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general surgery(三)
Department of Pediatrics
Soochow University Affiliated Children’s Hospital
Acquired surgical abnormalities
Pyloric stenosis
Pyloric stenosis
Definition
Infantile hypertrophic
pyloric stenosis (IHPS) is
a common surgical
condition encountered in
early infancy, occurring
in 2–3 per 1,000 live
births.
Pyloric stenosis
Definition
It is characterized by
hypertrophy of the circular
muscle, causing pyloric
narrowing and elongation and
producing partial or complete
luminal occlusion. The
incidence of the disease
varies widely with geographic
location, season, and ethnic
origin. Boys are affected four
times more than girls.
Pyloric stenosis
Description
The appearance of the pylorus in IHPS is that of an
enlarged, pale muscle mass usually measuring 2 to
2.5 cm in length and 1 to 1.5 cm in diameter.
Pyloric stenosis
Description
Histologically the mucosa
and adventitia are normal.
There is marked muscle
hypertrophy primarily
involving the circular layer,
which produces partial or
complete luminal occlusion
Pyloric stenosis
symptoms
The usual onset of symptoms occurs
between 2 and 8 weeks of age with peak
occurrence at 3–5 weeks of age.
It has been rarely reported in premature
infants, especially extremely low birth weight
infants, and these premature infants with IHPS
present the signs and symptoms 2–4 weeks
later as compared to normal term infants.
Pyloric stenosis
symptoms
The clinical features vary with the
length of symptoms. Initially the vomiting may not be
frequent and forceful, but over several days it
progresses to every feeding and becomes forceful
nonbilious vomiting described as “projectile”.
The emesis consists of gastric contents, which may
become blood tinged with protracted vomiting and
likely related to gastritis, with “coffee-ground”
appearance (17–18% of cases).
Pyloric stenosis
symptoms
Infants with IHPS do not appear ill or febrile in the early
stages.
A significant delay in diagnosis leads to severe
dehydration and weight loss due to inadequate fluid and
calorie intake.
Severe starvation can exacerbate diminished glucoronyl
transferase activity and jaundice associated with indirect
hyperbilirubimemia as seen in 2–5% of infants with IHPS.
Pyloric stenosis
symptoms
It should be possible to diagnose IHPS on clinical
features alone in 80–90% of infants. The important
diagnostic features are visible gastric peristaltic
waves in the left upper abdomen and a palpable
enlarged pylorus (“olive” like mass).
Pyloric stenosis
Diagnosis
cardinal features of IHPS:
no
bilious projectile vomiting
visible
peristaltic waves in the left upper
abdomen
Hypochloremic,hypokalemic
alkalosis
metabolic
Pyloric stenosis
Diagnosis
Ultrasonography
has
become
the
most
common imaging technique for the diagnosis
of IHPS under optimal circumstances, this
technique can be reliable.
Pyloric stenosis
Diagnosis
The most commonly used criteria for
a positive ultrasound study:
 a pyloric muscle thickness of 4 mm or
more
a
pyloric channel length of 16 mm or
more
Pyloric stenosis
Diagnosis
A
barium
upper
gastrointestinal
(UGI)
examination is highly effective in making the
diagnosis of IHPS and should demonstrate
an elongated pyloric channel and indentation
on the antral outline, which are indirect
findings of pyloric muscle enlargement .
Barium meal study of IHPS. Narrowed elongated
pyloric canal giving a “string” or “double track” sign caused by
compressed invaginated folds of mucosa in the pyloric canal
string sign
double track sign
Pyloric stenosis
Treatment
Pyloric stenosis can be cured with a surgical
procedure called a pyloromyotomy.
INTUSSUSCEPTION
INTUSSUSCEPTION
DEFINITION
 Intussusception is the most
common cause of intestinal
obstruction in children between
3 months and 6 years of age. It
occurs when a portion of the
bowel "telescopes" into itself,
causing intestinal obstruction.
 Intussusception occurs most commonly in
infants between 15 and 19 months of age
with only 10–25% of cases occurring after 2
years of age.

 Although 90% of intussusceptions occur in
children between 3 months to 3 years of age,
it has also been reported in utero, in
neonates, and in adults.
INTUSSUSCEPTION
EPIDEMIOLOGY
 Incidence 2 - 4 / 1000 live births
 Usual age group 3 months - 3 years
 Greatest incidence 6-12 months
 Male predominance (1.5-2 : 1)
 No clear hereditary association
 No seasonal distribution
 Frequently preceded by viral infection
 URI, ADENOVIRUS
INTUSSUSCEPTION
PATHOPHYSIOLOGY
 Precipitating mechanism unknown
 Obstruction of intussusceptum




mesentery
Venous and lymphatic obstruction
Third spacing of fluid into bowel
wall
Ischemic necrosis occurs in both
intussusceptum and
intussuscipiens
Pathologic bacterial translocation
When older children develop
intussusception, it is usually due to
what is referred to as a pathologic
lead point. A lead point is a
recognizable anatomic abnormality
that obstructs the bowel, thus
initiating the process of
intussusception. Meckel's
diverticulum and lymphoma of the
intestine are two classic examples of
lead points. Intestinal tumors and
polyps may also act as lead points.
