The Future Surgeons

351 SURG

Presentation and Management of Acute Abdomen in Children

Appendicitis
• The most common cause of abdominal surgical emergencies in children.
G
Occurs commonly at 7-13 years old.

Presentation:
Irritable.
Vomiting.
Refuse feeding.
Crying; when the baby cries, the abdomen become tense enabling us to see guarding or
rigidity.
uncooperative.
Deteriorate quickly, and can lead to death.

History:
Children less than 3 years:
Atypical presentation. (irritable, refuse to feed, vomiting) (all infant cry when
they have pain or when they are hungry, the problem it is difficult to
differentiate)
Can't express their complain of pain (i.e. cry, irritable, poor feeding).
Late presentation: septic (lethargic, non responsive, vomiting).
Children above 3 years:
Similar to adult symptom and signs:
.a Localized:
 Simple appendicitis.
 Abscess, RLQ mass (ruptured).
.b Generalized:
 Peritonitis (ruptured).
Girls between 12-16 years old:
Differential diagnosis includes ovarian pathology (e.g. rupture cyst, torsion).
Ultrasound is helpful.

Diagnosis:
Above 3 years, it is mainly clinical:
History, physical examination, CBC and differentiated blood cells (high neutrophilia).
G
Refuse to eat, vomiting, sepsis, fever.
Less than 3 years, especially infant, difficult to diagnose:
Early rupture (like elderly group).
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Sepsis (fever and leucocytosis).

Investigations:
Not needed if the clinical picture is clear.
Mainly used in difficult diagnoses such as:
Patient less than 3 years.
Atypical symptoms.
Girls above 12 years.
Urinary tract infection should be ruled out by dipstick and urinalysis.

Abdominal x-ray:
Not accurate nor important in diagnosis.
Rule out perforation (appearance of free air).
Might show:
Fecolith (a calcified stool).
Localized ileus.
 Right sided scoliosis.

Ultrasound (US):
Available.
No sedation needed.
No radiation.
Children have thin abdominal wall, we can see better through it.
Operator dependent (need a good radiologist).
Good for:
Ovarian cysts. G
Intussusception.
Free fluid.
Stones.
Not very good for:
Appendicitis.
Meckel's diverticulitis.
Volvulus.

CT scan:
Problems:
Radiation; carries a risk of future malignancies.
Young children need sedation (not to move).
Need IV contrast:
Allergies.
Renal failure.
Sometime it is used to diagnose appendicitis, especially if an abscess is suspected.
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Good for:
Abscess (late appendicitis), very accurate. G
Tumors.
If the history and examination don't suggest appendicitis:
Low probability; observe and reevaluate:
NPO, no analgesia, repeated examination and CBC.
If appendicitis, it will become clear (worse inflammation).
High probability:
Laparoscopic or open appendicectomy.
5-10% can be normal.
When normal:
Look for other differential diagnosis.
Do appendicectomy to avoid confusion and delay in diagnosing appendicitis
in the future.

Late presentation (ruptured):

Contained, abscess formation:
Percutaneous drainage and antibiotics.
Don not do surgery when abscess present because it is so inflamed.
After 6 weeks if the abscess disappears, do appendicectomy.

Diffuse peritonitis:
Because immunity is not optimum.
Resuscitation is first, iv fluid and antibiotics, then
Laparotomy or laparoscopy.
Abdominal washout.
Appendicectomy.

NOTE:
 If the patient is sick, has a rigid abdomen, and septic, then you
have to operate to prevent the occurrence of septic shock.
 Findings in the ultrasound, the appendix is non compressible
tubular structure, more than 7-10 cm in diameter (depends on the age),
and it is tender on pressure.

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Intussusception
Telescoping of the bowel.
The proximal becomes inside the distal part.
Caused usually by:
Hypertrophied Peyer's patches (submucosal lymphoid tissue) due to viral infection
PLP (pathological lead point):
Meckel's diverticulum.
Tumors, e.g. intestinal lymphoma.
Cystic fibrosis.
The most common site is ileocecal. G
Age 6-18 months:
If it presents later, it is likely to find PLP.

Presentation:
History of upper respiratory tract infection.
Colicky (on and off) abdominal pain.
The infant is calm between attacks. G
Current jelly stool (blood PR).
Vomiting may or may not be present
(intestinal obstruction is occurs late).

Diagnosis:
US, the best modality: G
Target sign, Donut sign.
95% accurate.
Contrast enema:
Diagnostic and therapeutic.

Treatment:
Pressure reduction:
Air is the most common (less
complications). G
Barium.
Water.
Failure of pressure reduction:
Only few patients (15%).
Next is surgical reduction, if can’t we do resection (likely PLP).
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Volvulus
75% at the first month of life, and 90% at the first year.
Malrotation is the risk for volvulus:
Small and large bowel are not fixed.
Narrow mesentery.
That’s why it is more likely to turn around itself.
Malrotation can cause or present with:
Volvulus; very dangerous (early diagnosis is
important).
Acute obstruction; common.
Chronic intermittent obstruction; rare.

Clinical findings:
Bilious vomiting. G
Pain:
If present (irritable), it is likely volvulus and ischemia.
If absent (calm), it is likely malrotation with obstruction.

Midgut volvulus:
An infant with bilious vomiting is considered as an
emergency.
Investigate (if the infant is not sick):
Upper gastrointestinal series (look for malrotation), the
most important investigation: G
No duodenal C-loop.
Duodenojejunal junction (ligament of Treitz) to the
right of vertebral column (normally it is on the left).
Duodenal obstruction.
Whirlpool or corkscrew sign (volvulus).
US:
Can diagnose volvulus (inversion of mesenteric vessels;
the artery becomes on the right).
Can’t rule out volvulus.

NOTE:
Volvulus is lethal; malrotation causes midgut volvulus which lead to midgut
intestinal death and subsequent surgical resection. Consequently, short gut
syndrome develops as a complication of surgery and it eventually lead to death
after a while.
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Time is valuable, the sooner you manage the more bowel you can save.
Treatment:
The patient should go directly for surgery if:
Can’t do investigation immediately.
Sick and has bilious vomiting.
Surgery:
Untwist (counter clock wise) to assess viability.
If there is an extensive ischemia, close and then look again 24-48 hours later.
If there is a viable small bowel, close and observe.
Ladd’s procedure:
Cut Ladd’s band.
Broaden midgut mesentery.
Place the small bowel on the right side and the colon on the left.
Appendicectomy.

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Meckel's Diverticulum
• The most common congenital malformation of the small intestine.
• It is a vestigial remnant of the omphalomesenteric, or vitelline, duct. G
• Has a "Role of two": G
 Present in approximately 2% of the population.
 Typically located 2 feet away from ileocecal valve.
 It is usually about 2 inches in length.
 Only 2% are symptomatic.

Presentation:
Lower gastrointestinal bleeding:
Ulcer from ectopic gastric mucosa.
Can cause severe bleeding.
Diverticulitis:
Like appendicitis (non shifting pain).
Intussusception (PLP).
Obstruction:
Fibrous band remnant.
Contained in the hernia of Littre.

Investigations:
Meckel's scan Tc99.
Uptake by gastric mucosa in Meckel's.

Treatment:
Laparoscopy or laparotomy.
• It is like appendicitis, and in Appendicectomy if the appendix is normal, look for
Meckel's diverticulitis. And remove it.

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Ovarian Torsion
Adolescent girls.
Acute sever abdominal pain (left or right).
US confirm diagnosis. G

Treatment:
Laparoscopy or laparotomy.
De rotate.
Assess viability:
If it is necrotic, remove it.
If it is dark, leave it.
Fix both sides. G

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