Common Pediatric Surgical Conditions

Posted on Aug 6, 2024 in Biology

Acute Hematogenous Osteomyelitis (AHO)

Pathophysiology

Bacteremia leads to bacteria localizing in the venous sinuses of long bones due to turbulent blood flow. This increases the risk of clotting and subsequent infection within the bone.

Progression of Infection Inside the Bone

1. Phlegmon (inflammatory exudate) formation in the bone marrow
2. Subperiosteal spread of the phlegmon (within 2-3 days)
3. Spread to the nearest joint
4. Spread of the phlegmon to soft tissue
5. Sequestrum formation (dead bone tissue)

Septic Arthritis

AHO can lead to septic arthritis. Here’s why:

1. Both AHO and septic arthritis are hematogenous (spread through the bloodstream).
2. Children have no bone marrow in the metaphysis of long bones, making it easier for bacteria to spread from the blood to the joint.
3. The joint fluid in children lacks immune cells, making it easier for infection to establish.

Neonates, early childhood, and early adolescence (0-2 years old and 9-11 years old) are the most susceptible to AHO and septic arthritis.

Common Bacteria

Staphylococcus aureus is more common than Streptococcus pneumoniae.

Clinical Features

• Fever, general malaise
• Pain
• Limping
• Restricted range of motion
• Swelling, redness, heat (signs of inflammation)
• Painful palpation and percussion

Diagnosis

I. Clinical Inspection

1. Examination of the metaphysis of the long bone
2. Assessment for subperiosteal abscess
3. Evaluation of the affected joint

II. Culture

• Samples should be taken from the metaphysis of the bone, subperiosteal abscess, and/or joint fluid.

III. Other Investigations

• Intraosseous pressure measurement (normal: 90-120 mm Hg)
• Cytological smear of aspirated fluid
• Imaging studies:
  • X-ray (visible changes appear after 10-12 days, sometimes as early as 2 weeks)
  • Bone scintigraphy with Technetium-99m
  • Ultrasound

Treatment

I. Conservative

• Immobilization of the affected limb for 4-6 weeks
• Antibiotic therapy:
  • Semisynthetic penicillins (oxacillin, methicillin)
  • First-generation cephalosporins (cefazolin)

II. Surgical

• Opening and decompression of the bone marrow
• Drainage of pus
• Local antiseptic lavage

Complications of AHO

1. Septic arthritis
2. Chronic osteomyelitis
3. Bone deformities
4. Contractures
5. Pathologic luxations (dislocations)
6. Ankylosis (joint stiffness)
7. Growth disorders
8. Pathologic fractures

Hydronephrosis

Definition

Hydronephrosis is the dilation of the renal pelvis and calyces due to the obstruction of urine flow.

Causes

1. Urinary tract obstruction (e.g., stones, tumors, strictures)
2. Vesicoureteral reflux

Clinical Features

• May be asymptomatic
• Flank/back pain and/or abdominal pain
• Palpable mass
• Recurrent urinary tract infections
• Hematuria after movement
• Oliguria (decreased urine output)
• Fever and features of UTI if infected (pyonephrosis)

Diagnosis

• Ultrasound: Shows hypoechoic dilation of the renal pelvis and calyces, distending the healthy parenchyma.
• Renal function tests: Elevated creatinine, especially in bilateral obstruction.

Surgical Indications

1. Worsening kidney function
2. Recurrent kidney infection
3. Renal sepsis of urinary origin
4. Hematuria

Treatment

1. Analgesics and prophylactic antibiotics
2. Decompression with ureteral stenting
3. Percutaneous nephrostomy
4. Urethral catheterization or suprapubic catheterization

Posterior Urethral Valves

Definition

Posterior urethral valves (PUV) are a congenital malformation in males where membranous folds obstruct the membranous and prostatic urethra, leading to urinary tract obstruction.

Epidemiology

The incidence of PUV is about 1 in 8,000 live births.

