Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Chapter 25. Nasogastric Tube Insertion Download Section PDF Listen Boris Sudel, MD, B U.K. Li, MD + • Decompression of the upper gastrointestinal tract (eg, pancreatitis, intestinal obstruction).• Gastric lavage.• Enteral feeding. +++ Absolute + • Unstable airway.• Intestinal perforation.• Cervical spine trauma.• Facial trauma. +++ Relative + • Coagulopathy (prothrombin time > 18 seconds).• Thrombocytopenia (platelet count < 100,000/mcL).• Recent intestinal tract surgery (< 1 month ago). + • Lubricant gel.• Nasogastric (NG) tube.• Larger diameter, polyethylene NG tube for suction and decompression.• Smaller diameter, silicone NG tube for enteral feeding.• Water or normal saline at room temperature.• Drainage bag or feeding pump.• 60-mL catheter tip syringe.• Stethoscope. + • Bleeding.• Perforation. + • Measure length of tube insertion by positioning the tube from the nares or mouth to the ear, then to the umbilicus.• There is also a standard table, which uses height of child.• If the tube is obstructed, flush first with water; longstanding obstruction may be removed by flushing the tube with caffeinated soda. + • Explain indication and risks to the patient and parents.• Inform the patient of the intention of the procedure. + • Patient should be sitting. + • Tube position from the nose to the stomach. + • Measure the length of insertion from the nares to the ear and to the epigastrium (Figure 25–1); mark it on the tube with an indelible pen. + • Lubricate tube with gel.• Insert the tube through the nose (Figure 25–2). + • Ask the patient to cooperate by swallowing while the tube is being inserted.• Advance the tube to the length mark.• To check position, aspirate tube with 50-mL syringe (Figure 25–3); gastric aspirate (pH = 1–3) confirms positioning in stomach. + • Insert small amount of air (20–30 mL) via NG tube while listening to epigastric area of stomach with stethoscope.• If unsure about tube placement, verify tube position by obtaining a chest film before starting enteral feeding or drug treatment.• Secure tube to the face with tape. ++Figure 25–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Measuring the length of tube for insertion. ++Figure 25–2.Graphic Jump LocationView Full Size||Download Slide (.ppt)Inserting the nasogastric tube. ++Figure 25–3.Graphic Jump LocationView Full Size||Download Slide (.ppt)Checking the position of the tube. + • Monitor intake and output volume.• Evaluate tube position.• Patient symptoms. + • Aspiration.• Infection.• Sinusitis (caused by long-term NG tube feeding).• Bleeding.• Perforation.• Mucosal tears. + • Call a doctor when any of the following clinical signs are present:• Fever.• Nausea and vomiting.• Melanotic stool or bright red hematemesis.• Persistent abdominal pain.• Abdominal distention.• Chest pain. ++Arbogast D. Enteral feedings with comfort and safety. Clin J Oncol Nurs. 2002;6:275–280. [PubMed: 12240488] ++Gopalan S, Khanna S. Enteral nutrition delivery technique. Curr Opin Clin Nutr Metab Care. 2003;6:313–317. [PubMed: 12690265] ++Levy H. Nasogastric and nasoenteric feeding tubes. Gastrointest Endosc Clin N Am. 1998;8:529–549. [PubMed: 9654567] + Chapter 26. Gastric Lavage Download Section PDF Listen Boris Sudel, MD, B U.K. Li, MD + • Therapeutically: To remove gastric contents after poisoning or drug overdose.• Diagnostically: To confirm upper gastrointestinal bleeding. +++ Absolute + • Unstable airway.• Intestinal perforation.• Cervical spine trauma.• Facial trauma. +++ Relative + • Coagulopathy (prothrombin time > 18 seconds).• Thrombocytopenia (platelet count < 100,000/mcL).• Recent intestinal tract surgery (< 1 month ago). + • Lubricant gel.• Large bore orogastric tube.• Terumo 60-mL catheter tip syringe.• Normal saline at 38 °C.• Drainage basin.• Stethoscope. + • Perforation.• Bleeding. + • Measure length of tube insertion by positioning the tube from the nares or mouth to the ear, and to the umbilicus.• There is also a standard table, which uses height of child.• If the tube is obstructed, flush first with water; longstanding obstruction may be removed by flushing the tube with caffeinated soda. + • Explain indication and risks to the patient and parents.• Inform the patient of the intention of the procedure. + • Left lateral head-down position with a 20-degree table tilt (Trendelenburg). + • Tube position from the nose to the stomach. + • Measure the length of insertion from the mouth to the ear to the epigastrium (Figure 26–1); mark it on the tube with an indelible pen. + • Lubricate tube with gel.