EM Command Center / Pediatrics & Obstetrics • 3 min read • 3 sections

Pediatric Abdominal Emergencies

Comprehensive emergency protocol for critical pediatric abdominal and gastrointestinal crises. Covers ultrasound identification and air-contrast reduction of intussusception, fluid and electrolyte resuscitation prior to pyloromyotomy in pyloric stenosis, emergent recognition of midgut volvulus, and pediatric appendicitis scoring.

Resuscitation Quick Ribbon (First 2 Minutes)

High-Acuity

Resus:Bilious emesis in neonate/infant = Volvulus until proven otherwise; decompress with NG tube, place large-bore IV, start IV crystalloid, obtain STAT Pediatric Surgery consult and Upper GI series.

Suspected Intussusception (colicky pain, drawing legs to abdomen, lethargy, currant jelly stool):Ultrasound abdomen (Target / Donut sign); treat with non-operative Air-Contrast Enema reduction.

Hypertrophic Pyloric Stenosis (3-8 week old projectile non-bilious vomiting):DO NOT rush to surgery; correct hypochloremic hypokalemic metabolic alkalosis with D5 0.45% NS + 20 mEq KCl first.

Testicular pain in infant/child:Sudden onset -> Emergent scrotal ultrasound and surgical exploration within 6 hours to salvage twisted testicle.

Bottom-Line Clinical Pearl

Bilious (green/yellow-green) vomiting in an infant or neonate is a true surgical emergency until malrotation with midgut volvulus is definitively excluded by an urgent upper GI series or exploratory laparotomy.

1. Critical Pediatric Abdominal Pathologies by Age

Condition	Typical Age	Classic Presentation & Key Signs	Diagnostic Modality & Management
Midgut Volvulus (Malrotation)	Neonates (< 1 month; 75% in first month)	Bilious vomiting, abdominal distension, hemodynamic collapse / shock	Stat Upper GI Series ('corkscrew' sign of twisted duodenum). Emergent surgical Ladd procedure.
Hypertrophic Pyloric Stenosis	3 to 8 weeks (rare > 3 months)	Non-bilious projectile vomiting immediately after feeding; infant remains hungry ('hungry vomiter'); palpable 'olive' mass in RUQ	Abdominal Ultrasound: Pyloric muscle thickness >= 3-4 mm, canal length >= 14-16 mm. Resuscitate electrolytes before pyloromyotomy.
Intussusception	3 months to 3 years (peak 6-12 months)	Intermittent severe colicky pain with knees drawn up, lethargy, 'currant jelly' stool (blood + mucus), sausage-shaped mass	Abdominal Ultrasound: 'Target' or 'Donut' sign (concentric bowel rings). Pneumatic (Air) Enema reduction (success > 85-90%).
Acute Appendicitis	Children > 5 years (can occur at any age)	Periumbilical pain migrating to RLQ, fever, anorexia, vomiting AFTER pain, peritoneal signs	Abdominal Ultrasound first-line (non-compressible appendix > 6 mm); CT abdomen/pelvis if US equivocal. Pediatric appendectomy.
Necrotizing Enterocolitis (NEC)	Premature / low birth weight infants	Abdominal distension, feeding intolerance, bloody stools, abdominal wall erythema	Abdominal X-ray: Pneumatosis intestinalis (gas in bowel wall), portal venous gas, pneumoperitoneum. NPO, broad-spectrum antibiotics, surgery.

2. Intussusception Ultrasound & Air-Enema Protocol

Intussusception is the invagination of proximal bowel (most commonly terminal ileum into cecum: ileocolic) caused by hypertrophied Peyer's patches (often following viral illness) or pathologic lead points (Meckel diverticulum, polyp, lymphoma):

Ultrasound Diagnostic Accuracy: Nearly 100% sensitivity and specificity when performed by experienced sonographers. Transverse view shows 'target' or 'donut' sign; longitudinal view shows 'pseudokidney' or 'sandwich' appearance.
Contraindications to Enema: Peritonitis, frank bowel perforation (free air on abdominal X-ray), or prolonged hemodynamic shock. These patients require immediate exploratory laparotomy.
Pneumatic (Air) Contrast Enema Technique: Performed under fluoroscopic or ultrasound guidance. Rectal catheter placed and air insufflated to a maximum safe pressure of 120 mmHg. Successful reduction is confirmed by reflux of air into multiple loops of terminal ileum.
Post-Reduction Observation: Observe in ED / short-stay for 4-6 hours; early recurrence occurs in 5-10% of cases within the first 24-48 hours.

3. Pyloric Stenosis Resuscitation Formula

Critical Pitfall / Contraindication

Surgical Principle: Hypertrophic pyloric stenosis is a MEDICAL resuscitation emergency, NOT a surgical emergency. Never take an infant to the OR with active hypochloremic hypokalemic metabolic alkalosis (risks severe intraoperative apnea and cardiac arrest). Resuscitate with IV D5 0.45% NS at 1.5x maintenance; add 20 mEq/L KCl once urine output is established. Target serum chloride > 100 mEq/L, bicarbonate < 30 mEq/L, and normal potassium prior to pyloromyotomy.

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