Pediatric

Surgery
Emergencies
Mohammed Ageel MD
 Contents of This Template
● Acute Appendicitis
● Intussusception
● Intestinal Atresia
● Hypertrophic Pyloric Stenosis
● Malrotation
● Testicular Torsion
 Hom
e

Case
• 11 year old boy came in
with 1 day history of RLQ
abdominal pain
associated with vomiting

His abdomen is soft with

tenderness in the RLQ
and positive rebound
 Acute Appendicitis

● Appendicitis is the most common pediatric abdominal

surgical emergency and remains an area of active

research

● The pathogenesis of acute and complicated

appendicitis, cost effective and safe diagnosis of the

condition, its optimal medical and surgical treatment

and management of complications are all being

 Acute Appendicitis

● The highest incidence (23 cases per 10,000 cases) is in

the those aged ten to nineteen years old

● Several studies have documented that between nine and

15% of pediatric appendicitis occurs in children less

than five years old but it is quite uncommon in neonates

and infants

● There is a slightly higher rate of appendicitis in males

than females (1.4:1)

 Acute Appendicitis

● Appendicitis has been thought to be due to luminal

obstruction leading to distension, obstructed venous

drainage and ischemia promoting the proliferation of

bacteria within the lumen

● Ischemia and infection then cause gangrene and

perforation of the appendix

 Acute Appendicitis

● The traditional teaching is that untreated acute

appendicitis progresses over time to perforated

appendicitis

● It is important to differentiate simple VS complicated

Appendicitis
 Presentation
Fever/ Tenderness/
Abdominal Pain
Tachycardia Rebound

RLQ tenderness,
Begins vague then start Simple VS complicated Rovsing’s sign and
to localize peritoneal signs
 Acute Appendicitis

-Atypical Presentation
● Toddlers??!!

● Urgency/dysuria

● Back pain

● ileus
 Assessment
Inflammatory
WBC Adjuncts
markers

Elevated WBC with a Urinanalysis, amylase

Are they really useful?
left shift etc
 Acute Appendicitis

-Imaging studies
● US >6mm, hyperemic, non-compressible, fecolith and

secondary signs (sensitive and specific)

● CT can only accurately predict perforation in 72% of

cases it can be helpful to diagnose complicated

appendicitis with abscess or phlegmon

● MRI In cases with equivocal ultrasound the MRI can be a

useful additional test

 Management

Resuscitate Non-Operative Operative

Hydration No Fecalith Timing

NPO No mass Safety
Abx No abscess Interval management
 Hom
e

Case
• 2 year old girl come in
with sever episodic
abdominal pain
associated with excessive
crying and passing of
mucus stool with red
streaks
 Intussusception

● Intussusception is one of the most frequent causes of

abdominal pain and bowel obstruction in the pediatric

population

● Significant complications can occur if there is

a delay in diagnosis
 Intussusception

● Intussusception is the most frequent cause of bowel

obstruction in infancy and the second most common

cause of abdominal pain and obstruction in the pediatric

population

● There is a slight male predilection (3:2) and the majority

present before one year of age (60%) with 80 %

occurring before two years of age

● The highest incidence occurs between five and nine

 Intussusception

● The theory for the pathogenesis of intussusception is a

mass within the bowel wall that disrupts the normal

peristalsis

● The most common idiopathic cause is enlarged lymphoid

tissue due to infection or inflammation

● 10% of cases have a pathologic lead point - most

frequently Meckel diverticulum, polyps or lymphoma

 Intussusception

● The most common type of intussusception is ileocolonic

(85%) followed by ileoileocolonic (10%) where the

ileoileal portion invaginates into the cecum

● Less common locations of intussusception include

appendicocolonic, cecocolic, colocolic (2.5%) and

jejunojeunal or ileoileal (2.5%)

 Presentation
(the Triad)
Colicky Current Jelly
Vomiting
abdominal pain Stool

Initially non-bilious but

Lasts 5-10 min with with time turns into Ischemia
period of relief bilious
 Intussception

- Other Presentation points

● Lethargy

● Recent Sickness

● Recent Immunization

● Tenderness on the right abdomen

● Sausage mass
 Assessment

Labs US CT

identify a pathologic
Most specific and
Non-specific lead point but should
sensitive
not be used Routinely
 Management
Contrast Enema
Resus Surgery
reduction

perforation, failure of
Always stabalize Saline VS Air nonoperative reduction
or suspicion of a
pathologic lead point
 Hom
e

Case
• 2 day old referred to you
for vomiting and an
abdominal xray
 Intestinal Atresia