• Insert the tube through the mouth midline after lubrication.• Ask the patient to cooperate by swallowing while the tube is being inserted.• Advance the tube to the length mark.• To check position, aspirate tube with 50-mL catheter tip syringe (Figure 26–2); gastric aspirate confirms positioning in stomach. + • Insert small amount of air (20–30 mL) via orogastric tube while listening to the epigastric area with stethoscope.• If unsure about tube position, obtain a chest film to confirm tube position.• Secure tube to the face with tape.• After insertion of the orogastric tube, begin to irrigate stomach with saline.• Use 10–15-mL/kg aliquots of warm (38 °C) isotonic saline.• Lavage should continue until the effluent is clear.• For diagnostic lavage, notice presence of fresh red blood, blood clots, or coffee ground material to confirm upper gastrointestinal bleeding.• At this time, diagnostic lavage should be stopped.• Confirm presence of blood with Gastroccult cards. ++Figure 26–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Measuring the length of tube for insertion. ++Figure 26–2.Graphic Jump LocationView Full Size||Download Slide (.ppt)Checking the position of the tube. + • Monitor intake and output volume.• Evaluate tube position.• Patient symptoms. + • Aspiration.• Bleeding.• Perforation.• Mucosal tears. + • There is no certain evidence that gastric lavage improves clinical outcome, and it can cause significant morbidity.• In experimental studies, the amount of marker removed by gastric lavage was highly variable and diminished with time.• Gastric lavage should not be considered unless a patient has ingested a potentially life-threatening amount of a poison and the procedure can be undertaken within 60 minutes of ingestion. Even then, clinical benefit has not been confirmed in controlled studies. + • Call a doctor when any of the following clinical signs are present:• Fever.• Nausea and vomiting.• Melanotic stool or bright red hematemesis.• Abdominal pain.• Abdominal distention.• Chest pain. ++Bartlett D. The ABCs of gastric decontamination. J Emerg Nurs. 2003;29:576–577. [PubMed: 14631350] ++Tucker JR. Indications for, techniques of, complications of, and efficacy of gastric lavage in the treatment of the poisoned child. Curr Opin Pediatr. 2000;12:163–165. [PubMed: 10763767] ++Vale JA, Kulig K; American Academy of Clinical Toxicology; European Association of Poisons Centres and Clinical Toxicologists. Position paper: gastric lavage. J Toxicol Clin Toxicol. 2004;42:933–943. [PubMed: 15641639] + Chapter 27. Gastrostomy Tube Replacement Download Section PDF Listen Boris Sudel, MD, B U.K. Li, MD + • First change should be performed 6–8 weeks after initial gastrostomy tube placement.• Dislodged gastrostomy tube or gastrostomy button.• Replacing a gastrostomy button.• Blocked gastrostomy tube or gastrostomy button. +++ Absolute + • Unstable airway.• Hemodynamically unstable patient.• Intestinal perforation. +++ Relative + • Coagulopathy (prothrombin time > 18 seconds).• Thrombocytopenia (platelet count < 100,000/mcL).• Recent intestinal tract surgery (< 1 month ago). + • Lubricant gel.• Gastrostomy catheter.• Button.• Normal saline.• 10-mL syringe. + • Bleeding.• Perforation. + • Explain indication and risks to the patient and parents.• Inform the patient of the intention of the procedure. + • Supine. + • The gastrostomy opening is usually located in the left upper quadrant of the abdomen with the bulb located in the body of the stomach. + • Prepare new tube for insertion.• Remove from package.• Check balloon integrity by inflating.• Deflate and lubricate end with gel.• Put stopper in place.• Remove old tube.• Deflate balloon fully with syringe and pull out firmly.• There is usually some resistance caused by the tube cuff.• Insert new tube into stoma.• If patient is obese, may need to go further.• Check old tube shaft measurements before removing.• Without moving the tube, inflate balloon fully.• Tug on tube to check whether the balloon is inflated and then secure (Figure 27–1). + • While firmly pulling tube upward, push fixation bolster down to the skin so that any in-out movement of the tube is prevented.• Small amount of slack (~2–5 mm) is advised for comfort and to prevent pressure necrosis.• Gastric contents will probably now be apparent in the tube.• If not, and stoma is new, aspirate tube to check.