Pediatric Annals

A Surgeon in Your Corner: Managing office-based surgical emergencies

Christopher P Coppola, MD

Abstract

MIDGUT VOLVULUS

Bilious vomiting indicates that contents of the post-pyloric gastrointestinal tract are being regurgitated into the stomach. The worst-case scenario associated with this symptom is malrotation of the intestinal tract and volvulus of the midgut This represents a true surgical emergency whose outcome is determined by how quickly the patient is transferred to the care of a pediatric surgeon.

Proper rotation of the midgut during intrauterine development causes the fourth portion of duodenum to become fixed in the left upper quadrant and the cecum to attach to the right lower quadrant. This leaves a long base of mesentery along a diagonal line from the left upper quadrant to the right lower quadrant like a row of hedges.

With malrotation, the duodenum and cecum are attached more closely than usual with Ladd's bands. Also, the base of the mesentery is a narrow stalk like the stem of a flower, rather than like a hedge row. This narrow mesentery of malrotation is prone to twist upon itself, blocking both the flow of succus within the intestine and its blood supply. If this condition is not corrected quickly, irreversible ischemia to the midgut may occur. Even if the child survives, he or she may infarct all the small intestine, with resultant short-gut syndrome.

Volvulus of the midgut can occur in an individual with malrotation at any time of life, from within the womb to rare reported cases in the eighth decade.1 Volvulus most typically occurs within the first month of life and must be ruled out in any child who exhibits bilious vomiting. It is important to ask the parents to describe the vomitus. It is even better if they have brought a sample on a cloth or the baby's clothes. It also is important to determine if the child has had a previous history of vomiting.

Examination sometimes reveals a child with signs of distress, dehydration, and abdominal distention but also may be normal. Neonates with volvulus may have a scaphoid abdomen due to the proximal obstruction of bowel. Blood should be drawn for electrolytes to ensure there are no derangements that need to be corrected before surgery. Plain radiographs of the abdomen occasionally show distended loops proximal to volvulus but also may be normal.

Bilious vomiting requires urgent consultation by a pediatric surgeon, typically in the emergency department or inpatient setting. Additionally, an upper gastrointestinal fluoroscopy series must be arranged as soon as possible. The surgeon may wish to be present while the study is performed. Barium contrast is best to give a definitive view of the sweep of the duodenum and to diagnose malrotation. However, the surgeon may wish the study to be done with watersoluble contrast or even rarely omitted if perforation is suspected.

Surgical treatment consists of immediate Ladd's procedure. The four components of Ladd's procedure are untwisting of the intestine, division of Ladd's bands between duodenum and cecum, derotation of the gut (leaving small bowel on right and colon on left, and appendectomy (because the new position of the appendix in the left upper quadrant will make the presentation of future appendicitis atypical). If malrotation is discovered incidentally in an absolutely asymptomatic child, it should be repaired electively.2 However, on closer scrutiny, most children with malrotation have subtle symptoms that justify urgent repair.

PYLORIC STENOSIS

In hypertrophic pyloric stenosis, the nature of the vomiting is different. Vomitus is undigested food and usually follows meals immediately or shortly thereafter. The peak incidence of presentation is ages 4 to 6 weeks, but the disease can occur in newborns and patients as old as 12 weeks.3,4 Parents describe a…

Pediatric surgical emergencies represent a small fraction of visits to an outpatient primary care pediatric setting. Although children often are unable to fully articulate their symptoms, the progression of most pediatric surgical emergencies is so typical that interviewing the parents with the right questions usually is more than sufficient to determine the diagnosis.

When children present with these emergencies, rapid recognition and coordination of care with a pediatric surgeon is needed. Transfer to an inpatient setting typically is required.

The clinical presentation, diagnostic evaluation, and surgical treatment of midgut volvulus, pyloric stenosis, incarcerated hernia, intussussception, appendicitis, and airway/esophageal foreign objects are discussed in this article. The Table (see page 904) provides a summary of typical characteristics of these common pediatric surgical emergencies.

