Добавил:

Sekretar kiopkiopkiop18@yandex.ru t.me/Prokururor I Вовсе не секретарь, но почту проверяю Опубликованный материал нарушает ваши авторские права? Сообщите нам.

Вуз:

Ростовский Государственный Медицинский Университет

Предмет:

Медицина общая

Файл:

@xirurgi_2025 - 795 - файл

.pdf

Скачиваний:

Добавлен:

29.08.2026

Размер:

12 Мб

Скачать

☆

<<< < Предыдущая 3 4 5 6 7 8 9 10 11 12 13 1415 / 3515 16 17 18 19 20 21 22 23 24 25 26 27 > Следующая >>>

Clinical features [Box19.1]

https://t.me/med1917

Symptoms

Pain is the most important symptom (85%). It typically commences as a colicky pain lasting 2–3 min, during which time the infant screams and draws up his knees. Spasms typically occur at intervals of 15–20 min. The infant becomes intermittently pale and clammy (similar to a syncopal episode in older children), exhausted and lethargic between spasms. After 12 h or so, the pain becomes more continuous.

Vomiting almost always occurs as well: usually once or twice in the first hours and then again if intestinal obstruction is fully established.

Signs

Children with intussusception look pale and lethargic, except when they are aroused by a spasm of severe pain. A mass (sometimes described as sausage shaped) is palpable in more than half the infants and is usually found in the right hypochondrium, although it may be anywhere between the line of the colon and the umbilicus [Fig.19.1]. The intussusception mass is most likely to be felt early, before being concealed by abdominal distension and increasing abdominal tenderness.

Normal or loose stools are often passed shortly after the onset of symptoms, and any diarrhoea tends to be of small volume and transient. About half the patients pass a stool containing blood and mucus (red currant jelly), formed by the diapedesis of red cells through the congested mucosa of the intussusceptum. Blood may be identified on the glove following rectal examination, which may disclose the apex of the intussusceptum within the rectum.

The infant is pale, limp and tired and has tachycardia. If there is delay in diagnosis, the infant becomes dehydrated, listless and febrile, has abdominal distension and looks ill. These are late signs and ideally the diagnosis should be made before they appear.

Box 19.1 Presenting features of intussusception

1 Vomiting 2 Abdominal colic 3 Pallor 4 Lethargy 5 Abdominal mass 6 Rectal bleeding

Chapter19: Intussusception 127

(a)

(b)

Figure 19.1 The site of the sausage-shaped mass of intussus-

ception in the abdomen, shown schematically in (a) and in a patient (b).

Differential diagnosis

Wind colic is common in the first 3 months after birth but rarely lasts more than an hour and usually is not accompanied by vomiting. Persisting severe colic for more than 1–2 h should arouse suspicion of an intussusception, particularly if accompanied by vomiting.

Colic and the passage of blood and mucus in severe cases of gastroenteritis may mimic intussusception, except that the volume of diarrhoea is greater. In intussusception, the small loose stools passed early in the course of the disease simply represent evacuation of the stimulated colon beyond the obstruction. Persistent vomiting and pain without diarrhoea is unlikely to be gastroenteritis.

A strangulated inguinal hernia may present with abdominal pain, vomiting and distension but is recognised

128 Part IV: Abdomen

https://t.me/med1917

easily when an irreducible lump is seen on examination ofthe inguinal region.

Investigations

A plain x-ray of the abdomen may be normal, show non-specific abnormalities or reveal a small bowel obstruction with air–fluid levels in the dilated small bowel. Occasionally, the apex of the intussusceptum may be seen.

The diagnosis is confirmed on ultrasonography, which is usually the first investigation when intussusception is suspected [Fig. 19.2]. An air or contrast enema study will also confirm the diagnosis and may be therapeutic (see the following).

Treatment

Enema reduction of intussusception should be attempted in most cases, unless there is clinical evidence of dead bowel, as demonstrated by peritonitis or septicaemia. Gas(air or oxygen) is the most commonly used enema medium and is preferred over the historical barium enema because of its superior efficacy and safety [Fig.19.3]. Enema reduction is slightly less likely to be successful if there are prolonged symptoms (>24 h), if the patient is outside the usual age range (<3 months or >24 months) or if there is an established small bowel obstruction with air–fluid levels on x-ray. Providing there is no peritonitis, it is still worth attempting enema reduction in these circumstances. If the child remains stable clinically after attempted, incomplete reduction, a delayed repeat enema 30 min to 2 h later is performed. Overall, 80–90% of intussusceptions should be reducible using a gas enema.