• If stoma is well established (> 3 months) and this is not the first tube change, aspiration test is unnecessary. ++Figure 27–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Inserting and positioning gastrostomy tube. +++ Checking the Balloon + • Balloons deflate over time (by osmosis), so contents should be checked monthly (more often leads to increased risk of bursting).• Withdraw the contents of balloon using a 10-mL syringe; hold the tube in place carefully to avoid displacement.• Observe amount withdrawn and top up to correct amount.• Refill balloon with normal saline.• Note: It is wise to push the tube down into the stomach to avoid accidentally pulling it out. (If this happens, simply push the tube back in.)• Caution:• You may feel resistance if you are inflating the balloon in the tract. Stop and push in further. Deflate the balloon and reposition the tube.• Pushing the tube in too far can place it through the pyloric sphincter into the duodenum. If you inflate the balloon there, the stomach cannot empty, causing excessive billous, formula free vomiting, and tube leakage. + • Assess balloon inflation.• Evaluate position of the gastrostomy tube for blockage, dislodgment.• Check the skin for infection or granulation tissue as well as around the tube for leakage. + • Perforation, creating false tract.• Pneumoperitoneum.• Bleeding.• Infection. + • Call a doctor when any of the following clinical signs are present:• Fever.• Nausea and vomiting.• Melanotic stool or bright red hematemesis.• Abdominal pain.• Abdominal distention. ++Arrowsmith H. Nursing management of patients receiving gastrostomy feeding. Br J Nurs. 1996;5:268–273. [PubMed: 8715740] ++Kirby DF, Craig RM, Tsang TK, Plotnick BH. Percutaneous endoscopic gastrostomies: a prospective evaluation and review of the literature. JPEN J Parenter Enteral Nutr. 1986;10:155–159. [PubMed: 3083129] ++Willwerth BM. Percutaneous endoscopic gastrostomy or skin-level gastrostomy tube replacement. Pediatr Emerg Care. 2001;17:55–58. [PubMed: 11265912] + Chapter 28. Paracentesis/Peritoneal Lavage Download Section PDF Listen Boris Sudel, MD, B U.K. Li, MD + • Diagnostic sampling of ascitic fluid (eg, internal bleeding following blunt abdominal trauma, chylous ascites after surgery, rule out malignancy, identification of infectious organism in spontaneous bacterial peritonitis).• Therapeutic removal of the ascitic fluid (eg, chylous ascites, tense ascites, intestinal lymphangiectasia). +++ Absolute + • Unstable airway.• Hemodynamically unstable patient.• Intestinal perforation. +++ Relative + • Infection of the abdominal wall.• Coagulopathy (prothrombin time > 18 seconds).• Thrombocytopenia (platelet count < 100,000/mcL).• Recent intestinal tract surgery (< 1 month ago). + • Alcohol swabs, povidone-iodine.• 23-gauge and 21-gauge needles or angiocatheters with syringes.• Local anesthetic (eg, 1% lidocaine).• Large bore needle with plastic catheter.• Sterile containers for fluid collection.• Appropriate culture tubes for microorganisms. + • Pneumoperitoneum.• Perforation: Intestine, solid organs.• Bleeding.• Infection. + • Explain indication and risks to the patient and parents.• Inform the patient of the intention of the procedure. + • Supine or side. + • The preferred site is in the midline approximately one-third of the distance from the umbilicus to the symphysis pubis (Figure 28–1). + • In infants, the fluid may bulge laterally, and the paracentesis may be obtained laterally to that point. ++Figure 28–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Anatomic landmarks and sites of entry. +++ Paracentesis + • The puncture site should be shaved, if necessary, and cleansed with povidone-iodine.• Inject local anesthetic, infiltrating the skin first and then penetrating into deeper layers.• A small 3-mm incision can be made with a scalpel to help insert the needle. Using Z-track technique, insert the tap needle 1–2 inches into the abdomen (Figure 28–2). + • Obtain a sample of fluid or withdraw as much fluid as necessary with a syringe (in case of therapeutic lavage) (Figure 28–3). + • Remove the needle and apply a pressure dressing to the puncture site.• If an incision was made, it may be closed using 1 or 2 stitches.