Paediatrics: Gastro Surgery

• Vomiting: The Vomiting Child — Approach | Reflux and GORD | Pyloric Stenosis | Malrotation and Volvulus | Intussusception
• Abdominal pain: Acute Abdominal Pain | Appendicitis | Recurrent and Functional Abdominal Pain
• Bowels: Constipation | Hirschsprung's Disease | Chronic Diarrhoea | Coeliac Disease | Inflammatory Bowel Disease | Blood in the Stools | Liver Problems in Children
• Groin and genitals: Hernias and Hydroceles | Undescended Testes | The Acute Scrotum | Foreskin, Hypospadias and the Penis
• Revision: Drug Reference Table | Spot the Diagnosis | Exam-style Scenarios | Key Points | Guidelines and Further Reading

🧒 Gastroenterology and surgery in children — vomiting, tummy pain and constipation are everyday problems, and most are benign. The skill is spotting the surgical emergencies: bilious vomiting (malrotation with volvulus), intussusception, appendicitis (often atypical and perforated in young children), and testicular torsion. Age is a powerful clue to the cause.
Your four questions for every child: Is the vomit green (bilious) — a surgical emergency? Is the child growing normally? Is there blood in the stool, a mass, or peritonism? In boys with abdominal pain, have I examined the testes?

The Vomiting Child — Approach

• Red flags:
  • Bilious (green) vomiting — surgical emergency (malrotation with volvulus until proven otherwise).
  • Projectile vomiting in a 2–8 week old (pyloric stenosis).
  • Blood in vomit (haematemesis) or stools.
  • Abdominal distension, tenderness, or a mass.
  • Dehydration, lethargy, bulging fontanelle, seizures, headache, early morning vomiting.
  • Faltering growth.

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Reflux and GORD

• Gastro-oesophageal reflux (GOR) — very common in babies (immature lower oesophageal sphincter, liquid diet, lying flat). Effortless regurgitation ("possetting"), starting before 8 weeks; usually resolves by 12 months. The baby is thriving — no treatment needed.
• GORD — reflux causing complications or troublesome symptoms.
• Features of GORD — distress, back arching and crying with feeds, feed refusal, faltering growth, chronic cough, hoarseness, recurrent pneumonia (aspiration), Sandifer syndrome (abnormal head and neck posturing).
• Higher risk — preterm, neurodisability (cerebral palsy), repaired oesophageal atresia or diaphragmatic hernia, obesity.
• Red flags (another cause likely) — bilious or projectile vomiting, haematemesis, starting after 6 months or persisting after 1 year, bloody stools, abdominal distension, fever, bulging fontanelle, faltering growth.
• Management (NICE NG1):
  • Reassurance — common, harmless, improves with time.
  • Feeding review — avoid overfeeding; smaller, more frequent feeds; keep upright after feeds; check breastfeeding technique.
  • Breastfed — trial of alginate (Gaviscon Infant) for 1–2 weeks.
  • Formula-fed — trial of thickened feeds (or anti-reflux formula), then alginate if no better.
  • PPI or H2 blocker (4-week trial) — only for unexplained feeding difficulties, distress or faltering growth with suspected oesophagitis, or in older children with heartburn.
  • Don't use positional treatment (raising the cot) — sleep flat on the back.
  • Consider CMPA (trial of hydrolysed formula) if other allergic features.
  • Severe cases — pH or impedance studies, endoscopy, fundoplication.

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Pyloric Stenosis

• What it is: Thickening of the pyloric muscle, blocking the stomach outlet.
• Who: Babies aged 2–8 weeks; boys (4–5 times more), often first-born; family history.
• Features:
  • Projectile, non-bilious vomiting straight after feeds, getting worse.
  • Hungry after vomiting ("hungry vomiter").
  • Weight loss, dehydration, constipation.
  • Olive-shaped mass in the right upper abdomen (felt during a test feed); visible peristalsis.
• Blood gas — hypochloraemic, hypokalaemic metabolic alkalosis (loss of stomach acid).
• Diagnosis — ultrasound (thickened, elongated pylorus).
• Management:
  • Correct dehydration and electrolytes first (IV 0.9% saline with glucose and potassium) — anaesthesia is unsafe with alkalosis (breathing depression).
  • Stop feeds; NG tube.
  • Pyloromyotomy (Ramstedt — laparoscopic or open); feeding restarts within hours; excellent outcome.

