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This is where a segment of bowel becomes invaginated into the immediately distal bowel.
- It is the most common cause of obstruction in children aged 5 months to 3 years.
- It accounts for 25% of all abdominal surgical emergencies in children aged younger than 5 years.
- It occurs in children aged 3 months to 6 years and, very occasionally, in the neonatal period.
- 66% are aged <1 year old and it is unusual after 3 years of age.[2, 3]
- Incidence varies from 1.6-4 cases per 1,000 live births in the UK.
- Abdominal pain, lethargy and vomiting are reported in 78% of infants.
- Ultrasound confirms the diagnosis in the majority of cases.
The 'classic' picture of intussusception might not be present, ie abdominal pain, vomiting and redcurrant jelly stools. Relying on 'classic' features alone might delay diagnosis and this is associated with poorer outcomes. The morbidity and mortality rate are otherwise very low after treatment.
Air (pneumostatic) or water (hydrostatic) reduction is successful in 82% cases. Delayed repeated air enema is sometimes successful in partially reduced cases. Children under 3 in whom a 'lead point' cannot be identified fare best with conventional treatment.
NB: in successful radiographic reduction the small bowel is usually visualised before the appendix. Visualisation of the appendix before visualisation of the small bowel may indicate that radiographic reduction is not possible and prevent further attempts. This is called the 'appendix sign'.
Nonoperative reduction is contra-indicated in patients with signs of peritonitis or if bowel perforation is suspected. Factors associated with increased risk of intestinal resection include:
Laparoscopic resection is now possible.
Hypertrophic pyloric stenosis
This is complete pyloric obstruction.
- It usually presents at 3-8 weeks of age.
- It is caused by hypertrophy of a ring of muscle.
- The baby starts to vomit after every feed, characteristically becoming projectile.
- The vomit is not bile-stained.
- The baby appears well and hungry, unless prolonged vomiting has produced dehydration.
- A 2 cm mass is normally palpable deeply below the liver during test feed, with the appearance of an 'olive'.
- Gastric peristaltic waves (visible through the abdominal wall) confirm the diagnosis.
- Ultrasound can be used to show obstruction.
- This is by the surgical procedure Ramstedt's pyloromyotomy. The laparoscopic route, now generally accepted as method of choice, has been shown to give a better cosmetic result without longer operation times or postoperative morbidity.
- A procedure called double-Y pyloromyotomy has been developed which may offer a better functional result than a Ramstedt's pyloromyotomy.
- Intravenous atropine has been used as a a potential medical method of management.
Strangulated inguinal hernia
- This is the most common cause of abdominal emergency in boys <2 years old.
- It is 10 times more common in boys than in girls.
- It is always associated with congenital patent processus vaginalis but hernia may not have been visible previously.
- Examination reveals a firm lump in the groin of a crying child, which may extend into the scrotum. The child may have vomited but is usually well.
- Paediatric surgeons will undertake repair soon after diagnosis, regardless of age or weight, in healthy full-term infant boys with asymptomatic reducible inguinal hernias. Emergency surgery is twenty times more likely to cause complications than an elective procedure.
- Premature infants with inguinal hernias are usually repaired prior to discharge from the neonatal intensive care unit (NICU) but this practice is changing, as infants are now being discharged home at much lower weights. Some surgeons prefer to postpone the surgery in these very small babies for 1-2 months to allow further growth.
- Immediate surgery is not always necessary in a case of strangulation: four out of five can be reduced manually.
- Tachycardia, fever or signs or obstructions are indications for surgery. Herniotomy is usually all that is required with ligation and excision of the patent processus vaginalis. If gangrenous bowel is present it should be excised and an end-to-end anastomosis performed.
- In girls, an inguinal hernia may contain an ovary.
It is very rare for the hernia to recur - less than 1 in 100. This is more common in children who have a wound infection after the operation or who do not avoid any excess physical activity for the first four to six weeks.
Rare complications can include infarction of the testis or ovary, iatrogenic orchidectomy or oophorectomy or intestinal injury.
This can be difficult to diagnose, particularly if young and female. Prior treatment with antibiotics delays diagnosis and can lead to further morbidity. There have been attempts to formulate a predictive model to aid diagnosis.
An American paper classified patients as 'low-risk' if:
- white blood cell count <9.5 x 109/L
- either no right lower-quadrant tenderness, or
- A neutrophil count <54%
Patients were classified as 'high-risk' if:
- white blood cell count >13.0 x 109/L with rebound tenderness, or
- both voluntary guarding and neutrophil count >82%
This model was more reliable than clinical practice with regard to 'missed' appendicitis, negative laparotomies and total number of imaging studies.
One study reported the successful use of laparoscopy in children, even in cases which involved complications such as peritonitis.
Swallowed foreign body
Usually these do not become trapped if they pass the oesophagus. A child may be brought in by the caregiver with a history that they have swallowed a foreign body or it has been noticed in the stools. Children who present aged 2 years old and younger, who have a documented fever and with respiratory findings should be considered at risk for having a retained oesophageal foreign body. Children with oesophageal abnormalities may also be at risk.
Symptoms of oesophageal foreign body may be vague in the early stages but may include food refusal, vomiting, drooling, gagging, sore throat, chest pain, stridor and altered mental state.