• The ascitic fluid removed may be replaced 1:1 with 5% albumin IV. ++Figure 28–2.Graphic Jump LocationView Full Size||Download Slide (.ppt)The Z-track. A: Needle is inserted perpendicular to skin while skin is pulled taut. B: Sagittal view. C: Alternatively, needle can be inserted at 45 degrees to skin and aimed caudally. D: Resultant Z-track (arrows). ++Figure 28–3.Graphic Jump LocationView Full Size||Download Slide (.ppt)Removing fluid. +++ Diagnostic Peritoneal Lavage ++Table Graphic Jump Location | Download (.pdf) | Print• Diagnostic peritoneal lavage is usually performed by a surgeon to rule out internal bleeding following trauma. + • The puncture site should be shaved, if necessary, and cleaned with povidone-iodine.• Inject local anesthetic, infiltrating the skin first and then penetrating into deeper layers.• A small 3-mm incision can be made with a scalpel to help insert the needle.• Insert the tap needle 1–2 inches into the abdomen. + • Insert a trochar and peritoneal catheter until the peritoneal cavity is reached (the resistance suddenly gives away).• Remove the trochar and fix the catheter to the skin with a stitch.• Aspirate.• If no bloody fluid is withdrawn, infuse 20 mL/kg of Ringer’s lactate over 5–10 minutes:• Turn the patient from side to side.• Siphon the fluid off.• Inspect for level of turbidity.• Send fluid to laboratory for red and white blood cell counts, bacterial culture, amylase.• Ascitic fluid should be sent for cytology, amylase, albumin, triglycerides, and culture. + • Monitor vital signs (a rapid loss of significant volumes of ascitic fluid may lead to hypotension). +++ Diagnostic Peritoneal Lavage ++Table Graphic Jump Location | Download (.pdf) | Print• The evidence for visceral blunt trauma with peritoneal lavage is gauged as positive, indeterminate, or negative. +++ Positive + • Aspiration of free flowing blood, or• Aspiration of feces, or• Bloody lavage fluid, from peritoneal lavage catheter containing:• RBC > 100,000/mcL.• WBC > 500/mcL.• Amylase > 175 IU/dL. +++ Indeterminate + • Serosanguinous lavage fluid:• RBC 50,000–100,000/mcL.• WBC 100–500/mcL.• Amylase > 75 IU/dL, < 175 IU/dL. +++ Negative + • Clear lavage fluid:• RBC < 50,000/mcL.• WBC < 100/mcL.• Amylase < 75 IU/dL. +++ Complications + • Pneumoperitoneum.• Perforation: Intestine, organ.• Bleeding.• Infection. + • Call a doctor when any of the following clinical signs is present:• Fever.• Nausea and vomiting.• Blood in the stool.• Abdominal pain.• Abdominal distention. ++Gerber DR, Bekes CE. Peritoneal catheterization. Crit Care Clin. 1992;8:727–742. [PubMed: 1393748] ++Grabau CM, Crago SF, Hoff LK et al. Performance standards for therapeutic abdominal paracentesis. Hepatology. 2004;40:484–488. [PubMed: 15368454] ++Kramer RE, Sokol RJ, Yerushalmi B et al. Large-volume paracentesis in the management of ascites in children. J Pediatr Gastroenterol Nutr. 2001;33:245–249. [PubMed: 11593116] ++Sartori M, Andorno S, Gambaro M et al. Diagnostic paracentesis. A two-step approach. Ital J Gastroenterol. 1996;28:81–85. [PubMed: 8781999] + Chapter 29. Hernia Reduction Download Section PDF Listen Marybeth Browne, MD, Anthony Chin, MD, Marleta Reynolds, MD + • A hernia is a benign process unless the contents within the hernia sac become incarcerated.• Incarceration is the inability of the hernia’s contents to be reduced.• The risk of incarceration is highest during infancy with a 28–31% incarceration rate before 3 months of age and 15–24% by 6 months of age.• Although the risk of incarceration gradually decreases with age, the severity of its consequences mandates immediate manual reduction when possible, followed by prompt operative repair. +++ Absolute + • Reduction should not be attempted if there has been bowel compromise or when the patient appears toxic.• Concern for toxicity should arise when the patient has any of the following:• Severe tachycardia.• Increased leukocyte count.• Bloody stool or positive result on modified guaiac test.• Severe pain with palpation.• Erythema of the hernia sac. +++ Relative + • Some surgeons do not advocate manual reduction if the patient has any signs or symptoms of intestinal obstruction. + • Gloves. +++ Risks + • There are few risks with manual reduction.• However, parents should be informed that once a hernia has been incarcerated, it has a high probability of recurring.• A hernia will not resolve on its own and operative management will be required in the near future.• If sedation is used during the reduction, a parent is required to sign a consent form and be made aware of the risks and benefits that accompany sedation.