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11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017
| Contributor Information
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Image courtesy of Medscape/Jaime Shalkow, MD, FACS.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Diagnosing acute intra-abdominal emergencies in infants can be challenging at the best of times. An infant with abdominal pain may present early with poor feeding, crying, or irritability. Ominous late findings often include lethargy, vomiting, or unresponsiveness. Early diagnosis is associated with a substantially better outcome and, consequently, decreased morbidity and mortality.
The surgical photograph is from a 1-year-old male who previously underwent a right radical nephrectomy for Wilms tumor. He presented to the emergency department with signs of a mechanical small bowel obstruction. A transition zone is clearly seen at the point where the small bowel is trapped on an internal hernia through a mesenteric gap (arrow).
Image courtesy of Medscape/Jaime Shalkow, MD, FACS.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
This surgical photograph from an 8-month-old reveals ileocolic intussusception.
Which of the following statements about pediatric intussusception is correct?
Intussusception is defined as the telescoping of a proximal portion of intestine into an adjacent distal portion.
Intussusception is one of the most common causes of bowel obstruction in infants and toddlers.
Vascular compromise and subsequent bowel necrosis are among the primary concerns with intussusception.
All of the above.
Image courtesy of Medscape/Jaime Shalkow, MD, FACS.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: D. All of the above[1,2]
Intussusception must be diagnosed promptly; the consequences can be bowel infarction and perforation.[1,2] There are two common and classic presentations for intussusception. The most common presentation is a child younger than 2 years with vomiting and cyclical abdominal pain that manifests as drawn-up legs with severe crying episodes lasting a few minutes alternating with periods of normal behavior in which they have no pain.[1-3] The less common presentation is that of a lethargic infant.
The photograph shows a 5-month-old male with intussusception and currant jelly stools (arrow), a classic, but uncommon, late finding.[1-3]
Image courtesy of Medscape/David E Wesson, MD.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
A child presents with abdominal distention and bilious emesis. What is the most emergent diagnosis that must be excluded?
Midgut volvulus
Necrotizing enterocolitis (NEC)
Jejunal atresia
Duodenal atresia
Image courtesy of Medscape/Jaime Shalkow, MD, FACS.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: A. Midgut volvulus[1-3]
The barium enema in the previous slide shows malrotation and midgut volvulus in an infant. Note the cecum in the right upper quadrant and the dilated loops of small bowel.
Malrotation is a fetal anatomic abnormality that predisposes to midgut volvulus which typically occurs in infants younger than 1 month, often within the first week of life. During fetal development, the midgut twists in a clockwise (instead of the typical counterclockwise) direction around the superior mesenteric vessels[1-3] and the mesentery is not properly anchored to the peritoneum. Although the malrotated bowel itself generally does not cause a problem, it has the potential, at any time, to twist around its narrow axis, compromising or obstructing flow through both the intestinal lumen and the splanchnic arteries. Unless blood flow is restored emergently, ischemia can cause necrotic bowel (arrow) and result in extensive loss of bowel; this may lead to short-gut syndrome or death.[2]
NEC, while life threatening, usually affects premature and low birth-weight infants in their second to third weeks of life.[2,4] Jejunal and duodenal atresias are generally not life threatening; due to the location of the obstruction, duodenal atresia does not present with bilious emesis.[1,5]
Image courtesy of Medscape.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
This operative photograph demonstrates midgut volvulus in a full-term newborn who underwent an upper gastrointestinal (GI) contrast study. Note the complete twist (>360°) of the entire small bowel over the narrow pedicle of its mesentery as well as the appearance of the small bowel, with congestion and cyanosis caused by vascular compromise from the volvulus.
Early operative intervention prevented the development of necrosis, and emergent untwisting combined with a Ladd procedure was successful.
Recent trends to diagnose malrotation with ultrasound have expedited the diagnosis in many cases, also limiting the infant's exposure to radiation during fluoroscopy. Physicians look for physiologic orientation of the superior mesenteric vein and artery. However, with a 360° twist as above, ultrasound may mislead the clinician, unless the entire course of the two vessels is followed to ensure that there is no twist.
