13- Paediatric Surgery Flashcards
peritonitis
Peritonitis is an infection of the peritoneum which is the membrane that lines your abdomen (the belly).
Primary
- Bacterial infection arising from the peritoneum itself
- e.g. intraperitoneal dialysis
- e.g. spontaneous bacterial peritonitis
Secondary
- E.g. perforation of bowel
define localised peritonitis
o Inflammation limited to area adjacent to an inflamed region e.g. appendix or diverticulum prior to rupture
generalised peritonitis
Inflammation is widespread e.g. after rupture of viscus
causes of peritonitis
- Peritoneal dialysis
- Bowel obstruction with perforation
- Appendix rupture
- Liver disease
peritonitis presentation
- High fever
- Abdominal pain
- Initially dull and poorly localised, becoming gradually worse and more localised
- Rebound tenderness
- Guarding
- Anorexia, nausea and vomiting
- Rectal examination may increase abdominal pain
- Bowel sounds may be absent
investigations for peritonitis
Bloods
- FBC, U&Es, LFTs, blood culture
Peritoneal fluids
Urinalysis
Imaging
- AXR
- Upright CXR
- US
- CT/MRI
management of peritonitis
- IV fluids
- Antibiotics
o SBP- cephalosporins
o Secondary peritonitis- systemic abx
appendicitis background
- Inflammation of the appendix
- Peak incidence 10 to 20 yo
appendicitis pathophysiology
Pathophysiology
- Appendix is a small, thin tube which comes off the caecum
- Infection trapped within appendix by etc faecolith or lymphoid hyperplasia, impacted stool can cause inflammation which can proceed to ischaemia, gangrene and rupture
- Releasing faecal content and infective material into the abdomen -> peritonitis
risk factor for appendicitis
- caucasian
- CF
- family history
presentation of appendicitis
Abdominal pain
- Starts centrally and moves down to the right iliac fossa over time and becomes localised to the RIF
- Tender at McBurneys point (one third distance from anterior superior iliac spine to the umbilicus)
Other symptoms
- Anorexia
- N and V
- Rovsings sign (palpation in left iliac fossa causes pain in the RIF)
- Guarding
- Rebound tenderness
- Percussion tenderness
In children
- Diarrhoea
- Urinary symptoms
- Possibly left sided pain
McBurneys point
differentials for appendicitis
- Ectopic pregnancy
- Ovarian cyst
- Testicular torsion
- Constipation
- Mesenteric adenitis (assoc with tonsilitis and URTI)
- Meckel’s diverticulum
investigations for appendicitis
- Clinical presentation of appendicitis: diagnostic laparoscopy to visualise appendix directly
- FBC: Raised inflammatory markers
Imaging
- CT scan to confirm diagnosis if another diagnosis is more likely
- US can be used to exclude ovarian and gynaecological pathology
- Definitive treatment appendicectomy
management of appendicitis
- Emergency admission under surgical team
- Definitive management for acute appendicitis: laparoscopic appendicectomy
complications of appendicectomy
o Complications: bleeding, infection, pain, scars
o Damage to bowel and bladder
o Removal of normal appendix
o Anaesthetic risks
o VTE
complications of appendicectomy
o Complications: bleeding, infection, pain, scars
o Damage to bowel and bladder
o Removal of normal appendix
o Anaesthetic risks
o VTE
intestinal obstruction background
Passage of food, fluids and gas become blocked.