Symptoms/Clinical Features

1. #1 cause of urinary tract obstruction in newborn males, leading to hydronephrosis and renal failure.
2. Respiratory distress secondary to pulmonary hypoplasia (underdeveloped lungs).
3. Abdominal distention due to bladder distention.
4. If late presentation:
   • Difficulty voiding, poor urinary stream
   • Recurrent UTIs, urosepsis
   • Diurnal enuresis (daytime wetting)
   • Failure to thrive

Diagnosis

1. Voiding cystourethrogram (VCUG) is diagnostic and demonstrates dilation/elongation of the posterior urethra during voiding. It may also reveal vesicoureteral reflux, if present.
2. Prenatal ultrasound may show a distended bladder, bilateral hydroureters, bilateral hydronephrosis, marked vesicoureteral reflux with megaureter, and oligohydramnios (low amniotic fluid), suggesting Potter sequence.

Pyloric Stenosis

Definition

Pyloric stenosis is the narrowing of the gastric pylorus due to hypertrophy (thickening) of the pyloric muscle.

Symptoms

• Onset between 3-5 weeks of age
• Projectile, non-bilious vomiting between feedings
• Metabolic alkalosis
• Dehydration
• Weight loss
• Constipation
• Oliguria

Diagnosis

1. History of persistent, projectile, non-bilious vomiting
2. Physical examination:
   • Palpable olive-sized mass in the epigastrium, commonly called the”pyloric tumo” or”oliv”
   • Epigastric distention
   • Visible gastric peristalsis
3. Ultrasonography: Shows a pyloric muscle thickness of >4 mm and a pyloric channel length of >16 mm.
4. X-ray: May show the”string sig” (a thin stream of contrast passing through the narrowed pylorus).
5. Upper gastrointestinal endoscopy (rarely needed)

Treatment

Surgical correction with a pyloromyotomy is the definitive treatment.

Esophageal Atresia and Tracheoesophageal Fistula

Definition

Esophageal atresia (EA) is a congenital anomaly where the esophagus ends in a blind pouch, preventing food from reaching the stomach. Tracheoesophageal fistula (TEF) is an abnormal connection between the esophagus and the trachea.

Pathophysiology

EA/TEF occurs due to incomplete formation of the esophagus during fetal development. The most common type is proximal esophageal atresia with a distal tracheoesophageal fistula (TEF).

Symptoms

• Symptoms typically start after birth and worsen with feeding.
• Bubbling from the mouth
• Cyanosis (blue discoloration of the skin)
• Dyspnea (difficulty breathing)
• Moist rales (crackling sounds heard on lung auscultation)
• Polyhydramnios (excessive amniotic fluid) may be present prenatally.

Diagnosis

• X-ray: Shows the inability to pass a nasogastric tube into the stomach (the”elephant tes”). The presence of gas in the stomach indicates a distal TEF, while the absence of gas suggests esophageal atresia without a fistula.

Treatment

• Initial management:
  • Nasogastric tube decompression
  • Intravenous fluids
  • Intravenous nutrition or gastrostomy (feeding tube placed directly into the stomach)
  • Intravenous antibiotics
  • Echocardiogram to evaluate for associated cardiac anomalies
• Surgical repair:
  • Division of the TEF
  • Reconstruction of the esophagus to establish continuity

Congenital Diaphragmatic Hernia (CDH)

Definition

CDH is a birth defect where there is a hole in the diaphragm, allowing abdominal organs to move into the chest cavity.

Types

• Bochdalek hernia (most common): Occurs at the back of the diaphragm.
• Morgagni hernia: Occurs at the front of the diaphragm.

Clinical Features

• Respiratory distress (dyspnea, tachypnea, cyanosis) at birth
• Paradoxic breathing (one side of the chest expands while the other collapses)
• Scaphoid abdomen (sunken appearance of the abdomen)
• Increased anteroposterior diameter of the chest
• Mediastinal shift (heart and other structures pushed to the opposite side)
• Absent breath sounds on the affected side

Diagnosis

• Prenatal ultrasound: May show polyhydramnios, mediastinal shift, and absence of the stomach bubble in the abdomen.
• Fetal MRI: Can confirm the diagnosis and assess the severity.
• Postnatal chest X-ray: Shows air-filled loops of bowel in the chest cavity.

