Pediatric surgeon Willieford Moses, MD, offers help with identifying frequently seen conditions – from hernias to bowel obstructions to ovarian cysts – by their typical presentation in babies and children, along with guidance on which kids need imaging or a trip to the OR. Includes a look at nonoperative management of appendicitis and an update on COVID-related surgical concerns.
the impetus where this talk came from. The questions I had going through fellowship training, about the challenges you guys must face seeing these patients as they present to the outpatient setting in clinic, uh, and trying to decipher whether or not these are surgical issues that require urgent intervention and or something that just requires routine follow up. And so I wanted to focus this on, uh, some of the more urgent conditions and maybe some of the typical presentations of those patients, and then a brief discussion regarding what happens next after they come to the hospital. And so, without much to do, I have nothing to disclose in terms of personal financial disclosures. I will say, however, particularly as this is a lunchtime talk, Uh, in an effort to maintain patient privacy. I've elected to use some of my chickens as our patients to discuss today. Uh, and I apologize for those that may in fact, be eating chicken for dinner or for lunch. Rather, uh, and then, secondly, I'll also be using my dog who was a willing participant in this study, Uh, and our presentation, uh, and at no point where any chickens or pets and dogs, uh, injured or harmed during the process. Uh, this is my dog Blue, as she was helping to build our chicken coop a few years back. Uh, so by the end of this session, my hope is that everybody can describe the common outpatient presentations of some of the urgent to emergency surgical conditions that can present, uh, that we can at least have a brief discussion regarding the surgical procedures. As I think this will be helpful in describing it to families as they may have questions to you before being transferred to refer to other urgent care facility or the emergency department. And then also just briefly to touch upon the sort of emerging role of non operative management, particularly appendicitis. As that comes to the forefront of of our current, um, you know, care with respect to covid. And so, um, just briefly, uh, this was a study that came out in 2018. Uh, it was out of the hospital in Pennsylvania that was looking at the emergency room visits and referrals from urgent care centers, and they're trying to ascertain whether or not those referrals were essential or non essential. Um, obviously, emergency rooms are somewhat overburdened with respect to the amount of patients that are being referred in many cases for non emergent issues. Uh, and so they actually used a panel of five physicians who are blinded to the outcomes of the patients to sort of come up with parameters for what they deemed essential versus nonessential. Uh, you know, if they needed a cute labs or imaging studies to guide a potential intervention now and, of course, be considered essential. If it was a rash that could otherwise be triaged to an outpatient dermatologist, uh, then that would be considered non essential. And so when they looked at their 450 or so patients over a two year period, interestingly, the most common chief complaints that they saw as essential for referral, uh, were those that were coming with either, uh, extremity, injury and or abdominal pain. Also interesting, though, is for the non essential referrals. The top reason was also for abdominal pain. So it's very difficult, frankly, to deduce whether or not this abdominal pain is considered an essential referral or a non essential referral. And frankly, when they actually came to look at the primary discharge, diagnosis, gastroenteritis and non surgical abdominal pain were essentially at the top of the list. Uh, and so it's very reasonable in almost all circumstances to send these patients to the emergency department. Uh, and I think that obviously it's a challenge, because in many instances it's not necessarily something that will lead to surgery. But I can certainly appreciate the challenges faced with, um, you know, outpatient providers and trying to figure that out. Uh, and so hopefully through this taco, at least you know, discuss those issues or conditions that lead to the operating room. So our first patient will be, uh, Penelope. Uh, she's a five year old girl she presents with worsening mid abdominal pain and discomfort. It lasted for about four days associated with nausea, vomiting, subjective fevers. This probably describes many patients that present, uh, you know, at this time of the year, uh, on exam, she has mild, diffuse abdominal pain, mainly in the mid abdomen, um, able to get laboratory studies. Uh, and they show Lucas psychosis of 15. That right there, I think, would be a main indication, particularly with this history of four days of abdominal pain to send them to the emergency department. Um, in most instances, the first step would be to get an ultrasound, which commonly and unfortunately will say that it was non visualized. And I know often when providers get these ultrasounds done as an outpatient on an urgent care setting, uh, you know, it's very typical to get a study that's inconclusive. And I think in that instance, referring to our hospital, uh, would be the next step. Uh, and in many times we'll just repeat the ultrasound, and it can come down to simply the technician who more commonly routinely is doing ultrasounds and Children is able to visualize the appendix. Uh, and it's, uh, more meaningful and insightful for us to know if they can't visualize the appendix, whether there's other inflammatory changes to suggest the need for C T skin. So in this case, if you will, the appendix was not visualized, and there was no fluid in the pelvis. Uh, and both ovaries were also checked and they were normal. And so if I saw this patient, my next step would be either CT scan or an MRI. And lo and behold on CT skin, you can see There's mild inflammation in the mid abdomen around what appears to be potentially a loop of bow. Not necessarily the appendix, which you'd expect in the right lower quadrant. Uh and so this is almost a classic history for metals