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35 Abdominal Emergencies in Infancy and Childhood 373
hernia in an infant and an adult is that the former presents a danger to the viability
of the testis, whereas with the latter the major concern is the potential for bowel
ischemia. Neonates with symptoms lasting for more than 24 hrs and with intestinal
obstruction are at the greatest risk of testicular infarction. Necrosis of incarcerated
bowel is extremely rare in pediatric hernias.
The diagnosis is straightforward because the baby cries and vomits, and
the parents have usually noticed a tender lump in the groin. The major differential diagnosis is with torsion of a maldescended testicle, acute inguinal lymphadenitis, and a hydrocele of the cord. After making the diagnosis, sedate the
infant and position the infant in a head-down position. In the majority of babies,
this will result in spontaneous reduction within 1–2 hrs. Let the tissue swelling
subside for a day or two and book the child for an elective herniotomy on the next
available operative schedule.
The operation for irreducible inguinal hernia in an infant is fraught with
danger and should be undertaken only by a surgeon with previous experience in
pediatric surgery. The hernia sac is edematous and extremely fragile, and the
ductus deferens is almost invisible. Simple herniotomy at the level of the neck of
the sac is all that is required. Always make sure that the testicle is safely replaced
into the lower part of the scrotum. In a female infant, a movable tender lump may
be an irreducible ovary. The child may be almost asymptomatic yet require
emergency herniotomy because of the risk of ovarian ischemia.
Testicular Torsion (see also > Chap. 34)
The key to successful treatment of testicular torsion is speedy detorsion,
within less than 6 hrs of the onset of symptoms. The incidence of torsion rises
sharply around age 12, with two of every three cases occurring between the ages
of 12 and 18. Some boys with testicular torsion present with lower abdominal and
inguinal pain, so you will miss the diagnosis if you fail to examine the scrotum. No
clinical sign or test is foolproof, and because the price of delay is loss of the testis,
the common wisdom is to have a low threshold for exploring an “acute scrotum.”
If prompt surgery is not available, manual detorsion in a lateral direction under sedation or local anesthetic infiltration of the cord may restore testicular blood
flow but is not a substitute for surgery. The operative procedure is bilateral orchidopexy to protect the ipsilateral testicle from recurrence and to secure the contralateral one as inadequate anatomic suspension is a bilateral phenomenon. After
induction of anesthesia, first examine the scrotum to rule out incarcerated hernia
or testicular tumor, both requiring an inguinal incision. Then, proceed with a scrotal exploration via a vertical incision in the median raphae of the scrotum or two
transverse incisions to access both sides. Enter the serosal compartment of the scrotum to deliver and detort the testis. Place it in warm moist sponges while exploring
374 Wojciech J. Górecki
the opposite hemiscrotum. If the affected testis remains necrotic, remove it.
Orchidopexy of the viable testis is performed by suturing the surface of the testis
(tunica albuginea) at four points to the wall of the serosal compartment using nonabsorbable sutures. If you find torsion of the testicular appendage, simply excise it.
Ovarian Torsion
Should you encounter pediatric ovarian torsion, be it deliberately or incidentally, the adolescent girl will be fortunate having you as the surgeon if you detort the
“nonviable” adnexa and leave it alone. The macroscopic appearance of the ovary is
not a reliable predictor of necrosis or the potential for gonad recovery. If an underly-
ing lesion is found, then cystectomy, tumorectomy (even in cases with a very large
teratomata, there is a rim of normal ovary at the hilum that can be preserved), or cyst
aspiration with possible oophoropexy should be considered. If you are not comfortable with this situation, just detort the ovary and close the abdomen. Remember the
key principle: you are more likely to preserve functional ovarian tissue than cause
any morbidity by leaving in situ what appears to you a nonviable ovary in little girls.
Pediatric Abdominal Injuries
Trauma is the major cause of death among children older than a year of age
and is responsible for more deaths than all other causes combined. In one of seven
injured children, the abdominal injury is paramount. The patterns of blunt abdominal trauma and the clinical pictures are similar to those in adults, with injuries to the kidneys, spleen, liver, and the intestines the most common (> Chap. 39).
Most cases can be treated conservatively, and laparotomy is required in only one
child in four. The major deterrents for operative approach to abdominal trauma in
children are the risks of nontherapeutic laparotomy and overwhelming postsplenectomy infection.
