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?
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---
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
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
Clinical features. Swelling/buldge/intermittent /painless/Buldge Is particularly while crying & resolves during night. :DD-hydroceal/lymphnode/hernia
Most hernias are conginential & are indirect inguinal hernias ,60% occur on right side/30%on left 10%bl
Testis starts to migrate by 28 weeks gestration
As a rule forcefull manual reduction is recommended in all cases of incarceration (except sings of toxicity), keep patient sediated & 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 & thumb then prolonged steady pressure applied…reducing hand needs to be kept in place for few seconds.
Incarceration is entrapment of viscus &second most common cause of bowel obstruction & 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 & hernia
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& discolored, labs leucocytosis -
Traid:vomitting +abdominal pain+passage of blood per rectum. Occurs rarely in malnourished baby
Dance sign is hall mark presentation
USG is hall mark –target sign & pseudo kidney sign …………………. Usg has 97% sensitivity & specificity
XRAY shows crescent /meniscus sign & target sign ,barium enema is most reliable ……….should do lateral decubitus xray
Lead point can be meckels diverticula, lymph node ,HSP there is submucosa bleed which can act as lead point
Enema is contraindicated if perforation or gangre is suspected …also should be avoided in childrens &gt;3 years of age due to possibility of surgical leag point
Initially there is visceral pain followed by somatic pain (after 17 hrs) after 36 hours there are chances of perforation
Xray:very low sensitivity & specificity –appendicolith can be seen in 2%cases,psoas obliteration/mass …USG non compressible tube,tenderness & diameter of 6mm