General Surgery Flashcards
Findings for malrotation with volvulus on AXR, US, and UGI?
AXR = double bubble sign US = whirlpool sign UGI = dilated duodenum, corkscrew sign
Intussception - age range, etiology, presentation, imaging findings, and management
Age = 3 months to 3 years Etiology = idiopathic (peyer's patches) or leadpoints (polyps, Meckel's, CF, IBD, lymphoma) Presentation = acute colicky abdo pain, currant jelly stools, bilious emesis, sausage mass Imaging = AXR (obstructive), US (target lesion) Management = enema reduction (if stable), surgical
Definition, management, + most common associated abnormality for hypospadias
= congenital defect where urethral opening is located on the ventral side of the penis
- Mgmt: Surgical correction 6-12 months of age, avoid circumcision until then (as may use the tissue)
- Chordee: fibrous band of tissue on ventral side causing curvature
Clinical presentation of intussception
- Classic triad (only 20%) = colicky pain, emesis, red currant bloody stool
- Other = toxic, shock, dehydration, RLQ mass, distention
Umbilical hernias: (a) approximate size when unlikely to spontaneously close and (b) what age to intervene if not closed?
(a) >1.5-2.0cm
(b) 5 years of age
Phimosis - definition + possible treatment
=narrowing of distal foreskin that prevents retraction over the glans penis
- Normal adhesions in the newborn
- May require circumcision
Paraphimosis - definition, complication, management steps
=incarceration of retracted foreskin behind the glans
- Progressive edema –> ischemia
- Ice, anesthesia, manual reduction –> surgical
Most common associated abnormality to gastroschisis?
intestinal atresia
Important initial steps in management of a neonate born with gastroschisis
- Wrap bowel in sterile/saline dressings + plastic wrap
- Maintain normothermic
- Fluids
- IV Abx
- OG for decompression
- Surgical intervention
What is the most common congenital anomaly of the GI tract?
Meckel’s Diverticulum
Rule of 2’s for Meckel’s Diverticulum
- 2% of the population
- 2:1 of M:F
- 2-6% symptomatic, complicated
- 50-75% symptomatic by age 2
- Within 2 feet of ileocecal valve
- 2 inches long
- 2 types of heterotropic mucosa - gastric, pancreatic
x3 main complications/presentations of Meckel’s Diverticulum
- Bleeding = most common, painless
- Diverticulitis
- Obstruction
What is the investigation (+what does it detect) for Meckel’s Diverticulum?
99Tc Meckel’s scan = gastric mucosa
US findings for pyloric stenosis
- Length >14mm + thickness >4mm
- Shouldering
Metabolic derangement in pyloric stenosis
- HypoCl metabolic alkalosis
- Paradoxical aciduria
x3 cardinal features of Hirschsprung’s disease
- Failure to pass meconium within 24 hours of birth
- Abdo distention
- Bilious emesis
Infectious complication of Hirschsprung disease, including symptoms
Hirschsprung-associated enterocolitis
-acute diarrhea, explosive stools, abdo distention
Important management steps for Malrotation
- Surgical center
- NG to LIS
- IVF resus
- IV Abx
- Surgical Ladd’s procedure
Top x5 diagnoses for bilious emesis
- Malrotation with midgut volvulus
- Duodenal or other atresia
- Annular pancreas
- Hirschsprung’s disease
- Ileus
Where is the level of obstruction if (a) no abdo distention vs (b) abdo distention?
(a) proximal
(b) distal
Reasons to repair an umbilical hernia early (x2)
- Bowel incarceration
- Hernia size = controversial
x3 risk factors for an inguinal hernia in children
- Prematurity
- VP shunt
- Peritoneal dialysis
Incarcerated inguinal hernia - rate of incidence (+ inc if prem)
~8%
-x2 greater if prem
If no clear reason for a hydrocele, what must you think about?
Secondary hydrocele - think of testicular pathology
When do most hydroceles resolve?
> 2/3 will resolve by 18-24 months
Timeline for hydrocele repair
-Typically a 2 year cut off
Best modality to differentiate hernia from hydrocele?
Transillumination
DDx for acute scrotum
- Testicular torsion
- Appendiceal torsion
- Epididymitis/orchitis
- Inguinal hernia - first presentation and/or complicated
- Acute hydrocele - primary or secondary
- Trauma
- HSP
- Tumors
x2 peaks in incidence during pediatrics for testicular torsion
- Infantile
- Post-pubertal
How to make dx of testicular torsion in adolescents?
Clinical
Clinical sign of appendiceal torsion
Blue dot sign
Tx for appendiceal torsion
NSAIDs + excision
Tx for testicular torsion
- Infantile: controversial, testicular salvage is rare because of ++delay in presentation
- Post-pubertal: manual detorsion < surgical consultation for testicular salvage
When should you refer a hydrocele to surgery?
One year of age
What bug in addition to STIs cause epididymitis?
E coli
At what age can you consider doxy over amox for lyme disease?
8 years old
When do you start Abx right away and when to test first for lyme disease that is symptomatic?
Tx right away if early and test before for late
Next step in evaluation to differentiate CDH vs eventration
Diaphragm fluoroscopy after CXR
What investigations should be done if epididymitis/orchitis?
- UA
- UCx
- Urethral swab for sexually active adolescents
- US
If bacterial epididymitis/orchitis then what Ix and referral are your next steps?
- Urology consultation
- VCUG
If there is bilateral cryptorchidism what must you think about?
Syndromic or DSD = requires immediate work-up
Main reasons for treating cryptorchidism?
- Malignancy
- Fertility
- Trauma
- Torsion
- Hernia
When to treat cryptorchidism?
Orchidopexy between 6-12 months of age
Role of US in cryptorchidism?
- Determine presence or size of testicle
- NOT helpful for position or to differentiate between undescended vs retractile
What x3 investigations should occur prior to OR repair of TEF?
- Rectal exam
- Echo - given association with VACTERL
- Abdo US (if no urination)
Location of defect for (a) gastroschisis vs (b) omphalocele
(a) right of umbilicus
(b) through umbilicus
What abdo wall defect is larger: (a) gastroschisis vs (b) omphalocele?
b
Best test to differentiate between CDH and eventruation?
Diaphragm fluoroscopy
Most common associated anomaly with gastrochisis?
Intestinal atresia
What is the primary mode of treatment for a perianal abscess in an infant or young child?
I+D
x2 most common complications from a ruptured appendicitis management (in order of prevalence)?
Wound infection > intra-abdo abscess
What are your first investigations if child with bilious emesis? - As per Tito
- XR = determine if gas in abdo
- If yes = LGI
- If no = UGI
Alvarado score
=Out of 10 § Anorexia § N/V § Migration of pain to RLQ § Fever § RLQ tenderness = 2 points § Rebound pain § WBC > 10 = 2 points (CRP no advantage) PMNs > 75%
When is an intussception most likely to recur?
Within 6 hours
What does a thoracotomy as an infant put you at risk of later on from an MSK perspective?
Scoliosis
