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    Pediatric Surg Trans

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    Sven Ordanza
    This document summarizes several pediatric surgical conditions: 1) Intussusception is the telescoping of one intestinal segment into another and is most commonly ileocolic. It typically occurs in infants 5-9 months old and causes abdominal pain and vomiting. Diagnosis is with ultrasound or contrast enema and treatment is usually non-operative hydrostatic or air reduction. 2) Hirschsprung's disease is a congenital absence of ganglion cells in the colon causing constipation. It results from failed migration of neuroenteric cells during development. Symptoms include chronic constipation and abdominal distention. 3) Anorectal malformations involve anomalies of the anus and rectum that can

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    Pediatric Surg Trans

    Uploaded by

    Sven Ordanza
    73 views4 pages
    This document summarizes several pediatric surgical conditions: 1) Intussusception is the telescoping of one intestinal segment into another and is most commonly ileocolic. It typically occurs in infants 5-9 months old and causes abdominal pain and vomiting. Diagnosis is with ultrasound or contrast enema and treatment is usually non-operative hydrostatic or air reduction. 2) Hirschsprung's disease is a congenital absence of ganglion cells in the colon causing constipation. It results from failed migration of neuroenteric cells during development. Symptoms include chronic constipation and abdominal distention. 3) Anorectal malformations involve anomalies of the anus and rectum that can

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    This document summarizes several pediatric surgical conditions: 1) Intussusception is the telescoping of one intestinal segment into another and is most commonly ileocolic. It typically occurs in infants 5-9 months old and causes abdominal pain and vomiting. Diagnosis is with ultrasound or contrast enema and treatment is usually non-operative hydrostatic or air reduction. 2) Hirschsprung's disease is a congenital absence of ganglion cells in the colon causing constipation. It results from failed migration of neuroenteric cells during development. Symptoms include chronic constipation and abdominal distention. 3) Anorectal malformations involve anomalies of the anus and rectum that can

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    73 views4 pages

    Pediatric Surg Trans

    Uploaded by

    Sven Ordanza
    This document summarizes several pediatric surgical conditions: 1) Intussusception is the telescoping of one intestinal segment into another and is most commonly ileocolic. It typically occurs in infants 5-9 months old and causes abdominal pain and vomiting. Diagnosis is with ultrasound or contrast enema and treatment is usually non-operative hydrostatic or air reduction. 2) Hirschsprung's disease is a congenital absence of ganglion cells in the colon causing constipation. It results from failed migration of neuroenteric cells during development. Symptoms include chronic constipation and abdominal distention. 3) Anorectal malformations involve anomalies of the anus and rectum that can

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    Pediatric Surgery:

    INTUSSUCEPTION, HIRSCHSPRUNG'S DISEASE AND ANORECTAL MALFORMATION

    Intussusception anatomical aberration. Often, the cecum is quite mobile,

    Telescoping of one segment to another which may predispose the insinuation of the proximal
    segment of the small bowel (ileocolic and ileoileal).
    Idiopathic or primary
    Non-idiopathic or secondary
    Clinical manifestation
    Iliocolic most common
    Sudden crampy abdominal pain in a previously well
    Appendix is almost always involved
    baby
    May have prolapse of intussusceptions into anal opening
    Screaming, drawing up of legs, pallor, sweating, and
    Ileoileal
    vomiting (reflux vomiting)
    Colocolic not very common
    Abdominal distention, baby tired after episode, vascular
    Jejunojejunal JJ type - not very common associated with compromise, sloughing of mucosa
    post-operative conditions, initial surgery usually not
    Can palpate sausage-shaped mass in empty RLQ
    associated with intussuception
    Well and hungry in between
    Bilious vomiting
    Incidence
    Currant Jelly Stools bloody, mucoid stools
    Majority are idiopathic
    Dance sign
    Between 5-9 months of life (90%) but can be 3-24
    Often referred late in the course of the disease due
    months
    to wrong impression, wrong diagnosis, and wrong
    >50% occur within <1 year old
    management
    10-20% occur in 2 year old
    M:F = 3:2
    Diagnosis
    History and PE
    Pathogenesis
    Abdominal x-ray - distended bowel loops
    Marked hypertrophy of the lymphoid tissue
    Barium / air enema coiled-spring sign, diagnostic and
    Occur in the wake of URTI/AGE
    therapeutic, except if disease process is:
    Adenovirus/rotavirus also implicated
    More than 48 hours
    Different caliber of the lumens cannot explain all cases
    Patient is already febrile
    of intussusception
    Already with peritoneal signs
    2-12% with anatomic lead points Already repeated bilious vomiting which
    Literature: Usually in the rainy season in the Philippines, signifies frank intestinal obstruction
    along with other viral infections (URTI, acute Ultrasound
    gastroenteritis) viruses possibly have something to do
    Pseudo-kidney appearance means
    with intussusception. No common virus that can be
    intussusception is still active
    isolated.
    Tire/donut sign means already has
    Literature: Noticed that majority of patients with
    spontaneous reduction, represents thickened
    intussusception have some form of a high peristaltic stage
    bowel wall
    due to viral acute gastroenteritis possible predisposition
    to intussusceptions.
    Literature: Intussusception could be associated with an

