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Surgical Problems in Children
Ricardo A. Caicedo, MDPediatric Gastroenterology
University of Florida
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ProblemsGASTROINTESTINAL- Pyloric stenosis- Malrotation
- Midgut volvulus- Duodenal atresia- Meconium ileus- Intussusception
- Meckel’s diverticulum- Hirschsprung’s disease
GENITOURINARY- Hypospadias- Phimosis/paraphimosis- Cryptorchidism- Hydrocele- Testicular torsion
OBJECTIVES-Recognize-Diagnose-Consult surgery
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Pyloric stenosisHypertrophy of the gastric outlet• 1:150 males, 1:750 females• 2-12 weeks of age
Repetitive vomiting• Projectile• Non-bilious
Dehydration• Hypochloremic alkalosis
Exam• Visible peristaltic wave• Palpable “olive” to right of umbilicus
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Pyloric stenosis
UGI
Delayed passage of barium through thickened pyloric channel
Ultrasound
Thickened, elongated pyloric channel
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Pyloric stenosisSurgical tx = pyloromyotomy
Hypertrophy of pylorus
Endoscopic balloon dilation
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Duodenum to right of spine
Cecum in left abdomen
MalrotationFailure of midgut to rotate into normal anatomic position during development- Colon and cecum in left- Duodenum on right side
- Bilious vomiting- Peritoneal (Ladd) bands cause
partial bowel obstruction- High risk for...
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Midgut volvulus
!SURGICAL
EMERGENCY
Twisting of bowel around its mesentery and vascular supply• Leads to ischemia, infarction, perforation, necrosis• Presentation: lethargy, abdominal distention, bloody stools
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Duodenal atresia
Double bubble sign
Obliteration of lumen• Failure to recanalize
Neonatal bilious vomitingAssociations• Prematurity• Congenital heart defects• Trisomy 21 ! Complete
small bowel obstruction
SURGICAL EMERGENCY
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Meconium ileusCYSTIC FIBROSIS• First manifestation in 15%
of CF cases• Thick meconium impacts in
ileum• Abdominal distention
• Bilious vomiting• Risk for
• Volvulus• Perforation
Microcolonwith meconiumplugs
!SURGICAL
EMERGENCY
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IntussusceptionTelescoping of one segment of bowel into another• Ileocolonic most common• 6 mos – 3 years old
Progressive course• Intermittent acute abd. pain• Vomiting• Bloody stools (currant jelly)• Fever, lethargy• Palpable sausage-shaped
mass in upper abdomen
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Intussusception Management
Abdominal X-ray: obstructionContrast enema• Diagnostic confirmation• Therapeutic in 75% of cases
• Hydrostatic pressure reduces the intussusception• Surgeon must be involved directly
• If enema reduction fails• Small bowel intussusceptions require surgical reduction
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Intussusception
Terminal ileum telescoped into cecum
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Meckel’s diverticulum• Remnant of
omphalomesenteric duct• Painless rectal bleeding
• Less commonly: intuss., volvulus, perforation
• Diagnosis• CT scan• Nuclear medicine scan• Endoscopy
• Treatment• Surgical resection
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Hirschsprung’s diseaseCongenital absence of ganglion cells in distal rectum
- and varying distance proximallyLack of peristalsis causes colonic obstructionAbdominal distentionFailure to pass meconiumFever and diarrhea suggest “toxic megacolon” !
SURGICAL EMERGENCY
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Hirschsprung’s
AXR: obstructive pattern Suction rectal bx
Absence ofganglion cellsin myentericplexus
Barium enema: Dilated proximal colon with transition zone
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Surgical treatment1. Colostomy2. Pull-through and removal of
aganglionic segmentHirschsprung’s
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Inguinal herniaMost common surgical problem • More common in male and premature
infants• Intestinal segment entering into scrotum
through processus vaginalis• Does not resolve spontaneously
Painless scrotal bulge• Increases in size with crying/straining
Management• Reducible: refer to surgery for repair• Incarcerated: immediate surgical consult
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Umbilical herniaIncomplete closure of umbilical ring fasciaMore common in premature and African-American infantsUsually close by 2-4 yrsRefer to surgery if:• Larger than 1.5 cm at 2 yrs• Present after 4 yrs• Supraumbilical
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HypospadiasAbnormal low position of urethral meatusAbsence of ventral foreskinAssociations• Undescended testes• Urinary tract anomalies
Management• Avoid circumcision• Refer to pediatric urology
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Phimosis vs. Paraphimosis
Phimosis: inability to retract foreskinTx: dorsal slit or circumcision
Paraphimosis: foreskin retracted behind coronal groove; tourniquet to glansTx: circumcision
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CryptorchidismUndescended testicle(s)• Spontaneous descent does not
occur beyond age 1 yr• Bilateral in 1/3 of cases
Associations• Inguinal hernia• Hypospadias• Higher incidence of
• Testicular torsion• Infertility• Cancer in cryptorchid testis
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CryptorchidismEndocrine eval.• Refer early: 6-12 mos of age• hCG stimulation test
• “Locates” functional testes• Can aid in descent
• Karyotype if hypospadias co-exists
Surgery• Orchidopexy
• Usually in 2nd yr of life
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Scrotal swellingPAINLESS
HydroceleVaricoceleSpermatoceleInguinal hernia
PAINFULTesticular torsionEpididymitisOrchitisIncarcerated hernia
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Hydrocele
• Mobile• Transilluminates• Spontaneous resolution
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!Testicular torsionSURGICAL
EMERGENCYTwisting of testis around spermatic cord• Caused by abnormal fixation of
testis to scrotum• Vascular supply compromised
Acute painful scrotal swelling• Severe tenderness• Redness or dusky color• Testis elevated• Cremasteric reflex absent
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Torsion6 hour window
for surgical detorsionR. testis: blood flow (Doppler)
L. testis: lack of blood flow
The consequence of delayed diagnosisUltrasound
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