Chapter 37: Surgical Pediatrics – Peritonitis, Meckel's, SMA Syndrome, Choledochal Cyst, Gallstones, Hernias

Primary peritonitis · Meckel's diverticulum · Superior mesenteric artery syndrome · Choledochal cyst · Cholelithiasis · Inguinal/femoral/umbilical/epigastric hernia · Hydrocele

🩺 Core principles: Primary peritonitis (spontaneous) often in nephrotic/ascites patients. Meckel's: rule of 2's, presents with bleeding, obstruction, inflammation. SMA syndrome: weight loss, aortomesenteric angle narrowing. Choledochal cyst: jaundice, abdominal mass, pain; excision required. Hernias: inguinal most common; incarceration risk; elective repair.

📘 Summary: key surgical conditions

🦠 Primary peritonitis
Spontaneous infection (usually streptococcus, pneumococcus) in children with ascites (nephrotic syndrome, cirrhosis). Treatment: antibiotics, paracentesis.
🩸 Meckel's diverticulum
True diverticulum (rule of 2's: 2% population, 2 feet from ileocecal valve, 2 inches long). Presents with painless rectal bleeding, obstruction, inflammation (mimics appendicitis).
🔄 SMA syndrome
Compression of 3rd part of duodenum by SMA. Associated with rapid weight loss, eating disorders. Diagnosis: upper GI series (cutoff). Treatment: nutritional support, positioning.
🫘 Choledochal cyst
Cystic dilation of bile duct (Type I most common). Triad: jaundice, abdominal mass, pain. Risk of cholangiocarcinoma. Treatment: complete excision + Roux-en-Y hepaticojejunostomy.
🪨 Cholelithiasis
Gallstones in children: hemolytic disease, obesity, parenteral nutrition, idiopathic. May be asymptomatic or biliary colic; cholecystectomy if symptomatic.
🧬 Inguinal hernia & hydrocele
Indirect inguinal hernia (patent processus vaginalis). Presents with bulge, risk of incarceration. Hydrocele: communicating vs non-communicating; surgery for communicating or symptomatic.
🚺 Femoral hernia
Less common in children; more in girls. Presents below inguinal ligament; high risk of incarceration. Surgical repair.
⚪ Umbilical & epigastric hernia
Umbilical: common, often closes by 4-5 years. Repair if persistent >4-5 y or symptomatic. Epigastric: midline defect, fat or omentum; surgical repair.

📊 Key imaging: Meckel's scan for bleeding. Upper GI for SMA syndrome. Ultrasound for choledochal cyst/gallstones. Hernia: clinical diagnosis.

🔍 Approach to pediatric surgical conditions

Primary peritonitis suspicion – Child with ascites (nephrotic, liver disease) + diffuse peritonitis. Paracentesis, empiric antibiotics (3rd gen cephalosporin).

Painless rectal bleeding in child – Think Meckel's diverticulum. Meckel's scan (Tc-99m pertechnetate). Surgical resection if positive.

Vomiting + weight loss + postprandial epigastric pain – SMA syndrome. Upper GI series (cutoff sign). Nutritional rehabilitation, positioning, surgery if refractory.

Palpable right upper quadrant mass + jaundice – Choledochal cyst. Ultrasound, MRCP. Complete surgical excision.

Groin bulge – Inguinal hernia (reducible, may become incarcerated). Ultrasound if uncertain. Elective repair; emergency if incarcerated.

📋 Stepwise management of surgical conditions

Incarcerated inguinal hernia – Gentle manual reduction (Trendelenburg, sedation). If successful → elective repair. If irreducible → emergency surgery.

Meckel's diverticulum (bleeding/obstruction) – Resection of diverticulum (segmental bowel resection if ischemic). Laparoscopic approach common.

Choledochal cyst (Todani type I) – Complete cyst excision + Roux-en-Y hepaticojejunostomy. Lifelong follow-up (risk of cholangitis, anastomotic stricture).

SMA syndrome – Conservative: nasojejunal feeds, total parenteral nutrition, weight gain. Surgery (duodenojejunostomy) if fails.

Uncomplicated umbilical hernia (<2 cm, <2 years) – Observation (likely spontaneous closure). Repair if persists >4-5 years, large, or symptomatic.

⚡ Key reminders: Primary peritonitis: no surgical source; treat with antibiotics alone. Meckel's: most common cause of massive GI bleed in older child. Umbilical hernia rarely incarcerates.

🧠 Reflex prompts – pediatric surgery

🩸 Painless rectal bleeding in child → think?
Meckel's diverticulum (rule of 2's).
🫀 Choledochal cyst – classic triad?
Jaundice, abdominal mass, pain.
🍽️ SMA syndrome – diagnostic finding on upper GI?
Cutoff/obstruction of 3rd part of duodenum.
🩹 Most common hernia in children?
Indirect inguinal hernia (patent processus vaginalis).
⚪ Umbilical hernia – management?
Observation (most close by 4-5 years).
💧 Hydrocele – differentiate from hernia?
Transillumination positive; usually non‑reducible; ultrasound can confirm.