● Atresia of the small bowel and colon is a major cause of

neonatal small bowel obstruction

● Atresia results from an in utero vascular compromise of

the intestine

● Atresia of the small intestine or colon is one of the major

neonatal index conditions evaluated and treated by

pediatric surgeons
 Intestinal Atresia

● Duodenal obstruction is the second most common site of

congenital intestinal obstruction they account for 50%

of cases of Intestinal atresia

● A failure of epithelial apoptosis (programmed cell death)

at the conclusion of the duodenal solid cord stage

prevents vacuolization and recanalization

 Presentation
Depends on the Degree of
Perforation
Location Obstruction

Vomiting non-bilious VS Peritonitis and

Complete VS Partial
Bilious abdominal wall
(web, stenosis)
Distention or not erythema
 Intestinal Atresia

-Associated Anomalies
● screening for congenital heart disease or neurologic abnormalities is warranted in

the absence of symptoms or signs

● Cystic Fibrosis

● Hirschsprung disease

● Malrotation point to the role of these conditions in causing neonatal bowel

obstruction or ischemia with resulting atresia

 Assessment

Plain X rays Contrast Studies Us/CT

Double- Bubble Contrast Peak sign

R/O other Diagnoses
Gas distribution Micro-colon
 Hom
e

Management
Surgery is the only option
 Hom
e

Case
• 1 month old baby
presents with acute
bilious vomiting with no
abdominal destention and
other wise stable baby
Introduction
● A congenital anatomical condition that may predisposes a significant portion of
intestine to twisting with subsequent obstruction and ischemic necrosis

● Midgut volvulus is a feared pediatric surgical emergency as the loss of small intestine
can potentially lead to short bowel syndrome and intestinal failure
 Malrotation

VOLVULUS
The Deference
Malrotation Volvulus
● Symptoms can be ● Symptoms and
as distinct as signs will be of
chronic acute sever
abdominal pain abdominal pain,
with or without bilious emesis
signs of bowel and distress
obstruction
Epidemiology
● Incidence is 1:200 (0.5%)

● Volvulus occur in 1:6000 which means from every thirty

malrotation patient one will develop a volvulus

● 70% will have symptoms in 1st year of life and of those

70% will have it in their 1st month of life
Embryology
Classification
Presentation
● Bilious emesis is a surgical emergency until proven
otherwise

● Even in a child who appears STABLE

● Abdominal distention, hematemesis, hematochezia and

hemodynamic instability are all late signs
Presentation
● Rotational abnormality should be suspected in older
pediatric patients with intermittent abdominal pain,
lethargy, FTT and vague chronic GI issues

● Patient with CDH, Gastroschisis and Omphalocele by

definition have intestinal rotational abnormality

● Patient with heterotaxia have a strong association with

IRA
Assessment● Clinical suspicion = Emergent Radiographic
evaluation
(No Room for Missing a Midgut
Volvulus)
● UGI contrast is the study of choice
- Equivocal results in 35-40%
- False positive 10-15%

● US with doppler SMA/SMV orientation

● CT and MRI are often used in older children and

adults
The presence of those three sonographic signs have a
sensitivity and specificity of 98-100%
Management
● Time is of the essence, surgeon should not leave the
bedside from the moment the suspicion arise

● Ladds Procedure:
- Devolvulizing the power clockwise
- Dividing the Ladd's bands and
intermesentric bands to widen the
mesentery
- Appendectomy and placing the bowel
 Hom
e

Case
• 5 weeks old baby boy
presenting with non-
bilious projectile vomiting
and dehydration
 Hypertrophic Pyloric Stenosis

● Hypertrophic pyloric stenosis (HPS) is the most common

cause of gastric outlet obstruction in infants

● HPS is roughly one in every three hundred live births

● Male to female ratio of approximately 4:1

● The typical presentation of a HPS patient is a 2-10 week

old infant
 Hypertrophic Pyloric Stenosis

● Hypertrophic pyloric stenosis is caused by hypertrophy

of the muscle fibers in the pylorus, principally the

circular layer
 Presentation

Vomiting Dehydration FTT

Vomiting non-bilious, hypochloremic

Delayed presentation
projectile and hypokalemic metabolic
Hungry agitated baby
progressive alkalosis
 Assessment

Labs US UGI

for serum electrolytes pyloric muscle

(including HCO3, Cl and thickness of 4 mm and Was the gold standered
K) length of 15 mm
 Management

Resus Surgery

Use Isotonic solution

HCO3<30 Pylormyotomy
CL>90
 References

● NaT
●Thank
● Coran Pediatric Surgery

s
● Journal of Pediatric Surgery

Do you have any questions?