paediatric hernia ,intussuseption,mackels diverticulum,appendicites ,intestinal obstruction main causes

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

6. Hernias in children

7. Patent Processus Vaginalis

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

9. Incarcerated Inguinal
Hernia

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

11. High Ligation of Sac

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--

13. “Currant jelly stool”

14. USG-HALLMARK

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

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

35. Meckel’s

36. thanks