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Embryology, Anatomy, and Physiology of the Pancreas

The human pancreas develops from the ventral and dorsal domains of the primitive duodenal endoderm beginning at about the 5th wk of gestation ( Fig. 374.1 ). The larger dorsal anlage, which develops into the tail, body, and part of the head of the pancreas, grows directly from the duodenum. The smaller ventral anlage develops as 1 or 2 buds from the primitive liver and eventually…

Inguinal Hernias

Inguinal hernias are one of the most common conditions seen in pediatric practice, with an overall incidence of 0.8–4.5% in term infants and children and increasing to nearly 30% in premature and low birthweight (<1 kg) infants. The repair of congenital inguinal hernia is the most common surgical procedure performed in pediatric surgical practice. The frequency of this condition, along with its potential morbidity of ischemic injury…

Tumors of the Digestive Tract

Tumors of the digestive tract in children are mostly polypoid. They are also commonly syndromic tumors and tumors with known genetic identification ( Table 372.1 ). They usually manifest as painless rectal bleeding, but when large they can cause obstruction or serve as lead points for intussusception. Most intestinal tumors can be generally classified into 2 groups: hamartomatous or adenomatous. Table 372.1 General Features of the…

Surgical Conditions of the Anus and Rectum

Anorectal Malformations Christina M. Shanti Keywords Imperforate anus Perineal fistula Fourchette fistula Rectovaginal fistula Cloaca Rectourethral fistula Caudal regression Anal stenosis Anterior ectopic anus Rectal atresia Currarino triad Tethered Cord PSARP: Posterior sagittal anorectoplasty Fecal continence ACE Antegrade continence enema MACE Malone antegrade continence enema To fully understand the spectrum of anorectal anomalies, it is necessary to consider the importance of the sphincter complex, a mass of…

Acute Appendicitis

Acute appendicitis remains the most common acute surgical condition in children and a major cause of childhood morbidity and health care costs, mostly associated with complicated/perforated appendicitis (PA). The peak incidence of acute appendicitis occurs in children in the second decade, and approximately 100,000 children are treated in children's hospitals for appendicitis each year. The broad spectrum of clinical presentation in acute appendicitis has been associated…

Functional Gastrointestinal Disorders

Functional gastrointestinal disorders (FGIDs) comprise a group of conditions that relate to the gastrointestinal (GI) tract. These disorders cannot be completely explained by anatomical or biochemical abnormalities (infectious, inflammatory). FGIDs commonly afflict children across a broad range of manifestations and are defined primarily by symptoms. The symptom-based criteria employed to classify FGIDs have been developed by expert consensus and opinion under the auspices of the Rome…

Chronic Diarrhea

Definition of Epidemiology Chronic diarrhea is defined as stool volume of more than 10 g/kg/day in toddlers/infants and greater than 200 g/day in older children that lasts for 4 wk or more. Persistent diarrhea began acutely but lasts longer than 14 days. In practice, this usually means having loose or watery stools more than 3 times a day . Awakening at night to pass stool is often a sign…

Acute Gastroenteritis in Children

The term gastroenteritis denotes inflammation of the gastrointestinal tract, most commonly the result of infections with bacterial, viral, or parasitic pathogens ( Tables 366.1 to 366.3 ). Many of these infections are foodborne illnesses ( Table 366.4 ). Several clinical syndromes are often described because they have different (albeit overlapping) etiologies, outcomes, and treatments. Acute gastroenteritis (AGE) captures the bulk of infectious cases of diarrhea. The…

Intestinal Transplantation in Children With Intestinal Failure

The introduction of tacrolimus and the development of the abdominal multiorgan procurement techniques allowed the tailoring of various types of intestine grafts that can contain other intraabdominal organs, such as the liver, pancreas, and stomach. The understanding that the liver protects the intestine against rejection demonstrates the interaction between recipient and donor immunocytes (host-versus-graft and graft-versus-host) which under the cover of immunosuppression allows varying degrees of…