Figure 19.2 Ultrasonography is the first investigation in infants

and children with suspected intussusception. Upper panel shows longitudinal view of intussusception, while lower panel is a transverse section.

Figure 19.3 Gas enema showing the end of the intussusceptum,

which confirms the diagnosis of intussusception (Reproduced with permission from Phelan et al. (1988)).

Chapter19: Intussusception 129

https://t.me/med1917

Technique of gas enema reduction

The patient is resuscitated with intravenous fluids and kept warm. A Foley catheter is inserted into the rectum. To achieve a seal, the catheter balloon is inflated and/orbuttocks are strapped tightly together. Gas (usually oxygen from the wall supply) is introduced into the colon through the catheter, the pressure being controlled by a manometer [Fig. 19.3]. Under continuous fluoroscopic control, progress of the reduction is monitored. Sudden filling of the small bowel with gas suggests reduction is complete. The infant may be fed within hours of the procedure.

Surgery

Operative intervention is indicated when the delayed repeat enema fails to reduce the intussusception, where there is peritonitis clinically or where there is strong evidence of a pathological lesion at the lead point, for example, circumoral pigmentation of Peutz–Jegher syndrome. Laparotomy via a transverse right supra-umbilical incision, or laparoscopy, may be used. The intussusception is reduced by manipulation, although segmental resection may be required if there is gangrene or where there is a pathological lesion at the lead point, for example, Meckel’s diverticulum or polyp.

Recurrent intussusception

Intussusception recurs in about 7% of patients and is more likely after enema reduction than surgery. It usually occurs within 2 or 3 days of the first

reduction. Recurrence usually presents early and is treated the same way as a first episode, although the possibility of a pathological lead point should be considered.

KEY POINTS

• Intussusception should be suspected when children between 3 months and 3 years present with vomiting, colicky abdominal pain and intermittent pallor.

• Intussusception is diagnosed by palpating a central/rightsided mass and conrming with x-ray, ultrasound scan or gas enema.

• Hydrostatic enema reduction corrects intussusception in about 85%, with 7% risk of recurrence.

Further reading

Beasley SW, Hutson JM, Auldist AW (1996) Intussusception.

In: Essential Pediatric Surgery. Arnold, London, pp. 45–51.

Fuchs JR, Langer JC (2006) Small bowel disorders. In: Stringer

MD, Oldham KT, Mouriquand PDE (eds) Pediatric Surgery and Urology: Long-Term Outcomes, 2nd Edn. Cambridge University Press, Cambridge, pp. 305–314.

Kaiser AD, Applegate KE, Ladd AP (2007) Current success in

the treatment of intussusception in children. Surgery 142(4): 469–477.

Ong N-T, Beasley SW (1990) The leadpoint in intussusception.

J Pediatr Surg 25: 640–643.

Phelan E, de Campo JF, Malecky G (1988) Comparison of

oxygen and barium reduction of ileocolic intussusception. AJR Am J Roentgenol 150(6): 1349–1352.

CHAPTER20

https://t.me/med1917

Abdominal Pain: Appendicitis?

CASE 1

A 6-year-old boy developed central abdominal pain and high fever yesterday. Today, he has pain in the right iliac fossa. He looks ushed and has enlarged, tender cervical lymph nodes. There is tenderness in both iliac fossae (right more so than left), but no peritonism.

Q 1.1

What is the likely diagnosis? What tests are required?

Q 1.2

Improved diagnosis of appendicitis has been a major factor in reducing its morbidity in children. As a rule, abdominal pain in childhood lasting more than 4 h should be regarded as evidence of a potential abdominal emergency, until proven otherwise. Likewise, diarrhoea lasting more than 24 h should raise the possibility of pelvic, retrocaecal or retro-ileal appendicitis, particularly if associated with lower abdominal pain. An illness may start with gastroenteritis and diarrhoea, but later, appendicitis may supervene. Importantly, only a minority of children presenting with acute abdominal pain are found to have a genuine surgical cause. Where there is a high index of suspicion of appendicitis, the child must be reassessed frequently, with early referral to a paediatric surgeon.