Image courtesy of Khan YA, Akhtar J. APSP J Case Rep. 2010;1(2):15. [Open access.] PMID: 22953258, PMCID: PMC3418002.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
All of the following statements regarding this image are true EXCEPT:
Pneumoperitoneum can be an incidental finding on routine radiograph in a preterm infant in the first week of life.
Placing the infant supine and performing an anteroposterior (AP) radiograph is the best view to reveal pneumoperitoneum.
Pneumoperitoneum can result from displaced air from a pneumothorax.
Pneumoperitoneum can result in oliguria/anuria and acute renal failure.
Image courtesy of Medscape/Beverly P Wood, MD, MSEd, PhD.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: B. Placing the infant supine and performing an anteroposterior (AP) radiograph is NOT the best view to reveal pneumoperitoneum.
The left lateral decubitus view (shown) is the best view to evaluate for free abdominal air in an infant.[6] The free air will rise above the liver shadow (arrow) but remain visible below the diaphragm. On the previous slide, the erect abdominal radiograph shows the presence of free gas not only under the dome of the diaphragm (top arrow) but also in the scrotum (bottom arrow) of a 4-day neonate. In a supine film, the free air will rise "to the top" which is anterior to the viscera. Thus, the clinician unwittingly will be observing the abdominal structures through the free air bubble, which cannot be discerned.
Pneumoperitoneum may be an incidental finding[7]; spontaneous intestinal perforation (SIP) is not uncommon in the first few days of life of a preterm infant[8] and may resolve spontaneously. Free air from a large pneumothorax can track down the lateral sulcus into the abdomen, resulting in pneumoperitoneum.[8] A tense abdomen from large amounts of free air can result in abdominal compartment syndrome, restricting renal arterial blood flow and leading to oliguria/anuria and renal failure.[9]
Image courtesy of Loren G Yamamoto, MD, MPH, Kapiolani Medical Center for Women & Children, University of Hawaii, with permission.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
What ominous finding does the arrow on this plain pediatric abdominal radiograph indicate?
Image courtesy of Medscape/Beverly P Wood, MD, MSEd, PhD.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer:Pneumatosis intestinalis
The radiographs on the previous and current slides show pneumatosis intestinalis ("railroad tracks"), which is pathognomonic for necrotizing enterocolitis (NEC).[1,2,10] In addition, multiple dilated loops of the large and small bowel with bubbly and linear gas collections in the bowel wall can be seen. As noted earlier, NEC is a life-threatening condition that primarily affects premature, low birth-weight infants younger than 1 month. Full-term infants may occasionally develop NEC, but their risk is generally low.[2,4] Although the pathogenesis of NEC is multi-factorial, weakened intraluminal endothelial junctions allow ingress of luminal bacteria into the intestinal wall; bacterial gas production results in visible intramural air that can lead to perforation, septic shock, intestinal necrosis, and death.[10]
Treatment options for this condition include all of the following EXCEPT:
Intestinal decompression
Aerobic and anaerobic parenteral antibacterial agents
Continuous breast milk feeds
Surgical consultation
Images courtesy of Medscape and Robert K Minkes, MD, PhD (left) and Jaime Shalkow, MD, FACS (right).
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: C. Continuous breast milk feeds
Although breast milk feeds have been shown to be protective against the occurrence of NEC, once the condition is diagnosed, treatment includes a protracted period of bowel rest.
Intestinal decompression is an important intervention for NEC, as is "triple" antibacterial therapy (ie, broad spectrum gram-positive, gram-negative, and anaerobic bacterial coverage).[2,4,10] Because intestinal perforation or necrosis is an indication for immediate surgical intervention, early surgical consultation is advisable.
The left image shows necrotizing enterocolitis totalis in which pneumatosis intestinalis and multiple areas of perforation were seen. The right image shows a micro-premature male with discoloration on the right lower quadrant of the abdomen (arrow) due to intestinal perforation caused by NEC. An umbilical catheter is in place.
