General Surgery Emergencies

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CHAPTER 44 General Surgery Emergencies

Kristine G. Williams, MD, MPH, Dee Hodge, III, MD

1 What is the classic presenting history in a child with suspected appendicitis?

Usually the child presents with a history of diffuse abdominal pain, possibly associated with vomiting and a low-grade fever. Some may have a history of anorexia. Unlike in adults, it is often hard to obtain an accurate and consistent history. The presenting symptoms of appendicitis are similar to those of many other childhood diseases. Gastroenteritis, urinary tract infections, streptococcal pharyngitis, constipation, and pneumonia are just a few of the illnesses that appendicitis can mimic. Most children with appendicitis complain of pain in the right lower quadrant (RLQ) once peritoneal inflammation occurs.

Bachur RG: Abdominal emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1605–1630.

eMedicine: General surgery articles: www.emedicine.com/ped/GENERAL_SURGERY.htm

2 Where else might a child with appendicitis localize pain?

If the appendix is located in the lateral gutter, the child may exhibit tenderness in the lateral abdomen or flank. An appendix pointing toward the pelvis might cause pubic pain and diarrhea. A retrocecal appendix causes pain on deep palpation. This information is important, since not all children with appendicitis present with RLQ pain.

3 Is diarrhea a presenting symptom of appendicitis?

Yes. Diarrhea may delay accurate diagnosis if the symptom is mistakenly associated with gastroenteritis rather than appendicitis. Children under 3 years old are the ones most likely to present with this symptom. A retrospective case series identified 63 children under the age of 3 who had an appendectomy for appendicitis at one of four teaching institutions. The mean age was 2.2 years. The mean delay from the onset of symptoms to presentation was 4.3 days, and 57% were misdiagnosed at initial presentation! Diarrhea was reported in one third of the patients. Although none of the children died, morbidity was increased: 84% had perforation or gangrene.

Serious and life-threatening disease processes must be kept in mind when a young child presents with symptoms that may look like simple gastroenteritis.

Horwitz JR, Gursoy M, Jaksic R, Lally KP: Importance of diarrhea as a presenting symptom of appendicitis in very young children. Am J Surg 173:80–82, 1997.

4 Does a white blood cell (WBC) count of only 11.5 cells/mm³ rule out appendicitis?

A child with a nonperforated appendicitis usually has a WBC count of 11,000–15,000 cells/mm³ in the first 1–2 days of illness. A higher WBC count with a left shift may be found later in the course, as the appendix undergoes further degeneration, or if the appendix has ruptured. Although laboratory values may help to support your clinical diagnosis, they should not replace a good history and a careful physical examination.

5 What laboratory findings are suggestive of appendicitis?

The two tests that should be done on all patients who are suspected of having appendicitis are a complete blood count with differential and a urinalysis. WBC counts appear to be highly associated with both uncomplicated acute and complicated acute appendicitis, and are a good tool to aid in diagnosis. The urinalysis may show ketosis due to decreased oral intake. If the inflamed appendix lies near the bladder or ureter, sterile pyuria may be seen as well. However, a normal complete blood count or a normal urinalysis do not rule out appendicitis.

6 Is C-reactive protein (CRP) helpful in diagnosing appendicitis?

Greatly elevated CRP levels (e.g., > 50 mg/L) have been found to be associated with perforated appendicitis. A patient with a normal WBC count AND a normal CRP level is unlikely to have appendicitis. Here is the evidence: Investigators have examined the use of CRP and WBC values to predict appendicitis at different stages. In one retrospective study, 100 adult and pediatric patients in each of the following categories had mean preoperative values calculated: uninflamed appendix, uncomplicated acute appendicitis, and complicated acute appendicitis. Although some of the patients with uninflamed appendices had increased WBC or CRP values, all patients with both values in the normal range had an uninflamed appendix. Those with uncomplicated acute appendicitis had either raised WBC counts and normal CRP levels, or elevated values of both. Most of those with complicated acute appendicitis had both values raised. A prospective study of pediatric patients with appendicitis showed a positive predictive value of 91% for perforation if the CRP level was > 50 mg/L. There was no difference in WBC counts among those with and without perforation.

Chung JL, Kong MS, Lin SL, et al: Diagnostic value of C-reactive protein in children with perforated appendicitis. Eur J Pediatr 155:529–531, 1996.