CASE 2

Alex is a 5-year-old who has been vaguely unwell with abdominal pain for 2 days. Today, he has pain in the right iliac fossa. He limps into the consulting room but does not look ushed, and his temperature is normal (37.2°C). There is tenderness and guarding very lateral in the right ank.

Q 2.1

What is the likely diagnosis?

What investigations, if any, will aid you making your diagnosis?

Q 2.2

Features suggesting that movement exacerbates the pain heighten the concern that peritonitis is present, for example, when an infant prefers to lie still, refuses to be cuddled, wants to be left untouched and is reluctant to be examined.

If abdominal pain persists, active observation must be continued and examination repeated until there are definite signs that indicate a need for an operation or until the pain has subsided. In most children whose pain is subsiding, an operation should be deferred if the physical signs are not completely diagnostic.

Assessment of physical findings

Interpreting abdominal pain inchildren

The interpretation of abdominal pain can be difficult in children who are young or have developmental delay. Significant pain is often recognised late by parents and clinicians alike, because of children’s inability to voice their symptoms adequately, but also because the pain of appendicitis may not be as dramatic in the younger age group.

Jones’ Clinical Paediatric Surgery, Seventh Edition. Edited by John M. Hutson, Michael O’Brien, Spencer W. Beasley, Warwick J. Teague and Sebastian K. King. © 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd.

130

Examination of the older cooperative child is relatively straightforward, whereas in a young, sick and frightened child, physical examination requires great skill. The examination must be unhurried, gentle and performed with warm hands with the examiner seated beside the child. The child should be supine and straight, with arms resting alongside. Useful assessment may sometimes be made if the child is asleep. In the toddler, the abdomen may be palpated from behind with both hands while the parent cuddles the child’s front against

Chapter20: Abdominal Pain: Appendicitis? 131

https://t.me/med1917

themselves. However, with a continually crying child, adequate assessment is difficult and re-examination must be undertaken later. Failure to acknowledge inadequate examination may result in serious diagnostic error.

Abdominal tenderness

Localised tenderness is found in conditions ranging from excess flatus, a faecally loaded colon or inflamed mesenteric lymph nodes to acute appendicitis and strangulated gut; consequently, tenderness alone is an insufficient reason for operation. Direct palpation over any distended or inflamed loop of the gut may elicit localised tenderness. This is a particular feature of the solitary distended loop in closed-loop intestinal obstruction but may also be observed in gastroenteritis. Inflamed visceral peritoneum will produce tenderness by direct, rather than by referred, pathways.

Localised tenderness in the right iliac fossa, without guarding or a strongly suggestive clinical history, may be due to causes other than appendicitis. Although localised tenderness is often the earliest sign of appendicitis, children requiring operation soon develop signs of peritonism to support the diagnosis. In contrast, tenderness due to non-surgical conditions typically subsides in the following days.

Peritonitis: Guarding and percussion tenderness

Children with localised or generalised peritonitis rarely display the board-like rigidity so often found in adults. More often, there is a variable degree of involuntary increased muscle resistance, referred to as guarding. Small differences in resistance in the lower and upper abdomen, or between right and left sides, may be significant when the findings are consistent.

Assessment of percussion tenderness is a sensitive test of peritoneal irritation in children and should be used in preference to rebound tenderness, which is unkind and unhelpful. Likewise, pain in the abdomen during micturition (as opposed to dysuria) is common in pelvic appendicitis, as the appendix lies close to and irritates the bladder.

There are no pathognomonic symptoms or signs of appendicitis itself, but when signs of peritonitis are localised to the right iliac fossa, appendicitis is likely.

Acute appendicitis may be missed when it presents with signs of local peritonitis outside the right iliac fossa.

The interposition of other structures between the appendix and the anterior abdominal wall in pelvic, retrocaecal and retro-ileal appendicitis may delay the appearance of abdominal signs until relatively late, and even then, they may be atypical.

In retrocaecal appendicitis, tenderness is maximally high and lateral on the right side, whereas in pelvic appendicitis, or in retro-ileal appendicitis, the signs are more central and lower and may even be predominantly left sided.