Even children with hemodynamic instability on admission often quickly
improve with crystalloid administration and remain hemodynamically stable
thereafter. If the situation stabilizes after three infusions of 20 ml/kg of fluid,
then it is safe to observe the child in an intensive care unit. If the child continues
to bleed and no other source of hemorrhage is apparent, a prompt laparotomy is
indicated.
The Achilles’ heel of this conservative approach is the possibility of missed
injuries to hollow organs. Thus, if the child develops increasing abdominal tenderness or peritonitis, this also is an indication for laparotomy. A useful clinical
marker of blunt bowel trauma is the triad of a fastened lap belt, a seatbelt sign on
the abdominal wall, and fracture of a lumbar vertebra.
35 Abdominal Emergencies in Infancy and Childhood 375
Fig. 35.4. “But … but I’m a pediatric surgeon…”
No discussion of pediatric trauma can be complete without emphasizing
the need for always suspecting child abuse. While isolated abdominal trauma is
a rare presentation of child abuse, unusually shaped or multiple bruises, associated long bone fractures, or inexplicable genital lesions should always raise the
suspicion of this tragic and potentially life-threatening condition.
Children are not small adults but … see > Fig. 35.4.
The AIDS Patient
1
Sai Sajja · Moshe Schein
The AIDS patient can suffer from acute appendicitis.
Human immunodeficiency virus (HIV) infection and its inevitable consequence of acquired immunodeficiency syndrome (AIDS) is a major public health
problem worldwide that has affected the way surgery and medicine are practiced. With advances in medical treatment, people infected with HIV are living
longer, so it is likely that most of you, wherever you practice, will encounter and
treat patients with HIV/AIDS. While the general principles of emergency abdominal surgery described elsewhere in this book are relevant to the HIV patient, we
highlight what is unique to this population.
Natural History
This disease presents a spectrum ranging from asymptomatic HIV infection
to advanced AIDS, including its associated opportunistic infections.
36
Depending on the CD4+ count, HIV disease is categorized as follows:
Early stage (CD4
Mid stage (CD4
Advanced (CD4
Terminal (CD4
A CD4
+
count of <2 00 c ell s/ml now is define d as AIDS irresp ect ive of the pres-
+
count >500 cells/ m l)
+
count 200–499 cells/ m l)
+
count 50–200 cells/ m l)
+
count <50 cells/ m l)
ence of symptoms or other illnesses. A long list of opportunistic infections and
cancers, when present, place the HIV-infected patient in the category of AIDS.
1
Why a separate chapter on HIV/AIDS? We’re sure we are not alone in deploring the current trend in
making some diseases (AIDS and breast cancer being the most notable) more “fashionable”, and
their sufferers more worthy of support and sympathy than regular patients. This chapter is emphatically not an addition to this regrettable development, but an acknowledgement that these patients
and their illness may be different in a surgically relevant way. [The Editors]
Sai Sajja
Susquehanna Health Medical Group, 777 Rural Avenue, Williamsport, PA 17701, USA
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_36, © Springer-Verlag Berlin Heidelberg 2010
377
378 Sai Sajja · Moshe Schein
Abdominal Pain
Abdominal pain and nonspecific gastrointestinal complaints are very common in patients with HIV/AIDS (> Fig. 36.1). Clinical evaluation is difficult as
many patients suffer from chronic abdominal symptoms, and for the physician
encountering the patient for the first time, what may be the baseline status for the
patient may appear very abnormal. Also, the list of differential diagnoses is much
larger in this population. White blood cell count, which is very valuable in the normal population, is not reliable because of pre-exsisting leukopenia. Patients often
have coexisting infections of the central nervous system, which makes evaluation
of the abdominal pain difficult. Antiviral medications frequently cause chronic
abdominal symptoms as well as acute pancreatitis. A thorough history, including
the stage of the HIV disease, the presence of opportunistic infections and the antiretroviral therapy, and a careful physical examination along with an erect chest
X-ray and abdominal X-rays and routine laboratory tests, including serum amylase and lipase, form the basis on which further management is planned.
