Pediatric Urology

 

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Hypospadias, Intersex

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Urinary Stones in Children

Eneuresis, Bedwetting, Urinary Incontinence, Neuropathic bladder

Multi Cystic Dysplastic Kidney, Wilms Tumor, Emergencies

Pediatric nephrology, chronic kidney disease

Acute Kidney Injury

Single kidney status

Pregnancy planning, Anomaly scan, Anomaly prevention

Paediatric Laparoscopic Surgery (Key Hole Surgery)

Common Paediatric Surgical Problems

Child Specialist, Vaccinations

 

Common Paediatric Surgical Problems

 

Congenital Diaphragmatic Hernia (CDH)

Oesophageal atresia/Tracheo oesophageal fistula (TOF)

Small Bowel Atresia

Hirschsprung’s Disease

Anorectal malformation,

Exomphalos

Gastroschisis

Congenital Cystic Adenomatoid Malformation (CCAM)

Necrotising enterocolitis (NEC)

Pyloric stenosis

Intusussception

Appendicitis


 

Congenital Diaphragmatic Hernia

What is it and why does it occur ?

The diaphragm is the sheet of muscle that separates the chest from the abdomen.  Diaphragmatic Hernia (CDH) is a hole in the diaphragm and may be from one inch to several inches across.  This results in the intestines (and sometimes the stomach) entering the chest cavity preventing lung growth.  It usually occurs on the left side of the chest. The cause of this condition is unknown.  This is a rare condition and occurs in about 1:2000 babies.  It happens at about the third month of pregnancy.

Can it be detected before birth? How serious is it?

If detected before birth CDH is diagnosed by seeing the stomach and some of the intestines in the chest area on the ultrasound scan.  CDH can be associated with other abnormalities. Therefore it is important to carry out other investigations such as amniocentesis and a detailed scan of the heart. CDH can also result in an increase in the amniotic fluid around the baby (known as Polyhydramnios) which may lead to an early delivery. CDH is a serious condition.  Overall 85% of those diagnosed antenatally may die before or after delivery, but of those with no other abnormalities approximately 50% survive.

What is expected at and after delivery?

It should be possible for normal delivery unless there are other reasons for requiring a Caesarean section.  It is preferable to deliver the baby where there is facility for breathing support (ventilation) and surgery after birth. Most babies have breathing difficulties at birth and will require immediate support for this.  In severe cases, this may not be successful and the baby may die within hours.  Surgery will usually be delayed until there are signs that the baby's lungs are strong enough.  This may take 2 - 3 weeks. During this time the baby will be receiving intensive care.

What does the surgery involve?                                            

The surgery is carried out through an incision on the abdomen.  The gut is pulled down from the chest cavity and the diaphragm repaired. If the hole in the diaphragm is large, there may be a need to use an artificial patch to repair it. The baby will still require help with breathing after surgery, so intensive care will continue. This may be needed for several weeks.

What are the long term effects?

There may be no long-term effects at all. However, these babies can grow up suffering from chronic lung problems in early childhood. This can result in repeated hospital admissions with respiratory infections.   These babies can also have feeding problems. The lungs can continue to mature up to 8 years of age. Most survivors will be able to attend school normally and have a good quality of life. Many will be entirely normal older children and adults.


 

Oesophageal Atresia / Tracheo Oesophageal Fistula (TOF)

What is it?

Oesophageal atresia is blockage in the oesophagus (food pipe). It is often associated with an abnormal connection between the oesophagus and trachea (wind pipe) below the level of blockage. This is known as Tracheo-oesophageal fistula (TOF). Some babies with TOF will have other problems with development of the kidneys, their bottom (anorectal abnormality) or other areas.

What happens after birth of such a baby?

Once diagnosed, it is important to stop feeding and give fluids via a drip in a vein.  Additionally a small tube is passed through the babies nose or mouth, down into the pouch of the oesophagus to suck out any secretions that may build up as your baby swallows.  This tube is known as a Replogle tube and it remains in place until the operation.

What does the operation involve?

The aim of the operation is to close the fistula and repair the oesophagus.  The type of operation will depend on the defect that is found during- the procedure.  This will be done under a general anaesthetic and the baby will be given some painkillers on return from theatre. The baby may be on a ventilator (breathing machine) for a while.  

