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Year 4 PAEDS > GI (Surgical) > Flashcards

GI (Surgical) Flashcards

1
Q

What is the most common cause of an acute surgical abdomen in a child?

A

Appendicitis

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2
Q

In what age range of children is appendicitis more common in?

A

It can occur in children of any age but it is very rare in children under the age of 3

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3
Q

What is different about some of the symptoms in a child with appendicitis and what are they?

A 
The presentation is unlikely to be as barn door as it is in most adults 
ANOREXIA, VOMITING and irritability might be predominate symptoms 
ABDO PAIN is likely to be a symptom but might not be as localised to RIF as in adult 
BOWEL CHANGES (diarrhoea OR constipation)
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4
Q

What clinical signs might a child with appendicitis have and how is it best to illicit these?

A

Guarding of the abdomen and rebound tenderness
It can every difficult to ascertain where the child is having pain. Asking the child to stand or hop on their Right leg can be a good way of seeing whether the pain is on that side
TEMP - Usually only low grade (<38)

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5
Q

What are some common complications of appendicitis?

A

Perforation - happens in about 1/3 cases in children - can be rapid as the omentum is less well developed
This will lead to clinical shock

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6
Q

What investigations might you require to confirm a diagnosis of appendicitis?

A

Sometimes it is obvious and ix might not be necessary - clinical diagnosis.
USS can confirm
FBC - look for WCC and in particular neutrophils
CRP and ESR useful

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7
Q

How should appendicitis be managed?

A

Appendicectomy

Cover with Cef + Met

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8
Q

What is another surgical abdominal condition that is commonly mistaken for appendicitis?

A

MESENTERIC ADENITIS
Thought to be caused by large lymph nodes in the mesenteries and is thought to be associated with URTIs and cervical lymphadenopathy

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9
Q

What is intussusception and how does this affect the bowel?

A

When the bowel invaginates or telescopes in on itself - this can cause compression of the invaginated bowel leading to an obstruction as well as ischaemia and bowel necrosis

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10
Q

Where is the most common location of intusussception?

A

The terminal ileum invaginating into the cecum

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11
Q

What is the common age range for intussusception?

A

Between 3 months and 2 years - most common cause of bowel obstruction after the neonatal period

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12
Q

What complications can occur with intussusception?

A

The condition of itself is serious and need urgent treatment but tangling of the mesentery can also lead to venous outflow obstruction which can lead to perforation, peritonitis and haemorrhage

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13
Q

What is the nature of pain in intussusception?

A

Colicky - during periods of pain children might become pale around the lips and mouth and draw their knees up to their chest - they will recover between waves of pain but will remain lethargic

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14
Q

What other symptoms are associated with intussusception?

A 
Anorexia 
Vomiting - may be bile stained 
Sausage shaped mass felt in abdomen 
RED-CURRANT JELLY STOOLS 
Abdominal distension and shock
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15
Q

What are some causes of intussusception?

A

Usually there is no identified cause - can be associated with a viral prodrome where it is thought that Peyer’s patches cause the bowel to invaginate

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16
Q

What investigations should be done in child in whom you suspect intussusception?

A

USS - target lesions
AXR - might be able to see intussusception and might see distended small bowel and absence of air on large bowel (obstruction)

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17
Q

How should intussusception be managed?

A

Air enema - done by radiologist with paediatrician present (will often require fluid resuscitation)
Drip and suck like with bowel obstruction in adult
About 25% will not have their intussusception successful reduced by enema and will need surgery

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18
Q

What is pyloric stenosis?

A

Hypertrophy of the pyloric muscle meaning food cannot properly leave the stomach and gets regurgitated

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19
Q

Who does pyloric stenosis occur in?

A

Doesn’t occur straight away as it takes time for the muscle to hypertrophy so peak presentation is around 2-7 weeks
More common in First-Born Males
More common in those with FH (particularly on mother’s side)

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20
Q

How does pyloric stenosis present?

A

The main feature is vomiting - this might start as fairly benign regurgitation of feeds and then becomes forceful, projectile vomiting - not bile-stained
Children will become irritable and will lose interest in feeds and will therefore begin to lose weight

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21
Q

What are some of the clinical SIGNS of pyloric stenosis?