diverticulitis. Uh, you know, many people very familiar with Merkel's diverticular as it can lead to bleeding. But there can also be an inflammatory process that almost mimics to the T um, you know, acute appendicitis. And so, as a review, Michel's diverticular, um, is an out patching in the intestinal wall, if you will. It's a remnant of them fell, um, esoteric duct or the vital induct, and it fails to obliterate, leaving a small little out patching along the intestines. What we call them miracles. Diverticular. It's on the anti mesen Terek side of the bowel wall, commonly a lead to either alterations and GI bleeds or no symptoms at all. Uh, it can be, incidentally, found at the time of an operation for another reason which point the surgeons always left with questioning if they should do something about it, and that sort of beyond the scope of this talk. But I'll say in most instances, uh, pediatric surgeons given at that point, a young child is going to have their entire life ahead of them will intervene as opposed to If you're doing an appendectomy on a 70 year old and, incidentally, find a Michel's diverticular, you probably aren't going to do anything, but their main presentations will end up being painless. Rectal bleeding, possibly hemorrhage. Uh, and uh, if we're unable to identify the source or it's not clear by imaging, a medical scan would be the next step. Very rarely, I found, uh, colonoscopies and or e g g s to be able to identify the medicals diverticular because that's in the small bowel, but they can exclude other potential causes. So when these patients present, they typically get a full work up. Uh, and the surgical intervention is a metals diverticular, and that can be done via tangential resection, which is essentially a staple line going across the anti Mesen Terek segment of the bow or a full on wedge resection and anastomosis. Important for us in terms of our postoperative management, probably not as important in the outpatient setting when they follow up with you in clinic, but nevertheless, these Children will have an actual operation with the Bauer section, and so they do need to be monitored for postoperative complications. Our next patient is Matilda. This is actually a Plymouth Rock. It's hard to tell when they're this small, but she actually grew into a very beautiful chicken. But when she was eight weeks old, she presented with her mother to clinic with progressively worsening feeding intolerance. Again, a very classic story that I'm sure is, uh, presenting to the outpatient setting all the time. Uh, the keys that I look for on history, our progressive course in which it started with small volume MSs or spit ups in over a short time period, or sometimes a protracted 2 to 3 week period. Uh, it progresses, and very commonly, we'll get the clinical history of a patient that was transitioned to different feeds in an attempt to evaluate whether or not, uh, this was a dietary allergy or otherwise. I can't fault the provider in that regard, given how common those are and how infrequent pylori stenosis would be. Uh, but projectile MSs, the classic sort of findings are certainly something that should motivate a transfer to the emergency Department for an ultrasound. Um, you know, identifying a olive on exam and a fussy baby is a very difficult thing to do. I know because I've done it on a very calm, intubated baby numerous times. And even in those settings, with the abdomen fully relaxed, it's still difficult to pick up the subtleties of the quote unquote palpable olive that you can appreciate in the epic gastric area. Uh, so the absence of it does not exclude pylori stenosis, and the best way to determine that is by ultrasound. Uh, so it typically occurs between babies 3 to 6 weeks old. We just had a baby that was two weeks old to turn baby two weeks old with pylori stenosis. There's a male to female predominance of 5 to 1. It can often be confused with a picture of curd. Um, you know, very rarely is there a downstream obstruction, but Guatemala trees or a proximal G I obstruction, particularly a Web can also, um, you know, the, uh, you know, on the differential for dilation of the tests of the stomach rather and poor feeding tolerance, the laboratory studies that we pay particularly close attention to are the potassium chlorate and bicarb, indicative of a baby that's been vomiting and having significant emphasis. And so by ultrasound, what we're looking for and you can see the measurements here on the right side. But by ultrasound, we're looking for the channel length and the channel thickness. Uh, and so you can see this hash mark of one going to the other side is the channel length, this being the pie Loris itself in the background, you see the liver, Uh, and then the thickness would be this number two measurement, uh, and so typically greater than 14 to 16 millimeters in length, which is the first measurement, uh, and 3 to 4 millimeters in thickness. The second measurement is what we look for as indicative of classic diagnosis. And just for the sake of understanding our anatomy here, if you can appreciate, this would be the stomach. And then this being the pilot channel, So what do we do? These Children will get admitted. Uh, you know, the most important thing is a volume resuscitation component to their early management as they can come in severely dehydrated, in some cases going to the NICU. Uh, the classic laboratory derangement being hypoglycemia, HIPAA, Chlorine, Mia and then a metabolic al galoshes again from all the throwing up and then a paradoxical Assyria as they're trying to essentially hold on to your in, uh, even though they're in the setting of Metabolic Al Colossus. Uh, and so we'll admit them with multiple. Boulis is starting an emergency department again, occasionally going to the NICU. And then we'll put them on D five half normal saline at 15 maintenance and eventually, once they're peeing. And that's in fact confirmed. And we'll add potassium. And we repeat the laboratory studies until there's a clear improvement in the metabolic arrangement, which we as a general standard. Um, you know, defined as a bicarb of less than 30 no longer al Kalanick in a chloride greater than 100 meaning you've adequately volume resuscitated them. It's been shown when a bicarb is still greater