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Pediatric Surgery (Pg 68-81) - page 10 / 33

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Pain in periumbilical area migrating to RLQ, but this classic presentation may not always be present.  Anorexia, N/V common. Temp is usually nl or slightly high.

Early high fever suggests other diagnosis.  Later, high fever indicates perforation.

Cheeks often flushed, child unusually quiet, knees pulled up.

Decreased bowel sounds w/ involuntary guarding, tenderness, and rebound in RLQ.

Patients with perforation:  often septic, abd distension d/t ileus, peritonitis, RLQ or rectal mass.

Labs:  Leukocytosis w/ left shift, few WBC/RBC present in urine consistent with inflamed appendix in congruity with the urinary tract.  Β-HCG levels should always be checked in adolescent girls to exclude ectopic pregnancy.  

Only pathognomic sign of appendicitis is calcified fecalith that can be visualized on abdominal xray in 5 – 15% of patients.

Ruptured appendix may lead to SBO and is the most common cause of obstruction in school-aged children.

U/S is 90% accurate in making the diagnosis.  Especially useful to rule-out ovarian cyst, adnexal torsion, and PID in girls.

Differential diagnosis:  Table 2-13.

Tx:  Urgent appendectomy after rapid IVF hydration and administration of broad-spectrum antibiotics.  Postop antibiotics unnecessary if perforation not present.  If perforation present, antibiotics continued for at least 3 days and d/c when patient is afebrile for 48 hrs w/ nl white count.  

Complications:  Intra-abdominal abscesses and wound infection.  Abscesses drained percutaneously or transrectally via US guidance.  Wound infections are opened and drained.  

Intussesception:

Telescoping of one portion of the intestine into another.

Usually ileocolic.

Emergency condition, involved intestine can become strangulated.

Typically affects children 6-18 months.  Viral hypertrophy of Peyer’s patches most common cause.

Less often causes:  pathologic lead point (e.g. Meckel’s diverticulum, polyp, lymphoma, hematoma)

Often follows viral illness.  

Presentation:  intermittent bouts of colicky abdominal pain, causing child to cry and pull knees in towards chest.  Between episodes child is initially well but becomes increasingly lethargic.  Vomiting is common and eventually becomes bilious.  Blood and mucus passed rectally as “currant jelly” stools d/t congestion and ischemia of intestinal mucosa.

Examination:  Irritable and somnolent, dehydrated, tender sausage shaped mass often palpable in RUQ.  Digital rectal exam often yields blood and mucous.  Abdominal xrays are normal or show paucity of air in RLQ, eventually showing dilated small intestinal loops consistent with obstruction.  

Diagnosis:  Barium or air-contrast enema.  Ileocolic intussusception appears as a filling defect in the colon, at which flow of contrast stops.  U/S can also be diagnostic.  Ileoileal intussusceptions are rare and are usually associated with a lead point of previous operation.

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