Review

Contemporary management of abdominal surgical emergencies in infants and children L. W. E. van Heurn1 , M. P. Pakarinen2 and T. Wester3 Departments of Paediatric Surgery, 1 Maastricht University Medical Centre, Maastricht, The Netherlands, 2 Children’s Hospital, Helsinki University, Helsinki, and 3 Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden Correspondence to: Professor L.W.E. van Heurn, Department of Paediatric Surgery, Maastricht University Medical Centre, Box 5800, 6202 AZ Maastricht, The Netherlands (e-mail: [email protected])

Background: Acute abdominal complaints in children are common presentations in the emergency

department. The aetiology, presentation, diagnosis and management often differ from those in adults. Methods: This review was based on expert paediatric surgical experience confirmed by evidence

from the literature obtained by searching PubMed and the Cochrane Library. Keywords used were the combinations of ‘abdominal emergencies’, ‘acute abdomen’ and the disorders ‘acute appendicitis’, ‘intussusception’, ‘volvulus’, ‘Meckel’s diverticulum’, ‘incarcerated inguinal hernia’, ‘testicular torsion’ and ‘ovarian torsion’ with ‘children’. Information was included from reviews, randomized clinical trials, meta-analyses, and prospective and retrospective cohort studies. Results: Presentation and symptoms of abdominal emergencies, especially in young children, vary widely, which renders recognition of the underlying disorder and treatment challenging. Critically targeted imaging techniques are becoming increasingly important in obtaining the correct diagnosis without unnecessary delay. Minimally invasive techniques have become the method of choice for the diagnosis and treatment of many abdominal emergencies in children. Conclusion: Knowledge of abdominal disorders in childhood, their specific presentation, diagnosis and treatment facilitates management of children with acute abdomen in emergency departments. Imaging and minimally invasive techniques are becoming increasingly important in the diagnosis of acute abdomen in children. Urgent operation remains the cornerstone of therapy for most acute abdominal disorders. Paper accepted 15 September 2013 Published online in Wiley Online Library (www.bjs.co.uk). DOI: 10.1002/bjs.9335

Introduction

Acute abdomen is a poorly defined term for a diverse range of acute abdominal disorders that require prompt treatment. The causes of these abdominal emergencies include inflammation and ischaemia of abdominal organs, obstruction and perforation of a hollow organ, and gastrointestinal bleeding. Children with acute abdomen often present with acute abdominal pain, but vomiting, rectal blood loss and even sepsis may be the first symptom of severe abdominal pathology. Children are often not able to provide the desired information, which makes recognition of the cause of abdominal complaints more difficult; the consequences of a missed diagnosis may be particularly devastating at a young age. The present review provides an overview of general symptoms of abdominal emergencies in children, and discusses the most common and the most  2013 BJS Society Ltd Published by John Wiley & Sons Ltd

devastating disorders that cause acute abdomen (Table 1). Neonates with acute abdomen and children with significant gastrointestinal bleeding are beyond the scope of this review. Methods

The review was based on expert paediatric surgical experience confirmed by evidence from the literature obtained by searching PubMed and the Cochrane Library. Keywords used were the combinations of ‘abdominal emergencies’, ‘acute abdomen’ and the disorders ‘acute appendicitis’, ‘intussusception’, ‘volvulus’, ‘Meckel’s diverticulum’, ‘incarcerated inguinal hernia’, ‘testicular torsion’ and ‘ovarian torsion’ with ‘children’. Included articles were reviews, randomized clinical trials, meta-analyses, and prospective and retrospective cohort studies. BJS 2014; 101: e24–e33

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Table 1

Causes of acute abdomen in children

Appendicitis Meckel’s diverticulum Intussusception Intestinal malrotation and midgut volvulus Adhesive bowel obstruction Testicular/ovarian torsion Incarcerated inguinal hernia Omental torsion Inflammatory bowel disease Pancreatitis Cholecystitis Urolithiasis Pelvic inflammatory disease Intra-abdominal malignancies Rare congenital malformations Intestinal duplication Urachal remnant Intestinal lymphatic malformation Constipation Pneumonia Urinary tract infection

