PITFALLS IN THE DIAGNOSIS OF PEDIATRIC SURGICAL PROBLEMS
Dr. V. R. Ravi Kumar, M.S.M.Ch. *
Formerly Professor of Pediatric Surgery, Coimbatore Medical College Hospital, Coimbatore. *
The article below is the summary of various pediatric surgical conditions you see as pediatrician in your day to day practice where proper examination, proper investigations and initial management may go wrong leading to some fault in diagnosis and management. An attempt is made to give you some case summaries where proper diagnosis will lead to correct management.

The fault may be either in diagnosis, the choice of investigations or in the initial management.

A proper diagnosis is always made if the mind is tuned towards correlation of certain symptoms with the diagnosis. For example, some slogans taught in the under graduate curriculum, or to the pediatricians, and obstetricians regarding the Neonatal surgical conditions can tune in your mind to make a proper diagnosis.

The Slogans are:
  1. Green vomitus is a red signal of intestinal obstruction.
  2. Recurrent bilious vomiting: malrotation of gut; scaphoid abdomen is an ominous sign.
  3. Scaphoid abdomen with respiratory distress - Diaphragmatic hernia.
  4. Scaphoid abdomen with drooling of saliva - Esophageal atresia.
  5. Scaphoid abdomen with bilious vomiting - Duodenal atresia.
  6. Scaphoid abdomen with bilious vomiting and bleeding per rectum - Malrotation of gut with volvulus.
  7. Distended bladder, dribbling of urine, male child - Posterior urethral valve.

Case 1
A three-day-old infant was admitted with history of bilious vomiting, abdominal distension and bleeding per rectum. Child had grunting respiration and gas filled loops in the X-Ray of abdomen. A diagnosis of Necrotizing enterocolitis was made. Since the child deteriorated, an exploratory Laparotomy revealed that the child had malrotation of gut with volvulus with gangrene of mid gut. The diagnosis of malrotation was not suspected because the child had abdominal distension. 20% of malrotation with volvulus will have abdominal distension. An ultrasonogram and a Doppler study would have shown that there was reversal of blood flow in the superior mesenteric vein called whirlpool sign.

Case 2
A newborn child was referred to our hospital as the child had not passed meconium after birth. A note was sent that a catheter was passed for 10 cm and wash was given and there was no meconium. Child had pneumoperitoneum on X-Ray and laparotomy showed that the child had ileal atresia and there was a rectal tear above the peritoneal reflexion. The rectal tear had occurred because the catheter passed per rectum tore the anterior rectal wall. The rectum takes an acute angulation at the sacral promontory and a stiff catheter can injure the anterior rectal wall. Catheter should not be passed beyond one inch and if need be, wash can be given using a plastic syringe.

Case 3
A three-week-old infant was brought with conjugated hyperbilirubinemia but passing yellow coloured stool. Treated as neonatal hepatitis since the colour of the motion was yellow. Careful examination of the stool revealed that the core of the motion was white and the surface was yellow. Child had biliary atresia. All children with neonatal jaundice with clay coloured stool should be diagnosed as biliary atresia. Early surgery gives better results.

Case 4
A two-month-old child with persistent vomiting and low sodium levels was referred as congenital adrenal hyperplasia. Child also had hypospadiac urethra. Severe vomiting with hyponatremia with hypospadiac urethra should alert one to congenital adrenal hyperplasia.

Case 5
A three-week-old infant ventilated for one week developed fever, which did not subside on conventional antibiotics including broad spectrum. Urine for fungal culture grew Aspergillosis and the child also had fungal balls in the left kidney, which destroyed the function needing nephrectomy. Persistent fever in neonate in nursery settings will need investigations to exclude fungal infections.

Case 6
A five-days-old male infant presented with ascites. Cause of ascites could not be ascertained. Aspiration revealed clear fluid. An MCU showed that the child had posterior urethral valve with urinary leak from the pelvis of the kidney. Male children with ascites, especially with distended bladder, one should suspect posterior urethral valve and MCU is mandatory.

Case 7
A newborn child was seen with right testicular swelling. Pediatrician thought that testicular torsion is unlikely so soon after birth and diagnosed as hematoma (birth trauma) in the testis. It turned out to be torsion. All acute scrotal swellings are torsion unless proved to be otherwise. Doppler ultrasonogram is not 100% reliable.

Case 8
A two-month-old child was admitted with recurrent attacks of aspiration pneumonia. Every time the right upper lobe was consolidated. Thought to be due to Gastro-esophageal reflux. But cinefluoroscopy showed that the lesion was H type of tracheoesophageal fistula. Surgery cured the patient. Cine fluoroscopy of the esophagus is mandatory in all recurrent respiratory problems.

Case 9
An eight-year-old boy was referred for surgery for unilateral undescended testis. Surgery was not advised earlier with the hope that the testis will descend over a period of time. It should be noted the fertility drops significantly beyond one year of age for every year of postponement. Hence, surgery should be advised beyond six months of age by which time spontaneous descent will not be present.

Case 10
An eight-month-old child was seen several times with recurrent UTI and straining to pass urine and ultrasound was normal. Examination showed that the child had adherent labia. A female child who strains to pass urine needs careful examination of vulva to exclude adherent labia, which is eminently treatable with simple separation of the labia.

Case 11
One-year-old child who had recurrent UTI had ultrasonogram and was normal. Further investigation was done since the USG was normal. His MCU showed that the child had bilateral reflux with contracted kidney on radioisotope study. Gross reflux may be present with normal USG and MCU is always mandatory in all cases of UTI.

Case 12
A three-year-old infant was seen with preputial swelling. Treated as ant-bite several times. Ant never bites selectively at the tip of the penis. It is always balanoposthitis and needs circumcision.

Case 13
A 12-year-old boy was seen with recurrent itching of the preputial region. Investigated for juvenile diabetes. But when the prepuce was retracted, he had concealed hypospadias.

Case 14
The author has come across several instances where apparent female looking external genitalia in children and reared as female inspite of the fact a gonad is palpable in the labia or the gonad could be kneaded into the labia from above. All gonads in labia are testes and all these children are male children. Careful evaluation is necessary for proper assignment of sex and rearing.

Case 15
A 12-year-old obese male child was referred as having a small penis. In most of the fat children, the penile size appears small due it being buried under the fat in mons pubis. Treatment of obesity and reassurance to the parents is needed. There is wide debate whether tongue-tie should be operated. Tongue-tie should be released before the child is eighteen months. Certain palatal consonants like da, tha, na ra, la, etc cannot be pronounced properly. Haemangiomata grow disproportionately in the first year and are stationary in the second year and slowly disappear over the next few years. Need treatment only if progressing rapidly with platelet trapping or situated over the eye or pressure points. Many can be treated with steroids and in those resistant to steroids, interferon alpha 2 has been found to be of use. It is very expensive.

Phimosis
The prepuce cannot be retracted well in all children till the child is three years of age. Ballooning and straining to pass urine does not call for circumcision. Circumcision is necessary with history of recurrent balanoposthitis, or recurrent UTI in whom no demonstrable cause could be made. It is done in VUR with break through infections.


Hydrocele, Hernia, Hypospadias
All hydroceles diagnosed soon after birth will undergo spontaneous regression within a year or two. All hernias need surgery except umbilical hernia which undergoes regression by three years of age. Hypospadias needs to be corrected before the child goes to school. Since many parents send their children to pre school by two or two and half years, they need correction before that time.
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