PAED SURGERY 2 Flashcards
What is intestinal obstruction?
What can it cause ?
Intestinal obstruction is where a physical obstruction prevents the flow of faeces through the intestines. This blockage will lead to a back-pressure through the gastrointestinal system, causing vomiting
It can cause absolute constipation, where the patient is unable to pass stools or wind.
Causes of Intestinal obstruction?
- Intussusception (most common in children)
- Meconium ileus
- Hirschsprung’s disease
- Oesophageal atresia
- Duodenal atresia (common in downs)
- ileal atresisa
- Imperforate anus
- malrotation of small bowel
- Malrotation of the intestines with a volvulus
- Strangulated hernia
How does intestinal obstruction present?
- Persistent vomiting-may be bilious
- Abdominal pain and distention
- Failure to pass stools or wind
- Abnormal bowel sounds. (high pitched / “tinkling” early in the obstruction and absent later.)
Investigations and findings for diagnosis of intestinal obstruction?
Imaging:
Abdominal xray
* dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction.
* Absence of air in the rectum.
Management of intestinal obstruction in children
- emergency referral to paediatric surgical unit
- nil by mouth
- NG tube - drain stomach / stop vommitting
- IV fluids - fluid / electroyle disturbance
When does Pyloric stenosis present?
typically 2-4 weeks of life with vomitting rarely up to 4 months
What is the pyloric spinchter?
With this in mind, explain the pathoysiology of pyloric stenosis and thus how it presents the way it does
What?
* pyloric sphincter is a ring of smooth muscle the forms the canal between the stomach and the duodenum.
Pathophysiology:
* Hypertrophy and narrowing causes pyloric stenosis. Food cannot travel from the stomach to the duodenum as normal.
Why presents as it does:
* After feeding, powerful peristalsis tries to push food from stomach into the duodenum. Its force ejects the food into the oesophagus, out of the mouth and across the room- “projectile vomiting”.
Features of pyloric stenosis?
Hungry / thin baby
pale
weight loss
dehydration - (mild to shock)
failing to thrive
projectile vomitting
Examination / observation and findings in pyloric stenosis?
Test feed
* with an NG tube in situ and stomach aspirated.
* observe left - right peristalsis of Left upper quadrant can see persitalsis on the abdomen.
Examine : Palpate
* firm, round mass in upper abdomen “olive sized” mass (hypertophic muscle)
* stand on left of baby and palpate with left hand at the lateral border of the right rectus in RUQ, during bottle / breast feed.
What might electrolyte / fluid status of a baby with pyloric stenosis be?
What should you test? why?
Severe H20 and NaCl deficit
Oxhandbook adds :hypochloraemic hypokalaemic metabolic alkalosis
Test:
urine output
plasma Cl-, K+
PH
Na (high or low)
Imaging: Abdo US to confirm diagnosis
Blood gas : hypochloric metabolic alkalosis
Why?:
to guide resuscitation and determine if surgery is safe.
Management of pyloric stenosis?
Before surgery:
* NG tube to correct electrolyte and metabolic distrubance
Surgery:
* laparoscopic pyloromyotomy (known as “Ramstedt’s operation“).
* An incision is made into the smooth muscle of the pylorus, widening the canal.
* Prognosis is excellent following the operation.
RF for pyloric stenosis?
Male
Family Hx
https://teachmepaediatrics.com/surgery/abdominal/pyloric-stenosis/
RF for pyloric stenosis?
Male
Family Hx
https://teachmepaediatrics.com/surgery/abdominal/pyloric-stenosis/
What does this blood gas show?
explain the pathophysiology behind electrolyte shifts
hypokalaemia, hypochloraemic metabolic alkalosis for a pt with pyloric stenosis
Patho:
The loss of HCL with repeated vomiting of stomach acid causes a hypochloraemia and metabolic alkalosis. The kidneys will then exchange potassium to retain protons to attempt to compensate, leading to a hypokalaemia.
Differentials for pyloric stenosis?
- Gastroenteritis
- Gastro-oesophageal reflux, including Sandifer syndrome
- Over-feeding
- Sepsis
- UTI
- Food allergy
If bilious vomiting is reported, don’t forget to think malrotation!
https://teachmepaediatrics.com/surgery/abdominal/pyloric-stenosis/
Complications of surgery for pyloric stenosis?
(Ramstedt’s pyloromyotomy)
Pre and post op (teach me paeds)
Pre-operative:
* Hypovolaemia
* Apnoea – secondary to hypoventilation associated with metabolic acidosis
Post-operative:
* Wound dehiscence
* Infection
* Bleeding
* Perforation
* Incomplete myotomy
What is Intussusception?
Where is it most common?
The telescoping of one bowel segment (the bowel folding inwards ) into another can lead to intestinal obstruction.
can occur anywhere but 90% of cases are of the ileo-colic type - where distal ileum passes into the caecum through ileo-caeceal valve.
Epidemiolgy of Intussuception?