Acute abdomen: general considerations

Clinical presentation The presenting symptoms of acute abdomen depend largely on the age of the child. In general, younger children present less often with abdominal pain and, if present, the pain is difficult to assess. Extra-abdominal disorders in children, including pneumonia and even pharyngitis, may present with abdominal pain; no specific diagnosis can be made in one-third of children presenting with acute abdominal pain. Localization of abdominal pain in children is notoriously unreliable. Vomiting can be caused by severe abdominal pain but also by infection, bowel obstruction, and neurological, metabolic or endocrine causes. Bilious vomiting, particularly in infants, is an alarming symptom that necessitates exclusion of midgut volvulus. Constipation and diarrhoea are often associated with abdominal complaints, but the diagnostic value is limited. Bloody stools in an ill child may be a sign of severe abdominal pathology.

Physical examination Physical examination starts with close observation of the child, soothing and distracting their attention. To facilitate examination of the abdomen, it can be palpated with the child on the parent’s lap, the child facing away, and peritoneal signs may become evident if the parent bounces the child up and down. Digital rectal examination has limited value in the diagnosis of undifferentiated  2013 BJS Society Ltd Published by John Wiley & Sons Ltd

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abdominal pain and does not add to the diagnostic accuracy of appendicitis1 . Examination of the groins and genitals is imperative. An incarcerated hernia and testicular torsion are often accompanied by abdominal complaints.

Pain medication Traditionally clinicians do not give adequate analgesia in patients with acute abdominal pain. There is a general opinion that opiate analgesia before surgical assessment obscures physical examination changes. However, opiate administration at a dose of 0·05–0·1 mg/kg morphine intravenously does not seem to be associated with a higher risk of management errors2 – 5 .

Radiological examination Imaging is an important part in the evaluation of a child with acute abdomen. Plain abdominal X-rays and contrast studies may be useful in many situations. Ultrasonography is usually the imaging method of first choice6 . It is fast, painless, relatively inexpensive and does not involve the use of ionizing radiation. However, the diagnostic accuracy is operator-dependent. Computed tomography (CT) is being used increasingly. It can be done rapidly, which eliminates the need for general anaesthesia to prevent the child from moving. It involves relatively high doses of radiation, resulting in an increased lifetime risk of cancer7 . Therefore, CT evaluation of the abdomen in children should be targeted by critical individual patient evaluation. Specific CT imaging protocols designed for children reduce radiation exposure significantly and should be employed whenever possible. Acute appendicitis

Clinical presentation Acute appendicitis in children is diagnosed mainly on the basis of the classical symptoms of migratory right iliac fossa pain, nausea or vomiting, right lower quadrant tenderness with rebound phenomenon, and a rectal temperature of 38–39◦ C. History and physical examination alone show a diagnostic accuracy of approximately 90 per cent8 . Appendicitis is less common in younger children. The presentation is often atypical and the disease progression faster9 . There is often a longer delay in the diagnosis and more often a perforated appendix, with a rate approaching 60 per cent in children aged less than 5 years. These children more often have diarrhoea and bilateral or general abdominal pain accompanied by guarding. www.bjs.co.uk