than 30 that you can have peri operative complications related to prolonged anesthesia and, uh, inability to excavate the child immediately. And so it's certainly one of the reasons to make sure that arrangements have been corrected. We treat it laparoscopically as seen on the right side, this being Excuse me a picture of what we find in the operating room. On the left, you can see we score that anti Mesen Terek side of the pillars. Uh, and then on the right side, you can see there's a small little spreader that we essentially used to open up and complete our my ah, to me, exposing the bulging mucosa underneath beneath very rarely about one in maybe 100 to 200 cases. There can be a perforation here. Um, you know, it's it's not a significant problem. Essentially, what we'll do is close that hole now and close the overlying bow that we are my, ah, to me that we just opened up. And then we'll repeat this process on the other side, the contra lateral side. Essentially, um, and so this does happen relatively infrequently, but those patients generally still do fine. If it's identified at the time of the operation, their postoperative course, uh, feed right away. Very rarely is there any issue with respect to this, but commonly these Children will still have a degree of postoperative nemesis, which we typically relate to. The fact that their stomach has been so distended like a floppy balloon essentially at this point, and it's not used to contracting and moving the fluid in the appropriate direction. And so kids can have a little GI upset, particularly if they've had a degree of reflux as well. It can still be some of that immediately post operatively uh, none of which has been shown to be indicative of failed intervention. So the likelihood that there was an incomplete my ah, to me is extremely, extremely low, even though there's still a degree of feeding intolerance that can occur and persist for typically 12 to 24 hours. And so we start feeding immediately after surgery, and we give them a few, uh, progressively increased volumes of feed, starting with 15 ml and then going to 30 MLS and 60 MLS. And if they're able to tolerate a couple, um, you know, policies of 60 MLS, then we send them home. Uh, typically, most surgeons will say that they should be on a restricted volume, but increased frequency of feeds afterwards. Uh, so doing two ounces every 2 to 3 hours, as opposed to going up to, say, 100 and 20 ounces every three or four hours. And that's typically so that you don't over distended stomach. But nevertheless, the mainstay is to feed right away and hopefully get them out of the hospital as soon as possible. Our next patient is Batgirl. Uh, we named her that because she kind of looked like a bat with her black and white coat. Uh, this was a black laced white and gold or silver lace. They called it, but this was a 10 year old who presented with abdominal pain and emphasis. Uh, he showed up in clinic, uh, and this was an actual patient that I had seen eventually in the operating room. But he had one month of intermittent abdominal pain. Uh, and that had progressed in 24 hours with no bowel movement in some nausea. Uh, interestingly, a couple weeks prior, he had been seen in clinic and was actually admitted to the hospital with gastroenteritis and after rehydration discharged home. Uh, but nevertheless, this pain persisted his past medical history unremarkable, uh, somewhat anxious kid with non distended abdomen. But tenderness too deep, Al patient with a mild glucose psychosis. So this history of now a month long of symptoms and in fact now progressing towards obstruction. I think it's very reasonable to send him to the emergency department because he needs a C t skin. I wouldn't feel confident discharging him from our emergency department without a full assessment of his about, uh and so interestingly, after he got a C T scan, what you can see here is this thickened loop in the central abdomen. Uh, and, um, looking closely and particularly on the axial images, you can see that there is what appears to be a target sign, uh, which is, you know, multiple loops of bowel essentially intercepted on one another. Uh, and so you see concentric circles of the bowel wall, uh, in this location that would be consistent with small about a small bowel intussusception. And we typically take that to the operator as opposed to the classic locations and a young child and 1 to 2 year old baby who comes in with Elia Colic in a secession from Mesoamerica, vaginitis or flu. Uh, when you have an older child in this case a young boy and it's small about a small bell, you certainly need to assess whether or not there's a pathologic lead point and in particular he had already shown signs of a bowel obstruction. Uh, and so regardless of the potential underlying ideology, they go to the operating room. Unfortunately, this occurred in the early portion of spring 2020 which happens to be, uh, the sort of, um I guess dark period for understanding of covid. Uh, it's dramatically changed in terms of how we manage the operating room setting, but at that point, we were still putting on everything and praying, Uh, and we have very little understanding as to the full extent of the things we needed to do. And so, as a result, we did essentially everything which meant, as you can see here, I had an n 95 mask on. Uh, I don't have goggles here, but typically where Goggles as well put on a paper. Uh, you know, we would all go into the operating room essentially holding our breath, not knowing what, uh, you know, we are potentially exposing ourselves to a lot of that obviously has changed. But in the operating room, what we found after identifying this loop of balance, reducing the interception was this large mass here largest relative. But it was probably about three centimeters or so, uh, and ultimately was found out Burkett's lymphoma. Uh, and so he, uh, ended up on chemotherapy has been doing well, but nevertheless, pathologic lead point is a very classic finding in essentially anybody within a secession over the age of two years old. So epidemiology. It's a frequent cause of bowel obstruction. Embassy. Slight male predominance. It's most typically between before two years old. 80%. Uh, the path of physiology. Is there something that obstructs the normal