Problems

GASTROINTESTINAL
Pyloric stenosis
Malrotation
Midgut volvulus
Duodenal atresia
Meconium ileus
Intussusception
Meckel’s diverticulum
appendicitis
Hirschsprung’s disease

GENITOURINARY
Inguinal hernia
Umbilical hernia
Hypospadias
Phimosis/paraphimosis
Cryptorchidism
Hydrocele
Testicular torsion

Pyloric stenosis
- Hypertrophy of the gastric outlet
150 males, 1:750 females
12 weeks of age
- Repetitive vomiting
Projectile
Non-bilious
- Dehydration
Hypochloremic alkalosis
- Exam
Visible peristaltic wave
Palpable -olive- to right of umbilicus

Malrotation
- Failure of midgut to rotate into normal anatomic position during development
Colon and cecum in left
Duodenum on right side
- Bilious vomiting
Peritoneal (Ladd) bands cause partial bowel obstruction
- High risk for...

Midgut volvulus
- Twisting of bowel around its mesentery and vascular supply
1- Leads to ischemia, infarction, perforation, necrosis
2- Presentation: lethargy, abdominal distention, bloody stools

MALROTATION
- Must consider in every infant with bilious emesis
- 30% present within first week of life
- 50% within first month
- Midgut volvulus with necrosis disastrous
- Can lead to SBS, death

CLINICAL PRESENTATION of MALROTATION
- Sudden onset of bilious emesis in 95%
- Abdominal distention common
- Blood stool +
- Bloody vomitus or diarrhea in 30%

RADIOLOGIC DX of MALROTATION
- KUB:Gasless abdomen, SBO, -double bubble-
- Contrast study: spiral or corkscrew appearance
- UTS: reversed position of SMA/SMV
- Study MUST be expeditious

PREOPERATIVE PREPARATION: MALROTATION WITH VOLVULUS
- Labs / unnecessary
- Mortality remains as high as 28%
- Preoperative preparation

OPERATIVE CORRECTION of MALROTATION
- Ladd procedure
- Position of corrected malrotation
* Small bowel descends on Right
* Large bowel on Left
* Appendix potentially in LUQ - Removed
- Role of second look operation

Duodenal atresia
- Obliteration of lumen
* Failure to recanalize
- Neonatal bilious vomiting
- Associations
* Prematurity
* Congenital heart defects
* Trisomy 21

Intussusception: Management
- Enema: diagnostic & therapeutic, -coiled spring-
- Surgery must be consulted prior to study.
- Barium vs. Air- 80% correction if within first 12-24 hrs.
- Air Enema- safer if perforation
- 5-10% recurrence rate in first 24-48h after barium enema reduction
- If free air on films or signs of peritonitis, do not administer barium, prepare child for surgery

Scrotal swelling
- PAINLESS
Hydrocele
Varicocele
Spermatocele
Inguinal hernia

- PAINFUL
Testicular torsion
Epididymitis
Orchitis
Incarcerated hernia

What to do?
- Always undress the child for exam
- Don’t forget Intussusception in lethargic children
- Utilize imaging liberally when child looks sick and know your radiologist’s expertise
- Any type of blood in stool may be due to Intussusception (not only currant jelly)
- Vomiting in infants should not be taken seriously
- Be conservative with children w/ unclear dx
- Be sure that the parent(s) understand return precautions. If they do not, then observe child

What not to do
- Don’t tell a patient that they DO NOT have appendicitis
- Don’t let a normal X-ray or U/S fool you
- Don’t forget to ask parents/child with vomiting about abdominal pain

Left

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