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Pediatric surgery Gi abnormalities.pptx
- 1. Pediatric surgery, Gastrointestinal abnormalities overview Dr. Maha Hafez. IV year general surgery resident Dr. Mohammad Auni. General surgery consultant Istiklal Hospital. General surgery department. General surgery residency program. Amman-Jordan
- 2. Embryogenesis of GI tract
- 3. ●Vomiting (emesis) refers to the forceful oral expulsion of gastric contents associated with coordinated contraction of the abdominal and chest wall musculature. ●Nausea generally refers to an unmistakable sensation of unpleasantness that may precede vomiting but may be present even in a child who does not vomit. It is often associated with autonomic changes such as salivation, increased heart and respiratory rates, and a reduction in gastric tone and mucosal blood flow Approach to the vomiting infant
- 4. Approach to the vomiting infant History of Presenting Illness Characteristics of vomitus Smell Quantity Colour Blood – bright red/dark red/coffee- ground Bilious Timing Onset Duration Frequency Time of day Triggers Associated Symptoms Diarrhea Fever Abdominal pain/distension Anorexia Stool frequency Urinary Output Headache Vertigo Lethargy Stiff neck Cough Sore throat Past medical history, medication, allergies Chronic illnesses (diabetes) Travel history (infectious gastroenteritis) Sexual history (pregnancy) Ineffective use of birth control Last menstrual period Recent head trauma Toxin exposure https://learn.pediatrics.ubc.ca/body-systems/gastrointestinal/approach-to-vomiting/
- 5. Approach to the vomiting infant Physical Exam Findings Vitals Fever – sign of infection Hypotension, tachycardia – volume loss Inspection Consciousness – intracranial hypertension, meningitis, metabolic disorders, toxic ingestion Weight loss – eating disorders, obstruction Head and Neck Red, bulging tympanic membrane – ear infection Bulging anterior fontanelle and nuchal rigidity – meningitis Erythematous tonsils – upper respiratory tract infection Cardiovascular system Tachycardia – infection, dehydration Abdominal exam Abdominal distention – obstruction, mass, congenital abnormality, organomegaly Bowel sounds – high pitched tinkle (obstruction), absent (ileus) Guarding, rigidity, rebound tenderness – appendicitis, peritoneal inflammation Skin and extremities Petechiae or purpura – serious infection Skin turgor, capillary refill – dehydration Jaundice – metabolic disorder Rashes – food intolerance, viral infection Red flags: Lethargy and listlessness Inconsolability and bulging fontanelle in an infant Nuchal rigidity, photophobia, and fever in an older child Peritoneal signs or abdominal distention (“surgical” abdomen) Persistent vomiting with poor growth or development https://learn.pediatrics.ubc.ca/body-systems/gastrointestinal/approach-to-vomiting/
- 6. Approach to the vomiting infant https://learn.pediatrics.ubc.ca/body-systems/gastrointestinal/approach-to-vomiting/
- 9. Duodenal atresia Congenital partial or complete blockage of the intestine. Duodenal atresia is associated with other anomalies in more than half of infants. Down syndrome is the most common associated disorder but can also be associated with biliary, cardiac, renal or vertebral anomalies. Jejunal and ileal atresia can be seen in meconium ileus secondary to cystic fibrosis.
- 10. Duodenal atresia Duodenal atresia appears as a double-bubble sign (gas in the stomach and enlarged proximal duodenum), with no gas distally.
- 14. Midgut volvulus Midgut volvulus is a condition in which the intestine has become twisted as a result of malrotation during. Malrotation of the intestine occurs when the normal embryologic sequence of bowel development and fixation is interrupted.
- 15. Meconium ileus
- 16. Meconium Ileus Initial medical management ● Manage both simple and complicated meconium ileus in newborns as an intestinal obstruction. ● Perform resuscitative measures, including mechanical respiratory support, if necessary. ● Initiate intravenous (IV) hydration with gastric decompression. ● Empiric antibiotic coverage. Under fluoroscopic control, infuse gastrografin enema through a catheter inserted into the rectum To help deconcentrate the inspissated meconium, 1% N- acetylcysteine may be added to the enema solution. This procedure usually prompts rapid passage of semiliquid meconium, which continues for 24-48 hours.
