24 - Paediatric Surgery Flashcards
How may appendicitis present in children?
- Increasing pain in right lower quadrant
- No previous episodes
- Anorexia
- Slight vomiting
- Fever and tachycardia
When is the highest incidence of appendicitis in children?
Aged 10-20
Rare if <5 years but high perforation rates of 90% as present in very atypical way
What is a test you can do to test for appendicitis in children?
Ask them to hop or cough and see if they have pain
What are some differentials for appendicitis like pain in children?
- Mesenteric adenitis (ask about viral illness like tonsillitis)
- Abdominal migraine
- Gastroenteritis
- UTI
- Torsion of testes or ovary
- Ruptured ovarian cyst
- Ectopic pregnancy
- Meckel’s Diverticulum
What investigations are done for suspected appendicitis in children?
- FBC (high WCC)
- CRP
- G+S
- Clotting
- US to rule out torsion
- CT scan
- Urine dipstick
- Pregnancy test
What scoring system can you use to estimate the likelihood of appendicitis and how do you interpret the score?
How is appendicitis managed in children?
- If negative imaging just antibiotics
- If negative but persistent pain then diagnostic laparoscopy
- If positive laparoscopic appendicectomy, risk of turning to laparotomy. Start antibiotics before surgery and only continue for 7 days if pus found on surgery
What are the complications associated with appendicectomy?
- Bleeding, infection, pain and scars
- Bowel obstruction
- Damage to bowel, bladder or other organs
- Removal of a normal appendix
- Anaesthetic risks
- VTE (PE or DVT)
What is mesenteric adenitis and the cause of this?
Acute or chronic inflammation of the mesenteric lymph nodes that can present similar to appendicitis
Usually due to viral infections
How does mesenteric adenitis present?
Usually abdominal pain in RIF. Always look in mouth
Symptoms
- Preceding illness: URTI or gastroenteritis
- Abdominal pain: may be generalised or localised to RIF
- Fever
- Nausea/vomiting
- Diarrhoea
Signs
- Fever
- Right lower quadrant tenderness and guarding
- Erythematous pharynx
- Peripheral lymphadenopathy
What investigations are done to diagnose mesenteric adenitis and what will they show if positive?
Abdominal US: enlarged abdominal lymph nodes in RLQ with normal appearing lymph nodes
Diagnostic Laparoscopy: if cannot differentiate between mesenteric adenitis and appendicitis
Others: FBC, CRP, Urine dipstick
How is mesenteric adenitis managed?
- Self limiting and resolves within 4 weeks
- Ensure adequate hydration and pain relief
- Keep in for observation and IV fluids if not sure to rule out appendicitis
What is biliary atresia?
Progressive destruction of the extra hepatic biliary system which results in obstruction to bile flow
Presents exclusively in the neonatal period with neonatal jaundice
Without surgical intervention to fix the obstruction, the condition is fatal
What is the most common cause of liver transplantation in children?
Biliary atresia
What is the aetiology and epidemiology of biliary atresia?
Epidemiology
- F>M
- Perinatal form presents first 2 weeks, post natal presents 2-8 weeks
Aetiology
IDIOPATHIC!!!!!!!!!!
- Viral (infectious)
- Genetic: CFC1 gene
- Toxic:
- Immune: a primary immune disorder
What are the different types of biliary atresia?
Ohi classification
- Type 1: common bile duct atresia
- Type 2: atresia of hepatic ducts
- Type 3 (most common): porta hepatis atresia (entry point of vessels and ducts to liver)
What are some associations with biliary atresia?
- Cardiac malformations
- Situs invertus
- Asplenia
- Intestinal atresia
- Imperforate anus
Associations are embryonic form of biliary atresia
How does biliary atresia present?
Jaundice in first 8 weeks of life that is prolonged
- Biliary obstruction: pale stools and dark urine
- Hepatomegalya
- Splenomegaly
- Associated congenital malformations
Biliary atresia causes prolonged jaundice in neonates. What is the first investigations to do when there is prolonged jaundice?