Arrange X-ray and serial films to track the progress of radio-opaque objects (radio-opaque foreign bodies are much more common than food in younger children). Radiolucent objects may require a small amount of contrast medium to show them up (contra-indicated if perforation is suspected, in which case endoscopy should be considered). Hand-held metal detectors have occasionally been used to good effect. Most foreign objects swallowed by children pass through without any problem but retained oesophageal foreign bodies may cause a multitude of problems, including:
- Mucosal ulceration.
- Inflammation or infection.
- Paraoesophageal or retropharyngeal abscess formation.
- Oesophageal perforation and aorta-oesophageal fistula formation.
Endoscopy is the gold standard method of removal. Other methods include inserting an non-inflated Foley catheter past the object and then inflating it to bring the object out of the oesophagus, and the use of a bougie to push the object down into the stomach. Both these methods are thought to be more cost-effective than endoscopy. The use of Magill forceps to remove objects from the upper oesophagus has been described.
Torsion of the testis
An acute scrotum in a child requires surgical exploration for a definitive diagnosis. A retrospective analysis of all boys aged less than 15 years old presenting with scrotal pain over a 2-year period revealed:
- 27% had testicular torsion.
- 57% had a torted appendage testis.
- 11% had epididymitis.
- 1% had fat necrosis.
- 4% had no abnormality detected.
29% of the torted testes were unsalvageable and required excision. This study concluded that both clinical impression and Doppler ultrasound scans were not reliable. However, another retrospective study found that pain duration of less than 24 hours, nausea or vomiting, high position of the testicle and abnormal cremasteric reflex were associated with a higher likelihood of torsion. An Israeli study reported that 18 out of 20 patients with torsion were successfully diagnosed with use of Doppler scanning.
Further reading and references
Jenkins JT, O'Dwyer PJ; Inguinal hernias. BMJ. 2008 Feb 2336(7638):269-72.
What to Do If Your Child Swallows Something; American Family Physician
Vasavada P; Ultrasound evaluation of acute abdominal emergencies in infants and children Radiol Clin N Am 42445– 456:2004
Blanco FC et al; Intussusception, Medscape, May 2012
Ito S, Tamura K, Nagae I, et al; Ultrasonographic diagnosis criteria using scoring for hypertrophic pyloric stenosis. J Pediatr Surg. 2000 Dec35(12):1714-8.
Buettcher M, Baer G, Bonhoeffer J, et al; Three-year surveillance of intussusception in children in Switzerland. Pediatrics. 2007 Sep120(3):473-80.
Justice FA, Auldist AW, Bines JE; Intussusception: Trends in clinical presentation and management. J Gastroenterol Hepatol. 2006 May21(5):842-6.
Blanch AJ, Perel SB, Acworth JP; Paediatric intussusception: epidemiology and outcome. Emerg Med Australas. 2007 Feb19(1):45-50.
Pazo A, Hill J, Losek JD; Delayed repeat enema in the management of intussusception. Pediatr Emerg Care. 2010 Sep26(9):640-5.
Henry MC, Breuer CK, Tashjian DB, et al; The appendix sign: a radiographic marker for irreducible intussusception. J Pediatr Surg. 2006 Mar41(3):487-9.
Hall NJ, Pacilli M, Eaton S, et al; Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a Lancet. 2009 Jan 31373(9661):390-8. Epub 2009 Jan 18.
Alalayet YF, Miserez M, Mansoor K, et al; Double-Y pyloromyotomy: a new technique for the surgical management of infantile Eur J Pediatr Surg. 2009 Feb19(1):17-20. Epub 2009 Feb 16.
Kawahara H, Takama Y, Yoshida H, et al; Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the "olive"? J Pediatr Surg. 2005 Dec40(12):1848-51.
McCrudden K et al; Abdominal Hernias, eMedicine, Apr 2010
Schier F, Danzer E, Bondartschuk M; Incidence of contralateral patent processus vaginalis in children with inguinal hernia. J Pediatr Surg. 2001 Oct36(10):1561-3.
England RJ, Crabbe DC; Delayed diagnosis of appendicitis in children treated with antibiotics. Pediatr Surg Int. 2006 Jun22(6):541-5. Epub 2006 Apr 29.
Birkhahn RH, Briggs M, Datillo PA, et al; Classifying patients suspected of appendicitis with regard to likelihood. Am J Surg. 2006 Apr191(4):497-502.
Wang X, Zhang W, Yang X, et al; Complicated appendicitis in children: is laparoscopic appendectomy appropriate? A J Pediatr Surg. 2009 Oct44(10):1924-7.
Louie JP, Alpern ER, Windreich RM; Witnessed and unwitnessed esophageal foreign bodies in children. Pediatr Emerg Care. 2005 Sep21(9):582-5.
Woolley SL, Smith DR; History of possible foreign body ingestion in children: don't forget the rarities. Eur J Emerg Med. 2005 Dec12(6):312-6.
Murphy FL, Fletcher L, Pease P; Early scrotal exploration in all cases is the investigation and intervention of choice in the acute paediatric scrotum. Pediatr Surg Int. 2006 May22(5):413-6. Epub 2006 Apr 7.
Beni-Israel T, Goldman M, Bar Chaim S, et al; Clinical predictors for testicular torsion as seen in the pediatric ED. Am J Emerg Med. 2010 Sep28(7):786-9. Epub 2010 Feb 25.
Yagil Y, Naroditsky I, Milhem J, et al; Role of Doppler ultrasonography in the triage of acute scrotum in the emergency J Ultrasound Med. 2010 Jan29(1):11-21.
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