A pathologic lead point
INTUSSUSCEPTION
CLINICAL CHARACTERISTICS
 The clinical presentation is more typical in infants
and is characterized by episodes of abdominal colic
associated with drawing up the legs and crying.
 These episodes occur in 15–30 min intervals. In
between episodes the infant is quiet.
 Initially there may be vomiting of undigested food
and streaks of blood in the stools.
INTUSSUSCEPTION
CLINICAL CHARACTERISTICS
 Subsequently the child becomes lethargic
between episodes, develops increasing
abdominal distension, bilious vomiting, and
passage of red currant jelly stools.
 Often these symptoms are preceded by an
episode of diarrheal illness. Sometimes there
is a history of change in diet with introduction
of weaning foods.
red currant jelly stools
INTUSSUSCEPTION
PHYSICAL EVALUATION
 On examination the child may be febrile and
dehydrated with signs of shock in case of
bowel ischemia. A curved sausage-shaped
mass can be palpated anywhere in the
abdomen when the infant is quiet.
 Rectal exam is positive for blood in 60–90%
of cases. Rarely a cervix-shaped mass is
seen protruding beyond the anal verge.
INTUSSUSCEPTION
 The classic triad of incessant cry due to
abdominal colic, red currant jelly stools,
and a palpable abdominal mass has been
reported in 20–60% of cases.
INTUSSUSCEPTION
 Ultrasonography of the abdomen is often diagnostic
for intussusception with a reported accuracy of up to
100% (Fig).
 The characteristic “target sign” is described as two
rings of low echogenicity with an intervening
hyperechoic ring similar to a donut. The edematous
walls of the intussusception appear as superimposed
hyperechoic and hypoechoic layers described as the
pseudo-kidney sign.
INTUSSUSCEPTION
TREATMENT
 The initial management of children with
intussusception begins with fluid resuscitation
in the emergency room.
 The correction of dehydration is crucial before
attempting reduction.
 Nasogastric decompression--argued that it is
not indicated in children who do not present
with vomiting.
 Antibiotic prophylaxis including anaerobic
coverage is started.
INTUSSUSCEPTION
REDUCTION
 Nonoperative Reduction
-pneumatic
-hydrostatic reduction
INTUSSUSCEPTION
PNEUMATIC REDUCTION
 Pneumoenema is a cheap, safe, and effective
option for the treatment of intussusception.
Various studies have quoted success rates of
80–92% in reducing the Also, recurrences are
less with air than barium and the morbidity is
less should a perforation occur.
INTUSSUSCEPTION
HYDROSTATIC REDUCTION
 Hydrostatic barium enema reduction under
fluoroscopic guidance is also successful in
children and is the preferred option in some
centers.
 Ultrasound-guided reduction using water
(diluted with water-soluble contrast at a
ratio of 9:1) has also been reported to have
a success rate of 90% in the reduction of
intussusception.
INTUSSUSCEPTION
NON-OPERATIVE REDUCTION
CONTRAINDICATIONS
 Absolute Contraindications
PERITONEAL SIGNS
SUSPECTED PERFORATION
 Relative Contraindications
SYMPTOMS > 24-48 HRS
RECTAL BLEEDING
POOR PROGNOSTIC INDICATORS
INTUSSUSCEPTION
FAILURE OF NON-OPERATIVE REDUCTION
 Factors associated with failure
SYMPTOMS > 48 HRS
RECTAL BLEEDING
SMALL BOWEL OBSTRUCTION
RADIOGRAPHICALLY
ILEOILEOCOLIC OR SMALL BOWEL TYPES
PRESENCE OF MECHANICAL LEAD POINT
AGE < 3 MONTHS
INTUSSUSCEPTION
POST-REDUCTION TREATMENT
 Admit patient for 24 hours
 May attempt feeding within 12 hrs
 Return to fluoroscopy for suspected
recurrence (occurs in ~ 4%)
1.CONSIDER PATHOLOGIC LEAD POINT
2.SCHEDULE MECKEL’S SCAN, ?