Gronoos JM, Gronoos P: Leukocyte count and C-reactive protein in the diagnosis of acute appendicitis. Br J Surg 86:501–504, 1999.

7 Is a plain x-ray useful in diagnosing appendicitis?

Plain radiography is not very helpful. It usually reveals nonspecific findings for appendicitis, unless a calcified appendicolith is present (< 10% of patients). The presence of air–fluid levels in the RLQ suggests a localized ileus. Although this finding may heighten one’s suspicion for appendicitis, beware! The same findings are also present in gastroenteritis. Plain films may reveal an alternate diagnosis, such as pneumonia.

Heller RM, Hernanz-Schulman M: Applications of new imaging modalities to the evaluation of common pediatric conditions. J Pediatr 135:632–639, 1999.

8 Is ultrasonography useful in evaluating for appendicitis?

Ultrasonography has a reported sensitivity of approximately 80% and a reported specificity of approximately 93% for the diagnosis of appendicitis. It is quick and does not involve large doses of radiation. It can identify ovarian pathology, such as ovarian cysts or torsion. However, there are limitations to this technology:

It requires an experienced technician.

It is difficult to scan overweight children.

It is uncomfortable for the patient because of a need for graded compression of overlying bowel.

It can be extremely difficult to perform on a crying or uncooperative child.

The appendix can be located anywhere in the abdomen, making visualization difficult at times. If visualized, the inflammation may be localized to a small segment that cannot be seen.

Thus, a positive result is highly suggestive, but a negative result should be followed with repeated physical examination and reassessment of your level of suspicion for the diagnosis. If the appendix cannot be visualized, appendicitis is not ruled out.

9 What is the value of computed tomography (CT) in diagnosing appendicitis?

CT is a valuable modality for appendicitis. It has a sensitivity of about 95% and a specificity of about 93% for the diagnosis of appendicitis. Of course, there are drawbacks to CT as well. The need for contrast material, exposure to radiation, higher cost, and a longer preparatory period prior to the study are a few of them. Although some patients with a suspected inflamed appendix may not need imaging, the most sensitive imaging modality is abdominal CT.

Sivit CJ, Applegate KE, Stallion A, et al: Imaging evaluation of suspected appendicitis in a pediatric population: Effectiveness of sonography versus CT. AJR 175:977–980, 2000.

10 What is focused CT of the abdomen?

Focused CT of the lower abdomen, beginning at the lower end of the third lumbar vertebral body and extending to the pubic ramus, may effectively diagnose appendicitis. It offers a lower dose of radiation and is therefore a good option in the diagnosis of appendicitis.

Fefferman NR, Roche KJ, Pinkney LP, et al: Suspected appendicitis in children: Focused CT technique for evaluation. Radiology 220:691–695, 2001.

11 Why does the pain of appendicitis typically start centrally (periumbilically) and then localize to the right lower quadrant?

The initial pain of appendicitis is visceral: a dull, aching pain localized to the mid- or lower abdomen. Visceral or splanchnic pain originates in those abdominal organs, such as the appendix, that have visceral peritoneum. Increased hollow viscous wall tension and ischemia cause impulses to be sent from the organ to the spinal cord. In the case of the appendix, visceral afferent autonomic nerves enter the spinal cord at T8–T10. These segments supply the periumbilical area, which explains the initial, poorly localized pain associated with appendicitis.

As the appendix becomes more inflamed, it causes inflammation of the serosa and parietal peritoneum. The inflammation triggers local somatic pain fibers. Somatic pain is mediated by afferent nerve fibers in segmental spinal nerves. Thus, the pain is sharper and more localized, usually to the RLQ.

12 Describe the pathophysiologic mechanism that leads to appendicitis.

The appendix contains increasing amounts of lymphatic tissue as a child ages. Acute appendicitis occurs when the lumen of the appendix becomes obstructed. Sources of obstruction include fecaliths, lymphatic hypertrophy, worms, vegetable matter, and tumors. The appendix continues to secrete mucosal fluid, leading to distention of the viscus. Intraluminal bacterial overgrowth develops.