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Malrotation and Volvulus

• What it is: The gut doesn't rotate properly in development, leaving the small bowel on a narrow mesentery that can twist (volvulus) and cut off its blood supply. The whole midgut can die within hours.
• Who: Usually in the first month (most in the first year), but can occur at any age.
• Features:
  • Sudden bilious (green) vomiting — the key sign.
  • Abdominal pain, irritability, distension (may be absent early).
  • Blood in stools, shock and peritonitis (late — bowel ischaemia).
  • Older children — intermittent pain and vomiting.
• Diagnosis — urgent upper GI contrast study (abnormal position of the duodenojejunal flexure; "corkscrew" duodenum); ultrasound may show whirlpool sign. Don't delay surgery for imaging if the child is unwell.
• Management — resuscitation, NG tube, IV antibiotics, emergency laparotomy (Ladd's procedure).

⚠️ Safety Pearl: Bilious vomiting in a baby is malrotation with volvulus until proven otherwise — refer immediately to paediatric surgery. Delay can mean losing the entire small bowel.

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Intussusception

• What it is: One segment of bowel telescopes into the next — usually the ileum into the caecum (ileocolic), causing obstruction and ischaemia.
• Who: 6 months to 2 years (peak 6–18 months); boys more than girls; often after a viral illness (enlarged lymphoid patches act as the lead point).
• Features:
  • Episodes of severe colicky pain — the child screams, draws up the legs, goes pale, then may be quiet or lethargic between episodes.
  • Vomiting (bilious later).
  • "Redcurrant jelly" stools (blood and mucus) — a late sign.
  • Sausage-shaped mass in the right upper abdomen; empty right iliac fossa.
  • Lethargy (may be the main feature); shock.
• Diagnosis — ultrasound ("target" or "doughnut" sign).
• Management:
  • Resuscitation (fluids), NG tube, antibiotics if unwell.
  • Air (pneumatic) enema reduction under X-ray guidance — successful in most.
  • Surgery if peritonitis, perforation, shock, or failed reduction.
  • Recurrence in about 10%.
• Older children (over 3) — look for a pathological lead point: Meckel's diverticulum, polyp, lymphoma, IgA vasculitis (HSP), CF.

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Acute Abdominal Pain

• Surgical causes — appendicitis, intussusception, malrotation, bowel obstruction (adhesions, hernia), testicular torsion, ovarian torsion, Meckel's diverticulitis, trauma (including NAI — liver, spleen, duodenal haematoma).
• Medical causes:
  • Gastroenteritis; constipation (very common).
  • Mesenteric adenitis — swollen abdominal lymph nodes after a viral illness; mimics appendicitis.
  • UTI and pyelonephritis.
  • Lower lobe pneumonia; tonsillitis (abdominal pain is common in young children).
  • DKA — always check glucose.
  • IgA vasculitis (HSP); sickle cell crisis; HUS.
  • Pancreatitis, gallstones (haemolytic disease), hepatitis; pregnancy and ectopic in teenagers.
• Examine — chest, throat, abdomen, hernial orifices and testes; urine dipstick; glucose; pregnancy test in girls after menarche.

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Appendicitis

• The commonest surgical emergency in children (peak 10–20 years; rare under 3).
• Features:
  • Central (periumbilical) pain moving to the right iliac fossa.
  • Loss of appetite, nausea, vomiting (usually after the pain starts).
  • Low-grade fever; pain on walking, jumping or coughing; lying still.
  • Tenderness and guarding at McBurney's point; rebound; Rovsing's sign.
• Young children (under 5) — atypical, harder to examine, and perforation is common at presentation (diffuse peritonitis, vomiting, fever, irritability, limp).
• Tests — FBC and CRP (raised but not diagnostic), urine (exclude UTI — mild pyuria can occur in appendicitis), pregnancy test; ultrasound; scoring tools (e.g. Paediatric Appendicitis Score, Alvarado).
• Management — analgesia (morphine is fine — doesn't mask signs), IV fluids, antibiotics, laparoscopic appendicectomy; antibiotics alone for selected uncomplicated cases (specialist decision). Perforated — longer antibiotics; abscess may need drainage.
• Mesenteric adenitis — recent viral illness, high fever, less localised tenderness; ultrasound shows enlarged nodes; self-limiting.

