- •Guide to Pediatric Urology and Surgery in Clinical Practice
- •Preface
- •Contributors
- •Key Points
- •1.1 Introduction
- •1.2 Risk Factors
- •1.3 Presentation
- •1.4 Diagnosis
- •1.5 Common Pathogens
- •1.6 Treatment
- •1.7 Imaging
- •1.8 Indications for Referral
- •Suggested Reading
- •Key Points
- •2.1 Introduction
- •2.2 Pathogenesis
- •2.3 Establishing the Diagnosis
- •2.4 Acute Management
- •2.5 Once the Diagnosis Is Established
- •2.6 Long Term Management
- •References
- •Key Points
- •3.1 Introduction
- •3.2 Aetiology
- •3.3 Pathogenesis and Risk Factors
- •3.4 Classification
- •3.5 Signs and Symptoms
- •3.6 Diagnosis
- •3.7 Imaging Studies
- •3.8 Ultrasound Scan (USG)
- •3.9 Voiding Cystourethrography (VCUG)
- •3.10 Dimercapto-Succinic Acid Scan (DMSA)
- •3.11 Treatment
- •3.12 Prophylaxis and Prevention
- •References
- •Key Points
- •4.1 Epidemiology
- •4.2 Presentation
- •4.3 Diagnosis and Workup
- •4.4 Management
- •4.5 Investigations after First UTI in a Child
- •4.6 Prevention of UTIs
- •4.7 Managing VUR and UTIs
- •References
- •Key Points
- •5.1 Introduction
- •5.2 Common Abnormalities of the Scrotum
- •5.4 Indications for Referral
- •Suggested Readings
- •Key Points
- •6.1 Introduction
- •6.2 Common Foreskin Conditions
- •6.3 Treatment of Conditions of the Foreskin
- •6.4 Indications for Referral
- •References
- •Key Points
- •7.1 Hypospadias
- •7.1.1 Introduction
- •7.1.2 Management Issues
- •7.1.3 Indications and Timing of Referral
- •7.1.4 Complications of Surgery
- •7.2 Epispadias
- •Key Points
- •7.2.1 Introduction
- •7.2.2 Management Issues
- •7.2.3 Surgery, Common complications, and Postoperative Issues
- •7.3 Concealed Penis
- •7.3.1 Introduction
- •7.3.2 Referral and Treatment
- •7.3.3 Complications
- •7.3.4 Benign Urethral Lesions in Boys
- •7.3.5 Treatment
- •7.3.6 Follow-Up After Treatment
- •Key Points
- •References
- •Key Points
- •8.1 Introduction
- •8.2 Common Conditions
- •8.3 Treatment of Undescended Testis
- •8.4 Indications for Referral
- •References
- •Key Points
- •9.1 Natural History of the Prepuce
- •9.2 Benefits of Circumcision
- •9.3 Absolute Indications for Circumcision
- •9.4 Relative Indications for Circumcision
- •9.5 Surgical Options
- •9.6 Contraindications to Circumcision
- •9.7 Complications of Circumcision
- •9.8 Conclusion
- •References
- •Key Points
- •10.1 Introduction
- •10.2 Labial Adhesions
- •10.3 Interlabial Masses
- •10.4 Paraurethral (Skene’s Duct) Cyst
- •10.5 Imperforate Hymen with Hydrocolpos
- •10.6 Prolapsed Ectopic Ureterocele
- •10.7 Urethral Prolapse
- •10.8 Urethral Polyp
- •10.10 Vaginal Discharge and Vaginal Bleeding
- •References
- •Key Points
- •11.1 Introduction
- •11.2 Functional LUTS
- •11.2.1 Overactive Bladder
- •11.2.2 Dysfunctional Voiding
- •11.2.3 Underactive Bladder
- •11.2.4 Uroflowmetry
- •11.2.5 Treatment
- •11.2.5.1 Standard Outpatient Urotherapy
- •11.2.5.2 The Failed Training
- •11.2.6 Giggle Incontinence, Incontinentia Risoria
- •References
- •Key Points
- •12.1 Introduction
- •12.1.1 Definition
- •12.1.2 Prevalence
- •12.1.3 Causes
- •12.1.4 Monosymptomatic Enuresis
- •12.1.4.1 Genetics
- •12.1.4.2 Sleep
- •12.1.4.3 Sleep-Disordered Breathing
- •12.1.4.4 Small Functional Bladder Capacity
- •12.1.4.5 Psychological/Behavioral
- •12.1.5 Nonmonosymptomatic (Organic) Enuresis
- •12.1.5.2 Polyuria
- •12.1.5.3 ADH Secretion
- •12.1.5.4 Food Sensitivity
- •12.2 Investigations
- •12.2.1 History
- •12.2.2 Physical Examination
- •12.2.3 Laboratory Tests
- •12.2.4 Imaging Studies
- •12.2.5 Evaluation of Functional Capacity
- •12.3 Conventional Treatment