Image courtesy of Medscape/Gerald Mandell, MD, FACR, FAAP, FACNM.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Chromosomal karyotype is included in a comprehensive evaluation of patients with the condition shown.
True or false?
Image courtesy of Alorainy IA, Barlas NB, Al-Boukai AA. Indian J Radiol Imaging. 2010;20(3):174-81. [Open access.] PMID: 21042439, PMCID: PMC2963757.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: True
The abdominal radiographs on the previous and current slides depict duodenal atresia, an obstructive condition commonly found in patients with trisomy 21; therefore, a karyotype is indicated.[11,12] Both radiographs show a classic "double bubble" sign, with the stomach bubble (arrow) and the proximal duodenum (arrowhead) distended with air, and no distal air.[1,11-14] Also note the flattened acetabular angles and broadened ilia of a patient with trisomy 21[15] and, in this image, bilateral patchy basal pneumonia due to aspiration.[13]
Because normal fetal swallowing of amniotic fluid can be disrupted, this condition may be associated with polyhydramnios prior to birth.[11,12] Unlike more distal intestinal atresias, which are caused by fetal vascular accidents and are typically isolated, duodenal atresia is thought to be the result of a developmental error, and is frequently associated with other anomalies.
Duodenal atresia is surgically repaired by a duodenoduodenostomy.[1,14]
Image courtesy of Ome M, Wangnapi R, Hamura N, et al. BMC Pediatr. 2013;13:70. [Open access.] PMID: 23651554, PMCID: PMC3653680.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
All of the following statements are true regarding the condition shown EXCEPT:
This is an isolated absence of anterior abdominal wall musculature.
About 97% of affected babies are male.
The underlying pathology is abnormal development of the urinary system.
Oligohydramnios during pregnancy can lead to respiratory difficulties after birth.
Image courtesy of Medscape.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: A. This is NOT an isolated absence of anterior abdominal wall musculature.
Prune belly syndrome is a life-threatening condition that primarily affects males.[16] It involves a constellation of abnormalities, including partial or complete lack of abdominal musculature (shown), multiple urinary tract obstructive and anatomic abnormalities, and undescended testicles in males.[7,11,16] The underlying pathophysiology may be a fetal obstructed prostatic urethra, leading to bladder distention (shown) and urinary reflux. The massively distended bladder not only disturbs normal renal development but also prevents development of abdominal musculature and testicular descent.[7,16] Lack of fetal voiding results in oligohydramnios,[7] which delays normal pulmonary development and can lead to intrauterine bony deformations.[17] Many affected fetuses are stillborn.[16] Treatment is surgical,[7,16] with varying long-term outcomes and quality of life.
On the previous slide, the left image shows a newborn with prune belly syndrome manifested by a distended, wrinkled abdomen (from absent abdominal musculature) and a small chest (from lung hypoplasia). The right image is close-up of the abnormal male genitalia in the same infant. Note the undersized and underdeveloped scrotum (with absent testes), penile aplasia, and absent urethral meatus.
Image from Science Photo Library.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
An umbilical granuloma (shown following initial cauterization of the umbilical cord with silver nitrate) occurs as a result of improper postnatal umbilical cord care.
True or false?
Image courtesy of Bernard A Cohen, MD, Dermatlas.org.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: False
An umbilical (cord) granuloma is pink or bright red scar tissue that remains on the umbilical stump after the cord has separated (shown); there may be persistent drainage of a serous or serosanguineous fluid.[18,19] The reason it forms is unknown, but the formation of umbilical granulomas does not appear to be related to postnatal umbilical cord care.[20]
Umbilical cord granulomas per se are usually not clinically concerning. However, rarely, the persistent tissue may be a remnant of the bladder or other part of the urinary tract (persistent urachus or omphalomesenteric duct [OMD] cyst), which require surgical repair.[21,22] Therefore, any persistent umbilical tissue should be evaluated.