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Recurrent and Functional Abdominal Pain

• Very common in school-age children (about 1 in 10); most is functional (no disease found).
• Functional abdominal pain disorders:
  • Functional abdominal pain — central pain, often linked to stress (school, family), well between episodes, normal growth.
  • Irritable bowel syndrome — pain with change in stool form or frequency.
  • Abdominal migraine — episodes of central pain with nausea, vomiting, pallor, lasting hours; family history of migraine; later migraine headaches.
  • Functional dyspepsia.
• Red flags (look for organic disease):
  • Pain that wakes the child; pain away from the umbilicus (especially right-sided).
  • Weight loss, faltering growth, delayed puberty.
  • Blood in stools, chronic diarrhoea, persistent vomiting.
  • Fever, joint pains, rash, mouth ulcers, perianal disease.
  • Family history of IBD or coeliac disease.
  • Abnormal examination; raised inflammatory markers or calprotectin.
• Organic causes — constipation, coeliac disease, IBD, UTI, H. pylori, lactose intolerance, gallstones, pancreatitis, gynaecological causes in teenagers.
• Basic tests — FBC, CRP/ESR, coeliac serology, urine, faecal calprotectin (if diarrhoea).
• Management of functional pain — explanation that the pain is real but not dangerous; address triggers and school stress; regular routines; CBT and gut-directed hypnotherapy; avoid repeated unnecessary tests.

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Constipation

• Very common; usually functional (idiopathic) — often starts with weaning, toilet training or starting school, or after a painful stool (fissure), leading to withholding.
• Features — infrequent hard stools (fewer than 3 a week), large stools that may block the toilet, straining and pain, "rabbit droppings", overflow soiling (loose, smelly stools leaking — often mistaken for diarrhoea), withholding behaviours (stiff legs, hiding), abdominal pain, poor appetite.
• Red flags (NICE CG99 — possible underlying cause):
  • Starting from birth or the first few weeks.
  • Delayed passage of meconium (over 48 hours in a term baby) — Hirschsprung's, CF.
  • "Ribbon" stools; abnormal anus position.
  • Abdominal distension with vomiting.
  • Abnormal lower limb neurology, gait, or spine (sacral dimple, hair tuft — spinal cord problems).
  • Faltering growth.
  • Possible abuse (perianal bruising, fissures in unusual places).
• Other causes — hypothyroidism, coeliac disease, hypercalcaemia, CMPA (infants), drugs (opioids), Hirschsprung's, anal problems.
• Management (NICE CG99):
  • Disimpaction (if faecal loading) — macrogol (polyethylene glycol, e.g. Movicol Paediatric Plain) in an escalating dose over up to 2 weeks until the impaction clears; add a stimulant (senna or sodium picosulfate) if not effective. Warn about increased soiling at first. Rectal treatments only if oral fails.
  • Maintenance — macrogol (dose adjusted to produce soft stools) for several weeks after a regular pattern is established, then reduce gradually over months; add senna if needed.
  • Behavioural — regular toilet sitting after meals (5 minutes), footstool, reward charts (for sitting, not for clean pants).
  • Diet — adequate fluids and fibre (fruit, vegetables, wholegrain) — but don't rely on diet alone at first.
  • Infants — extra water or fruit juice; lactulose if needed; macrogol from 1 year (off-label under).
  • Review regularly; refer if no response after 3 months.
• Anal fissure — painful stools with streaks of bright red blood; treat constipation; topical anaesthetic or GTN in specialist care.

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Hirschsprung's Disease

• What it is: Absence of nerve cells (ganglion cells) in a segment of the bowel wall — always starting at the rectum and extending upwards. The affected bowel can't relax, causing obstruction.
• Associations — boys; Down syndrome; family history; MEN2 (RET gene).
• Features:
  • Newborn — delayed passage of meconium (over 48 hours), abdominal distension, bilious vomiting.
  • Older children — chronic constipation from birth, distension, faltering growth.
  • Rectal examination may release an explosive gush of stool and gas.
• Hirschsprung-associated enterocolitis — fever, distension, explosive foul diarrhoea, sepsis — can be fatal (IV antibiotics, rectal washouts).
• Diagnosis — rectal suction biopsy (absent ganglion cells, increased acetylcholinesterase-positive nerve fibres); contrast enema (transition zone).
• Treatment — rectal washouts initially; surgical pull-through (removing the aganglionic bowel); sometimes a temporary stoma.

