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6.Gastrochisis: this is a surgical emergency. Immediate management at birth involves protection of the bowel by wrapping it in plastic film, prevention of heat loss, and insertion of a nasogastric tube. The bowel should be returned to the abdominal cavity as soon after birth as possible, and the defect closed.
20.4 Indications for Referral
1.An umbilical hernia that has not resolved by the age of 3–4 years.
2.A presumed umbilical granuloma/ectopic bowel mucosa unresponsive to ligation or topical application with Silver Nitrate.
3.Suspicion of a patent vitellointestinal tract or urachus (both will have a sinus opening at the umbilicus).
4.All exomphalos and gastrochisis infants: antenatal diagnosis allows transfer to a pediatric surgical centre prior to birth; failing that, the newborn infant is transported to the tertiary centre as soon after birth as possible.
20.5 Epigastric Hernia
20.5.1 Introduction
An epigastric hernia becomes apparent as a small midline lump, usually midway between the xiphisternum and umbilicus (Fig. 20.4). The swelling is often less than a centimeter in diameter. The bulge is due to extra-peritoneal fat protruding through a small defect in the linea alba.
The parents often notice a small non-tender swelling in the midline or adjacent to it. It may be more prominent or cause discomfort after meals.
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FIGURE 20.4. An epigastric hernia appears as a midline lump usually midway between the xiphisternum and umbilicus.
It is a relatively harmless condition, but if it causes discomfort, it is best repaired under a short general anesthetic as a day case.
20.6 Divarication of the Rectus
Abdominus Muscle
This is best considered a variant of normal, rather than an abnormality. Often, in infants and small children, there is a longitudinal bulge between the xiphisternum and the umbilicus that is most obvious when the abdominal muscles (rectus abdominus) are contracted. This can be demonstrated by getting the child to lift his/her head up while lying supine (Fig. 20.5).
It is of no significance, other than it often causes concern to parents or a medical practitioner unfamiliar with the condition.
No treatment is required. It has no long term sequelae. It never causes discomfort.
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FIGURE 20.5. Divarication of the rectus abdominus in association with an umbilical hernia.
References
1.The umbilicus. In: Hutson JM, O’Brien M, Woodward AA, Beasley SW,eds.Jones’ Clinical Paediatric Surgery:Diagnosis and Management. 6th ed. Blackwell Publishing; 2008:117-120.
2.Campbell J, Beasley SW, McMullin ND, Hutson JM. Umbilical swellings and discharges in children. Med J Aust. 1986;145:450-453.
Chapter 21
Surgical Aspects
of Abdominal Pain
John A. Sandoval
Key Points
››Appendicitis, intussusception, and malrotation with volvulus may be among the most elusive diagnoses in children.
››Appendicitis may occur together with another illness (gastroenteritis).
››Midgut volvulus, intussusception, and ovarian torsion are the three surgical conditions that have acute onset of pain as the initial symptom.
››There is a need to arrive at a diagnosis of acute abdomen promptly, as a delay may have devastating consequences to the child.
21.1 Introduction
Abdominal pain remains a common complaint in children and accounts for a frequent number of surgical consultations. Rapid, accurate diagnosis of abdominal pain in children reduces the morbidity of common causes of pediatric abdominal pain. Clinical evaluation may help identify which children with abdominal pain should undergo immediate surgical consultation and which children with equivocal presentations
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Surgery in Clinical Practice, DOI: 10.1007/978-1-84996-366-4_21,
© Springer-Verlag London Limited 2011