Pediatric surgery

notes

Mohamed Abdelkader
Osman

Professor of pediatric
surgery

2021-2022
Differences between children, adolescents and adults

There are a many differences between children, adolescents and

adults (physiological, anatomical, cognitive, social and emotional),
which all impact on the way illness and disease present in children and
young people, as well as the way healthcare is provided. Specialist
pediatric training is important because children, adolescents and adults:

 Present with illness differently, so people working with children

need the skills and knowledge to identify and diagnose illness in a
child or adolescent, and be aware of illnesses specific to different
age groups.
 Often require age-appropriate treatments, approaches to
treatment and environments.
 Have different contexts:
 Children and adolescents come with family, who generally
have a greater role in their wellbeing, so health
professionals need to work with family as well as the
patient.
 Activities are different for different ages - play becomes less
important with age, but the need for stimulation, school and
employment in other activities remains important.
 Children and adolescents are still developing, so their
responses to similar situations will be different and
experiences they have will impact on their future
development.

Anatomical/physiological differences
 Larger body surface area (BSA) - Children have a proportionately
larger BSA than adults do. The smaller the patient, the greater
the ratio of surface area (skin) to size.
As a result, children are at greater risk of excessive loss of heat
and fluids and are affected more quickly and easily by toxins that
are absorbed through the skin.
 Thinner skin - Children have thinner skin than adults. Their
epidermis is thinner and under-keratinized, compared with
adults.
As a result, children are at risk for increased absorption of agents
that can be absorbed through the skin.
 Rapidly dividing cells - Children's cells divide more rapidly than
adults to assist in their rapid rate of growth. As a result, children
are more susceptible to the effects of radiation than adults.
 Higher heart rate and respiratory rate - Children have higher
respiratory rates than adults. Higher respiratory rates lead to
proportionately higher minute volumes. As a result, children may
be more susceptible to agents absorbed through the pulmonary
route than adults with the same exposure. Children may also
respond more rapidly to such agents. Signs and symptoms in
children may be an "early warning" of a chemical, biological, or
radiological incident.
 Immature blood-brain barrier - Children have immature blood-
brain barriers and enhanced central nervous system (CNS)
receptivity. As a result, children may exhibit a prevalence of
neurological symptoms. Nerve agents may produce more
symptoms in pediatric patients, requiring levels of treatment for
children that are not indicated for adults with the same level of
exposure.
 Higher metabolic rate - Children are more susceptible to
contaminants in food or water and are at greater risk for
increased loss of water when they are ill or stressed. Medication
doses must be carefully calculated based on the child's weight
and body size.
 Immature immune systems - Children are at a greater risk of
infection and have less herd immunity from some infections.
Preoperative nursing care of neonates
Nursing the surgical neonate requires considerable skill and
expertise. This includes specialist knowledge and practical skills required
to care for the otherwise well newborn with an isolated surgical condition
and neonates with more multiple, complex surgical and medical problems.
Multidisciplinary input from a wide array of specialties is essential to
achieve the best outcome in this challenging area of pediatric surgery.
Nursing staff are integral to ensuring seamless coordination of this care.

General principles
Thermoregulation

Neonates have immature temperature control systems, poorly

developed subcutaneous fat layers, and high body surface to body
weight ratio, leaving them prone to hypothermia.
The surgical neonate may be more vulnerable due to
exposed viscera in anterior abdominal wall defects, in
particular gastroschisis, and in neural tube defects.

Preterm infants or those babies who are metabolically stressed,

including those undergoing surgery, are especially at risk. The surgical
neonate should have core temperature maintained at 36.7-37.3°C by
control of ambient and/or skin temperature. To achieve this, most
infants require an environmental temperature of 34-36.5°C.
A radiant warmer is an efficient means of providing heat and allows
easy access to the critically ill neonate. Disadvantages include
increased insensible water losses and extreme drying of the skin,
making it unsuitable for the very preterm infant and those infants with
abdominal wall or neural tube defects.
Hats, bootees, and bubble or plastic wrap may further reduce heat loss.

Dealing with respiratory compromise

Cardiac and respiratory function may be compromised in infants with

major surgical conditions, and continuous monitoring of heart rate,
respirations, and oxygen saturation (SaO2) is essential.
As newborn infants are obligatory nose breathers, upper airway
obstructions including choanal atresia or stenosis and conditions
associated with micrognathia (Pierre Robin syndrome) are more likely
to cause respiratory distress or apnea.
 Central nervous system disorders complicated by hydrocephalus and
raised intracranial pressure have been linked with central apnea. If the
surgical condition allows, infants with obstructive apnea may benefit
from being nursed prone at a 30-degree angle, as this position
improves both oxygenation and minute ventilation and can reduce the
risk of reflux or aspiration.
Administration of low-flow oxygen may help maintain oxygen saturation
and prevent further respiratory distress.

