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General Surgery Flashcards

1
Q

List 5 indications for splenectomy

A 
Traumatic splenic rupture
Anatomic defects
Severe transfusion dependent hemolytic anemia
Refractory immune cytopenias
Metabolic storage diseases
Secondary hypersplenism
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2
Q

List 4 risk factors for pyloric stenosis

A

-Family history PS
Neonate erythromycin use in 1st 2 weeks of life
-First born
-Male
-Conditions-Apert, Zellweger, T18, eosinophilic gastroenteritis, Smith lemli opitz

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3
Q

What is the typical age of presentation of pyloric stenosis?

A

2 weeks – 2 months

Prematures diagnosed later

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4
Q

List 4 clinical features of pyloric stenosis

A

Projectile vomiting

Hungry in between

Visible gastric perstaltic wave

Olive (above and to right of umbilicus)

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5
Q

List the ultrasonographic diagnostic criteria for pyloric stenosis?

A
  1. Pyloric thickness >=4 mm

2. Pyloric length >=14 mm

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6
Q

Why do you need to correct alkalosis prior to pyloromyotomy?

A

Prevent post-op apnea

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7
Q

What fluid should you use for patient with pyloric stenosis and hypokalemic, hypochloremic metabolic alkalosis AND WHY?

A

Give large amounts of chlorinatedfluid=D5W0.45NS +20mmol/L of KCl

A) Chloride will help decrease the bicarb (incr Cl in IVF more strongly correlated with decr in serum HCO3)
B) Solution should correct hyponatremia and hypokalemia as well
C) Want to treat alkalosis prior to surgery to prevent apnea

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8
Q

What is the most common age of presentation of intussuseption?

A

3 months – 3 years

90% <2 years

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9
Q

In a child with intususseption, above what age should you think about a pathologic lead point?

A

> 2 years

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10
Q

List 5 pathologic lead points in intususseption

A 
Meckel’s diverticulum (most common)
Polyps
Intestinal duplication
Neurofibroma
Henoch-Schonlein purpura
Appendix
Hemangioma
Foreign body
Ectopic mucosa
Hamartoma
Peutz-Jaeger’s***
Malignancy (lymphoma, SB tumors, melanoma)
CF
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11
Q

List 3 contraindications to air enema in intususseption

A

Peritonitis
Persistent hypotension
Free air/pneumoperitoneum

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12
Q

List 3 conditions associated with malrotation

A

CDH
Gastroschisis
Omphalocele
Heterotaxy syndrome (CHD, malrotation,and asplenia or polysplenia)

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13
Q

List 3 conditions causing bilious vomiting

A
  1. Midgut volvulus
  2. Malrotation
  3. Duodenal or other atresias
  4. Hirschsprung’s disease
  5. Ileus
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14
Q

List 3 conditions associated with duodenal atresia

A 
Trisomy 21
Malrotation
Congenital heart disease
GU
anomalies
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15
Q

Why should you do hearing test in hirschsprungs?

A

Associated with Waardenburg syndrome

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16
Q

Which is more likely to be associated with other congenital anomalies-omphalocele or gastroschisis?

A

Omphalocele-80% associated with anomalies

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17
Q

List 3 conditions associated with omphalocele

A

Beckwith Wiedmann***most common

CHARGE

OEIS (Omphalocele-exstrophy-imperforate anus-spinal defects)

Pentalogy of Canrell ( defects involving the diaphragm, abdominal wall, pericardium, heart and lower sternum.)

Aneuploidy (trisomies 13>18> 21)

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18
Q

List 3 anomalies associated with gastroschisis

A

Most cases have no extraintestinal abnormalities

Associated GI problems are common:

  1. Intestinal atresia
  2. Malrotation
  3. Stenosis
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19
Q

List 2 steps in the initial management of abdominal wall defects

A
  1. NG tube to decompress the stomach
  2. Wrap bowel in saline soaked gauze and plastic wrap
  3. IV access and start TFI 120 mL/kg/day (include NaCl in maintenance
    solution)
  4. Broad spectrum antibiotics
  5. Keep neonate in thermoneutral environment
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20
Q

List 3 long term complications of gastroschisis

A 
Decreased GI motility
Bowel obstruction***(most common)
Perforated bowel/strictures
GERD
Cholestasis
Short Bowel
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21
Q

What is the natural history of umbilical hernia?

A

Most appear before 6mo and resolve by 1yr

Large hernia disappear by 5-6yrs

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22
Q

Above what size are umbilical hernias unlikely to close spontaneously?

A

> 2 cm

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23
Q

Indications for surgery for umbilical hernia

A

Persists beyond 5yrs
Symptomatic
Strangulated
Progressively larger after 1-2 yrs

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24
Q

What is the anatomy of indirect hernia?

A

Most common!