How does the baby feed after the operation?

When the operation is done a feeding tube is passed through the nose and the repaired oesophagus into the stomach.  This enables the baby to be fed through the tube, in most cases, within a few days of surgery. When the baby is ready to start having feeds a small amount is given frequently to begin with before increasing to the required amount.  An x-ray may be done prior to this to make sure that the repaired area has healed. 

Problems with Food Lumps: This occur most frequently as the baby is introduced to solids, and, more significantly later on when your baby is about 18 months and is able to self feed.  These tend to get stuck at the join (anastamosis).  It does not always mean that there is a stricture.  Children can usually clear the lumps by taking a drink or by stretching to dislodge it.  However, some lumps need removal under general anaesthetic.

Reflux of Stomach Contents: This is quite an uncomfortable condition for your baby.  It is as if the baby has ‘heartburn’.  It may be minor to severe and may predispose to a stricture. Babies may present with vomiting (again either minor or severe), irritability and in some pain.  Treatment may be medication, but some 20% require operation for persistent problems such as failure to grow, noisy breathing and blue attacks, and possibly recurrent chest infections.

Small bowel atresia

What is it? 

The small bowel is the section of bowel between the stomach and the large bowel (colon). It is about 300cm long in a newborn baby at term and its function is to absorb food. An atresia is a gap in the bowel causing a complete blockage (obstruction) of the bowel. It occurs in about 1 in 5000 babies.

Why does it occur?

Atresia is believed to be caused by damage to the blood vessels of the bowel. Why the blood vessels are damaged is not known but this damage can happen at any time during pregnancy.

What are the types?

Most commonly the bowel is blocked but none is missing. In some babies there is a section missing and although usually this is an insignificant amount, in some babies it may be enough to interfere with the baby's ability to absorb milk. Babies can have over half the bowel missing without there being much effect on milk (or, later, food) absorption. However in some babies there is so much bowel missing that special feeding is needed. This is known as short bowel syndrome. It could mean long term hospitalisation and drip feeding.

What is the initial management?

Babies with small bowel atresia vomit soon after birth and the vomit is bile-stained (green).  Milk feeds will be stopped.  A tube will be passed through the nose into the stomach to drain away any fluid and air collecting in it. Fluids will be given through a vein (drip).

How is the diagnosis made?

In a few babies the diagnosis may be suspected on antenatal ultrasound scan.There are a number of causes of blockage other than atresia. An x-ray of the baby's abdomen may suggest a blockage but the final diagnosis of atresia may only be made at operation.

How is the atresia treated?

An operation will be necessary in the first few days of life. The ends of the

atresia are cut away and the bowel joined back together. This is usually simple

to do.

What happens after the operation?

Small amounts of milk are usually started after 2 or 3 days and gradually increased. Most babies are able to go home about 2 weeks after the operation. If the section of bowel above the blockage has become very dilated before birth it may take longer to start working and so some babies need to stay longer. During this time your baby will need drip feeds (Parenteral Nutrition) through a long line. This line is usually placed in a small vein in an arm or leg and fed through into a large vein.Milk feeds will be slowly introduced and increased, as the baby is able to tolerate them. Once recovery has occurred the baby should be able to feed normally, either by bottle or breast.

 

What are the long term effects?

Provided there is plenty of bowel length there are no long term consequences of small bowel atresia. If a moderate amount of bowel is missing the baby may have rather loose and frequent bowel motions but this tends to improve over a few months. Following an operation there is always a small risk of future obstruction occurring. If your baby has a bilious vomit or a distended abdomen medical advice should be sought.

 

Hirschsprung's Disease

What is Hirschsprung’s Disease?

Hirschsprung’s Disease (HD) is a rare condition in which the nerve cells (known as ganglion cells) are absent in a segment of bowel. The ganglion cells control the muscles of the bowel. Because the muscles can’t relax well it creates a functional blockage. Contents are pushed along until they reach the affected part of bowel where the passage slows and a blockage occurs.

How common is HD? Can it run in families?

HD occurs in 1: 5000 babies and is more common in boys than girls. We do not know what causes HD to occur; sometimes it can run in families. HD affects the rectum and a variable length of the large bowel above it. This length is usually a few centimetres but sometimes may affect the entire large intestine.