When the initial examination is inconclusive, serial examinations often yield
valuable information. In the absence of clinical peritonitis, free intraperitoneal air,
and exsanguinating hemorrhage, computed tomographic (CT) scan of the abdomen and pelvis is indispensable for investigation in AIDS patients. It often identifies nonsurgical pathology and avoids a nontherapeutic laparotomy.
shows causes of abdominal pain in HIV/AIDS, and > Fig. 36.2 shows the suggested
clinical approach. (Note that the algorithm in that figure differs from the management of a patient not affected by HIV/AIDS really only in the early and uniform use
of CT scanning in patients not scheduled for an emergency operation.)
>
Tabl e 36.1
Fig. 36.1. “Is it appendicitis or CMV colitis again?”
36 The AIDS Patient 379
Table 36.1. HIV-related and HIV-unrelated causes of abdominal pain according to the
need for source control
HIV-related conditions Non-HIV-related
Surgical procedure
usually indicated
Usually conservative
management
CMV cytomegalovirus; MAC Mycobacterium avium complex
CMV bowel perforation Appendicitis
CMV-related toxic megacolon Cholecystitis
Acalculous cholecystitis Secondary peritonitis
Kaposi sarcoma Intra-abdominal
Lymphoma with bowel perforation Intestinal ischemia
Splenic abscess Trauma
Uncomplicated CMV infection Organomegaly
Mycobacterium avium complex Constipation
Mycobacterium tuberculosis Uncomplicated peptic
Pancreatitis: infectious (CMV,
MAC), drug induced
(pentamidine, dideoxyinosine,
trimethoprim-sulfamethaxazole)
Specific Conditions
abscesses
ulcer
disease
Uncomplicated pelvic
inflammatory disease
Acute appendicitis. That a patient suffers from AIDS does not mean that he
or she cannot develop acute appendicitis; in fact, the incidence of appendicitis in
the HIV population appears to be higher than in the general population. While
some patients present with typical symptoms and localizing signs in the right
lower quadrant, often the presentation is atypical: diarrhea and vomiting are seen
frequently, while fever and leukocytosis are not very reliable. CT scan is the diagnostic imaging study of choice when the presentation is atypical. Interestingly,
CMV (cytomegalovirus) infection and Kaposi sarcoma of the base of the appendix have been reported to cause appendicitis. The operative and postoperative
management is similar to that in the non-HIV-affected population (> Chap. 28).
Cytomegalovirus. In the AIDS patient, CMV is found in every organ system
in the body, is the most common opportunistic infection of the gastrointestinal
tract, and often involves the colon—causing fever, diarrhea, and abdominal pain.
CMV infects endothelial cells, leading to thrombosis of the submucosal blood vessels, which results in mucosal ischemia, ulceration, hemorrhage, perforation, and
380 Sai Sajja · Moshe Schein
History and physical examination
Complete Blood Count, Amylase, Lipase, Chest X-ray and Abdominal X-Rays
Rigid/Tender Abdomen +/− peritoneal signs
Free airNo free air
CT Scan
Explore
Explore
Surgical pathology
Non-surgical pathology
Serial Evaluation
Fig. 36.2. An approach to abdominal pain in AIDS patients
toxic megacolon. Diagnosis is established by colonoscopy and biopsy, which shows
characteristic intranuclear inclusion bodies. CT scan findings of thickening of
bowel wall and mural ulceration are nonspecific. Once the diagnosis is established,
treatment with ganciclovir or foscarnet is started. It is very important to keep these
patients under close observation while they are on medical therapy to identify early
the development of complications. Despite aggressive medical management, some
patients develop perforation, toxic megacolon, and hemorrhage—complications
that require urgent surgical intervention—following adequate fluid resuscitation
and institution of broad-spectrum antibiotic therapy. The perforations related to
CMV appear punctate when viewed from the serosal surface. Resection of the involved segment of bowel and formation of a colostomy or ileostomy—rather than
primary anastomosis—is the treatment of choice. Toxic megacolon with impending perforation is best managed with a subtotal colectomy and ileostomy.