KEY POINTS: COMMON FINDINGS IN ACUTE APPENDICITIS

1 Diffuse or periumbilical abdominal pain

2 Low-grade fever

3 Vomiting or diarrhea

4 Anorexia

13 Which of these patients with appendicitis is most likely to present with a perforation? Why?

A A 2-year-old boy with pain for a few days

B A 12-year-old girl with severe pain for 24 hours

C An 8-year-old boy with a temperature of 40° C

D A 16-year-old with a WBC count of 18,000 cells/mm³

Although any one of the patients could present with a perforated appendix, the 2-year-old with pain for 2 days is statistically most likely to have perforation at presentation. The rates of perforation are higher in younger children because of the following several factors: (1) the appendix is more thin walled, predisposing them to early perforation; (2) younger children are less able to communicate clearly, resulting in prolonged symptoms before diagnosis; and (3) the level of suspicion for appendicitis is often lower in younger age groups, leading to a delay in diagnosis.

14 Why does perforated appendicitis progress to peritonitis more quickly in infants and children than in adults?

The omentum is not as well developed in infants and children as it is in adults. Since the omentum is primarily responsible for walling off the infection in a perforated appendicitis, its insufficiency contributes to the development of peritonitis. This complication of perforated appendicitis may play a role in the increased mortality in young children with appendicitis.

15 What conditions must be considered in a teenage girl with symptoms of appendicitis?

Gynecologic conditions and emergencies should be a part of the differential diagnosis of any teenage girl with RLQ pain. In particular, ovarian cysts, corpus luteal cysts, mittelschmerz, tubal pregnancy, ovarian torsion, tubo ovarian abscess, and salpingitis can all present similarly to appendicitis.

16 What is the most common cause of acute pancreatitis in children?

Abdominal trauma.

17 What are the radiographic findings in a child with acute mechanical bowel obstruction?

Multiple, dilated loops of bowel and an air-fluid level visible in the upright or lateral decubitus views on plain films are common.

18 What is the most common cause of acute intestinal obstruction in a child 3–12 months of age?

Intussusception. This occurs when a proximal segment of bowel telescopes into a distal segment. It is commonly ileocolic, but small bowel may also telescope into itself.

19 Define lead point.

The lead point is the area that is thought to initiate the intussusceptum. The causes of lead points differ by age. In infants, lead points are often hypertrophied Peyer’s patches. In older children, there are many possibilities for focal lead points, including intestinal polyps, Meckel’s diverticulum, or a tumor.

Bachur RG: Abdominal emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1605–1630.

20 What causes intussusception?

There is no definitive cause, though there is an association between intussusception and a history of a preceding viral illness, diarrhea, or, perhaps, Henoch-Schönlein purpura. The association between the rotavirus vaccine and increased frequency of intussusception led to the recall of the original rotavirus vaccine.

Centers for Disease Control and Prevention: Intussusception among recipients of rotavirus vaccine—United States 1998–1999. MMWR Morb Mortal Wkly Rep 282:520–521, 1999.

21 How does the child with intussusception present?

There may be several different presentations. The classic history is that the patient has crampy abdominal pain. Since this is a disease that mostly occurs in preverbal children, the parent may give the history that the child acts normally or is only slightly irritable, but has episodic bouts of severe abdominal pain characterized by drawing his knees to his chest, lying still, or screaming inconsolably. Some children may present with profound lethargy. Vomiting may become bilious as the small bowel becomes completely obstructed. On physical examination, the child’s abdomen may be normal or may be distended because of the partial or complete obstruction of the bowel. A sausage-like mass may be palpable in the right side of the abdomen.

eMedicine: General surgery articles: www.emedicine.com/ped/GENERAL_SURGERY.htm

22 What is the origin of pain in intussusception?

Intussusception is the result of invagination of a portion of proximal intestine into distal intestine. The intussuscepted mass can obstruct the intestinal lumen. Abdominal pain is due to distention and peristaltic rushes against the mass.

23 What is “currant jelly” stool?

Currant jelly is made from a small, round, acid berry that may be black or red. This term is used to describe the reddish, heme-positive stool of mixed mucous and blood associated with late stages of intussusception. It occurs when the edematous bowel causes compression of the mesenteric veins. It indicates mucosal damage and is present in only about one-third of patients. Intussusception cannot be ruled out in the absence of currant jelly stool.

