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