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Pediatric abdominal
emergencies
Dr ABDUL RUB SHERWANI
Attending consultant A&e
Outline Continued
 What are the important points about the history?
 What are the physical findings?
 What is the differential diagnosis?
 What further workup is needed?
 How is patient managed?
Outline
 Appendicitis
 Intussusception
 Incarcerated Inguinal hernias
 Intestinal obstruction
 Meckels diverticulum
Case 1
 6mo infant with vomiting, poor po intake,
abdominal distension
 Previous 32wk gest age & hypospadias
 Non-bilious emesis
 Looks ill
 Some respiratory problems as neonate
 No history of surgeries, no meds
 Physical exam---
KUB
Hernias in children
Patent Processus Vaginalis
Hernia Reduction
From Surgery of Infants and Children, Oldham, et. al., 1997
Incarcerated Inguinal
Hernia
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
High Ligation of Sac
Case 2
 6mo infant with vomiting, poor po intake,
abdominal distension
 Otherwise healthy infant, no previous feeding
intolerance
 Looks well ,chubby, mom says intermittent severe
abdominal pain
 Mom says pt passed reddish, thick-mucous stool
 Physical exam--
“Currant jelly stool”
USG-HALLMARK
Intussusception
 Inversion of the bowel upon itself secondary to a
lead point
 Juvenile intussusception most often idiopathic
 Also secondary to Meckel’s
 Presents 6 months to 2 years of age
 As early as 1 month
 Incarceration. lethargy
Management
 Nonoperative reduction:
 Therapeutic enemas :
 Hydrostatic: With barium or water-soluble contrast
 Pneumatic: With air insufflation; this is the
treatment of choice in many institutions, and the
risk of major complications with this technique is
small
Case 3
 6yo male, otherwise healthy, presents to
pediatrician with abdominal pain and nausea
Case 3
 6yo male, otherwise healthy, presents to
pediatrician with abdominal pain and nausea
 Dad says pt started complaining about abd pain
yesterday after school (1st
day of school)
 Ate dinner but then woke up around midnight c/o
pain again
 Vomited once this am
 Walks hunched over
 H/O occasional constipation
DemographicsDemographics
 Most common acute surgical condition
 Life-time risk: 8.7% in boys; 6.7% in girls[1]
 Age specific risk: extremely low neonates to peak 12-18
years
 Up to 50 % initially misdiagnosedUp to 50 % initially misdiagnosed
ƒ < 2 yrs. : perforation rate approaches 100 %< 2 yrs. : perforation rate approaches 100 %
ƒ 3 to 5 yrs. = 71 %3 to 5 yrs. = 71 %
ƒ 6 to 10 yrs. = 40 %6 to 10 yrs. = 40 %
ƒ Most commonly misdiagnosed as AGE ,Most commonly misdiagnosed as AGE , localizedlocalized
tenderness is never a feature of AGEtenderness is never a feature of AGE
Alvarado ScoreAlvarado Score
 Abdominal pain that migrates to the right iliac fossa
 Anorexia (loss of appetite) or ketones in the urine
 Nausea or vomiting
 Pain on pressure in the right iliac fossa
 Rebound tenderness
 Fever of 37.3 °C or more
 Leukocytosis, or more than 10000 white blood cells per
microliter in the serum
 Neutrophilia, or an increase in the percentage of
neutrophils in the serum white blood cell count
RIF pain and leucocytosis score 2 points each
0-3: Sensitivity no AA 96% -› Discharge
4-6: Sensitivity of AA 36% -› Imaging
>7: Sensitivity of AA 78% -› +/- theatre
DiagnosisDiagnosis
 Classic Triad
 WBC 11-16000/mm³ significantly higher in
cases of perforation[8]
 RBC’s, WBC’s and protein common in
urine
 No evidence CRP superior to WBC count
in children – unnecessary expence[9]
 Normal WBC and CRP doesn’t exclude
Dx [10]
8/Guraya S.Y., Al-Tuwaijri T.A., Khairy G.A., et al: Validity of leukocyte count to predict the severity of acute appendicitis.
 Saudi Med J  2005; 26:1945-1947.
9/Rodríguez-Sanjuán J.C., Martín-Parra J.I., Seco I., et al: 
C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in children. Dis Colon Rectum  1999; 42:1325-
Do We Need Imaging Studies?Do We Need Imaging Studies?
