Acute Surgical Problems in Children

Segment of bowel becomes invaginated into immediately distal bowel.

• Commonest cause of obstruction in infants.
• Occurs in children aged 3 months to 6 years.
• 66% aged <1. Unusual after age 3 years.¹
• The combination of abdominal pain, lethargy and vomiting is reported in 78% of infants.²
• Air enema confirms the diagnosis of intussusception in the great majority cases.
• Air (pneumostatic) or water (hydrostatic) reduction is successful in most cases (82%).²
• In successful radiographic reduction the small bowel is usually visualized before the appendix. Visualization of the appendix before visualization of the small bowel may indicate that radiographic reduction is not possible and prevent further attempts. This is called the'appendix sign'.³

Factors associated with increased risk of intestinal resection include;

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

This is complete pyloric obstruction

• Presenting at 3-8 weeks of age
• Due to hypertrophy of a ring of muscle
• Baby starts to vomit after every feed
• Characteristically becoming projectile
• Vomitus not bile stained
• Baby appears well and hungry unless prolonged vomiting has produced dehydration
• 2cm mass normally palpable deeply below liver during test feed. Appearance of an 'olive'.
• Gastric peristaltic waves visible through abdominal wall confirm diagnosis.
• Ultrasound can be used to show obstruction.¹

Management is 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.⁴
Intravenous atropine has been used as a a potential medical method of management.⁵

• Commonest cause of abdominal emergency in boys < 2 years
• 10x more common in boys than girls
• Always associated congenital patent processus vaginalis but hernia may not have been visible previously.⁶
• Examination reveals a firm lump in groin of crying child (that may extend into scrotum). May have vomited but is usually well.
• Management is surgical.
• 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.⁷There have been attempts to formulate a predictive model to aid diagnosis.
A recent American paper ⁸classified patients as "low risk" if ;

• White blood cell count <9.5 x 10 9/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 10 9/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.

Usually does not become trapped, if it passes the oesophagus.
Arrange x-ray, and serial films can track progress of radio-opaque objects.
Mercury batteries are dangerous and need urgent removal.
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 formation.⁹

An acute scrotum in a child requires surgical exploration for a definitive diagnosis. A recent retrospective analysis¹⁰ of all boys less than 15 years old presenting with scrotal pain over a 2 year period revealed

• 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.