Pediatric Surgery

Topic
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Patient profile

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Admit 28 2557
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 Chief complaint

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 Present illness

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 Past history

Prenatal : G2P1 ,

Perinatal : ND
Postnatal :



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 Physical examination

GA: A Thai boy, good consciousness

V/S: BT 38.5 C ,RR 24/min,BP - PR 128/min ,pulse
full
capillary refill < 2 s.
BW 12 kg, HT 80 cm
HEENT: mild pale conjunctiva, anicteric sclera, dry
lips, no sunken eye ball
Heart: normal S1S2, no murmur.
Lung: normal breath sound equal both lung, no
adventitious sound
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 Physical examination

Inspection:
moderate distention, no visible bowel loop

Auscultation: hypoactive bowel sound

Palpation: generalized tenderness,guarding, tender

on percussion x x
X X X
X X

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 Physical examination

Musculoskeletal: WNL
Neurological examination: E4V5M6
Motor power : grade V all extremities
Sensory : intact

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Investigation
 CBC

RBC 4.12x10^6/uL WBC 24,300 /uL

Hb 9.2 g/dL. Neutrophil 77.2 %
Hct 28.2 9 % Lymphocye 14.9 %
MCV 70.2 fl. Monocyte 7.0 %
MCH 22.4 pg. Eosinophil 0.0 %
MCHC 31.9 g/dL. Basophil 0.9 %
Plt 541x10^3 /uL.
BUN 9 Electrolyte
Cr 0.40 Na+ 136 mmol/L
eGFR (CKD-EPI) 189 K+ 3.53 mmol/L
eGFR (MDRD) 372 Cl+ 95 mmol/L
CO2 24 mmol/L
 Operation
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Clinical diagnosis : Peritonitis
Post- operation :Rupture appendicitis
Operation :Explore- lap with appendectomy with lysis adhesion
Finding : - Rupture appendicitis
- Marked small bowel dilatation
- Pus fluid with fibrin coat along abdominal cavity, liver,
GB with adhesion band
Abdominal pain
in pediatrics
 Abdominal pain in pediatrics

The most common surgical cause of

abdominal pain in children is appendicitis.
Other causes may be suspected based on
symptoms and age.

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 Abdominal pain in pediatrics

Common causes of pediatric abdominal pain

Age group Diagnoses
any age intestinal malrotation/volvulus
mechanical bowel obstruction
adhesive
intraluminal foreign body (non-
neonate/infant), distal intestinal obstruction
syndrome (cystic fibrosis), constipation
Meckel diverticulitis
neutropenic enterocolitis
perforated viscus
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 Abdominal pain in pediatrics

newborn neonatal obstruction, congenital

lesion internal hernia/volvulus
omphalomesenteric duct remnant,
duplication cyst, mesenteric cyst
necrotizing enterocolitis
incarcerated inguinal hernia
infant intussusception
incarcerated inguinal hernia
nonaccidental abdominal trauma
Hirschsprung associated
enterocolitis
abdominal/retroperitoneal
neoplasm
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 Abdominal pain in pediatrics
toddler intussusception
appendicitis complicated
Hirschsprung associated
enterocolitis
abdominal/retroperitoneal
neoplasm
pre-adolescent child appendicitis
acute
complicated
gallstone complications
pigment gallstones
cholecystitis
choledocholithiasis
gallstone pancreatitis
epiploic fat torsion/infarction
omental torsion/infarction
Henoch-Schonlein purpura
viral gastroenteritis
ovarian torsion (female)
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 Abdominal pain in pediatrics
adolescent appendicitis
gallstone complications pigment
and cholesterol gallstones
cholecystitis
choledocholithiasis
gallstone pancreatitis
biliary dyskinesia
gastroesophageal reflux
inflammatory bowel disease
ovarian pathology (female)
torsion
ruptured cyst
pelvic inflammatory disease(female)
perforated gastric/duodenal ulcer
epiploic fat torsion/infarction
omental torsion/infarction
Henoch-Schonlein purpura
urinary tract infection
urolithiasis

