Dr.

Samer Al-Hakkak

Ph.D.(General surgeon)

FRCS, FACS

COMMON PAEDIATRIC SURGICAL CONDITIONS ((Continue))

D-Intussusception
Most intussusceptions in children are seen from two months to two years of age. They are
life-threatening. Intussusception typically causes a strangulating bowel obstruction, which
can progress to gangrene and perforation.

Intussusception is classified according to the site of the intussusceptum

and intussuscipiens. In children, more than 80 % are ileocolic,beginning several centimetres

proximal to the ileocaecal valve with their apex found in the ascending or transverse colon.

In the majority, the cause is hyperplasia of Peyer’s patches (lymphoid tissue), which may be
secondary to a viral infection. In 10 % of children, intussusception is secondary to a

pathological lead point, such as a Meckel’s diverticulum, enteric duplication cyst or even a
small bowel lymphoma. Such cases are more likely in children over the age of two years and
in those with recurrent intussusception. Classically, a previously healthy infant presents with
colicky pain and vomiting (milk, then bile). Between episodes, the child initially appears
well. Later, they may pass a ‘redcurrant jelly’stool. Clinical signs include dehydration,
abdominal distension and a palpable sausage-shaped mass in the right upper
quadrant.Rectal examination may reveal blood or rarely the apex of an intussusceptum.

A plain radiograph is rarely requested but if done it commonly shows signs of small bowel
obstruction and a soft-tissue opacity. Diagnosis is confirmed on an abdominal ultrasound.

After resuscitation with intravenous fluids, broad-spectrum antibiotics and nasogastric

drainage, non-operative reduction is attempted using an air enema. Successful reduction
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is recognised if air flows into the small bowel, together with later resolution of symptoms
and signs. An air enema is contraindicated if there is peritonitis, perforation or shock.

More than 70 per cent of intussusceptions can be reduced nonoperatively.

Strangulated bowel and pathological lead points are unlikely to reduce. Perforation of the
colon during pneumatic reduction is a recognised hazard, but is rare. Recurrent
intussusception occurs in up to 5 per cent of patients after nonoperative reduction.

If an operative reduction is needed, this is usually performed open. The intussusception is

milked distally by gentle compression from its apex. Both the intussusceptum and the

intussuscipiens are inspected for areas of non-viability. An irreducible intussusception or one

complicated by infarction or a pathological lead point requires resection and primary

anastomosis.

E-Acute abdominal pain in children over three years of age

Between 1/3 and 1/2 of children admitted to hospital with acute abdominal pain have non-
specific abdominal pain, Another 1/3 have acute appendicitis. Relatively benign conditions,
such as constipation and urinary tract infection (UTI), account for most of the remainder.

A small proportion of children have more serious pathology.

1-Acute non-specific abdominal pain (NSAP)

The clinical features of (NSAP) are similar to acute appendicitis, but the pain is poorly
localised, not aggravated by movement and rarely accompanied by guarding. The site and
severity of maximum tenderness often vary during the course of repeated examinations.
Symptoms are typically self-limiting within 48 hours.

The aetiology is obscure, but viral infections and transient intussusception account for some
cases. Viral infections can cause reactive lymphadenopathy, fever and diffuse abdominal
pain.

2-Acute appendicitis and its pitfalls

Classically, there is anorexia and a few episodes of vomiting with central abdominal pain
which settles in the right iliac fossa. In

early acute appendicitis, there is a fever of 37.3–38.4°C and localised tenderness. Finding
persistent guarding in the right iliac fossa on repeated examination is the key to making the
diagnosis and distinguishing it from NSAP which usually resolves over 24 to 48 hours.

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NSAP does not have persistent guarding.

Acute appendicitis is a clinical diagnosis and investigations may help, but cannot replace
regular expert clinical review. The pitfalls include wrongly making the diagnosis of
gastroenteritis when there are loose stools or attributing pain on micturition and pyuria to a
UTI. Both of these can occur when there is a pelvic appendicitis or a pelvic collection.
Consider also referred pain from a possible right lower lobe pneumonia and remember that
if antibiotics have been given the signs may be subdued and presentation can be delayed.

