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Peads > GI (Surgical) > Flashcards

GI (Surgical) Flashcards

1
Q

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

A

Appendicitis (inflammation of the appendix caused be feacoliths)

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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 
Appendicitis 
-Guarding of the abdomen 
-Rebound tenderness
-TEMP - Usually only low grade (<38)
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
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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 peritonitis and 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
  • CRP initially
  • FBC - look for WCC and in particular neutrophils
  • LFTs and U&Es should also be got as standard
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7
Q

How should appendicitis be managed?

A
  • Appendicectomy-laparoscopic (keyhole)

- Cover with Cef(uroxime) + Met

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8
Q

What is another surgical abdominal condition that is commonly mistaken for appendicitis?
How does it present?
What causes it?
Treatment?

A

MESENTERIC ADENITIS

Presentation

  • Non-specific abdominal pain that is less severe (even sometimes tenderness in the RIF)
  • Quite often it is accompanied by a URTI with cervical lymphadenopathy

Cause
-swollen large mesenteric lymph nodes

Treatment

  • normally just supportive-fever and pain
  • some of these children the pain does not resolve and an appenidectomy is performed
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9
Q

What is intussusception and how does this affect the bowel?

A
  • When the bowel telescopes in on itself
  • Can cause compression>obstruction>ischaemia and bowel necrosis
  • can also cause perforation/peritonitis/sepsis/haemorrhage
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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 (age where they put everything in their mouths>Peyers patches)
  • Most common cause of bowel obstruction after the neonatal period
  • M>F
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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, HAEMORRHAGE

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13
Q

What are the symptoms in intussusception?

A

Intussuseption causes severe colicky pain

  • episodic high pitched crying (every 10/20 mins)
  • pale around the lips and mouth during episodes
  • draw their knees up to their chest
  • they will recover between waves of pain but will remain lethargic
  • won’t want to eat (anorexia)
  • bile stained vomiting
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14
Q

What signs are assosiated with intussusception?

A 
SYMPTOMS INTUSSUSEPTION
SIGNS INTUSSUSCEPTION 
-Sausage shaped mass felt in RUQ abdomen 
-Absent of bowel in RLQ (Dance's sign)
-Neurological signs 
	○ Lethargy 
	○ Hypotonia 
	○ Sudden alterations of consciousness may occur 
-Abdominal distension 
-Dehydration/shock
-Late mucoid and bloody redcurrant stools appear later (around 25% children- ischeamia)
-Late pyrexia
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15
Q

What are some causes of intussusception?

A

Usually there is no identified cause (90%) - can be associated with a viral prodrome where it is thought that Peyer’s patches cause the bowel to invaginate

  • in 10% it is caused by something
    • e.g. Meckel’s diverticulum (75%) or Henoch-Schonlein purpura (3%)
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16
Q

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

A

INTUSSUSEPTION
USS done to confirm - target lesions/psuedokidney)

  • AXR - might be able to see intussusception and might see obstruction (distended small bowel and absence of air on large bowel)
  • FBC might show neutrophilia
  • Us and Es might reflect dehydration
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17
Q

How should intussusception be managed?

A

INTUSSUSEPTION IS AN EMERGENCY
1. Resuscitation- Drip and suck method of resuscitation fluids (NG tube and IV fluids AND ANTIBIOTICS)
2. Then treat with an AIR ENEMA – put a catheter into the rectum, pass air into the bowel, see how far it goes (done by radiologist)
○ This works best for ileocolic intussusception
○ Lots of children wont tolerate-need sedation
○25% will need further surgery
○ If long history-bowel might be perforated
- Antibiotics and morphine

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18
Q

What is pyloric stenosis?

A

Thickening of the pyloric muscle meaning food cannot properly leave the stomach and gets regurgitated up food pipe

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19
Q

Who does pyloric stenosis occur in?