A

VISIBLE PERISTALSIS on the surface of the child’s abdomen
Can sometimes feel an olive-shaped mass on the child’s stomach
Child might be dehydrated (not feeding)
Might be hypochloraemic and hypokalaemia leading to a METABOLIC ALKALOSIS

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22
Q

How should we investigate a child with pyloric stenosis?

A

Always get a blood gas- looking at their pH will give you a good idea of how severe the case is
TEST FEED - observe vomiting or peristalsis
USS - might visualise the hypertrophic pylorus
Low sodium

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23
Q

How should pyloric stenosis be managed?

A

Resuscitate with fluids and correct electrolyte imbalances (0.45% saline with 5% dextrose and potassium supplementation)
Surgical management - pyloromyotomy

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24
Q

What is duodenal atresia?

A

This is when the duodenum does not form properly and contents cannot pass through

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25
Q

Who does duodenal atresia occur in?

A

This is a problem with the development of the tubes and so it will present in the neonatal period
Baby that is a few days old will be vomiting up its feeds and will soon stop feeding

26
Q

How does duodenal atresia present?

A

Baby of a few days old vomiting profusely after every feed - vomit MAY BE billious (Depending on level of atresia)
Usually the baby will have passed its meconium (every distal to blockage will be passed) - this can make the obstructive picture more difficult to interpret
- however NO MORE stool will be passed after the first meconium

27
Q

How should we investigate duodenal atresia?

A

AXR - classical DOUBLE BUBBLE SIGN - very distended stomach and proximal duodenum

28
Q

Is duodenal atresia associated with any other conditions?

A

1/3 cases of DA will have T21

29
Q

What is an oesophageal atresia?

A

Malformation of the oesophagus meaning food can’t pass down - can be associated with fusion/malformation of the trachea (TOF)

30
Q

What pregnancy complication is oesophageal atresia associated with?

A

Polyhydramnios - baby not swallowing fluid

31
Q

What other malformations is oesophageal atresia associated with?

A 
VACTERL 
V - Vertebral 
A - Anorectal 
C - cardiac malformations 
T - TOF 
E - Esophageal 
R - Renal 
L - Radial Limb
32
Q

How does oesohageal atresia present?

A

Persistent drooling and excessive saliva after birth - child unable to swallow spit.
Inability to feed - cyanotic episodes
Coughing /choking

33
Q

How is oesophageal atresia investigated?

A

A feeding tube is passed and then we x-ray to see if it has reached the stomach

34
Q

How do we managed oesophageal atresia?

A

Constant suction in oesophageal pouch to clear saliva and surgical correction

35
Q

How does malrotation and volvulus occur?

A

When the fetal bowel is developing it grows faster than the space in the abdominal cavity where it will eventually reside. Therefore the bowel grows outside the body and before it goes back in it rotates in 2 very specific axis before re-inserting.
Sometimes this rotation does not occur properly and the bowel gets twisted, tangled and the blood supply can be compromised (volvulus)

36
Q

Who does malrotation and volvulus usually occur in?

A

Volvulus secondary to malrotation can occur in someone of any age but more likely in neonates

37
Q

How does malrotation and volvulus occur?

A

Vomit is bilious
The abdomen will be very painful and tender
The bowel could perforate leading to peritonitis and death
Shock

38
Q

What imagine should be ordered for a suspected case of malrotation and volvulus?

A

AXR - no bowel gas seen and characteristic corkscrew jejunum

39
Q

How should malrotation and volvulus be managed?

A

Urgent surgical intervention

40
Q

What is an inguinal hernia and what are the types?

A

Protrusion of bowel into the inguinal canal
Can be direct (poking through the posterior wall of the canal) or indirect (entering through the deep inguinal ring)
Indirect more common in children and usually due to patent ductus vaginalis

41
Q

In which children are inguinal hernias more common?

A

Males (almost exclusively)
Pre-term
(also more common on the RHS)

42
Q

How will an inguinal hernia present?