Esophageal atresia

Infants with esophageal atresia usually present shortly after birth with
excessive saliva frothing at the mouth and coughing and choking as
secretions spill over from the proximal esophageal pouch into the
trachea.
Inability to pass a nasogastric tube into the stomach aids the diagnosis,
but this can be confirmed by a chest radiograph demonstrating the tube
coiled in the upper esophageal pouch. A double lumen sump drain
(Replogle®) passed into the upper pouch and placed on low continuous
suction of 10-12 kPa is used to keep the proximal pouch emptied of
saliva and secretions. It is imperative that the tube is patent at all times;
therefore, flushing the tube with 0.5-1.0 mL of normal saline or air every
15 minutes will assist in drainage of excess thick saliva. Elevating the
head of the cot 45 degrees may prevent aspiration of stomach contents
into the lungs if a distal tracheoesophageal fistula is present.

Tracheostomy

Until the first tracheostomy tube change (by specialist medical staff),
the airway is extremely vulnerable. Great care is needed to prevent
accidental displacement of the tube. Spare tubes (including a size
smaller than the one in situ) should always be at the cot side.

Gastric decompression

Intestinal obstruction

Intestinal obstruction may present as nonbilious vomiting (eg, pyloric

stenosis) or bilious vomiting (eg, duodenal atresia, intestinal volvulus or
atresia, necrotizing enterocolitis, Hirschsprung disease). Abdominal
distension may be a feature. Severe abdominal distension may result in
splinting of the diaphragm and compromise of the neonate's respiratory
function. The risk of aspiration of stomach contents also increases. A
large-bore nasogastric tube (preferably 10 Fr) should be passed to
decompress the stomach and prevent vomiting. This should be left to
drain freely and aspirated hourly.
Initial resuscitation and timing of investigations and surgical intervention
will depend on the suspected underlying diagnosis.

Congenital diaphragmatic hernia

In congenital diaphragmatic hernia, parts of the gastrointestinal tract

are likely to be in the thoracic cavity. The key to initial management is
to minimize intestinal distension and further respiratory compromise by
the passage of a nasogastric tube and early intubation, avoiding bag
and mask ventilation. If not diagnosed prenatally, respiratory
compromise, deviated apex beat, and a scaphoid abdomen should
prompt the diagnosis.

Protection of exposed viscera

Gastroschisis preoperation

Exposed viscera are managed by using transparent plastic film or a

clear silastic bag, which will also preserve the integrity of the serosa by
preventing drying and allows easy observation.
Saline-impregnated swabs are not recommended as they may increase
heat loss, leave fibers on the mucosa, and, if allowed to dry, are more
difficult to remove.
Positioning the newborn with gastroschisis right side down helps avoid
vascular compression from the weight of the intestines compressing
the mesentery over the edge of the defect.
Repair by primary closure is possible in the majority of patients.
Staged repair of gastroschisis with silo
Contents are closely observed, checking color and the condition of the
bowel. Leakage from silo is recorded as well as level of contents in silo.
The surrounding skin is protected and its condition monitored. Silo
contents are reduced daily by the surgeon or advanced neonatal nurse
practitioner trained to do this procedure until permanent closure can be
achieved, usually in 5-7 days.
Exomphalos major
This is a particularly challenging condition that requires considerable
nursing input for a successful outcome. Primary repair is not normally
an option, and conservative treatment with topical application of an
agent to facilitate eepithelialization is necessary.
The lesion is then securely supported by the use of an appliance to
maintain a midline position. Once there is sufficient epithelialization,
gentle downward pressure is exerted to encourage the abdomen to
grow to accommodate the external viscera to facilitate later closure of
the defect.
Open neural tube defect
Although the incidence of open neural tube defects has decreased over
the past few decades, this condition continues to be a challenge for
medical and nursing care. Initially, the exposed neural tube is covered
with a nonadhesive dressing and the baby is positioned
prone. Cerebrospinal fluid leak preoperatively may be problematic and
requires regular dressing changes under aseptic conditions.
Postoperatively, the wound is often under tension and is at risk of
breakdown. Continued prone positioning of the infant will minimize
tension on the wound and reduce contamination of the wound by urine
and stool. Nursing staff should liaise with the physiotherapist to ensure
optimal positioning for associated hip and foot deformities (eg, hip
dislocation and talipes).