A
  • NOT at birth- around 2-7 weeks (takes time for muscle to hypertrophy)
  • 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? (symptoms)

A

SYMPTOMS OF PYLORIC STENOSIS

  • NON BILIOUS projectile vomiting
    • White/yellow- just milk/digested milk
    • Doesn’t have to be projectile-early stages
    • Vomiting frequency/projectililty will increase over time - Not feeding (still hungry after so lose interest)
  • Failure to thrive
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21
Q

What are some of the clinical SIGNS of pyloric stenosis?

A

SIGNS OF PYLORIC STENOSIS

  • VISIBLE PERISTALSIS on the surface of the child’s abdomen
  • olive shaped mass
  • signs of dehydration
  • METABOLIC ALKALOSIS (hypochloraemic (Cl-)/hypokalaemia (K+)/ Hyponatreamic (Na+)
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22
Q

How should we investigate a child with pyloric stenosis?

A

PYLORIS STENOSIS

  • USS-hypertrophic pylorus (looks like a donut), measurements of >3mm in thickness and 15mm in length are diagnostic
  • CapGas to check for metabolic alkalosis
  • TEST FEED- observe for vomiting, visible peristalsis and olive shaped mass
  • AXR- can also be useful and show enlarged stomach as air is trapped behind it
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23
Q

How should pyloric stenosis be managed?

A

PYLORIC STENOSIS

  1. Resuscitate with fluids and correct electrolyte imbalances (0.45% saline with 5% dextrose and potassium supplementation)
  2. Surgical management - pyloromyotomy
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24
Q

What is duodenal atresia?

What is the treatment?

A
  • This is when the duodenum does not form properly and contents cannot pass through
  • Drip and suck (IV fluids and NG decompression) then SURGERY
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25
Q

When does duodenal atresia present?

How common is it?

A
  • This is a problem with the development of the tubes and so it will present in the neonatal period(usually antenatal)
  • It’s the most common cause of obstruction in neonates
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26
Q

How does duodenal atresia present?

A
  • Baby of a few days old vomiting profusely after every feed and will soon stop feeding
  • vomit MAY BE billious (85%-because atresia is distil to ampulla)
  • 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
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27
Q

How should we investigate duodenal atresia?

A

USS

AXR - classical DOUBLE BUBBLE SIGN - very distended stomach and proximal duodenum (deflated rest of bowel)

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28
Q

Is duodenal atresia associated with any other conditions?

A

1/3 cases of DA will have T21 (downs syndrome)

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29
Q

What is an oesophageal atresia?

whats it assosistaed with?

A
  • Malformation of the oesophagus meaning food can’t pass down
  • nearly always associated with fusion/malformation of the trachea (TOF)
30
Q

What pregnancy complication is oesophageal atresia associated with?

A

Polyhydramnios - this is because the baby has not been swallowing fluid

31
Q

What other malformations is oesophageal atresia associated with?

A 
VACTERL (congenital malformations) ALWAYS LOOK! 
V - Vertebral 
A - Anal abnormalities (e.g. atresia) 
C - cardiac malformations (e.g. VSD) 
T - Tracheosophageal fistular ( TOF) 
E - Esophageal altresìa
R - Renal 
L -Limb (absent radius)
32
Q

How does oesohageal atresia present?

A

OSOPHAGEAL ALTRESIA

  • Persistent drooling and excessive saliva after birth - child unable to swallow spit.
  • Inability to feed - cyanotic episodes/coughing /choking (might be cos its going down wrong way)
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

OSOPHAGEAL ALTRESIA

-Constant suction in oesophageal pouch to clear saliva - -Followed by SURGERY

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.
  • Therefore the bowel grows outside the body and before it goes back in it rotates in 2 very specific axis before re-inserting (270 degrees anticlockwise around theSUPERIOR MESENTERIC ARTERY, 90, then 180)
  • Brings ceacum to right lower quadrant
  • Can get twisted and affect the blood supply (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
  • More common in boys
37
Q

How does malrotation and volvulus present?

