PEM Playbook – The Pediatric Surgical Abdomen
- Aug 17th, 2018
- Tim Horeczko
Originally published at Pediatric Emergency Playbook on Augsut 1, 2017 – Visit to listen to accompanying podcast. Reposted with permission.
Follow Dr. Tim Horeczko on twitter @EMTogether
Abdominal pain is common; so are strongly held myths and legends about what is concerning, and what is not.
One of our largest responsibilities in the Emergency Department is sorting out benign from surgical or medical causes of abdominal pain. Morbidity and mortality varies by age and condition.
Abdominal Surgical Emergencies in Children: A Relative Timeline
Neonate (birth to one month)
- Typically presents in 1st week of life (case reports to 6 months in chronically ill children)
- Extend suspicion longer in NICU graduates
- Up to 10% of all cases of necrotizing enterocolitis are in full-term children
- Pathophysiology is unknown, but likely a translocation of bacteria
- Feeding intolerance, abdominal distention
- Abdominal XR: pneumatosis intestinalis
- IV access, NG tube, broad-spectrum antibiotics, surgery consult, ICU admission
Intestinal Malrotation with Volvulus
- Bilious vomiting (80-100%) in the 1st month; especially in the 1stweek
- May look well initially, then rapidly present in shock
- Ladd’s bands: abnormally high tethering of cecum to abdominal wall; peristalsis, volvulus, ischemia
- History of bilious emesis is sufficient to involve surgeons
- Upper GI series: corkscrew appearance
- US (if ordered) may show abnormal orientation of and/or flow to superior mesenteric artery and vein
- Stat surgical consult
- IV access, resuscitation, NG tube to decompress (bowel wall perfusion at risk, distention worsens)
- Problem in migration of neural crest cells
- Aganglionic colon (80% rectosigmoid; 15-20% proximal to sigmoid; 5% total colonic aganglionosis) colon (known as short-segment disease)
- Poor to no peristalsis: constipation, perforation, and/or sepsis
- May be diagnosed early as “failure to pass meconium in 1st 48 hours”
- In ED, presents as either bowel obstruction or enterocolitis
- Contrast enema
- Beware of the toxic megacolon (vomiting, distention, sepsis)
- Resuscitation, antibiotics, NG tube decompression, surgical consultation; stable patients may need rectal biopsy for confirmation
- Staged surgery (abdominoperineal pull-through with diverting colostomy, subsequent anastomosis) versus one-stage repair.
Infant and Toddler (1 month to 2 years)
- Hypertrophy of pyloric sphincter; genetic, environmental, exposure factorsString Sign in Pyloric Stenosis.
- Hungry, hungry, not-so-hippos; they want to eat all of the time, but cannot keep things down
- Poor weight gain (less than 20-30 g/day)
- US: “π–loric stenosis” (3.14); pylorus dimensions > 3 mm x 14 mm
- UGI: “string sign”
- Trial of medical treatment with oral atropine via NGT (muscarinic effects decrease pyloric tone)
- Ramstedt pyloromyotomy (definitive)
- Majority (90%) ileocolic; no pathological lead point
- Small minority (4%) ileoileocolic due to lead point: Meckel’s diverticulum, polyp, Peyer’s patches, Henoch-Schönlein purpura (intestinal hematoma)
- Ultrasound sensitivity and specificity near 100% in experienced hands
- Abdominal XR may show non-specific signs; used mainly to screen for perforation before reduction
- Hydrostatic enema: contrast (barium or water-soluble contrast with fluoroscopy) or saline (with ultrasound)
- Air-contrast enema: air or carbon dioxide (with either fluoroscopy or ultrasound); higher risk for perforation than hydrostatic (1% risk), but generally safer than perforation from contrast
- Consider involving surgical service early (precaution before reduction)
- Traditional disposition is admission; controversial: home discharge from ED
Young Child and Older (2 years and up)
- Appendicitis occurs in all ages, but rarer in infants. Infants do not have fecalith; rather they have some other anatomic or congenital condition.
- More common in school-aged children (5-12 years) and adolescents
- Younger children present atypically, more likely to have perforated when diagnosed.
- Non-specific signs and symptoms
- Often have abdominal pain first; vomiting comes later
- Location/orientation of appendix varies
- Appendicitis scores vary in their performance
- Respect fever and abdominal pain
- Traditional: surgical
- On the horizon: identification of low-risk children who may benefit from trial of antibiotics
- If perforated, interval appendectomy (IV antibiotics via PICC for 4-6 weeks, then surgery)
- Same pathophysiology and epidemiology as adults: “ABC” – adhesions, “bulges” (hernias), and cancer.
- Obstruction is a sign of another condition. Look for cause of obstruction: surgical versus medical
- Abdominal XR in low pre-test probability
- CT abdomen/pelvis for moderate-to-high risk; confirmation and/or surgical planning
- Treat underlying cause
- NG tube to low intermittent wall suction
- Admission, fluid management, serial examinations
Take these pearls home:
- Consider surgical pathology early in encounter
- Resuscitate while you investigate
- Have a low threshold for imaging and/or consultation, especially in preverbal children
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Malrotation with Midgut Volvulus
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This post and podcast are dedicated to Mr Ross Fisher for his passion and spirit of collaboration in all things #FOAMed. Thank you, sir!
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