Stomas

Stomas are an integral part of many neonatal surgical operations.

Close postoperative observation is required as dusky or purple stomas
may indicate impending necrosis and require surgical review. The
stoma should be protected with a Vaseline gauze and a simple
dressing until the stoma is active, when a suitable stoma appliance can
be applied. Subsequent complications include bleeding, infection,
prolapse, retraction, skin breakdown, increased stoma losses, and
granulation tissue.

Skin and wound care

The newborn skin acts as a barrier to toxic substances and

microorganisms. It also controls thermoregulation and transepidermal
water losses and is a useful indicator of tissue perfusion.
The preterm neonate's skin is not fully mature until 10 days postnatal,
placing them at risk of skin injury. The surgical neonate, even if term, is
at increased risk of skin and tissue damage due to the following factors:
surgery, edema, ventilation and paralysis, ostomies, silos, wounds,
central venous lines, tubes, urinary catheters, and inotropic drugs.
General considerations for maintaining good skin integrity and wound
healing include:
•
Assessment, evaluation, and management of wounds and skin
injury by the use of a wound assessment chart/tool, which clearly
identifies each phase of wound healing.

Preoperative fasting and medication in children

The goal of safe, nonstressful, and anxiety-free induction of anesthesia
for pediatric patients can be facilitated by minimizing the risks of
aspiration pneumonitis and the conscientious use of an armamentarium
of preoperative medications. The healthy child (ASA I or II) presenting
for elective surgery, particularly in the day-surgery context, need not
undertake a prolonged fast or be heavily premedicated before induction
of anesthesia. Guidelines recommend clear liquids up to 2 hours before
surgery, breast feeding up to 4 hours, light meals up to 6 hours, and
heavy/fatty meals for up to 8 hours before surgery. The suggestions
differentiate depending on the age of the patient and the type of the
food eaten.

4 tips to help prepare your child for a blood test

Explain the procedure – Explain what is going to happen a few days
before. If your child asks “will it hurt?” Give the child an honest answer
– “Some children say it hurts a bit, others are not so bothered.”

Distract them–Depending on whether you have an infant, toddler or

teenager, distract them with food, toys, books, music or talking to them
etc

Positioning – Try sitting your toddler on your lap which provides

security and comfort. Older children may like to lie down or sit in the
chair and watch the procedure. Maintain contact by holding their hand
or giving them a hug.

Reward them – Stay with your child until they are calm. Give positive
encouragement by saying they did a great job and how proud you are
of them. Reward them for being brave.
 Congenital hernia and hydrocele

1- Congenital inguinal hernia

Indirect inguinal hernia

Due to continued patency of processus vaginalis (PV), patent PV
sac is potential for hernia or and hydrocele. In hernia the sac is wider and
contains an intra-abdominal structure. In hydrocele the sac is narrow and
contains fluids

Processus Vaginalis
PV developed during 12th week of gestation, out pouching of the peritoneal
cavity through the internal ring, PV plays an integral role in the descent of the
testis, PV obliterates spontaneously from the internal ring to the testis, distal
portion remains as tunica vaginalis

Incidence
0.8 -4%, highest in 1st year of life, increased in premature infants 16 -
25%,male to female is 6: 1, right 60%, left 30%, bilateral 10%

Factors contributing to development of hernia

Undescended testis, increased peritoneal fluid (as in ascites, VP

shunt),increased abdominal pressure, chronic respiratory disease,
connective tissue disorders

Clinical features
Bulge in inguinal area extending towards/into scrotum withcrying / straining
May be present at birth or appear later, reduces in size when the child is
relaxed, smooth soft-firm mass that emerges from the external ring lateral
and above pubic tubercle enlarges with increased abdominal pressure, can
be reduced with gentle pressure with gurgling noise, thickening and silking
on palpating the cord as it crosses pubic tubercle

Management
Inguinal hernia does not resolve spontaneously, must be
operated because of high risk of incarceration. Operation is herniotomy (high
suture ligation of the sac at the internal ring), open or laparoscopy
Irreducible Hernia
Incarcerated hernia: contents can not be easly reduced into peritoneal
cavity, child is irritable with pain in groin/abdomen, with vomiting. Tense
tender non fluctuant mass in the groin, may extend into scrotum, not
transilluminant.Bilious vomiting, abdominal distension indicates obstruction
of bowel

Strangulated hernia
Tightly constricted at the neck resulting in ischemia of contents
Pain intensifies, vomiting becomes bilious, blood in stools, mass is tender,
edema and reddening of overlying skin, and fever.

