Lecture 6: pediatric surgery, ophthalmology ENT Flashcards
1
Q
common pediatric surgical problems
A
- Acute Appendicitis
- Intussusception
- Malrotation and Volvulus
- Pyloric Stenosis
- Umbilical Hernia
- Inguinal Hernia
- Abdominal wall defects:
- Diaphragmatic Hernia
- Omphalocele
- Gastroschesis
2
Q
acute appendicitis
A
- Most common indication for emergency abdominal surgery in children
- frequency increases with age
- unusual in infants and small children
- 5% of all pediatric cases are in age <5 years
- Incidence of perforation is high in infants and children
- lots of other reasons for similar symptoms
- small children do not localize pain well
- Etiology: Assumed that outlet of appendix becomes blocked by fecalith and causes inflammation.
3
Q
acute appendicitis signs and symptoms
A
- Signs & Symptoms
- short history of worsening symptoms (a few days)
- anorexia +/- vomiting
- +/- fever
- classical abdominal pain
- begins as periumbilical & diffuse pain (visceral)
- McBurney’s Point Pain
- often difficult to localize well in children
- Classic signs of peritonitis:
- rebound tenderness
- involuntary guarding
- tenderness to percussion
- shaking the bed
- jumping up and down
- Pain going over curbs and speed bumps in the car
- Physical Exam Findings:
- Psoas
- Obturator
- Rosving’s-Palpating LLQ elicits pain in RLQ
- Perforation
- immediate relief of symptoms, followed by worsening of overall abdominal pain, distress, and toxicity (vomiting, signs of sepsis, etc.)
- Obturator Sign: Pain with pain with passive internal rotation of the flexed hip. Caused from irritation of inflamed tissues that are disturbed from movement of obturator muscle.
- Psoas Sign: Passive extension of the the hip causes stretching of the psoas muscle that irritates inflamed tissue around the appendix and results in pain.
4
Q
workup of acute appendicitis
A
- CBC: leukocytosis increases suspicion, but a normal WBC does not rule out appendicitis
- WBC >10k in 89% of those with appendicitis and 93% of those with perforation
- WBC > 10k in 62% of those without appendicitis!
- CMP: Looking for other causes of abdominal pain.
- Ultrasound- Must note if appendix is seen. Means nothing if the appendix is not found on exam.
- unperforated – noncompressible (diagnostic), large (>6mm, nondiagostic) appendix
- perforated – phlegmon in RLQ
- CT
- Most sensitive, but often avoided due to concern for radiation.
- a contrast-filled appendix rules out appendicitis
- peri-appendiceal fat stranding is often not evident in thin children, who have very little intra-abdominal fat
- KUB: appendicolith (lucky!) or if perforated, possibly free air
- Urinalysis: +/- pyuria (peritonitis near bladder may create pyuria)
5
Q
pediatric appendicits score (PAS)
A
-
Scores/Management:
- Score ≤2 or 3: Low risk, can discharge home with strict return precautions.
- Score ≥7 or 8: Appendicitis likely. Urgent imaging or surgical consult.
6
Q
Treatment of acute appendicitis
A
- laparoscopic vs. open appendectomy
- perforated appendicitis typically first treated with antibiotics for days or weeks before operative intervention
7
Q
intususception
A
- Telescoping of bowel to produce obstruction
- Ileocolic is most common
- Clinical findings
- Episodic cramping abdominal pain
- Emesis/diarrhea
- Blood in stool
- Classic “currant jelly” stool is a late finding
- May appear lethargic between bouts of pain
- Diagnosis:
- Abdominal Film: Target sign (next slide), crescent sign, signs of bowel obstruction. (Great case review: https://www.hawaii.edu/medicine/pediatrics/pemxray/v7c18.html)
- Ultrasound
- Air/contrast enema: Diagnostic and Therapeutic
- Treatment – the longer this exists, the more likely you will be dealing with necrotic bowel
- Initial:
- Air enema: 70-85% effective
- If complicated (ex. Unstable vitals, signs of perforation) then open reduction of intussusception
- Recurrence
- 10% in children who underwent non-opperative reduction. Half of recurrences occur in the first 72 hours after reduction.
- Initial:
8
Q
malrotation and volvulus
A
- During embryonic development the growing intestines come out of the fetus to perform a complex set of rotations to achieve the proper orientation of the normal gut.
- If the rotations do not occur (nonrotation) or occur incompletely
(malrotation) then the final orientation of the gut wil be compromised. - Patients with malrotation and non rotation can present with signs of obstruction. 75% present befor 5 yo.
- Vomiting
- Abdominal Distention
- Abdominal Pain
- Hemodynamic Instability
- Peritonitis
- Hematochezia
- In malrotation the small intestine has a narrow mesenteric base that allows for the mesentery to twist and cause an obstruction. This twisting is called volvulus.
- Most common presentation is vomiting. May not be bilious.
- >90% of patients who present with malrotation in infancy present with volvulus.
9
Q
pyloric stenosis
A
- diagnosed mainly on history THERE WILL BE A QUESTION ON THE EXAM
- Gastric outlet obstruction resulting from hypertrophy of muscle around the pylorus
- Epidemiology
- 3 out of 1000 live births
- Hereditary component
- Common in first born
- Increased risk with bottle feeding
- Macrolide antibiotics (erythromycin, azithromycin) in the first 2 weeks of life (systemic)
- Presentation
- Symptoms usually start in the first 3-4 weeks of life.
- Regurgitation of feeds that progressively worsens
- Nonbilious vomiting that may become projectile (>3 feet)
- Chronic emesis can lead to an emaciated and dehydrated infant with electrolyte abnormalities and hemodynamic instability.
- Classic triad
- hypochloremia
- hypokalemia
- metabolic alkalosis
- Infrequent finding of abdominal “olive” when palpating the stomach
- Diagnosis
- Ultrasonography
- Upper GI contrast study
- Treatment
- Correction of electrolyte abnormality
- Hydration
- Pyloromyotomy
10
Q
umbilical hernia
A
- Etiology
- weakness in the midline fascia surrounding the umbilical area
- herniation of abdominal contents
- incarceration is a surgical emergency
- Treatment
- observation with education for signs of incarceration
- rarely causes incarceration
- Surgical correction considered around age 3 yo
11
Q
inguinal hernia
A
- will need surgical correction unlike the umbilical hernia which can go away on its own
- Weakness in lower abdominal wall often where the processus vaginalis remains open
- abdominal contents (intestine, ovary, etc.) can slip down towards the scrotum or labium
- common in pre-term infants
- much less common in girls
- Presentation:
- “fullness”
- evidence of swelling during crying or Valsalva
- thick or full spermatic cord
- incarceration is a surgical emergency
- Management:
- Referral should be made to surgery when hernia is detected. Surgical repair will be done to prevent further complications.
12
Q
diaphragmatic hernia
A
- Extrusion of the abdominal contents into the pleural cavity through a hole in the diaphragm.
- Predominantly on left
- Contraindication to positive-pressure ventilation
13
Q
omphalocele
A
- Extrusion of abdominal contents through umbilical defect, typically encased in a membrane
- Often associated with other malformations as part of a syndrome.
14
Q
gastroschisis
A
- Extrusion of abdominal contents through non-umbilical defect, typically without a membrane
15
Q
vision screening
A
- 5-10% of children have vision problems
- Objectively screened up to 3 years of age
- red reflex – used to assess for cataracts and intraglobular tumors. (refer to neonatology lectures)
- fixation and tracking
- test of pupillary reflex
- corneal light reflex
- blink to threat
- Subjectively screened when older and able.