Disorders of Malabsorption

All disorders of malabsorption are associated with diminished intestinal absorption of one or more dietary nutrients. Malabsorption can result from a defect in the nutrient digestion in the intestinal lumen or from defective mucosal absorption. Malabsorption disorders can be categorized into generalized mucosal abnormalities usually resulting in malabsorption of multiple nutrients ( Table 364.1 ) or malabsorption of specific nutrients (carbohydrate, fat, protein, vitamins, minerals, and…

Inflammatory Bowel Disease

The term inflammatory bowel disease (IBD) is used to represent 2 distinctive disorders of idiopathic chronic intestinal inflammation: Crohn disease and ulcerative colitis. Their respective etiologies are poorly understood, and both disorders are characterized by unpredictable exacerbations and remissions. The most common time of onset of IBD is during the preadolescent/adolescent era and young adulthood. A bimodal distribution has been shown with an early onset at…

Peptic Ulcer Disease in Children

Peptic ulcer disease, resulting from inflammation caused by an imbalance between cytoprotective and cytotoxic factors in the stomach and duodenum, manifests with varying degrees of gastritis or frank ulceration. The pathogenesis of peptic ulcer disease is multifactorial, but the final common pathway for the development of ulcers is the action of acid and pepsin-laden contents of the stomach on the gastric and duodenal mucosa and the…

Foreign Bodies and Bezoars

Foreign Bodies in the Stomach and Intestine Asim Maqbool Chris A. Liacouras Once in the stomach, 95% of all ingested objects pass without difficulty through the remainder of the gastrointestinal tract. Perforation after ingestion of a foreign body is estimated to be <1% of all objects ingested. Perforation tends to occur in areas of physiologic sphincters (pylorus, ileocecal valve), acute angulation (duodenal sweep), congenital gut malformations (webs, diaphragms,…

Ileus, Adhesions, Intussusception, and Closed-Loop Obstructions

Ileus Asim Maqbool Chris A Liacouras Ileus is the failure of intestinal peristalsis caused by loss of coordinated gut motility without evidence of mechanical obstruction. In children, it is most often associated with abdominal surgery or infection (gastroenteritis, pneumonia, peritonitis). Ileus also accompanies metabolic abnormalities (e.g., uremia, hypokalemia, hypercalcemia, hypermagnesemia, acidosis) or administration of certain drugs, such as opiates, vincristine, and antimotility agents such as loperamide when used…

Motility Disorders and Hirschsprung Disease

Chronic Intestinal Pseudoobstruction Asim Maqbool Kristin N. Fiorino Chris A. Liacouras Chronic intestinal pseudoobstruction (CIPO) comprises a group of primary and secondary disorders characterized as a motility disorder with the dominant defect of impaired peristalsis; symptoms are consistent with intestinal obstruction in the absence of mechanical obstruction ( Table 358.1 ). The natural history of primary pseudoobstruction is that of a progressive disorder, although there are occasional cases of…

Intestinal Duplications, Meckel Diverticulum, and Other Remnants of the Omphalomesenteric Duct

Intestinal Duplication Asim Maqbool Chris A. Liacouras Duplications of the intestinal tract are rare anomalies that consist of well-formed tubular or spherical structures firmly attached to the intestine with a common blood supply. The lining of the duplications resembles that of the gastrointestinal (GI) tract. Duplications are located on the mesenteric border and can communicate with the intestinal lumen. Duplications can be classified into three categories: localized duplications,…

Intestinal Atresia, Stenosis, and Malrotation

Approximately 1 in 1,500 children is born with intestinal obstruction. Obstruction may be partial or complete, and it may be characterized as simple or strangulating. Luminal contents fails to progress in an aboral direction in simple obstruction, whereas blood flow to the intestine is also impaired in strangulating obstruction. If strangulating obstruction is not promptly relieved, it can lead to bowel infarction and perforation. Intestinal obstruction…

Pyloric Stenosis and Other Congenital Anomalies of the Stomach

Hypertrophic Pyloric Stenosis Asim Maqbool Chris A. Liacouras Hypertrophic pyloric stenosis occurs in 1-3/1,000 infants in the United States. It is more common in whites of northern European ancestry, less common in blacks, and rare in Asians. Males (especially firstborns) are affected approximately 4-6 times as often as females. The offspring of a mother and, to a lesser extent, the father who had pyloric stenosis are at higher…