Common Paediatric Surgical Problems Flashcards
Name surgical diseases of the newborn?
- Common surgical causes of respiratory distress
- Intestinal obstruction
- Necrotizing enterocolitis - Anterior abdominal wall defects
- Hydrocephalus
- Genito-urinary problems
Post neonatal surgical problems?
- Acute abdominal pain
- Abdominal masses
- Scrotal swellings
- Anterior abdominal wall hernia’s
- Pyloric stenosis
- Surgical infections
- Trauma
- Constipation
Surgical causes of respiratory distress?
- Abdominal distension
- Neck masses compressing the trachea
e.g. cystic hygroma - Esophageal atresia and trachea-esophageal fistula
- Congenital hernia diaphragmatica
Types of esophageal atresia with tracheo-esophageal fistula?
- esophageal atresia
- esophageal atresia + proximial TE fistula
- esophageal atresia + distal TE fistula
- most common - esophageal atresia + proximal and distal TE fistula
- TE fistula without esophageal atresia
Esophageal atresia with tracheo-esophageal fistula is associated with?
congenital anomalies
VACTERL
1. vertebral anomalies
2. anorectal anomalies (ana atresia)
3. cardiac anomalies
4. tracheo-esophageal fistula or atresia
5. renal anomalies
6. limb anomalies
Complications of esophageal atresia with TE fistula?
- May cause respiratory distress because of aspiration of saliva which can not be swallowed or reflux of gastric content
- If feeding is attempted aspiration is very likely and results in severe pneumonia.
NB: Passing a nasogastric tube will fail
Diagnosis of esophageal atresia with TE fistula?
- Passing a nasogastric tube will fail
- Early diagnosis is possible if foaming of saliva is observed and passing of an NG tube is not possible because of obstruction
- Investigation: plain chest X-ray and abdominal X ray
What is a diaphragmatic hernia?
a birth defect in which there is an abnormal opening in the diaphragm
Describe the diaphragmatic hernia?
- Mostly left sided
- Respiratory problems due to space-occupying effect of abdominal viscera in the chest
- Shift of the mediastinum / apex beat
- Be careful with bag and mask ventilation
Management of diaphragmatic hernia?
Placement of a naso-gastric tube in the stomach helps to minimize distension of this organ
Note: Bagging via a face mask is dangerous as some of the air will end up in the stomach and compound the problem
What is the most common manifestation of congenital diaphragmatic hernia?
- The Bochdalek hernia, also known as a postero-lateral diaphragmatic hernia, - accounting for more than 95% of cases
Describe the Bochdalek hernia?
- In this instance the diaphragm abnormality is characterized by a hole in the postero-lateral corner of the diaphragm which allows passage of the abdominal viscera into the chest cavity
- The majority of Bochdalek hernias (80-85%) occur on the left side of the diaphragm, a large proportion of the remaining cases occur on the right side. - To date, it carries a high mortality and an active area of clinical research.
What is necrotizing enterocolitis?
inflammation of the intestine leading to bacterial invasion causing cellular damage and cellular death and necrosis of the colon and intestine
When do we usually see necrotizing enterocolitis?
- respiratory distress
- prematurity
- infection
- septicemia
Pathogenesis of necrotizing enterocolitis?
Ischaemic infarction of intestinal wall
Clinical manifestation of NEC?
- Vomiting
- blood in stool
Management of NEC?
- Preferably conservative management
- Surgery when perforation
Investigations in NEC?
Pneumatosis intestinalis characteristic finding on abdominal X-ray
What causes intestinal obstruction?
- proximal bowel obstruction
- distal bowel obstruction
- anal atresia
What is proximal bowel obstruction?
at or above the level of the jejunum
- The more distal the obstruction, the greater the distension and vice versa.
NB: It needs emergency treatment as the infant loses fluids and electrolytes and can not be fed
Clinical signs of proximal bowel obstruction?
- vomiting
- bilious: obstruction is post-ampullary
- clear: obstruction is above the ampulla of Vater - can have passed meconium
- distended upper abdomen
- associated with epigastric fullness
Investigations in proximal bowel obstruction?
abdominal x-ray
e.g. duodenal atresia shows fluid levels
What is distal bowel obstruction?
Obstruction at level of distal jejunum, ileum, colon and ano-rectal level
Clinical signs of distal bowel obstruction?
- vomiting
- distended abdomen
- no stool
Causes of distal bowel obstruction?
- ano-rectal atresia’s
- Hirschsprung’s disease
- Although Hirschsprung does not need to present in the neonatal period, may present later even as a toddler
Investigations in distal bowel obstruction?
- Abdominal X-ray
- may not always be conclusive about the level of obstruction - barium enema
- this will show at which level the obstruction is
e.g. In anal atresia air can be used as a contrast and an inverted X-ray can be done – the level of the air and the distance between the anus and the air level will indicate the level of the obstruction
Describe anal atresia?
- Most common problem
- Sometimes in combination with fistula (especially in girls)
- Fistula usually low lesion
- Associated with other congenital malformations (VACTERL)
Causes of anterior abdominal wall defects?
- omphalocele
- gastroschisis
- ectopia vesicae
What is an exomphalos/omphalocele?
- the herniation of abdominal organs through a central abdominal wall defect
- it has a membrane that covers the abdominal contents
- associated with congenital abnormalities or part of a syndrome
Features of gastroschisis?
