Paediatric surgery Flashcards
What are the essential surgery topics in paediatrics?
Acute abdomen in children Acute scrotum Foreskin problems Groin swellings Head and neck lumps Umbilicus Undescended testes Vomiting infant
What is it important to do with a child presenting with abdominal pain?
Always examine testes in males
How do you diagnose testicular torsion?
Surgical exploration
How do you diagnose acute scrotal pain?
Surgical exploration
How long do you have to save the testicle from onset of testicular torsion?
6 hours
What are the differential diagnoses of acute scrotal pain?
TESTICULAR TORSION Torsion of hydatid (torsion of appendix testis) Epididymo-orchitis Trauma - needs to be significant Acute hydrocele Idiopathic scrotal oedema (3,4,5)
What investigations should you do in a child with acute scrotal pain?
Surgical exploration
Urine dip - rules out epididymo-orchitis
How common is testicular torsion?
2 peaks of incidence - neonatal and puberty
1 in 4000/year
Can happen at any time
What are the S&S of testicular torsion?
Sudden onset pain
Often severe pain so vomiting
Tender testicle
Redness and swelling are LATE signs
What is the appendix testis?
Hydatid of morgagni
Remnant of paramesonephric/malarian duct
What are the S&S of torsion of appendix testis?
Mimics testicular torsion
Often in pre-pubertal boys
Pain not usually as severe or as acute onset as torsion
Can be blue dot in 1/3 cases - infarcted section on upper pole of testes
What is idiopathic scrotal oedema?
Condition that occurs in young children with no particular cause
What are the S&S of idiopathic scrotal oedema?
Becomes red and swollen Urticarial appearance Oedema Redness goes up onto groin area and down onto perianal area Not particularly painful
How is idiopathic scrotal oedema treated?
Rest
NSAIDs
Is non-retractile foreskin normal?
Yes
What condition should you circumcise?
Balanitis xerotica obliterans
Why do we circumcise BXO?
If untreated goes on to affect the glands
What is hypospadias?
Birth defect where opening of urethra located at tip of penis
Foreskin is hooded
Penis has bend when erect
What should you check in a child with hypospadias and why?
Check testes are palpable
Check whether baby is actually XX but has been exposed to a lot of testosterone in womb due to congenital adrenal hyperplasia
What is the other problem with congenital adrenal hyperplasia?
Aldosterone not working properly so baby can get very ill
How do you treat hypospadia?
Recommend to parents not to get baby circumcised even for religious reasons
Refer to paediatric urology
What is the importance of the inguinal canal?
Testes descend through inguinal canal
What are the two main groin problems?
Hernia
Hydrocele
How do you differentiate between a hernia and a hydrocele?
Can you get above it?
Can’t get above a hernia
How common are inguinal hernias?
Incidence 1%
80% male
Slight R>L
10% bilateral
Which inguinal hernia do you get in children?
Indirect (through deep inguinal ring)
Do you more urgently repair a hernia in younger or older children and why?
Younger
- Within days in neonates
- Within weeks in infants
Higher risk of complications such as strangulation in younger children
How common are hydroceles?
Very common in children
By what age do hydroceles tend to have cleared by?
4/5
How do you treat a hydrocele?
Leave them
If symptomatic/very large/haven’t cleared by 4/5 may do surgery
Why should you not transiluminate in children?
Bowel will also transiluminate due to thin bowel wall
What are possible differentials of neck lumps in children?
Lymph nodes Thyroglossal remnants Malignany Branchial arch/cleft remnants Sternomastoid tumour Cystic hydroma Haemangioma Pilomatrixoma
What are the possible differentials for head lumps?
Lymph nodes
Dermoid cyst
Encephalocoele
Tumour secondaries
What is a thyroglossal remnant?
Moves when stick tongue out
Need surgery as can become infected/inflamed
Chunk of hyoid bone often removed too to prevent recurrence
What happens with branchial arch/cleft remants?
Sinus
Fistula
Cyst
Often weeps on neck
What is a dermoid cyst?
Folds of skin in development get trapped under other folds of skin
Get larger over time
If laterally over face don’t need to worry
If in midline then high risk of tracking into CSF so refer to neurosurgeons
When do we worry with lymphadenopathy?
> 2cm
Inflamed > 2 weeks
Enlarging
BUT very common in children and may not go back down in size
When do you operate on capillary haemangiomas?