- Small bowel more common than large bowel
- Results in build up of gas and faecal matter proximal to obstruction
o Back pressure- vomiting and dilatation of proximal intestines
o Surgical emergency
how can bowel obstruction cause dehydration
- Obstruction also reduces fluid reabsorption in the colon- fluid loss from intravascular space – hypovolaemia
- This is called third-spacing
- Higher up the obstruction the worse the fluid losses- less bowel where the fluid can be reabsorbed
pathophysiology of obstruction presentation
- Obstruction leads to back-pressure through the GI system causing vomiting
- Causes absolute constipation
presentation of intestinal obstruction
- Vomiting (particularly green bilious vomiting)
-> Early- upper obstruction
-> Later- lower - Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence (early in lower,
Late in upper)
“Tinkling” bowel sounds may be heard in earlybowel obstruction- become absent later
causes of bowel obstruction general
The big three (HAM)
* Hernias (small bowel)
* Adhesions (small bowel)
* Malignancy (large bowel)
causes of bowel small bowel obstruction
o Hernias
o Adhesions
Scar tissue that binds abdominal contents
together
Causing kinking or squeezing of the
bowel
Causes
* Surgery
* Peritonitis
* Infection
* Endometriosis
causes of large bowel obstruction
- Malignancy
- Volvulus- bowel twists on self
- Diverticular disease
which pathologies cause both small and large intestine obstruction
- Stricture e.g. secondary to Crohns
- Intussusception (in young children 6m-2y)
risk factors for bowel obstruction
- Abdominal surgery
- Cancer
- Hernias
- Crohns disease
investigations for bowel obstruction
- Abdominal X-ray – distended loops of bowel
- May skip straight to contrast abdominal CT- confirm diagnosis and establish site and if perforation has occurred- modality of choice
- Blood tests: U and E (electrolytes), venous blood gas (metabolic alkalosis due to loss of HCL in vomit), bowel ischaemia- raised lactate)
abdominal X-ray normal diameter of bowel
Upper limits of normal diameter of bowel
- 3cm small bowel
- 6cm colon
- 9cm caecum
findings of small bowel obstruction on x-ray
- Dilated >3cm
- Central, valvulae conniventes
- String of pearls sign
- Paucity of gas in large bowel
- no gas in rectum
findings of large bowel obstruction on x-ray
- Colon >6cm, caecum >9cm
- Peripheral and haustra (don’t extend full width)
general management of bowel obstruction
- ABCDE
o Hypovolaemia shock due to third spacing
o Bowel ischaemia
o Bowel perforation
o Sepsis - Nill by mouth
- Analgesia, catheterise
- IV fluids to hydrate and correct electrolyte imbalances
- NG tube with free drainage to allow stomach contents to freely drain and reduce risk of vomiting and aspiration
- Conservative treatment if adhesions or volvulus, where this fails- surgery
surgical intervention only if closed loop or ischaemia (pain)
Laparoscopy or laparotomy
o Exploratory surgery in patients with an unclear underlying cause
o Adhesiolysis to treat adhesions
o Hernia repair
o Emergency resection of the obstructing tumour- may need stoma
intussusception
- Condition where one part of the bowel ‘telescopes’ into another part
- Leads to bowel obstruction
- Typically 6 months to 2 years (peak 5-7 months)
pathophysiology of intussuscpetion
- Telescoping of the bowel into itself causing intestinal obstruction
- Most common” ileo-colic type (90%)
o Distal ileum passes into the caecum through ileo-caecal valve
risk factors for intussusception
- Boys
- Concurrent viral illness
- Henoch-Schoenlein purpura
- CF
- Intestinal polyps
- Meckel’s diverticulum
Intusseception Presentation
- Severe, colicky abdominal pain
- Severe inconsolable crying
- Baby draws knees to chest
- Pale, lethargic and unwell child
* “Redcurrant jelly stool”- key - Right upper quadrant mass on palpation. This is described as “sausage-shaped”- key
- Vomiting
- Presence of bowel sounds
- Intestinal obstruction
Intusseception Presentation
- Severe, colicky abdominal pain
- Severe inconsolable crying
- Baby draws knees to chest
- Pale, lethargic and unwell child
*** “Redcurrant jelly stool”- key ** - Right upper quadrant mass on palpation. This is described as “sausage-shaped”- key
- Vomiting
- Presence of bowel sounds
- Intestinal obstruction
investigations for intusseseption
