Paediatric surgical emergencies Mani Thyagarajan BWCH
General points Always discuss Call consultant for help ASAP CT scan is a bad modality in paediatrics
Ultrasound? Intussusception? Renal colic? UTI Issues with Transplant Kidney? Malrotation? Appendicitis? Ovarian cause? Intestinal obstruction
Ultrasound Full bladder for pelvis Fasted for hepato-bilairy system and pancreas
Fluoroscopy Bilious vomitters Failure to pass meconium Intussception reduction NJ tube insertion
CT scan Source of infection??? Post appendectomy
Pyloric stenosis
Appendicitis Abdominal radiography Plain radiographs rarely add to the diagnosis because they are typically normal in appendicitis. Abdominal radiographs should be obtained in any patient with an examination concerning for intestinal obstruction or with peritoneal signs. The presence of a calcified appendiceal fecalith occurs in fewer than 10% of cases.
Literature What they did: Meta-analysis 26 studies involving children 9,356 total patients Primary outcome: Pooled sensitivity and specificity of CT and US in diagnosis of acute appendicitis in children Results: Pooled sensitivity and specificity for US in diagnosis of appendicitis in children: 88% and 94% Pooled sensitivity and specificity for CT in diagnosis of appendicitis in children: 94% and 95% Conclusion: CT has a higher sensitivity than US for diagnosis of acute appendicitis in children.
Literature The decision to obtain an US vs CT for children with suspected appendicitis remains a challenge. On a case by case basis, one should consider the following 4 major goals in care: Minimize rates of missed appendicitis Minimize risk from radiation exposure Avoid misdiagnosis leading to negative appendectomy Properly identify appendicitis before perforation
Background Children have a higher risk/unit dose Why? Growing tissue more susceptible Longer life span to develop malignancies For 600,000 CT-head/abdo s performed in <15 yr olds 2 ~ 500 fatal cancers within their lifetime.
Background Corresponds to lifetime risk of fatal cancer of ~ 1 in 1000 0.18% for CT-abdomen 0.07% for CT-head
Concept or risk keep in context! Lifetime risk of dying from cancer - 1:3 Fatal slip in the bath/shower - 1:2500 (~same as a 5yr old developing a fatal cancer from a CTchest) Striking it rich on the antiques roadshow - 1:60,000 Marrying a supermodel - 1:88,000
Results Risk per investigation For a 5yr old, what is the lifetime risk of developing a fatal cancer from each investigation? <1 in 40,000 ~1 in 20,000 ~1 in 6000 ~1 in 3000 ~1 in 1500 CXR CT Head 6 44 CT Chest 5 44 CT A/P 5 44 MRI + Gad 65 31 Ba Swallow 27 48 MCUG 26 47 Ultrasound 76 24
Literature
Radiation Protection use of CT, thus Dose reduction Education and awareness Ionising Radiation (Medical Exposure) Regulations, 2000 IRMER.
Appendicitis
Appendicitis
Unwell pyrexial vague abdominal pain
Right iliac fossa pain
Ovarian Torsion USS has a vital role in the examination of women with lower abdominal and pelvic pain Typically, the affected ovary is enlarged, with multiple immature or small follicles along its periphery Color Doppler sonography can help in determining whether blood flow is impaired MRI can serve as a secondary modality when ultrasonographic findings are nondiagnostic
Torsion Ovary
Normal left ovary
Ovarian cyst haemorrhagic
Meckel s diverticulum
Intussusception Role of plain film is controversial Not necessary Role of ultrasound Diagnosis Looking for contraindications for pneumatic reduction Pneumatic reduction
Intussception
Intussception
Role of Ultrasound Torsion testis
Torsion testis
Strangulated Hernia
Hernia Role of Ultrasound
Urinary tract infection Role of Imaging Normal imaging does not rule out infection To look for conditions predisposing to infection Complications of infection
PUV Ultrasound any male child with bilateral hydroneprosis with hydroureter with or without thick walled bladder is PUV unless proved otherwise by a MCUG MCUG
Caecal volvulus