What are the symptoms?

There is normally a delay in your baby passing meconium (black sticky stool normally passed within 24 hours of delivery).Many babies with HD present at around three days of age having never had their bowels open. The baby may be reluctant to feed and may vomit a green fluid called bile which would normally pass through the bowel. The baby may be uncomfortable because of constipation and trapped air in the bowel. The abdomen (tummy) becomes distended. Sometimes the bowels become inflamed and a very serious infection called enterocolitis can develop.

What is the treatment?

Initially the following steps will be taken. Milk feeds will be stopped. A tube will be passed through the nose into the stomach to drain away any fluid and air collecting in it. Fluids will be given through a vein (drip). Your baby will need to have washouts to decompress the bowel and reduce discomfort. Usually the washouts will need to be done once or twice every day and will take 20-30 minutes. Bowel washouts empty the lower large bowel of air and stool and reduce the risk of enterocolitis developing. Occasionally the abdomen cannot be decompressed adequately by washouts. Your baby would then need an operation (colostomy formation) to ensure that the bowel remains decompressed.

How is theDiagnosis made?

An X-Ray of your baby’s abdomen will show dilated bowels. A special X-Ray called Barium enema helps to make the diagnosis. The only definite way to test your baby for HD is by taking a sample of tissue from the lining of the rectum with a small instrument through your baby’s bottom. This is called a Rectal Biopsy. Your baby may need to remain in hospital while having bowel washouts and waiting for surgery. Sometimes your baby may go home and return to hospital daily for the washouts. During this time your baby should be able to feed normally. While awaiting surgery your baby remains at risk of developing enterocolitis

What is Enterocolitis?

Enterocolitis is an infection of the large bowel and is a potentially very serious complication of HD. It is treated with antibiotics (given through a drip into a vein) and regular bowel washouts. Some babies who develop enterocolitis need to have a stoma formed.The symptoms and signs to look for are: Distended abdomen (tummy),Reluctance to feed, Vomiting - this may be green in colour, Explosive / offensive watery stools, A high temperature, Tummy ache, Dehydration (baby is pale and floppy).Enterocolitis can occur both before and after surgery but the risk after surgery is very much less. If you are at all concerned about your baby please obtain medical advice urgently.

What does the corrective surgery involve?

This operation is called a “Pull through” and is usually performed at a few weeks/months of age. It involves taking out the part of the bowel affected by HD and connecting the healthy bowel to the anus. Sometimes this can be done using a laparoscopic approach (keyhole surgery). Your baby will be in hospital for 5-7 days after the operation.

What is the long term outcome?

Many babies with HD suffer with long term problems such as diarrhoea, constipation, soiling and abdominal pain. Sometimes medicines are needed to help with these problems.You will find that your child takes longer to toilet train.

 

Ano rectal Malformation

What is anorectal malformation?

1 in 5000 babies are born with this problem where there is no opening at the anus; therefore the baby cannot pass stools normally. Often the opening is connected by a fistula to a wrong place. It may be in to the urinary tract in boys or the birth canal in girls. Sometimes there is no connection any where and these babies have bowel obstruction because this.

How is it detected?

Babies generally pass the first black stool within few hours; if this does not happen one has to inspect the bottom for presence of a normal anal opening; in babies with this problem it is absent or very narrow or wrongly located.

Is it associated with other problems?

30% of these babies can have kidney problems; 25% - 50% can have problems with spine and spinal cord. They may also have cardiac problems, limb anomalies; and problems in food pipe (Oesophageal atresia and tracheo oesophageal fistula).

What is the treatment for this condition?

The paediatric surgeon has to assess whether the problem is a low one or high one. If the bowel ends low, especially in a boy child, a single operation to establish communication called anoplasty is performed. If the bowel ends higher or in a girl child, two stage operation is required. The immediate treatment is to create a stoma (colostomy); where bowel opening is created on the surface of tummy. This involves general anaesthesia. Once the stoma starts working (2-3 days) feeds can be started. The stoma enables the baby to pass stools normally, feed and grow.

What is the definitive operation?

The definitive operation involves a pull through performed at around 8-12 months, where the bowel is pulled down and stitched to the normal anal location. It is done under general anaesthesia and involves 7-8 days stay.