2- Congenital hydrocele

Usually noted in early infancy, can occur at any time, often bilateral, soft,
bluish fluctuant swelling surrounding the testis, fluctuate in size; smaller at
night when the child is relaxed. Neck of the hydrocele is narrow at the
external ring and usually does not extent into inguinal canal. Hallmark:
Brilliant transillumination. In the most children with congenital hydreocele the
PV sac closes and hydrocele resolves between 12-24 months
 Intussusception

Definition:

Telescoping invagination of an intestinal segment into the lumen of a

proximal segment

Lead point:
A lead point is a lesion or variation in the intestine that is trapped by
peristalsis and dragged into a distal segment of the intestine, causing
intussusception. A Meckel diverticulum, polyp, tumor, hematoma, or vascular
malformation can act as a lead point for intussusception.

Epidemiology:

The male to female ratio is approximately 3:2

Two thirds of the patients are under one year old, the peak age being
between 5 – 10 months
Intussusception is the most common cause of intestinal obstruction in
patients aged 5 months – 3 years and accounts for up to 25% of abdominal
emergencies in children up to age 5.
It is rare in preterm

Pathogenesis

It occurs most often near the ileocecal junction, jejunojejunal,

jejunoileal, colocolic.
The intussusceptum, a proximal segment of bowel, telescopes into
the intussuscipiens, a distal segment, dragging the associated mesentery
with it. This leads to the development of venous and lymphatic congestion
with resulting intestinal edema, which leads to ischemia, perforation, and
peritonitis

Causes and associated conditions

Non-pathological lead point (90%)
Viral 50 %
Shigella
Peyer's pathes hypertophy
Pathological (10%)
Meckel's diverticulum, polyps, hematoma, lymphoma, cystic fibrosis,
inflamed appendicitis, and others
Presentation

It is usually of sudden onset, may be more insidious in the older child.

There are paroxysms ( about every 10 – 20 minutes) of colicky abdominal
pain and crying
There is early vomiting, rapidly becoming bile-stained
Neurological symptoms such as lethargy, hypotonia or sudden alternations
of consciousness can occur.
There may be a palpable sausage-shaped mass in right upper quadrant
There may be absence of the bowel in the right lower quadrant (Dance's
sign)
Hydration, pallor shock, irritability, sweating
Later, mucoid and bloody stool (redcurrent stools)

Diagnosis
Depends on the clinical suspicion fot intussusception and experience
radiologists
Patients with a typical presentation (sudden onsent of intermittent severe
abdominal pain with or without rectal bleeding) or characteristic findings on
radiography, may proceed directly to nonoperative reduction using
hydrostatic or pneumatic enema
Abdominal ultrasound and or abdominal plain films

Investigatins
Abdominal X-ray may show dilated gas-filled bowel, paucity of gas distally,
multiple fluid levels
Ultrasound may show doughnut or target sign, pseudokidney/sandwish
appearance
Bowel enema- barium has been gold standard (crescent sing, filling defect)
CT/MRI scanning more often used in adults than in children

Management
IV line
Antibiotic
Nasogastric tube
Reduction: hydrostatic or pneumatic for 3 trials
Exploration after failure of hydrostatic or pneumatic reduction
 Anorectal malformation

Definition
Anorectal malformations are developmental deformities of the lower
end of the alimentary tract i.e the anorectal canal

Incidence
Minor abnormalities of the anus and rectum occur in 1 in 500 living
newborns while major abnormalities occur in 1 in 5000 living infants

Causes
The exact cause of these malformations is not known. It occurs due to
the arrest in embryonic development in the anus, lower rectum and
urogenital tract at the 8th week of embryonic life. The membrane that
separates the endodermal hindgut from the ectodermal anal dimple
perforates and a continuous canal is formed, outlet of which is anus. If the
membrane separating rectum from the anus is not absorbed, and if the union
does not take place, an anorectal anomaly results. Approximately 40% of the
neonates with anorectal malformation have associated anomalies like
Down's syndrome, congenital hart disease, undescended testes, renal
abnormalities, esophageal atresia and neural tube defect