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Diagnosis Laboratory tests, including white blood cell (WBC) count and C-reactive protein (CRP) measurement, do not provide additional information in the diagnosis of appendicitis10 . In 98 per cent of children with acute appendicitis, levels are raised in at least one of these tests but the results are not specific; normal values of WBC count and CRP are unlikely in acute appendicitis, but do not exclude the diagnosis10,11 . Hyperbilirubinaemia and a high procalcitonin level have little value in diagnosing appendicitis12,13 . Abdominal ultrasonography is an excellent screening tool for acute appendicitis, with a high sensitivity (88 per cent) and specificity (94 per cent)14 . The diagnosis can usually be made if the appendix is non-compressible and the outer diameter greater than 6 mm. To exclude appendicitis, it is not always necessary to identify a normal appendix. If there are no other ultrasonographic signs of appendicitis and a low clinical suspicion, evaluation of the appendix can be terminated15 . Ultrasonography can also establish alternative diagnoses, which are revealed in 20–30 per cent of children with suspected appendicitis16 . CT has a slightly higher sensitivity (94 per cent) and specificity (95 per cent) than ultrasonography, and is associated with a lower negative appendicectomy rate17 . This rate does not increase in young adults with suspected appendicitis with the use of low-dose CT, which gives less radiation exposure18 . Despite the lower radiation dose, it remains questionable whether the higher diagnostic accuracy of CT justifies the radiation exposure for the diagnosis of acute appendicitis. A retrospective cohort study19 has shown that magnetic resonance imaging (MRI) has a high sensitivity (100 per cent) and specificity (96 per cent) for diagnosing appendicitis in children with inconclusive ultrasound findings. However, MRI is relatively expensive and requires general anaesthesia in most children, which limits its use19 .

L. W. E. van Heurn, M. P. Pakarinen and T. Wester

are no signs of infection or obstruction by a faecalith, and the diagnosis of other, previously undiagnosed, pathology. A recent systematic review24 did not show differences between the two techniques for uncomplicated appendicitis, apart from a shorter hospital stay after a laparoscopic procedure. For perforated appendicitis, gangrenous appendicitis or appendicitis with abscesses, the pooled odds ratios for wound infection, hospital stay and bowel obstruction episodes were reduced after laparoscopic appendicectomy, whereas there was a slightly increased incidence of intra-abdominal abscess and longer duration of operation24 . Intussusception

In intussusception, peristalsis brings a segment of proximal bowel (intussusceptum) into a more distal segment, causing obstruction of the bowel lumen, obstruction of the mesenteric vessels, and eventually ischaemia and necrosis of the intussusceptum. In most patients intussusception is idiopathic or associated with a viral infection. In a minority there is a pathological cause, which is more common with increasing age and in recurrent intussusception. Common causes are listed in Table 2. The overwhelming majority of the patients have ileocolic (85 per cent) or ileoileocolic (10 per cent) intussusception. Ninety per cent of intussusceptions are fixed and do not reduce spontaneously25 .

Clinical presentation Children with intussusception typically present with short periods of colicky pain with pain-free intervals. Abdominal pain, vomiting, bloody or ‘redcurrant’ stools, irritability and lethargy are the most common symptoms. Five per cent of the patients are in hypovolaemic shock26,27 . Importantly, the classical triad of symptoms of intussusception (abdominal pain, bloody stools and vomiting) is present in less than half of patients26 . Physical

Treatment Causes of intussusception

In children in whom the diagnosis of appendicitis remains equivocal, a short period of in-hospital observation with repeat examination is safe and effective20,21 . The generally accepted treatment for appendicitis is appendicectomy. Although it has been suggested that non-operative treatment of children with uncomplicated appendicitis may be successful, there is inadequate evidence to advocate antibiotic treatment instead of surgery22,23 . The conventional operative method for appendicitis is appendicectomy with a McBurney minilaparotomy. Laparoscopic appendicectomy enables both a macroscopic view of the appendix, which can be left in situ if there

Table 2

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Lymphoid hyperplasia Meckel’s diverticulum Duplication cyst Haemangioma Adhesions Cystic fibrosis Worm infection Intramural haematoma Malignancies (lymphoma) Polyps ¨ Henoch–Schonlein purpura Ventriculoperitoneal shunt

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examination is relatively non-specific. There may be an abdominal mass, abdominal tenderness and abdominal distension. Occasionally a rectal mass is found26,27 .

