Childhood surgical illness..........pptx

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1. Common Childhood surgical illness Mekdelawit M. (MD, Pediatric Surgeon FCS-ECSA)

2. Objectives To know the common childhood surgical illnesses To understand clinical presentation and diagnostic modalities of common childhood surgical illnesses To understand the principles of management of common childhood surgical illnesses

3. Children are not little adults, but they are little people. Pediatric patients have distinct surgical diseases and special perioperative needs The surgical management of Pediatric patients and children requires delicate, careful, and professional interactions with patient.

4. 1. Foreign Body Aspiration Is inhalation of a FB in to the larynx and respiratory system. Risk factors Age 1-3 years Toddlers are inquisitive & place objects in their mouths Don’t distinguish edible from inedible objects Relatively immature swallowing mechanism Lack dentition for grinding food Supervision is challenging Less common in infants and usually involves liquids

5. Other factors Male gender Neurologic impairment Seizure disorders Unsafe environment Child neglect or abuse

6. Foreign Body Aspiration Children can aspirate anything they place in their mouths Food is the most commonly aspirated ( 50-80%) Nonfood FB account for 30% 68% of FB related mortality is from nonfood Peanuts Swell as they absorb water The peanut oil causes a marked inflammatory reaction

7. Clinical features Choking episode (95%)…most sensitive clinical parameter Clinical findings (50-90% of patients) Persistent cough, respiratory compromise, hemoptysis, fever FBs in the larynx and trachea can be completely obstructive causing sudden death 20-50% of FBs are diagnosed more than a week after aspiration Features that distinguish FBA from other causes Witnessed aspiration Sudden onset Absence of antecedent fever

8. Imagings Radiographs (AP and Lateral) Completely normal Show indirect signs of a foreign body hyperinflation, mediastinal shift ,consolidation, pneumonia, atelectasis Show radiopaque object CT scan Depict the FB, identify secondary changes

9. Management Definitive management Rigid bronchoscopy Complete obstruction Bronchotomy

10. Foreign Body ingestion 80% children are 6months – 3 years . 80-90%- pass spontaneously. 10-20% require endoscopic 1-2% surgical removal intervention. Common sites of impaction 1. anatomic constrictions UES ( Cricopharyngeus muscle) 70% Mid esophagus (Broncho-aortic) 15%. LES ~15 %. 2. underlying esophageal pathology

11. Clinical Presentation Hyper salivation , drooling Regurgitation , vomiting , gagging, retching , hiccup. Dysphagia / Odynophagia , poor feeding and feeding refusal. Hematoemesis , hematochesia , melena , Vomiting , Fever , abdominal distention and pain . Signs of obstruction Imaging

12. Management Immediate removal Urgent( 12-24hrs) Non-Urgent Airway compromise Complete esophageal obstruction. Active bleeding Gastric/intestinal perforation /obstruction Disk/button batteries in esophagus Sharp- pointed objects in esophagus Sharp –pointed objects in stomach or duodenum Objects >6 cm long or >2.5cm in diameter in stomach above at or above 1 st part of duodenum Multiple magnets or single magnet Disk batteries in stomach. Blunt objects stationary in stomach for 4 wks. Patient discharged if (looks well, pain free , no respiratory Sx & able to eat and drink)

13. Esophageal Atresia/ TracheoEsophageal Fistula Theories of EA/TEF Failure of recanalization (historical) Failure of lateral tracheoesophageal folds to meet at mid line Cranial and caudal folds growth imbalance Risk factors; Twin pregnancy White race (>60% risky than non-white) Drugs (thalidomide, methimazole ) First pregnancy Maternal diabetes Increasing maternal age ?? in vitro fertilization patients

14. Classification Type A Type B Type C Type D H-Type (Type E)

15. Associated anomalies

16. Diagnosis Antenatal Ultrasound pouch sign, polyhydramnios , absence of stomach Detection rate <20% Postnatal Presentations Excess salivation Cough, chocking, cyanosis and respiratory distress worsened by feeding X-ray– coiling of NG tube in the esophagus

17. Management Resuscitation and stabilization Antibiotics Definitive surgery (open or laparoscopic)

18. 2. IHPS ( INFANTILE HYPERTROPHIC PYLORIC STENOSIS) IHPS is the most common cause of GOO in infants Incidence: 1.5-4:1000 live births Male: female 4:1 More in first born babies, white infants & during spring and autumn, family history Peak incidence is between 3-5 weeks of age Premature infants are diagnosed on average 2 weeks later than term