peristaltic movement of the bow? Whether that's an enlarged lymph node or medicals diverticular, um, or in this case, uh, aluminum ass, Uh, and that then serves as the point that telescopes into the other Val, uh, classic triad of the college, uh, colic type pain with vomiting and current jelly stools, uh, can be seen, but it's not certainly going to be, you know, 100% there's gonna be many different forms of presentation. I would say the most common is just simply someone with intermittent abdominal pain of a colicky nature, uh, without vomiting and without current jelly stools. And in fact, the majority of these young Children will be managed without surgery. uh, so that being said, the most common lead points when we look beyond just Mesoamerica vaginitis and a two year old, uh, is looking for miracles diverticular, um, the potential for lymphoma, not just Burkett's, but all comers. There are vascular anomalies, and then also there can be infectious causes, for example, leading to the Mesoamerica tendonitis, which, while still, you know, we don't necessarily know going into the operating room. Uh, certainly, in the absence of finding some thickened mass or explanation is what we typically will conclude. What's the problem? So illegal colic and deception. The most common location, thought to be secondary to Mesoamerica tonight is in the terminal ilium leading to the telescope in of the bow, You can see, as it essentially squeezes in on itself that as inflammation sets in the bowel, Lumen decreases in size, and ultimately you can end up with an obstruction. It's being our target science seen on ultrasound and then also on CT scan. Here, uh, these patients will be admitted, Uh, typically, um or at least, um, you know, plan for admission depending on the results from radiology. But if they're stable, we can try to Matic or hydrostatic reduction, which can happen in the emergency room in each hospital has a different sort of protocol as to whether or not they need to be observed afterwards if they're successful in reduction or if they need to potentially be admitted. But if there's any concerns regarding either prepared tonight is an exam or, in fact, that the child is unstable. We just go straight to the operating room. Uh, I'd say this is a rare but still, um you know, um, you know, common enough issue that we're prepared to take them to the operating room, which is why, in most instances, regardless of whether or not the plan is for a pneumatic or hydrostatic reduction, the surgery team will be consulted to assess the child to make sure they don't need to go straight to the O. R. Different types of ways to try to reduce it by the radiologist. Uh, you know, in this case would be a pneumatic attempt in which Foley catheters instilled with air into the pelvis. Excuse me into the rectum, the balloon inflated to essentially block that air from coming out of the rectum. Uh, and then they'll just continue under direct Flora Skopje Monitor that air progression through the bowel. You can see here as they start the enema. Essentially, you can see the area in the right upper. Uh, actually, on the left upper quadrant of his pictures, Uh, intussusception. And then as it gets pushed down, down, and then essentially pops as that. Let me be particular. In my Frasier, it doesn't pop as in the bowel, but the actual intussusception pops back into place. Uh, and so that's what we consider a successful reduction. And this can be done with water and or barium contrast. So you can see a similar process as that barium, retrograde feels the colon, and then it gets to the point of in a reception and then, with increased application of pressure, you see that entirely reduced if it's unsuccessful or if it Rikers multiple times. Despite initial success with the non operative reduction, we go to the operating room. This can be done laparoscopically sometimes makes it difficult to identify. The lead point is if you can't actually palpate yourself. But nevertheless, in a common indication, being a one or two year old child with Elio Colic, um, in a secession. Typically, it can be reduced without further assessment of the bow, because the most common reason again, the Mesoamerica vaginitis, uh, moving on. So 13 year old presents with lower abdominal pain will call her old E. Uh, right. Lower quadrant cramp e. She's had it, um, with associated nausea and vomiting. Her last period was about a month ago. Six months back, she informs you that she had an ultrasound for also bad cramps, which showed she had a seven centimeter ovarian cyst. Uh, and as unfortunately come in the case, she was supposed to follow up with an adolescent gynecologist. But unfortunately, that hadn't happened yet. Uh, so certainly I think most people would be concerned about ovarian torsion. It's actually relatively infrequent, but nevertheless a concern enough that we take it very, very seriously with respect, the need for a potential emergent intervention to rule out the potential for tours in And, of course, compromise of that ovary on the differential can be, um, hemorrhagic cyst, corpus, little cyst, portable cyst. Um, you know as well as underlying, uh, tumors that can lead to essentially an enlarged cyst or master within the ovary. Um, for whatever reason. Um, you know, if there's an enlarged ovary after it hits about 4 to 5 centimeters, the risk of it twisting on itself starts going up nearly exponentially. Uh, and so in most instances, yeah, if it's found as a small incidental 34 centimetres cyst, we can watch that. But once it hits five centimeters because of that risk of twisting, will typically electively go in, uh, and do a cyst ectomy. So this seven centimetres cysts that was identified. I think it's very reasonable at that size to send a child to the emergency department or to give our access centre recall, uh, so that we can help sort of figure out how to expedite intervention to avoid the potential. Restrict concerns of lost to follow up or that gap in between. You know, their outpatient referral and being seen, and then potentially, uh, horsing. In that time period, our work up typically, if there's major concern, goes straight to the operating room. It's always beneficial to try to get labs beforehand to ensure, particularly if this is an underlying tumor that led to