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