Table

TABLE.Typical Characteristics of Common Pediatric Surgical Emergencies

TABLE.

Typical Characteristics of Common Pediatric Surgical Emergencies

MIDGUT VOLVULUS

Bilious vomiting indicates that contents of the post-pyloric gastrointestinal tract are being regurgitated into the stomach. The worst-case scenario associated with this symptom is malrotation of the intestinal tract and volvulus of the midgut This represents a true surgical emergency whose outcome is determined by how quickly the patient is transferred to the care of a pediatric surgeon.

Proper rotation of the midgut during intrauterine development causes the fourth portion of duodenum to become fixed in the left upper quadrant and the cecum to attach to the right lower quadrant. This leaves a long base of mesentery along a diagonal line from the left upper quadrant to the right lower quadrant like a row of hedges.

With malrotation, the duodenum and cecum are attached more closely than usual with Ladd's bands. Also, the base of the mesentery is a narrow stalk like the stem of a flower, rather than like a hedge row. This narrow mesentery of malrotation is prone to twist upon itself, blocking both the flow of succus within the intestine and its blood supply. If this condition is not corrected quickly, irreversible ischemia to the midgut may occur. Even if the child survives, he or she may infarct all the small intestine, with resultant short-gut syndrome.

Volvulus of the midgut can occur in an individual with malrotation at any time of life, from within the womb to rare reported cases in the eighth decade.1 Volvulus most typically occurs within the first month of life and must be ruled out in any child who exhibits bilious vomiting. It is important to ask the parents to describe the vomitus. It is even better if they have brought a sample on a cloth or the baby's clothes. It also is important to determine if the child has had a previous history of vomiting.

Examination sometimes reveals a child with signs of distress, dehydration, and abdominal distention but also may be normal. Neonates with volvulus may have a scaphoid abdomen due to the proximal obstruction of bowel. Blood should be drawn for electrolytes to ensure there are no derangements that need to be corrected before surgery. Plain radiographs of the abdomen occasionally show distended loops proximal to volvulus but also may be normal.

Bilious vomiting requires urgent consultation by a pediatric surgeon, typically in the emergency department or inpatient setting. Additionally, an upper gastrointestinal fluoroscopy series must be arranged as soon as possible. The surgeon may wish to be present while the study is performed. Barium contrast is best to give a definitive view of the sweep of the duodenum and to diagnose malrotation. However, the surgeon may wish the study to be done with watersoluble contrast or even rarely omitted if perforation is suspected.

Surgical treatment consists of immediate Ladd's procedure. The four components of Ladd's procedure are untwisting of the intestine, division of Ladd's bands between duodenum and cecum, derotation of the gut (leaving small bowel on right and colon on left, and appendectomy (because the new position of the appendix in the left upper quadrant will make the presentation of future appendicitis atypical). If malrotation is discovered incidentally in an absolutely asymptomatic child, it should be repaired electively.2 However, on closer scrutiny, most children with malrotation have subtle symptoms that justify urgent repair.

PYLORIC STENOSIS

In hypertrophic pyloric stenosis, the nature of the vomiting is different. Vomitus is undigested food and usually follows meals immediately or shortly thereafter. The peak incidence of presentation is ages 4 to 6 weeks, but the disease can occur in newborns and patients as old as 12 weeks.3,4 Parents describe a 1- to 2-week increase in forcefulness of vomiting. Classic projectile vomiting is not seen in all cases, but the timing of the vomiting is after every meal. Parents report that it seems that all food eaten (or even more!) is regurgitated. A small number comment on the presence of succession waves, which are undulations of exaggerated gastric peristalsis visible on the surface of the abdomen.