24 How do you diagnose intussusception?

Aside from a good history and physical examination, air contrast enema is the best diagnostic test. However, you may choose to start with an obstruction series, which may demonstrate small bowel obstruction and free peritoneal air. Some authors suggest ultrasonography as a second step, since it can unequivocally identify intussusception and may help to identify the leading edge of the intussusceptum, the presence of a lead point, and the presence of blood flow within the intussusceptum. Whether or not you choose to begin with an obstructive series or ultrasonography, if the suspicion of intussusception remains, then contrast enema is the next step. Air contrast enema is preferred in many pediatric institutions, though some still use barium. Note that it is wise to inform your surgical colleagues of the case prior to the contrast enema because of the risk of perforation during the study.

Hadidi AT, El Shal N: Childhood intussusception: A comparative study of nonsurgical management. J Pediatr Surg 34:304–307, 1999.

25 What are the only absolute contraindications to enema in the diagnosis of intussusception?

The presence of free air or signs of peritoneal irritation are the only absolute contraindications.

KEY POINTS: CLASSIC FINDINGS IN INTUSSUSCEPTION

1 Intense, intermittent abdominal pain

2 Currant jelly stool

3 Irritability

4 Vomiting

5 Lethargy

26 How do you treat intussusception?

This is a trick question because the diagnostic test (enema) is usually therapeutic as well. Intussusception can be reduced by air enema in the majority of cases. If the child is toxic, however, he or she may require surgical intervention. Recurrence rates are 5–8%, regardless of the means of reduction. Admit the patient to the hospital after the intussusception is reduced.

27 Why are inguinal hernias usually repaired when detected in young infants?

There is a high risk of intestinal incarceration in male infants and adnexal entrapment in female infants. Hernias that reduce spontaneously are generally repaired electively soon after detection. Those that require sedation or manual reduction are usually repaired 24–48 hours after reduction.

28 Is an incarcerated hernia more common in girls or boys?

Contrary to what you might think, it is more common in girls and usually involves the ovary rather than the intestine.

29 What is the difference between an incarcerated and a strangulated hernia?

Incarceration means that the intestine or ovary is nonreducible, but not necessarily gangrenous. However, if the hernia is not reduced, it can become strangulated. Once the hernia is strangulated, venous and lymphatic obstruction occur, leading to occlusion of arterial supply. This sets the stage for necrosis and possible perforation.

30 On examination of a 3-month-old child brought in for a minor complaint, you notice a large umbilical hernia. The mother asks you what she should do about it. What do you tell her?

Umbilical hernias are common in infants and young children, especially African Americans. Incarceration of an umbilical hernia is rare. Your best advice is to reassure the parent that most of these reduce spontaneously. If there is a large ring that has not diminished by age 2, or if an incarceration has occurred, the defect should be closed operatively. Otherwise, the hernia can be closed electively at age 5 or 6.

Bachur RG: Abdominal emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1605–1630.

KEY POINTS: WHICH TEST IS BEST?

1 Appendicitis = CT

2 Pyloric stenosis = ultrasonography

3 Intussusception = air contrast enema

4 Malrotation = upper gastrointestinal series

31 A 10-month-old, previously well child presents to the emergency department (ED) with acute onset of abdominal pain associated with bilious vomiting. The child is afebrile and ill-appearing and has a slightly distended abdomen that is diffusely tender. The rectal examination reveals blood on the examiner’s finger. On routine abdominal radiography, the emergency physician notes air–fluid levels and a few dilated loops of bowel. The upright film shows a “double-bubble” sign. An upper gastrointestinal study reveals absence of the ligament of Treitz. What should the physician do next?

The physician should call a surgeon and reserve the operating room as soon as possible. The “double-bubble” sign on the upright abdominal radiograph represents partial obstruction of the duodenum causing distention of the stomach and the first part of the duodenum. The absence of the ligament of Treitz on the upper gastrointestinal study almost clinches the diagnosis (malrotation of the bowel with volvulus), especially if it is associated with finding the duodenum to the right of the spine and a coiled appearance of the jejunum in the RUQ. This is a true surgical emergency.

32 What is the most common surgically correctable cause of vomiting in infants?

Pyloric stenosis. This is estimated to occur in about 1 in 400 births.

33 What is pyloric stenosis? How does it present?

Pyloric stenosis is a narrowing of the outflow tract of the stomach due to hypertrophy of the pyloric musculature. Pyloric stenosis is often found among first-born males, and males predominate by a factor of 4 to 5. There may be a family history for this condition. The infants are usually clinically normal at birth. In the typical history, the infant does well for the first few weeks of life, usually regaining birth weight. At about the third week of life, the infant starts to vomit, usually at the end of feedings. The vomiting eventually becomes projectile. It is typically nonbilious, though blood may be seen because of associated gastritis or esophagitis. Most patients present between 2–6 weeks of age. The infant is often described as hungry all the time, eating even after vomiting, because the infant cannot achieve adequate nutrition. In time, the infant may become profoundly dehydrated and emaciated.