Diagnosis Plain abdominal X-rays have a low accuracy for diagnosing intussusception, but can be useful in identifying free air, indicating perforation. Ultrasound imaging is the method of choice to diagnose intussusception, with an accuracy approaching 100 per cent. The typical finding is described as a ‘doughnut’, ‘pseudokidney’ or ‘target’ sign representing the intussusceptum. Ultrasound examination is non-invasive and radiation exposure is avoided, but it depends largely on ultrasonographic expertise. Ultrasound imaging can also detect pathological lead points and be useful for differential diagnosis of intussusception. Contrast enema is also accurate, but is invasive, needs radiation and cannot diagnose ileoileal intussusception28,29 .

Treatment The patient’s general condition has to be assessed before reduction of the intussusception. Peritonitis, shock and dehydration must be treated with immediate intravenous fluid resuscitation28 . Evidence of shock, peritonitis, sepsis, or radiological signs of perforation with free air are contraindications to enema reduction28 . Prophylactic antibiotics are often given, although their usefulness has been questioned30 .

Non-operative treatment Non-operative enema reduction is the treatment of choice for uncomplicated ileocolic intussusception31 . Current techniques for non-operative reduction of intussusception include pneumatic or hydrostatic pressure enemas with fluoroscopy or ultrasound monitoring28 . Pneumatic reduction with ultrasound monitoring is accepted widely and being used increasingly, with a success rate of 90 per cent32,33 . It is easy to perform, requires no radiation, and results in less contamination of the peritoneal cavity compared with hydrostatic reduction if a perforation occurs. A potential disadvantage is the risk of tension pneumoperitoneum in the event of perforation. Contrast enema is also a safe and effective method for reducing intussusception28 . There is contradictory evidence regarding whether longstanding intussusception reduces the success rate of enema reduction34,35 . It is generally accepted that non-operative reduction should also be attempted in patients with prolonged symptoms if there is no peritonitis36 .  2013 BJS Society Ltd Published by John Wiley & Sons Ltd

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Previously, patients were operated on if the intussusception could not be reduced with a single attempt at radiological reduction. Delayed repeat enemas after a few hours of observation are successful in approximately half of patients37,38 . Contraindications to delayed repeat enemas are failure to move the intussusceptum during the first attempt and haemodynamic instability.

Surgical treatment Surgery is necessary if enema reduction fails or is contraindicated. Laparoscopic reduction is often successful, although the conversion rate is relatively high39 . Time to full feeds and hospital stay are probably shorter after laparoscopic reduction40,41 . If laparoscopic reduction fails, the intussusception is reduced at laparotomy by gentle compression and slight traction of the proximal bowel. If bowel viability is in doubt, the necrotic part is resected. Usually a primary anastomosis is made. Complications Recurrence of intussusception after pneumatic or hydrostatic enema reduction occurs in roughly 10 per cent of patients31 . The most important complication of enema reduction is perforation, in approximately 0·8 per cent. The mortality rate in developed countries is less than 1 per cent25 . Malrotation and midgut volvulus

Incomplete intestinal rotation and attachment between the first and third months of embryonic development leads to abnormal intestinal rotation known as malrotation. The prevalence of malrotation is approximately one in 500. The non-fixed caecum in the upper abdominal cavity gives rise to lateral adhesive bands overrunning or enclosing the caudally directed duodenum. The narrow mesentery predisposes to midgut volvulus (Fig. 1).

Clinical presentation Only a small proportion of affected individuals become symptomatic and most are otherwise healthy42 . In the vast majority, symptoms present during the first months of life1 . The clinical presentation may be divided into acute and chronic forms. Acute presentation refers to midgut volvulus in which the entire midgut from the proximal jejunum to the proximal colon twists around the narrow mesenteric base, often without any previous symptoms. Volvulus may lead to intestinal necrosis in several hours without surgical treatment. Rapid-onset and bilious vomiting, www.bjs.co.uk