• In addition, a parent should be instructed not to feed the child should the hernia become strangulated or is not reducible and the patient requires emergent operative intervention. + • The most common differential diagnosis for a bulge in the groin consists of the following:• Hernia.• Hydrocele.• Lymphadenopathy.• Abscess.• Undescended testis.• A testicle in the groin may resemble a hernia; thus, it is imperative to confirm the presence of the testis in the scrotum during initial evaluation.• A hydrocele is usually present at birth and can also be bilateral in nature. It is generally described by the parents as a rapid swelling of the scrotum that may cause the child discomfort if tense.• With a communicating hydrocele, the swelling is most prominent at the end of the day and reduces over night.• On examination, a hydrocele is a soft, bluish, cystic swelling within the scrotal sac that cannot be reduced.• With a hydrocele, the spermatic cord should be able to be felt at its upper limits unlike a hernia, whose upper margin is not clearly defined and continues into the internal ring.• Transillumination may help differentiate a hernia from a hydrocele.• Hernias do not transilluminate as brightly as hydroceles.• However, hernias can transilluminate if they are filled with an air-filled loop.• Simple hydroceles generally resolve by the age of 1 year and do not require an operation until after this time. + • The child should be examined supine and undressed to observe any asymmetry or obvious masses in the scrotum or groin area.• Both testicles should be palpated and identified separately from the mass.• Next, the index finger should be placed over the inguinal canal in the attempt to palpate the cord structures.• While perpendicular to the inguinal structures, the finger should be rubbed from side to side.• If the cord structures appear thickened compared with the normal side, this is considered a positive silk glove sign.• Ideally, this should feel similar to rubbing 2 pieces of silk together or running your fingers over a plastic baggy that contains a drop of water.• If there is a good history of a hernia but the physical examination does not demonstrate a bulge, attempts to reproduce the hernia may be accomplished by increasing the intra-abdominal pressure.• This can be achieved in infants by holding the patient with legs and arms extended, which will cause some struggle and an increase in intra-abdominal pressure.• For older children, a Valsalva maneuver, such as blowing up a balloon or pretending to blow out candles, may be performed.• It is important to note the extent of the hernia sac and the ease by which it reduces when the child is relaxed. + • The anatomy for the inguinal region is basically that of the adult (Figure 29–1). + • However, the inguinal canal is not completely developed, making it extremely short, and the external ring is placed almost directly over the internal ring. ++Figure 29–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Anatomy for the inguinal region. + • The patient should be placed supine and allowed to relax.• If the hernia does not reduce with gentle pressure, consider using mild or conscious sedation. After allowing enough time for the sedation to take effect, attempts are made to align the hernia sac in the inguinal canal.• When attempting manual reduction, it is important to remember that the inguinal canal is not completely developed, making it extremely short, and the external ring is placed almost directly over the internal ring.• After alignment, firm, constant, posterior, and upward pressure is applied to the hernia sac with the contralateral hand while guiding the hernia’s contents through the internal ring with the ipsilateral hand (Figure 29–2). + • This may take several minutes of constant pressure and several attempts at reduction.• Placing the patient in the Trendelenburg position, as well as applying an ice pack to the groin area for several minutes prior to manipulation, may help ease the reduction. ++Figure 29–2.Graphic Jump LocationView Full Size||Download Slide (.ppt)Reduction of inguinal hernia. + • Manual reduction has few complications.• However, the physician who performs the reduction should be aware that, with too much force, it is possible to cause a bowel perforation.• There is also the possibility that a piece of strangulated bowel may be reduced together with the hernia sac.• If this should occur, the patient’s symptoms will not resolve.• Peritonitis may develop, requiring an emergent operation. + • Over 80% of incarcerated hernias can be initially reduced with manual reduction.