Due to patent process vaginalis

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25
When is the risk of incarceration highest for inguinal hernia?
1st year of life
26
List risk factors for inguinal hernias
Prematurity ``` Urogenital • Cryptorchidism • Exstrophy of the bladder or cloaca • Ambiguous genitalia • Hypospadius/epispadius ``` Increased peritoneal fluid • Ascites • Ventriculoperitoneal shunt • Peritoneal dialysis catheter Increased intra-abdominal pressure • Repair of abdominal wall defects • Severe ascites (chylous) • Meconium peritonitis Chronic respiratory disease • Cystic fibrosis ``` Connective tissue disorders • Ehlers-Danlos syndrome • Hunter-Hurler syndrome • Marfan syndrome • Mucopolysaccharidosis ```
27
When should hernias be repaired?
Early repair (6-12mo) reduces risk of incarceration and complications Urgent referral if child is <1yr
28
Management of incarcerated hernia
Attempt reduction | Surgical repair 24-48 hours later
29
Management of strangulated hernia
Surgery ASAP
30
Anatomy of direct inguinal hernia
Rare in children Acquired Groin masses that extend toward femoral vessels due to muscular defect
31
What is the anatomy of malrotation?
Failure of the cecum to move into the right lower quadrant which prevents normal broad based adherence to the posterior abdominal wall The mesentery, including SMA, is tethered by narrow stalk-->prone to volvulus Ladds bands between cecum and RUQ can compress duodenum
32
List 5 risk factors for gall stones
``` Hemolytic disorders (sickle cell, HS) Obesity Crohn's disease Short gut (esp ileal resection) CF TPN Diuretic use Cephalosporin use ```
33
List 3 conditions that have increased risk of hirschsprungs
``` T21 Goldberg-Shprintzen Smith-Lemli-Opitz Shah-Waardenburg Cartilage-hair hypoplasia Congenital hypoventilation syndrome ```
34
Differential for delayed passage of meconium
``` HD Meconium ileus Small left colon syndrome Intestinal atresia ARM ```
35
What was the risk of re-intussuseption after air enema reduction?
10% | Should be observed 12-24 hours
36
What serum marker is elevated antenatal in abdominal wall defects (gastroschisis and omphalocele)?
Elevated maternal serum AFP
37
What antenatal US finding in omphalocele is associated with aneuploidy?
80% contain part of the liver Non-liver containing is associated with fetal aneuploidy
38
List 2 differences on physical exam between gastroschisis and omphalocele
1. Presence of covering membrane - Present in omphalocele 2. Location of defect - Gastroschisis: right of the umbilical cord insertion site - Omphalocele: midline 3. Liver location - Gastroschisis: intracorporeal - Omphalocele: extracorporeal
39
Of the following, which is most commonly associated with extraintestinal anomalies: 1) Duodenal atresia 2) Jejunal atresia 3) ileal atresia
Duodenal atresia-Most commonly T21 (33%)
40
List 3 congenital anomalies assocaited with duodenal atresia
``` CHD Malrotation Annular pancreas Renal anomalies EA Skeletal malformations ARM ```
41
Why is rectal biopsy gold standard to diagnose Hirschsprungs instead of contrast enema?
10% of Hirschsprung’s won’t have transition zone on constrast enema
42
During what weeks GA does intestine usually rotate during fetal development?
5th-12th week gestation
43
List 2 contraindications to air enema reduction in intussusception (past SAQ)
1. Prolonged intussusception 2. Signs of shock 3. Peritonitis 4. Intestinal perforation 5. Pneumatosis intestinalis
44
List 2 situations in which air enema reduction for intussusception would be unsuccessful (past SAQ)
1. Intussusception due to pathologic lead point | 2. SB-SB intussusception
45
In what age group is appendicitis most common?
12-18 years | Rare in children <5 years
46
List the criteria of the Pediatric Appendicitis score
- Fever >38°C (1) - Anorexia (1) - Nausea/vomiting (1) - Cough/percussion/hopping tenderness (2) - Right lower quadrant tenderness (2) - Migration of pain (1) - Leukocytosis >10,000 (109/L) (1) - Polymorphonuclear-neutrophilia >7,500 (109/L) (1) - Score of ≤2= very low likelihood of appendicitis - Score of ≥8 are highly associated with appendicitis
47
What are the ultrasound criteria for diagnosis of appendicitis?
- Wall thickness ≥6 mm - Luminal distention - Lack of compressibility - Complex mass in the RLQ or a fecalith - Normal appendix must be visualized to exclude appendicitis by ultrasound
48
When should patients with appendicitis have surgery?
Semi-elective | Within 24-48 hr of diagnosis
49
Management of perforated appendicitis
1. Fluid resuscitation 2. Antibiotics-Amp, gent, flagyl 3. Percutaneous drainage of collections by IR 4. Delayed appendectomy
50
List 3 complications of appendicitis
1. Wound infection 2. Intrabdominal abscess***most common 3. Post-op ileus
51
Treatment of perianal abscess
In infants: 1. No treatment, even if fistula In children: 1. Large abscesses require I+D 2. Limited role for antibiotics (unless systemically unwell or immunocompromised) 3. Surgery if fistulas
52
List three conditions associated with perianal fistulas
1. Repaired HD 2. TB 3. Crohns
53
List 3 initial management priorities in CDH
1. Immediate intubation and sedation 2. Avoid prolonged PPV 3. Treat PHTN
54
When are most CDHs repaired?
Most centers wait at least 48 hr after stabilization and resolution of the pulmonary hypertension
55
List 3 long term complications of CDH
``` BPD GERD Delayed growth in first 2 years of life Bowel obstruction Neurocognitive defects Scoliosis ```
56
What is diaphragmatic eventration?
Abnormal elevation of the hemidiaphram, because of thinned diaphragmatic muscle Elevated hemidiaphgram on CXR
57
How do you differentiate between diaphgragmatic eventration or CDH?
U/S
58
List 3 acute complications of G-tube insertion
- Pneumoperitoneum - Peritonitis - Ileus - Perforation
59
How do you treat hypergranulation tissue at a G-tube site?
- Silver Nitrate Ablation | - Hypertonic saline or steroid creams
60
What should be done for a G-tube that is pulled out?
If mature tract (>4 weeks): -Replace with foley If not mature tract: - Do not replace - Allow tract to heal - Replace G-tube at difference site
61
List 3 complications of short gut syndrome
``` FTT Malabsorption Micronutrient deficiency Liver disease Gall stones Increased risk of infection Hyperoxaluria and kidney stones Oral aversion ```

FRCPC (27 decks)

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