A palpable mass

Apart from faecal masses and symptomless masses inthe loin (Chapter25), the most common mass in a child’s abdomen is an appendiceal abscess (or phlegmon), particularly in children under 5 years of age, in the developmentally delayed child or when the appendix is in an unusual position.

Scrotal examination

Torsion of the testis or appendix testis occasionally presents with referred pain in the iliac fossa and may be mistaken for appendicitis. The scrotum must always be examined to exclude this important finding.

Rectal examination

Rectal examination is not indicated if appendicitis can be diagnosed on history and anterior abdominal signs alone. However, it may aid diagnosis of a pelvic mass with a perforated pelvic appendicitis should an ultrasound scan be unavailable or equivocal. When required, rectal examination should be performed by a member of the surgical team, having first gained informed consent from the carers and ensured a chaperone is present.

Signs arising in other systems

Infections in the ear, tonsils or respiratory passages may be accompanied by abdominal pain and vomiting and simulate an abdominal emergency. Measles or chickenpox may produce abdominal signs, as may many other viral infections, by causing mesenteric lymphadenitis. Acute appendicitis may coexist with other conditions, so that proven pneumonia, tonsillitis or generalised lymphadenopathy should not divert attention from any abdominal signs, which also may be present. Similarly, gastroenteritis may progress to appendicitis, so that even a well-established and undoubted diagnosis of gastroenteritis should be subject to review. Special

132 Part IV: Abdomen

https://t.me/med1917

diagnostic difficulties may be presented by the abdominal crises of diabetic ketoacidosis, Henoch–Schönlein purpura and various haematological disorders, including sickle cell disease and haemophilia. In these conditions, an operative intervention is usually contraindicated. Active observation and re-examination for signs of peritonitis are essential.

Acute appendicitis

The mortality of acute appendicitis in children is less than 0.2%, due to early diagnosis and the management of fluids and electrolytes before and after operation.

The clinical diagnosis is determined by localised tenderness and objective signs of localised or generalised peritonitis. The value of history lies in arousing suspicion that an abdominal emergency is present and in determining its most likely cause. However, acute appendicitis is not only a common abdominal emergency, but also a great imitator, and it may appear in a variety of guises [Box20.1].

Differential diagnosis

A perforated appendix is the only common cause of general peritonitis in childhood. In most children with an appendiceal abscess, there are signs of localised or generalised peritonitis. Occasionally, however, an appendiceal mass may be present with little or no constitutional upset or localised signs of peritoneal irritation.

Infections of the urinary tract may mimic appendicitis and vice versa. Lower urinary tract infection may give rise to tenderness in the right iliac fossa, but does not exhibit the guarding typical of peritoneal irritation. Conversely, a high retrocaecal appendicitis occasionally imitates acute pyelonephritis with prominent loin tenderness. In pelvic appendicitis, the child may complain of lower abdominal pain during micturition. Mild pyuria (20–50 white cells/mm to an inflamed appendix adjacent to the ureter or bladder.

Referred pain to the right abdomen may occur with right lower lobe pneumonia or right testicular torsion.

Peritonitis in the young child

Peritonitis is a frequent complication of appendicitis that may be difficult to recognise in infants and young children. Tenderness may be diffuse rather than localised

) may occur in appendicitis due

Box 20.1 The various presentations of acute appendicitis:

Presentation and differential diagnosis

Local tenderness in the right iliac fossa

Simple colic Bilious attack (food poisoning) Gastroenteritis Acute constipation Mild mesenteric adenitis Urolithiasis Deep iliac lymphadenitis

Local peritonitis (mostly in the right iliac fossa)

Severe mesenteric adenitis Primary peritonitis Meckel’s diverticulitis Ruptured luteal cyst Ovarian torsion Omental torsion Suppurating deep iliac lymph nodes

Generalised peritonitis

Primary peritonitis Perforated Meckel’s diverticulum

Urinary tract infection

Urinary tract infection Acute pyelonephritis

An inflammatory mass

Intussusception Duplication of the gut Ectopic kidney Retroperitoneal masses (Chapter25)

Intestinal obstruction

Adhesive bowel obstruction Internal hernia Meckel’s band

Acutely painful scrotum (Chapter 29)

Torsion of testis

Torsion of appendix testis Gastroenteritis (from the retro-ileal or pelvic appendix)

Gastroenteritis

and marked guarding may be absent, even with advanced generalised peritonitis. Often, a lesser degree of involuntary muscular rigidity or guarding is encountered. Differences in muscle tone between the right and left sides, or between the lower and upper abdomen, are highly significant.

