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
How should an acute appendicitis be managed?
Abx = in uncomplicated cases
Laparoscopic appendicectomy = appendix sent to histopathology
Describe the pathophysiology of an inguinal hernia
Abdo contents enter the inguinal canal
DIRECT = bowel enters inguinal canal “directly” through a weakness in wall, Hesselbach’s triangle
INDIRECT = bowel enters the inguinal canal via the deep inguinal ring
How can you differentiate between an indirect and direct inguinal hernia?
Indirect hernias will be lateral to the inferior epigastric vessel
Direct hernias will be medial to the inferior epigastric vessels
How does an inguinal hernia present?
Lump in groin = will disappear with minimal pressure
Discomfort which can worsen with activity or standing
Incarcerated = painful, tender, erythematous
Strangulated = pain out of proportion to clinical signs
How should an inguinal hernia be investigated?
Exam = reduce hernia, place pressure over deep inguinal ring (mid-point of the inguinal ligament), before asking the patient to cough, protrusion = direct
Explorative surgery = definitive diagnosis
US = to exclude other pathology
How should an inguinal hernia be managed?
Surgical repair = open or laparoscopic
Outline the pathophysiology of testicular torsion
Twisting of spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle = surgical emergency
Rate of testicular viability decreases significantly after 6 hours from onset of symptoms
Twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle
Bell-clapper deformity (commonly adolescents) = attachment of tunica vaginalis to the testicle is inappropriately high, spermatic cord can rotate within it = intravaginal torsion
Extravaginal torsion (commonly neonates) = tunica vaginalis is not yet secured to the gubernaculum and, therefore, the spermatic cord, as well as the tunica vaginalis, undergo torsion as a unit
What are the signs and symptoms of testicular torsion?
Sudden onset (may be related to trauma) of severe unilateral scrotal pain
Followed by inguinal and/or scrotal swelling
Nausea
Vomiting
Absence of cremasteric reflex
Abnormal testicular direction
Painful urination
Scrotal erythema
How should testicular torsion be investigated?
Surgical exploration
Scrotal exam = diff due to pain and scrotal oedema
TWIST scoring = testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1), high-riding testis (1)
Urinalysis = exclude UTI
