25 - Paediatric Surgery 2 Flashcards
What is gut malrotation in infants?
Midgut rotates and fixes in an abnormal position making it prone to volvulus. Caecum is high midline rather than RIF
Duodenum can also get compressed by peritoneal bands (Ladd bands)
How may volvulus due to intestinal marination present and how is this diagnosed?
- Always consider in bilious vomiting
- Upper GI contrast study and US. ‘Corkscrew’
How is malrotation treated?
Laparotomy and Ladd’s Procedure if has a volvulus or high risk of volvulus
Make NBM and pass NG tube
How is a caecal and sigmoid volvulus treated?
More common to have caecal in children
What is the pathophysiology and epidemiology of a congenital diaphragmatic hernia?
Herniation of abdominal viscera into chest cavity due to incomplete diaphragm formation. Leads to pulmonary hypoplasia, hypertension and RDS at birth
Failure of pleuroperitoneal canal to close completely
1 in 2000 babies
How is CDH diagnosed?
Antenatally: US
Post natal: CXR, RDS, difficulty resuscitating, bowel sounds heard in chest
How is CDH managed?
Prenatal: Referral to tertiary fetal medicine centre for fetal surgery. Tracheal balloon to push viscera out of the way to allow lungs to develop
Postnatal: Insert NG tube to keep all air out of gut. Immediately intubate and then surgical repair
What is the prognosis with CDH?
50% MORTALITY
When is a hydrocele pathological in an infant?
If still there at 2 years
Processus vaginalis is patent until around 1 year of age so observe until that point
Why are inguinal hernias common in children and how do they present?
Common in males as patent processus vaginalis to allow testicles to descend
May see bulge lateral to pubic tubercle when baby cries
Can’t get above it and may be reducible
How are inguinal hernias in children managed?
High risk of strangulation the younger the child so repair urgently if first few months. If over 1 can do elective procedure as lower risk
Laparoscopic herniotomy without implantation of mesh is sufficient
Done as day case but premature and neonates kept in overnight due to risk of post-operative apnea
What is the difference between an umbilical and paraumbilical hernia?
Which babies are more likely to have an umbilical hernia?
20% of babies have this
- Afrocaribbean
- Downs syndrome
- Premature
How is an infant with an umbilical hernia managed?
Observation until 3 years as will spontaneously close by then most of the time
Strangulation is rare
What are some differentials for an abdominal mass/abdominal distension in a child?
- Meconium Ileus plug
- Faeces from constipation
- Wilm’s Tumour (Nephroblastoma)
- Neuroblastoma
- Hernia
- Intussusception
- Hepatomegaly
- Splenomegaly
What are some differentials for acute abdominal pain in children?
- Constipation
- Appendicitis
- Abdominal migraine (periodic with vomiting)
- UTI
- Obstruction, Volvulus, Intussusception
- Gastroenteritis
- Viral illnesses (eg tonsillitis with mesenteric adenitis)
- Meckel’s Diverticulum
- Crohn’s/US
- Testicular torsion
- Sickle cell crisis
- DKA
- Pneumonia
What investigations should you do for abdominal pain in children?
- Urine dip
- AXR
- US
- FBC/CRP/U+Es
What are some causes of scrotal pain and swelling in children?
- Testicular torsion
- Epidiymoorchitis
- Hydrocele
- Varicocele
- Inguinal hernia
- Torsion of Hyatid of Morgani
What are some causes of urinary incontinence in a child?
- Overflow
- Abuse
- UTI
- Seizures
- Diabetes
- Constipation
- Ectopic ureter
- Neurological issue
If a child had bilious vomiting what differentials do we need to consider?
ALWAYS OBSTRUCTION AND NEEDS SURGICAL INPUT UNTIL PROVEN OTHERWISE
- Malrotation with volvulus
- Duodenal atresia
- Intussusception
- NEC
- Meconium Ileus
How is bilious vomiting managed in a neonate?
- NG
- NBM
- IV Fluids
- Urgent surgical referral
What are some causes of non-bilious vomiting in children?
- DKA
- Raised ICP
- Testicular torsion
- Appendicitis
- Gastroenteritis
- Pyloric stenosis
- Migraine
What investigations should you consider for non-bilious vomiting in children?
Always work out how dehydrated they are and their electrolyte disturbance
What is epididymo-orchitis and how may it present? (usually in boys aged over 15)
ALWAYS NEED TO RULE OUT TESTICULAR TORSION
Infection of the epididymis +/- testes resulting in pain and swelling. Usually from GU system e.g N.Gonnorrhoea, E.Coli, C.Trachomatis
- Severe scrotal pain
- Erythematous swollen scrotum
- Temperature
- Vomiting
- Prehn’s positive
What are some virus that can cause orchitis?