the enlargement that we have tumor markers to follow once it's actually removed but nevertheless, getting him to the O. R as soon as possible is is our main street. And so, uh, algorithm is relatively straightforward. This is what I teach the residents and our medical students. If there's abdominal pain and an enlarged ovary, we're going to the operating room. Um, you know, uh, there are nuances, if you will, with respect to do an ultrasound, which can be reassuring, but not 100% that there's flow to the ovary. Uh, an m r. I is somewhat emerging as an option as well. But nevertheless, if there's a if there's severe abdominal pain and enlarged ovary, uh, you know, if it's greater than five centimeters, it needs to come out anyway. There's there's no benefit to delaying intervention in that setting. Um and so, uh, you know this unfortunate scenario in which a three month old who's an ex primi was still in the NICU, uh, and had what was thought to be a label abscess that didn't resolve on antibiotics, got an ultrasound and, unfortunately, had a torched ovary. It's actually relatively uncommon for, you know, inguinal hernias when they're when they're containing the ovary to actually Toros, uh, so in most instances it doesn't necessarily need to be done. Emergent Lee. But you know, if there's era theme if there is redness, if there's a question about something regarding pain or tenderness and there's ovary that's stuck in an inguinal canal, uh, we should see that patient in the emergency department to avoid that potential complication. All right, So next Chuck, the local rooster, uh, is a three year old boy presented to their urgent care clinic, complaining of a mildly tender bulbs for one day on the right groin. I'm sure you guys probably see this on a near weekly, if not more frequent basis. Uh, had a bowel movement this morning. Breakfast at 7 a.m. On further history was three weeks premature. No other medical issues. He appears mildly fuzzy, his abdomen soft, though non distended, uh, and certainly has a bulge in his right groin and mildly tender, so certainly consistent with an inguinal hernia. It doesn't take much by a physical exam to identify it, uh, just to review briefly. So it's typically in infants and babies thought to be a failure of the closure of the processes Vaginal is, and so when it remains Peyton that can certainly allow for fluid to pass through a hydro steel communicating hydro steel. Uh, if it is relatively closed and there's fluid that's trapped distantly, then there can be a non communicating hydro seal. In some instances, that potential space can actually swell due to, for example, third spacing that happens during the cold season. So it's common for a child who had never had known inguinal hernia before. Uh, now Mom notices a bulge in his scrotum, while certainly the story is concerning for potentially, uh, an inguinal hernias. This is a new finding, uh, simply the fact that the kid had a viral infection and is now third spacing fluid, including into the potential space that was. This hydro seal is now leading to a bulge that's very difficult to determine on physical exam, though, um, if you're not used to examining this in that setting, and so transferring to the emergency department is certainly an appropriate step. An ultrasound can very easily distinguish non communicating hydro steel from a loop of bowel that is hibernating down into the scrotum. Uh, and so, um, the management, I won't. I won't spend too much time on this because I think most people are familiar. But essentially, if it's incarcerated, it cannot be reduced. Um, you know, send them to the emergency department. There are tricks that we can do, uh, and simply just, uh you know, having the backup of the O. R can often, uh, precipitate people pushing a little harder than maybe you would and clinic. It's very understandable to, um, you know, have a very frustrated baby that's bearing down and crying and be unable to reduce it. Uh, so it's relatively common for these Children to come to our e. D with incarcerated hernia and after, uh, even, uh, you know, sweeties or a pacifier and turning the lights down, we're able to reduce it. And then the next question becomes when to operate, which is often a little nuance, depending upon how close the patient lives to the hospital, what sort of follow up we'd be able to provide for them, the risk of them incarcerated again and nobody being able to reduce it. Uh, and so, uh, typically we we do take them to the operating room. The timing again is a little sort of nuanced as well depending upon if they're a premature baby, Uh, for an elective surgery because of the risk of a zombies with anesthesia. If they're still young under typically 50 to 54 weeks, uh, corrected gestational age. But nevertheless, uh, you know, going to the O. R. Is a mainstay for an inguinal hernia. The question is just timing and the degree of urgency, I will say, as some people may question when you get the operative report. Uh, when there's a hernia on one side, there's about a 30% risk of the contra lateral side also having a hernia. That risk goes down as the Children get older, but nevertheless, if they are, you know, if hernias identified as a premature baby as a three month old as a six month old, most surgeons will place a small camera through the opening that's made in the groin for repair of that side hernia to take a look with that camera on the contra lateral side. And if there's a hernia on the on that side as well, we repair that at that same time, so that under the same anesthesia, you can hopefully prevent that other side from becoming problematic in the future again. Most commonly, though, we'll take a look and there's no hernia on the other side. And then we just proceed with our repair as previously planned. Uh, in terms of techniques, uh, you know, turning the lights down low is what I always remind myself trying to get that baby as comfortable and calm as possible. Uh, And then, as you can see on the right side, if you just sort of push down on this bulge, you're not really going to get anywhere. If you can recreate the internal and external ring essentially the inguinal canal, you can facilitate it going back in. And so what does this look like? Well, fortunately, Google provided me with a nice image