NEJMNEJM : Suspected Appendicitis Jan. 2003: Suspected Appendicitis Jan. 2003
Patients with classic presentation should goPatients with classic presentation should go
to O.R. Diagnostic accuracy approaches 95to O.R. Diagnostic accuracy approaches 95
%%
If equivocal or suspect perforation : CTIf equivocal or suspect perforation : CT
US reserved for pregnant women or highUS reserved for pregnant women or high
suspicion of GYN diseasesuspicion of GYN disease
If study indeterminate, observe withIf study indeterminate, observe with
repeated exams or laparoscopyrepeated exams or laparoscopy
Radiological imagingRadiological imaging
 Abdominal X-ray, no benefit except in setting
of bowel obstruction and young patients
 Ultrasound, safe, non-invasive, radiation and
contrast free, but operator dependent
 Review of multiple paediatric series
(N=5000+)
 Sensitivity 78-94% Specificity 89-98%[13]
 CT Scan Sensitivity and Specificity 95%[14]
 MRI extremely accurate (no radiation) [15]
13/Vignault F., Filiatrault D., Brandt M.L., et al: Acute appendicitis in children: Evaluation with US. Radiology  1990; 176:501-504.
14/Horton M.D., Counter S.F., Florence M.G., et al: 
A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient. Am J
Surg  2000; 179:379-381.
15/Horman M., Paya K., Eibenberger K., et al: 
MR imaging in children with nonperforated acute appendicitis: Value of unenhanced MR imaging in sonographically selected cases. AJR
Am J Roentgenol  1998; 171:467-470.
Medical ManagementMedical Management
 Treatment starts with IV fluid and
antibiotics
 Uncomplicated appendicitis: current
evidence suggests single pre-op dose
sufficient[16]
 Post-op antibiotics indicated in
perforation
 Duration of treatment determined by
resolution of symptoms
 CDC guidelines for peritonitis 7-10 days
16/Mui L.M., Ng C.S., Wong S.K., et al: Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis. Aust
NZ J Surg  2005; 75:425-428.
Antibiotic regimensAntibiotic regimens
 Triple therapy
(ampicillin,gentamycin,metronidazole)
 Piptaz as effective as triples[17]
 Ceftriaxone and metronidazole daily as
effective as triples (cost and time benefit)
[18]
 Early transition to oral antibiotics as
effective as prolonged IV’s [19]
17/Nadler E.P., Reblock K.K., Ford H.R., et al: Monotherapy versus multi-drug therapy for the treatment of perforated appendicitis in children.
 Surg Infect (Larchmt)  2003; 4:327-333.
18/St Peter S.D., Little D.C., Calkins C.M., et al: A simple and more cost-effective antibiotic regimen for perforated appendicitis. J Pediatr
Surg  2006; 41:1020-1024.
19/Adibe O.O., Barnaby K., Dobies J., et al: Postoperative antibiotic therapy for children with perforated appendicitis: Long course of intravenous 
antibiotics versus early conversion to an oral regimen. Am J Surg  2008; 195:141-143.
AnalgesiaAnalgesia

Sir Zachary Cope's 1921 textbook of surgery saidSir Zachary Cope's 1921 textbook of surgery said nono
wayway
Prospective studies (both EM and Surgery literature)Prospective studies (both EM and Surgery literature)
now show appropriatenow show appropriate use of IV narcoticsuse of IV narcotics
does not decrease diagnosticdoes not decrease diagnostic
accuracy, and may improve examaccuracy, and may improve exam
Analgesia, cont'd.Analgesia, cont'd.
Journal of American College of Surgeons :Journal of American College of Surgeons :
Jan. 2003Jan. 2003
Prospective, randomized, double blind studyProspective, randomized, double blind study
Adults with abd. pain got up to 15 mgAdults with abd. pain got up to 15 mg
morphine vs. placebomorphine vs. placebo
Increased pain relief, with noIncreased pain relief, with no
change in diagnostic accuracychange in diagnostic accuracy
 Not all surgeons read their own literature, so give them a chance to come in a reasonableNot all surgeons read their own literature, so give them a chance to come in a reasonable
time frame or give the medstime frame or give the meds
Surgical ManagementSurgical Management
Acute Appendicitis
 Acute appendicitis cured with surgery
 Prompt appendicectomy treatment of
choice
 Appendicitis can be treated with
antibiotics alone[20]
 Antibiotics change from emergency to
elective
 Appendicectomy in the middle of the
night not justified[21]
20/ Styrud J., Eriksson S., Nilsson I., et al: Appendectomy versus antibiotic treatment in acute appendicitis: A prospective 
multicenter randomized controlled trial. World J Surg  2006; 30:1033-1037. 