• However, because most inguinal hernias do not spontaneously resolve and have a risk of recurrent incarceration or possible strangulation, definitive operative repair is necessary.• Most surgeons will attempt operative repair 48 hours after the manual reduction, allowing tissue swelling to resolve prior to the procedure. + • A pediatric surgeon should be contacted to arrange for prompt follow-up in all patients with an incarcerated hernia.• However, if a patient has signs of intestinal obstruction, toxicity, bowel strangulation, or an incarcerated hernia that cannot be reduced, a pediatric surgeon should be notified immediately and the patient prepared for operative repair. ++Coles J. Operative cure of inguinal hernia in infancy and childhood. Am J Surg. 1945;69:366. ++D’Agostino J. Common abdominal emergencies in children. Emerg Med Clin North Am. 2002;20:139–153. [PubMed: 11826631] ++Grosfeld JL. Current concepts in inguinal hernia in infants and children. World J Surg. 1989;13:506–515. [PubMed: 2573200] ++Gross RE. Inguinal Hernia. In Gross RE, ed. The Surgery of Infancy and Childhood. Philadelphia: WB Saunders Company; 1953:449–462. ++Kapur P, Caty MG, Glick PL. Pediatric hernias and hydroceles. Pediatr Clin North Am. 1998;45:773–789. [PubMed: 9728185] ++Ladd WE, Gross RE. Abdominal Surgery in Infancy and Childhood. Philadelphia: WB Saunders Company; 1941. ++Ziegler MM, Azizkhan RG, Weber TR, eds. Inguinal and Femoral Hernia. In: Operative Pediatric Surgery. New York: McGraw-Hill Co; 2003:543–554. + Chapter 30. Rectal Prolapse Reduction Download Section PDF Listen Anthony Chin, MD, Marybeth Browne, MD, Marleta Reynolds, MD + • Most cases of rectal prolapse reduce spontaneously.• Rarely, a surgical procedure may be necessary to correct a full-thickness prolapse.• Rectal prolapse should be promptly reduced to prevent a sustained prolapse that allows edema to form and potential subsequent venous congestion and thrombosis to develop, which may lead to ulceration of the rectal mucosa with bowel ischemia and infarction.• A rectal examination needs to be performed to differentiate prolapse from an intussusception or rectal polyp.• Diagnostic studies are often not necessary, but a proctoscopy, colonoscopy, or barium enema may be indicated when the patient has a history of rectal bleeding.• Children need to be tested for parasites and cystic fibrosis as well as other causes of anal straining (including neuromuscular problems, proctitis, and inflammatory bowel disease). +++ Absolute + • Presence of nonviable bowel or rupture of rectal mucosa.• Child appears toxic (ie, with fever, tachycardia, or leukocytosis). +++ Relative + • Uncooperative patient.• Questionable viability of bowel.• Mucosal ulceration.• Recent rectal pull-through procedure. + • Gloves.• Lubrication.• Table sugar or salt.• 6F rectal tube. + • There are very few risks with manual reduction.• Parents should be informed that prolapse may recur and instructed on proper technique for reduction.• Discuss the potential risk of sedative medication.• Recurrent prolapse or a prolapse that is not amenable to manual reduction may require operative intervention. + • Rectal prolapse commonly presents in children between the ages of 1 and 3 years, with a primary symptom of anal discomfort or prolapse after defecation; occasionally it may present as bleeding.• When a prolapse is not immediately present and the child is old enough to cooperate, diagnosis can potentially be made with the child squatting or straining on the toilet.• A glycerine suppository may also aid in the diagnosis.• Palpate the prolapsed segment between the fingers and thumb to help differentiate mucosa from full-thickness prolapse.• Mucosal prolapse tends to have radial folds and full-thickness prolapse exhibits concentric folds (Table 30–1).• Differentiate from polyp, which is plum-colored and does not involve the entire anal circumference.• Differentiate from intussusception, which on digital examination allows the examiner to insert between the anal wall and the protruding mass. With a prolapse, there is no space between the perianal skin and the protruding mass. ++Table Graphic Jump LocationTable 30–1. Classification of rectal prolapse.View Table||Download (.pdf)Table 30–1. Classification of rectal prolapse.CharacteristicsMucosal ProlapseFull-thickness Prolapse (Procidentia)Layers involvedMucosa onlyAll layers of the rectumPhysical appearanceRosette appearing with radial folds at anal junctionCircular folds in prolapsed mucosa May not be seen with significant edema + • Consider use of ketamine or midazolam. + • Have the patient lie supine in the Trendelenburg position on a padded surface.