for everybody. Uh, and so what you see here is essentially the left hand, and this is exactly how I do it. The left hand applies a little pressure over the inguinal canal. Uh, and then I try to direct my index finger and my thumb right over what I assume to be the external ring. And so as I try to slowly milk this bow back with my right hand, essentially as opposed to just jamming the whole thing forward, which essentially would create what we saw in that first picture on the left side, this side here, um, instead trying to do what the right side did, which is re create a tunnel to help facilitate this ball going in. I can't say it works all the time. We certainly end up going to the operating room occasionally for an incarcerated and or strangulated hernia. But for the most part, these can be reduced if given, you know, appropriate time. Um, if the lights are turned down, if the baby is calm and relaxed, uh, and appropriate technique is done to the so Billy presents its a nine month old, she comes in with bilious emphasis. Uh, and so I think everybody is familiar with bilious emphasis being a stop. Do not pass. Go scenario. Um, you know, interestingly, many of our residents don't come in with that understanding. I didn't have it as a general surgery resident. Not until, uh, you know, rotating on pediatric surgery. Uh, did I appreciate, uh, both the rationale And then also the ramifications of missing, uh, you know, a child with bilious emphasis and the potential underlying pathology. Uh, certainly bile can take the form of many different colours. Uh, you know, it's very difficult to distinguish, you know, as soon as anybody mentions yellow, I start thinking about so unless it looks essentially like milk and or clear gastric fluid, Uh, it's violent till proven otherwise. Uh, you know, what if Billy was 14 years old? Well, obviously the color spectrum goes up. But nevertheless, unless it's clear even a 14 year old can have, um, you know, Mitvol villus related to undie or not previously diagnosed mall rotation. Uh, and I've seen that before, and it ends up with something like this in the operating room, which is, uh, intestinal rotation anomaly. The child went through life without issue, Uh, and then, for whatever reason, valve realized at some point. Most commonly, this happens within the first year of life, second year of life. But unfortunately, uh, these Children can present older, and there's often a delay because most people don't assume a 14 year old with bilious emphasis is in fact, mitt valueless as it's classically uh, early. Um, you know, infant or in the neo neonatal period, but nevertheless, they can essentially happen at any point in life. So how do we treat this when they come to the emergency department? And there's concerns. The most prudent thing is to determine if they need to go to the operating room. And if they're stable, Uh, and they don't require emergency intervention for what appears to be a compromised abdominal exam. We start with doing an upper GI series. And so the things that we look for on an upper GI are essentially four things. One that that contrast goes from the stomach and crosses midline from left to right, indicative of the normal trajectory of the stomach and pie. Loris that you see a sea sweep of the duodenum. Uh, and so you see the bow sweeping back over in the shape of a C Essentially, uh, And then you see, uh, the DJ Junction So that Guadagno Digital Junction as the quantum transitions to the June Um uh, that it happens essentially the level of the pie, Loris. And this may be a slightly lower, but nevertheless that there's a C suite that comes all the way back up. And then somewhere around here, it turns into the duodenum, as opposed to maybe not so clear sea, and then the loops just start spiraling down. And then the last thing is that the Dwan impasses posterior early. So the majority of the Dwan, um, is a retro peritoneal structure. So even though it starts at the stomach, which is clearly intra peritoneal when they turned the baby into a lateral position, which you can identify by the spine being on the right side here you see that the contrast goes from stomach, and then it goes posterior towards the spine, that telling you that there's a normal transition and trajectory of the duodenum. So all of these things make the likelihood of mall rotation extremely low. And that's if they don't have mall rotation. The likelihood of a mid gut vulva list drops to I won't say zero but close to it now. There could be a segmental valueless. There's other reasons for bowel obstruction, and there's certainly other complications or problems. But everybody can breathe a sigh of relief once they see this on an upper GI. Because even though there's maybe downstream obstructions still, uh, you know, we were, fortunately unlikely. Be dealing with middle of Oculus. I won't go into the operation. I think most people are familiar with the concept of a Ladd's procedure to try to correct that. If there's not compromised bowel, hopefully you don't need to respect anything. So, Chuck, the rooster his back is now 12 year old referred to the E d for abdominal pain. Um, you know, uh, ignore the fact that my dog's name is actually blue old collar Chuck for now, uh, and call her a him So woke up at 1 a.m. and had severe pain. It was peri umbilical. It migrated to the right lower quadrant associated nausea, no vomiting. Uh, there's no fever. Diarrhea had a bowel movement yesterday. This is a classic story for appendicitis. Uh, we get an ultrasound and white blood cell count If there's Lucas psychosis. If they can't compress the appendix. If there's inflammation at the tip surrounding inflammation or fluid, these are all classic findings. This is seen probably one or two times a day here at our hospital. Feel free to refer them to us. We know how to manage appendicitis. That being said as, um, we've appreciated the management options have evolved somewhat and particularly in the setting of covid. It's changed, but the main ST typically is an appendicitis is going to get a lab risk. OPIC Appendectomy three Incision operation If it's just acute appendicitis for simple appendicitis, they can potentially go home the same day. Um, you know, particularly it's done early in the day and their pain is well controlled, Which