21/Surana R., Quinn F., Puri P.: Is it necessary to perform appendectomy in the middle of the night in 
children?. BMJ  1993; 306:1168.
" No single evaluation can" No single evaluation can
substitute for the diagnosticsubstitute for the diagnostic
accuracy of the experiencedaccuracy of the experienced
physician."physician."
Meckel’s
 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
Meckel’s
 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 don’t need transfusion
Meckel’s
thanks

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Pediatric surgical emergencies

  • 1. Pediatric abdominal emergencies Dr ABDUL RUB SHERWANI Attending consultant A&e
  • 2. Outline Continued  What are the important points about the history?  What are the physical findings?  What is the differential diagnosis?  What further workup is needed?  How is patient managed?
  • 3. Outline  Appendicitis  Intussusception  Incarcerated Inguinal hernias  Intestinal obstruction  Meckels diverticulum
  • 4. Case 1  6mo infant with vomiting, poor po intake, abdominal distension  Previous 32wk gest age & hypospadias  Non-bilious emesis  Looks ill  Some respiratory problems as neonate  No history of surgeries, no meds  Physical exam---
  • 5. KUB
  • 8. Hernia Reduction From Surgery of Infants and Children, Oldham, et. al., 1997
  • 10. 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
  • 12. Case 2  6mo infant with vomiting, poor po intake, abdominal distension  Otherwise healthy infant, no previous feeding intolerance  Looks well ,chubby, mom says intermittent severe abdominal pain  Mom says pt passed reddish, thick-mucous stool  Physical exam--
  • 15.
  • 16. Intussusception  Inversion of the bowel upon itself secondary to a lead point  Juvenile intussusception most often idiopathic  Also secondary to Meckel’s  Presents 6 months to 2 years of age  As early as 1 month  Incarceration. lethargy
  • 17. Management  Nonoperative reduction:  Therapeutic enemas :  Hydrostatic: With barium or water-soluble contrast  Pneumatic: With air insufflation; this is the treatment of choice in many institutions, and the risk of major complications with this technique is small
  • 18. Case 3  6yo male, otherwise healthy, presents to pediatrician with abdominal pain and nausea
  • 19. Case 3  6yo male, otherwise healthy, presents to pediatrician with abdominal pain and nausea  Dad says pt started complaining about abd pain yesterday after school (1st day of school)  Ate dinner but then woke up around midnight c/o pain again  Vomited once this am  Walks hunched over  H/O occasional constipation
  • 20. DemographicsDemographics  Most common acute surgical condition  Life-time risk: 8.7% in boys; 6.7% in girls[1]  Age specific risk: extremely low neonates to peak 12-18 years  Up to 50 % initially misdiagnosedUp to 50 % initially misdiagnosed ƒ < 2 yrs. : perforation rate approaches 100 %< 2 yrs. : perforation rate approaches 100 % ƒ 3 to 5 yrs. = 71 %3 to 5 yrs. = 71 % ƒ 6 to 10 yrs. = 40 %6 to 10 yrs. = 40 % ƒ Most commonly misdiagnosed as AGE ,Most commonly misdiagnosed as AGE , localizedlocalized tenderness is never a feature of AGEtenderness is never a feature of AGE
  • 21. Alvarado ScoreAlvarado Score  Abdominal pain that migrates to the right iliac fossa  Anorexia (loss of appetite) or ketones in the urine  Nausea or vomiting  Pain on pressure in the right iliac fossa  Rebound tenderness  Fever of 37.3 °C or more  Leukocytosis, or more than 10000 white blood cells per microliter in the serum  Neutrophilia, or an increase in the percentage of neutrophils in the serum white blood cell count RIF pain and leucocytosis score 2 points each 0-3: Sensitivity no AA 96% -› Discharge 4-6: Sensitivity of AA 36% -› Imaging >7: Sensitivity of AA 78% -› +/- theatre