What are the long term problems?

The new opening created becomes narrow (anal stenosis) in 20-30% requiring dilatation or further revision surgery. Constipation is a problem in 30-40%. Soiling and poor control of stools can be a problem in 30-40%. These problems are more in children with high anomaly and associated spinal problem. There can also be problems with urine control in children with associated spinal defects.

 

EXOMPHALOS (Omphalocele)

What is Exomphalos?

Exomphalos is a weakness of the baby’s abdominal wall where the umbilical cord joins it. This weakness allows the abdominal contents, mainly the bowel and the liver to protrude outside the abdominal cavity where they are contained in a loose sac that surrounds the umbilical cord. Because the contents are lying outside it, the abdominal cavity often does not develop properly and remains small in size

Why does it occur? How common is it?

The cause of this condition is unknown. This is a rare problem occurring in about 1 in 5000 pregnancies. We do not know why this happens in babies. About half of all babies with exomphalos will have problems affecting other body systems. Most commonly affected are the heart, lungs, and kidneys. Detailed scans will be performed but it is not always possible to detect problems before the baby is born. There is also an increased risk of a chromosomal abnormality and you will be offered an amniocentesis.

What happens after the delivery?

It should be possible for you to deliver your baby in the normal way unless the exomphalos is very large, or there are other reasons for requiring a Caesarean Section. After your baby is born the sac will be wrapped in Clingfilm® to both protect it and reduce heat and fluid loss. A drip will be placed into a small vein so that intravenous fluids can be given. A tube will be passed through your baby’s nose into the stomach to drain away the green fluid (bile) that collects in the stomach. This lessens the risk of your baby vomiting and reduces discomfort. Your baby will be examined in order to identify any problems with other body systems and may need further tests. If there are associated lung problems assistance may be required with breathing.

What does the surgery involve?

The size of the sac and its contents can vary greatly from being very small to very large. It is therefore impossible to say exactly what type of operation is required for Exomphalos until your baby is born and the actual size can be seen. However there are a number of different treatments any of which can be used depending upon the size of the exomphalos.

Primary Repair: If small, it is possible in one operation to replace the exomphalos inside the abdominal cavity and repair the muscles and skin.

Staged Repair: If the exomphalos is extremely very large, it may not be possible to close it in one single operation.

Conservative treatment

If the exomphalos is very extremely large it may not be possible to close immediately. Here medicines are applied to promote skin growth.  Skin will gradually grow over the exomphalos over a period of several weeks/months.

What does follow up involve?

Following an operation there is always a small risk of future obstruction occurring. If your baby has a bilious vomit or a distended abdomen medical advice should be sought.

GASTROSCHISIS

What is Gastroschisis?

Gastroschisis is a condition where the baby has a small hole in the front of the abdomen, just to the side of the umbilical cord, through which some of the bowel (intestine) is protruding. This bowel is easily visible on the ultrasound scan. This is a rare problem, which occurs in around one in every 3000 births.

What happens for the delivery?

It may be possible for you to deliver your baby in the normal way unless there are other reasons for requiring Caesarean Section. It is preferable to deliver the baby where surgical facilites are available soon after the operation. Following delivery the bowel will be wrapped in a plastic sheet to both protect it and reduce heat and fluid loss. A drip will be placed into a small vein so that intravenous fluids can be given, as your baby will not be able to feed in the normal way. A tube will be passed through your baby’s nose into the stomach to drain away the bile (green fluid) that collects here. This lessens the risk of vomiting and reduces discomfort.

What does the surgery involve?

Within a few hours of birth, the baby will have an operation to attempt to replace the bowel back into the abdominal cavity. This may be straightforward to do, or it may be quite difficult because of the small cavity of the abdomen. If it is not possible to replace all the bowel in the abdomen at this first operation, a temporary envelope made of plastic sheeting, called a silo, will be constructed on the outside of the baby’s abdomen to hold the bowel. The silo would then be made smaller every day or so, so that the abdominal contents are gradually pushed back inside the abdomen over the next 10 -14 days. A second operation is needed to completely replace the bowel and repair the muscles and skin. If the closure is tight the baby may need help with breathing for a few days. The baby will be given analgesia (painkillers) to help alleviate any pain or distress they may feel.