for me means that they're on Tylenol and ibuprofen. Uh, then we send them home in outpatient follow up. Some people will give oxycodone briefly, but certainly we don't want them going home on multiple doses. Uh, and a full bottle of narcotics, We have them follow up, which can be done by zoom and or in clinic. Now, the question, though, is what if Chuck had covid. Uh And so, uh, you know, this is something that we see with increasing frequency right now, whether or not they're asymptomatic or they're having mild respiratory symptoms or florid covid. Uh, they nevertheless can still have appendicitis. And and we've had the spectrum of these stations present of which, over time, as there's been more and more known about covid, there's been an increased appreciation that potentially we can manage them conservatively. uh, and avoid the risk vote to the patient of undergoing a procedure in the setting of a potential respiratory infection and also the risk to the providers. And so this was a study that came out of Colombia. They actually looked at the, uh, appendicitis patients that came in between March and May of 2020 and they compared it to March and May of 2019. So to try to deduce whether or not they are now seeing edition a different patient population in the midst of the pandemic. What they found was that there is an increase in symptom duration from two days to one. That's actually pretty significant. So the majority of the patients, on average, came in now a day later. And that was likely because of hesitation to go to the hospital in the midst of a pandemic and or, uh, increased awareness of potentially, you know, they're at home, they can be monitored at home. Maybe they don't need to go. And maybe this is gastroenteritis. So patients were presenting later, which meant there was an increased rate of perforation, an increased rate of abscess formation. But interestingly, there is also an increased rate of those patients that they chose to manage non operatively, which previously so this is now a year before Covid struck was 7% and it had gone up to 25%. And so what is non operative management? I think everybody, Hopefully it's somewhat familiar with this because we've done this with increasing frequency over the years. But as was initially characterized in, uh, in veterans and our service workers who were, um, on submarines who can't undergo general anesthesia, Uh, you know, there is data that came out that appendicitis can be managed with antibiotics alone. They obviously can't just emerge from their submarine and be flown to, uh, an operating room. And, in fact, they would remain on the submarine and be treated with antibiotics. And so those early studies demonstrated that it can be done. And so over time, there's been a slow transition towards managing at least some patients with, uh, interest antibiotics alone and then a question later on as to whether or not the Bendix in fact needs to be removed. But as of this study in 2014 and the scales are off, so I'll just make sure that's pointed out here. Still, the overwhelming majority near 90 92% are being managed with an operation. But you can see this subtle increase over time. Of those being managed non operatively to about 4% in 2014 again from the Columbia study, they suggested that it was as high as UM, 7% and the year prior to Covid and again gone up to 20% 25% since covid began. So there's certainly a little bit of a balancing act with respect to the risks and the benefits of managing non operative, irrespective of covid one. From the non operative standpoint, you can convert them to an elective operation and the possibility of them not needing an appendectomy, depending on some of the characteristics of their initial presentation. In the operative camp, though, it decreases the risk of recurrence. You know, if the appendix is gone, it's not going to come back when they're on their family vacation in Timbuktu. Uh, it also means that there's not gonna be a treatment failure. Obviously, there's risks of an operation itself, but they don't need to stay in the hospital monitored to make sure they're doing okay. They don't need to take the next week off from school so that their parents can stare at them. Uh, and they're potentially going to get better immediately and go home. Like I mentioned the same day. If it's straightforward. So these things are also, um, you know, certainly compounded by return to any visits, the potential need for additional X rays. Are they going to, in fact, take their antibiotics? We all know that fragile is not well tolerated. Are they gonna need ivy, home antibiotics and some institutions that's still done for non operative management. And then what about the anxiety? Both the patient and the family. Um, but again, operations are not, you know, a chip shot. Necessarily. Even though it is relatively straightforward, there are complications, and particularly with anesthetic care in the setting of covid, Uh, those are real things to, you know, slowly be quantified as we learn more about it. Uh, and so, um, uh, the question as to whether or not non operative management works well, it's well characterized. It's been characterized in adults. The question being who actually is going to potentially fail and need an operation and what percentage what do we tell the patients? So this was an adult study? Is looking at five randomized controlled trials looking at antibiotics for appendectomy. Uh, they found that 8% of patients still ended up having an appendectomy within the first month from their initial presentations. So that means that 8% of people just aren't going to respond to antibiotics alone and ultimately need an operation when they looked at the remaining people. So the other 510 patients and they looked back over the course of the following 11 months, how many of those people required an appendectomy? That number was 22% for recurrent appendicitis. So set another way, uh, 60% or so, uh, 70 70% Rather still had their appendix. After one year, a similar study and kids was done, which essentially looked at, in this case, non randomized patients who had simple appendicitis, which they defined as no fecal. If no abscess. Appendix itself was less than 1.1 centimeters, and the surgeon had a discussion with the family regarding whether