The accuracy of high-definition ultrasonography largely has supplanted the diagnosis of pyloric stenosis by physical examination. If examination is attempted, the baby must be calm with a relaxed belly. Techniques including having the mother or father hold the child in the lap, diaper removed, with legs pointing upward and flexed at the hips. The enlarged pylorus will be an olive-like mass with a horizontal lie, best palpated by moving the fingers in a vertical direction up or down over the right upper quadrant. The rib margin, liver edge, and upper pole of the right kidney all can be mistaken for an enlarged pylorus.

To appreciate succussion waves, the best results are obtained by emptying the stomach with a ten frenen nasogastric tube and stimulating gastric peristalsis with a sugar binkie (four by four sponge oentaining a packet of sugar, gathered into a nipple-shape with a rubber band and moistened with tap water). However, ultrasonography achieves a more accurate diagnosis, so this technique has declined in use. Positive criteria on ultrasonography vary by center, but common determinants are pylorus muscle thickness (one side of channel) of 3.5 mm, pylorus channel length of 16 mm, and typical shape of the hypertrophied pylorus bulging out on one side like a kidney bean.5,6

When pyloric stenosis is suspected or diagnosed, the patient should be seen by a pediatric surgeon that same day. The treatment is pyloromyotomy. Although the condition is a surgical emergency and can lead to severe dehydration or even death in rare cases, the operation itself is not an emergency. Prolonged vomiting can result in hypochloremic hypokalemic metabolic alkalosis, which must be corrected before the operation is performed.

INCARCERATED HERNIA

Inguinal hernia is the most common condition requiring surgical repair in children.7 Hernia repairs, inguinal and umbilical combined, represent a large portion of operations performed by pediatric surgeons. Inguinal hernia is more common in boys and premature neonates.8 Inguinal hernias do not resolve spontaneously, and all need repair.

The majority of umbilical hernias in children resolve spontaneously and should not be repaired unless incarcerated, symptomatic, extremely large (proboscis-type, or shaped like an elephant's trunk), or persistent past age 2. Reducible hernias do not require urgent surgical attention, and the child can be referred to a pediatric surgeon on an elective basis within a month or so.

Surgical consultation can help differentiate hernias from alternate diagnoses, such as hydrocele, varicocele, and inguinal lymphadenopathy. Additionally, parents can be counseled, and surgery can be scheduled if indicated. An incarcerated hernia or a painful scrotum, however, represents a surgical emergency and must be evaluated within hours by a pediatric surgeon.

Parents of a child with an incarcerated hernia often know the hernia exists because it usually does not present intially as incarcerated. In these cases, the parent will describe that the hernia bulge is harder and larger than usual. The child is fussy and uncomfortable but is not in severe pain except while the hernia is being manipulated. Appetite is decreased, and in cases of intestinal obstruction from the incarceration, the child may have vomited.

Unless the clinician takes off the diaper, the diagnosis will be missed. Often, examination of the abdomen is completely normal. Examination of the groin begins on the normal side with a check of the testicles and spermatic cord, feeling for any other contents in the scrotum. Next, the clinician should follow the spermatic cord up over the pubic tubercle and laterally across the groin. Here, it enters the external inguinal ring just superior to the line of the inguinal ligament. A hernia should begin at the external inguinal ring and extend as a continuous mass inferiorly. In contrast, a hydrocele is an isolated sac that transüluminates with a penlight, and a varicocele is a spongy enlargement of the spermatic cord vessels. Although it may take examination by a pediatric surgeon or urologist to be certain of these diagnoses, hydroceles and varicoceles do not require urgent attention.

If there is no mass in the scrotum but instead an enlarged and tender testicle, the alternate diagnosis of testicular torsion must be ruled out with ultrasonography. Testicular torsion is a surgical emergency, and delay can threaten the viability of the testicle. If a hernia is identified, it must be reduced by squeezing upward from the scrotum using three or more fingers. This is much like squeezing toothpaste from a tube or squeezing an egg out of a sock. The technique is similar for reducing a groin hernia in a female or an umbilical hernia.