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 Presentation

Obstruction
Peritonitis/inflammation
Mass

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 Obstruction

Cardinal sign of intestinal obstruction

-abdominal pain
-vomiting
-distension
-constipation
Cardinal sign of intestinal obstruction NB
- Polyhydramnios
- Billous vomiting
- Abdominal distension
- Delayed pass meconium
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 Obstruction
congenital
intestinal malrotation/volvulus
internal hernia/volvulus
omphalomesenteric duct
remnant/Meckel diverticulum
incarcerated inguinal hernia
intraluminal obstruction
distal intestinal obstruction
syndrome
functional obstruction
Hirschsprung associated
enterocolitis
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acquired
intussusception
adhesive bowel obstruction
Crohn disease partial
obstruction, stricture
superior mesenteric artery
syndrome
intraluminal obstruction
foreign bodies
Henoch-Schonlein purpura
constipation
 Peritonitis

Tender abdomen other intestinal

perforated viscus
with rebound peptic ulcer disease
tenderness foreign bodies
appendicitis nonaccidental abdominal
complicated/perforated trauma
gallstone complications pneumonia
cholecystitis viral mesenteric
choledocholithiasis/ adenitis/gastroenteritis
cholangitis
pancreatitis
pelvic inflammatory disease
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 Laboratory and radiologic tests

CBC,UA
Film Acute abdomen series
Ultrasound
CT scan

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 Acute
Appendicitis
 introduction

Obstruction of the lumen can occur from

multiple causes
fecal material (fecalith)
lymphoid hyperplasia
foreign body
parasites

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 introduction

Young children have a higher appendiceal

perforation rate compared to older children.

Younger children have less ability to understand or

articulate their developing symptoms.

Children younger than 5 years has perforation rate 82%

and perforation rate 100% in 1-year olds.

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 Pathophysiology

As the inflammation starts, the visceral

nerves send a message of general unease, which
may manifest as pain referred to the umbilical
region

Abdominal pain commonly located

in the periumbilical region

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 Pathophysiology

Anorexia, typically followed by nausea.

A young child has a hard time explaining this
feeling and may show only anorexia and decreased
activity.

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 Pathophysiology

Vomiting, fever, guarding, and abdominal pain with

any movement (especially walking).

As inflammation increases and the parietal peritoneum

becomes irritated, the somatic nerves begin to
signal that something is wrong.

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 Pathophysiology

This pain usually is appreciated in the area two thirds of the

distance from the umbilicus to the anterior superior iliac
spine (McBurney point). Pain and tenderness in this location
are sensitive signs for appendicitis but, unfortunately, are not
specific for appendicitis

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 Laboratory

CBC:
leukocytosis (Markedly elevated leukocyte count
suggests perforation)
left-shifted differential count(greater than 3 mg/dL)
Urine analysis
Few or moderate number of red or white blood cells may be
found

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 Laboratory and radiologic tests

Film Acute abdomen series

- Can show fecaliths in 1020%
Ultrasound
- Fluid-filled, noncompressible
appendix, a diameter greater than 6 mm
CT scan
- enlarged appendix (>6 mm), appendiceal wall thickening
(>1 mm), periappendiceal fat stranding, and appendiceal
wall enhancement
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 Laboratory and radiologic tests

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 Treatment

IV fluid administration
Broad spectrum ATB
Current best evidence suggests once-a-day dosing
with Ceftriaxone(50 mg/kg/day) + Metronidazole(30
mg/kg/day) provides the simplest and least
expensive regimen.

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 Treatment

The recommended duration is from a single,

Preoperative dose to 24 hours of postoperative antibiotic
therapy for simple appendicitis.
For complicated appendicitis, recent studies have
suggested that as little as 48 hours of coverage is
adequate.

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 Treatment

Surgery: Appendectomy : Open, Laparoscopic

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