- •12.3.1 Behavioral Therapy
- •12.3.2 Alarm Therapy
- •12.3.3 Pharmacologic Therapy
- •12.4 Alternative Treatment
- •12.5 Conclusion
- •12.5.1 Areas of Uncertainty
- •12.5.2 Guidelines
- •References
- •Key Points
- •13.1 Introduction
- •13.2 Definition of Constipation
- •13.3 Evaluation
- •13.4 Treatment of Constipation
- •13.5 Indications for Referral
- •Suggested Readings
- •Key Points
- •14.1 Hematuria
- •14.1.1 Important Points in the History
- •14.1.2 Causes of Hematuria
- •14.1.3 Investigations
- •14.1.4 Management
- •14.2 Proteinuria
- •14.2.1 Quantification of Proteinuria
- •14.2.2 Causes of Proteinuria
- •14.2.2.1 Non-Pathological Proteinuria
- •14.2.2.2 Orthostatic Proteinuria (Postural Proteinuria)
- •14.2.2.3 Pathological Proteinuria
- •14.2.3 Investigations
- •References
- •Key Points
- •15.1 Introduction
- •15.2 Indications for Referral
- •References
- •Key Points
- •16.1 Introduction
- •16.2 Treatment of Angular Dermoid
- •16.3 Indications for Referral
- •16.4.1 Introduction
- •Suggested Reading
- •Key Points
- •17.1 Introduction
- •17.2.1 Thryoglossal Duct Cyst
- •17.2.2 Midline Dermoid Cyst
- •17.2.3 Lymph Nodes
- •17.2.4 Thyroid Nodule
- •17.2.5 “Plunging” Ranula
- •17.2.6 Investigations
- •17.3 Treatment
- •17.3.1 Thryoglossal Duct Cyst
- •17.3.2 Midline Dermoid Cyst
- •17.3.3 Lymph Nodes
- •17.3.4 Plunging Ranula
- •Key Points
- •18.1 Introduction
- •18.2.1 Lymph Nodes
- •18.2.1.1 Infective
- •18.2.1.2 Inflammatory
- •18.2.1.3 Neoplastic
- •18.2.2.1 Investigations
- •Key Points
- •19.1 Introduction
- •19.2 Etiology and Types of Torticollis
- •19.3 Treatment of Torticollis
- •19.4 Indications for Referral
- •Suggested Readings
- •Key Points
- •20.1 Introduction
- •20.2 Common Umbilical Conditions
- •20.4 Indications for Referral
- •20.5 Epigastric Hernia
- •20.5.1 Introduction
- •References
- •Key Points
- •21.1 Introduction
- •21.2 Common Sources of Abdominal Pain
- •21.2.1 Children
- •21.2.2 Infants
- •21.3 Treatment of Conditions
- •21.4 Indications for Surgical Referral in Children with Abdominal Pain
- •References
- •Key Points
- •22.1 Introduction
- •22.2 History
- •22.3 Physical Examination
- •22.4 Laboratory Tests
- •22.5 Diagnostic Imaging
- •Suggested Readings
- •Key Points
- •23.1 Introduction
- •23.2 Investigations
- •23.3 Treatment
- •References
- •Key Points
- •24.1 General Principles
- •24.2 Neonates and Newborn
- •24.3 Infants and Young Toddlers
- •24.4 Older Children
- •24.5 Conclusion
- •References
- •Key Points
- •25.1 Introduction
- •25.3 Neonatal Intestinal Obstruction (Distal)
- •25.4 Childhood Intestinal Obstruction
- •References
- •26.1 Introduction
- •26.3 Initial Management
- •26.4 Causes of Neonatal Bilious Vomiting
- •Key Points
- •26.6 Necrotizing Enterocolitis
- •26.7 Duodenal Atresia
- •26.8 Small Bowel Atresia
- •26.9 Meconium Ileus
- •26.10 Hirschsprung’s Disease
- •26.11 Anorectal Malformations
- •26.12 Conclusion
- •References
- •Key Points
- •27.1 Introduction
- •27.2 Presentation
- •27.3 Investigations
- •27.4 Management
- •References
- •Key Points
- •28.1 Introduction
- •28.2 Presentation
- •28.3 Investigations
- •28.4 Management
- •28.5 Surgical Management
- •References
- •Key Points
- •29.1 Introduction
- •29.2 Types of Vascular Anomalies
- •29.3 Investigation of Vascular Anomalies
- •29.4 Treatment of Vascular Anomalies
- •29.5 Indications for Referral
- •Suggested Readings
- •Index
Chapter 26
Unique Considerations in the
Neonate and Infant: Bile-Stained
Vomiting in the Neonate
Robert T. Peters and Sean S. Marven
Key Points
››Bile in vomit or gastric aspirate is green.