Dinkevich E, Ozuah PO: Pyloric stenosis. Pediatr Rev 21:249–250, 2000.

Hernanz-Schulman M: Infantile hypertrophic pyloric stenosis. Radiology 227:319–331, 2003.

34 How do you examine an infant with suspected pyloric stenosis?

Examine the infant on his or her back, preferably on the parent’s lap, and while he or she is quiet. Hold the infant’s legs and flex them to 90 degrees at the hips to help relax the abdominal musculature. A bit of sugar or juice on a pacifier may help to relax the child. Begin the examination from below the liver, palpating in a rocking motion. A firm, ballotable mass may be felt in the region of the pylorus. This is the classic physical finding of pyloric stenosis—the “olive.” If you cannot palpate an olive and still have a high suspicion for pyloric stenosis, ultrasonography is the test of choice.

Hernanz-Schulman M: Infantile hypertrophic pyloric stenosis. Radiology 227:319–331, 2003.

35 Where is the “olive” usually found?

Usually it is found to the right, just below the xiphoid.

36 What ultrasonography findings are associated with pyloric stenosis?

Ultrasonography allows visualization of the hypertrophied pylorus muscle. If the pyloric canal lengthening is > 16 mm and the wall thickness is > 4 mm, suspect pyloric stenosis. Ultrasonography is quickly becoming the favored radiologic test for diagnosing pyloric stenosis because that it involves no radiation and no need to introduce barium into the gastrointestinal tract of a potential surgical candidate who is at high risk for aspiration.

Hernanz-Schulman M: Infantile hypertrophic pyloric stenosis. Radiology 227:319–331, 2003.

37 What is the classic laboratory finding in a child with pyloric stenosis?

The classic finding is hypochloremic, hypokalemic metabolic alkalosis. Serum bicarbonate levels may be as high as 65–75 mEq/L. Acidosis usually signifies a more dangerous metabolic state due to extreme dehydration.

38 How does the metabolic derangement occur?

The metabolic alkalosis is due to loss of acid and retention of bicarbonate. Several mechanisms play a part in achieving this. Frequent vomiting leads to depletion of potassium chloride and hydrogen chloride. Additionally, as intravascular volume decreases with prolonged vomiting and dehydration, the concentration of bicarbonate in the plasma increases, resulting in a contraction alkalosis. As plasma potassium levels fall because of gastric losses, potassium moves out of the cells to restore extracellular concentrations. Hydrogen ions then move into cells to maintain electroneutrality. The net result is metabolic alkalosis. Although the serum potassium level may be normal or low, total-body potassium is often depleted.

However, this is only part of the picture. The kidneys also play a role in the development of metabolic alkalosis. To maximize intravascular volume in the face of ongoing gastric losses, the kidneys reabsorb bicarbonate in the distal tubules despite alkalosis. If excess bicarbonate is excreted in the urine, it obligates sodium loss (think electroneutrality, again). Remember that water follows sodium, which would result in further volume loss. A lot of chloride has been lost through vomiting. Decreased delivery of chloride to the macula densa of the kidneys results in renin release and secondary hyperaldosteronism, leading to increased distal hydrogen secretion and the paradoxical finding of aciduria in the presence of a metabolic alkalosis. Finally, in response to the total-body depletion of potassium, the distal tubules reabsorb potassium in exchange for hydrogen, leading to further acid loss.

Dinkevich E, Ozuah PO: Pyloric stenosis. Pediatr Rev 21:249–250, 2000.

KEY POINTS: FINDINGS THAT REQUIRE IMMEDIATE SURGICAL CONSULTATION

1 Strangulated hernia on physical examination

2 Distended abdomen and “double-bubble” sign on upright abdominal radiograph

3 Bilious emesis, especially in the first few months of life

4 Absence of the ligament of Treitz on upper gastrointestinal study

5 Ultrasonography findings consistent with ovarian torsion

39 How is pyloric stenosis treated?

Initially, the infant’s fluid and electrolyte status must be corrected with IV fluids. Once the infant is euvolemic and the electrolytes have returned to normal, a surgeon should perform a pyloromyotomy.