  • 22. DiagnosisDiagnosis  Classic Triad  WBC 11-16000/mm³ significantly higher in cases of perforation[8]  RBC’s, WBC’s and protein common in urine  No evidence CRP superior to WBC count in children – unnecessary expence[9]  Normal WBC and CRP doesn’t exclude Dx [10] 8/Guraya S.Y., Al-Tuwaijri T.A., Khairy G.A., et al: Validity of leukocyte count to predict the severity of acute appendicitis.  Saudi Med J  2005; 26:1945-1947. 9/Rodríguez-Sanjuán J.C., Martín-Parra J.I., Seco I., et al:  C-reactive protein and leukocyte count in the diagnosis of acute appendicitis in children. Dis Colon Rectum  1999; 42:1325-
  • 23. Do We Need Imaging Studies?Do We Need Imaging Studies? NEJMNEJM : Suspected Appendicitis Jan. 2003: Suspected Appendicitis Jan. 2003 Patients with classic presentation should goPatients with classic presentation should go to O.R. Diagnostic accuracy approaches 95to O.R. Diagnostic accuracy approaches 95 %% If equivocal or suspect perforation : CTIf equivocal or suspect perforation : CT US reserved for pregnant women or highUS reserved for pregnant women or high suspicion of GYN diseasesuspicion of GYN disease If study indeterminate, observe withIf study indeterminate, observe with repeated exams or laparoscopyrepeated exams or laparoscopy
  • 24. Radiological imagingRadiological imaging  Abdominal X-ray, no benefit except in setting of bowel obstruction and young patients  Ultrasound, safe, non-invasive, radiation and contrast free, but operator dependent  Review of multiple paediatric series (N=5000+)  Sensitivity 78-94% Specificity 89-98%[13]  CT Scan Sensitivity and Specificity 95%[14]  MRI extremely accurate (no radiation) [15] 13/Vignault F., Filiatrault D., Brandt M.L., et al: Acute appendicitis in children: Evaluation with US. Radiology  1990; 176:501-504. 14/Horton M.D., Counter S.F., Florence M.G., et al:  A prospective trial of computed tomography and ultrasonography for diagnosing appendicitis in the atypical patient. Am J Surg  2000; 179:379-381. 15/Horman M., Paya K., Eibenberger K., et al:  MR imaging in children with nonperforated acute appendicitis: Value of unenhanced MR imaging in sonographically selected cases. AJR Am J Roentgenol  1998; 171:467-470.
  • 25. Medical ManagementMedical Management  Treatment starts with IV fluid and antibiotics  Uncomplicated appendicitis: current evidence suggests single pre-op dose sufficient[16]  Post-op antibiotics indicated in perforation  Duration of treatment determined by resolution of symptoms  CDC guidelines for peritonitis 7-10 days 16/Mui L.M., Ng C.S., Wong S.K., et al: Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis. Aust NZ J Surg  2005; 75:425-428.
  • 26. Antibiotic regimensAntibiotic regimens  Triple therapy (ampicillin,gentamycin,metronidazole)  Piptaz as effective as triples[17]  Ceftriaxone and metronidazole daily as effective as triples (cost and time benefit) [18]  Early transition to oral antibiotics as effective as prolonged IV’s [19] 17/Nadler E.P., Reblock K.K., Ford H.R., et al: Monotherapy versus multi-drug therapy for the treatment of perforated appendicitis in children.  Surg Infect (Larchmt)  2003; 4:327-333. 18/St Peter S.D., Little D.C., Calkins C.M., et al: A simple and more cost-effective antibiotic regimen for perforated appendicitis. J Pediatr Surg  2006; 41:1020-1024. 19/Adibe O.O., Barnaby K., Dobies J., et al: Postoperative antibiotic therapy for children with perforated appendicitis: Long course of intravenous  antibiotics versus early conversion to an oral regimen. Am J Surg  2008; 195:141-143.