A hernia cannot be called incarcerated until is it not reducible by the surgeon. Often, it is just a matter of applying enough brute force to squeeze the hernia back in After warning the parents, attempts at reducing the hernia should be made but limited in number and duration to minimize pain experienced by the child. It is worth the pain to have the most experienced clinician make an earnest attempt to reduce the hernia, because success converts a surgical emergency to an elective case. In a small fraction of cases, reduction of an incarcerated hernia is possible only with the application of moderate to deep sedation.

Necrosis of bowel can occur in a matter of hours if an incarcerated hernia is not reduced. There is a traditional surgical dictum that necrotic bowel cannot be reduced, but rare exceptions to this rule have been observed.9 For this reason, it is of value to observe patients overnight after reducing a particularly stubborn hernia with sedation If the hernia can be reduced, its repair should occur in 3 to 5 days to allow better visualization of tissues once swelling has subsided, thereby reducing the risk of recurrence or injury to the vas deferens. If the hernia cannot be reduced, emergent repair is indicated.

INTUSSUSSCEPTION

The peak incidence of intussussception is ages 6 to 10 months, but the condition should be considered in children ages 6 months to 3 years.10 The pathognomonic "currant jelly stool" does not occur in all cases, and gross blood per rectum can be minimal or absent Parents may report that the child has periods of distress, abdominal pain, and crying alternating with periods of lethargy and decreased interactivity. Diarrhea is common, and the differential diagnosis includes viral gastroenteritis and bacterial enteritis.

On examination, the child typically appears lethargic and may experience an episode of colicky pain and crying. The abdomen usually is tender but without peritoneal signs. The intussussceptum, which is most often the terminal ileum entering the right colon, occasionally can be palpated as a mass, usually in the right upper quadrant. This is described as the empty right lower quadrant syndrome, or Dance's sign.

Plain radiographs of the abdomen may show distended loops of small bowel proximal to the terminal ileum and an empty right lower quadrant. The colon is empty or has a small amount of scattered gas. In fact being able to visualize air in the cecum nearly rules out the diagnosis. Because the cecum is retroperitoneal, this effect can be emphasized by taking a plain radiograph of the abdomen with the patient in the prone position.

Intussussception is a surgical emergency that can result in perforation and necrosis of intestine if not treated in time. The condition can be diagnosed easily with ultrasonography. When diagnosed, 90% of cases can be reduced by air or water-soluble contrast enema under fluoroscopic or ultrasonographic monitoring.11 However, prior to performance of enema, a pediatric surgeon should be consulted for two reasons. First, the surgeon may feel that there are signs of perforation and peritonitis (or there may be free air on the plain film), prompting the surgeon to proceed to surgery immediately. Secondly, the surgeon may wish to be present at the enema to see it firsthand. When enema reduction of intussussception fails, treatment is operative reduction and, in rare cases, resection of necrotic bowel.

APPENDICITIS

Appendicitis is very common and can present in such varied forms, even mimicking rarer illnesses, that it is known as the "great pretender." Appendicitis is most common in the age range of 4 to 1 5, but it can occur rarely in infants, and the curve of incidence extends into adulthood.

Appendicitis is hard to differentiate from a viral illness initially, but the diagnosis is made easier with the passage of time, because the symptoms progress in severity without amelioration For this reason, appendicitis on day one has a different presentation from appendicitis on day three. It is important to match chronology with symptoms. Parents may not present with their child for evaluation until symptoms have failed to abate for a few days. There may be a prodrome of a viral upper respiratory illness before onset of abdominal pain.

Initially, patients describe fatigue, headache, loss of appetite, and malaise. As the condition progresses, abdominal pain and nausea develop, and nearly every case is accompanied by fever. Pain starts at the umbilicus, representing stimulus from the visceral peritoneum carried via the poorly discriminating celiac ganglion. When the inflammation of the appendix becomes transmural, it causes inflammation of the parietal peritoneum, resulting in focal right lower quadrant pain carried along more finely cUsaimmating somatic pain fibers. After perforation, peritonitis with diffuse pain results.