Treatment

• Preoperative management:
  • Resuscitation and stabilization
  • Mechanical ventilation
  • Extracorporeal membrane oxygenation (ECMO) in severe cases
• Surgical repair:
  • Reduction of the herniated organs back into the abdomen
  • Closure of the diaphragmatic defect

Intussusception

Definition

Intussusception is a serious condition where part of the intestine slides into an adjacent part, causing obstruction.

Treatment

I. Non-operative

• Hydrostatic reduction: Using a barium enema to push the invaginated bowel back into place.
• Pneumatic reduction: Using air pressure to reduce the intussusception.

II. Operative

Surgical intervention is indicated when:

• Non-operative reduction is unsuccessful or incomplete.
• Signs of peritonitis are present.
• A pathological lead point (e.g., tumor, Meckel’s diverticulum) is identified.
• Radiographic evidence of pneumoperitoneum (free air in the abdomen) is seen.

Surgical options include laparoscopic or open reduction.

Umbilical Hernia

Causes

• Weakness in the abdominal wall at the umbilicus
• Incomplete closure of the umbilical ring after birth
• Increased intra-abdominal pressure (e.g., from obesity, coughing, straining)

Classification

• Direct vs. indirect
• Congenital vs. acquired

Surgical Indications

• Painful hernia
• Hernia persisting beyond 5 years of age
• Strangulation or incarceration (blood supply to the herniated contents is compromised)
• Very large defect in children under 2 years old, causing cosmetic concerns for parents
• Hernia in children with connective tissue disorders

Surgical Technique

1. General anesthesia
2. Dissection of subcutaneous layers to expose the hernia sac
3. Excision of the hernia sac
4. Closure of the fascial defect with non-absorbable sutures

Complications

• Infection
• Recurrence

Inguinal Hernia

Symptoms

• Inguinal swelling, especially when crying
• Inguinal asymmetry
• Palpable mass at the inguinal ring
• Intestinal obstruction (if the hernia is incarcerated or strangulated), presenting with fever and vomiting

Differential Diagnosis

1. Hydrocele (fluid collection around the testicle)
2. Testicular torsion (twisting of the spermatic cord)
3. Torsion of the appendix testis (twisting of a small appendage on the testicle)
4. Inguinal lymphadenopathy (enlarged lymph nodes)
5. Femoral hernia (hernia through the femoral canal)

Complications

• Incarceration and strangulation
• Intestinal wall necrosis
• Compromised testicular circulation

Treatment

All inguinal hernias in children require surgical repair.

1. General anesthesia
2. Incision in the lower abdominal fold
3. Opening of the fascia
4. Reduction of the hernia sac
5. Closure of the fascia
6. Skin closure with intradermal sutures

Complications of Surgery

• Injury to the vas deferens or testicular vessels
• Recurrence
• Testicular atrophy

Vitelline Duct Remnants

I. Patent Ductus Omphaloentericus

• Presents with umbilical discharge around 4-8 weeks of age
• Diagnosis: Clinical examination, ultrasound, fistulography
• Treatment: Conservative management if no fistula is present; surgery if a fistula is present

II. Meckel’s Diverticulum

• A common congenital anomaly representing a persistent portion of the vitelline duct
• Complications: Bleeding, perforation, diverticulitis, intestinal obstruction, intussusception

III. Vitelline Duct Cyst

• Usually asymptomatic
• Treatment: Surgical excision

Omphalitis

Definition

Omphalitis is an infection of the umbilicus and surrounding tissues.

