General surgery Flashcards
what is the most common surgical emergency?
appendicitis
what is the peak age for appendicitis
11-12 years
Ddx of appendicitis
GI: gastroenteritis, lymphadenitis, colitis/IBD, Meckel’s, cholecystitis
GU: UTI, pyelonephritis, renal calculi
Ob-Gyn: ectopic pregnancy, ovarian torsion, ovarian cyst, tuba-ovarian abscess/PID
Other: DKA, HSP, RLL pneumonia
what is the management for simple appendicitis
laproscopic technique no antibiotics (just at induction of surgery) discharge home within 24 hours
what is the management for perforated appendicitis
managed more and more non operatively with IV antibiotics until afebrile
typically abc for 7-10d
may require drainage procedure for large abscess
what is the non-operative management of acute appendicitis in children?
IV abs for 24-72 hours then oral for 1 week
high rate of failure or recurrence in 1st year (40%)
what is the age for presentation of hypertrophic pyloric stenosis
2 week to 2 months
- premature babies diagnosed later
pyloric stenosis
classic presentation
risk factors
olive
classic presentation: non bilious projectile emesis
- emesis is progressive over a short period of time until it occurs with every feed
- coffee grounds in emesis are not uncommon
M>F
risk factors: family history, first born, maternal feeding patterns
olive= pylorus
what is the gold standard for diagnosis of pyloric stenosis
ultrasound
length >14 mm
width >4 mm
UGIS another option- see string sign
what are the metabolic derangements seen with pyloric stenosis
hypochloremic hypokalemic metabolic alkalosis
lose electrolytes in non bilious vomiting- especially H+ and Cl-
kidney tries to correct pH and Cl- by excreting Na and HCO3 making alkalosis worse
when more volume depleted aldosterone kicks in and reabsorbs Na and volume at expense of H+ and K+
therefore you get a PARADOXICAL ACIDURIA
- K+ loss is really mediated and occurs with prolonged emesis
What is the initial management for a patient with pyloric stenosis? what do the electrolytes have to be to be safe for anesthesia?
IV fluid bolus with 0.9%NS- 10mL/kg until urine output resumes
then switch to D51/2NS + 20-40meq/L KCL
reassess fluid and electrolyte status to ensure normalization of metabolic status prior to OR
Cl>95
HCO3<28
K+>3.5
Correction of the alkalosis is essential to prevent postoperative apnea, which may be associated with anesthesia.
what is the surgical treatment for pyloric stenosis?
pyloromyotomy
what are some complications of pyloromoyomy (2)
mucosal perforation- become septic
incomplete pyloromyomy
if you think there is a leak then do UGI
what is the most common pathological lead point seen with intussusception?
meckel’s diverticulum
what is intussusception
teloscoping or prolapse of one portion of the bowel into an immediately distal adjoining part
what age do we see intussusception? gender preference?
3 months to 3 years
peak at 9months-12 months
M>F 3:1
what time frame is highest risk for recurrence of intussusception?
first 24 hours
what is the most common type of intussusception
ileocolic
what type of intussusception is seen with HSP
Ileo-ileal
what are the 4 types of intussusception?
ileocolic
ileo-ileal
coli-colic
jejuno-jejunal
what is the common presentation of intussusception
intermittent cramps colicky pain with sudden onset
inconsolable during “crisis”
quiet between episodes
what is the most common cause of intussuception
idiopathic- lymphoid hyperplasia
predisposing factors- recent upper respiratory illness (Adenovirus)
recent diarrheal illness (enterovirus)
what are some pathological lead points for intussusception? Whats the most common?
Meckels (MOST COMMON)
HSP
appendix, hemangioma, foreign body, ectopic mucosa, hamartoma
malignancy (lymphoma, small bowel tumors, melanoma)
what is the gold standard investigation for intussusception?
ultrasound
once ultrasound has suggested a diagnosis of intussusception what is done to confirm
air enema (PNEUMATIC REDUCTION) or contrast enema
what are 3 absolute contraindications for pneumatic reduction of intussusception
peritonitis
persistent hypotension
free air (pneumoperitoneum)
what presents with painless rectal bleeding
Meckel’s diverticulum
- typically see a drop in hemoglobin
Meckel diverticulum accounts for 50% of all lower GI bleeds in children younger than 2 yr of age.
acid-secreting mucosa that causes intermittent painless rectal bleeding by ulceration of the adjacent normal ileal mucosa.
what is the most common congenital anomaly of the GI tract?
Meckel’s diverticulum
what are the rules of 2 for Meckels diverticulum
2% of the population
2:1 M: F
2-6% symptomatic, complicated
2 years (50-75% symptomatic by age 2 years)
2 feet from ileocecal valve
2 inches long
2 types of heterotypic mucosa: gastric, pancreatic
what investigation do you do for Meckel’s diverticulum?
