Pediatric emergency medicine trisk 942
Bạn đang xem bản rút gọn của tài liệu. Xem và tải ngay bản đầy đủ của tài liệu tại đây (227.56 KB, 4 trang )
sometimes takes a high position, and this could give a false impression of
malrotation. If an US is obtained, as with possible pyloric stenosis or
intussusception, an abnormal relationship between the superior mesenteric artery
and vein should lead to an upper GI series.
As in the case of a child with an unreduced intussusception, a child with a
possible volvulus should be prepared for immediate surgery. The operating room
and operating team should be notified. IV fluid and electrolyte replacement
should begin immediately. Laboratory studies should be obtained, but they do not
add to the diagnostic evaluation. A nasogastric tube should be inserted and blood
cross-matched. Because this entity can present even in adulthood, every physician
should understand the pathogenesis and the need for emergency surgical
treatment of volvulus. If immediate transfer to a pediatric hospital cannot be
accomplished within an hour, a laparotomy should be performed without delay.
FIGURE 116.11 Malrotation. Upper gastrointestinal study showing absence of the ligament of
Treitz and coiled spring appearance of jejunum.
FIGURE 116.12 Sigmoid volvulus. Abdominal radiograph shows a markedly distended
sigmoid colon (arrows ). (Reprinted with permission from Lee E. Pediatric Radiology:
Practical Imaging Evaluation of Infants and Children . Philadelphia, PA: Wolters Kluwer;
2017.)
Sigmoid Volvulus
Children with a history of severe chronic constipation or colonic dysmotility are
at risk of developing sigmoid volvulus due to dilatation of the sigmoid colon.
Symptoms may be insidious in onset but often progress to signs and symptoms of
complete bowel obstruction. Children with a history of colonic dysmotility who
present with acute severe abdominal pain, especially if vomiting or distension are
present, should have abdominal radiographs obtained in order to evaluate for
possible sigmoid volvulus ( Fig. 116.12 ).
Pyloric Stenosis
Goals of Treatment
Pyloric stenosis is not a surgical emergency, but proper diagnosis and correction
of electrolyte abnormalities are important for rapid recovery of the infant.
CLINICAL PEARLS AND PITFALLS
Pyloric stenosis leads to nonbilious emesis only
Pyloric stenosis may present with hematemesis
Severe metabolic alkalosis can lead to apnea
Very early in the course of pyloric stenosis, ultrasound diagnosis based
on measurements may be falsely reassuring; repeat US should be
performed if symptoms persist
Current Evidence
Pyloric stenosis refers to an idiopathic hypertrophy of the pyloric muscle and
occurs in 1 in 250 births. There is a male:female ratio of 4:1, and first born males
are at higher risk. A familial incidence has been shown, particularly if the mother
had hypertrophic pyloric stenosis as an infant. The age of onset is usually 2 to 5
weeks. Rarely, the onset may be late in the second month of life. The cause of the
muscle hypertrophy is unknown, but the symptoms, diagnosis, and therapy are
well defined.
Clinical Considerations
Initial Assessment. Characteristically, the infant does well, without vomiting, for
the first few weeks of life and then starts vomiting, either at the end of feedings or
within 30 minutes. The infant is hungry and will eat immediately after vomiting.
The vomiting becomes more prominent and eventually becomes forceful,
projectile emesis. The vomitus is always nonbilious. With protracted emesis,
hematemesis can occur. Infants with pyloric stenosis may also become jaundiced
with the onset of the other symptoms. The hyperbilirubinemia usually improves
or abates postoperatively for reasons that are unknown.
Early in the course, infants may appear perfectly active and well hydrated. In
infants with protracted symptoms, moderate to severe dehydration may exist. The
abdomen is soft and nondistended and if the infant is relaxed, an “olive” mass
may be palpable in the midepigastrium. Sugar water can be used to help relax the