What are the associated anomalies?

Gastroschisis is not normally associated with other congenital anomalies. We expect most babies born with this condition to survive normally.In a few babies with Gastroschisis there is a gap in the bowel called an atresia. This may be noticed at the first operation or not be suspected until around four to six weeks of age if the baby is not able to tolerate milk. X-rays are carried out to confirm whether an atresia is present. If an atresia is confirmed the baby would need a further operation to join the bowel together. However in a small number of babies the Gastroschisis is complicated by further problems with the bowel that are not normally detected before the baby is born. The blood supply to the bowel is sometimes interrupted resulting in parts of the bowel being irreversibly damaged or missing. This is known as short bowel syndrome.  It could mean long term hospitalisation and its risks.

What complications can occur?

Other complications occasionally encountered after the operation are wound infections, inflammation/infection of the bowel and further obstruction of the bowel.

How long does it take for the baby to recover?

Because the bowel has been outside the abdominal cavity and has been subjected to movement and bruising by the baby’s activities, it is often extremely slow to work. Consequently the baby is unable to be fed milk in the usual way for a period of time, usually about 3 – 6 weeks. During this time your baby will need drip feeds (Parenteral Nutrition) through a centra line or long line. This line is usually placed in a small vein in an arm or leg and fed through into a large vein. It should be possible for the baby to grow quite normally on this form of feeding while the bowel is recovering. Milk feeds will be slowly introduced and increased, as the baby is able to tolerate them. Once recovery has occurred the baby should be able to feed normally, either by bottle or breast.

What are the long-term problems?

Some babies with gastroschisis are sometimes slower at establishing weight gain and some may have problems with constipation but these are normally short term problems. Babies who have had a silo will not have an umbilicus (tummy button) but it is now possible to have surgery later in childhood to create one.Following an operation there is always a small risk of future obstruction occurring. If your baby has a bilious vomit or a distended abdomen medical advice should be sought.
 

CONGENITAL CYSTIC ADENOMATOID MALFORMATION OF THE LUNG

What is it and why does it occur?

This is a very rare abnormality only occurring in about 1:10,000 babies. In this condition there are multiple cysts (water bubble) in one of the parts of the lung, which can result in one of the lobes developing as a group of cysts, rather than a proper piece of lung tissue.  Occasionally more than one lobe can be affected but it is usually confined to one lobe.  This can be detected on ultrasound before birth and has various appearances ranging from a small number of large cysts to a large number of small cysts. The effect that this may have on the baby is very difficult to predict.  In some babies the cyst can enlarge quite rapidly during pregnancy resulting in major problems for the baby before birth.  More often, however, the cysts do not grow rapidly and may not grow at all.  In fact, in some cases the cysts may actually disappear completely before the birth and the baby will be born with no problems whatsoever.  For this reason it would be important to check on the changes on the baby’s scan by doing repeat ultrasounds throughout the pregnancy.

What happens for the delivery? 

Providing all goes well during the pregnancy, then there should be no need to alter the timing or method of delivery.  However it is better to deliver the baby in a hospital where paediatric surgical and intensive care facilities are available.  Following the delivery the baby may have no problems whatsoever and appear to be quite normal in which case X-rays need to be done on the first day or two to determine whether any further treatment is necessary. 

However, in some babies, the cyst causes some compression of the rest of the lung and the baby has some difficulty in breathing.  This may be quite minor, resulting only in a rather fast rate of breathing, or can be quite major, requiring immediate oxygen and resuscitation.  The baby may start off well with very little difficulty in breathing but this may get worse in the first few days, so it is very important that the baby is monitored carefully during this time. Some babies with this problem require an operation in the first few days or weeks of life to remove the lobe that is affected by the cyst.  In other babies X-rays may show that the cysts have become so tiny that surgery is not needed.  

When is an operation required?

If an operation is needed, the exact timing of the operation depends on how badly the baby is affected and how difficult the breathing is. The more difficulty there is with breathing, the quicker the operation is done. In some cases this results in the operation being performed in the first 24 - 48 hours of life, and in others the operation is deferred for 2 - 3 weeks or more. In these cases the baby will have no symptoms and can be cared for usually at home for some weeks before planned surgery is undertaken.  At present, even if the baby has no symptoms, we would recommend removal of the cyst as infections can occur as the baby grows causing the baby to become quite unwell.

