Management of Common Paediatric Surgical G.I. Problems

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1 Management of Common Paediatric Surgical G.I. Problems Dr. Loh Ser Kheng Dale Lincoln Senior Consultant Department of Paediatric Surgery National University Hospital National University Health System

2 Tongue Tie (Ankyloglossia) Short lingual frenulum Inserts at or near the tip of the tongue Difficulty lifting the tongue to the upper dental alveolus Inability to protrude the tongue past the lower central incisiors Impaired side-to-side movement Notched or heart-shaped tongue when protruded

3 Tongue Tie (Ankyloglossia) Breast feeding problems Poor latch Maternal nipple pain Articulation problems It does not prevent vocalization May affect sibilants and lingual sounds (eg, t, d, z, s, th, n,l ) Mechanical problems Difficulty in oral hygiene May result in periodontal disease Local discomfort Diastasis between the lower central incisors Difficulty licking an ice-cream cone, playing a wind instrument or kissing

4 Tongue Tie (Ankyloglossia) Treatment: Frenotomy (Frenulotomy) Clipping of the frenulum Carried out on infants without a GA Frenuloplasty Involves release of ankyloglossia with plastic repair Requires GA

5 Pyloric Stenosis Incidence: 2-3 per 1000 live births Male to Female ratio: 4:1 Strong Familial pattern of inheritance Presents from 2 weeks to 8 weeks of age Projectile non-bilious vomiting O/E: Visible peristalsis Diagnosis: Test-feed Confirmed with Ultrasound

6 Pyloric Stenosis Treatment: Resuscitate with IV Normal saline + KCL Operation: Ramstedt s Pyloromyotomy via open(ruq or umbilical approach) or laparoscopic

7 Malrotation/Volvulus 60% present in the first month of life (2/3 of these in the 1 st week) Presents with bilious vomiting, minimal or no abdominal distension AXR: Enlarged stomach, no gas distally

8 Malrotation/Volvulus Diagnosis is confirmed with Barium meal and Follow-through Classical Cock-screw appearance of volvulus Treatment: Laparotomy and Ladd s procedure and appendicectomy

9 Intussusception It is an invagination of one part of the intestine (intussusceptum) into another part of the intestine (intusscipiens) Commonest area ileum Age: 6 to 36 months Commonly occurs after viral illness Idiopathic Enlarged Peyer s patches Dx: Ultrasound

10 Intussusception Management: N/G tube, IVI and fluid bolus if necessary Treatment: Air-enema reduction If not successful, then laparotomy and manual reduction and appendicectomy

11 Umbilical Granuloma Usually develops after the cord falls off Produces a yellowish discharge and stains clothing If small in size, treat with silver nitrate pencil. Be careful! Can cause chemical burns to the normal skin (Protect normal skin with petroleum based Vaseline) If large, then can ligate the base with a suture. Beware of umbilcal polyps

12 Vitello-intestinal Duct remnants Can easily be mistaken for a umbilical granuloma Discharge is green in colour and bubbles can been seen If there is a sinus/fistula present, then a sinogram/fistulogram study can be done

13 Vitello-intestinal Duct remnants Treatment is surgical. Excision of fistulous connection and small bowel anastomosis Meckel s diverticulum is present in approximately 2% of the population Can present with various symptoms painless rectal bleeding, IO, intussusception Urachal remnants

14 Often associated with constipation Infant will complain of pain and bleeding with defacation Chronic fissures may also have a sentinel skin tag near the fissure Treatment is with stool softeners e.g. lactulose, Sitz baths Fissure-in-ano

15 Perianal abscess/fistula-in-ano Usually arise from the anal glands that lie in or near the plane between the internal and external sphincters Treatment is incision and drainage 50% may have a fistula-inano after the abscess has been drained surgically or spontaneously If it is a low fistula, then laying open of the fistula If higher, may need a Seton

16 Hirschsprung s Disease Incidence: 1 in 5000 live births May be familial Associated with Trisomy 21 Presents as distal intestinal obstruction Delayed passage of meconium (>24hrs after birth) AXR: Dilated loop of sigmoid colon & no rectal gas Confirmation by Contrast enema and rectal biopsies

17 Hirschsprung s Disease Initial treatment: Defunctioning sigmoid colostomy Pull-through Different types: Soave, Duhamel. Swenson Laterly, closure of colostomy Single stage pullthrough without colostomy

18 Thank you!

19 Contact Information Dr Loh Ser Kheng Dale Lincoln, Senior Consultant, Department of Paediatric Surgery, National University Hospital Telephone:

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