Abdominal US (gold standard)
- Doughnut/target sign
Contrast enema
*
Abdominal X-ray not recommended due to low sensitivity*
management of intussusception
- Fluid resus
- NG tube to decompress
- Therapeutic enema
Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position - Surgical reduction may be necessary if enemas do not work
- If bowel becomes gangrenous or perforates will require surgical resection
complications of intussesception
- Obstruction
- Gangrenous bowel
- Perforation
- Death
volvulus background
- When the bowel twists around itself and the mesentery that it is attached to
- The bowel gets its blood supply from the mesentery
Can lead to bowel ischaemia, necrosis and eventually perforation - Leads to a closed-loop bowel obstruction -> where a section of bowel is isolated by obstruction on either side
types of volvulus
sigmoid
caecal
sigmoid volvulus
o More common in older adults
o Associated with high fibre diet and excessive use of laxatives
o Coffee bean sign
caecal volvulus
o Less common
o Affects younger patients
o Twist occurs in caecum
o Embryo sign
risk factors for volvulus
- Chronic constipation
- High fibre diet
- Adhesions
risk factors for volvulus
- Chronic constipation
- High fibre diet
- Adhesions
presentation of volvulus
- Vomiting (green bilious)
- Abdominal distention
- Diffuse pain
- Absolute constipation and lack of flatulence
investigations for volvulus
- AXR- coffee bean and embryo sign
- Contrast CT investigation of choice
management of volvulus
- Initially: nil by mouth, NG tube, IV fluids
- First line: endoscopic decompression (flexible sigmoidoscope)
- Surgical management
o Laparotomy
o Hartman’s procedure
o Ileocecal resection or right hemicolectomy for caecal volvulus
define hernia
the protrusion of viscus through a defect of the walls of its containing cavity e.g. bowel that would. normally be contained within that cavity to be passed through the cavity wall
define hernia
the protrusion of viscus through a defect of the walls of its containing cavity e.g. bowel that would. normally be contained within that cavity to be passed through the cavity wall
Types of hernia
- Inguinal- MOST COMMON IN CHILDREN
- Femoral
- Umbilical- COMMON IN NEONATES
- Incisional
- Hiatus hernia
Differential diagnoses for a lump in the inguinal region:
- Femoral hernia
- Lymph node
- Saphena varix (dilation of saphenous vein at junction with femoral vein in groin)
- Femoral aneurysm
- Abscess
- Undescended / ectopic testes
- Kidney transplant
hernia investigations
Investigations
- Clinical examination
- Ultrasound or CT
- If negative but high clinical suspicion- MRI
presentation of hernia
- Hernial lump
- Obstruction
o Vomiting
o Constipation
o Abdominal pain/discomfort - Strangulation
o pain
complications of hernias
incarceration
obstruction
strangulation
Incarceration
- Where hernia cannot be reduced back into proper position (irreducible)
- Can lead to obstruction and strangulation of hernia- bowel ischemia
Obstruction
- Blockage in passage of faeces through bowel
- Vomiting, pain and absolute constipation
strangulation
o Non reducible and base of hernia becomes so tight it cuts of blood supply- ischaemia
o Significant pain and tenderness
o Surgical emergency
management of hernia
Conservative management
Surgery
- Tension free repair
- Tension repair
conservative management of hernia
o Leaving hernia
o Appropriate when hernia is wide neck and if pt not a good candidate for surgery
tension free repair
o Placing mesh over the defect in the abdominal wall
o Mesh is sutured to the muscles and tissues on either side of the defect, covering and preventing herniation of the cavity contents
o Over time tissue grows into mesh- more support
Complications
- chronic pain due to mesh
- Lower recurrent rate than tension repair
Tension repair (surgery)
o Suture the muscles and tissues on either side of the defect back together
o Rarely performed
o Complications – pain
o High recurrence rate of hernia
which hernias are most common in children
inidrect inguinal hernia
inguinal hernia backgroun
Indirect – MOST COMMON IN CHILDREN
- Where bowel herniates through inguinal canal
pathophysiology of inguinal hernia
- Normally, after the testes descend through the inguinal canal, the deep inguinal ring closes and the processus vaginalis is obliterated.