Split bilirubin: Look at unconjugated and conjugated separately, will be high conjugated in biliary atresia
Total bilirubin may be normal but split may have high conjugated
Once biliary atresia is suspected with split bilirubin results, what investigations are done to diagnose this condition?
(IMPORTANT CARD)
INTRAOPERATIVE CHOLANGIOGRAM IS DEFINITIVE DIAGNOSIS
- Abdominal US: non-diagnostic, helps exclude external compression (e.g. cyst)
- Hepatobiliary scintigraphy: excretion of a radioactive tracer into the bowel via the biliary system
- Liver biopsy: characteristic changes of biliary atresia and exclude other causes
- Intraoperative Cholangiogram: passage of contrast through the biliary system. Confirms obstruction. Gold standard.
How is biliary atresia managed once diagnosed?
Hepatoportoenterostomy (Kasai Procedure)
Should be performed within 45-60 days of life to be successful as otherwise will need immediate liver transplant
The majority will require a liver transplantation at some point due to slowly progressive liver disease. At least 50% will need a liver transplant by two years old.
What is the prognosis with biliary atresia?
- >90% survive into adulthood
- 60-80% of patients with biliary atresia will ultimately need a liver transplant
What are the indications for a liver transplant in biliary atresia?
- Portal hypertension
- Progressive liver dysfunction
- Growth failure
What is Hirschsprung’s disease and the pathophysiology of this?
Parasympathetic ganglionic cells of the myenteric plexuses in the bowel aren’t present proximally from the anus to a variable length along the large intestine
The aganglionic segment remains in a constricted state leading to failure in peristalsis and bowel movements. Faeces in the rectum fail to trigger relaxation of the internal anal sphincter, due to aganglionosis. The accumulation of faeces in the rectosigmoid region is responsible for the functional obstruction.
If not recognised bacterial proliferation can occur which is Hirschprung’s enterocolitis which can lead to sepsis and death
What are the different subtypes of Hirschsprung’s disease?
- Short segment: most common
- Long segment
- Total colonic aganglionosis
What are some risk factors for Hirschsprung’s disease?
- Male
- Family history (RETproto-oncogene on chromosome 10q11)
- Downs syndrome
What is the presentation of Hirschsprung’s?
Usually presents on day 2
- Delay in passing meconium (more than 48 hours)
- Billous vomiting
- Abdominal distention
- Chronic constipation since birth
- Poor weight gain and failure to thrive
What are some differentials for Hirschprung’s disease?
ALL HAVE SOME ABDOMINAL DISTENSION
- Meconium Plug Syndrome: symptoms should resolve after passage of plug
- Meconium Ileus: Distal small bowel is impacted by meconium leading to
- Intestinal atresia
- Intestinal malrotation
- Anorectal malformation (anal stenosis, imperforate anus)
- Constipation: Difficulty in passing stools. This is a diagnosis of exclusion.
What are some differentials for Hirschprung’s disease?
ALL HAVE SOME ABDOMINAL DISTENSION
- Meconium Plug Syndrome: symptoms should resolve after passage of plug
- Meconium Ileus: Distal small bowel is impacted by meconium leading to
- Intestinal atresia
- Intestinal malrotation
- Anorectal malformation (anal stenosis, imperforate anus)
- Constipation: Difficulty in passing stools. This is a diagnosis of exclusion.
What investigations are done to diagnose Hirschprung’s disease?
Initial investigation: AXR for signs of bowel obstruction
Definitive investigation: Rectal suction biopsy showing aganglionosis. Give antibiotics and good decompression of the bowel
Contrast enema: aid with diagnosis and exclusion of differentials, though imaging alone is not diagnostic. Useful to determine the transition zone in HD and the extent of aganglionosis that will be resected in surgery
What is a contraindication for contrast enema?
Perforation, do Laparotomy instead
What are the risks with rectal suction biopsy?
- Bleeding
- Perforation
- Inadequate sample so need repeat
How is Hirschsprung’s disease managed?