- no sac
- lateral to umbilical cord
- Chemical peritonitis
- Associated abnormalities uncommon
Management of gastroschisis and exomphalos?
- Ensure that sac of exomphalos doesn’t rupture, becomes dry and infected
- Prevent fluid loss from exposed viscerae
- Wrap in sterile moist gauze
- Surgical repair?
Describe features of exomphalos/omphalocele?
- most common
- due to failure of the abdominal viscerae to return to the abdomen from the yolk sac
- mass protruding from the abdomen through a central defect covered by a sac
- No peritonitis
- Associated congenital abnormalities common
What is gastroschisis?
birth defect where the baby’s intestines exit their body from a 2-5 cm hole beside their belly button during fetal development
What is ectopia vesicae?
- absence of the anterior abdominal wall of the bladder and the part of the rectus muscle ant.
- symphysis pubis is widely separated
- exposing the posterior bladder wall and the ureteric orifices
What is pyloric stenosis?
narrowing of the pyloric canal as it exits the stomach
Features of pyloric stenosis?
- projectile vomiting
- olive sized bulge below right costal margin
Management of pyloric stenosis?
pylorotomy
Causes of acute colicky abdominal pain?
With mass?
Groin
1. obstructed hernia
Abdomen
1. intussusception
2. ascaris bowel obstruction
Causes of acute abdominal pain?
No mass?
sickle cell crisis
Causes of continuous acute abdominal pain?
Localized?
acute appendicitis
Causes of continuous acute abdominal pain?
Generalized?
- fever precedes pain
- perforated typhoid - pain precedes fever
- perforated appendix
What is intussusception?
telescoping of a portion of the intestine into the lumen of the immediately adjoining part of the
- mostly ileo - coecal
Epidemiology of intussusception?
- peak between 4 and 12 months
- male : female ratio is 3 : 2
Features of intussusception?
- sometimes polyp, Meckel’s diverticle
- pain - colicky
- vomiting
- blood per rectum - redcurrant jelly
- sausage shaped mass palpable
Diagnosis of intussusception?
Diagnosis by abdominal ultrasound
– doughnut target or concentric ring and pseudokidney sign suggest intussusception
Management of intussusception?
- rectal reduction if possible at X-ray – air enema
- If fails surgical
- If signs of peritonitis no air-enema, but surgery
NB: Peritonitis suggests the presence of gangrenous intestines.
What is appendicitis?
inflammation of the inner lining of the vermiform appendix
Diagnosis of appendicitis?
target like appearance due to thickened wall and surrounding loculated fluid collection
What is a hydrocele?
It is a collection of fluid in the tunica vaginalis
- Localized to the scrotum
Note: Fluctuation of the scrotal size during the day
Types of hydrocele?
- communicating
- non-communicating
What is a communicating hydrocele?
when the sac does not close the fluid around the testicle can flow back up into the abdomen
- the hydrocele looks smaller early in the day and larger in the evening
What is a non communicating hydrocele?
no connection between the abdominal cavity and the sac around the testicle in the scrotum
Diagnosis of hydrocele?
- transillumination
- pelvic ultrasound
Management of hydrocele?
Observation for 1 to 2 years of age, before recommending repair hydrocele
Note: do not aspirate
Most common inguinal hernia in pediatrics?
indirect hernia
Epidemiology of indirect hernia?
- Indirect 99%
- 1% to 3% of all children
- 3% to 5% in preterm baby
- R 60%, L 30% Bilateral 10-15%
- Males to female’s ratio is 6:1
Features of an inguinal hernia?
- Present as bulge in the groin, scrotum, or labia
- A reliable history is sufficient to make the diagnosis, even if the hernia cannot identify
- An incarcerated inguinal hernia presents as a mass in the labia or scrotum that does not reduce spontaneously
What is hydrocephalus?
This refers to enlargement of the ventricles (hydrocephalus internus) or of the subarachnoid space (hydrocephalus externus) due to a disturbance in the flow of cerebrospinal fluid
Causes of hydrocephalus?
congenital, such as
1. aqueduct stenosis
2. Chiari malformation
acquired,
1. after meningitis
2. intra ventricular haemorrhage
Clinical presentation of hydrocephalus?
clinical presentation related to enlarged head and the pressure effects on intracranial structures
Treatment of hydrocephalus?
VP shunt
What is hydronephrosis?
This occurs following obstruction to urine flow at or distal to the pelvic-ureteric junction, with progressive dilatation of the calyces and pelvis and pressure on the adjacent renal parenchyma
Features of hydronephrosis?
- a flank mass
- secondary infection from stasis
- Haematuria and pyuria are common presenting symptoms in older children
Diagnosis of hydronephrosis?
- renal ultrasound
- CT
What are posterior urethral valves?
obstructive membranes that develop in the urethra close to the bladder
- the valve can obstruct or block the outflow of urine through the urethra
Epidemiology of posterior urethral valves?
usually in boys, uncommon in girls
Features of posterior urethral valves?
Presents with urinary retention, poor stream
Diagnosis of posterior urethral valves?
Diagnosis by voiding cystourethrogram, cystoscopy
Treatment of posterior urethral valves?
endoscopic valve ablation
Other common pediatric surgical problems?
- Trauma
- Burns
- Cleft palate
- Surgical infections
- ENT