- However, in some patients, the inguinal ring remains patent, and the processus vaginalis remains intact. This leaves a tract or tunnel from the abdominal contents, through the inguinal canal and into the scrotum. The bowel can herniate along this tract, creating an indirect inguinal hernia.
the inguinal canal
The inguinal canal is a tube that runs between the deep inguinal ring (where it connects to the peritoneal cavity), and the superficial inguinal ring (where it connects to the scrotum).
- In males, the inguinal canal is what allows the spermatic cord and its contents to travel from inside the peritoneal cavity, through the abdominal wall and into the scrotum.
- In females, the round ligament is attaches to the uterus and passes through the deep inguinal ring, inguinal canal and then attaches to the labia majora.
how to differentiate between indirect and direct inguinal hernia
presentation of indirect inguinal hernia
- On examination, there is an inguinal/inguino-scrotal mass that you cannot ‘get above’, is reducible when lying flat, does not transilluminate, and has a positive cough reflex. However, a hernia that has strangulated will present as an irreducible and tender tense lump, with the pain often being out of proportion to clinical signs; this may be accompanied with clinical features of bowel obstruction.
direct inguinal hernia
- Due to weakness in abdominal at Hesselbachs triangle
- Hernia protrude directly through the abdominal wall (not along the inguinal canal like indirect)
o Due to weakness in posterior wall (Hesselbachs) - Presentation (how to differentiate between direct and indirect)
o Medial to inferior epigastric vessel
o Pressure over the deep inguinal ring will not stop herniation
risk factors for inguinal hernia
o Prematurity
o Male sex
o Family history
investigation for inguinal hernia
- US
- CT scan – mainly in patient with features of obstruction and strangulation, or when there is uncertainty in. diagnosis)
management of inguinal hernia
- Definitive management: Surgical repair of hernia (herniotomy) performed in all full term male infants with asymptomatic reducible inguinal hernia
- Emergency surgery for irreducible hernia
complications of inguinal hernia
- Recurrence
- Strangulation
- Incarceration
- Bowel obstruction
Femoral hernias
involve herniation of the abdominal contents through the femoral canal. This occurs below the inguinal ligament, at the top of the thigh.
The opening between the peritoneal cavity and the femoral canal is the femoral ring. The femoral ring leaves only a narrow opening for femoral hernias, putting femoral hernias at high risk of:
* Incarceration
* Obstruction
* Strangulation
incisional hernia
Incisional hernias occur at the site of an incision from previous surgery.
Cause
They are due to weakness where the muscles and tissues were closed after a surgical incision.
Risk factors
- The bigger the incision, the higher the risk of a hernia forming.
- Medical co-morbidities put patients at higher risk due to poor healing.
Management
- Incisional hernias can be difficult to repair, with a high rate of recurrence.
- They are often left alone if they are large, with a wide neck and low risk of complications, particularly in patients with multiple co-morbidities.
Umbilical hernia
.
Occur around the umbilicus .
Causes defect in the muscle around the umbilicus.
Risk factors
- Umbilical hernias are common in neonates and can resolve spontaneously.
- They can also occur in older adults
Epigastric hernia
An epigastric hernia is simply a hernia in the epigastric area (upper abdomen).
Ileus Background
A condition which affects the small bowel, where normal peristalsis that pushes contents along the length of the intestines, temporarily stops.
Usually resolves with supportive care within a few days
causes of ileus
- Injury to the bowel
- Handling of the bowel during surgery
- Inflammation or infection in, or nearby, the bowel (e.g., peritonitis, appendicitis, pancreatitis or pneumonia)
- Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)
presentation of ileus
- Vomiting (particularly green bilious vomiting)
- Abdominal distention
- Diffuse abdominal pain
- Absolute constipation and lack of flatulence
- Absent bowel sounds (as opposed to the “tinkling” bowel sounds of mechanical obstruction)