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a

Normal intestinal position

b

Intestinal malrotation

Fig. 1 a In normally rotated intestine, wide mesenteric attachment from the duodenojejunal flexure to the ileocaecal region prevents twisting. b In malrotation, narrow mesentery predisposes to midgut volvulus

proceeding to metabolic acidosis, lactataemia, oligouria, haematochezia, hypotension and shock with advancing ischaemia, govern the clinical picture43 . Early in the disease course inflammatory parameters including CRP level and WBC count are normal. Among newborns with acute serious illness of unclear aetiology, the differential diagnosis should always include the possibility of malrotation and midgut volvulus. The incidence of malrotation-associated volvulus declines with age44 . Chronic symptoms of malrotation are thought to result from either partial duodenal obstruction owing to lateral adhesive bands or recurrent partial volvulus. Typical chronic complaints include episodic vomiting, recurrent colicky abdominal pain, diarrhoea and failure to thrive1,3 . Malrotation should be ruled out in every child with recurrent bilious vomiting.

Diagnosis Upper gastrointestinal contrast radiography is the standard diagnostic method for the assessment of malrotation4 . The diagnosis is based on aberrant location of the duodenojejunal flexure to the right of the vertebral column and below the inferior margin of the duodenal bulb4 . In midgut volvulus findings are consistent with duodenal obstruction. Location of the caecum is not diagnostic. Abdominal ultrasonography may demonstrate  2013 BJS Society Ltd Published by John Wiley & Sons Ltd

the ‘whirlpool’ sign resulting from twisting of the superior mesenteric vessels around each other. The false-negative rate of upper gastrointestinal contrast study is 3–6 per cent and the false-positive rate 15 per cent28 . Laparoscopy is a useful diagnostic tool in patients without a definitive diagnosis45 .

Treatment Symptomatic malrotation requires urgent surgery, which consists of Ladd’s procedure: detorsion of the volvulus when present, division of the duodenal bands, broadening of the mesentery by dividing the anterior mesenteric peritoneum, placement of the small bowel to the right and the colon to the left, and appendicectomy. Some surgeons consider routine appendicectomy in these patients to be unnecessary, as modern imaging may facilitate the diagnosis of appendicitis at an unusual location46 . Emergency operation is crucial in patients with suspected volvulus and may be performed without radiological confirmation if development of irreversible ischaemia is suspected. Fluid resuscitation is rapid and should not postpone surgery. Ladd’s procedure is performed if the bowel is viable after detorsion of the volvulus. Necrotic bowel is removed. A second-look operation may be performed after 24 h when the margins of www.bjs.co.uk

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necrosis have become delineated more clearly, guiding extension of the resection. Elective Ladd’s procedure, which effectively prevents recurrent volvulus, may be also done laparoscopically42,45,47 . Meckel’s diverticulum

Clinical presentation The prevalence of Meckel’s diverticulum in the general population is around 2 per cent, but only a small proportion ever give rise to clinical symptoms. These are most commonly encountered during the first years of life. Gastrointestinal manifestations of Meckel’s diverticulum include, in order of frequency: bleeding, intestinal obstruction and diverticulitis. Neoplastic changes are extremely rare during childhood. Gastrointestinal bleeding results from ulceration of heterotopic acid-producing gastric mucosa of Meckel’s diverticulum. Bleeding is typically intermittent and associated with mild or moderate iron deficiency anaemia. It may be associated with melaena or bloody stools, especially in infants. Meckel’s diverticulum is the most important cause of significant gastrointestinal bleeding before school age. Bowel occlusion is usually caused by a fibrous band between the umbilicus and Meckel’s diverticulum, with a typical presentation of distal small intestinal obstruction (Fig. 2). Diverticulitis usually occurs in older children and is often misdiagnosed as appendicitis owing to its similar clinical course. Meckel’s diverticulitis should be ruled out in any patient with a negative appendicectomy.

