Paediatrics: Paediatric Surgery Symptoms and signs that should cause concern

Paediatric Surgery

Symptoms and signs that should cause concern

Neonates and infants

As a paediatrician you will be involved with the surgical care of newborn babies, infants, and older children. It is important that you recognize im-portant symptoms and signs that indicate a surgical emergency.

Neonatal intestinal obstruction

•   Bile-stained vomiting: the cardinal sign of an intestinal obstruction.

•   Emergency assessment: check vital signs and commence resuscitation. Pass a 10F NGT if the baby is vomiting.

•   X-ray: all children with bile-stained vomiting should have an AXR taken.

Radiology

·  Dilated bowel loops on the AXR suggest an intestinal obstruction.

•   Look for free air to indicate a perforation. In the supine film this will outline the falciform ligament (umbilical vein).

•   Be aware of the radiological appearance of a midgut volvulus (prompt diagnosis is essential if the bowel is to be salvaged.

Clinical assessment

•   Anus: make sure the baby has an anus, especially females.

•   Meconium: most babies pass meconium within 24hr of birth. Delayed passage of meconium in a baby with abdominal distension could mean Hirschsprung’s disease (HSD).

•   Rectal examination: do not perform a rectal examination, insert a suppository, or perform a rectal washout without seeking advice first because some surgeons use lower GI contrast studies for diagnosis and this may obscure the signs of HSD.

Oesophageal atresia (OA)

•   The combination of polyhydramnios and a mucousy baby is suspicious of OA.

•   Pass a 10F NGT before feeding the baby.

•   Babies with OA and a tracheo-oesophageal fistula (TOF) who are ventilated represent a surgical emergency because air escapes down the fistula causing gastric distension that cannot be relieved. These babies are at risk of gastric perforation.

Congenital diaphragmatic hernia (CDH)

Most CDHs are now diagnosed antenatally. Delivery should be arranged in a neonatal surgical centre. At delivery secure IV access so that the baby can be sedated, paralysed, and then intubated.

•   Avoid ventilating the baby with a bag and mask because this distends the stomach.

•   If the diagnosis is not made prenatally, suspect CDH in a baby with respiratory distress and apparent dextrocardia

Intussusception in infants

Suspect intussusception in any infant with gastroenteritis who is not get-ting better, is unusually miserable, vomits bile or has blood in the stool (The classical presentation is an infant with:

• intermittent colicky abdominal pain;

• episodic drawing up of the knees;

• passes ‘red currant jelly’ stool (late sign).

Assessment

• Resuscitation: these patients often require large volumes of fluid to restore the circulation.

• Confirm diagnosis by US.

• Do not consider radiological reduction unless you have a surgeon and anaesthetist who are able to operate on the child in the event of perforation or failure.

Incarcerated inguinal hernia

An irreducible swelling in the groin in a baby who is ill and vomiting is probably an incarcerated inguinal hernia.

• Resuscitate the baby.

• Pass a NGT.

• AXR may clarify the diagnosis by showing an intestinal obstruction and a gas shadow in the bowel trapped in the hernia.

• Transfer to a paediatric surgeon; do not wait overnight.

Older children

Acute appendicitis

Be wary of children with abdominal pain who are taking antibiotics for a presumed sore throat or UTI. The diagnosis may be appendicitis, but the history will be atypical and the abdominal signs are difficult to decipher or absent.

• Observe: admit the child for observation.

• Urine: urinalysis is abnormal in 30% of children with acute appendicitis. Resist the temptation to assume the diagnosis is a UTI unless the urine culture is positive.

• US: request an US scan if there is clinical doubt.

• Pelvic appendicitis: presentation is with diarrhoea and the abdominal signs will be minimal or absent. Exclude a pelvic abscess with US before assuming the diagnosis is gastroenteritis.

Acute scrotal pain

Any boy with acute scrotal pain has a testicular torsion until proven oth-erwise.

• Refer all these children to a surgeon.

The medicolegal consequences of missing a torsion are substantial.