Acute cholecystitis. Right upper quadrant abdominal pain associated
with fever, nausea, and vomiting is a common complaint in patients with HIV/
AIDS. While the cause of this pain may be due to hepatomegaly associated with
granulomatous infiltration or colitis, the possibility of biliary pathology needs
to be investigated. Although gallstones are present in many HIV/AIDS patients
undergoing cholecystectomy, they are also believed to have a relatively high
incidence of acalculous cholecystitis. CMV and Cryptosporidium are the most
common opportunistic microorganisms isolated from the affected gallbladders;
overwhelming growth of these pathogens seems to cause inflammation and
36 The AIDS Patient 381
functional obstruction. This is different from the combination of hypotension,
ischemia, and sepsis that is believed to be the cause of acalculous cholecystitis
in the non-HIV-affected, critically ill patient. Ultrasound is the initial imaging
study of choice; gallstones, size of the common bile duct, gallbladder wall thickness, pericholecystic fluid, and intramural air can be demonstrated. CT scan and
HI DA s can (radioisotope hepatic iminodiacetic acid) are useful when the sonogram is inconclusive. Once the diagnosis is established, depending on the overall
condition of the patient, surgical intervention is recommended. Laparoscopic
cholecystectomy can be safely performed as experimental observations have not
substantiated the concerns of aerosolization of HIV virus in the laparoscopy gas.
To prevent blood spray during retrieval of the gallbladder, the pneumoperitoneum must be evacuated first. The routine use of specimen bags is recommended
to prevent the accidental spillage of infected contents. The relatively high morbidity and mortality of cholecystectomy in these patients reflects the fact that
acalculous cholecystitis occurs in the more advanced stages of AIDS.
Splenic abscess. Splenic abscess is more common in patients with HIV/AIDS.
Metastatic spread from other infections, secondary infection of a splenic infarct,
and contiguous spread from an adjacent organ are the possible mechanisms of its
development. CT scan or ultrasound establishes the diagnosis. In the absence of
loculations, percutaneous CT-guided drainage of splenic abscess has a reasonable
success rate. Splenectomy is the definitive treatment when radiological features do
not favor percutaneous drainage or to salvage a failed radiological intervention.
Perianal sepsis. Acute anorectal conditions are discussed in > Chap. 29, but
AIDS patients are different. Anorectal pathology is very prevalent in the HIV/AIDS
population, especially in those who practice anal-receptive intercourse. While
being susceptible to anorectal problems of the general population, HIV/AIDS patients are also prone to a variety of opportunistic infections like CMV, herpes, and
benign and malignant neoplasms in the perianal area. Careful inspection of the
perianal area, gentle digital rectal examination and a proctoscopic visualization
will identify the perianal condition. Examination under anesthesia is an essential
part of evaluation before definitive surgical therapy. As in the non-HIV-affected
population, perianal sepsis in this population could result from cryptoglandular
disease or, by contrast, be associated with HIV-related anorectal ulcers or result
from secondary infection of anal proliferative lesions. The abscesses associated with HIV-related anorectal ulcers tend to be very deep—transgressing the
sphincter planes—with variable destruction of the sphincter mechanism. Surgical intervention is usually necessary. Abscesses should be liberally drained, and
sp eci men s sho uld be o bta in ed fo r ac id-f ast staini ng a nd cu lture. B iop sy fo r hist ology is done if underlying malignancy is suspected. The principles of treatment are
similar to the management of perianal sepsis in Crohn’s disease—treatment has
to be conservative. Damage to the sphincters is avoided, and noncutting setons
and drains are used liberally. Delayed wound healing is a major concern with
CD4+ cell count of less than 50/ml a predictor of delayed wound healing.
382 Sai Sajja · Moshe Schein
Remember
The general principles of surgical care described in this book are applicable
to the HIV/AIDS patients; however, a thorough understanding of the natu-
ral history and the spectrum of HIV disease is essential. The pathology may
or may not be related to the HIV status.
Abdominal complaints are extremely common in the HIV population,
and clinical evaluation is often difficult. Serial clinical examination and
frequent use of CT scan are essential to prevent nontherapeutic interven-
tions.
Early diagnosis and prompt intervention are essential for non-HIV-related
surgical pathology like acute appendicitis and cholecystitis. Surgical in-
tervention is also essential for complications of opportunistic infections
like CMV perforation. The morbidity and mortality for surgical procedures
depends on the stage of the HIV disease and the nature of the pathology.
Surgical intervention should not be denied to this population because of
the risk of occupational transmission and the fear of high complication
rates. Relief of symptoms and improvement in quality of life are the chief
considerations.
Abdominal Emergencies
in the “Third World”
Robin Kaushik · Graeme Pitcher · Craig Joseph
37
M. Schein et al. (eds.), Schein’s Common Sense Emergency Abdominal Surger y,
DOI: 10.1007/978-3-540-74821-2_37, © Springer-Verlag Berlin Heidelberg 2010
383
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