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General surgery Flashcards

1
Q

what is the most common surgical emergency?

A

appendicitis

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2
Q

what is the peak age for appendicitis

A

11-12 years

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3
Q

Ddx of appendicitis

A

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

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4
Q

what is the management for simple appendicitis

A 
laproscopic technique
no antibiotics (just at induction of surgery)
discharge home within 24 hours
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5
Q

what is the management for perforated appendicitis

A

managed more and more non operatively with IV antibiotics until afebrile
typically abc for 7-10d
may require drainage procedure for large abscess

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6
Q

what is the non-operative management of acute appendicitis in children?

A

IV abs for 24-72 hours then oral for 1 week

high rate of failure or recurrence in 1st year (40%)

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7
Q

what is the age for presentation of hypertrophic pyloric stenosis

A

2 week to 2 months

- premature babies diagnosed later

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8
Q

pyloric stenosis
classic presentation
risk factors
olive

A

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

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9
Q

what is the gold standard for diagnosis of pyloric stenosis

A

ultrasound
length >14 mm
width >4 mm

UGIS another option- see string sign

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10
Q

what are the metabolic derangements seen with pyloric stenosis

A

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

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11
Q

What is the initial management for a patient with pyloric stenosis? what do the electrolytes have to be to be safe for anesthesia?

A

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.

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12
Q

what is the surgical treatment for pyloric stenosis?

A

pyloromyotomy

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13
Q

what are some complications of pyloromoyomy (2)

A

mucosal perforation- become septic
incomplete pyloromyomy

if you think there is a leak then do UGI

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14
Q

what is the most common pathological lead point seen with intussusception?

A

meckel’s diverticulum

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15
Q

what is intussusception

A

teloscoping or prolapse of one portion of the bowel into an immediately distal adjoining part

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16
Q

what age do we see intussusception? gender preference?

A

3 months to 3 years
peak at 9months-12 months
M>F 3:1

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17
Q

what time frame is highest risk for recurrence of intussusception?

A

first 24 hours

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18
Q

what is the most common type of intussusception

A

ileocolic

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19
Q

what type of intussusception is seen with HSP

A

Ileo-ileal

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20
Q

what are the 4 types of intussusception?

A

ileocolic
ileo-ileal
coli-colic
jejuno-jejunal

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21
Q

what is the common presentation of intussusception

A

intermittent cramps colicky pain with sudden onset
inconsolable during “crisis”
quiet between episodes

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22
Q

what is the most common cause of intussuception

A

idiopathic- lymphoid hyperplasia
predisposing factors- recent upper respiratory illness (Adenovirus)
recent diarrheal illness (enterovirus)

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23
Q

what are some pathological lead points for intussusception? Whats the most common?

A

Meckels (MOST COMMON)
HSP
appendix, hemangioma, foreign body, ectopic mucosa, hamartoma
malignancy (lymphoma, small bowel tumors, melanoma)

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24
Q

what is the gold standard investigation for intussusception?