Meckel’s scan
99Tc scan
- detects gastric mucosa
-pretreat with H2-blocker (enhances uptake)
what is the most common presentation of Meckel’s? what’s another presentation?
painless rectal bleeding is the most common presentation
20-25% present with diverticulitis (resect with laparoscopy)
what is the management of a baby born with known congenital diaphragmatic hernia (2)
Intubate on first breath
NG tube to decompress the stomach
what investigation should be done for a baby with CDH?
cardiac echo
should also look for chromosomal anomalies
what is the most important predictor of outcome for babies with CDH
size of the defect
what is the most important maneuver to confirm a diagnosis of EA-TEF?
attempt insertion of NG tube
what major anomaly occurs MOST frequently with EA-TEF?
cardiovascular
remember that TEF is a part of VACTERL therefore need to work up for VACTERL
what is a red flag on feeding history for TEF?
coughing, gagging, cyanosis with feeding
profuse oral secretions
what size NG should you use to check for TEF
8-10F
usually blocks at 10cm
how can you confirm the presence of a fistula with esophageal atresia on x ray
air in stomach/abdomen confirms presence of fistula
what is the management of TEF
urgent surgical consult
closure of fistula is essential even if atresia cannot be repaired at same time (aspiration)
minimal investigations prior to OR: echo, NGT, rectal exam
if infant urinates then no need for abdominal US until after OR
why do we follow babies with TEF long term
they need long term surveillance for feeding, growth, GERD and other anomalies as needed
what is considered normal rotation
complete C loop
duodenojejunal junction at the level of the pylorus
proximal jejunum to the left of the left vertebral pedicle
first loops that fill should be the LUQ
what is the management of a patient with midgut volvulus
NG to low suction
IV fluid resuscitation
IV antibiotics
transfer to surgical centre
what is the gold standard test for volvulus?
UGIS
what is the treatment of volvulus
Ladd’s procedure
- retort
- lyse Ladd’s bands
- widen messentary
- remove appendix
Ddx Bilious vomiting
midgut volvulus malrotation duodenal or other atresia hirschprung's disease ileus
what is the triad for intussusception
pain
palpable sausage-shaped abdominal mass (most often in the right upper abdomen)
red currant jelly stool
what does intussusception look like on ultrasound
doughnut or target on transverse views
what is the recurrence rate after reduction of intussusceptions?
The recurrence rate after reduction of intussusceptions is approximately 10%, and after surgical reduction it is 2–5%
what is the treatment for symptomatic Meckel’s?
The treatment of a symptomatic Meckel diverticulum is surgical excision, diverticulectomy
what is Meckel’s Diverticulum?
outpouching of the ileum along the antimesenteric border approximately 2 feet from the ileocecal valve
Is TEF associated with oligo or polyhydramnios?
polyhydramnios
what is the treatment for esophageal atresia and TEF
Surgical ligation of the TEF
primary end-to-end anastomosis of the esophagus via right-sided thoracotomy
what are 2 future complications of esophageal atresia and TEF
Gastroesophageal reflux disease contributes significantly to the respiratory disease (reactive airway disease)
what is the most common form of esophageal atresia and TEF
the upper esophagus ends in a blind pouch and the TEF is connected to the distal esophagus (type C).
how might H type fistula present
TEF in the absence of EA (“H-type” fistula) might come to medical attention later in life with chronic respiratory problems
(refractory bronchospasm, recurrent pneumonias)
Name 3 syndromes associated with Hirschprung’s disease
Trisomy 21
NF
MEN2
congenital hypoventilation
if hirschprung disease is not diagnosed what complication can they have
enterocolitis
fever, distension, lethargy, hemodynamic instability
treat with antibiotics
what is the gold standard for diagnosing Hirschsprung disease
Rectal suction biopsy is the “gold standard”
how does a baby with Hirschsprung disease present?
- Failure to pass meconium within 24 hours of birth
- Abdominal distension
- Vomiting (bilious)
Infants with a missed diagnosis may present with severe
constipation
where is the aganglionic segment for Hirschsprung disease located in 80% of patients?
The aganglionic segment is limited to the rectosigmoid in 80% of patients.
what is seen on rectal biopsy for Hirschsprung disease?
- No ganglion cells (G)
- Hypertrophic nerves
- Increased acetylcholinesterase staining
what is seen with contrast enema for Hirschsprung disease
Contrast enema reveals a “transition zone” in 80%
what is the treatment for Hirschsprung disease?
primary pull-through procedure
• Soave
• Swenson
• Duhamel
what is the management of Hirschsprung disease
rectal decompression with saline irrigations
omphaocele is associated with what syndrome
Beckwith-Wiedemann syndrome
Omphalocele
• Defect THRU UMBILICUS • Defect can be “giant” • Contains liver or >5cm • Peritoneal sac • Normal bowel • 50% associated with other anomalies, especially cardiac • Prompt recovery of bowel function
Gastroschisis
• Defect RIGHT of umbilicus • Defect usually small • No peritoneal sac • “Angry” bowel • 10% associated with atresia & volvulus • No other system anomalies • Prolonged ileus/gastro-intestinal dysfunction
what is the most common age for inguinal hernia
Most common in children under 1 year
• 30% less than 6 months
M>F
60% right sided
who’s at highest risk of incarceration for inguinal hernia
newborns
Highest in children < 1 year (12-17%)
• Attempt reduction with sedation with repair in 24-48 hours (allows edema to resorb)
what is the technique for reducing an inguinal hernia
Push down towards pubis w/ left fingers push up towards canal w/ right fingers maintain pressure use sedation if child cries difficult reduction: observe overnight
when should pediatric hernias be repaired?