A

Usually as a painless groin swelling that might come and go
Mass made larger/present by coughing/laughing/sneezing
Swelling might extend to scrotum
Usually this swelling is irreducible (indirect) - although nearly all swellings are reducible with analgesic cover
Lump might be quite firm and may be tender

43
Q

When you examine a possible hernia what should you be looking for?

A

Reducibility - if the lump cannot be reduced then risk that it is strangulated - more urgent
Always try and feel for the testicle in the scrotum
Ask the child to cough or bear down
Assess for tenderness

44
Q

How should an inguinal hernia be managed?

A

Try to reduce under analgesic cover
If successfully reduced then operate in 24-48 hours (wait for oedema to go down
If not reducible operate more urgent (?strangulated)

45
Q

What needs to be checked in the external genitalia in a newborn examination?

A

Check for presence of testicles in scrotum

46
Q

If the testes are not in the scrotum in a newborn what should you do?

A

Feel up and along the inguinal canal and see if you can find them.
If found, can you drag them down into the scrotum?

47
Q

Describe the descent of the testes

A

they are in the abdomen around the kidneys until third trimester - they go through the inguinal canal into the scrotum and take with them a layer of peritoneum - tunica vaginalis

48
Q

What % of males at birth at cryptorchidism? What percent will still have it by 3/12?

A

4%

1.5% (majority will correct themselves) - if not corrected by now will need intervention

49
Q

If the testes cannot initially be felt in the scrotum what are the three possibilities?

A

It might be RETRACTILE - felt higher up an able to manipulate down into scrotum (pulled back up by cremasteric muscle)
Might be able to feel in but not manipulate it down - PALPABLE
Might not be able to feel it at all - IMPALPABLE

50
Q

What investigations should be done in cryptorchidism?

A

USS - not useful in abdominal testes or obese boys
Hormonal assays is bilaterally impalpable - inject bHCG IM and this should cause testosterone surge
Laparoscopy and ExLap

51
Q

What are some possible complications with cryptorchidism?

A

Reduced fertility - for maximal spermatogenesis testicles should be a couple of degrees below body temp
Abdominal testicles are more likely to become MALIGNANT

52
Q

How is cryptorchidism managed?

A

Orchidoplexy by inguinal incision

53
Q

What anatomical abnormality predisposes to testicular torsion?

A

Bell-Clapper testes - horizontal lay/not fixed in place

Also more likely if hx of cryptorchidism

54
Q

How does torsion present?

A

Sudden onset testicular/abdominal pain
Abdominal pain
Vomiting
- like in appendicitis picture might be slightly less obvious in paediatric patient

55
Q

What would be some examination findings with torsion?

A

Testicle might be high, swollen, oedematous and very tender
Absent cremasteric reflex
Painful abdomen but this is usually not tender

56
Q

How should torsion be investigated?

A

If it is obvious torsion then doesn’t need investigating - get surgical r/v immediately
If less clear can get USS scanning

57
Q

How is torsion managed?

A

Surgical exploration

Even if not sure surgery is usually done because there is a chance of saving a testicle

58
Q

What is biliary atresia?

A

Failure of the extra-hepatic billiary tree to form

59
Q

How does biliary atresia present?

A

Normal at birth
Will then develop persistent jaundice with pale stools and dark urine (obstructive pattern)
Hepatomegaly will occur and then splenomegaly (d/t portal hypertension)

60
Q

How should you investigate suspected biliary atresia?

A

LFTs NOT useful
Fasting abdo USS- might show contracted or absent GB
LIVER BIOPSY - features of extra-hepatic obstruction
OPERATIVE CHOLIOANGOGRAPHY

61
Q

How is biliary atresia treated?

A

Surgical bypass of absent/fibrotic ducts - HEPATOPORTOENTEROSTOMY
jejunum anasatmosed to porta hepatis
If this is done BEFORE 60days chances of survival are good but they decline after this age
CORRECT COMPLICATIONS (Vit A, D, E and K) and cholangitis
LIVER TRANSPLANT

Year 4 PAEDS (18 decks)

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