Surgical and Urological Advice for RHCG ED

Abdominal pain (? Appendicitis).

• Fewer than 10% of children referred with abdominal pain will require an operation.
• The diagnosis is predominantly clinical with history and examination being crucial. ‘Active observation’ (repeated examination) is the mainstay of diagnosis, but blood investigations can support the clinical impression and occasionally if, despite repeated examination over a 12-24hr period, the situation remains unclear an USS may help. 
• If the history, symptoms and signs are non specific, it is reasonable to assess and discharge home, provided it is made clear that if the situation changes at home the child must return for further assessment.
• In borderline cases, normal urinalysis and blood investigations may reassure sufficiently to allow discharge home as above.
• It is uncommon to operate on a patient with appendicitis overnight. Even in complicated appendicitis (e.g. perforated, widespread peritonitis), IV fluid resuscitation and analgesia over a few hours will make the child more stable for prompt surgical intervention the following morning. In line with sepsis 6 guidance, consider early antibiotics if evolving sepsis suspected, but in this scenario early discussion with the surgical registrar/ consultant would be mandated.
• Pitfalls:
  • Under 5 yrs: Presentation is often atypical and non-specific. If there is no clear other diagnosis, discuss with registrar for likely admission.
  • ‘UTI’: a pelvic appendix can mimic UTI symptoms, often the ‘dysuria’ is actually ‘abdominal dysuria’ (felt in the lower abdomen due to filling and emptying of an contraction of an inflamed bladder) and there is some GI upset. Urinalysis may well have leucocytes/protein/blood and can even have nitrites (bacterial translocation from the appendix). Make the diagnosis of UTI with caution where there are abdominal / GI symptoms / signs.
  • Abdominal signs with recent antibiotic treatment for respiratory tract infection/tonsillitis/UTI etc. Antibiotics will modify the disease history. The diagnosis can be difficult and may require admission and imaging.
  • Consider ovarian torsion in girls with sudden onset lower abdominal pain. Tenderness is often suprapubic and they may describe abdominal pain on micturition.
  • Children on immunosuppressant or high dose steroid medications
  • Children with significant communication disorders (including autistic spectrum disorders).
• Management for patients with reasonable suspicion:
  • Analgesia (paracetamol, NSAID, opiate). Analgesia will not obscure the diagnosis and may help settle the child allowing more effective examination. This should be given early and in adequate dosage.
  • Insert peripheral IV access and request following blood tests - FBC, U&E, CRP, Glucose LFT.
  • Urinalysis (Beta hCG must be done as per RHC guidelines).
  • IV fluid bolus 0.9% NaCl if required then IV fluid maintenance as per RHC IV fluid policy
  • Do not give antibiotics unless a clear diagnosis has been made - as above, antibiotics will make the diagnosis harder to confirm and may lead to mismanagement.
  • If progression of symptoms / signs or only minimal resolution, discuss with surgical registrar for review and admission. If stable or better, with reassuring bloods / urinalysis consider home with advice.

Bilious Vomiting

In older children, the positive predictive value of bilious (green) vomiting for having surgical pathology is less significant than it is in neonates and infants. However, in the absence of a history of multiple previous episodes of non-bilious vomiting which then became bilious, or if there are other features of concern, such as a previous history of abdominal surgery, abdominal distension or abnormal haemodynamics, older children with bilious vomiting should be discussed with the surgical registrar on-call.

The situation in neonates and young infants is very different. In these age groups, bilious vomiting should be viewed as a sign of intestinal obstruction until proven otherwise.

The archetypal time-critical condition presenting with bilious vomiting in this age group is midgut volvulus, which occurs when an abnormally rotated midgut twists on its narrow pedicle, leading to progressive ischaemia and necrosis of the bowel. Midgut volvulus usually presents in the first 6 months of life (but can present at any age). For this reason, bilious vomiting in neonates and young infants almost always warrants immediate surgical review and investigation (normally an upper GI contrast study, in the absence of another obvious cause).

• Inform the surgical registrar IMMEDIATELY on the baby’s arrival.
• Obtain a focused history and examination (often benign) but a convincing history of bilious vomiting should always be taken seriously.
• IV access and blood tests - FBC, U&E, CRP, venous blood gas, blood cultures, G+S.
• Resuscitation as necessary.
• Pass NG tube and place on free drainage. AXR is non-diagnostic, but might be considered if other diagnoses are suggested by history (e.g. previous surgery - adhesive obstruction).
• The surgical registrar will review and arrange an urgent upper GI contrast study, usually with the consultant surgeon present.