On examination, the patient should be distracted, and palpation should begin away from the right lower quadrant. Palpation is gentle, and an effective maneuver is to palpate deeper by gently shaking the viscera. As long as perforation and diffuse peritonitis have not yet developed, appendicitis is appreciated on exam as a focal right lower quadrant tenderness. Palpation results in an involuntary spasm of the abdominal muscles when the inflamed appendix is jostled. The diagnosis is often in doubt, and the evaluation is supplemented by checking for an elevated white blood cell count or left shift, as well as assessing for urinary tract infection with urinalysis and urine culture.

Overnight observation, the traditional method of assessing confusing cases, can be avoided by using either ultrasonography or contrast computed tomography. Ultrasonography of the appendix requires a practitioner experienced in the technique, but either of these modalities can diagnose appendicitis with a high degree of accuracy. Before obtaining an imaging study, it is useful to discuss the case with a pediatric surgeon.

If the child is hydrating well orally and the parents are reliable, a viable option is to monitor a questionable case as an outpatient. The patient should return the following day or if symptoms worsen. When patients cannot tolerate enteral hydration or there are doubts that the family will be able to return promptly to seek care, the patient should be monitored as an inpatient Clinicians should be especially cautious with a patient who has presented for care on multiple occasions or to multiple providers; this may indicate a missed appendicitis.

Once the diagnosis of appendicitis is made, the treatment is prompt referral to a surgeon and appendectomy. In rare cases of late presentation with a large abscess, percutaneous drainage of abscess and intravenous antibiotics with removal of the appendix after an interval of 6 weeks is appropriate.

AIRWAY/ESOPHAGEAL FOREIGN OBJECT

The usual age for presentation of an aspirated or swallowed foreign object is 9 months to 3 years. Children who are not crawling are not able to obtain foreign objects to put in their mouths unless there are older siblings in the household to do it for them. Coins are the most common objects stuck in the esophagus, while seeds and nuts are the most frequently found aspirated objects.12,13

Parents usually know that their child has swallowed a coin or other object The child may initially cough, spit and vomit but frequently will become calm after that The child usually has difficulty with oral intake, solids worse than liquids. If there is obstruction of the esophagus, such as an impaction of meat or other food, the patient cannot swallow saliva and drools constantly.

With an aspirated object the patient will continue to have cough, hoarseness, and difficulty breathing. Rarely, an aspirated object not seen by the parents will pass to a smaller bronchus and present chronically with a series of respiratory infections over a period of weeks. As aspirated foreign bodies are usually radiolucent nuts and seeds, there may have been previous chest films performed without detection of the condition.

An aspirated foreign object can be a life-threatening emergency. On presentation, the patient should be evaluated for adequacy of breathing, and basic life support measures should be initiated if needed. The patient should be transported by ambulance to an emergency department or inpatient setting for treatment. An otolaryngologist or pediatric surgeon should be contacted immediately.

An esophageal foreign object typically does not require the emergency care of an aspirated foreign object but should be evaluated and treated urgently for several reasons. It is possible for objects in the upper esophagus to dislodge and become an airway obstruction. Over time, pressure on the wall of the esophagus can cause erosion or perforation. Lastly, even when the swallowed object was witnessed by the parent, there is always the possibility that it is a watch or button battery, which can cause a caustic injury or perforation of the esophagus in a very short time.