As localised peritonitis progresses, the signs become more definite in the right iliac fossa. Paradoxically, as peritonitis becomes more generalised and the abdomen more distended, the right iliac fossa signs may appear to diminish in some children. In this situation, abdominal distension and the child’s reluctance to allow abdominal palpation are signs of great significance.

Chapter20: Abdominal Pain: Appendicitis? 133

https://t.me/med1917

Even without distension, however, persisting pain with or without accompanying diarrhoea demands careful assessment, re-examination of the abdomen and sometimes a rectal examination.

Treatment

The management of acute appendicitis involves:

1 Adequate preoperative replacement of fluid and elec-

trolyte deficits

2 Operative removal of the appendix 3 Irrigation of the peritoneal cavity to remove pus and

contaminated free fluid

4 Effective antibiotic treatment to cover aerobic and anaer-

obic organisms commencing prior to the operation A dehydrated, toxic child is an anaesthetic risk. Obstructed airways by inhaled vomitus, unexpected cardiac arrest and prolonged surgical shock with circulatory collapse are all minimised by adequate preoperative resuscitation. This includes intravenous replacement of fluid and electrolyte deficits and, in children with marked abdominal distension, nasogastric tube decompression of the bowel.

An operation by laparoscopy or laparotomy aims to remove the appendix and perform intraperitoneal lavage.

Antibiotics reduce the septic complications of appendicitis, which is a polymicrobial infection caused by bowel organisms. A combination of an anti-aerobic agent (e.g. cephalosporin derivative) and an anti-anaerobic agent (e.g. metronidazole) is effective, but complicated cases may require broader cover. Antibiotics should be commenced at induction, or earlier if there is significant preoperative delay or the child is unwell. Preoperative antibiotics can reduce wound infection resulting from intra-operative soiling by infected peritoneal fluid.

absence of guarding (the inflammation is confined to mucosa only) and failure of the signs to progress mesenteric adenitis. A succussion splash in the right iliac fossa on palpation is typical and reflects an ileus with stagnant loops containing air and fluid without guarding from peritonitis.

suggests

Abdominal emergencies in developmentally delayed children

Acute appendicitis is still the most common abdominal emergency in developmentally delayed children, but perforation by an ingested foreign body is more frequent than in children with normal development.

The diagnostic difficulty depends on the severity of delay. In the most severely affected children, with hyperkinesia, hypertonia, inability to speak and a high threshold of pain, there may be few symptoms, and abdominal signs – for example, tenderness or rigidity – may be difficult to detect or evaluate. Abdominal distension and absent bowel sounds, although late developments, are usually present once attention is first drawn to the abdomen. Vomiting, fever and tachycardia may also be present.

Similar to preschool children, appendicitis in develop mentally delayed children more often presents with a local abscess or spreading peritonitis. A pelvic mass or intestinal obstruction from the small bowel adhering to the wall of an appendiceal abscess is common. The delayed diagnosis leads to increased complications and, consequently, an increase in mortality.

Intestinal obstruction

Abdominal pain of uncertain origin

There are some children [Box 20.1] where the final diagnosis remains in doubt. Indigestion, wind pains, acute constipation and other minor bowel disturbances are not objective diagnoses, but which tend to be attached to a number of children.

Mesenteric adenitis non-specific viral infection of the ileum causes difficulty in distinguishing some cases from acute appendicitis. The combination of high fever, mild abdominal tenderness that varies in location, the

A common cause of intestinal obstruction is a strangulated inguinal hernia [Box20.2], which, if recognised, presents few problems in diagnosis or management.

In children with no previous abdominal operation, the cause of obstruction may be a volvulus (Chapter 7), Meckel’s band or diverticulum (Chapter23), an intestinal duplication (Chapter7) or, very rarely, an internal hernia [see Box20.2].

