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Child Health > Paediatric GI - Malrotation, Hernias and Appendicitis > Flashcards

Paediatric GI - Malrotation, Hernias and Appendicitis Flashcards

1
Q

Where do the caecum and duodenojejunal flexure lie in a normal abdomen?

A

Caecum - RIF

Duodenojejunal flexure - left of midline

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2
Q

Where do the caecum and duodenojejunal flexure lie in a child with malrotation?

A

Caecum - RUQ

Duodenojejunal flexure - midline

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3
Q

How does the mesentery run and act in a normal abdomen?

A

Mesentery runs diagonally and is tight to provide stability

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4
Q

How does the mesentery behave in a child with malrotation?

A

The mesentery is mobile and can lead to a volvulus

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5
Q

How is a malrotated gut generally picked up?

A

Incidental finding on abdominal imaging

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6
Q

How does a malrotated gut generally present?

A

It is normally asymptomatic

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7
Q

If a malrotated gut is picked up early, how is it managed?

A

Ladd’s procedure

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8
Q

What is a volvulus?

A

High intestinal obstruction at the duodenal level followed by infarction of the entire midgut

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9
Q

How does a volvulus present?

A

Bile stained vomit

Tender abdomen

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10
Q

What investigations would you request if you suspect a volvulus?

A

AXR

GI contrast study

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11
Q

What would you see on AXR in a volvulus?

A

Double bubble sign - dilated stomach and duodenum

No other air-fluid level

Few small pockets of residual gas in bowel

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12
Q

What would you see on GI contrast study in a volvulus?

A

Bird beak obstruction

Corkscrew duodenum

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13
Q

How is a volvulus managed if healthy bowel?

A

Urgent laparotomy to untwist volvulus

Ladd’s procedure done

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14
Q

How is a volvulus managed if the bowel is not viable?

A

Urgent laparotomy to remove gut and place child on permanent IV feeds

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15
Q

What happens in a congenital diaphragmatic hernia?

A

Diaphragm fail to fuse properly

Herniation of intestines through diaphragm

Pulmonary hypoplasia and hypertension

Apparent dextrocardia due to mediastinal shift

Lack or surfactant

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16
Q

What signs would be present in congenital diaphragmatic hernia?

A

Bowel sounds in chest

Scaphoid abdomen seen - abdomen sucked inwards

Signs of respiratory distress

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17
Q

How is congenital diaphragmatic hernia normally picked up?

A

A lot in antenatal screening - preparations for birth put in place

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18
Q

What types of congenital diaphragmatic hernia are there?

A

Morgagni - anterior

Bochdalek - posterior (more common)

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19
Q

How is a congenital diaphragmatic hernia managed?

A

Sedation and mechanical ventilation at birth

Resus done in head up position

Surgical repair after a few days if baby still alive

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20
Q

Why is resuscitation done avoiding bag-mask ventilation?

A

Not having head up position and using a bag-mask ventilation would dilate the intestines leading to further compression of the lung

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21
Q

What complications are associated with congenital diaphragmatic hernia?

A

Chronic lung disease
Neurological damage –> hypoxia
GORD

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22
Q

What causes an umbilical hernia in a child?

A

Failure of the muscle wall to close after midgut rotation

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23
Q

What is the normal lifecycle of an umbilical hernia?

A

Common in newborns and will normally resolve by 3 years

24
Q

When are you likely to refer a child for repair of an umbilical hernia?

A

<2cm and asymptomatic - 4/5yo

> 2cm or symptomatic - 2/3yo

25
Q

What risk factors are associated with umbilical hernia?

A

Afro-caribbean

Down’s syndrome

26
Q

Who is an inguinal hernia more likely to affect?

A

Males - testis migration

27
Q

If an inguinal hernia presents in the first few months of life, what do you do and why?

A

Urgent herniotomy due to risk of strangulation

28
Q

If an inguinal hernia presents after 1 year old, what do you do?

A

Elective herniotomy due to low strangulation risk

29
Q

What risk is associated with a herniotomy?

A

Risk of apnoea in neonates and pre-terms

30
Q

Who is appendicitis most common?

A

In Males between 10-20 yo

31
Q

Why is appendicitis less common in infants?

A

Appendix wider and well drained

32
Q

What can cause appendicitis?

A

Obstruction - faecolith

Inflamed by lymphatic hyperplasia

Stasis - bacterial overgrowth

33
Q

What is the classical presentation of appendicitis?

A

Periumbilical pain (splanchnic visceral nerves)

Localise to right iliac fossa (peritoneal involvement)

Nausea, vomiting and low grade fever

34
Q

What signs are present in classical appendicitis?

A

Rebound tenderness at McBurney’s point

Rovsing’s sign

35
Q

Where is McBurney’s point?

A

2/3 between umbilicus and ASIS

36
Q

What is Rovsing’s sign?

A

Pain in RIF when LIF palpated

37
Q

Why must you be wary of appendicitis in children?

A

Often doesn’t present in a classical way

40-45% present atypically

38
Q

What symptoms can be seen in infants with appendicitis?

A

Watery diarrhoea

Vomiting

39
Q

What symptoms can be seen in young children with appendicitis?

A

Vague abdominal pain

Anorexia

40
Q

How would a pelvic appendix present?

A

Pain initially in RIF

Pain on urination - can be suprapubic

Profuse diarrhoea

41
Q

How would a retrocaecal appendix present?

A

Pain localise to:

Psoas muscle
Flank
RUQ

42
Q

How would a retroileal appendix present?

A

Testicular pain due to irritation of the spermatic artery or ureter

43
Q

How would an appendix with a long tip present?

A

Pain in left lower quadrant

44
Q

How would a perforated appendix present?

A

Generalised abdominal pain

Tachycardia

High fever >38

45
Q

What investigations are useful when diagnosing appendicitis?

A

Diagnosis is clinical!

Contrast CT
USS

CXR
FBC, U&E, CRP, ESR
Urine dip
Pregnancy test

46
Q

What are the pros and cons of a contrast CT and USS in appendicitis?

A

CT
Pros - sensitive and specific
Cons - radiation and long

USS
Pros - quick and no radiation
Cons - can be inconclusive esp. if overlying bowel gas

47
Q

What should you be aware of when diagnosing a child with appendicitis if they have had pain for >48 hours?

A

It is likely to have perforated

48
Q

How is appendicitis risk scored?

A

Paediatric Appendicitis Score

RIPASA

Alvarado

49
Q

What is the paediatric appendicitis scoring system?

A 
Migration of pain - 1
Anorexia - 1
Nausea - 1
RIF tenderness - 2
Fever - 1
Leucocytosis - 1
Raised immature white cells - 1
Coughing, hopping, percussion pain - 2

Total 10

50
Q

What places a child at low risk in the paediatric appendicitis scoring ? What does it mean?

A

<4

Low likelihood of appendicitis

51
Q

What places a child at medium risk in the paediatric appendicitis scoring? What does it mean?

A

4-6

Further monitoring req.
Imaging useful

52
Q

What places a child at high risk in the paediatric appendicitis scoring? What does it mean?

A

> 6
Refer to surgical team
Highly likely appendicitis

53
Q

How is appendicitis initially managed?

A

IV access
Fluid resus
Contact surgical team - discuss IV antibiotics and putting child NBM

54
Q

What is the surgical management for appendicitis?

A

Appendicectomy - can be laparoscopy or a laparotomy

55
Q

What are the key complications of appendicitis to be aware of?

A 
Perforation
Peritonitis
Abscess
Sepsis
Death

Child Health (30 decks)

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