Pediatric Surgical Emergencies
Tae Ah Kim1
1TBD, Ajou University Medical Center, Republic of Korea
Successful treatment of pediatric surgical emergencies requires timely evaluation and prompt recognition of the surgical problem. Key to making this happen is a close working relationship between surgeons and emergency medicine physicians. The presentation is aimed toward strengthening this relationship by offering a better understanding of the surgeon’s perspective on a variety of pediatric surgical emergencies.
1. Non-traumatic surgical emergencies
1) Malrotation with midgut volvulus
Congenital malrotation of the midgut portion of the intestine is often the cause of volvulus in the neonatal period. Malrotation occurs during the fifth to eighth week in embryonic life when the intestine projects out of the abdominal cavity, rotates 270 degrees, then returns into the abdomen. Ischemia subsequently develops, which constitutes a true surgical emergency because bowel necrosis can occur within hours.
2) Hypertrophic pyloric stenosis
Hypertrophic pyloric stenosis (HPS) is caused by a narrowing of the pyloric canal caused by hypertrophy of the musculature. HPS usually presents during the third to fifth week of life. Symptoms begin rather benignly with occasional vomiting at the end of feeding or soon thereafter. Emesis is nonbilious because the stenosis is proximal to the duodenum. As the disease progresses, vomiting increases to follow every feed and can become projectile.
3) Meckel’s diverticulum
Meckel’s diverticulum is the most common congenital abnormality of the small intestine. A Meckel’s diverticulum is a remnant of the omphalomesenteric (vitelline) duct, which normally disappears by the seventh week of gestation. Abdominal pain, distension, and vomiting can occur if the obstruction has occurred. A Meckel’s diverticulum can also ulcerate and perforate, presenting as a bowel perforation or acting as a lead point, resulting in intussusception.
Intussusception is the prolapse of one part of the intestine into the lumen of an immediately distal adjoining part. During the invagination, the mesentery is dragged along into the distal lumen and venous return is obstructed, which leads to edema, bleeding of the mucosa, increased pressure in the area, and eventually obstruction to arterial flow. Gangrene and perforation result.
5) Bowel atresia
Congenital intestinal obstruction is a common cause of neonatal intestinal obstruction. Bowel atresia usually presents during the first few days of life. Atresias can occur anywhere in the gastrointestinal tract from the pharynx to the anus.
Appendicitis is the most common surgical cause of abdominal pain in childhood. Because of the difficulty in evaluating young children who have abdominal pain, perforation rates for appendicitis are higher than in the general adult population (30–65%).
2. Traumatic surgical emergencies
Injuries to intra-abdominal organs occur in 10–15% of injured children. As the number of children with significant abdominal injuries is relatively low, but the consequences of a missed injury are high, accurate diagnosis is important. Important physical findings include vital signs (particularly the presence of persistent tachycardia), abdominal contusions or abrasions, tenderness, or distention. Particular physical findings, such as the ‘seat belt sign’ and ‘handle bar mark,’ are suspicious for the presence of intra-abdominal injury.