Initial management
- IV antibiotics
- IV fluids
- NG tube insertion
- Bowel decompression with washout and irrigation
Definitive
- Surgery: resect aganglionic section of bowel and connect unaffected bowel to dentate line
What are the complications of surgery in Hirschsprung’s disease?
- Constipation
- Enterocolitis
- Perianal abscess
- Adhesions
- Incontinence
What is the main cause of mortality in Hirschsprung’s and how does it present?
Hirschsprung associated enterocolitis (HAEC)
Stasis of faeces leads to bacterial overgrowth (usually C.Diff and S.Aureus)
Presentation: fever, vomiting, diarrhoea, abdominal tenderness, and eventually bowel perforation and sepsis
Approximately 25-30% of postoperative patients develop HAEC, usually within the first year after surgery
How is HAEC avoided after surgery?
- Prophylactic antibiotics
- Colonic irrigations
How is HAEC treated?
- Urgent antibiotics
- Fluid resuscitation
- Decompression of the obstructed bowel
Risk of toxic megacolon and perforation if not treated
What are the causes of intestinal obstruction in children?
- Intussusception: most common
- Meckel’s Diverticulum
- Constipation
- NEC
- Meconium ileus
- Hirschsprung’s disease
- Oesophageal atresia
- Duodenal atresia
- Imperforate anus
- Malrotation of the intestines with a volvulus
- Strangulated hernia
How does intestinal obstruction present in children?
- Vomiting (usually bilious)
- Abdominal pain and distention
- Absolute constipation (failure to pass stools or wind)
- Abnormal bowel sounds (high pitchedand “tinkling” early then absent later)
How is intestinal obstruction in children diagnosed?
AXR: Dilatation of bowel proximal to obstruction, collapse distal. No air in rectum
How is intestinal obstruction in children managed?
- Make NBM
- Admit to surgical ward
- NG tube
- IV fluids
- Treat underlying cause e.g intususseption
What is the difference between ileus and obstruction?
Ileus: slowing down of smooth muscle in bowel so disruption to peristalsis so functional obstruction
Obstruction: physical obstruction
What are some causes of ileus in children?
- Hypothyroidism
- Drugs: opioids, antidepressants
- Low potassium
- Surgery
- Gastroenteritis
Treated same as obstruction
What is intussusception?
Most common cause of intestinal obstruction in children
Proximal bowel telescopes into more distal bowel
This thickens the overall size of the bowel and narrows the lumen at the folded area, leading to a palpable mass in the abdomen and obstruction to the passage of faeces through the bowel
What is the epidemiology of intususseption and what is the most common type?
- More common in boys
- 6months to 2 years peak presentation
- Ileocaecal
What are some risk factors for inussusception?
Most of the time it is idiopathic
- Meckel diverticulum (most common)
- Concurrent viral illness (rotavirus)
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
A pathological cause should be suspected if the child is older or has a high recurrence rate
How does intussusception present?
- “Redcurrant jelly stool”
- Sausage shaped pass in RUQ
- Recent viral URTI
- Intestinal obstruction: vomiting, severe colicky abdo pain, absolue constipation, abdominal distension
- Normal bowel sounds
How may a young child with intussusception present?
Remember the pain is intermittent and in between may be no signs
- Pale
- Draw knees up to chest (colic)
- Episodic Inconsolable crying
- Refusing feeds
- Fine between episodes
What are some differentials for intussusception?
- Colic (excessive crying and drawing up of legs in otherwise well infant)
- Testicular torsion (always check testes in male infant with excessive crying)
- Appendicitis
- Gastroenteritis
- Volvulus
What investigations are done for intussusception and what do they show?
Abdominal US is diagnostic
- Abdominal US: Target sign on transverse plane, Pseudokindey sign on longitudinal plane
- Contrast enema: contraindicated if perforation or peritonitis
- AXR: POOR SENSITIVITY, will show signs of obstruction but not good for diagnosis
How is intussusception managed?
Supportive: NBM, IV fluids, NG tube
Therapeutic enemas: Usually air enema, pumped into colon to force folded bowel out of the bowel
Surgical reduction: if enemas do not work, if gangrenous or perforated then need surgical resection
What are the complications of intussusception?