Symptoms

• Onset within the first two weeks of life
• Redness, warmth, swelling, and pain around the umbilical stump
• Pus discharge from the umbilical stump
• Fever
• Tachycardia (rapid heart rate)
• Hypotension (low blood pressure)
• Somnolence (sleepiness)
• Poor feeding
• Jaundice (yellowing of the skin)

Complications

• Sepsis
• Necrotizing fasciitis (flesh-eating disease)
• Spontaneous evisceration (protrusion of intestines through the umbilical wound)
• Peritonitis
• Intra-abdominal abscess
• Hepatic abscess
• Adhesive intestinal obstruction

Treatment

• Intravenous antibiotics active against Staphylococcus aureus
• Supportive care for complications (e.g., fluid resuscitation for hypotension)

Purulent Diseases of the Skin

I. Omphalitis

• Simple form: Local wound care
• Phlegmonous form: Antibiotics and local wound care
• Necrotic form: Antibiotics, local wound care, and surgical debridement

II. Mastitis

• Infiltrative stage: Antibiotics and warm compresses
• Abscess formation: Incision and drainage

III. Necrotizing Fasciitis

• Antibiotics
• Surgical debridement of necrotic tissue

IV. Other Purulent Skin Infections

• Paronychia (infection around the fingernail): Incision, drainage, antibiotics
• Purulent lymphadenitis: Treatment of the primary infection source, antibiotics, incision and drainage if necessary

Anorectal Malformations (ARMs)

ARMs are a spectrum of congenital anomalies affecting the anus and rectum. They are classified based on the level of the rectal pouch in relation to the puborectalis muscle.

Classification

Common Types

• Low ARMs:
  • Boys: Anorectal cutaneous fistula is the most common.
  • Girls: Anovestibular fistula is the most common.
• High ARMs:
  • Boys: Anorectal agenesis with rectourethral or rectovesicular fistula
  • Girls: Rectovaginal fistula

Hypospadias

Definition

Hypospadias is a congenital anomaly where the urethral opening is located on the underside of the penis, instead of at the tip.

Causes

• Incomplete fusion of the urethral folds during fetal development
• Genetic factors
• Endocrine factors (e.g., 5-alpha-reductase deficiency)
• Environmental factors

Diagnosis

Clinical examination is usually sufficient for diagnosis.

Treatment

• Mild cases may not require surgery.
• Significant displacement or urinary symptoms warrant surgical repair, typically performed around 6 months of age. This may involve urethroplasty (reconstruction of the urethra) and/or penile straightening.
• Severe cases may require a staged repair.

Complications of Repair

• Urethral fistula
• Meatal stenosis (narrowing of the urethral opening)

Acute Scrotum

I. Testicular Torsion

• Cause: Twisting of the spermatic cord, cutting off blood supply to the testicle
• Treatment:
  • Prompt diagnosis is crucial.
  • Emergency surgery to untwist the spermatic cord
  • Orchiectomy (removal of the testicle) if the testicle is not salvageable

II. Torsion of the Appendix Testis

• Treatment:
  • Conservative management with pain relief and scrotal support

III. Epididymitis

• Cause: Infection of the epididymis, usually caused by bacteria (e.g., Chlamydia trachomatis, Escherichia coli, Neisseria gonorrhoeae)
• Treatment:
  • Antibiotics
  • Scrotal elevation
  • Cold compresses
  • Pain relief
  • Surgery is rarely required (e.g., for abscess drainage)

IV. Scrotal Trauma

• Minor trauma: NSAIDs, cold packs, scrotal support
• Major trauma: Manual detorsion, surgical exploration, drainage, repair

Wilms Tumor (Nephroblastoma)

Definition

Wilms tumor is a type of kidney cancer that typically affects children.

Diagnosis

• Ultrasound and CT scan: To determine the size and location of the tumor and assess for involvement of surrounding structures.
• Biopsy: To confirm the diagnosis.
• Chest CT scan: To check for metastases (spread to other parts of the body).

Treatment

• Surgery
• Chemotherapy
• Radiation therapy (in some cases)

Pectus Excavatum (Sunken Chest)

Clinical Features

• Sunken appearance of the sternum
• Possible displacement or rotation of the heart
• Decreased lung capacity
• Mitral valve prolapse (in some cases)

Surgical Indications

• Cardiopulmonary impairment
• Exercise intolerance
• Chest pain
• Psychological distress
• Anticipated need for future sternotomy (e.g., for heart surgery)

Treatment

• Ravitch procedure: Involves removing cartilage and repositioning the sternum.
• Nuss procedure: Involves placing a metal bar under the sternum to reshape it.
• Vacuum bell therapy: Uses a suction device to gradually lift the sternum.

