Paediatric Surgery
Neonatal emergencies
Bilious vomiting in a neonate is malrotation with volvulus until excluded - urgent contrast study and surgery. Duodenal atresia gives a double bubble with no distal gas; jejunoileal atresia gives multiple dilated loops. Hirschsprung disease presents with delayed meconium and a transition zone on contrast enema; necrotising enterocolitis affects premature babies with feeding intolerance, abdominal distension and pneumatosis. Congenital diaphragmatic hernia presents with respiratory distress, scaphoid abdomen and bowel loops in the chest. Oesophageal atresia with tracheo-oesophageal fistula presents with drooling and choking on first feed; gastroschisis and omphalocele need early surgical cover.
Infants and children
Hypertrophic pyloric stenosis at 3–6 weeks: non-bilious projectile vomiting, hypochloraemic hypokalaemic metabolic alkalosis, treated after correction with pyloromyotomy. Intussusception at 6–36 months: colicky pain, redcurrant jelly stool, target sign; air enema is diagnostic and therapeutic if there is no peritonitis. Testicular torsion is a surgical emergency; salvage falls after 6 hours. Appendicitis is common but often atypical; Meckel's diverticulum causes painless bleeding.
Traps and rule of thumb
Do not give a bolus of sodium bicarbonate to correct alkalosis in pyloric stenosis - rehydrate with saline and add potassium first. In a child with bilious vomiting, an apparently well abdomen is still a surgical abdomen.