  • 27. AnalgesiaAnalgesia  Sir Zachary Cope's 1921 textbook of surgery saidSir Zachary Cope's 1921 textbook of surgery said nono wayway Prospective studies (both EM and Surgery literature)Prospective studies (both EM and Surgery literature) now show appropriatenow show appropriate use of IV narcoticsuse of IV narcotics does not decrease diagnosticdoes not decrease diagnostic accuracy, and may improve examaccuracy, and may improve exam
  • 28. Analgesia, cont'd.Analgesia, cont'd. Journal of American College of Surgeons :Journal of American College of Surgeons : Jan. 2003Jan. 2003 Prospective, randomized, double blind studyProspective, randomized, double blind study Adults with abd. pain got up to 15 mgAdults with abd. pain got up to 15 mg morphine vs. placebomorphine vs. placebo Increased pain relief, with noIncreased pain relief, with no change in diagnostic accuracychange in diagnostic accuracy  Not all surgeons read their own literature, so give them a chance to come in a reasonableNot all surgeons read their own literature, so give them a chance to come in a reasonable time frame or give the medstime frame or give the meds
  • 29. Surgical ManagementSurgical Management Acute Appendicitis  Acute appendicitis cured with surgery  Prompt appendicectomy treatment of choice  Appendicitis can be treated with antibiotics alone[20]  Antibiotics change from emergency to elective  Appendicectomy in the middle of the night not justified[21] 20/ Styrud J., Eriksson S., Nilsson I., et al: Appendectomy versus antibiotic treatment in acute appendicitis: A prospective  multicenter randomized controlled trial. World J Surg  2006; 30:1033-1037.  21/Surana R., Quinn F., Puri P.: Is it necessary to perform appendectomy in the middle of the night in  children?. BMJ  1993; 306:1168.
  • 30. " No single evaluation can" No single evaluation can substitute for the diagnosticsubstitute for the diagnostic accuracy of the experiencedaccuracy of the experienced physician."physician."
  • 31. Meckel’s  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
  • 32.
  • 33. Meckel’s  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 don’t need transfusion
  • 34.

Editor's Notes

  1. Clue :premature (7-30% incidence)/ hypospasdias
  2. Clinical features. Swelling/buldge/intermittent /painless/Buldge Is particularly while crying &amp; resolves during night. :DD-hydroceal/lymphnode/hernia
  3. Most hernias are conginential &amp; are indirect inguinal hernias ,60% occur on right side/30%on left 10%bl
  4. Testis starts to migrate by 28 weeks gestration
  5. As a rule forcefull manual reduction is recommended in all cases of incarceration (except sings of toxicity), keep patient sediated &amp; tendelburgs position-90% chances of reduction –if fails urgent OT Manuer:particular leg is externally rotated ,1st two fingers are kept over external inguinal ring (hernial bulge) then apex of hernia is grasped by 1st two fingers &amp; thumb then prolonged steady pressure applied…reducing hand needs to be kept in place for few seconds.
  6. Incarceration is entrapment of viscus &amp;second most common cause of bowel obstruction &amp; leading to strangulation.what we need to do in ER is differentiate hydroceal from hernia by transilumination test or by doing PR examination.SILK SIGN –palpation of hernia over cord –inguinal hernia.usg can be used to D/B hydroceal &amp; hernia
  7. All pedia hernias require surgery to prevent incarceration /strangulation-there is 60 % chance of incarceration of hernia in pedia group.tender firm mass ,child is fussy unwilling to feed ,crying,skin over hernia is edematous ,erythematous&amp; discolored, labs leucocytosis -
  8. Traid:vomitting +abdominal pain+passage of blood per rectum. Occurs rarely in malnourished baby
  9. Dance sign is hall mark presentation
  10. USG is hall mark –target sign &amp; pseudo kidney sign …………………. Usg has 97% sensitivity &amp; specificity
  11. XRAY shows crescent /meniscus sign &amp; target sign ,barium enema is most reliable ……….should do lateral decubitus xray
  12. Lead point can be meckels diverticula, lymph node ,HSP there is submucosa bleed which can act as lead point
  13. Enema is contraindicated if perforation or gangre is suspected …also should be avoided in childrens &amp;gt;3 years of age due to possibility of surgical leag point
  14. Initially there is visceral pain followed by somatic pain (after 17 hrs) after 36 hours there are chances of perforation
  15. Xray:very low sensitivity &amp; specificity –appendicolith can be seen in 2%cases,psoas obliteration/mass …USG non compressible tube,tenderness &amp; diameter of 6mm
  16. Gastric tissue/ pancreatic tissue
  17. Mikel&amp;apos;s scan