Common Surgical Problems

Question 1

6 week old baby
projectile vomiting of milk after feed
no wet nappies
large lumps in abdomen

Answer 1

pyloric stenosis

lumps are just the waves of peristalsis in the stomach pushing against the closed pyloric sphinctor

Question 2

why is pyloric stenosis common at 6 weeks?

Answer 2

pyloric muscle thickens and can cause a physical obstruction

Question 3

how is pyloric stenosis managed surgically?

Answer 3

pyloromyotomy

Question 4

stereotypical presentation of pyloric stenosis?

Answer 4

6 weeks old

projectile vomiting milk

Question 5

6 months old
vomiting - began with food, then yellow, then green
not been very well for a few days
lumps in the lower abdomen
- sausage like mass in the abdomen
blood in the nappy (red currant jelly)

Answer 5

intussusception

can cause child to become very sick very quickly so need quick diagnosis

Question 6

US image of intussusception?

Answer 6

target like appearance on cross section

kidney like appearance from side on view

Question 7

description of intussusception?

Answer 7

where part of the tubing of the bowel telescopes into another causing a blockage

Question 8

how is intussusception managed?

Answer 8

radiologically
child is fully resuscitated and then air is blown into the bowel via rectum
air travels backwards around large bowel and pushes intussuscepted bowel back out
works in most
surgery used is unsuccessful

Question 9

6 years old
tummy pain
vomiting
journey to hospital - didn’t like the bumps on the road

Answer 9

peritonitis due to appendicitis

Question 10

investigation of the 6 year old child with abdominal pain?

Answer 10

get them up and out of bed - ask if they can jump
- can distinguish whether peritonitis is present
US - if you can see the appendix then its probably inflamed

Question 11

features of peritonitis in children?

Answer 11

cant jump
mild temperature
severe abdominal pain
vomiting

Question 12

baby

vomiting green

Answer 12

could me malrotation with volvulus

medical emergency

Question 13

what diagnosis must be excluded in a child which is vomiting green and how can this be done?

Answer 13

malrotation
clarify with parent whether vomit it yellow or green (often range of colours called “green”)
babies with malrotation vomit green due to obstruction just after where bile enters small bowel

Question 14

what is the largest distance across the abdomen and what 2 points is this between?
what is the significance of this?

Answer 14

two fixed points between splenic flexure to beginning of ascending colon
supply to midgut (from superior mesenteric) is between these 2 points
gut hangs from these two fixed points
if these 2 fixed points are not in the right place and the distance between them is small, then all the blood supply comes between them and rest of mid-gut can be deprived of blood
the rest of the gut hanging from these two points can also become twisted if hanging from these 2 close fixed points
= malrotation

Question 15

what are the risks of malrotation?

Answer 15

ischaemic bowel/death of bowel

Question 16

main causes of acute scrotum?

Answer 16

testicular torsion - can cause ischaemia and death of the testical
infection/inflammation of the testicle (e.g inflamed epididymis)
torsion of the hydatid? - black dot on top of the testicle - must be removed

Question 17

what is the most common acute scrotum presentation?

Answer 17

torsion of the hydatid

Question 18

what is the (hydatid?)

Answer 18

remnants of the females parts

Question 19

inflammation of scrotum spreading down over perineum and into abdomen?

Answer 19

idiopathic scrotal oedema

usually disappears with analgesia

Question 20

balanitis xerotica (BXO)

Answer 20

white scarring around opening of the penis

managed with circumcision

Question 21

hypospadias?

Answer 21

opening not on the penis but below it

penis is shortened and slightly bent

Question 22

what can cause huge scrotal swelling in the scrotum in a baby?

Answer 22

herniation of the bowel into the scrotum

Question 23

what is the management if a baby is born with a testicle in the groin and why?

Answer 23

remove testicle and place into scrotum
so the testicle can be examined
can have fertility issues

Question 24

where is testicle likely to be found if not in the scrotum?

Answer 24

along the inguinal ligament

Question 25

blood supply to the testicle?

Answer 25

testicular artery (branches off the aorta)

Question 26

sign on imaging which can indicate a missing testicle?

Answer 26

lack of formed testicular artery

instead lots of spidery blood vessels that don’t really go anywhere

Question 27

how is a testicle moved down into the scrotum?

Answer 27

cut the testicular artery and leave for a few months to try and get the blood supply from below to become the main blood supply
therefore the testicle is no longer tethered by the testicular artery and can be swung around and moved down into the scrotum