Intussusception usually affects infants between 6-18 months old.
Boys are affected twice as often as girls
Risk factors for intussusception?
Most idiopathic
25% have a underlyinf cause - creating a lead point allowing the bowel to telescope
- Meckel diverticulum (most common)
- Polyps
- Henoch-Schönlein purpura
- Lymphoma and other tumors
- Post-operative
(Suspect a pathological cause if child is older or has a high recurrence rate)
Clinical features in the history for Intussusception?
- intermittent, severe, crampy, progressive abdominal pain
- sudden onset episodic intermittent inconsolable crying episodes
- drawing up legs (colic) and turning pale
- vomitting
- PR blood (redcurrant jam -late sign)
Clinical features on examination of intussusception?
Abdo exam Assess::
- Distention
- A palpable ‘sausage-shaped’ abdominal mass which can be found in the right upper quadrant (ileo-ceceal type) which is thickened bowel
- Signs of peritonism
- Presence of bowel sounds
- Signs of dehydration or shock to assess severity.
What conditions is Intussusception asosciated with?
- Concurrent viral illness
- Henoch-Schonlein purpura
- Cystic fibrosis
- Intestinal polyps
- Meckel diverticulum
Differencial diagnosis for intussusception?
- Colic (excessive crying and drawing up of legs in otherwise well infant)
- Testicular torsion (always check testes in a male infant presenting with excessive crying)
- Appendicitis (tends to occur in older children. Pain might be localised to right iliac fossa)
- Gastroenteritis
- Volvulus
Investigation for Intussusception?
Abdominal US
* sensitive and can exclude other diagnoses
* Donut / target sign on transverse plane (image)
* psuedokidney sign on longitudinal plane
Contrast enema
* where contrast fails to adequately pass through obstruction.
* Sometimes this is theraputic as it can reverse the obstrctuion
* CONTRAINDICATED in peritonitis or perforation
Management of intussusception?
Therapeutic enemas
* reduce the intussusception.
* Contrast, water or air are pumped into the colon to force the folded bowel out of the bowel and into the normal position.
Surgical reduction may be necessary if enemas do not work.
* surgery needed if bowel gangrenous or perforated
Complications of intussusception?
- Obstruction
- Gangrenous bowel
- Perforation
- Death
What is cryptochordism?
congenital absence of one or both testes in the scrotum due to a failure of the testes to descend into the scrotum during development.
Epidiemiology of cryptochordism?
- 6% of newborns
- drops to 1.5-3.5% of males at 3 months.
- 15-50% premature babies
What are the 3 types of crytpochordism (undescended testes)?
True undescended testis:
* where testis is absent from the scrotum but lies along the line of testicular descent
Ectopic testis:
* where the testis is found away from the normal path of decent
Ascending testis:
* where a testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum.
- Pathophysiology of normal testicle descent
- Pathophysiology in abnormal / crytpochordism
- Under normal embryological development the testis descends from the abdomen to the scrotum, pulled by the gubernaculum, within the processes vaginalis.
- ABNORMAL: The process above is
* incomplete in true undescended testis
* or tracks to an abnormal position in an ectopic testis.
With bilateral cryptochordism what causes must you exclude first?
Hormonal causes e.g.
* such as androgen insensitivity syndrome
* disorder of sex development
RF for cryptorchidism?
- prematurity,
- low birth weight,
- having other abnormalities of genitalia (i.e. hypospadias)
- having a first degree relative with cryptorchidism.
- maternal smoking during pregnancy
- small for gestational age
What to establish in history of suspected cryptochordism?
- have the testes ever been seen or palpated within the scrotum i.e. newborn check
- sometimes parents notice the testicles in scrotum in warm bath
Examination of a child with suspected cryptochordism?
Inspection
palpate: 80% are palpable
see if tested can be “gently milked down to the base of the scrotum” - retractile testes (dont need surgery).
Around 20% of undescended testis are impalpable and are therefore: ectopic, intra-abdominal, absent, or impalpably small.
Differencials for cryptochordism?
Normal retractile testis
* the testis is seen intermittently in the scrotum and with minimal traction can be pulled to the base of the scrotum
A true undescended testis
* (palpable or impalpable) – testicle located along the normal decent pathway, but cannot be manipulated to the base of the scrotum
Ectopic testis
* testis is present, but is not found along the normal pathway of decent.
Absent testis or “vanishing testis”
* Bilaterally impalpable testes in the context of underlying DSD or endocrine
DSD- disorder of sex development
If supect / find:
* disorder of sex development
* undescended testis +/- ambiguous genitalia / hypospadias
* bilateral undescended testes
what should you do and why ?
- urgent referral to senior paediatrician within 24 hours
- need paediatric endocrinology and urology input.
- This may be a presentation of congenital adrenal hyperplasia (CAH)
- CAH - Risk of salt-losing crisis, requiring high dose sodium chloride therapy and careful glucose monitoring followed by steroid replacement.
