3. Paeds [Surgery and Urology]

Question 1

Top 5 causes of bilious vomiting in a baby:

Answer 1

1. Malrotation +/- volvulus until proven otherwise
2. NEC
3. Atresia
4. Hirschprung’s disease (aganglionic colon)
5. Meconium disease

Question 2

Describe the typical presentation of Hirschprung’s disease in a newborn vs later presentation.

Answer 2

Newborn; failure to pass meconium in first 24 hours, due to intestinal obstruction.
+ bilious vomiting, abdo distension and ?enterocolitis.
Upon rectal exam, narrow segment and release of liquid stool on exit.

Older; chronic constipation + abdominal distension + ? faltering growth

Question 3

What is Hirschprung’s disease and what causes it?

Answer 3

Aganglionic segment of bowel extending from rectum, due to developmental failure of Auerbach’s and Meissner’s plexuses.
Failure of parasympathetic neuroblasts to migrate from the neural crest to the distal colon, resulting in developmental failure of the parasympathetic system.

Question 4

What is the impact on bowel function of Hirschprung’s disease?

Answer 4

Aganglionic colon –> uncoordinated peristalsis –> bowel obstruction

Question 5

How do you investigate for suspected Hirschprung’s disease?

Answer 5

AXR
Full thickness rectal biopsy

Question 6

Describe the epidemiology of Hirschprung’s disease, including MvsF.

Answer 6

M:F = 3:1

30% of patients with Hirschprung’s also have Trisomy 21

Question 7

State both the immediate and definitive management for Hirschprung’s disease.

Answer 7

Initial; irrigation and wash out

Definitive; surgical. Initial colostomy, then anastomosis of normally innervated bowel to anus.

Question 8

What type of muscle is the pyloric muscle?

Answer 8

Circular

Question 9

What is pyloric stenosis?

Answer 9

Hypertrophy of the pylorus muscle resulting in gastric outlet obstruction.

Question 10

At what age does pyloric stenosis present?

Answer 10

2-8 weeks, regardless of gestation at birth

Question 11

M:F ratio of pyloric stenosis?

Answer 11

4:1

Question 12

Clinical features of pyloric stenosis (3):

Answer 12

Non-bilious vomiting that becomes more violent and eventually projectile.
Feeds normally after vomiting until dehydration leads to loss of interest in feeding.
Weight loss if picked up late.

Question 13

What is the gold standard imaging for pyloric stenosis?

Answer 13

Abdominal Ultrasound

Question 14

What is the management of pyloric stenosis?

Answer 14

Correct acid base disturbance

Pyloromyotomy

Question 15

What acid base disturbance occurs in pyloric stenosis?

Answer 15

Hypochloraemic, hypokalaemia metabolic alkalosis + hyponatraemia

Question 16

What examination findings may you discover in a patient with pyloric stenosis?

Answer 16

VISIBLE gastric peristalsis seen L to R across abdomen.

Pyloric mass in RUQ.

*stomach usually overdistended with air and often must be drained via NG before examination.

Question 17

Outline the common presentation of oesophageal atresia.

Answer 17

Choking and cyanotic episodes post feeding due to aspiration of milk +/or stomach acid.

Question 18

Oesophageal atresia has VACTERL associations. What is meant by this?

Answer 18

The condition is associated with other conditions that are remembered in the mnemonic VACTERL.
Vertebral
Anorectal
Cardiac
Tracheo-
oEsophageal
Renal
Limb

Question 19

Complications of oesophageal atresia (3):

Answer 19

GORD
Chronic cough
Oesophageal dilatation may be required in infancy or childhood

Question 20

90% of oesophageal atresia cases also have a what present?

Answer 20

Tracheo-oesophageal fistula

Question 21

What features may you pick up at antenatal screening if the baby has oesophageal atresia?

Answer 21

Polyhydramnios
Absent stomach bubble

Question 22

Discuss the management of oesophageal atresia.

Answer 22

If suspected before birth; pass large feeding tube after birth and check position on x-ray.

Continuous suction to remove aspiration of saliva and secretions.
SURGERY is definitive.

Question 23

What happens to result in hypospadias?

Answer 23

Failure of ventral closure of the tissue of the penis.

Question 24

What is the incidence of hypospadias?

Answer 24

1/200

Question 25

What are the aims of surgery for hypospadias?

Answer 25

To achieve a straight line urine stream and straight erection

Question 26

When is the surgical correction of hypospadias usually performed?

Answer 26

Around 12 months.
Must not circumcise as the tissue may be used in the surgery.

Question 27

Give 3 potential clinical features in a patient with hypospadias.

Answer 27

1. Abnormal site of ventral urethral meatus. (75% is distal)
2. Ventral curvature of shaft, most apparent on erection.
3. Hooded foreskin.

Question 28

Give 2 conditions that are associated with hypospadias.

Answer 28

Cryptorchidism in 10%
Inguinal hernia

Question 29

What percentage of patients with oesophageal atresia will also have another VACTERL condition?

Answer 29

Nearly 50%