ABDOMINAL CT
 May also recur up to one year
 Need to follow as outpatient
INTUSSUSCEPTION
Operative Reduction
 Operative
 MANUAL
 RESECTION AND REANASTAMOSIS
If the attempts at nonoperative reduction are
unsuccessful,the patient is shifted to the
operating
room for a laparotomy and manual reduction of
intussusception.
Meckel's
diverticulum
Meckel's diverticulum
Definition
Meckel's diverticulum is a congenital
pouch (diverticulum) approximately two
inches in length and located at the lower
(distal) end of the small intestine. It was
named for Johann F. Meckel, a German
anatomist who first described the structure.
Meckel's diverticulum
Description
The diverticulum is most easily described as
a blind pouch that is a remnant of the
omphalomesenteric duct or yolk sac that
nourished the early embryo. It contains all
layers of the intestine and may have ectopic
tissue present from either the pancreas or
stomach.
Meckel's diverticulum
Description
The rule of 2s is the classical description. It is located
about 2 ft from the end of the small intestine, is often
about 2 in in length, occurs in about 2% of the
population, is twice as common in males as females,
and can contain two types of ectopic tissue-stomach or
pancreas. Many who have a Meckel's diverticulum
never have trouble but those that do present in the first
two decades of life and often in the first two years.
Meckel's diverticulum
Description
three major complications：
Inflammation or infection
Bleeding
Obstruction
Meckel's diverticulum
Causes and symptoms
Meckel's diverticulum is not hereditary. It is a
vestigial remnant of the omphalomesenteric duct, an
embryonic structure that becomes the intestine. As
such, there is no genetic defect or abnormality.
Meckel's diverticulum
Causes and symptoms
Symptoms usually occur in children under
10 years of age. There may be bleeding
from the rectum, pain and vomiting, or
simply tiredness and weakness from
unnoticed blood loss.
Meckel's diverticulum
Causes and symptoms
It is common for a Meckel's diverticulum
to be mistaken for the much more common
disease appendicitis. If there is obstruction,
the abdomen will distend and there will be
cramping pain and vomiting.
Meckel's diverticulum
Diagnosis
The situation may be so acute that surgery is
needed on an emergency basis. This is often
the case with bowel obstruction.
With heavy bleeding or severe pain, whatever
the cause, surgery is required. The finer points
of diagnosis can be accomplished when the
abdomen is open for inspection during a
surgical procedure. This situation is called an
acute abdomen.
Meckel's diverticulum
Diagnosis
If there is more time (not an emergency situation),
the best way to diagnose Meckel's diverticulum is
with a nuclear scan. A radioactive isotope injected
into the bloodstream will accumulate at sites of
bleeding or in stomach tissue. If a piece of stomach
tissue or a pool of blood shows up in the lower
intestine, Meckel's diverticulum is indicated.
Meckel's diverticulum
Treatment
A Meckel's diverticulum that is causing
discomfort, bleeding, or obstruction must
be surgically removed. This procedure is
very similar to an appendectomy.
Meckel's diverticulum
Prognosis
The outcome after surgery is usually
excellent. The source of bleeding, pain,
or obstruction is removed so the
symptoms also disappear. A Meckel's
diverticulum will not return.
Appendicitis
Definition
Acute appendicitis is the most
common surgical emergency in
childhood. Appendicitis may
present at any age, although it is
uncommon in preschool children.
Approximately one-third of
children with acute appendicitis
have perforation by the time of
operation.
Appendicitis
Definition
Despite improved fluid
resuscitation and better
antibiotics, appendicitis in
children, especially in
preschool children, is still
associated with significant
morbidity.
Left radiograph shows a barium filled cecum and appendix. In most people the appendix buds from the posteromedial wall of the cecum just
slightly below the ileocecal valve. The radiograph on the right is a mesenteric arteriogram demonstrating the rich blood supply that spreads
through the mesentery to supply the bowel and appendix. Appendicular and ileocolic arteries branches supply the appendix from the inferior
mesenteric artery (arrow)
McBurney’s point, two-thirds distance between
the umbilicus and right anterior superior iliac spine
Appendicitis
diagnosis
The diagnosis of acute appendicitis in childhood can
sometimes be difficult. Definite diagnosis is made in only
43–72% of patients at the time of initial assessment. The
rate of negative pediatric appendectomy is in the range
4–50% in various reports. The patient’s history and
clinical examination are the most important tools for the
diagnosis of appendicitis.
Appendicitis
diagnosis
Periumbilical pain is often the first symptom,
followed by vomiting and fever. When the
inflammation progresses, the pain
localizes to the right lower quadrant, and right lower
quadrant tenderness develops.
Appendices located in the retrocaecal position may
cause pain, radiating to the back.
Appendices in pelvic position may present with
diarrhea.
