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My Tummy Hurts
Joshua B Glenn, MDAssistant Professor of SurgeryDirector Pediatric SurgeryMercer University School of MedicineNavicent Health Children’s Hospital
Disclosures
Financial disclosure None
Unapproved/Unlabeled Use None
Objectives
Discuss common surgical conditions in infants and children
Recognize surgical emergencies
Emesis
Bilious – Surgical Emergency Malrotation with volvulus Obstruction
Intussusception Adhesive obstruction
Nonbilious Hypertophic Pyloric Stenosis GERD Ileus
Emesis
4 week old infant with nonbilious emesis for 1 week
Progressively worsening Happens 10 mins after feeds “spews across the room” Often many formula changes attempted Lethargic, sunken fontanelle, poor skin turgor
Olive palpated on exam Tests?
Pyloric Stenosis
Diagnosis US UGI
Labs BMP No CBC required
Pyloric Stenosis
1:150 live births Rare in African Americans and Asians Males 4x more common than females Hereditary predisposition Hypertrophied pyloric muscle Unknown etiology
Hypochloremic, hypokalemic metabolic alkalosis
Pyloric Stenosis
Volume loss causes aldosterone secretion
Na+ conserved in exchange for H+ in proximal tubule (kidney protects volume over pH); H+ in urine aciduria, worsening metabolic alkalosis
Na+ resorption/K+ loss (exchange) in late distal tubule; K+ loss exacerbated by K+/H+ exchange in distal tubule in an effort to correct pH
Pyloric Stenosis
Medical Emergency – Not a surgical Emergency
Effective preoperative rehydration is imperative Reestablish ECFV Replace Na+ and Cl- to enable kidney to excrete
HCO3-, correcting alkalosis (Cl-/HCO3
- exchanger) Replace K+ - Do not believe the hyperkalemia on
the Heel stick Replace with D5 ½ NS with 20+ meq KCl at
150 ml/kg/day (maintenance and ½); Severe Dehydration bolus with 20 ml/kg NS
Pyloric Stenosis
Emesis #2
2 month old infant, former 35 week preemie
Poor weight gain/failure to thrive Nonbilious emesis after feeds ? Acute Life-Threatening Events (ALTE) –
“turned blue, stopped breathing for a second”
Questions and workup?
Reflux Disease – Diagnostic Tests Good clinical history – nothing else needed UGI – 50-60% sensitivity
Primary use is confirming normal anatomy Milk Scan – 70-80% sensitivity
pH probe – gold standard 90% sensitivity Hard to get Have to be off meds
Reflux Disease
Babies throw up a lot Reflux is usually self limiting and/or responds to
medical therapy When to think of surgery
Younger infants Failure to thrive ALTE/Respiratory Symptoms Neurologic impairment
Older infants Failure medical management Esophagitis recurrent/refractory respiratory symptoms
(aspiration pneumonia, RAD)
Emesis #3
2 yr old with low grade fever, cough and runny nose x 3 days
Intense, crampy pain – “balls legs up and screams”
Green tinged emesis Bloody stool
Intussusception
Viral Symptoms Paroxysmal, Crampy Abdominal pain Currant-Jelly Stools Emesis (may be bilious) Often can feel mass RLQ Contrast enema if no peritoneal signs Surgical Reduction
Laparoscopic or open
Emesis #4
Newborn male 2 day old has fed well now with “green spits”
Slightly distended Uncomfortable, lethargic
Bilious Emesis
Malrotation
Malrotation
Malrotation
Malrotation
Malrotation with volvulus
Must consider in every child with bilious emesis
Many variations of malrotation/nonfixation 30% present within 1st week of life 50% within first month KUB – gasless, can be normal if early(does
not rule out) Contrast study – UGI best test US – reversal of position of SMA/SMV Whatever you do, do it fast
Malrotation with volvulus
No labs - need to go to OR ASAP IVF if can be done expeditiously
Mortality remains high – 28% SBS, intestinal transplant
Operation Ladd procedure
Detorsion of bowel Divide abnormal bands Small bowel right, colon left Remove Appendix
Emesis #5
6 yr old with low grade temp and abdominal pain since this AM
Started at umbilicus Pain started first now has had nonbilious
emesis Pain now at RLQ Doesn’t want to walk
Appendicitis
Low grade fever Anorexia Luekocytosis RLQ pain Diagnosis
Physical Exam US (operator dependent) CT (IV contrast only is adequate)
High incidence of perforation children <5
Emesis #6
3 day old infant with abdominal distention and bilious emesis
Physical exam normal except distended firm abdomen
OGT with bilious material Anus patent and in normal position No hernias
Questions/Workup?
Low intestinal obstruction
Ileal/Colonic Atresia Meconium Ileus Hirschsprung’s Disease Meconium Plug Micro-colon Anorectal malformation Medical causes
Sepsis, ileus, electrolyte imbalance, thyroid disease
How to Diagnose? Tests?
Hirschsprung’s Disease
Lack of progression of propulsive waves and relaxation of internal and anal sphincter due to anganglionosis
Etiology unknown Genetic factors
RET-tyrosine receptor kinase Presentation
Neonate – failure to pass meconium, distention Later – failure to thrive, constipation, episodes of
distention and watery diarrhea with “explosive stools”
Hirschsprung’s Disease
Management Decompression – NGT, rectal irrigations Antibiotics IVF
Diagnosis BE Rectal biopsy
Surgery Colostomy Definitive procedure
Swenson, Duhamel, Soave
Hirschsprung’s Disease
Complications Constipation Fecal soiling
Enterocolitis
Enterocolitis
Commonly misdiagnosed as gastroeneteritis Can occur after surgical correction of HD Distended, tender abdomen Explosive gas and stool on DRE Prompt recognition essential
Aggressive IV fluid resuscitation Broad Spectrum Antibiotics Rectal washouts with warm saline every 6 hrs
Can be life threatening
Put duodenal atresia xray here
Duodenal Atresia
Failure of recannalization of duodenum 3rd week embryonic development 2nd portion
duodenum gives off pancreatic and biliary buds
Duodenum goes through “solid” phase then recannalizes by coalescence of vacuoles
Stenosis, windsock deformity, atresia 50% associated anomalies
Cardiac, GU, anorectal 40% with trisomy 21
Duodenal Atresia
Polyhydramnios secondary to intestinal obstruction
Emesis after birth – clear or bilious, aspiration >20ml via OG tube
Distention often not present
Decompress, IVF, look for associated anomalies ECHO, renal US
Put tef xray here
Esophageal Atresia Tracheoesophageal Fistula VACTERL – vertebral, anorectal, TEF,
renal, limb abnormalities Inability to pass NG Initial management
Elevate HOB, 10 french sump catheter in upper pouch
Esophageal Atresia Tracheoesophageal Fistula
Insert CDH here