- Obstruction
- Gangrenous bowel
- Perforation
- Dehydration and shock
What is Meckel’s diverticulum and what is the rules of 2?
Remnant of the vitellointestinal duct in small intestine and contains ectopic ileal, gastric or pancreatic mucosa.
Rule of 2s
- Occurs in 2% of the population
- Is 2 feet from the ileocaecal valve
- Is 2 inches long
- 2 mucosa
- 2 complications (bleeding and obstruction)
- 2x more common in males
What are the two main complications of Meckel’s Diverticulum?
- PR Bleeding
- Obstruction/Intussusception
Meckel’s Diverticulum is often asymptomatic and never discovered. How does Meckel’s Diverticulum present if there is a complication?
- Discharge from umbilicus
- Painless rectal bleeding (ectopic gastric tissue)
- Abdominal pain: mimic appendicitis
- Intussusception
- Obstruction: if trapped in a hernia it (then termed a Littre’s hernia)
What investigations are done to diagnose Meckel’s Diverticulum?
- Meckel’s Scan: 99m technetium pertechnetate taken up by gastric mucosa if present ectopically
- Mesenteric arteriography
How is a Meckel’s diverticulum causing a complication managed?
- Treat clinical presentation appropriately (e.g. obstruction with NG tube)
2. Resection of diverticulum (wedge excision or small bowel resection and anastomosis)
What are some causes of peritonitis in children?
- SBP: due to nephrotic syndrome or liver disease
- Appendicitis
- Intusussception
- Peritoneal dialysis: for kidney disease
How may peritonitis present?
- Patient laying completely still
- Abdominal pain
- Nausea and vomiting
- Fever
- Shock/Low blood pressure
- Tachycardia
- Guarding
- Rebound tenderness
How is peritonitis treated?
Very high chance of sepsis and shock so prompt treatment
- Broad spectrum antibiotics
- Treat underlying cause: often surgery
What is pyloric stenosis and the epidemiology of this?
Narrowing of the pylorus due to hypertrophy causing gastric outflow obstruction
Classically presents with projectile non-bilious vomiting in infants 2-8 weeks old
1 in 500 births
What are some risk factors for pyloric stenosis?
- Male
- Family history
How does pyloric stenosis present and what type of emergency is it?
Medical Emergency NOT surgical
- Non bilious projectile vomiting getting worse
- 30-60 minutes after feeding
- Before 8 weeks
- Failure to thrive
- Examination: visible peristalsis and a palpable olive-sized pyloric mass
What are some differentials for pyloric stenosis?
- Gastroenteritis
- GORD (Sandifer syndrome)
- Over-feeding
- Sepsis
- UTI
- Food allergy
If bilious vomiting is reported, don’t forget to think malrotation!
What investigations are done to diagnose pyloric stenosis and what will they show?
Bloods
Hypochloraemic, Hypokalaemia Metabolic Alkalosis
- FBC
- Renal function & serum electrolytes
- Capillary blood gas
Abdominal US
Definitive diagnosis, shows thickened pylorus >3mm
Before definitive surgical management, how is pyloric stenosis managed?
Correct electrolytes
- 10-20ml/kg fluid boluses for acute hypovolaemia
- NBM and give NG tube aspirated at 4 hourly intervals
- 150ml/kg/day, using crystalloid
- Blood gases and U+E’s should be checked regularly
What is the surgical management of pyloric stenosis?
Pyloromyotomy
- Ramstedt’s pyloromyotomy: open procedure performed through an incision in the RUQ
- Laparoscopic pyloromyotomy: minimally invasive approach
How long after pyloromyotomy can feeding recommence and what are the complications with this surgery?
6 hours, may still have some residual vomiting this is normal as post-operative, does not mean incomplete myotomy
- Wound dehiscence
- Infection
- Bleeding
- Perforation
- Incomplete myotomy
What are the complications of pyloric stenosis if left untreated?
- Hypovolaemia
- Apnea: due to metabolic alkalosis
