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Pediatric Surgery (Pg 68-81) - page 11 / 33

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Treatment:  Pressure of barium or air is used to reduce intussusception and is successful in most cases.  Also saline enema under US guidance can be used.  Surgery is performed promptly if nonoperative reduction fails, which includes manual reduction and appendectomy.  If intestine is necrotic or pathologic lead point is identified, that section of intestine is resected.

Recurrent intussusception occurs in 5 -8% of children, regardless of method of reduction.  

Meckel’s Diverticulum

Occurs in 2% of population

Located in ileum, within 100 cm of the ileocecal valve.

Contains heterotopic tissue in 50% of symptomatic patients.  Most often lined with gastric mucosa.

Embryologic remnant of vitelline duct, which communicates the intestine with the yolk sac.

Most remain asymptomatic, but some may be complicated by bleeding, obstruction and inflammation.  

Bleeding results from ulceration adjacent to ectopic gastric mucosa of the diverticulum.  Usually occurs in children younger than age 5.  The blood is usually dark red, painless, and can be massive.

Technetium pertechnetate scans show increased uptake in gastric tissue in 50% of cases.

Can cause intestinal obstruction by acting as the lead point of an intussusception or by allowing the intestine to twist around it causing volvus.  

Meckel’s Diverticulitis occurs in older children and is almost always misdiagnosed preop b/c manifestations similar to those of appendicitis.  Whenever nl appendix is found on laparotomy for presumptive appendicitis, distal ileum must be inspected for the possibility of Meckel’s diverticulitis.

Tx:  resected by laparotomy or laproscopic surgery.  Asymptomatic diverticuli found incidentally at surgery are resected if: the child is young, diverticuli has narrow neck, ectopic tissue is palpable within lumen, or it is attached to abdominal wall.  

Gastrointestinal Bleeding:

Most likely source of bleeding in a child may be suspected by the patient’s age, level of bleeding, the color and amount of blood, and associated findings.

Common causes of GI bleeding according to age:  Table 2-14.

Gastroesophageal Reflux:

Reflux of stomach contents into esophagus.

Common in infants and children who have neurological impairments due to motor and reflex abnormalities of foregut, including: disordered swallowing, decreased esophageal clearance, an incompetent LES and delayed gastric emptying.

Common in normal babies because lower esophageal sphincter is relatively incompetent for first few months of life.  This is usually self-limiting: incidence and severity decreases with growth.

In children with GERD, vomiting is more severe and may even mimic pyloric stenosis.

Clinically significant complications of GERD:

1.

failure to thrive (due to chronic regurgitation)

2.

aspiration of gastric contents into airway recurrent pneumonia

3.

apnea, probably because of reflux-induced laryngospasm or a vagal reflex (possible cause of SIDS ?)

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