Types

According to the visibility of the anus

a- with a visible abnormal opening of the bowel

1) anal stenosis; it accounts for 10% of all ARMs a stricture is
at the anus or at the levels1 to 4 ccm above the anus, or extends the
entiere length of the anus
2) ano-perineal fistula
3) anovestibular fistula in female

b- with an invisible but manifested opening of the bowel

1) rectovaginal fistula in female
2) rectouretheral fistula in male
3) rectovesicular fistula

c- no manifested opening of the bowel

1) persistent anal membrane or imperforate anus, here there is
an imperforate anal membrane that proceds obstruction behind which the
meconium is seen
2) rectal atresia
According to the levator ani muscle
 a- supralevator or high anorectal malformations; the rectum
terminates above the levator ani muscle, which is found as rectal atresia,
rectoprostatic fistula, and rectovaginal fistula.
b- translevator or low anorectal malformations; when the rectum
terminated below the levator ani muscle found in ano-cutaneous fistula and
anovestibular fistula

Diagnostic tests

Physical examination by passing the gloved little finger through the

anus and by observing the passage through which meconium was passed.

Ultrasound scan to locate the rectal pouch

x- ray with inverted infant called as invertogram.

Urine examination for presence of meconium and epithelial debris

Micturating cystourethrogram to detect urinary abnormalities

Management

The reconstructive surgery is done to correct or repair the congenital

malformations. It depends upon the type of the anomaly and sex of the infant

In cases of low ARMs, where there is less than 1 cm distance between

the anal dimple and rectal pouchm redtal cutback anoplasty or Y-V plasty is
done for male infants and dilation of fistula with definitive repair or perineal
anoplasty is performed for female infant.

In case of high ARMs, where there is more than 1 cm distanc between

the anal dimple and the rectal pouch. Initial colostomy is done in the
neonatal period followed by definitive reconstructive surgery as posterior
sagittial anorectoplasty at the age of 10 to 12 months or when the infant is
having 7 to 9 kg body weight. Colostomy closure is done after 10 to 12
weeks of successful definitive surgery
 Pediatric intestinal obstruction

It is the cessation of passage of stool, it is partial or complete

Causes

1- Hirschsprung's disease
2- Incarcerated hernia
3- Intussusception
4- Gastric volvulous
5- malrotation
6- Ileus
7- Adhesion
8- Superior mesenteric artery syndrome
9- Foreign bodies
10- Bezoars
11- Pyloric stenosis

Management

All obstructions will be treated with IV fluids and electrolyte correction.

Occasionally, a nasogastric tube is placed to remove fluid and gas backing
up in the upper digestive tract. Medications are used to help with nausea
and severe pain. A complete obstruction may require surgery

Tests and procedures used to diagnose intestinal obstruction include:

1. Physical exam.. ...

2. X-ray. To confirm a diagnosis ...
3. Computerized tomography (CT). ...
4. Ultrasound. ...
5. Air or barium enema
6.
7.
 Cryptorchidism
Undescended testes

Cryptorchidism or Undescended testis is the absence of one or both testes from

the scrotum. It is the most common birth defect of the male genital tract.
About 3% of full-term and 30% of premature infant boys are born with at least one
undescended testis.
However, about 80% of cryptorchid testes descend by the first year of life (the
majority within three months), making the true incidence of cryptorchidism around
1% overall. Cryptorchidism may develop after infancy, sometimes as late as young
adulthood, but that is exceptional.
A testis absent from the normal scrotal position may be:

1. Anywhere along the "path of descent" from high in the posterior

(retroperitoneal) abdomen, just below the kidney, to the inguinal ring
2. In the inguinal canal
3. Ectopic, having "wandered" from the path of descent, usually outside the
inguinal canal and sometimes even under the skin of the thigh, the perineum,
the opposite scrotum, or the femoral canal
4. Undeveloped (hypoplastic) or severely abnormal (dysgenetic)
5. Missing (also see anorchia).
About two-thirds of cases without other abnormalities are unilateral; most of the other
third involve both testes. In 90% of cases, an undescended testis can be felt in the
inguinal canal. In a small minority of cases, missing testes may be found in the
abdomen or appear to be nonexistent (truly "hidden").
Undescended testes are associated with reduced fertility, increased risk of testicular
germ-cell tumors, and psychological problems when the boy is grown. Undescended
testes are also more susceptible to testicular torsion (and subsequent infarction)
and inguinal hernias. Without intervention, an undescended testicle will usually
descend during the first year of life, but to reduce these risks, undescended testes can
be brought into the scrotum in infancy by a surgical procedure called an orchiopexy.[3]
Although cryptorchidism nearly always refers to congenital absence or maldescent, a
testis observed in the scrotum in early infancy can occasionally "reascend" (move
back up) into the inguinal canal. A testis which can readily move or be moved
between the scrotum and canal is referred to as retractile
 Abdominal wall defects
Omphalocele
Definition it is a defect in abdominal wall musculature and skin with protrusion of
abdominal viscera contained within a membranous sac
Incidence small omphalocele 1:5000, large omphalocele 1:10000, male to female ratio
1:1
Cause: due to failure of the midgut to return to abdominal cavity by 10 th week of
gestation
Clinical findings
Covered cilical defect of the umbilical ring, defect may vary from 2-10 cm. sac is
composed of amnion, wharten's jelly and peritneum, 50% have accompanying liver,
and the cord is attached to the sac. The sac may rupture from delivery process