What does the surgery involve?

The operation that is undertaken is a fairly major one but is usually fairly straight forward.  The length of stay following surgery would vary from a few days to, in the most extreme cases, perhaps some weeks. Although the operation itself will involve removing one of the 5 lobes of the baby’s lungs, this is an area that would not have been any use to the baby anyway and the remainder of the lung will grow to compensate for the piece that has been removed.

 What are the long term problems?

In the long term, provided that there have not been any extreme breathing difficulties at the beginning, the vast majority of these babies make a complete recovery within a few days and do not have any long term problems with their lungs at all.  They can -grow up to be perfectly healthy normal children

 

Necrotising Enterocolitis

What is Necrotising Enterocolitis (NEC)?

NEC is an inflammation of the bowel (intestines) that may damage the bowel to a variable extent. It usually causes a temporary intolerance of milk feeds but at its worse the bowel may be so damaged that parts of it actually die. NEC may affect just a small part of the bowel or on occasions the whole bowel may be affected.

What are the symptoms?

It has a variable course ranging from feed intolerance and abdominal distension (swelling) to a sudden collapse of a baby who had previously been relatively well.A baby with NEC may have: A tender tummy, Blood in the stool, and Bile (green) vomiting. There may be signs of generalised illness and infection, for example, increased apnoeas and  bradycardias, low blood pressure. Occasionally a baby may become acutely and profoundly unwell and require extensive medical intervention.

Who gets NEC?

NEC is a condition that is almost exclusively confined to newborn babies in the first days to weeks after birth. It is much more common in premature infants and particularly those who have a lot of other medical problems or who have been unwell prior to birth for example, if they have not been growing properly in the womb. Occasionally bigger term babies may develop NEC. Again, problems in the womb or during birth may predispose such babies to NEC, as do some other problems like congenital heart conditions or abnormalities of the bowel.

What is the treatment?

If a baby is suspected to be developing NEC or has definite evidence of NEC the following treatments may be started:  Stopping milk feeds – resting the bowel appears to help the bowel recover; Starting antibiotics to treat any infection – bacteria seem to play some part in the development of NEC and therefore antibiotics may help settle the process down;  Intravenous feeding is required to keep the baby nourished while milk feeds cannot be given. If the baby becomes generally unwell a number of other treatments may be necessary, for example, help with breathing, medication to help blood pressure. X-rays and blood tests will be done to both confirm the diagnosis and monitor the response to treatment. Many babies who develop NEC recover with these ‘medical’ treatments. However if an area of bowel dies or there is a perforation (hole) of the bowel further treatment may be necessary:

What are the surgical options?

Insertion of drain - A drain can be inserted into the baby’s abdomen to allow any free air or fluid to drain out. This is often performed in the first instance especially if the baby is too unwell for an operation, however an operation may still be necessary at a later point.

Laparotomy - An operation under general anaesthetic. The surgeon will aim to remove the part of bowel that has died and rejoin the two ends together (resection and anastomosis). Sometimes it may be very difficult to operate in the abdomen so a stoma (bowel opening onto the abdominal surface) maybe created. In this case the baby will need a further operation to rejoin the bowel together.

What are the risks?

About 50% of babies referred for surgery with NEC do not survive. This may be before an operation is done or sometime after. The risks of surgery are greater if your baby is very sick.

What special care is required after the operation?

The baby will:need help with breathing so will be connected to a ventilator. Needs to be closely monitored and will be attached to various monitors. Likely to be intravenously fed. A long line will probably be needed for intravenous feeding.; be given pain relief as necessary; need blood products and other medications.

Are there any long term problems from NEC?

Most babies who recover from NEC do not have further problems; but future problems are possible especially if there has been bowel perforation. NEC may recur the wound may become infected or break down. The bowel may narrow due to scar tissue either caused by damage to the bowel  or at the operation site. This is called a stricture. If this occurs another operation will be necessary to remove this piece of bowel. Sometimes if a lot of bowel has been removed this may cause problems with food  absorption and therefore growth. Longer term intravenous feeding may be necessary (short bowel syndrome).