Bachur RG: Abdominal emergencies. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1605–1630.

40 What are the most common surgically correctable causes of vomiting in the following infant age groups: First week of life? First month of life? Beyond the neonatal period?

In the first week of life, consider anatomic malformations. Esophageal atresia, duodenal or jejunal atresia, duodenal stenosis, midgut malrotation, ileal atresia, and meconium ileus are the most common causes.

In the first month of life, consider pyloric stenosis and gastroesophageal reflux. As a general rule, gastroesophageal reflux can be managed medically. However, if medical management fails and the infant is failing to gain weight, bleeding, or aspirating, a surgical antireflux operation, such as a fundoplication, may be warranted. Other causes of vomiting in babies this age include Hirschsprung’s disease, esophageal or intestinal webs, infection, increased intracranial pressure, and metabolic defects.

Beyond the neonatal period, consider intussusception, appendicitis, and bowel obstruction caused by malrotation, incarcerated or strangulated hernia, duplication cysts, or Meckel’s diverticulum.

Moir CR: Abdominal pain in infants and children. Mayo Clin Proc 71:984–989, 1996

41 What are the common causes of rectal bleeding in the pediatric age group? How do they present?

Fissures. This is probably the most common cause. Often there is a history of constipation or passing a large, hard stool. The blood typically is bright red and found in streaks on the outside of the stool or on the toilet tissue. The diagnosis can be made by anal examination under a good light source. Treatment consists of sitz baths and lubrication of the rectal area with petroleum jelly. If the child suffers from constipation, address this as well.

Juvenile polyps. These occur in older infants and children in the lower part of the colon. They may be palpated on digital rectal examination and may bleed, especially if they break free. They are not premalignant, but they may serve as a lead point for intussusception.

Meckel’s diverticulum. Remember the rule of 2s! Two percent of the population is born with a Meckel’s diverticulum. It is usually located about 2 feet proximal to the terminal ileum. Also, only 2% of people with a Meckel’s diverticulum have any clinical problems. Meckel’s diverticuli usually contain ectopic gastric mucosa, and the acid secretion produces erosion at the junction of the normal ileal mucosa and the Meckel’s mucosa. It may present with painless rectal bleeding, perforation with peritonitis, diverticulitis, or intussusception.

Henoch-Schönlein purpura. This type of vasculitis can cause symptoms ranging from painless rectal bleeding to abdominal pain and hematuria. The associated submucosal hemorrhage may also serve as a lead point for intussusception.

Other causes. Intestinal vascular malformations, intussusception, inflammatory bowel disease, duplications, swallowed blood, bleeding peptic ulcer disease, bleeding varices, and trauma.

42 A 3-year-old child swallowed a safety pin that she found on the floor. You have located the object in her stomach on plain films, and the pin appears to be open. What do you do now?

Most foreign bodies that reach the stomach will pass completely through the gastrointestinal tract and be evacuated in the stool. Even an open safety pin may be allowed to pass. It is advisable to repeat an abdominal radiograph in about 5 days to be sure the pin has moved. Occasionally, a foreign body may get stuck at the junction of the duodenum and jejunum at the ligament of Treitz. These are usually long, thin objects such as bobby pins or long nails. Since perforation may occur, objects that “catch” beyond the pylorus should be removed surgically. Occasionally, objects get caught in the appendix, necessitating appendectomy. Obtain an x-ray in all children who have a history of swallowing a foreign body, both for the already mentioned reasons and to make sure that it is not lodged above the level of the thoracic inlet, where it could be aspirated if the child coughs.

43 What is a vascular ring?

This is a congenital condition that causes airway or esophageal obstruction. The obstruction is usually at the level of the trachea, but a ductus arteriosus or a pulmonary artery sling can also compress the bronchi. Many of these rings are caused by failure of involution of various segments of the six embryologic aortic arches. Infants who present with stridor, recurrent pneumonia, or a history of noisy breathing since birth should prompt the consideration of this diagnosis.