- 17. Meconium Ileus This gross technique begins by performing a celiotomy with a muscle-sparing horizontal incision just above the umbilicus. Upon exploration, a decision is made, based on the viability and length of the bowel, either to create an enterotomy for irrigation and evacuation of the meconium or to resect the segment of impacted intestine. The author then creates side-by-side separate enterostomies without creating a common wall. Stomas are placed within the abdominal incision to the right; these may be covered with a single ostomy collecting device. Postoperatively, each stoma may be irrigated to remove residual meconium. Instillation of dilute enteral feedings high in glutamine, via the distal stoma, may also be performed to stimulate growth of the unused distal bowel. Postoperatively instillation of N - acetylcysteine via a nasogastric tube or an ileostomy helps solubilize residual meconium. Intestinal continuity is usually restored within 6 weeks if bowel function resumes and the infant tolerates oral feedings.
- 22. Intussusception target sign” or “bull’s eye” “hayfork” or “pseudo-kidney”
- 23. Intussusception
- 24. Appendicitis in pediatric population The appendix is less likely to be fixed to mesentery and has greater mobility. If the omentum is underdeveloped, note a higher rate of diffuse peritonitis if perforation occurs (as the omentum cannot contain purulent material). In children, presentations are often vague or nonspecific, and pain localization is challenging. Children with abdominal pain have especially atypical manifestations and are at higher risk for perforation The majority of children with appendicitis, the outcomes are excellent after surgery. However, the rate of perforation is much higher in children compared to adults. About 1- 3% of children develop an intra- abdominal abscess and small bowel obstruction as a result of the perforation.
- 25. Appendicitis in pediatric population
- 26. CAT in AUA in children should consider older age, larger outer appendiceal diameter and high WBC counts as risk-factors for recurrent AUA and subsequent appendectomy. The proposed decision tree model may help both clinicians and parents before CAT is chosen. …Antibiotic regimes were intravenous ceftriaxone/metronidazole or amoxicillin/clavulanic acid for 48 h, followed by oral antibiotics to complete total 10-days course….
- 28. Mesenteric cyst Mesenteric cysts are intra-abdominal masses of congenital origin, which most frequently occur in children, with an incidence of approximately 1 case per 20,000 pediatric admissions. Its progression can be asymptomatic, and its diagnosis can be incidental.symptomatic cases generally present with abdominal distention and few associated symptoms other than vague abdominal pain with or without a palpable mass. The mass may be huge, simulating ascites. The most common mode of acute presentation in children is that of a small-bowel obstruction, which may be associated with intestinal volvulus or infarction Mesenteric cysts most commonly occur in the small-bowel mesentery on the mesenteric side of the bowel. They can often be shelled out from between the leaves of the mesentery with care taken to avoid damage to the mesenteric vessels, or they may require concomitant bowel resection in order to ensure that the blood supply to the bowel is not compromised Are thought to represent benign proliferations of ectopic lymphatics that lack communication with the normal lymphatic system.
- 29. Anorectal malformations Consist of a wide spectrum of congenital abnormalities which involve the anus and rectum. These malformations range from skin level defects such as rectoperineal fistulas to complex lesions such as persistent cloaca. They occur in approximately 1 in 5000 live births
- 31. Thank you
Editor's Notes
- Gray and Skandalakis classified duodenal atresia in three types Type I - these have a web formed by mucosa and submucosa with no defect in the muscle coat. A windsock deformity may occur if the web is thin. Base of the membrane is in second part of duodenum. These constitute 92% case. Type II – duodenal ends are atretic, separated by some distance but attached by a cord. Mesentery is intact. 1% Type III - duodenal ends are atretic, separated by some distance but without any tissue intervening. Mesentery has a V shaped defect. 7%
- done between transversely opened proximal pouch and longitudinally opened distal pouch
- The Ladd's procedure is the standard corrective measure for intestinal malrotation in children and consists of division of peritoneal bands (Ladd's bands) traversing the posterior abdomen, reduction of volvulus, appendectomy, and functional postioning of the intestine with or without fixation.
- Bloody stools may be a late finding and could be a sign that the affected bowel is not receiving enough blood supply, called ischemia, and subsequent tissue death or necrosis may be occurring.
- Air or Contrast Enema If the intussusception is uncomplicated, then an air or contrast enema can be performed to try to reduce it. If the first attempt is unsuccessful, then a repeat attempt could potentially be performed in about 30 minutes to 4 hours under certain circumstances. The patient would need to be stable without signs of peritonitis or any other complications. Again this should be a joint decision between surgical, radiological, and any other appropriate teams. A successful second attempt could potentially avoid the need for surgery. That brings us to the second form of treatment which is surgical intervention. 2. Surgery Surgery may be necessary if non-operative approaches fail, or if there are complications such as an unstable patient, bowel perforation, peritonitis, or any other contraindications to a non-operative approach.