Pyloric stenosis

What is Pyloric Stenosis?

In this condition the muscle around the stomach outlet becomes thick; because of this milk cannot pass across and a blockage results. It typically affects babies 4-6 wks after birth. The exact cause of this problem is not known. But it is known to run in families affecting mainly the first male child.

What are the symptoms?

The baby starts to vomit feeds around 4 weeks after delivery. It gradually becomes forceful. The vomit contains milk or curdled milk mainly. As there is no vomiting and no milk absorption, there is less urine, and less stools. Also the baby gets dehydrated and loses weight.

How is it diagnosed?

When the baby is examined during a feed, one can see the stomach pushing hard to empty; also the muscle thickening can be felt as a mass. Ultrasound scan helps to confirm the diagnosis.

What is the treatment?

The baby needs to be admitted for IV fluids and correction of abnormalities in salt content of the body, which is often present because of vomiting. After this a surgery called ‘pyloromyotomy’ is required. Under general anaesthesia, through a small cut in the tummy, the muscle fibres blocking stomach outlet are divided.

What is the outcome?

Generally this surgery has a success rate of 98%. Babies can start feeds next day. Wound infection and poor healing resulting in a hernia are some of the well known complications. Complications like perforation, recurrence of the problem are extremely rare.

 

Intusussception

What is Intussusception?

In this condition a segment of small bowel goes inside another bowel segment further downstream. This leads to blockage of bowel. It typically affects babies of 6-9 months age. The exact cause of this problem is not known. It could be initiated by weaning of milk or a mild viral infection.

What are the symptoms?

The baby starts to cry in a high pitch due to pain. Some babies pass blood mixed with slime. They refuse feeds and may also start vomiting yellow liquid. Also the baby gets dehydrated and tired over time.

How is it diagnosed?

A bowel mass may be felt during examination. Ultrasound scan shows the bowel mass like a ‘doughnut’.

What is the treatment?

The baby needs to be admitted for IV fluids and correction of abnormalities in salt content of the body, which is often present because of vomiting. If the baby is brought soon enough, the bowel can be put back with the help of air enema. In this air is pumped up the bottom under x-ray and the bowel is reduced back. If this fails or the baby is brought late, surgery is required. Under general anaesthesia, through a small cut in the belly, the bowel mass is reduced manually.  If this fails, the affected portion needs to be removed and continuity restored.

What is the outcome?

After x ray reduction the intussusception can come back in 10-20%. Even after open surgery there is a 5% chance for recurrence. In the long term there may be bowel obstruction in 10% of children due to adhesions; In this, the bowel gets stuck inside the tummy and a blockage results. The parents need to watch out for, pain, vomiting and tummy distension. If these happen, an x-ray is required to look for obstruction. Surgery may be required to correct this.

 

Appendicitis

What is Appendicitis?

In this condition there is infection followed by inflammation of the appendix. Appendix is a tail like structure found at the junction of small and large bowel. It is a rudimentary organ (not necessary for normal function of gut), only useful in animals.

What are the symptoms?

Typically there is pain in the right lower part of tummy. This is sudden onset with sometimes vomiting and fever associated. Any movement or cough will aggravate the pain. The pain to start of is in the centre of tummy, but with time localises to right lower part where the appendix is situated.

How is it diagnosed?

Often the diagnosis is by clinical examination. Typical location of pain is there. On pressing the right lower part, the child winces in pain. Blood counts may show elevated white cells. Ultrasound is often performed, not to look for appendix, but to exclude other causes of abdominal pain like kidney stones or ovarian cyst.

What is the treatment?

The treatment is emergency surgery to remove the infected appendix. Laparoscopic operation can be performed to minimise scar and hasten recovery.

What is the outcome?

If not operated in time, rupture of appendix can lead to a life threatening complication called peritonitis, where pus is spread all inside the abdomen. Operation and recovery after peritonitis are complicated. However for simple appendicitis, a quick recovery is the norm.

 

 

Dr. Ramesh Babu, MS, MCh, FRCS, Consultant Paediatric Surgeon and Paediatric Urologist,  Chennai. For further information contact:  r1babu@yahoo.com  Mobile 9840359062