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Chronic Diarrhoea

• Toddler's diarrhoea — the commonest cause in 1–5 year olds: loose stools with undigested food (peas, carrots), often more in the day; the child is well and growing normally. Advice — normal fat and fibre, limit fruit juice and squash ("4 Fs": fat, fibre, fluid, fruit juice).
• Other causes:
  • Coeliac disease.
  • Cow's milk protein allergy (infants).
  • Lactose intolerance (often secondary after gastroenteritis — temporary).
  • Inflammatory bowel disease.
  • Infection — Giardia, persistent bacterial infection.
  • Cystic fibrosis (steatorrhoea).
  • Overflow from constipation.
  • Laxative misuse; hyperthyroidism; immunodeficiency.
• Red flags — faltering growth, blood in stools, abdominal pain waking the child, nocturnal diarrhoea, weight loss.
• Tests — growth, FBC, CRP, coeliac serology, stool microscopy and culture, faecal calprotectin, faecal elastase (pancreatic insufficiency), sweat test.

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Coeliac Disease

• What it is: An autoimmune reaction to gluten (wheat, barley, rye) damaging the small bowel lining (villous atrophy). About 1 in 100 people; many undiagnosed.
• Features in children:
  • Young children (after gluten is introduced) — diarrhoea, pale bulky smelly stools, distended abdomen, wasted buttocks, faltering growth, irritability.
  • Older children — abdominal pain, constipation, tiredness, short stature, delayed puberty, iron deficiency anaemia, mouth ulcers, dermatitis herpetiformis (itchy blistering rash on elbows, knees, buttocks).
  • Many have few symptoms.
• Who to test — symptoms above; type 1 diabetes; autoimmune thyroid disease; Down syndrome, Turner syndrome, Williams syndrome; first-degree relatives; IBS-type symptoms.
• Tests:
  • tTG IgA (tissue transglutaminase) with total IgA (IgA deficiency gives false negatives — use IgG tests).
  • The child must be eating gluten (in more than one meal a day for at least 6 weeks) before testing.
  • No-biopsy route (ESPGHAN, for children) — tTG IgA 10 times or more the upper limit, with positive endomysial antibodies on a second sample. Otherwise duodenal biopsy.
• Management:
  • Lifelong strict gluten-free diet (dietitian); oats are usually tolerated.
  • Check iron, folate, vitamin D, calcium; growth and puberty monitoring.
  • Yearly review; repeat tTG to check adherence.
• Untreated — poor growth, osteoporosis, anaemia, small increased risk of lymphoma.

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Inflammatory Bowel Disease

• About a quarter of IBD starts in childhood; Crohn's disease is more common than ulcerative colitis in children.
• Crohn's disease:
  • Abdominal pain, diarrhoea (may be no blood), weight loss, growth failure and delayed puberty (sometimes the only sign), tiredness, fever.
  • Perianal disease (tags, fissures, fistulas, abscesses), mouth ulcers, lip swelling.
  • Extra-intestinal — joint pains, erythema nodosum, uveitis.
• Ulcerative colitis — bloody diarrhoea, urgency, abdominal pain; often extensive (pancolitis) in children.
• Tests — FBC (anaemia, raised platelets), CRP, ESR, albumin, faecal calprotectin; stool cultures; endoscopy and colonoscopy with biopsies; MRI small bowel.
• Treatment (paediatric gastroenterology):
  • Crohn's — exclusive enteral nutrition (liquid formula only for 6–8 weeks) is first-line induction (as effective as steroids, better for growth); steroids if not suitable; maintenance with azathioprine or methotrexate; anti-TNF (infliximab, adalimumab) for moderate to severe disease; surgery for complications.
  • UC — aminosalicylates (mesalazine); steroids for flares; azathioprine; biologics; colectomy for severe disease.
  • Acute severe colitis — IV steroids, rescue therapy (infliximab), surgery; watch for toxic megacolon.
  • Growth, bone health, nutrition, psychological support, transition to adult services.
• See the Inflammatory Bowel Disease chapter.

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Blood in the Stools

• Meckel's diverticulum — a remnant of the vitelline duct in the small bowel; "rule of 2s" — about 2% of people, 2 feet from the ileocaecal valve, about 2 inches long, often presents under 2 years, may contain 2 types of tissue (gastric, pancreatic):
  • Painless, heavy rectal bleeding (dark red or maroon) in a young child — from ulceration by acid-secreting gastric tissue.
  • Also intussusception, obstruction, diverticulitis (mimics appendicitis).
  • Technetium-99m pertechnetate scan ("Meckel's scan"); surgical removal.
• Juvenile polyps — painless bright red bleeding; usually single and benign; multiple polyps suggest a polyposis syndrome (Peutz–Jeghers — lip freckles; familial adenomatous polyposis).
• Upper GI bleeding — swallowed blood (nosebleed), Mallory–Weiss tear (after vomiting), oesophagitis, gastritis (NSAIDs), varices (portal hypertension — biliary atresia), foreign body (button battery).

