Surgical Emergencies in Childhood

This is where a segment of bowel becomes invaginated into the immediately distal bowel.¹

• Commonest cause of obstruction in infants
• Occurs in children aged 3 months to 6 years
• 66% aged <1 year old and unusual after 3 years of age^2,3
• Abdominal pain, lethargy and vomiting is reported in 78% of infants⁴
• Air enema confirms the diagnosis in the majority of cases

The 'classic' picture of intussusception might not be present i.e. abdominal pain, vomiting and redcurrant jelly stools. Relying on 'classic' features alone might delay diagnosis and this is associated with poorer outcomes.⁵

Management

Air (pneumostatic) or water (hydrostatic) reduction is successful in 82% cases⁴

NB: In successful radiographic reduction the small bowel is usually visualised before the appendix. Visualisation of the appendix before Visualisation of the small bowel may indicate that radiographic reduction is not possible and prevent further attempts. This is called the 'appendix sign'.⁶

Factors associated with increased risk of intestinal resection include:

• Abdominal distension
• Bowel obstruction on abdominal X-ray
• Hypovolaemic shock

This is complete pyloric obstruction.

• It usually presents at 3-8 weeks of age.
• It is caused by hypertrophy of a ring of muscle.
• The baby starts to vomit after every feed, characteristically becoming projectile.
• The vomit is not bile stained.
• The baby appears well and hungry, unless prolonged vomiting has produced dehydration.
• A 2 cm mass is normally palpable deeply below the liver during test feed, with the appearance of an 'olive'.
• Gastric peristaltic waves (visible through abdominal wall) confirm the diagnosis.
• Ultrasound can be used to show obstruction.²

Management

• This is by the surgical procedure Ramstedt's pyloromyomotomy. The laparoscopic route, now generally accepted as method of choice, has been shown to give a better cosmetic result without longer operation times or post-op morbidity.⁷
• Intravenous atropine has been used as a a potential medical method of management.⁸

• This is the commonest cause of abdominal emergency in boys < 2 years old.
• It is 10x more common in boys than girls.
• It is always associated congenital patent processus vaginalis, but hernia may not have been visible previously.⁹
• Examination reveals a firm lump in the groin of a crying child - that may extend into the scrotum. The child may have vomited, but is usually well.

Management

• Paediatric surgeons will repair soon after diagnosis, regardless of age or weight, in healthy full-term infant boys with asymptomatic reducible inguinal hernias.
• Premature infants with inguinal hernias are usually repaired prior to discharge from the neonatal intensive care unit (NICU), but this practice is changing, as infants are now being discharged home at much lower weights. Some surgeons prefer to postpone the surgery in these very small babies for 1-2 months to allow further growth.
• Herniotomy is all that is required with ligation and excision of the patent processus vaginalis.

It is very rare for the hernia to recur - less than 1 in 100. This is more common in children who have a wound infection after the operation or who do not avoid any excess physical activity for the first four to six weeks.

This can be difficult to diagnose, particularly if young and female. Prior treatment with antibiotics delays diagnosis and can lead to further morbidity.¹⁰
There have been attempts to formulate a predictive model to aid diagnosis.
An American paper classified patients as "low risk" if:¹¹

• White blood cell count <9.5 x 10⁹/litre
• Either no right lower-quadrant tenderness or
• A neutrophil count <54%

Patients were classified as "high risk" if:

• They had a white blood cell count >13.0x 10⁹/litre with rebound tenderness
• Or both voluntary guarding and neutrophil count >82%

This model was more reliable than clinical practice with regard to "missed" appendicitis, negative laparotomies and total number of imaging studies.

These do usually not become trapped if they pass the oesophagus. Children who present aged two years old and younger, who have a documented fever and with respiratory findings should be considered at risk for having a retained oesophageal foreign body. Children with oesophageal abnormalities may also be at risk.¹²

Management

Arrange x-ray and serial films to track the progress of radio-opaque objects.¹³
Retained oesophageal foreign bodies may cause a multitude of problems, including:

• Mucosal ulceration
• Inflammation or infection
• Paraoesophageal or retropharyngeal abscess formation
• Mediastinitis
• Empyema
• Oesophageal perforation and aorta-oesophageal fistula formation¹⁴

An acute scrotum in a child requires surgical exploration for a definitive diagnosis. A retrospective analysis of all boys less than 15 years old presenting with scrotal pain over a 2 year period revealed:¹⁵

• 27% had testicular torsion
• 57% had a torted appendage testis
• 11% had epididymitis
• 1% had fat necrosis
• 4% had no abnormality detected

29% of the torted testes were unsalvageable and required excision. Both clinical impression and doppler ultrasound scans were not reliable.