce without sedation: urgent
surgical referral with repair soon
If extremely difficult (sedation, surgical
referral): repair next day
Watch child for obstructive symptoms

Meckels
In newborns and infants present as bowel
obstruction (volvulus, intussusception)
Bleeding most common presentation in
children
Painless, massive, requiring transfusion
Bleeding due to peptic ulceration at the base
of diverticulum

Meckels
Can diagnose with a Technetium scan
Pretreatment with Cimetidine enhances
uptake of tracer and improves sensitivity
Often have to repeat scan more than once
If a 1-3 year old has two significant LGI
bleeds requiring transfusion, exploration
warranted even if scan negative
Polyps usually dont need transfusion

Meckels

Foreign Bodies
Laryngeal: Hoarseness, aphonia, dyspnea,
cyanosis
Hot dog most common cause of fatal
aspiration
Tracheal: asthmoid wheeze, subglottic
thud
Bronchial: period of coughing and
wheezing, then asymptomatic interval

Bronchial Foreign Body

Check valve obstruction
partial obstruction inspiration, complete
obstruction expiration
obstructed lung expanded during
expiration
Stop valve obstruction
complete obstruction of
inspiratory/expiratory phase
distal atelectasis

Check Valve Obstruction

Stop Valve Obstruction

Treatment
Removal under direct vision as soon as
possible by a skilled bronchoscopist
removal with grasper or balloon catheter
Occasionally will need thoracotomy to
milk FB into position for scope
Laryngeal FB may require emergent
cricothyrotomy

Complications
Loss of airway
partial obstruction object may become
complete with paralysis
Pneumothorax
vigorous positive pressure ventilation
Post-obstructive pneumonia

Esophageal Foreign Bodies

Coins most common
Four cardinal areas or narrowing
below the cricopharyngeus muscle
level of the aortic arch
carina
just above the diaphragm

Signs and Symptoms

Episode of coughing, choking and drooling
Pain and dysphagia
After an asymptomatic period get signs of
obstruction
Pain, fever, and shock occur with
perforation

Diagnosis
History suggests
CXR/Neck films show radiopaque coins
and foreign bodies
May need contrast study to diagnoses
radiolucent objects

Esophageal Coin

Esophageal Pop Top

Treatment
Removal of foreign body under direct
vision with rigid esophagoscope
If object has passed into stomach,
observation warranted
Foley catheter removal possible if less than
24 to 48 hour history
Post removal CXR

Complications
Aspiration pneumonia
Esophageal stricture
Esophageal perforation
secondary to erosion
iatrogenic
Small bowel obstruction

Batteries
If in esophagus, treat with removal
Most recommend removal endoscopically if
in stomach
Difficulty arises if already in small bowel
would require laparotomy to remove
reports of ulceration/perforation as well
as successful passage

Question 2?

Why are Pediatric Surgeons so

interested in flatus?
Contrary to popular
belief, kids (and
adults) with
obstruction can still
have bowel
movements, but they
wont pass gas!

Summary

Bowel Obstruction
Atresias
Hirschsprungs
Malrotation
Volvulus
Intussusception

NEC
The Acute Groin
Bleeding Meckels
Foreign Bodies