Pediatric emergency medicine trisk 639

Hernias
Goals of Treatment
Umbilical and inguinal hernias can lead to bowel entrapment, incarceration, and
ultimately necrosis. The goal of treatment is to reduce the hernia prior to bowel
ischemia or injury. If clinicians are unable to reduce the hernia at the bedside,
urgent surgical consultation is warranted in order to preserve bowel health.


FIGURE 96.40 Necrotizing enterocolitis. A: Multiple loops of distended bowel have bubbly
and linear radiolucencies in the bowel wall, representing pneumatosis intestinalis (arrows ). B:
Another patient with linear pneumatosis of the wall of the intestines (arrows ). C: Another


infant showing pneumatosis intestinalis and branching radiolucencies (arrowheads ) within the
liver representing air within the portovenous system. D: US of another infant with perforation
following necrotizing enterocolitis shows free intraperitoneal fluid (F) containing echogenic
debris and punctated areas of high echogenicity within the intestinal wall (arrows ), consistent
with pneumatosis intestinalis. E: Left lateral decubitus radiograph shows free intraperitoneal air
(arrow ) indicating perforation in an infant with necrotizing enterocolitis. (Reprinted with
permission from Brant WE, Helms C. Fundamentals of Diagnostic Radiology . Philadelphia,
PA: Lippincott Williams & Wilkins; 2012.)

CLINICAL PEARLS AND PITFALLS
Reduction of an incarcerated hernia may require sedation to facilitate
adequate muscle relaxation; sedation in the neonate requires additional
post-sedation monitoring.
Patients with abdominal wall defects, connective tissue disorders, or
chronically increased intra-abdominal pressure (ascites, dialysis,
ventriculoperitoneal shunting, etc.) are at increased risk for umbilical or
inguinal hernias.
In females, inguinal hernias may contain the ovary and may present

with labial swelling.
Inguinal Hernia
Inguinal hernias result when abdominal contents pass through the inguinal canal.
The overall incidence is between 1% and 4% but can be as high as 30% in
preterm infants. Similarly, the rates of incarceration increase with decreasing
gestational age. Hernias often will present with an intermittent bulge in the groin,
or swelling of the testes (boys) or labia (girls) that can be exacerbated during
crying or Valsalva maneuvers. While most inguinal hernias are painless, an
incarcerated hernia will present with a bulge that does not reduce spontaneously
and may be associated with irritability, pain, and/or vomiting. The differential
diagnosis of an inguinal mass includes hydrocele, testicular torsion, or
lymphadenopathy. Distinguishing between inguinal hernias and hydroceles may
be difficult at this age, and transillumination of the scrotal sac may not be a
reliable test. In general, hydroceles rarely cause pain and typically do not fully
reduce. In testicular torsion the testes is palpable and hard, and may or may not
be tender on examination. While most hernias, hydroceles, and torsions can be
differentiated on examination, US can be a helpful adjuvant.
Given the high rate of incarceration, surgical repair is recommended once an
inguinal hernia is identified, and can be done as an elective outpatient procedure.
If the hernia was difficult to reduce, surgical intervention should be performed


more urgently and a hernia that cannot be reduced should undergo immediate
surgical evaluation. Noncommunicating hydroceles often resolve spontaneously,
and given their more benign nature, can be observed as an outpatient.
Communicating hydroceles represent a patent tunica vaginalis and potential
hernia and therefore are repaired electively. Acute testicular torsion requires
emergent surgical reduction to reestablish blood flow to the testis prior to the
onset of necrosis (see Chapters 39 Inguinal Masses , 61 Pain: Scrotal , and 119
Genitourinary Emergencies ).

Umbilical Hernia
Umbilical hernias result when abdominal contents pass through an umbilical ring
that has not fully closed after birth. A common and frequently benign finding,
umbilical hernias often spontaneously resolve without intervention. Incarceration
of herniated bowel is a rare but serious complication that requires urgent
evaluation to preserve bowel integrity. Trisomy disorders are often accompanied
by laxity of abdominal wall and may be associated with umbilical hernias, as can
hypothyroidism. Surgical intervention is warranted if the hernia cannot be
reduced and/or shows signs of obstruction or incarceration. If the hernia persists
into early childhood, outpatient surgical repair may be recommended.

Umbilical Cord Anomalies
Goals of Treatment
The goal of treatment is to recognize and describe normal umbilical cord care,
and identify congenital cord anomalies, as well as acquired complications of the
umbilical cord.
CLINICAL PEARLS AND PITFALLS
Purulent or serosanguinous drainage from the umbilical stump may
represent omphalitis, which can proceed to life-threatening necrotizing
fasciitis if untreated.
Bleeding from the umbilicus can represent hemorrhagic disease of the
newborn or vitamin K deficiency.
Prolonged cord separation beyond 3 weeks can be a presenting sign of
leukocyte adhesion deficiency.
Normal Appearance of the Umbilical Cord Remnant