19. Diagnosis Projectile, progressive non-bilious vomiting followed by eagerness to feed (hungry vomiters) Dehydration Olive on palpation Malnutrition, anemia Hypochloraemic hypokalaemic metabolic alkalosis Paradoxical aciduria Hyperbilirubinemia Abdominal ultrasound sensitivity and specificity of almost 100%. Pyloric channel length>16mm Pyloric muscle wall thickness>3-4mm Barium study

20. Management Preoperative preparation :- resuscitation and electrolyte management is a crucial step Operative management Pyloromyotomy (Open or laparoscopic ) Non operative management Prolonged hospital

21. 3. Intussusception Incidence 2–4 cases/1000 live births Seasonal variation (viral infection in 30%) Commonest age is 3 months - 6yrs Sex M:F = 2 : 1 85% ileo-colic 10 % ileo – ileo- colic 2.5% jejuno -jejunal / ileo-ileal 2.5% appendico- colic / ceco-colic / colo-colic

22. Pathogenesis Proximal gut ( intussuceptum ) invaginate/telescope to distal segment ( intussucepiens )  Drags mesentry with it  venous congestion and bowel edema  progress to arterial compromise 20% transient (reduced spontaneously) Risk factors Idiopathic (95%) Adenovirus and rotavirus infections Pathologic Lead point (4%) post operative (1%)

23. Presentation and diagnosis Vomiting colicky pain Currant jelly stool History of upper respiratory tract infections or Gastroenteritis Fever, Peritonitis Obstruction intra abdominal mass with empty right lower quadrant (dancing sign ) ULS:- gold standard --doughnut, bull’s eye, coiled spring-pseudo-kidney… vascularity of the bowel, lead point

24. Management Resuscitation and stabilization conservative management for short segment small bowel intussusception Hydrostatic or Pneumatic reduction - -- Viable ileocolic \ colo -colic intussusception Surgical-- Signs of ischemia obstruction or peritonitis

25. 4. Undescended Testis 35-40th week of gestation –descends into the scrotum Left testis descends before the right About 96% of testes have descended at birth Incidence 2-5% of full-term new born & prevalence stabilizes at 0.7–1.0% of one-year-old boys 30% of premature infants Occurs on the right-50%, left-35%, bilateral-10-15%

26. Evaluation and Diagnosis Presentation Most patients presents in infancy and around school age & a few present after puberty. May present with Absence of one or both testes Swelling in the groin (may be the testis or a hernia) For associated hypospadias. More proximal it is more are the chances of UDT. attacks of pain in the groin due either to recurrent torsion of the testis or strangulation of an associated hernia.

27. Options of management Observation Testes complete descent within 3-4 months old and spontaneous descent is rare after six months of age Observation and “watchful waiting” strategy is not justified after 6 months Hormonal Therapy Rational is Administration of gonadotropins (either hCG or LHRH) Evidence showed Highly variable success rates reported from 0% to 20%(max) Surgery Orchidopexy

28. 5. Congenital Hydrocele Hydrocele  is a fluid collection within the tunica vaginalis of the scrotum or along the spermatic cord  processus vaginalis communication allows the movement of peritoneal fluid but is too small to allow the intra-abdominal contents to herniate.

29. Types of hyd

30. Types of hydrocele There are 4 types of primary hydrocele: (1) congenital hydrocele , which occurs when the processus vaginalis is patent and communicates with the peritoneal cavity; (2) infantile hydrocele, in which the processus vaginalis gets obliterated at the level of the deep inguinal ring; (3) encysted hydrocele of the cord, in which both the proximal and the distal portions of the processus vaginalis get obliterated; (4) vaginal hydrocele, in which the processus vaginalis remains patent only around the testes.

31. Complications Infection. Pyocele . Haematocele . Atrophy of testes. Infertility (resulting from the spermatogenesis halt due to increased pressure on the blood supply on the testis from edema) Hernia of hydrocele

32. Management conservative vs surgical Timing of surgery

33. Inguinal hernia Commonest type in pediatrics is indirect inguinal hernia protrusion of intra-abdominal contents through a patent process Hernias occur in 1% to 4% of all infants; the incidence may reach 30% in premature infants sus vaginalis.   male to female ratio of 6:1

34. Complications and management