44 What is the difference between a pilonidal dimple and a pilonidal sinus?

Both are located in the midline in the sacrococcygeal area. Close inspection reveals that the dimple does not have a central pore, while the sinus does. The sinus is a tract lined by stratified squamous epithelium that extends toward the spinal canal, but not into it. The sinus is asymptomatic until it becomes infected or obstructed, usually in adolescence. Predisposing factors are male sex, being overweight or hirsute, and a sedentary lifestyle. Once infection occurs, an abscess forms and expands deep to the skin surface. Patients usually report low back pain that is worse with sitting. They may also report localized tenderness. On examination, you will note a tender, indurated area in the sacrococcygeal region.

45 How is a pilonidal abscess treated?

Because these lesions typically expand inward, they must be incised and drained. Probe the abscess cavity to break up any loculations, and remove hair because it acts as a foreign body. Following incision and drainage, sitz baths and oral antimicrobial therapy (targeting staphylococcus, anaerobes, and fecal flora) are recommended. Once the inflammation has resolved, elective incision of the entire cyst and its sinus tracts is recommended.

46 What is omphalitis?

Omphalitis is an infection of a newborn’s umbilical cord stump and the surrounding tissues, usually occurring in the first 2 weeks of life. Often, the infant initially presents with purulent, foul-smelling drainage from the umbilical stump and surrounding abdominal erythema, indicative of cellulitis. If the infection is not diagnosed and treated early, it can lead to more serious problems, such as peritonitis, liver abscess, or sepsis. The usual bacterial pathogens are Streptococcus pyogenes, Staphylococcus aureus, group B streptococcus, and gram-negative rods.

47 How is omphalitis treated?

If the findings are not clearly suggestive of omphalitis (i.e., there is minimal drainage or erythema), the infant can be treated at home with good skin and cord care (cleaning the cord with each diaper change and using topical antibiotics). Re-evaluation in 24 hours is recommended. Parents should be instructed to return for re-examination if the child has a change in feeding, activity, or disposition. If the infant appears toxic with obvious signs of omphalitis, he or she should be presumed to have a serious systemic infection. In this case, obtain appropriate laboratory evaluation for sepsis, admit, and treat with IV antibiotics.

48 Why have physicians typically been taught not to use analgesics in patients being evaluated for abdominal pain?

For almost a century, the teaching was to avoid pain relief for patients with abdominal pain to keep from masking the “true examination.” When this idea was originally taught at the turn of the century (the 19th century, that is!), the clinician had only a physical examination and history upon which to base a diagnosis. To increase diagnostic accuracy, serial examinations were performed. In addition, few analgesics were available, and none of them were reversible. Given the limitations of the era, the rule of “no analgesics in abdominal pain” made sense. None of it, however, was evidence-based.

Fortunately, we now have many methods for evaluating abdominal pain, and the old teaching should be reassessed. Although history and physical examination remain foremost in the process of diagnosing the cause of abdominal pain, laboratory and radiologic evaluation allow physicians to assess the anatomy prior to surgery. And the analgesic options are better understood, often reversible, and more effective.

49 Your 10-year-old patient with presumed appendicitis is in extreme pain. His tearful mother is asking if there is anything you can give him to make him feel better. The surgeons won’t be available to examine him for another hour. What should you do?

Providing pain relief for patients with abdominal pain is becoming more accepted because of increasing evidence. Studies in adults have shown that administration of opiates decreases self-reported pain scores but does not hide evidence of peritoneal irritation. Studies in children are limited by small numbers of patients and serial observations by the same examiners, but suggest that opiate administration provides pain relief without adversely affecting the examination or the ability to diagnose children with surgical conditions.

Despite the growing evidence that opiate administration will not affect diagnostic accuracy, many experienced surgeons prefer to examine patients prior to administration of pain medication. It is important to respect the practice in your institution, while remaining aware of the current literature. Reassure your patient’s mother that you will address the issue, and give your surgical colleagues a call to let them know your plan.

Kim MK, Galustyan S, Sato TT, Bergholte J, Hennes HH: Analgesia for children with abdominal pain: A survey of pediatric emergency physicians and pediatric surgeons. Pediatrics 111:1122–1126, 2003.

Kim MK, Strait RT, Sato TT, Hennes HM: A randomized clinical trial of analgesia in children with acute abdominal pain. Acad Emerg Med 9:281–287, 2002.

Kokki H, Lintula H, Vanamo K, Heiskanen M, Eskelinen M: Oxycodone vs placebo in children with undifferentiated abdominal pain. Arch Pediatr Adolesc Med 159:320–325, 2005.

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