If covering something like eye/nose
How are umbilical hernias treated?
Leave, conservative management
95% resolve spontaneously
Risk of incarceration very low
Operate age 4-5 if not closed
What is omphalitis?
Umbilical infection
Why is omphalitis very serious?
Good lymphatic drainage connections to IVC via umbilical ligament so can rapidly cause sepsis
How is omphalitis treated?
Admit and treat with IV antibiotics
How are granulomas of the umbilicus treated?
Treat with saline washes
How common are undescended testes?
Up to 5% at birth
1% at 6 months - a lot will slowly descend if leave
When should you operate on undescended testes and why?
Optimal around 9 months
If not descended after 6 months then unlikely to descend any more, if leave after 1 year then unlikely to be fertile testes
How commonly might you be able to palpate an undescended testes?
Palpable 80%
Impalpable 20% - not there? Intrabdominal? Ectopic?
Bilateral impalpable testes in newborn male - medical emergency
How do you investigate undescended testes?
Surgical exploration
How is an undescended testes treated?
Move the testes
Laparoscopy and examination under anaesthetic for impalpable
May need 2 stages for intrabdominal
Risk of re-ascent later in life
What should you thing of and do with a baby with bright green vomit?
Malrotation
Refer to surgery immediately
What is gastroschisis?
Bowel exposed and come through umbilicus
How common is gastroschisis?
1 in 1000
Not really related to congenital abnormalities (when it is it’s related to bowel injury)
How is gastroschisis treated?
Reduced surgically or preformed silo (generally silo as abdomen often too small as bowel hasn’t developed in abdomen)
What is exomphalos?
Bowel come through umbilicus but still in a sac
How common is exomphalos?
1 in 5000
Related to congenital anomalies - chromosomal, cardiac, Beckwith-Weidemann
Can be giant including liver through too
What can cause neonatal surgical respiratory distress?
Oesophageal atresia
Thoracic problems
- Congenital diaphragmatic hernia
- Congenital pulmonary airway malformations
How common is oesophageal atresia?
1 in 3000
VACTERL associated
What is VACTERL association?
Vertebral defects Anal atresia Cardiac defects Tracheo-oesophageal fistula Renal anomalies Limb abnormalities
What are the two types of oesophageal atresia?
Proximal - no way through at all
Distal - attached to airway instead
How is the oesophagus formed?
Lungs formed from bud within embryonic foregut which will form oesophagus and trachea
How common are congenital diaphragmatic hernias?
1 in 2500 50% overall survival rate Antenatal diagnosis Usually left sided Usually posterolateral
How common are congenital pulmonary airway malformations?
1 in 10,000
Leave alone if small and asymptomatic
Antenatal diagnosis
How common is duodenal atresia and what is it associated with?
1 in 5000
Trisomy 21
VACTERL
How does duodenal atresia present?
Double bubble appearance on XR
90% bilious vomiting
How common are small bowel atresias?
1 in 5000
Can be multiple
Can be short bowel (bowel loss)
Can be very discrepant - might have to anastamose bowel
How common are anorectal malformations and what is it related to?
1 in 5000
VACTERL
Many different types
How are anorectal malformations treated?
Stoma then PSARP operation
How common is Hirschsprung’s disease?
1 in 5000
What is Hirschsprung’s disease?
Distal aganglionosis
How does Hirschsprung’s disease present?
Failure to pass meconium (normally 95% passed by 24 hrs)
Progressive abdominal distension
How is Hirschsprung’s disease treated?
Washouts
Pullthrough operation
What is meconium ileus related to?
10% CF patients
Why is meconium ileus related to CF?
Thick intestinal secretions form pellets
Blocks terminal ileum
How is meconium ileus treated?
Laparotomy
How common is trauma in children?
Leading cause of death in over 15s
Cancer higher until then
How is trauma different to adults?
Different injury patterns
Different imaging protocols
Different management
Who gets necrotising enterocolitis?
Premature babies
How does necrotising enterocolitis present?
Red distended abdomen Bowel inflamed - undergoes necrosis Pneumatosis Blood in stool Bile vomit Feed intolerance
Why does necrotising enterocolitis occur?
Premature babies have immature and fragile bowels but still need feeding and some get infection
How is necrotising enterocolitis treated?
Bowel rest
Might need surgery to prevent bowel dying and to repair any perforations
What is the prognosis of necrotising enterocolitis?
50% mortality rate in those needing surgery
