Pediatric Primary Care (84 page)

2.  Supports/trusses are not indicated, may be hazardous.

I.  Follow up.

1.  Referral to pediatric surgeon when diagnosis of inguinal hernia made.

J.  Complications.

1.  Incarcerated hernia: immediate referral for reduction under sedation.

2.  Strangulated incarcerated hernia: blood supply compromised: surgical emergency.

3.  Ischemia/infarction of testis: can occur in boys with undescended testicles, inguinal hernia.

4.  Ovary/fallopian tube infarction.

K.  Education.

1.  Uncomplicated indirect inguinal hernia: review signs, symptoms of incarcerated/strangulated hernia with family: abdominal distention, vomiting, pain, persistent bulge that does not reduce.

2.  Family understands importance of following through with surgical appointments.

3.  Operative repair necessary within first year of life due to increased incidence of incarceration after that time.

IX. HERNIA, UMBILICAL

A.  Protrusion of part of intestine at umbilicus; defect is at abdominal wall, protruding bowel covered with skin, subcutaneous tissue.

B.   Etiology.

1.  Due to weakness/incomplete closure of umbilical ring.

C.  Occurrence.

1.  Increased incidence among African American infants, low-birth-weight infants, females.

D.  Clinical manifestations.

1.  Soft mass covered by skin that protrudes from umbilicus, usually with increased intra-abdominal pressure (crying/straining) or may be more persistent (ask parent about fluctuations in mass size/presence).

2.  Size of defect varies from 1 cm in diameter to 5 cm.

3.  Usually disappears spontaneously by 1 year of age. Larger hernias may resolve spontaneously by 5-6 years of age unless defect 2 cm.

E.  Physical findings.

1.  Examine infant in supine position.

2.  Abdomen will reveal soft protrusion through umbilicus, usually easy to reduce through fibrous umbilical ring. Assess for abdominal distention.

3.  Increased size may be visible with crying. Observe for signs of pain.

F.  Diagnostic tests.

1.  None.

G.  Differential diagnosis.

Hernia, strangulated umbilical, 552.1

1.  Strangulated umbilical hernia (very rare): may show signs of intestinal obstruction such as pain, vomiting, persistent umbilical bulge that will not reduce.

H.  Treatment.

1.  Most resolve spontaneously.

2.  Surgery reserved for hernias after 3-4 years of age, those causing symptoms (become strangulated), those becoming progressively larger after 1-2 years of age.

I.  Follow up.

1.  Assess hernia routinely at all visits. Immediate return if signs of incarceration.

J.  Complications.

Incarceration umbilical hernia, 552.1

1.  Incarceration: very rare.

K.  Education.

1.  Instruct parent not to tape or bind umbilicus and on signs, symptoms of incarceration.

2.  Reassure most resolve spontaneously.

X. INTUSSUSCEPTION

A.  Prolapse or “telescoping” of one part of intestine into lumen of adjoining intestine.

B.  Etiology.

1.  Can follow infections such as gastroenteritis, otitis media, URI, adenovirus.

2.  About 10% have “lead point” such as Meckel's diverticulum, polyp, duplication.

3.  May be alteration in intestinal peristalsis that provokes condition.

C.  Occurrence.

1.  Most common cause of intestinal obstruction 3 months to 6 years of age.

2.  60% occur in infants younger than 1 year, 80% by 2 years. Rare in neonates.

3.  Incidence 1-4 in 1000 live births.

4.  Male-to-female ratio is 4:1.

5.  Peaks in spring and fall.

D.  Clinical manifestations.

1.  Sudden onset severe abdominal pain, usually periumbilical/lower abdomen, in previously well child.

2.  Pain colicky, paroxysmal occurring at frequent intervals.

3.  Child may appear well between episodes of pain at first.

4.  During pain, child flexes legs, pulls knees toward abdomen, cries.

5.  Vomiting common.

6.  Stools may appear normal in first few hours, after which little or no stool.

7.  Blood per rectum can occur within first 12 hours or up to 2 days after symptoms start. May be mixed with mucus described as “currant jelly stool.”

8.  If symptoms unrecognized, may progress to lethargy, bilious vomiting, shock.

E.  Physical findings.

1.  Weight, temperature, vital signs.

2.  Assess overall affect and activity level, observe during pain episode.

3.  Abdomen may be distended. Guarding during exam if having pain. About 70% may have palpable, ill-defined (“sausage-shaped”) mass, may be mildly tender.

4.  Rectal exam may reveal bloody mucus.

F.  Diagnostic tests.

1.  Diagnosis usually made by history and physical exam.

2.  Barium enema: may show filling defect.

3.  Abdominal ultrasound can also detect intussusception.

G.  Differential diagnosis.

1.  Gastroenteritis.

2.  Meckel's diverticulum: painless, rectal bleeding from congenital appendage of ileum.

3.  Henoch-Schönlein purpura: associated with joint symptoms, purpura rash.

H.  Treatment.

1.  Barium enema: hydrostatic/”air contrast” used to diagnose, treat intussusception.

2.  Untreated, condition almost always fatal.

3.  10% recurrence rate after reduction by barium enema.

4.  Intussusception secondary to “lead point” from Meckel's diverticulum or polyp requires surgery.

I.  Follow up.

1.  Immediate referral to tertiary care facility.

2.  Telephone or clinic follow up after reduction.

J.  Complications.

Dehydration, 276.5

1.  Dehydration, bowel necrosis, death.

K.  Education.

1.  Reassure parent that vast majority of cases have no specific lead point and are successfully treated with barium enema.

2.  Counsel family to call immediately if any signs of abdominal pain, rectal bleeding following reduction.

XI. IRRITABLE BOWEL SYNDROME (IBS)

A.  Functional bowel disorder characterized by abdominal pain and changes in bowel function. Diagnostic criteria (fulfilled at least once/week for at least 2 months prior to diagnosis): Must include both of the following:

1 Abdominal discomfort or pain associated with 2 or more of the following at least 25% of the time:

a.  Improvement with defecation.

b.  Onset associated with change in frequency of stool.

c.  Onset associated with change in appearance of stool.

2.  No evidence of an inflammatory, anatomic, metabolic, or neoplastic process that explains the patient's symptoms.

B.  Etiology.

1.  Thought to be combination of visceral hypersensitivity and possibly altered gut motility. May be due to alterations in enteric nervous system (ENS) and relationship to central nervous system (CNS).

2.  Stress/anxiety may induce/worsen symptoms but probably not root cause.

3.  May be preceded by episode of viral gastroenteritis or past history of constipation.

C.  Occurrence.