• Elevate the lower extremities and flex the patient’s hips. + • Rectal prolapse occurs with stretching of the pelvic peritoneum, weakening and dilation of the rectal suspension mechanism, and a low resting anal sphincter pressure that may be secondary to protracted straining due to diarrhea and constipation.• It may also be attributed to poor posterior rectal fixation, redundant rectosigmoid colon, neurologic diseases, cystic fibrosis, infections, malnutrition, previous surgery, undiagnosed Hirschsprung disease, or imperforate anus.• On examination, a mucosal prolapse is described as a swollen rosette of mucosa with radial folds at the anal junction (Figure 30–1). + • A full-thickness prolapse (procidentia), involving all layers of the rectum, has circular folds of prolapsed mucosa (Figure 30–2). ++Figure 30–1.Graphic Jump LocationView Full Size||Download Slide (.ppt)Mucosal prolapse. ++Figure 30–2.Graphic Jump LocationView Full Size||Download Slide (.ppt)Full-thickness prolapse. + • The prolapsed rectum may be reduced with gentle and steady digital pressure.• The herniated bowel should be grasped with a lubricated glove between fingertips with cephalad pressure applied to the tip of the prolapsed rectum until reduction is complete.• Firm and steady pressure for several minutes may be necessary in edematous bowel to reduce swelling and allow reduction.• A digital examination at the end of the procedure is necessary to verify that the reduction is complete.• Taping of the buttocks has been used in the past but is not always effective.• If manual reduction is unsuccessful, sedation and perianal field block with local anesthesia may aid in the success of reduction.• With significant bowel edema, the application of topical sucrose or table salt applied to the prolapsed rectum may decrease edema and allow reduction of herniated bowel.• It has also been described that use of a soft, lubricated, 6F rectal tube inserted through a segment of prolapsed bowel may help guide reduction (Figure 30–3). + • Reduction is accomplished by pushing the prolapsed segment over the tube.• If all attempts fail, the prolapse needs to be surgically reduced.• The parents should be instructed on how to reduce the prolapsed rectum should it occur at home and instructed to call or return to the emergency department if they are unable to reduce the prolapse.• Surgical consultation should be obtained for the reduction under the following circumstances:• Presence of mucosal ulceration.• Failure of reduction.• Severe pain and discomfort.• Patient with history of pull-through procedure for imperforate anus and Hirschsprung disease. ++Figure 30–3.Graphic Jump LocationView Full Size||Download Slide (.ppt)Reduction of prolapse with rectal tube. + • Monitor patient vital signs if using sedation. + • Recurrence.• Mucosal ulceration.• Necrosis of bowel wall.• Bleeding.• Infection from inadvertent injury to the rectum during reduction. + • Treatment of rectal prolapse involves treating the underlying cause of straining during defecation. Therapy includes dietary modifications and identifying the cause (eg, intractable diarrhea or constipation).• If recurrent prolapse persists after several months of appropriate and adequate medical therapy, surgical intervention in the form of a cerclage, sclerotherapy, cauterization therapy, or transanal or perineal rectopexy may be necessary. + • Instruct parents to notify you if prolapse recurs and is unable to be reduced. ++Bhandarkar DS, Tamhane RG. Reduction of complete rectal prolapse. Trop Doct. 1992;22:180. [PubMed: 1440901] ++Coburn WM III, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. 1997;30:347–349. [PubMed: 9287900] ++Corman ML. Rectal prolapse in children. Dis Colon Rectum. 1985;28:535–539. [PubMed: 3893949] ++Duhamel J, Pernin P. Anal prolapse in the child. Ann Gastroenterol Hepatol (Paris). 1985;21:361–362. [PubMed: 4096498] ++Groff DB, Nagaraj HS. Rectal prolapse in infants and children. Am J Surg. 1990;160:531–532. [PubMed: 2240390] ++Siafakas C, Vottler TP, Andersen JM. Rectal prolapse in pediatrics. Clin Pediatr (Phila). 1999;38:63–72. [PubMed: 10047938] ++Stafford PW. Other Disorders of the Anus and Rectum, Anorectal Function. In: O’Neil JA et al, eds. Pediatric Surgery. 5th edition. St Louis: Mosby; 1998:1449–1460.