A

ultrasound

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25
once ultrasound has suggested a diagnosis of intussusception what is done to confirm
``` air enema (PNEUMATIC REDUCTION) or contrast enema ```
26
what are 3 absolute contraindications for pneumatic reduction of intussusception
peritonitis persistent hypotension free air (pneumoperitoneum)
27
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.
28
what is the most common congenital anomaly of the GI tract?
Meckel's diverticulum
29
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
30
what investigation do you do for Meckel's diverticulum?
Meckel's scan 99Tc scan - detects gastric mucosa -pretreat with H2-blocker (enhances uptake)
31
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)
32
what is the management of a baby born with known congenital diaphragmatic hernia (2)
Intubate on first breath | NG tube to decompress the stomach
33
what investigation should be done for a baby with CDH?
cardiac echo | should also look for chromosomal anomalies
34
what is the most important predictor of outcome for babies with CDH
size of the defect
35
what is the most important maneuver to confirm a diagnosis of EA-TEF?
attempt insertion of NG tube
36
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
37
what is a red flag on feeding history for TEF?
coughing, gagging, cyanosis with feeding | profuse oral secretions
38
what size NG should you use to check for TEF
8-10F | usually blocks at 10cm
39
how can you confirm the presence of a fistula with esophageal atresia on x ray
air in stomach/abdomen confirms presence of fistula
40
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
41
why do we follow babies with TEF long term
they need long term surveillance for feeding, growth, GERD and other anomalies as needed
42
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
43
what is the management of a patient with midgut volvulus
NG to low suction IV fluid resuscitation IV antibiotics transfer to surgical centre
44
what is the gold standard test for volvulus?
UGIS
45
what is the treatment of volvulus
Ladd's procedure - retort - lyse Ladd's bands - widen messentary - remove appendix
46
Ddx Bilious vomiting
``` midgut volvulus malrotation duodenal or other atresia hirschprung's disease ileus ```
47
what is the triad for intussusception
pain palpable sausage-shaped abdominal mass (most often in the right upper abdomen) red currant jelly stool
48
what does intussusception look like on ultrasound
doughnut or target on transverse views
49
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%
50
what is the treatment for symptomatic Meckel's?
The treatment of a symptomatic Meckel diverticulum is surgical excision, diverticulectomy
51
what is Meckel's Diverticulum?
outpouching of the ileum along the antimesenteric border approximately 2 feet from the ileocecal valve
52
Is TEF associated with oligo or polyhydramnios?
polyhydramnios
53
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
54
what are 2 future complications of esophageal atresia and TEF
Gastroesophageal reflux disease contributes significantly to the respiratory disease (reactive airway disease)
55
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).
56
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)
57
Name 3 syndromes associated with Hirschprung's disease
Trisomy 21 NF MEN2 congenital hypoventilation
58
if hirschprung disease is not diagnosed what complication can they have
enterocolitis fever, distension, lethargy, hemodynamic instability treat with antibiotics
59
what is the gold standard for diagnosing Hirschsprung disease
Rectal suction biopsy is the “gold standard”
60
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
61
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.
62
what is seen on rectal biopsy for Hirschsprung disease?
* No ganglion cells (G) * Hypertrophic nerves * Increased acetylcholinesterase staining
63
what is seen with contrast enema for Hirschsprung disease
Contrast enema reveals a “transition zone” in 80%
64
what is the treatment for Hirschsprung disease?
primary pull-through procedure • Soave • Swenson • Duhamel
65
what is the management of Hirschsprung disease
rectal decompression with saline irrigations
66
omphaocele is associated with what syndrome
Beckwith-Wiedemann syndrome
67
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 ```
68
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 ```
69
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
70
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)
71
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 ```
72
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
73
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
74
what is the treatment for inguinal hernias
high ligation of the hernia sac
75
what patients are at higher risk of recurrence of inguinal hernias? (3)
VP shunts Peritoneal dialysis premature infants incarcerated
76
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%
77
What is the MAIN indication for orchidopexy for undescended testes?
risk of infertility changes start @ 9-12 months • decreased spermatogonia • increasing interstitial fibrosis
78
``` 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
79
what is the treatment for an undescended testis
Surgical: inguinal orchidopexy
80
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
81
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
82
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
83
what is the most common inguinal hernia in children?
congenital indirect hernias (99%) because of a patent processus vaginalis (PV)
84
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
85
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.
86
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
87
what does incarcerated hernia mean?
hernia sac cannot be reduced | 2/3 occur in 1st year of life
88
when should you consider surgery for umbilical hernia
if it persists beyond 4-5y | defects >2cm are less likely to close spontaneously
89
TIME BEFORE SURGERY (hr) ORAL INTAKE
2- Clear, sweet liquids 4- Breast milk 6- Infant formula, fruit juices, gelatin 8- Solid food
90
Name 2 indications for surgery for a hydrocele (3)
1. persists >18 months 2. unable to clearly examine the testis 3. unable to distinguish from an inguinal hernia
91
Picture of gastroschisis (still same poor picture). Most common associated anomaly? a. Intestinal atresia b. cardiac defect c. renal defects
intestinal atresia
92
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.
1. Appendicitis 2. Ovarian torsion 3. Ectopic pregnancy
93
DDX vomiting with abdominal distension
``` ž + Abdo Distension ž Hirschsprung’s ž Volvulus ž Jejunal/ileal atresia ž Meconium ileus ž Imperforate anus ž Meconium plug ž Colonic atresia ž NEC stricture ```
94
DDX vomiting without abdominal distension
``` Duodenal atresia/stenosis/web Malrotation/Volvulus žAnnular pancreas žHPS žAntral stenosis žPreduodenal portal vein ```
95
The MOST COMMON cardiac malformation | associated with omphalocele is:
Tetralogy of Fallot

Pediatrics- Noelle (28 decks)

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