Suspected / possible Intussusception

Incidence is 1.6 - 4 cases per 1000 live births. With M:F 3:1. In >4 years of age M:F 8:1.  2/3rds of cases present before 1^st birthday with Peak incidence aged 5-10 months.  Event can often be preceded by URTI. 

Once the possibility of a diagnosis of intussusception has been raised, patients usually undergo an urgent ultrasound scan. A supine abdominal film may assist in changing the index of suspicion but cannot categorically exclude this diagnosis. 

• Obtain a focused history and examination - if there is a possible diagnosis of intussusception then contact the surgical registrar.
• IV access and blood tests - FBC, U&E, CRP, G+S.
• Analgesia is important - enteral route (PO/PR) absorption will be variable (vomiting, and bloody stool) so IV morphine is probably the best option. Be very cautious with opiates in these children - they may have significant fluid deficit and be in compensated shock – opiates may precipitate decompensation.  Also following successful reduction ,there is an almost immediate reduction in pain / stimulation, which has in the past led to cardiovascular collapse in radiology – patient should always be accompanied by Surgical team for US and should be prepared for this situation.
• The fluid deficit (loss and mal-distribution) will often require very significant volume resuscitation and if the history is sufficiently worrying, these patients should all get an IV fluid bolus of 0.9% NaCl, with further boluses as required, in addition to IV fluid maintenance as per RHC IV fluid policy  Delay in resuscitation may delay attempts at reduction and reduce the chance of success – do not wait for the surgical registrar review prior to starting resuscitation / urgent treatment.
• The surgical registrar will review and arrange the USS +/- air enema reduction +/- surgery.

Blunt abdominal trauma (including handlebar related injuries).

More than 90% of blunt abdominal trauma in children does not require a laparotomy. The management is largely conservative and involves identifying the injury, providing supportive measures and initial bed rest in an appropriate clinical setting. Once the child has been assessed, inform the surgical registrar. In some scenarios, it would be beneficial to notify the surgical team prior to the child’s arrival in hospital, so that they can be in attendance in resus when the child arrives. The patient should have peripheral intravenous access sited, and bloods for FBC, U&E, LFT, amylase, VBG and G+S. Check urinalysis for blood. Appropriate imaging should be discussed and organised following discussion / review by the surgical registrar.  Consider other injuries and discuss with appropriate teams.

Possible Adhesional Intestinal obstruction

If a child has had a previous intra-abdominal operation and they present with bilious vomiting and abdominal distension, it is likely that they have adhesional bowel obstruction (caused by the strands of scar tissue in the abdomen kinking or obstructing the bowel).  Adhesional intestinal obstruction can occur without prior intra-abdominal surgery.  Most will require admission for observation with around half of children ultimately coming to surgery.  Establishing good management early will make the child feel better and optimise the chance of conservative resolution.

• Inform the surgical registrar.
• Pass an appropriately large NG tube and place it on free drainage (measure the initial aspirate) to decompress (if PEG in situ – this should be decompressed) and ask the nurses to aspirate it every 2-4 hours. Leave nil by mouth (NBM) - essential medication will need to be converted to IV.
• IV fluids = IV fluid maintenance as per RHC IV fluid policy + replace NG losses (0.9%NaCl + 10mmol KCl). IV 0.9% NaCl fluid boluses titrated against response if indicated (an initial 10ml/kg is usually required)
• Abdominal x-ray - this seldom leads to immediate surgery but helps to confirm diagnosis, ensure adequate position and efficacy of NGT and can be used to assess change over the period of observation.
• The presence of abdominal tenderness or a tachycardia/ acidosis which does not respond to appropriate fluid resuscitation is concerning as it may indicate intestinal ischaemia, mandating urgent surgical intervention

Post-operative wound problems

May or may not require admission. Assess - if evidence of infection treat with antibiotics. Collections may require drainage. Arrange for surgical review as required.

Post – operative surgical presentation

Should be seen by operating specialist team.  If clinically unstable then initial stabilisation will be by the ED team in discussion with the operating specialist team.

Lacerations

Lacerations referred overnight with no significant associated injury and controlled bleeding can be asked to attend, fasted the following morning.  Lacerations with tissue loss, and those sited on the limbs (especially hands and feet) and face, will require discussion with orthopaedics and plastic surgery respectively.

Abscesses

If the patient is not septic, these can be reviewed in the morning. If an abscess is referred overnight and is clinically well, the child can be asked to attend, fasted the following morning (location for review to be arranged with the on-call surgical team).  Abscesses on limbs (especially hands and feet) will require discussion with Plastic Surgery or Orthopaedics.