- Mumps
- Varicella Zoster
How does mumps orchitis present?
What investigations are done for epididymitis?
- Urine dip and MSU
- STI screen if older sexually active child
- US to look for testicular torsion and any structurally abnormalities of urinary system
How is epidiymitis treated?
- Adequate analgesia
- Enteric organisms – Ofloxacin for 14 days
- STI organisms – Ceftriaxone 500mg IM single dose and Doxycycline 100mg PO twice daily for 10-14 days
What are the complications of epididymitis?
- Hydrocele
- Abscess
- Infertility
Testicular torsion is most common in 10-30 year olds. How does this present?
- Testicular pain
- Referred abdominal pain
- Vomiting
- Loss of cremasteric reflex
- Swollen testicle
- Prehn’s sign negative (elevation does not relieve pain)
- High lying testicle
How is testicular torsion investigated and managed?
- Urgent surgical exploration and orchidopexy within 4-6 hrs
- Strong analgesia and antiemetic
- Make NBM as soon as presents
- Doppler US if uncertainty
How may torsion of the Hyatid of Morgagni present differently to testicular torsion?
- Normal lie
- Less swelling
What is the epidemiology of cryptochordism?
Failure of testicular descent into the scrotum
6% of newborns, 1-2% of males at 3 months
3 groups:
- True undescended testis: testis absent from scrotum but lies along line of testicular descent
- Ectopic testis: testis is found away from normal path of decent
- Ascending testis: testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum
What are some risk factors for cryptochordism?
- Prematurity
- Low birth weight
- Maternal smoking during pregnancy
- Having other abnormalities of genitalia (i.e. hypospadias)
- First degree relative with cryptorchidism
What are the issues with undescended testes?
- Infertility
- Malignancy (higher rate if intra-abdominal)
- Cosmetics
- Increased risk of testicular torsion
How do you have to examine a child to work out if they have undescended testes as 80% of undescended testes are palpable?
- Laid flat on the bed relaxed
- With warm hands, palpate laterally with your left hand, from inguinal ring and work along the inguinal canal to pubic symphysis
- If found see if the testis can be gently milked down to the base of the scrotum, in which case a diagnosis of retractile testis can be made
- Around 20% are impalpable as intrabdominal or ectopic
What are some differentials for undescended testes?
What is retractile testes?
- Prepubertal boys testes may move out of scrotum into inguinal canal when cold or cremasteric reflex activated
- Usually resolves through puberty but if not need orchidopexy
- Follow up annually as risk of becoming undescended
How is undescended testes found on newborn examination managed?
Initial management
Consider urgent referral to paediatrician if bilateral as could be CAH at at risk of salt-losing crisis
Long-term management
- At birth: watch and wait until 6-8 weeks of age as most will resolve by 6 months
- 3 months: if still no descent see paediatric urologist
- 6-12 months: orchidopexy if palpable, laparoscopic examination if impalpable
What is the epidemiology of hypospadias and how does it present? (image important)
Urethral meatus displaced to ventral side of penis
1 in 300 male births
Usually picked up on newborn examination, parents may complain of abnormal urine flow
What are the different classifications of hypospadias?
Epispadias if on dorsal side
How is hypospadias managed?
Always need to rule out DSD
- TELL PARENTS NOT TO CIRCUMCISE UNTIL UROLOGIST SAYS IT IS OK
- Urethroplasty: Single stage or a 2-stage repair, using a graft from foreskin. Move meatus to glans and straighten penis. Done aged around 12 months
What are the complications of hypospadias?
Untreated
- Difficulty directing urination
- Cosmetic and psychological concerns
- Sexual dysfunction
Treated
- Urethral fistula
- Meatal or urethral stenosis
Complications often occur years later
What are some medical indications for circumcision?
- Phimosis after puberty (normal physiology before this)
- Balanitis xerotica obliterans
- Paraphimosis
How does BXO present?
- Ballooning of the foreskin during micturition (normal aged 2-4)
- Glans is white, fibrotic and scarred
Physiological phimosis will not have white scarring
How is BXO managed?
- Circumcision
- Send to histopathology to confirm diagnosis
What are the benefits of circumcision?
- Lower risk of penile cancer
- Lower risk of UTI
- Lower risk of STIs and HIV
What is important to ask if a child has an umbilical granuloma before applying silver nitrate?
Is there any discharge as could be patent urachus
How are strawberry naevus treated?
Propanolol
If a child has PR bleeding what differentials are you thinking?
- NEC
- Meckel’s
- Intussusception
- Fissures
- Polyps
How long do hydroceles take to resolve?
2 years so reassure parents to watch and wait
Refer if in any doubt of there being inguinal hernia