Management of cryptochordism
surgery (orchidopexy) ideally around 6-12 months of age
- unpalpable testes- examination under GA and laprascopy to see if absent or intrabdominal
- testes palpable - open orchidopexy - testis mobilised and fixed in scrotum
- Intra-abdominal - Fowler-Stephen procedure
Complications of surgery for crytochordism?
Short term complications: infection, bleeding and wound dehiscence.
Long term: small risk of testicular atrophy and testicular re-ascent.
Complications of cryptochordism
impaired fertility
* increases with delayed correction. testis are 2-3 degrees warmed intrabdominally so can affect spermatogenesis
Testicular cancer:
* 2-3 x more common
Torsion
* undescended are at higher risk of torsion
What is testicular torsion?
Testicular torsion occurs when the spermatic cord and its contents twists within the tunica vaginalis, compromising the blood supply to the testicle.
Why is testicular torsion an emergency?
without treatment the affected testicle will infarct within hours
in what age range is testicular torsion most common?
peak incidence:
* neonates
* adolescents - 13 to 16 years (NICE CKS)
AR what you can remember about the anatomy of the testes
Pathophysiology of testicular torsion?
Torsion occurs when a mobile testis rotates on the spermatic cord. This leads to reduced arterial blood flow, impaired venous return, venous congestion, resultant oedema and infarction to the testis if not corrected.
What anatomical vairant makes testicular torsion more likely?
- Males with a horizontal lie to their testes- ‘bell-clapper deformity’
- Testis lacks a normal attachment to the tunica vaginalis.
- testicle is more mobile, increasing the likelihood of it twisting on the cord structures.
neonatal testicular torsion:
Why does it happen (anatomy)?
What type of tosion is it?
- In neonates the attachment between the scrotum and tunica vaginalis is not fully formed and the entire testis and tunica vaginalis can tort.
- it is known as ‘extra-vaginal torsion’. Almost all other torsions will be ‘intra-vaginal’, with the freely moving cord and testis torting within the tunica vaginalis.
- It can occur in-utero and new-borns must be thoroughly examined at their first check.
RF for testicular torsion?
- Age (most common 12-25yrs, with peak between 13-16)
- Previous testicular torsion*
- Family history of testicular torsion
- Undescended testes
Clinical features and examination findings of testicular torsion?
Features:
* sudden onset
* severe unilateral testicualr pain
* nausea
* vommitting
* referred abdominal pain
Examination
* high position of testis compared to other side
* swollen
* tender
* absent cremasteric reflex
* pain continues despite raising testicle (negative Prehn’s sign - +ve in epidymo-orchitis)
DD for testicular torsion
- epidyo-orchitis
- incarcerate inguinal hernia
- testicualr cancer
- renal colic
- hydrocele
- idiopathic
- testicular cancer
- scrotal oedema
- torsion of the hyatid morgani
What do you know about Torsion of the Hydatid of Morgagni?
- hydatid of morgani a remnant of mullerian duct
- structure can become torted causing sudden onset pain
- affects younger children than testicular tosion
- exam: scrotum less erythematous and has a normal lie unlike TT
- ‘blue dot’ sign upper scrotum - visible infarcted hydatid
Investigations for Testicular torsion?
- clincial diagnosis - ASAP theatre for scrotal exploration
- Doppler ultrasound to look for compromised blood flow to testis
- urine dipstick - infection rule out differencials
Management of testicular torsion?
- surgical emergency - 4-6 hour window from onset of symptoms to save testis before ischaemic damage
- strong analgesia, NBM, maintenace fluids
- urgent surgical exploration of testes and spermatic cord
Surgery:
* bilateral orchidopexy - testicles untwisted and fixed to scrotum
* Orhidectomy if testes not viable, prosthesis can be inserted.
Complications of testicular torsion
- testicular infarction
- atropy
- chronic pain
- risk to future fertility
- palpable suture
What is hypospadias?
Hypospadias is a condition affecting males, where the urethral meatus (the opening of the urethra) is abnormally displaced to the ventral side (underside) of the penis, towards the scrotum.
congenital condition affecting babies from birth and is usually diagnosed on the examination of the newborn.
Where anatomically is the defect in hypospadias?
variations
- Ventral (underside of penis)
- towards bottom of the glans (90%)
- halfway down the shaft
- base of the shaft.
What is epispadias? What can it be associated with?
- meatus is displaced to the dorsal side (top side) of the penis.
- Usually, the foreskin is abnormally formed to match the position of the meatus.
- Can be associated with chordee - a condition where the head of the penis bends downwards.
Management of hypospadias?
- referral to a paediatric specialist urologist
- warn parents not to circumcise the infant until a urologist indicates this is ok.
- Mild cases may not require any treatment
- Surgery is usually performed after 3 – 4 months of age
- Surgery aims to correct the position of the meatus and straighten the penis
Complications of hypospadias?
- Difficulty directing urination
- Cosmetic and psychological concerns
- Sexual dysfunction