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Liver Problems in Children

• Neonatal jaundice and biliary atresia — see the Neonatology chapter.
• Viral hepatitis — hepatitis A (mild in children, often without jaundice), B and C (vertical transmission), EBV, CMV.
• Wilson's disease — consider in any child over 5 with unexplained liver disease (or neurological or psychiatric symptoms): low caeruloplasmin, high urine copper, Kayser–Fleischer rings; chelation (penicillamine, trientine), zinc.
• Autoimmune hepatitis — teenage girls; raised IgG, autoantibodies; steroids and azathioprine.
• Alpha-1 antitrypsin deficiency — neonatal cholestasis, later liver disease.
• Fatty liver (MASLD) — rising with childhood obesity.
• Paracetamol overdose — the commonest cause of acute liver failure in teenagers (often intentional); see the Paediatric Emergencies chapter.
• Gallstones — haemolytic disorders (sickle cell, hereditary spherocytosis), obesity, long-term TPN.
• Hepatoblastoma — liver tumour in young children (raised AFP).
• Signs of chronic liver disease — jaundice, itch, hepatosplenomegaly, ascites, faltering growth, easy bruising, spider naevi.

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Hernias and Hydroceles

• Inguinal hernia:
  • An indirect hernia — the processus vaginalis stays open, letting bowel (or an ovary in girls) into the groin or scrotum.
  • More common in boys and preterm babies.
  • A groin or scrotal swelling that comes and goes, more obvious when crying or straining; you can't "get above" it.
  • High risk of incarceration (trapped bowel) in infants — irritability, vomiting, a tender, firm, irreducible lump: emergency (reduce if possible, then surgery).
  • Refer for surgery promptly — urgently for infants (within days to weeks; within 2 weeks for babies under 6 weeks old); herniotomy.
• Umbilical hernia — very common in babies (especially Black and preterm babies); soft, reducible; rarely strangulates; most close by 3–5 years; surgery if still present at about 4–5 years or very large.
• Hydrocele — fluid around the testis:
  • Painless, soft scrotal swelling that transilluminates; you can get above it; the testis is often hard to feel.
  • Communicating (patent processus vaginalis) — size changes during the day.
  • Most resolve by 1–2 years; surgery if persistent after 2 years.
  • New hydrocele in an older boy — exclude underlying causes (torsion, tumour, infection) with ultrasound.
• Epigastric hernia — small midline lump above the umbilicus; surgery if symptomatic.

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Undescended Testes

• Cryptorchidism — a testis not in the scrotum. About 3–5% of term boys (more in preterm); many descend by 3 months.
• Types:
  • Retractile testis — can be brought down into the scrotum and stays there briefly (active cremaster reflex) — normal; review yearly (can "ascend").
  • Undescended — palpable in the groin (most) or impalpable (in the abdomen, or absent).
  • Ectopic — outside the normal path (perineum, femoral).
• Management:
  • Bilateral undescended testes at birth — urgent senior review (within 24 hours) — exclude disorders of sex development (e.g. CAH in a virilised girl — salt-wasting risk).
  • One undescended testis — review at 6–8 weeks; if still undescended at 3 months, refer to paediatric surgery.
  • Orchidopexy — ideally at 6–12 months (and before 18 months).
  • Impalpable testes — laparoscopy.
• Risks if untreated — reduced fertility, testicular cancer (risk higher even after surgery — teach self-examination), torsion, trauma, psychological effects, inguinal hernia.

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The Acute Scrotum

• Testicular torsion is a surgical emergency:
  • Immediate surgical exploration — the testis can usually be saved if untwisted within 6 hours.
  • Don't delay for ultrasound if the diagnosis is likely.
  • Fix both testes (bilateral orchidopexy); remove a dead testis.
  • Analgesia; nil by mouth.

⚠️ Safety Pearl: Teenage boys with "abdominal pain" may be too embarrassed to mention testicular pain. Always examine the testes in a boy with lower abdominal pain or vomiting — torsion can cost a testis within hours.