Pilonidal or breast abscesses may require input from adult surgical services however the primary point of referral for this patient cohort from RHC ED will remain the on-call paediatric surgical registrar.

Head Injuries

Follow the RHC ED guideline. 

Pyloric Stenosis

Pyloric stenosis is the most common cause of intestinal obstruction in infancy. It occurs secondary to hypertrophy and hyperplasia of the muscular layers of the pylorus, causing a functional gastric outlet obstruction.  Incidence is 2-4 per 1000 live births, with peak age of presentation between 2 – 6 weeks of life.  Approximately 95% of cases are diagnosed in those aged 3-12 weeks. History is of forceful non-bilious vomiting (“projectile”) typically with specific pattern of progressively projectile vomiting.

If clinical concerns about possible pyloric stenosis, then ensure that the following management steps are followed:

• Obtain IV access and check a venous blood gas and FBC, U&E.
• Contact surgical registrar.
• Assess the fluid volume status of the patient. If there is evidence of hypovolaemia or if the blood results show the classical hypochloraemic hypokalaemic metabolic alkalosis of this condition, following adequate initial resuscitation as necessary, commence IV fluids as per hospital IV fluid guidance.
• Surgical admitting team may wish to alter IV fluid prescription following their clinical review and with results of blood tests for the patient. The surgical IV fluid prescription for these children is aimed at correcting the acid base imbalance.
• Place an NG tube and aspirate 2- 4 hourly. Replace losses using 0.9% NaCl + 10mmol KCl  per 500ml bag. In general avoid free drainage as siphoning may lead to excess losses.

History of Hirschsprungs’ Disease

Hirschsprung’s Disease is a relatively uncommon condition where the innervation of the distal colon is abnormal. This can affect a varying length of bowel which leads to a wide spectrum of disease and clinical presentation.  Almost all cases are prone to an aggressive form of gastroenteritis (Hirschsprung’s enterocolitis) and the risk of this persists, even following corrective surgery. The risk is higher in complex cases and those with associated anomalies or syndromes, such as Down syndrome.  Over time these episodes become less frequent and severe, but should always be considered when there is a history of Hirschsprung’s disease. 

All patients with PMHx of Hirschsprungs’ disease presenting with GI disturbance should be discussed with the surgical on-call team.

Children usually present with a subtle change in stooling (usually loose stools which can be offensive), distension and anorexia / vomiting - symptoms that in other children can be very safely managed at home.  However, in the fulminant form of Hirschsprung’s enterocolitis these benign symptoms/ signs can progress in a matter of hours to septic shock and collapse. At present we have no investigation to predict who will follow a benign vs. fulminant course.  Management is primarily with IV fluids, IV antibiotics and urgent bowel decompression, usually by rectal washouts. Prompt intervention on presentation may prevent rapid decline and speed recovery and discharge.

Management:

1. Contact the surgical registrar (some patients are well known and may have specific management plans)
2. IV access - check U&E, FBC, CRP. Start maintenance IV fluids with IV fluid bolus if indicated.
3. Following discussion, iv antibiotics should be started – usually cefotaxime and metronidazole (sometimes others are required if previous cultures have shown specific organisms e.g. Diff, VRE, ESBL etc.)
4. Nil by mouth until review
5. Consider
   • NGT on free drainage and 4 hourly aspirates
   • AXR
   • The surgical team may decide to do an urgent rectal examination to calibrate the anastomosis and release some gas/ stool to allow decompression, usually followed by a rectal washout.

Bleeding Circumcision

Around 1% of surgical circumcisions will bleed. The bleeding can be very significant and even life threatening. Bleeding rates from community circumcisions are unknown, but probably higher. Community circumcisions are primarily carried out for religious reasons in the Muslim community, often using a plastibell (the plastibell is a plastic ring which fits over the glans - a tie is then placed over this to stop bleeding and then the foreskin is cut away. Eventually the plastibell should fall off).

Assessment:

• It is important to assess the degree of blood loss.
• If there has been a significant bleed, or persistent ooze over a long period, an IV cannula should be sited and Hb checked (and a Group and Save sent at the same time)
• Oozing may respond to a pro-coagulant dressing (kaltostat, surgicel) and pressure. A good pressure dressing is called Snogg, it adheres to itself and wraps round the penis leaving the glans exposed (this is available in ED and theatres).
• Consider infection- a delayed bleed may be due to this.

After assessment likely outcomes are:

• No significant history with minimal ooze - dressing if required and discharge.
• Strong history but Hb OK and bleeding controlled with dressing – discharge. with dressing off at 24hrs if still in place.
• If significant bleed or ongoing ‘drip’ then take FBC & VBG – dressing & discuss with General Surgical registrar.
• Life threatening bleed - resuscitation +/- transfusion, urgent General Surgical registrar review, pressure dressing and plan for theatre.