Delayed separation of the entire umbilical cord, in contrast to a persistent remnant, can be an indicator of a leukocyte adhesion defect and should be assessed.[22] In some populations, the cultural practice of placing cow dung on the umbilical stump after birth has been associated with fatal neonatal tetanus.[22]
Image courtesy of Jangid MK, Khan YA, Yadav SK, Taqi E. APSP J Case Rep. 2014;5(2):20. [Open access.] PMID: 25057473, PMCID: PMC4090818.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Although an umbilical granuloma and a patent urachus may look the same on physical examination, they are not. The urachus is a fetal structure that is the precursor to the trigone of the bladder, the entire urethra in females and, in males, part of the prostatic urethra.[22,23] By the end of the second trimester, this tissue should have formed the medial umbilical ligament, and then involuted. When it does not, it can create a persistent connection between the urinary bladder and the umbilical stump, resulting in urine leakage through the umbilicus and frequent urinary tract infection.[19,24] Unlike an umbilical granuloma, a patent urachus must be surgically resected; therefore, casual cauterization of a presumed umbilical granuloma could be potentially damaging to an occult urachal structure.
The perioperative image shows a patent urachus extending up to the urinary bladder.
Image courtesy of Aziz Khan Y, Qureshi MA, Akhtar J. Pak J Med Sci. 2013;29(3):866-8. [Open access.] PMID: 24353646, PMCID: PMC3809310.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
On microscopic examination, an omphalomesenteric duct (OMD) cyst contains cells from the gastrointestinal tract rather than from the genitourinary tract.
True or false?
Images courtesy of Mohite PN, Bhatnagar AM, Hathila VP, Mistry JH. J Med Case Rep. 2007;1:49. [Open access.] PMID: 17629924, PMCID: PMC1948009.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: True[25]
The OMD, also known as the vitelline duct, is an embryologic remnant of the yolk stalk, and serves as an early fetal connection between the midgut and yolk sac.[24,25] It usually obliterates by the end of the first trimester; if it does not completely involute, a variety of abnormalities may result, including Meckel diverticulum, umbilical polyp, complete patency, or an OMD cyst. Intestinal obstruction may result.
The diagnosis of an OMD is often made on physical examination.[22] Microscopic examination of the lining of OMD cysts reveal columnar epithelium that resemble gastric, small intestinal, or colonic mucosa; occasionally, small islands of pancreatic tissue may be found.[25] Treatment of OMDs is surgical resection.[19,22]
The image on the previous slide is a perioperative photograph of a cystically dilated bowel segment in the region of Meckel diverticulum, in continuity with proximal and distal ileal loops.
On this slide, the left image reveals a "Y" shaped loop emerging from the abdominal wall of a 5-month-old male at presentation; this is a prolapse of an inverted loop of small intestine. The right image from the same infant is after reduction of the prolapse; a 2 × 2-cm defect (shown) in the small intestine where it adhered to the abdominal wall was diagnosed as a patent OMD.
Image courtesy of Mirza B, Sheikh A. APSP J Case Rep. 2010;1(1):2. [Open access.] PMID: 22953245, PMCID: PMC3417985.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
This image shows a gastroschisis with evisceration of matted and massively edematous intestinal loops, the liver, and the gallbladder; an imperforate anus; and an ectopically placed vestibule with meconium inside.
Which of the following statements about gastroschisis is TRUE?
The abdominal contents extrude through the umbilical aperture.
It is typically associated with other so-called "midline" anatomic defects.
Vaginal birth is not contraindicated for an affected fetus.
This condition is genetically coded and often includes imperforate anus as an associated finding.
Image courtesy of Medscape/James G Glasser, MD, MA, FACS.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: C. Vaginal birth is not contraindicated for a fetus with gastroschisis.
Gastroschisis (shown) is not an indication for cesarean delivery: Vaginal delivery should be attempted if obstetrically indicated.
