Pediatric emergency medicine trisk 639

Hernias Goals of Treatment Umbilical and inguinal hernias can lead to bowel entrapment, incarceration, and ultimately necrosis The goal of treatment is to reduce the hernia prior to bowel ischemia or injury If clinicians are unable to reduce the hernia at the bedside, urgent surgical consultation is warranted in order to preserve bowel health FIGURE 96.40 Necrotizing enterocolitis A: Multiple loops of distended bowel have bubbly and linear radiolucencies in the bowel wall, representing pneumatosis intestinalis (arrows ) B: Another patient with linear pneumatosis of the wall of the intestines (arrows ) C: Another infant showing pneumatosis intestinalis and branching radiolucencies (arrowheads ) within the liver representing air within the portovenous system D: US of another infant with perforation following necrotizing enterocolitis shows free intraperitoneal fluid (F) containing echogenic debris and punctated areas of high echogenicity within the intestinal wall (arrows ), consistent with pneumatosis intestinalis E: Left lateral decubitus radiograph shows free intraperitoneal air (arrow ) indicating perforation in an infant with necrotizing enterocolitis (Reprinted with permission from Brant WE, Helms C Fundamentals of Diagnostic Radiology Philadelphia, PA: Lippincott Williams & Wilkins; 2012.) CLINICAL PEARLS AND PITFALLS Reduction of an incarcerated hernia may require sedation to facilitate adequate muscle relaxation; sedation in the neonate requires additional post-sedation monitoring Patients with abdominal wall defects, connective tissue disorders, or chronically increased intra-abdominal pressure (ascites, dialysis, ventriculoperitoneal shunting, etc.) are at increased risk for umbilical or inguinal hernias In females, inguinal hernias may contain the ovary and may present with labial swelling Inguinal Hernia Inguinal hernias result when abdominal contents pass through the inguinal canal The overall incidence is between 1% and 4% but can be as high as 30% in preterm infants Similarly, the rates of incarceration increase with decreasing gestational age Hernias often will present with an intermittent bulge in the groin, or swelling of the testes (boys) or labia (girls) that can be exacerbated during crying or Valsalva maneuvers While most inguinal hernias are painless, an incarcerated hernia will present with a bulge that does not reduce spontaneously and may be associated with irritability, pain, and/or vomiting The differential diagnosis of an inguinal mass includes hydrocele, testicular torsion, or lymphadenopathy Distinguishing between inguinal hernias and hydroceles may be difficult at this age, and transillumination of the scrotal sac may not be a reliable test In general, hydroceles rarely cause pain and typically not fully reduce In testicular torsion the testes is palpable and hard, and may or may not be tender on examination While most hernias, hydroceles, and torsions can be differentiated on examination, US can be a helpful adjuvant Given the high rate of incarceration, surgical repair is recommended once an inguinal hernia is identified, and can be done as an elective outpatient procedure If the hernia was difficult to reduce, surgical intervention should be performed more urgently and a hernia that cannot be reduced should undergo immediate surgical evaluation Noncommunicating hydroceles often resolve spontaneously, and given their more benign nature, can be observed as an outpatient Communicating hydroceles represent a patent tunica vaginalis and potential hernia and therefore are repaired electively Acute testicular torsion requires emergent surgical reduction to reestablish blood flow to the testis prior to the onset of necrosis (see Chapters 39 Inguinal Masses , 61 Pain: Scrotal , and 119 Genitourinary Emergencies ) Umbilical Hernia Umbilical hernias result when abdominal contents pass through an umbilical ring that has not fully closed after birth A common and frequently benign finding, umbilical hernias often spontaneously resolve without intervention Incarceration of herniated bowel is a rare but serious complication that requires urgent evaluation to preserve bowel integrity Trisomy disorders are often accompanied by laxity of abdominal wall and may be associated with umbilical hernias, as can hypothyroidism Surgical intervention is warranted if the hernia cannot be reduced and/or shows signs of obstruction or incarceration If the hernia persists into early childhood, outpatient surgical repair may be recommended Umbilical Cord Anomalies Goals of Treatment The goal of treatment is to recognize and describe normal umbilical cord care, and identify congenital cord anomalies, as well as acquired complications of the umbilical cord CLINICAL PEARLS AND PITFALLS Purulent or serosanguinous drainage from the umbilical stump may represent omphalitis, which can proceed to life-threatening necrotizing fasciitis if untreated Bleeding from the umbilicus can represent hemorrhagic disease of the newborn or vitamin K deficiency Prolonged cord separation beyond weeks can be a presenting sign of leukocyte adhesion deficiency Normal Appearance of the Umbilical Cord Remnant