A

VOLVULUS

  • Billious vomiting
  • Abdo pain/tenderness
  • Peritonitis/shock (can lead to death)
38
Q

What imaging should be ordered for a suspected case of malrotation and volvulus?
what would you see?

A

AXR (contrast) - no bowel gas seen and characteristic corkscrew jejunum (duodenum and proximal jejunum also dont cross midline-go inferior instead

39
Q

How should malrotation and volvulus be managed?

A

Urgent surgical intervention (LADDS PROCEEDURE untwist, remove ladds bands and appendix, reposition)

40
Q

What is an inguinal hernia and what are the types?

A

-Protrusion of bowel into the inguinal canal
DIRECT
-poking through the posterior wall of the canal
-rare in children (unless complex needs/connective tissue problem)

  • INDIRECT
  • entering through the deep inguinal ring)
  • 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

○ Intermittent swelling in scrotum or groin
○Swelling might be made larger by crying, coughing, running around
○ It is usually not painful but it might be tender to the touch

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

NEONATAL INGUINAL HERNIAS>SURGERY
1. Give opioid analgesics and try to reduce hernia (most will be reducible with pain killers)
2. Once the lump has been reduced it should be operated on (wait for 24-48 hours for the oedema to go down)
3. If the lump absolutely cannot be reduced (incarcerated) then it need to be operated on urgently
Risk of strangulation> may lead to ischemia

45
Q

What needs to be checked in the external genitalia in a newborn boy 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
    a) are they in the rightt path or are they ectopic
    b) if in right path can you drag them down into the scrotum?
47
Q

Describe the descent of the testes

A
  • start abdomen around the kidneys
  • from the third month of pregnancy up until term the testes should begin descending
  • abdo>inguinal canal >scrotum
  • they should take with them a layer of peritoneum that will become the tunica vaginalis.
48
Q

What % will have cryptorchidism at birth?
Who is it most common in?
When will majority resolve?

A
  • 4% of males will have cryptorchidism at birth
  • more common in preterm because the majority of descent will occur in the third trimester
  • Majority will correct themselves by 3 months
49
Q

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

A

-RETRACTILE - felt higher up an able to manipulate down into scrotum (pulled back up by cremasteric muscle, less worrying as will usually settle)

-PALPABLE -feel but can’t manipulate it down -
(remember it may be ectopic and not in inguinal canal)

-IMPALPABLE- might not be able to feel it at all (might be in abdomen)

50
Q

When should we escalate cryptorchidism?

A

CHRYPTORCHIDISM

  • If bilateral refer to pediatrics (sexual development) within 24 hours
  • If unilateral-do follow up at 3 months (if still not descended refer to surgeons before they are 6 months)

*surgery will probs happen after 1 year

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

Cryptorchidism
○ Found: Orchidoplexy via inguinal incision
○ Can’t find: Exploratory Laparoscopy (ExLap)
- USS can be done but is not that useful for abdominal testis
- Hormonal assays are useful especially if the testes are impalpable bilaterally (IM injection to trigger testosterone)

53
Q

Who is more likely to get testicular torsion?

A
  • Bell-Clapper testes - horizontal lay/not fixed in place
  • Also more likely if hx of cryptorchidism (undescended testicle
  • Peak in infancy and adolescence
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
  • Pain and tender testicle
  • Absent cremastueric reflex
  • Negative Phrens sign (pain not relieved by elevating testicle)
  • Painful abdomen but this is usually not tender
56
Q

How should torsion be investigated?

A
  • If it is obvious- REFER SURGERY IMMEDIATELY

- If less clear can get USS scanning (with doppler)

57
Q

How is torsion managed?

A
  • Surgically with detorsion of the testis

- Even if some doubt-surgical exploration is usually done because there is a chance of saving a testicle

58
Q

What is biliary atresia?

