Pediatric emergency medicine trisk 941
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be attempted. The child should be given opioid pain medications, such as
intranasal fentanyl or IV fentanyl, with standard cardiopulmonary monitoring.
The mother should then cuddle the baby until it relaxes and falls asleep. An older
child may be placed in the Trendelenburg position to allow gravity to facilitate
the reduction. Once the child is asleep, gentle manipulation of the incarcerated
mass should be attempted. Mild pressure should be exerted at the internal ring
with one hand, while the other attempts to squeeze gas or fluid out of the
incarcerated bowel back into the abdominal cavity. If the reduction is
unsuccessful, a surgeon should be consulted immediately.
Disposition. After the hernia has been reduced manually, the child may be
admitted for observation but not immediate repair. The hernia sac and spermatic
cord are edematous after a reduction, making the repair difficult. Usually, it is
done 24 hours after admission. If a child has persistent emesis after a manual
reduction of a hernia, consider the possibility that the bowel was incompletely
reduced. Children that develop peritoneal signs after manual reduction should be
evaluated for possible perforation associated with gangrenous bowel. Rarely
should a child be sent home after a manual reduction unless the parents are
properly informed concerning signs of recurrence or intestinal obstruction.
Incarcerated Umbilical Hernia
Incarceration of an umbilical hernia is rare. If present, there is a persistent and
tender bulge in the umbilical hernia sac. If the incarceration is of short duration, a
gentle effort might be made to reduce it manually, but it is often necessary to
prepare the child for urgent surgery. At the time of surgery, the loop of
incarcerated bowel should be inspected, rather than letting it drop back into the
abdominal cavity, to be certain there has been no vascular impairment.
Malrotation of the Bowel With Volvulus
Goals of Treatment
The goals of treatment are simple: early recognition, emergency surgical
consultation, treatment of shock, and immediate operative care to preserve
viability of the bowel.
CLINICAL PEARLS AND PITFALLS
Volvulus is the most serious etiology of intestinal obstruction
Neonates with bilious emesis should be emergently evaluated for
malrotation and volvulus even if well-appearing
Sudden onset of abdominal pain and bilious emesis in a child should
prompt rapid evaluation for midgut volvulus
Current Evidence
Malrotation of the bowel is a congenital condition associated with abnormal
fixation of the mesentery of the bowel ( Fig. 116.9 ). Therefore, the bowel has a
tendency to volvulize and obstruct at points of abnormal fixation. Although
malrotation with volvulus usually occurs either in utero or during early neonatal
life, malrotation can be unrecognized until childhood (25% of cases present after
1 year of age). This is an extraordinarily dangerous situation because a complete
volvulus of the bowel for more than an hour or two can obstruct blood supply to
the bowel completely, leading to complete necrosis of the involved segment.
When a volvulus involves the midgut, the entire small bowel and ascending colon
may be lost. To prevent such a catastrophe, physicians should have a high index
of suspicion for malrotation in any child with signs of obstruction and be
prepared to get a child with a presumed volvulus to the operating room
immediately.
Clinical Considerations
Initial Assessment. Any child with bilious vomiting and abdominal pain may
have malrotation with volvulus. The pain is usually intense and constant,
although infants with early volvulus may initially appear well. Blood may appear
in the stool within a few hours and suggests the development of ischemia and
possible necrosis of the bowel. Clinically, malrotation can present in several
different ways: first, and most dangerous, is the sudden onset of abdominal pain
with bilious vomiting with no prior history of GI problems; second is a similar
abrupt onset of obstruction in a child who previously seemed to have “feeding
problems” with transient episodes of bilious vomiting; and third is a child with
failure to thrive because of alleged intolerance of feedings.
FIGURE 116.9 Malrotation with volvulus. A: Normal small bowel mesenteric attachment (as
demonstrated by the arrow ). This prevents twisting of small bowel because of the broad
fixation of the mesentery. B: Malrotation of colon with obstructing duodenal bands. C: Midgut
volvulus around the superior mesenteric artery caused by the narrow base of the mesentery.
FIGURE 116.10 A: Malrotation of the bowel. Supine plain roentgenogram of the abdomen
shows distended stomach and proximal duodenal loop. B: Same patient as in (A ). Upper
gastrointestinal series shows dilated proximal duodenum with abrupt transition to normal
caliber of small bowel. Abnormally placed ligament of Treitz. Proximal jejunum in the right
abdomen.
On physical examination, there may be only mild distension of the abdomen
because the obstruction usually occurs high in the GI tract. On palpation, the
physician may discern one or two prominently dilated loops of bowel. The
abdomen may be diffusely tender and yet not have signs of peritonitis early in the
course. On rectal examination, the presence of blood on the examining finger is
an alarming sign of impending ischemia and gangrene of the bowel.
Management. The key to management is to be suspicious of malrotation and to
obtain supine and upright radiographs of the abdomen immediately. The presence
of loops of small bowel overriding the liver shadow is suggestive of an
underlying malrotation. When complete volvulus has occurred, there may be only
a few dilated loops of bowel with air–fluid levels. Distal to the volvulus, there
may be little or no gas in the GI tract. A “double-bubble sign” is often present on
an upright film because of partial obstruction of the duodenum causing distension
of the stomach and first part of the duodenum ( Fig. 116.10A ).
When a child is being assessed for possible malrotation (with or without
volvulus), an upper GI series is the study of choice. The ligament of Treitz is
absent in the malrotation anomaly; therefore, the C-loop of the duodenum is not
present, the duodenum lies to the right of the spine, and the jejunum presents a
coiled spring appearance in the right upper quadrant ( Figs. 116.10B and 116.11 ).
The cecum is not fixed and usually assumes a position in the right upper
quadrant. However, because of its mobility, the cecum on barium enema may be
seen in its normal position in the right lower quadrant. Therefore, a barium enema
is not the most reliable study to rule out malrotation. In the neonate, the cecum