››Any child with bilious vomiting/bile-stained aspirates should be referred to a pediatric surgeon urgently.
››Malrotation with midgut volvulus is a life-threatening emergency
26.1 Introduction
It is normal for babies in the first few months of life to bring up small amounts of milk during or following feeds (possetting).As long as they are otherwise well and continue to grow then nothing further need be done.
This chapter concerns bile-stained, i.e., green vomiting in the first month of life. Any neonate with bilious vomiting or bile-stained aspirates should be referred urgently to a pediatric surgeon to rule out an obstructive cause of the vomiting. Over one third of neonates admitted to a pediatric surgical unit with bilious vomiting may have a surgical cause.1 Bile enters the gut in the second part of the duodenum and obstruction at any point below this level can result in bilious
P.P. Godbole et al. (eds.), Guide to Pediatric Urology and |
239 |
Surgery in Clinical Practice, DOI: 10.1007/978-1-84996-366-4_26,
© Springer-Verlag London Limited 2011
240 R.T. Peters and S.S. Marven
FIGURE 26.1. Neonate with bilious aspirate.
vomiting. It is possible that yellow vomit/aspirate may be seen early in intestinal obstruction but it would normally become green. Obstruction proximal to the second part of the duodenum, e.g., esophageal atresia or pyloric atresia (rare) will therefore not cause bilious vomiting.
Amongst parents and healthcare professionals there is little agreement about the color of bile in the newborn. When shown four shades of yellow and four shades of green as part of a questionnaire study, 56% of parents, 25% of GPs and 10% of midwives did not choose any of the shades of green as a possible match for bile.2 It is therefore paramount when referred or seeing a neonate with reported vomiting that a clear history is taken from the parents or referring clinician about the actual color of the vomit/aspirate (Fig. 26.1).
26.2 Assessment of the Neonate
With Bilious Vomiting
Assessment of the neonate includes a detailed maternal, pregnancy and labor history with a search for clues that may
Chapter 26. Unique Considerations in the Neonate and Infant |
241 |
give the cause for the vomiting. Points from the history include:
History
Maternal |
Labor |
|||
• |
Medical conditions |
• |
Mode of delivery |
|
• |
Medications |
• Risk factors for sepsis |
||
• |
Family history |
• |
Condition at birth |
|
• |
Consanguinity |
• |
meconium-stained liquor |
|
Pregnancy |
• green liquor (fetal vomiting) |
|||
• |
Antenatal scans |
Early neonatal period |
||
|
– |
Timing |
• |
Vitamin K given? |
|
– |
Bright or dilated |
• |
Any feeds given/tolerated? |
|
|
Bowel |
|
|
|
|
|
• |
Delayed/failure to pass |
|
|
|
|
meconium |
|
|
|
• |
onset of vomiting/color |
|
|
|
|
|
The examination of the neonate includes an assessment of its general condition with a search for co-existing abnormalities and it may provide an estimate of the level of obstruction if present and a search for co-existing abnormalities:
Examination
Respiratory condition |
External appearance of |
Hydration/perfusion |
perineum/anus |
Jaundice |
Sacrum/spine normal? |
Dysmorphic features |
Hernia? |
Degree of abdominal distension |
|
Initial investigations will be guided by your assessment of the child so far and the clinical setting you are in. The
242 R.T. Peters and S.S. Marven
following should be considered but are by no means a prescriptive list nor exhaustive:
Investigations
Bedside |
Radiological |
• Urine dipstix |
• Supine plain abdominal |
|
x-ray |
•Capillary blood gas
•Bilirubin Laboratory
•Contrast studies (usually in tertiary pediatric centre
–Upper or lower GI contrast
• |
Full blood count |
– (Ultrasound) |
|
(¯ platelets NEC/sepsis) |
|
• |
Lactate |
|
|
( NEC/ischemia) |
|
• |
Biochemistry (note |
|
|
renal function is |
|
|
maternal in first 24 h) |
|
The purpose of the assessment is to determine the cause of the vomiting and guide initial management. The key features in neonatal bowel obstruction are:
1.Bile-stained vomiting
2.Abdominal distension
3.Failure to pass or delayed passage of meconium
The level of obstruction determines the degree of abdominal distension.A neonate with a high obstruction may have no or a small degree of abdominal distension. They may also pass meconium initially and are likely to have onset of vomiting early. Conversely, a neonate with more distal obstruction will usually not pass meconium and may tolerate feeds initially. Over the first 24 h of life the abdomen will become progressively distended and they will then begin to vomit. At birth there is no air in the gastrointestinal tract but in a normal child it can take as little as 6 h for swallowed air to reach the rectum.