What causes it?

What happens if its untreated?

A

Absence/ blockage of bile duct (mostly extra-hepatic billiary tree). Rare, but most common cause of surgically treated jaundice in neonates

Genetics and environment (toxins, viral)

if left untreated build up of bile> can leak into blood> conjugated bile> jaundice

59
Q

How does biliary atresia present?

A

BILIARY ATRESIA

  • NORMAL at birth and meconium passed
  • Jaundice at two or three weeks after birth (with pale stools and dark urine (obstructive pattern)
  • Hepatomegaly will occur and then splenomegaly (d/t portal hypertension)
  • Can be easily mistaken for neonatal hepatitis
60
Q

How should you investigate suspected biliary atresia?

What are some important conditions to rule out?

A

BILARY ATRESIA

  • serum bilirubin (union and con) CONJUGATED HIGH
  • DIAGNOTSIC:cholioangograohy (x rays with contrast)
  • Liver biopsy will show extra-hepatic obstruction
  • fasting abdo USS (Bilary tree and liver)
  • LFTs raised but cannot differentiate between other causes
  • Rule out Anti1 antitrypsin and cystic fibrosis (sweat test)
61
Q

How is biliary atresia treated?

A

BILIARY ATRESIA

  • CORRECT COMPLICATIONS (Vit A, D, E and K) and cholangitis
  • SURGERY Kasai procedure/hepato-porto-enterostomy (small bowel used to mimic ducts)
  • Required ASAP (60 days) to improve survival
  • Normally will still need liver transplant (around 2 years) because of chronic liver disease
62
Q

What is the surgical sieve?

A

VITAMIN CDEF

Vascular, Inflammatory / Infective, Trauma, Autoimmune, Metabolic, Iatrogenic, Neoplastic, Congenital, Degenerative, Endocrine and Functional.

63
Q

What conditions are assosiated with malrotation?

A

Malrotation can be a feature in

  • exomphalos
  • congenital diaphragmatic hernia
  • intrinsic duodenal atresia
64
Q

What is Meckels diverticulum?

Epidemiology of Meckels diverticulum?

A

Meckels diverticulum

  • Most common congenital abnormality of the small intestine
  • Can also get ectopic gastric and pancreatic tissue
  • 2% population, 2 years, twice common in males
65
Q

how does Meckels diverticulum present?

A
  • RLQ pain
  • Most common cause of dark red PR bleed in peads
  • Can cause intussusception/volvulus/obstruction
66
Q

What is Hirschsprung’s disease?

A

This is an absence of ganglionic cells in the bowel
- this could be just in a small section of the bowel or it could be over a much large proportion (in 10% the whole bowel is involved)

67
Q

Where in the bowel is most commonly affect by Hirschsprung’s?
What affect does this have on the bowel?

A

The rectum - then there is varying degrees of proximal extension
The affected bowel is narrowed and contracted

68
Q

How and when does Hirschsprung’s usually present?

A
  • FAIL TO PASS MECONIUM IN THE FIRST 24 HOURS OF LIFE
  • Abdominal distension
  • Babies can develop BILE-STAINED VOMIT but this is a late sign - should have been identified before this
69
Q

What is a complication of Hirschsprung’s?

A

Hirscprung related ENTEROCOLITIS (due to C.diff)- this occurs in severe Hirshprungs

70
Q

How should you investigate for Hirschsprung’s?

A
  • Full thickness rectal biopsy with AB cover (just in case of perforation)- lack of ganglionic cells under microscope
  • BARIUM enema with X ray- shows how long the aganglionic area is extending (agangionic segment will appear thin)
71
Q

How is Hirschsprung’s treated?

A
  • Initially colonic washouts
  • Then (6-9 months) PULL THROUGH proceedure colostomy followed by anastomosis of normally innervated bowel to the anus (colostomy might not be lifelong)

Peads (29 decks)

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