In gastroschisis, the full-thickness defect in the anterior abdominal wall is to the right of the umbilical stump (as was the case of the infant in the previous slide) and the umbilical cord remains attached to the abdomen; these crucial findings distinguish it from an omphalocele.[11,19,24] Also, unlike an omphalocele, gastroschisis is not covered by a peritoneal membrane. It is usually an isolated defect, unassociated with other anatomic abnormalities.[11,19,24]
This condition is considered a surgical emergency[19] and handling of the bowel in the first minutes and hours after birth can affect outcomes. Surgical treatment involves slowly encouraging the viscera to return to the abdominal cavity, which may need to be stretched to accommodate the volume.[7,19,24] Return of normal bowel function may take weeks and multiple surgeries may be required. Long-term parenteral nutrition in patients with intestinal failure may result in cholestasis and lead to hepatic injury.[26] Infection is also an ongoing concern.
The photograph shows an infant with gastroschisis complicated by jejunal atresia and loss of the entire distal small bowel (the gray tissue).
Image courtesy of Medscape/James G Glasser, MD, MA, FACS.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
The image shows an infant with a giant omphalocele following several weeks of treatment with topical agents.
Which of the following statements regarding omphaloceles is TRUE?
Like gastroschisis, an omphalocele is usually an isolated defect, unassociated with other abnormalities.
It is particularly important to monitor the blood sugars of affected newborns.
To the observer, omphalocele and gastroschisis look the same, and the distinction can only be made by pathologic examination.
It is a uniformly fatal abnormality.
Image courtesy of Medscape/James G Glasser, MD, MA, FACS.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: B. It is particularly important to monitor the blood sugars of affected newborns.[7,24]
Babies with omphalocele (shown) may suffer from Beckwith-Weidemann syndrome, which includes hypoglycemia; therefore, close monitoring of the glucose levels is important.[7,24]
Omphalocele and gastroschisis are both surgical emergencies. They can be immediately distinguished from one another in the delivery room: In omphalocele, the abdominal contents are covered by a peritoneal membrane and herniated into the umbilical cord; they are visible within the cord. Even if the cord is ruptured, the intestines protrude from the umbilicus, whereas in gastroschisis, as previously discussed, the bowel segments protrude from a separate anterior abdominal wall defect, usually to the right of the umbilicus.[11,19,24] Omphalocele can be surgically repaired, although long-term nutritional and abdominal morbidities may persist and associated organ system abnormalities may worsen overall outcomes.
Images courtesy of Ebert AK, Reutter H, Ludwig M, Rosch WH. Orphanet J Rare Dis. 2009;4:23. [Open access.] PMID: 19878548, PMCID: PMC2777855.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
The images show a male (left) and female (right) infant affected by the same condition.
All of the following statements are true regarding the condition shown EXCEPT:
The abnormalities occur more often in males than in females.
The abnormalities occur more often in babies born as a result of assisted reproduction techniques.
Neural tube defects may be present in some affected babies.
The abnormalities are rare and appear to be the result of an embryonic accident rather than genetically mediated.
Image courtesy of Ebert AK, Reutter H, Ludwig M, Rosch WH. Orphanet J Rare Dis. 2009;4:23. [Open access.] PMID: 19878548, PMCID: PMC2777855.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Answer: D. The abnormalities are rare and appear to be the result of an embryonic accident, AND THEY MAY BE genetically mediated.[27,28]
Exstrophy-epispadias complex (EEC) comprises a spectrum of genitourinary anomalies that range in severity from most severe with exstrophy of the cloaca (EC) (shown), to classic bladder exstrophy (CBE) (most prevalent), to least severe with epispadias (E).[19,27-29] These are considered urologic emergencies.
The lower abdominal musculature and pelvic bones are formed during the first trimester by mesodermal ingrowth between the ecto- and endodermal layers of the cloacal membrane.[19,27-29] When the cloacal membrane ruptures prematurely, the anterior abdominal wall does not close normally. The timing of the premature rupture determines the extent of the exstrophy that occurs in the developing structures.[28] Neural tube defects may occur in a small percentage of infants with EEC.[27,28]
These abnormalities typically occur more often in males than females as well as in babies born by assisted reproduction techniques.[28] The incidence of EEC varies with condition, from 1 in 117,000 male births (1 in 484,000 female births) for complete E, to 1 in 10,000-50,000 births for CBE, to 1 in 200,000-400,000 births for CE.[19,24,28]
The infants on the previous slide have CBD, in which the bladder and posterior urethral mucosa are exposed through a defect in the anterior abdominal wall.[24] Typically, the ureteral orifices are clearly visible.[19] Affected males generally have a complete epispadias; affected girls may have a bifid clitoris.[24]
Image courtesy of Biophoto Associates / Science Source.
