Paediatric GI - Malrotation, Hernias and Appendicitis

Question 1

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

Answer 1

Caecum - RIF

Duodenojejunal flexure - left of midline

Question 2

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

Answer 2

Caecum - RUQ

Duodenojejunal flexure - midline

Question 3

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

Answer 3

Mesentery runs diagonally and is tight to provide stability

Question 4

How does the mesentery behave in a child with malrotation?

Answer 4

The mesentery is mobile and can lead to a volvulus

Question 5

How is a malrotated gut generally picked up?

Answer 5

Incidental finding on abdominal imaging

Question 6

How does a malrotated gut generally present?

Answer 6

It is normally asymptomatic

Question 7

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

Answer 7

Ladd’s procedure

Question 8

What is a volvulus?

Answer 8

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

Question 9

How does a volvulus present?

Answer 9

Bile stained vomit

Tender abdomen

Question 10

What investigations would you request if you suspect a volvulus?

Answer 10

AXR

GI contrast study

Question 11

What would you see on AXR in a volvulus?

Answer 11

Double bubble sign - dilated stomach and duodenum

No other air-fluid level

Few small pockets of residual gas in bowel

Question 12

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

Answer 12

Bird beak obstruction

Corkscrew duodenum

Question 13

How is a volvulus managed if healthy bowel?

Answer 13

Urgent laparotomy to untwist volvulus

Ladd’s procedure done

Question 14

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

Answer 14

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

Question 15

What happens in a congenital diaphragmatic hernia?

Answer 15

Diaphragm fail to fuse properly

Herniation of intestines through diaphragm

Pulmonary hypoplasia and hypertension

Apparent dextrocardia due to mediastinal shift

Lack or surfactant

Question 16

What signs would be present in congenital diaphragmatic hernia?

Answer 16

Bowel sounds in chest

Scaphoid abdomen seen - abdomen sucked inwards

Signs of respiratory distress

Question 17

How is congenital diaphragmatic hernia normally picked up?

Answer 17

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

Question 18

What types of congenital diaphragmatic hernia are there?

Answer 18

Morgagni - anterior

Bochdalek - posterior (more common)

Question 19

How is a congenital diaphragmatic hernia managed?

Answer 19

Sedation and mechanical ventilation at birth

Resus done in head up position

Surgical repair after a few days if baby still alive

Question 20

Why is resuscitation done avoiding bag-mask ventilation?

Answer 20

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

Question 21

What complications are associated with congenital diaphragmatic hernia?

Answer 21

Chronic lung disease
Neurological damage –> hypoxia
GORD

Question 22

What causes an umbilical hernia in a child?

Answer 22

Failure of the muscle wall to close after midgut rotation

Question 23

What is the normal lifecycle of an umbilical hernia?

Answer 23

Common in newborns and will normally resolve by 3 years

Question 24

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

Answer 24

<2cm and asymptomatic - 4/5yo

> 2cm or symptomatic - 2/3yo

Question 25

What risk factors are associated with umbilical hernia?

Answer 25

Afro-caribbean | Down's syndrome

Question 26

Who is an inguinal hernia more likely to affect?

Answer 26

Males - testis migration

Question 27

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

Answer 27

Urgent herniotomy due to risk of strangulation

Question 28

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

Answer 28

Elective herniotomy due to low strangulation risk

Question 29

What risk is associated with a herniotomy?

Answer 29

Risk of apnoea in neonates and pre-terms

Question 30

Who is appendicitis most common?

Answer 30

In Males between 10-20 yo

Question 31

Why is appendicitis less common in infants?

Answer 31

Appendix wider and well drained

Question 32

What can cause appendicitis?

Answer 32

Obstruction - faecolith Inflamed by lymphatic hyperplasia Stasis - bacterial overgrowth

Question 33

What is the classical presentation of appendicitis?

Answer 33

Periumbilical pain (splanchnic visceral nerves) Localise to right iliac fossa (peritoneal involvement) Nausea, vomiting and low grade fever

Question 34

What signs are present in classical appendicitis?

Answer 34

Rebound tenderness at McBurney's point Rovsing's sign

Question 35

Where is McBurney's point?

Answer 35

2/3 between umbilicus and ASIS

Question 36

What is Rovsing's sign?

Answer 36

Pain in RIF when LIF palpated

Question 37

Why must you be wary of appendicitis in children?

Answer 37

Often doesn't present in a classical way 40-45% present atypically

Question 38

What symptoms can be seen in infants with appendicitis?

Answer 38

Watery diarrhoea | Vomiting

Question 39

What symptoms can be seen in young children with appendicitis?

Answer 39

Vague abdominal pain Anorexia

Question 40

How would a pelvic appendix present?

Answer 40

Pain initially in RIF Pain on urination - can be suprapubic Profuse diarrhoea

Question 41

How would a retrocaecal appendix present?

Answer 41

Pain localise to: Psoas muscle Flank RUQ

Question 42

How would a retroileal appendix present?

Answer 42

Testicular pain due to irritation of the spermatic artery or ureter

Question 43

How would an appendix with a long tip present?

Answer 43

Pain in left lower quadrant

Question 44

How would a perforated appendix present?

Answer 44

Generalised abdominal pain Tachycardia High fever >38

Question 45

What investigations are useful when diagnosing appendicitis?

Answer 45

Diagnosis is clinical! Contrast CT USS CXR FBC, U&E, CRP, ESR Urine dip Pregnancy test

Question 46

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

Answer 46

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

Question 47

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

Answer 47

It is likely to have perforated

Question 48

How is appendicitis risk scored?

Answer 48

Paediatric Appendicitis Score RIPASA Alvarado

Question 49

What is the paediatric appendicitis scoring system?

Answer 49

``` 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

Question 50

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

Answer 50

<4 Low likelihood of appendicitis

Question 51

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

Answer 51

4-6 Further monitoring req. Imaging useful

Question 52

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

Answer 52

>6 Refer to surgical team Highly likely appendicitis

Question 53

How is appendicitis initially managed?

Answer 53

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

Question 54

What is the surgical management for appendicitis?

Answer 54

Appendicectomy - can be laparoscopy or a laparotomy

Question 55

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

Answer 55

``` Perforation Peritonitis Abscess Sepsis Death ```