All pediatric hernias should be repaired soon after diagnosis (median 2 weeks)
Doubled risk of incarceration if wait >30 days
when is CONTRALATERAL exploration for inguinal hernia indicated?
The only current indication for contralateral exploration is for the infant with a history of prematurity
Only 5-8% of children develop contralateral hernias
what is the treatment for inguinal hernias
high ligation of the hernia sac
what patients are at higher risk of recurrence of inguinal hernias? (3)
VP shunts
Peritoneal dialysis
premature infants
incarcerated
what are some complications of inguinal hernia repair?
Scrotal swelling/hematoma – resolves within 10-14 days
iatrogenic undescended testicle – 0.2%
Recurrence – up to 0.8% all comers (15% in premature infants, 20% if incarcerated)
Injury to vas deferens – 0.2%
Testicular atrophy – 2.3%
What is the MAIN indication for orchidopexy for undescended testes?
risk of infertility
changes start @ 9-12 months
• decreased spermatogonia
• increasing interstitial fibrosis
Definitions: Undescended Ectopic Absent or atrophic Retractile Ascending testicle
Undescended – arrest of descent along normal path
Ectopic –arrest of descent outside normal path
Absent or atrophic – perinatal testicular torsion
Retractile – “high” resting position but able to be brought
down to scrotum
Ascending testicle – ascends with time
what is the treatment for an undescended testis
Surgical: inguinal orchidopexy
when should you refer a patient with an undescended testis?
Current recommendations indicate surgical
referral by 6-9 months of age
spontaneous descent of the testis will not occur after 4 mo of age.
• Rationale: gonocytes change to “adult dark” spermatogonia at 2-3 months age
transform primary spermatocytes at 4-5 years of age
what is the most common tumor that develops in an undescended testis
The most common tumor developing in an undescended testis in an adolescent or adult is a seminoma
In a newborn phenotypic male with bilateral nonpalpable testes what should you consider?
a newborn phenotypic male with bilateral nonpalpable testes, as the child could be a virilized female with congenital adrenal hyperplasia
what is the most common inguinal hernia in children?
congenital indirect hernias (99%) because of a patent processus vaginalis (PV)
what is a strangulated hernia?
A strangulated hernia is one that is tightly constricted in its passage through the inguinal canal, and as a result, the hernia contents have become ischemic or gangrenous
How long should you observe patients after inguinal hernia repair if <3mo or preterm <60 weeks
Full-term infants <3 mo of age and preterm infants <60 wk postconceptual age should be observed following repair for a minimum of 12 hr postoperatively and potentially overnight following general anesthesia for the development of apnea and bradycardia.
what are the hallmark signs of an inguinal hernia on physical exam?
The hallmark signs of an inguinal hernia on physical examination are a smooth, firm mass that emerges through the external inguinal ring lateral to the pubic tubercle and enlarges with increased intraabdominal pressure
what does incarcerated hernia mean?
hernia sac cannot be reduced
2/3 occur in 1st year of life
when should you consider surgery for umbilical hernia
if it persists beyond 4-5y
defects >2cm are less likely to close spontaneously
TIME BEFORE SURGERY (hr) ORAL INTAKE
2- Clear, sweet liquids
4- Breast milk
6- Infant formula, fruit juices, gelatin
8- Solid food
Name 2 indications for surgery for a hydrocele (3)
- persists >18 months
- unable to clearly examine the testis
- unable to distinguish from an inguinal hernia
Picture of gastroschisis (still same poor picture). Most common associated anomaly?
a. Intestinal atresia
b. cardiac defect
c. renal defects
intestinal atresia
A 15 year old girl presents with right lower quadrant pain and vomiting. On examination, she has right lower quadrant tenderness and rebound tenderness. Name three serious conditions you need to consider.
- Appendicitis
- Ovarian torsion
- Ectopic pregnancy
DDX vomiting with abdominal distension
+ Abdo Distension Hirschsprung’s Volvulus Jejunal/ileal atresia Meconium ileus Imperforate anus Meconium plug Colonic atresia NEC stricture
DDX vomiting without abdominal distension
Duodenal atresia/stenosis/web Malrotation/Volvulus Annular pancreas HPS Antral stenosis Preduodenal portal vein
The MOST COMMON cardiac malformation
associated with omphalocele is:
Tetralogy of Fallot
