18. Surgery Flashcards
What is Balanitis (BXO), how does it present and what is its DDx?
Around 95% of pathological phimosis is due to the process ‘Balanitis xerotica obliterans’ (BXO); where keratinisation of the tip of the foreskin causes scaring and the prepuce remains non-retractile.
Peak incidence for BXO is 9-11 years of age
S+S = irritation, dysuria, haematuria, local infection, prepuce will appear as a white/fibrotic/scarred preputial tip
DDx = Phimosis, balanitis, buried penis, zoon plasma cell balanitis
What is Cryptorchidism, how does it present and what is its DDx?
Failure of testicular descent into the scrotum
- True undescended testis = testis absent from scrotum but lies along the line of testicular descent
- Ectopic testis = testis found away from the normal path of decent
- Ascending testis = testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum
Hormonal causes such as androgen insensitivity syndrome or disorder of sex development must also be excluded.
S+S = not palpable in scrotum
DDx = normal retractile testis, true undescended testis , ectopic testis, absent testis, bilaterally impalpable testes
l. Cervical lymphadenopathy
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What is a diaphragmatic hernia, how does it present and what is its DDx?
Congenital birth defect = opening in the diaphragm allowing herniation of abdo contents into the thorax - leading to impaired lung devel
S+S = diff resus at birth, resp distress, bowel sounds in one hemithorax, cyanosis
DDx = bronchopulmonary sequestration, congenital cystic adenomatoid malformation, bronchogenic cysts, and enteric cysts
What is a Hydrocele, how does it present and what is its DDx?
Abnormal collection of fluid between the visceral and parietal layers of the tunica vaginalis and/or along the spermatic cord
Processus vaginalis patent at birth allowing only fluid from the peritoneal cavity to pass down
S+S = painless swelling of one or both testicles
DDx = Spermatocele, varicocele, haematocele, inguinal hernia (bowel), testicular tumours
What is Malrotation, how does it present and what is its DDx?
Absent attachment of the SI mesentery can cause mid-gut rotation or obstruction in the third-part of the duodenum by fibrotic bands
S+S = bilious vomiting, PR bleeding
DDx = Bowel Obstruction in the Newborn, congenital band, intestinal Volvulus, necrotizing enterocolitis, neonatal Sepsis, paediatric duodenal atresia
p. Necrotising enterocolitis
Typically occurs in 2-3w of life in premature, formula-fed infants
Portion of the bowel dies, exact cause is unclear, underlying mechanism is believed to involve a combination of poor blood flow and infection of the intestines
S+S = poor feeding, bloating, decreased activity, blood in the stool, or vomiting of bile
DDx = sepsis, anal fissure, infectious enterocolitis, Hirschsprung disease
What is a Trachea-oesophageal fistula, how does it present and what is its DDx?
Congenital birth defect
Connection between the oesophagus and the trachea
S+S = copious salivation associated with choking, coughing, vomiting, and cyanosis coincident with the onset of feeding
DDx = laryngo-tracheoesophageal cleft, oesophageal webs, oesophageal stricture, oesophageal diverticulum, tubular oesophageal duplications, congenital short oesophagus, and tracheal agenesis/atresia
What is the aetiology and pathophysiology of Pyloric stenosis?
Aetiology = unknown
Path = progressive hypertrophy of the pyloric muscle, causing gastric outlet obstruction
How does pyloric stenosis present?
- 4-6 weeks of age
- projectile non-bilious vomiting after every feed
- Haematemesis
- Weight loss and dehydration
- Visible peristalsis
- Palpable olive-sized pyloric mass
Outline how pyloric stenosis should be investigated?
Test feed:
- NG tube in situ and the stomach aspirated
- palpate for a pyloric mass and observe for visible peristalsis during
USS = hypertrophy of the pyloric muscle, with wall thickness >3mm, length >15mm and diameter >11mm
Describe the Mx of pyloric stenosis
Correct fluid or electrolyte abnormalities
Ramstedt’s pyloromyotomy ( incision is made in the longitudinal and circular muscles of the pylorus)
Babies can resume feeding after 6 hours, although there may be some residual vomiting
What is the pathophysiology and aetiology of an acute appendicitis?
Inflam of the appendix
Aetiology =
- Faecolith = stony mass of faeces
- Lymphoid hyperplasia
- Impacted stool
- Caecal tumour
How does an acute appendicitis present?
- Abdominal pain = initially dull peri-umbilical localising to the RIF (sharp)
- Vomiting
- Anorexia
- Nausea
- Diarrhoea
- Constipation
- Tachycardia
- Tachypnoeic
- Pyrexia
- Rebound tenderness
- Percussion pain over McBurney’s point
- Guarding = if perforated
Rovsing’s sign: RIF fossa pain on palpation of the LIF
Psoas sign: RIF pain with flexion of the right hip (inflamed appendix abutting psoas major muscle in a retrocaecal position)
How should a suspected acute appendicitis be investigated?
Urinalysis = exclude UTI, renal, urological cause
Pregnancy test
Routine bloods = FBC, CRP
Pelvic exam in females of reproductive age = gynaecological pathology
Trans-abdominal US = most useful in children (less abdo fat)
CT scan = used in older pts