Evaluation of an airway foreign body involves examining the patient's mouth for signs of the object or for trauma. Auscultation of the neck and chest may reveal stridor, wheezing, crepitus from airway perforation, or decreased breath sounds from either a ball-valved hyperinflated segment or from airway collapse distal to the point of a complete bronchial obstruction. Plain radiographs should be performed. Even if the child presents with previous films, new studies should be obtained because the object may have shifted during transportation Bilateral decubitus films can detect hyperinflation, the presence of a radiolucent object, and pneumomediastinum caused by perforation. Because of the D-shaped rings of the trachea, coins in the trachea lie front to back, and coins in the esophagus lie side to side. Removal of airway foreign objects should be performed only in the operating room by a skilled surgical specialist and pediatric anesthesiologist.

If a swallowed foreign object has traversed the lower esophageal sphincter into the stomach, it will likely travel through the entire gastrointestinal tract and pass the anus. Esophageal foreign objects can possibly be removed in awake patients under fluoroscopic guidance but are most reliably removed under general anesthesia in the operating room

SUMMARY

The surgical emergencies presented in this article encompass the vast majority of the nontraumatic emergencies seen by a pediatric surgeon but represent only a small proportion of surgical disease in children. Most children seeking outpatient medical care do not need a surgeon, but those who do need one quickly. When one of the processes detailed above is suspected, it is always best to avail oneself of the opinion of a surgeon in a timely manner.

REFERENCES

1 . Dietz DW, Walsh RM, Grundfest-Broniatowski S, et al. Intestinal malrotation: a rare but important cause of bowel obstruction in adults. Dis Colon Rectum. 2002;45(10):1381-1386.

2. Powell DM, Othersen HB, Smith CD. Malrotation of the intestines in children: the effect of age on presentation and therapy. / Pediatr Surg. 1989;24(8):777-780.

3. Ostlie DJ, Woodall CE, Wade KR, et al. An effective pyloromyotomy length in infants undergoing laparoscopic pyloromyotomy. Surgery. 2004;136(4):827-832.

4. Chen EA, Luks FI, Gilchrist BF, Wesselhoeft CW Jr, DeLuca FG. Pyloric stenosis in the age of ultrasonography: fading skills, better patients? J Pediatr Surg. 1996;31(6):829-830.

5. Rohrschneider WK, Mittnacht H, Darge K, Troger J. Pyloric muscle in asymptomatic infants: sonographic evaluation and discrimination from idiopathic hypertrophic pyloric stenosis. Pediatr Radiol. 1998;28(6):429-434.

6. LamM N, Athey PA, Round ME, Watson AB Jr, Pfleger MJ. Hypertrophic pyloric stenosis in the neonate - diagnostic criteria revisited. Can Assoc Radiol J. 1993;44(l):21-24.

7. Borenstein SH, To T, Wajja A, Langer JC. Effect of subspecialty training and volume on outcome after pediatric inguinal hernia repair. J Pediatr Surg. 2005;40(l):75-80.

8. DeCou JM, GaudererMW. Inguinal hernia in infants with very low birth weight. Semin Pediatr Surg. 2000;9(2):84-87.

9. Strauch ED, Voigt RW, Hill JL. Gangrenous intestine in a hernia can be reduced. J Pediatr Surg. 2002;37(6):919-920.

10. Bratton SL, Haberkern CM, Waldhausen JH, Sawin RS, Allison JW. Intussusception: hospital size and risk of surgery. Pediatrics. 2001;107(2):299-303.

11. Navarro OM, Daneman A, Chae A. Intussusception: the use of delayed, repeated reduction attempts and the management of intussusceptions due to pathologic lead points in pediatric patients. AJR Am J Roentgenol. 2004; 1 82(5): 1 169-1 176.

12. Kay M, Wy lue R. Pediatric foreign bodies and their management. Curr Gastroenterol Rep. 2005;7(3):212-218.

13. Tan HK, Brown K, McGiIl T, et al. Airway foreign bodies (FB): a 10-year review. Int J Pediatr Otorhinolaryngol. 2000;56(2):91-99.

TABLE.

Typical Characteristics of Common Pediatric Surgical Emergencies

10.3928/0090-4481-20051101-14

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