Most cases of obstruction in older children are due to adhesions following a previous operation. Recurrent pain, accompanied by bile-stained vomiting, generally causes these patients to present early. Visible or palpable

134 Part IV: Abdomen

https://t.me/med1917

Box 20.2 Causes of bowel obstruction in children after the

neonatal period

Common

Adhesive bowel obstruction Intussusception Appendicitis Strangulated inguinal hernia

Uncommon

Malrotation with volvulus Meckel’s band (closed-loop obstruction or localised

volvulus) Duplication cyst Internal hernia

distended intestinal loops, or air–fluid levels on an abdominal x-ray, confirm the diagnosis.

Bowel obstruction is less obvious and so more likely to be overlooked in (i) the early post-operative period after abdominal surgery, when pain is difficult to interpret and the expected delay in recovery from paralytic ileus may mask an early adhesive bowel obstruction, and (ii) proximal small bowel obstruction, in which pain and abdominal distension may be minimal and vomiting alone is the presenting feature.

Treatment

The mainstay of management is non-operative: oral intake is withheld, the stomach is aspirated by nasogastric tube, and resuscitation (and maintenance) intravenous fluids are commenced. Some children respond promptly to this regimen and symptoms may subside within a few hours.

Most adhesive bowel obstructions will self-resolve within 1–2 days of initiating the aforementioned non-operative management. However, continuing or increasing volumes of aspirate or persistent localised abdominal tenderness are sufficient grounds for surgery, preferably before a rising pulse rate, severe pain and increasing abdominal tenderness that suggest impending strangulation of the bowel.

Meckel’s diverticulum

A Meckel’s diverticulum may cause abdominal pain in a variety of ways. The tip of a Meckel’s diverticulum may still be joined to the umbilicus by a fibrous band, which may entrap the bowel, causing a closed-loop obstruc-

tion or a localised volvulus. Therefore, A Meckel’s diverticulum may also be suspected in intestinal obstruction in a child with no previous abdominal operation.

Alternatively, Meckel’s diverticulum may become inflamed. The clinical manifestations are rarely distinguishable clinically from appendicitis, and the diagnosis often only becomes apparent at operation.

Finally, Meckel’s diverticulum is the most common cause of major gastrointestinal bleeding in childhood and presents when the child passes dark-red stools associated with dull abdominal pain and tenderness. Often, the child looks pale and anaemic (Chapter23).

Primary peritonitis

Primary peritonitis (also known as spontaneous bacterial peritonitis) presents with a sudden onset of high fever greater than 39°C with diffuse abdominal distension and tenderness with guarding. This is a primary infection of the peritoneum and the abdominal contents are normal.

The condition is more common in girls, but often, it is not related to tubal infection. It may occur in patients with ascites secondary to nephrotic syndrome. Laparoscopy is performed as the presumed clinical diagnosis is appendicitis with secondary peritonitis. Odourless peritoneal fluid with a soapy feel is found, along with a normal appendix. Sometimes, the infecting organism is Streptococcus pyogenes, but in most cases, the culture is negative. The prognosis is good and the peritonitis resolves rapidly.

Paediatric gynaecologic emergencies

In menarcheal or pubertal girls, a gynaecologic disorder may present with acute abdominal pain. This group of conditions includes intraperitoneal bleeding at the normal time of ovulation (Mittelschmerz bleeding) or rupture of a small luteal cyst. Tubal menstruation, torsion of the ovary and acute salpingitis are all uncommon. Physical examination of girls with any of these conditions will typically reveal lower abdominal tenderness and guarding. Pelvic inflammatory disease may also present with fever and vaginal discharge.

Rectal examination is occasionally performed after informed consent and with a nurse chaperone, but a pelvic/ abdominal ultrasound scan will diagnose most conditions.

Chapter20: Abdominal Pain: Appendicitis? 135

https://t.me/med1917

Ovarian torsion demands urgent surgery, and the ovary is usually preserved after untwisting the torsion.

KEY POINTS

• Abdominal pain requires careful physical assessment to determine the cause.

• Peritonitis is hard to diagnose in preschool children: beware of a toddler who refuses examination.

• Localised peritonitis in the right iliac fossa is likely to be appendicitis.

• Pelvic appendicitis (by ultrasonography or rectal exam) and testicular torsion (by scrotal exam) need exclusion in children with vague pains in the right iliac fossa.