11 Abdominal Emergencies in Infants
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Shown is a patient with a hydrocele and an ectopic (undescended) testicle.
In males, the abdominal testis descends through the inguinal canal into its anatomic position in the scrotum. As it descends, it pulls the processus vaginalis with it. After the descent is complete, if the processus vaginalis fails to involute completely (and doesn't close the connection with the peritoneal cavity), the peritoneal cavity and scrotal sac remain in communication. This allows fluid (hydrocele) and, potentially, viscera (inguinal hernia) to slip into the scrotum.
Thus, hydroceles are abnormal collections of fluid within the tunica vaginalis of the scrotum or along the spermatic cord—or, rarely, along the canal of Nuck in females.[24,30,31] Hydroceles may be communicating, meaning the channel remains open, or noncommunicating. They are typically asymptomatic, are often bilateral in infants but may be unilateral (most often on the right). A noncommunicating hydrocele will resolve spontaneously by age 1-2 years;[24,30] if it does not resolve, than it is a communicating hydrocele by default and surgical closure is indicated. In and of themselves, hydroceles are generally not of significant clinical concern, other than the potential for herniation through a patent communication.
Inguinal hernias, however, must be evaluated promptly.[24,30] Although they are often painless, reducible, and appear intermittently, incarceration, strangulation, or obstruction of the hernia may occur (accompanied by abdominal pain, vomiting, constipation). These are surgical emergencies owing to the potential for bowel necrosis and perforation, as well as the possibility of spermatic cord[24] or ovarian[19] involvement.
Shelley C Springer, MD, MBA, MSc, FAAP, JD | October 3, 2017 | Contributor Information
Testicular torsion occurs when the testicle twists on its spermatic cord (shown), restricting blood flow and leading to ischemic necrosis and infarction.[19,32] This condition occurs when the testicle fails to be fixed posteriorly to the scrotal wall by the tunica vaginalis, known as the "bell-clapper abnormality."[19,24,32] It is more common in pre-pubertal males. The presentation often includes acute scrotal pain, a high-riding testicle, and an absent cremasteric reflex, as well as scrotal swelling and edema.
Testicular torsion is a surgical emergency, as tissue death can occur within 6-8 hours[19]; thus, clinical history and physical examination are frequently used to guide management decisions. When available, color Doppler ultrasonography is the most commonly used imaging modality to confirm the diagnosis.[24] A recent case series utilized pulse oximetry on the scrotum to identify compromised/differential blood flow in a resource-poor setting,[33] but such is not standard diagnostic technique. Occasionally, torsion will occur in utero and the male infant is born with a nonviable testis. Scrotal implants may be offered to these patients after puberty if desired for cosmetic or psychosocial reasons.
During the elegant and complex development of the genitourinary system, a variety of congenital abnormalities can arise. Learn more about how to recognize and address these conditions.Slideshows, September 2017
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Shelley C Springer, MD, MBA, MSc, FAAP, JD
Pediatrician/Neonatologist
Casper Children's Center
Casper, Wyoming
Disclosure: Shelley C Springer, MD, MBA, MSc, FAAP, JD, has
disclosed no relevant financial relationships.
Editors
Mark P Brady, MS, PA-C
Physician Assistant
Department of Emergency Medicine
Cambridge Health Alliance
Cambridge, Massachusetts
Disclosure: Mark P Brady, MS, PA-C, has disclosed no relevant
financial relationships
Olivia Wong, DO
Section Editor
Medscape Drugs & Diseases
New York, New York
Disclosure: Olivia Wong, DO, has disclosed no relevant financial
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References
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