    2016 SURGICAL BLOCK page 1 of 4


    Pediatric Surgery:
    INTUSSUCEPTION, HIRSCHSPRUNG'S DISEASE AND ANORECTAL MALFORMATION

    Treatment Hirschsprungs Disease


    Resuscitation Identifying Patients
    Hydrate Before, it was typical to see a malnourished patient
    Correct electrolyte imbalances with big belly who is chronically constipated
    Prepare blood for possible OR Because of availability of fast food, appearance of
    patients are totally different well-nourished, heavier
    Non-operative management side, normal looking, constipated
    Barium/air reduction done under double set up,
    meaning you repair as if you are going to operate, Embryology
    success rate as high as 85% in early intussusception (as Neuroenteric cells migrate distally along the course of
    high as 92% in a study in China) the vagus nerve by end of 1st trimester, entire GIT is
    Big bore needle into intestine innervated

    Infuse barium with pressure or just by gravity 5th week AOG esophagus

    Air reduction infuse between 60-90 mmHg, as high as 7th week AOG midgut
    120 mmHg 12th week AOG complete migration
    Done under fluoroscopy, monitor reduction real-time Transmural migration
    Principle: try to push intussusception out
    Observe for 12 hours, feed patient, send patient home Pathophysiology

    If failure of barium reduction, need to operate manual Absence of ganglion cells

    reduction Meissners submucosal


    Auerbach intermyenteric
    Operative management Henle submucosal
    Manual reduction gently milk distal segment Histologic diagnosis, no skip lesions all or none
    Resection / EEA (end-to-end anastomosis) if already Peristalsis - If a bulk of feces is introduced in the colon,
    ischemic and cant manually reduce the distal portion relaxes then proximal portion
    Appendectomy appendix is involved and supplied contracts
    by end-artery of ileocolic artery, may predispose to If you denervate skeletal muscle, the effect is flaccid
    development to appendicitis later on due to ischemia paralysis (i.e. post-stroke patients who cannot move
    (but then how can you explain successful reduction by their extremities)
    barium enema with appendix still there?); small If you denervate smooth muscle, the effect is spastic
    babies with incision on right side, if baby develops paralysis.
    abdominal pain later in life, someone may rule out If you Hirschsprungs in distal portion of GIT, distal
    appendicitis due to seeing scar in RLQ portion will not relax because it is denervated and has
    spastic paralysis causes obstruction and constipation
    Early recognition and diagnosis is a must Loss of intrinsic enteric inhibitory nerves
    Recurrence rate is 3-5% Short segment in 80-85% - involves rectum and
    sigmoid
    Beyond sigmoid long segment

    2016 SURGICAL BLOCK page 2 of 4


    Pediatric Surgery:
    INTUSSUCEPTION, HIRSCHSPRUNG'S DISEASE AND ANORECTAL MALFORMATION

    Involves entire colon total colonic aganglionosis 1st 24 hours


    Ultra short segment / internal sphincter achalasia Failure to pass meconium within the 1st 24 hours of life
    only the internal sphincters are aganglionic 95% of patients with Hirschsprungs
    2 major group of sphincters Severity of constipation vary between patients
    External striated Explosive discharge of fluid stools and air on DRE
    Internal smooth muscles Enterocolitis
    At end of GIT (anal area) Complete obstruction at birth
    Delayed passage of meconium followed by repeated
    Etiology obstruction
    Exact etiology is not known Mild constipation followed by acute obstruction
    Genetic cause Mild symptoms followed by enterocolitis
    May affect more than one sibling Mild chronic constipation
    Sibling or index patients; female = 360x, male
    130x Diagnostic
    The longer the disease, the higher the rate of History and PE
    familial incidence Radiography
    Plain abdominal x-ray
    Genetic Etiology Barium enema
    Deletion of I0q11.2 and q21.2 Anorectal manometry
    13q22 recessive susceptibility locus Rectal biopsy
    Error in endothelin B receptor gene (EDNRB) exon 4
    RET protooncogene, a transmembrane receptor Treatment
    Control of normal cell growth and development, Non-surgical
    enteric nervous system NGT
    MEN 2A and 2B Colonic washout
    Surgical
    Incidence
    3 stage procedure
    1:2000 live births, 70-80% are males
    2 stage procedure
    Familial predisposition
    1 stage procedure (open, laparoscopic, incisionless)
    25% with associated anomalies in familial case
    Pull through procedures
    Most are isolated in non-familial case
    Swenson
    Observed in all races but less common in blacks
    Soave
    Scott-Boley
    Clinical Presentation
    Duhamel
    Most present with intestinal obstruction or
    Transanal (incisionless)
    constipation severity of constipation may vary among
    individuals
    95% of normal full-term babies will pass meconium in

    2016 SURGICAL BLOCK page 3 of 4


    Pediatric Surgery:
    INTUSSUCEPTION, HIRSCHSPRUNG'S DISEASE AND ANORECTAL MALFORMATION

    Anorectal Malformation Treatment

    Incidence Low Lesions = Perineal Anoplasty

    Exact cause is not known High Lesions

    I:4,000 5,000 live births Colostomy at birth

    2/3 of males have high lesion PSARP* at 4-6 months

    2/3 of females have low lesions Closure of Colostomy after 3 months

    VACTERL association *Posterior Sagittal AnoRectoplasty

    Diagnosis
    History

    PE

    Classification
    History & PE
    Radiography
    Babygram
    Invertogram (Rice-Wangesteen)
    Prone Cross-Table Lateral View
    Perineal / Hypogastric Ultrasound
    Contrast Studies
    Anatomic
    High
    Intermediate Levator Ani muscle
    Low
    Radiographic
    High Type = > 1cm
    Low Type = > 1cm
    Rectovestibular Fistula
    Rectovaginal Fistula
    Persistent Cloaca
    Rectourethral Fistula
    Rectoprostatic Fistula
    Rectovesical Fistula

    2016 SURGICAL BLOCK page 4 of 4

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