Appendicitis
diagnosis
Clinical examination in a typical case with appendicitis reveals
tenderness, guarding and rigidity in the right lower quadrant of
abdomen.
Laboratory investigations and plain radiographs are neither
sensitive nor specific in the diagnosis of appendicitis.
Barium enema is an unreliable test because of its high falsepositive and false-negative rates.
Appendicitis
diagnosis
In recent years, graded compression ultrasonography
of the right lower quadrant has been shown to be a
useful tool in the evaluation of patients with clinical
findings that are suggestive but not diagnostic of
appendicitis, with a sensitivity of 80–100%, a specificity
of 78–98%, and an overall accuracy of 91%.
Appendicitis
diagnosis
Ultrasound is portable, fast, and free of irradiation
exposure, of modest incremental cost and of use in
delineating gynecologic disease. However, it is of limited
use in obese adolescents and is highly user dependent.
The only sonographic sign that is specific for appendicitis
is an enlarged, non-compressible appendix measuring
greater than 6 mm in maximal diameter (Fig). The
appendix may not be visible following perforation.
Ultrasonography in a 12-year-old patient with acute
appendicitis—enlarged and thickened (1.1 cm) appendix
Appendicitis
diagnosis
Recently, computed tomography
(CT) has been used as an adjunct to the diagnosis of
appendicitis and appeared to have an immediate impact,
reducing negative appendectomy rates to 4.1% and
perforation rates to 14.7%.
The principal advantages of CT are its operator
independency and enhanced delineation of disease extent in
perforated appendicitis. Sensitivity, specificity and accuracy
for unenhanced limited CT have approached 97%, 100% and
99%, respectively.
Appendicitis
Treatment
Non-perforated appendicitis
 Treatment for appendicitis is removal of the appendix
(appendectomy). Patients receive antibiotics both before
and after surgery.
In some cases, laparoscopic surgery rather than open
surgery is performed. This technique involves making a
few small incisions in the belly and inserting a very small
camera and surgical instruments. The pediatric surgeon
then removes the appendix with the instruments.
laparoscopic removal of the appendix
Appendicitis
Treatment
Non-perforated appendicitis
An open appendectomy involves one larger incision in
the lower right side of the abdomen. Regardless of which
surgical technique is used, if the appendix has not
perforated, most children are able to go home from the
hospital within 24-48 hours and are able to return to
school in one week.
Appendicitis
Treatment
Perforated appendicitis
If the child's appendix is
perforated, an open
surgery is often done.
The child is then treated
with a course of
antibiotics, which is
often completed at
home.
Appendicitis
Treatment
Perforated appendicitis with abscess
At times, when the appendix has perforated and
the infection has localized to one area, an
abscess forms.
Treatment of the abscess includes drainage of
the infection and a course of intravenous (IV)
antibiotics.
Appendicitis
Treatment
Perforated appendicitis with abscess
Percutaneous (through the skin) drainage is
done using ultrasound to help guide a small tube
through the skin into the infected area in the belly.
An appendectomy is then performed
approximately 6-8 weeks after the infection has
been treated.
This CT image shows the entry needle advanced to the abscess
This CT image demonstrates the successful placement of a
drainage catheter into the abscess.
Inflammatory Bowel Disease / IBD
Definition
Ulcerative colitis and Crohn's disease are
called inflammatory bowel disease(s) / IBD.
Ulcerative colitis and Crohn's disease have
many similar symptoms (including diarrhea,
rectal bleeding, and abdominal pain). These
diseases are not contagious.
Inflammatory Bowel Disease / IBD
Definition
About one million Americans have IBD. Thirty
thousand new cases are diagnosed every year.
Although the exact cause(s) of IBD is not known,
these are thought to play a role in both diseases:
A genetic tendency
An environmental trigger
The patient's immune system
Bacteria that are normally in the intestine
Inflammatory Bowel Disease / IBD
Diagnosis
Diagnosing these diseases requires several
tests:
Blood tests
X-rays
Endoscopy (looking inside the bowel with a
flexible tube)
Ulcerative colitis can be cured by removing the
colon (colectomy). There is no cure for
Crohn's disease
Inflammatory Bowel Disease / IBD
Treatment
Medicine is tried first to help control
inflammation for both ulcerative colitis and
Crohn's disease. When inflammation is
severe, steroids such as prednisone are used.
In many cases, medications work to control
both diseases, so surgery is not needed for
a very long time
Inflammatory Bowel Disease / IBD
Treatment
Surgery may be recommended when medicine
cannot control the symptoms or when there are
other medical problems.
In ulcerative colitis, the disease is cured if the
colon is removed.
Surgery for Crohn's disease may help relieve
constant symptoms or correct problems. It is not
a cure for Crohn's disease because the disease
usually comes back.