Gastroschaisis
Definition it is the defect in the abdominal wall displaced to the right of the umbilicus
and eviscerated bowel was not covered by a membrane.
Incidence: 1:20000 sex ratio 1:1, 10% have associated anomalies
Cause
Abnormal involution of right umbilical vein and failure of migration and fusion of the
lateral folds of the embryonic disc on the 3rd -4th week of gestation
Clinical findings
Defect to the right of intact umbilical cord allowing of extrusion of the abdominal
contents, defect less than 4 cm, and no covering
Management
Heat management, through strile wrap or strile bowel bag and radiant warmer), fluid
management nothing per mouth, nasogastric tube, antibiotic, and surgical
management

Pediatric umbilical hernia

Definition Umbilical hernia presents as a bulge at the site of the umbilicus. It is a
common finding during routine well-baby visits for the first few months of life.
Etiology
Umbilical hernia in children results from incomplete closure of the fascia the
umbilical ring, through which intra-abdominal contents may protrude.
Epidemiology:
Umbilical hernia are common in children, it is estimated 10-30% of all white children
at birth, decreasing to 2-10% at one year, with boys and girls affected equally. It is
common in African infants
History and physical
The history given byarents might include a swelling of the belly button, which
increases when the baby is crying, coughing, or straining. Patients with incarcerated
or strangulated umbilical hernia usually present with abdominal pain, nausea, and
vomiting
Treatment / Management
Repair of the umbilical hernia in infants is usually postponed due to a low rate of
complications and the majority of the umbilical defects will be closed spontaneously
within 2 years. Surgery is indicated for complications of the hernia which includes
incarceration, strangulation, or rupture.
 Congenital diaphragmatic hernia
Congenital diaphragmatic hernia occurs when the diaphragm, the muscle that separate
the chest from the abdomen, fails to close during prenatal development. This opening
allows the abdominal contents to migrate into chest, impacting the growth and
development of the lungs. The lungs will be smaller in size (pulmonary hypoplasia),
and will have less developed vessels. This causes high blood pressure in lungs
(pulmonary hypertension).
Sings and symptoms
Congenital diaphragmatic hernia is usually discovered during a routine prenatal
ultrasound. Sonographer may notice stomach, intestine or liver in chest. The heart
may also be pushed to one side by extra organs in the chest.
Treatment
Surgical repair of the diaphragmatic defect
 Hirschsprung's disease
Hirschsprung's disease also called congenital megacolon, or aganglionosis
Hirschsprung's disease is a condition that affects the large intestine (colon) and causes
problems with passing stools.
Symptoms
Signs and symptoms of Hirschsprung's vary with the severity of the condition.
Usually sings and symptoms appear shortly after birth, but sometimes they are not
apparent untile later in life. Typically, the most obvious sing is a newborn's failure to
have a bowel movement (defecation) within 48 hours after birth. Other signs and
symptoms in newborn may include; swollen abdomen, vomiting, constipation, or
diarrhea. In older children, sings and symptoms can include; swollen abdomen,
chronic constipation, failure to thrive and fatigue.
Causes
Hirschsprung's disease occurs when nerve cells in colon do not form completely.
Nerves in colon control the muscle contractions that move food through the bowels,
without the contractions, stool stays in the large intestine.
Diagnosis
Abdominal X-ray using a contrast dye; barium or gastrographin dye.
Anal moanometery
Biopsy

Treatment
Hirschsprung's disease is treated with surgery to bypass the part of the colon that's
lacking of nerve cells. There are two ways this can be done: a pull-through operationor a
colostomy surgery
.