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Diagnosis and treatment When Meckel’s diverticulum is the underlying cause of small bowel obstruction or abdominal inflammation (diverticulitis), the final diagnosis is most often reached during surgery. Bleeding from Meckel’s diverticulum may be difficult to confirm. Ordinary imaging modalities and endoscopic investigations are of limited value. Technetium scan is commonly used to demonstrate heterotopic acidproducing mucosa of Meckel’s diverticulum. However, it has low accuracy with a false-negative rate of 20–35 per cent. Based on clinical suspicion, Meckel’s diverticulum can be ruled out easily by laparoscopy, and resected when encountered during the same operation. It may be advisable to leave incidentally detected Meckel’s diverticulum to reduce the risk of postoperative complications48 . Inguinal hernia

Clinical presentation Inguinal hernia is a common finding in emergency departments. Most hernias reduce without treatment or can be reduced easily with a little manual pressure. In general, these hernias can be operated on electively. Incarcerated inguinal hernia is an emergency. There is a tender swelling in the groin that may be difficult to distinguish from a de novo hydrocele, but pain, redness, close attachment to the external inguinal ring and absence of translumination confirm the diagnosis. Prolonged incarceration may be associated with signs of intestinal obstruction, including poor feeding, vomiting and abdominal distension. Girls may present with a 1–2cm, mobile swelling in the groin, which is not attached to the external inguinal fascia. This swelling is usually not painful and difficult to reduce. Herniation of the ovary is the most probable diagnosis in these girls.

Diagnosis Inguinal hernia is a clinical diagnosis. If there are serious doubts about the diagnosis of an irreducible hernia, ultrasonography can confirm the diagnosis before the child is operated on.

Treatment

Meckel’s diverticulum with a fibrous band extending to the umbilicus predisposing to small intestinal obstruction

Fig. 2

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Inguinal hernias that are easily reduced are operated on electively via a small incision in the groin, or laparoscopically49 . Although open hernia repair is a relatively simple operation with a low complication rate and excellent cosmetic results, some surgeons prefer a www.bjs.co.uk

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is deficient fixation of the spermatic cord, and in this type of torsion the entire cord, including the tunica vaginalis, is twisted. Torsion of the testicular appendage, an embryonic remnant of the testis or epididymis, is associated with similar presenting symptoms, but without the same high risk of testicular loss.

Clinical presentation

Reduction of an incarcerated inguinal hernia. One hand is applying firm and constant pressure on the hernia mass, while the other is guiding the mass into the external inguinal ring. First published as Fig. 9.2 in Leerboek chirurgie, 2012, 2nd ed. Reprinted with permission from Bohn Stafleu van Loghum.

Fig. 3

laparoscopic approach, particularly for bilateral hernias or to exclude an open processus vaginalis on the contralateral side. An incarcerated hernia requires urgent reduction, accomplished with firm and continuous manual pressure on the hernia mass, which is successful in the majority of children (Fig. 3). After reduction, surgery is usually delayed for 1 or 2 days to avoid dissection through oedematous tissue50 . This can be avoided by a laparoscopic approach, making immediate hernia repair feasible after incarceration51 . Irreducible ovary is not an indication for emergency surgery, but requires urgent operation because of the higher risk of ovarian torsion52 .

Pain medication Reduction of an incarcerated inguinal hernia is relatively painful. It is advisable to use a combination of intravenous sedation (midazolam) and analgesia (fentanyl, morphine, ketamine) to reduce pain and anxiety53,54 . After hernia reduction the child is admitted to hospital for monitoring and hernia repair in the short term. Testicular torsion

Testicular torsion requires treatment within 4–8 h from the onset of symptoms. Intravaginal torsion is the most common type, with torsion of the testis and spermatic cord within the tunica vaginalis. The incidence is highest in puberty but the condition may also occur at other ages. Extravaginal torsion is usually found at neonatal age. There  2013 BJS Society Ltd Published by John Wiley & Sons Ltd

Patients with testicular torsion typically present with acute unilateral scrotal pain, often accompanied by abdominal complaints. Nausea and vomiting have a high predictive value for testicular torsion in children with acute scrotal pain55 . Findings at physical examination include a swollen and high-riding, transverse-lying testis with loss of the cremaster reflex. In torsion of a testicular appendage the onset of complaints is usually more gradual, with fewer systemic complaints, and there may be a bluish discoloration of the scrotal skin. Epididymitis is often associated with more localized testicular pain, fever and sometimes dysuria. Spreading of the inflammation makes differentiation from testicular torsion difficult. Fever and bluish discoloration are non-specific symptoms and do not exclude the diagnosis of testicular torsion56 .