Paraphimosis

This is where the foreskin is unable to return to its natural position having been retracted. The longer the foreskin is retracted, the more it swells up and the less the chance of a successful reduction. However, the vast majority can be put back with a simple technique:

• Give adequate analgesia+/- Entonox
• Warn the patient that it will be sore, before squeezing the oedematous fluid out of the foreskin. The best way to do this is by gripping the glans and foreskin with your left hand and squeezing for 3-4 minutes.
• Use your right thumb to push the glans down while pulling the foreskin up with your left hand (making a thumb into left fist type action).
• If unable to be reduced by the ED team then referral should be made to the General Surgical registrar.
• If fully reduced and the patient is passing urine, they can go home. If there is significant bruising or problems passing urine discuss with the surgical registrar for admission.

Acute Scrotum? Torsion

A presentation where a child has acute pain in the scrotum with tenderness. It is often associated with swelling and erythema.

The differential diagnosis is extensive but, with a few exceptions, making the diagnosis clinically or with simple investigations is not possible and the default position should be to surgically explore (medico legally it is difficult to defend missing a torsion). As the time limit for successful recovery of a torsion is <6 hours these should be referred to the surgical registrar immediately.

Patients with acute testicular problems will be seen in ED by Surgical team directly (can be called from triage) for primary review in:

• Boys with less than 24 hours history of testicle pain - in order that these can be expedited if theatre is required

ED team to conduct primary review in the following:

• Primary presenting symptom not testicular/scrotal e.g, respiratory symptoms.
• Over 24 hours of testicular pain
• Scrotal swelling without pain - more likely to be hydrocele or reducible hernia needing OP review

Other causes of scrotal swelling / pain:

• Acute hydroceles - develop suddenly and often at the time of an intercurrent illness. Have all the features of hydroceles and are not generally tender.
• Idiopathic scrotal oedema - an unusual condition with erythema and oedema of the scrotum and groin. A clinical diagnosis and again the testis itself is non tender.
• Hernias - still may well require admission and surgery
• Rare causes like HSP with the classical rash. Same vasculitis can affect the testis, often bilateral and usually not terribly tender.

Once diagnostic experience increases, you may become more comfortable assessing and considering some of the exceptions. However, the default position must always if any diagnostic uncertainty, then referral and assessment by surgical registrar should be considered.

Post OP hypospadias

The majority of hypospadias surgery is performed as a daycase procedure with the children being cared for at home by their parents with telephone advice from CNS Urology available during office hours. Many of the Children have a catheter inserted to drain their urine, this can be a urethral foley catheter, a suprapubic catheter or a dripping stent which empties directly into the nappy. The penis either has a dressing supporting it or is covered in glue. Some children have no catheter inserted and the wound is covered in dermabond. This dermabond lifts like a scab after 5 or 6 days to reveal the underlying repair.

Listed below are some common post operative problems with their management.

• Pain- a small amount of pain is to be expected after hypospadias surgery, but it should be improving and controlled with simple analgesics
• Bladder spasms- acute severe episodes of pain that are felt at the tip of the penis. They are managed routinely with prophylactic oxybutinin but are made worse by constipation which may need treatment with laxatives.
• Blocked catheter- with bypassing of urine around the tube. This can be treated with flushing of the stent with 5mls of 0.9% Saline. If the child has a dripping stent then a blunt needle can be attached to a syringe and inserted into the tube.
• The children who have had a complex reconstruction often have a supra pubic catheter placed just in case their urethral catheter gets blocked. This is left capped off but can be opened and drained if required.
• Concern regarding wound- After the dressing has been reviewed concern is expressed about how the wound looks. If the boy is passing urine well and the penis is looking better day by day no action is required.

Surgical or CNS urology review is required if the simple measures above are not improving the situation. Surgical review is definitely required where there is excessive pain, penile swelling, temperature and or urinary retention.

Red foreskin (balanitis)

A common complaint is a red painful foreskin that causes pain on urinating.

• Redness at the tip of the foreskin is secondary to chemical balanitis and no treatment is required other than increasing the child’s fluid intake.
• Swelling and redness extending to the shaft of the penis requires a 5 day course of oral co-amoxiclav with review by the primary care team, if these episodes occur frequently then they can refer the boy for consideration of a circumcision.
• Urgent surgical review of the boy is only required if the patient is in urinary retention or the eythema of the penis has extended proximal to the shaft of the penis.