or not they want to try non operative management or an appendectomy. So there are nuances here, but Clearly, this is not randomized, but nevertheless, what they did was look at those patients in a similar fashion to the previous study. So they had 1000 patients 370 of whom elected to be non operative. We managed, uh, and so 75% of those patients had followed when I looked at the 370 15% had an appendectomy within the first month. So again, that's considered a treatment failure or excuse me within the index hospitalization. So considered treatment failure, meaning that for whatever reason, they didn't respond to antibiotics. Whether that was persistent fevers, abdominal pain, peel intolerance. But nevertheless, they ended up having an appendectomy. So removing that 15% if you were able to get out of the hospital and antibiotics alone, then we have the remaining group. And over the course of that year, 23% of those remaining non operative we manage patients ultimately developed recurrent appendicitis. So what does that mean? That means 62% of patients who are non operative we managed that one year follow up still have their appendix. Uh, so how do we counsel patients about this? Well, if you don't have a fecal if if there's no abscess, if it's a small appendix and were successful and non operative management, the risk of you having another episode is maybe one in five. For some people, that risk is so high that they want an interval appendectomy. For other people, that risk is so low that they say, Well, you know, we're not traveling anywhere. We live, you know, two blocks from the hospital. I think, Well, you know, just see how our child does and then they don't necessarily need an interval. Appendectomy. So what's the deal with the technical If well, we know that that is just back so we can see the picture essentially a stool ball that leads to the obstruction that increased Luminal pressure. The perforation is going to be much more common when there's a pickle, if present, but nevertheless, those don't just dissolve with antibiotics, and so they're at a higher risk for recurrence. Uh, and so this was a study looking at 96 patients that are non operative. We managed after they removed the 6% that had an initial treatment failure and gotten appendectomy, and then the 41 patients that elected to have a prophylactic interval appendectomies. So that's all comers where you discuss with the family and clinic. Oh, do you want to have an appendectomy? There's a 20% risk of it coming back. Parents said Yes, let's do it. So, uh, 41 of the patients in this 96 patients study had an appendectomy, Uh, for those patients that were the remaining 49 72% record with a fickle if only 23% without. So if there's a chocolate on the ultrasound, I'm telling the family that there is a high risk that this will come back. And as such, I would personally recommend an appendectomy. But it's still a discussion that happens so complicated. Appendicitis. We won't spend much time on it, but certainly many patients, because of delays, for one reason or another come in and therapeutics has essentially ruptured or exploded. Uh, those patients will often get an appendectomy when they follow up, uh, interval appendectomies. Some of the challenges are these patients get lost to follow up, meaning they either moved away or they lost insurance. Uh, they may end up in your office, and they may ask you what they're supposed to do. You can cite some of this data. Ultimately, if they asked for a need for surgery and it's unclear, just refer them back to us. We're happy to see these patients. There's no fecal if maybe they don't need it. If they're traveling, maybe they do. Uh, so appendicitis, Uh, in the time of covid, this will be, you know, one of my last few slides. Uh, so the management is still debated, whether or not we should intervene or treat them all non operatively, I can tell you, over the last few months we've shifted almost entirely to try and up front non operative management. It avoids the potential exposures to our staff to the hospital. Um, it's not clear if it necessarily prolongs the hospitalization, depending on how they presented, but certainly as soon as they're tolerating the diet and they're tolerating their antibiotics, we try to get them home, and then we have a follow up discussion regarding whether or not they need to have that appendix removed. It certainly poses anxiety to the family, but we found that most patients completely understand that when you have active covid, it may not be the best time to have what can be converted to an elective surgery if we just wait with antibiotics alone. So, in summary, intermittent cramping, abdominal pain that can be a metals or in a secession. Progressive feeding, intolerance and emphasis and a young baby pilot stenosis, abdominal pain and an enlarged ovary almost in all cases going straight to the operating room to rule out towards in question as to the role for MRI and ultrasound and maybe decreasing that risk. Bilious emphasis is still a surgical emergency, not saying they need surgery. But they need some assessment, which needs to happen in the emergency department as soon as possible. And then our non operative management for simple appendicitis has been well characterized even before. Covid and you guys should all expect to see more patients over time presenting to your clinic and follow up as they've been non operatively managed and a question regarding whether or not they're going to need their appendix removed. And so with that, I'm very happy to have joined a very large group of pediatric surgeons, both here in Oakland and also in San Francisco. Um, I think amongst the group of us. We cover essentially any and all pediatric surgical issue that can arise. Uh, and happy to take, uh, any referrals and also questions particularly, um, for those with concerns for the patient in front of you to feel free to reach out to our access center, whoever the surgeon is on call will be readily able to troubleshoot and maybe help you decide whether or not there needs to be a degree of urgency to them. Get into the emergency department for further evaluation. Uh, and so this is how to refer to the patients, and I'll just leave this slide up, and that'll be the conclusion of at least the talk for now.