Diagnosis The diagnosis of testicular torsion is primarily clinical. Colour Doppler ultrasonography of the testis and groin is the imaging modality of choice to rule out testicular torsion, but there remains a considerable risk of misdiagnosis57 . The sensitivity of Doppler ultrasonography is reported to be 76 per cent; this increases if high-resolution ultrasonography is used, but results are largely operator-dependent58 . It remains at least questionable whether ultrasonographic findings can be relied on fully. Some authors use ultrasonography to postpone emergency exploration when there is no testicular flow with parenchymal heterogeneity as this is highly predictive of orchidectomy at operation59 . Furthermore, ultrasound imaging can visualize the testis in cryptorchid testicular torsion if the testis cannot be palpated60 . Urinalysis, urine culture and serum infection parameters are helpful in supporting the diagnosis of an inflammatory cause of acute scrotum.

Treatment Immediate surgical exploration minimizes the risk of testicular loss56 . Patients with a delayed presentation also need urgent evaluation as immediate surgery may salvage viable, incompletely strangulated testes61 . This www.bjs.co.uk

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liberal approach to surgery is associated with a high rate of ‘negative’ exploration, but improves the testicular salvage rate and reduces medicolegal risks62 . In patients with a low suspicion of torsion, increased testicular flow on Doppler ultrasonography may justify non-operative treatment. Operation includes detorsion of the testis with either orchidopexy, if the testis is viable, or orchidectomy. There is no consensus on whether a marginally viable testis should be removed in postpubertal adolescents. Particularly after orchidopexy, there is abnormal sperm morphology and a predisposition to increased levels of antisperm antibodies with preserved hormonal function63,64 . Contralateral orchidopexy is part of the standard operative procedure. There are no effective drug therapies for minimizing ischaemia–reperfusion injury and testicular damage after torsion65 . Ovarian torsion

Ovarian torsion is a relatively uncommon cause of acute abdominal pain. It requires an urgent diagnosis and treatment to salvage the ovary. It can be found in every age group, including infants, children and, particularly, premenarchal or menarchal girls, when ovarian cysts are relatively common as the cause.

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are removed. Oophoropexy is controversial and not done routinely. It is advisable to reassess the ovary with transabdominal ultrasound imaging 6–8 weeks after surgery, when the image is not obscured by oedema, congestion and haematoma, to exclude an underlying malignancy68 . Discussion

Imaging techniques are becoming increasingly important in the diagnosis of acute abdomen in children, with emphasis on ultrasonography and targeted low-radiation CT. Urgent operative intervention remains the best treatment for most acute abdominal disorders. Although the focus is increasingly on minimally invasive approaches, for both diagnosis and treatment, the surgical approach with the best outcome expectations should be chosen based on a careful evaluation of the clinical picture and individual expertise of a surgeon. Disclosure

The authors declare no conflict of interest. References

Clinical presentation Acute-onset lower abdominal pain on the side of the torsion is the typical presenting symptom. It is often accompanied by nausea and vomiting66 . Physical findings are nonspecific; peritoneal signs are not usually present. Pelvic examination is generally not performed in the paediatric age group.

Diagnosis and treatment The diagnosis is suggested if there is an enlarged ovary on ultrasonography. The presence of ovarian blood flow on colour Doppler imaging does not exclude ovarian torsion. CT and MRI do not contribute to the diagnosis of adnexal torsion. Suspected ovarian torsion requires emergency laparoscopy to salvage the compromised ovary, even if there is a long interval between the onset of pain and presentation at the emergency department. The primary treatment includes detorsion with or without cystectomy. Reliable peroperative assessment of necrosis is difficult as a large proportion of ovaries that remain blue or black after detorsion are completely normal at postoperative ultrasonography if left in situ67 . Obviously necrotic ovaries  2013 BJS Society Ltd Published by John Wiley & Sons Ltd

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