Acute Appendicitis in Children

Clinical Features

• Abdominal pain:
  • Periumbilical at onset
  • Migrates to the right lower quadrant (RLQ) within a few hours
  • Colicky in nature
• Flank or back pain
• Dysuria (painful urination)
• Vomiting (usually after the onset of pain)
• Normal bowel movements in the early stages
• Low-grade fever

Diagnosis

• Laboratory tests: White blood cell count may be normal in the early stages. Urinalysis is important to rule out urinary tract infection.
• Ultrasound: Can help visualize the appendix and look for signs of inflammation.

Complications

• Perforation
• Intra-abdominal abscess
• Sepsis
• Wound infection
• Small bowel obstruction

Treatment

• Surgical appendectomy:
  • Open or laparoscopic approach
  • Peritoneal lavage (rinsing of the abdominal cavity) if perforation is present
• Antibiotics: Prophylactic antibiotics are given before surgery and continued postoperatively if necessary.

Acute Appendicitis in Toddlers

Diagnosis can be challenging in toddlers due to:

• Poor history taking
• Muscular rigidity from crying
• Resistance to examination
• Nonspecific symptoms

Pediatric Peritonitis

Definition

Peritonitis is inflammation of the peritoneum, the lining of the abdominal cavity. In children, it is often caused by a perforated appendix.

Clinical Features

• Severe abdominal pain
• Abdominal distention
• Guarding (tensing of abdominal muscles)
• Rebound tenderness (pain upon release of pressure on the abdomen)
• Fever
• Tachycardia
• Vomiting

Treatment

• Intravenous fluids
• Antibiotics
• Peritoneal lavage
• Surgery to address the underlying cause (e.g., appendectomy)

Complications

• Sepsis
• Shock
• Death

Neonatal Peritonitis

Causes

Clinical Features

• Onset typically between the second and sixth day of life
• Poor feeding
• Vomiting
• Abdominal distention
• Tenderness
• Edema of the abdominal wall
• Dilated abdominal veins

Diagnosis

• Abdominal X-ray: May show thickened bowel loops, air-fluid levels, and/or pneumatosis intestinalis (gas in the bowel wall).

Treatment

• Perforation: Surgery (e.g., resection of the perforated bowel, stoma creation, peritoneal lavage)
• Non-perforation: Non-operative management with bowel rest, intravenous fluids, and antibiotics

Gastrointestinal Bleeding in Children

Urgent Causes

Neonatal GI Bleeding

• Swallowed maternal blood
• Hemorrhagic disease of the newborn (vitamin K deficiency)
• Necrotizing enterocolitis (NEC)

Common Causes by Age Group

• Newborns: Swallowed maternal blood, NEC, hemorrhagic disease of the newborn, volvulus, milk allergy, anal fissure, coagulopathies, intestinal duplication, vascular anomalies, Hirschsprung’s disease complicated by enterocolitis
• Infants: Gastritis, esophagitis, peptic ulcer disease, foreign body ingestion, esophageal varices, aortoenteric fistula
• Toddlers and older children: Esophagitis, esophageal varices, gastritis, peptic ulcer disease, Mallory-Weiss syndrome, hemobilia (bleeding into the biliary tract), thrombocytopenia, polyps, Meckel’s diverticulum, infectious enterocolitis, anal fissure

Childhood Cancers

Common Types

• Leukemia (33%)
• Brain tumors (21%)
• Lymphomas (8%)
• Bone cancers (osteosarcoma, Ewing sarcoma) (4%)
• Neuroblastoma (7%)
• Wilms tumor (5%)
• Rhabdomyosarcoma (3-4%)
• Retinoblastoma (3%)

Treatment-Related Complications

• Infertility
• Growth retardation
• Cardiac damage
• Secondary cancers