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Foreskin, Hypospadias and the Penis

• Physiological phimosis — the foreskin normally can't be pulled back in young boys (adhesions to the glans); most become retractable by 5–10 years (some later). Ballooning of the foreskin during urination is normal. Don't force it back.
• Balanitis — inflamed glans and foreskin: hygiene, warm baths, topical antifungal or antibiotics if infected; recurrent episodes may need circumcision.
• Pathological phimosis — scarred, white, tight foreskin (balanitis xerotica obliterans — lichen sclerosus); urinary obstruction. Topical steroids; circumcision.
• Paraphimosis — a retracted foreskin can't be pulled back, causing a painful swollen glans: emergency — analgesia, ice or compression, manual reduction; dorsal slit or circumcision if it fails.
• Hypospadias:
  • The urethral opening is on the underside of the penis (anywhere from glans to perineum); hooded foreskin (incomplete on the underside); chordee (downward curve).
  • About 1 in 300 boys; picked up at the newborn examination.
  • Don't circumcise — the foreskin is used in the repair.
  • Surgical repair at about 6–18 months.
  • Severe hypospadias with undescended testes — consider a disorder of sex development (CAH, karyotype).
• Epispadias — opening on the upper side; linked to bladder exstrophy.
• Circumcision — medical indications: pathological phimosis, recurrent balanitis, recurrent UTIs with urinary tract abnormalities; also done for religious and cultural reasons (consent from those with parental responsibility).
• Labial adhesions (girls) — fused labia minora in young girls; usually harmless and resolve at puberty; topical oestrogen if causing urinary problems.

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Drug Reference Table

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Spot the Diagnosis

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Exam-style Scenarios

1. A 6-week-old boy has had projectile vomiting after every feed for 4 days and seems hungry afterwards. Gas: pH 7.52, chloride 88, potassium 2.9.
Answer: Pyloric stenosis with hypochloraemic hypokalaemic alkalosis.

• Stop feeds; IV fluids (0.9% saline with glucose and potassium) to correct electrolytes.
• Ultrasound to confirm.
• Pyloromyotomy once electrolytes are normal.

2. A 10-month-old has episodes of screaming and drawing up his legs every 15 minutes, with pallor and lethargy between. He has vomited twice and passed a bloody stool.
Answer: Intussusception.

• Resuscitation, IV access, NG tube.
• Urgent ultrasound; air enema reduction.
• Surgery if peritonitis or failed reduction.

3. A 7-year-old has opened her bowels twice a week for months with painful large stools and soiling. Abdomen shows a palpable faecal mass. No red flags.
Answer: Functional constipation with impaction and overflow.

• Disimpaction with escalating-dose macrogol over up to 2 weeks (add senna if needed); warn about more soiling at first.
• Maintenance macrogol for months; toilet routine after meals; rewards; fluids and fibre.
• Review regularly.

4. A 13-year-old boy woke at 5 am with severe left testicular pain and vomiting. The left testis lies high and horizontal and is very tender.
Answer: Testicular torsion.

• Analgesia; nil by mouth; immediate urology/paediatric surgical exploration (don't wait for a scan).
• Untwist and fix both testes; remove if non-viable.

5. A newborn boy has the urethral opening on the underside of the penis shaft and an incomplete foreskin. Both testes are in the scrotum.
Answer: Hypospadias.

• Refer to paediatric urology; advise no circumcision.
• Repair at about 6–18 months.

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Key Points

• Bilious vomiting = malrotation with volvulus until proven otherwise — emergency surgical referral.
• Reflux in a thriving baby is normal and settles by 12 months; alginate or thickened feeds before acid suppression.
• Pyloric stenosis: 2–8 weeks, projectile non-bilious vomiting, hungry baby, alkalosis — correct fluids before pyloromyotomy.
• Intussusception: 6–18 months, colicky screaming, pallor, redcurrant jelly stool, target sign — air enema.
• Appendicitis in young children is atypical and often perforated; give analgesia.
• Check glucose, urine and testes in children with abdominal pain.
• Functional constipation: macrogol disimpaction then months of maintenance; red flags include onset from birth and delayed meconium.
• Hirschsprung's: delayed meconium, distension, Down syndrome — rectal biopsy; beware enterocolitis.
• Coeliac: test while eating gluten; tTG IgA with total IgA; no-biopsy route if tTG 10 times normal and EMA positive.
• Paediatric Crohn's: growth failure and delayed puberty; exclusive enteral nutrition first line.
• Meckel's: painless heavy rectal bleeding in young children — technetium scan.
• Inguinal hernias need prompt surgery (incarceration risk); umbilical hernias and hydroceles usually resolve.
• Undescended testis: refer at 3 months; orchidopexy at 6–12 months; bilateral impalpable at birth — urgent (CAH/DSD).
• Torsion: explore within 6 hours; fix both sides.
• Hypospadias: no circumcision; repair at 6–18 months.