The diagnosis can be difficult in those under five years of age. However, many patients
under the age of five present with a perforated appendix, not because the diagnosis is made
late but rather the omentum is less well developed and inflammation is not well contained.

The treatment starts with resuscitation with intravenous fluids, analgesia and broad-
spectrum antibiotics.Appendicectomy can be performed laparoscopically or through

a muscle-splitting right iliac fossa incision. An appendix mass in a child who is not
obstructed may respond to conservative management with antibiotics and an interval
appendicectomy can be considered 6 weeks later.

3-Other causes of acute abdominal pain in children

a-Intestinal obstruction.( intussusception, inguinal hernia, adhesions and secondary to a
Meckel’s diverticulum).

b-Constipation Constipation is more often a cause of acute abdominal pain in a child who

has been treated for Hirschsprung’s disease or an anorectal malformation.

c-Urinary tract disorders. Boys with pelviureteric junction obstruction can present with
acute or recurrent abdominal pain and no urinary symptoms.

d-Gastroenteritis May cause colicky abdominal pain. Onset of pain before the diarrhoea
and the presence of lower abdominal tenderness should raise the suspicion of appendicitis

e-Tropical diseases. Ascariasis, typhoid and amoebiasis can cause acute abdominal pain.

f-Rare causes Henoch–Schönlein purpura, sickle cell disease,primary peritonitis, acute

pancreatitis, biliary colic, testicular torsion.

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4-Urinary tract infection

may be due to a urinary tract abnormality which may carry a risk of developing
renal scarring from ascending infection. Infection and obstructionis particularly
hazardous. Older children complain of dysuria and frequency, whereas infants present with
vomiting, fever and/or poor feeding. Urine specimens from children are easily contaminated
during collection and results must be interpreted with care. A proven infection is
investigated by an ultrasound scan. Micturating cystography and radioisotope renography
are helpful in excluding vesicoureteric reflux and renal scarring.

Treatment aims to relieve symptoms, correct causes and prevent renal scarring.

F-Anorectal problems
1- Constipation

The passage of hard or infrequent stools is common in children in the West. Severe
constipation may be secondary to an anal fissure, Hirschsprung’s disease, an anorectal
malformation or a neuropathic bowel. In the absence of specific underlying pathology,

the child is best managed jointly with a paediatrician using a combination of diet, extra
fluids, reward systems, laxatives and,in some cases, psychological intervention.

2- Rectal prolapse
Mucosal rectal prolapse can occur in toddlers and is exacerbated by straining or squatting
on a potty. It is typically intermittent and frequently self-limiting. The differential diagnosis
includes a prolapsing rectal polyp. Underlying factors such as constipation should be
treated. Recurrent symptomatic prolapse usually responds to injection sclerotherapy.

3- Rectal bleeding
Unlike in adults, malignancy is an exceptionally rare cause of rectal bleeding. In newborns,
the life-threatening causes are malrotation and necrotising enterocolitis and in older infants

and children, intussusception. The quantities of blood loss are small, but the conditions
serious. Other causes include anal fissures, juvenile polyps and certain gastroenteritides
(e.g. Campylobacter infection). The four-year-old patient who presents with an Hb of 4 gm/

dL will most likely have bled profusely from an ulcer adjacent to a Meckel’s diverticulum
containing ectopic gastric mucosa. A technetium scan may confirm the presence of ectopic
gastric mucosa A Meckel’s diverticulum may also be complicated by an obstructing band

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between the diverticulum and the umbilicus, diverticulitis, intussusception,intestinal
volvulus or perforation.

Swallowed foreign bodies

Coins are the most frequently swallowed foreign bodies in children.Once beyond the cardia,
they are usually passed in a few days. A plain radiograph of the abdomen, chest and neck
should establish the site of radio-opaque objects. Oesophageal objects can be removed
endoscopically under general anaesthesia.Button batteries must be removed within hours. If
they remain in the oesophagus they can cause gastrointestinal perforation into the trachea.
Batteries in the stomach are either removed urgently or followed very closely with repeat x-
rays over a couple of days. The need to remove sharp objects depends on their

size, the age of the child and their position in the gut. Ingested magnets can cause entero-
enteric fistulae when they fix to one another in adjacent loops of bowel.