Paediatric Surgery Flashcards

Question

What are red flag signs of urinary incontinence?

Answer 1

``` Signs or concerns of sexual abuse Excessive thirst, polyuria, weight loss Prolonged primary diurnal incontinence Any neurologic signs Physical signs of neurologic impairment ```

Answer 2

``` Focused history Physical examination Bladder diary Urinalysis USS of urinary tract Urodynamic studies MRI spinal cord ```

Answer 3

In the abdomen | Gradually migrate down through inguinal canal and into the scrotum

Answer 4

Higher risk of testicular torsion, infertility and testicular cancer.

Answer 5

``` Family history Low birth weight Small for gestational age Prematurity Maternal smoking during pregnancy ```

Answer 6

Watching and waiting in newborns, most will descend within 3-6 months If not descended by 6 months - seen by urologist Orchidopexy - surgical correction between 6-12 months of age

Answer 7

Normal for those who have not reached puberty for testes to move out of scrotum and into inguinal canal when cold/cremasteric reflex

Answer 8

Urethral meatus is abnormally displaced to the ventral side - underside of penis Congenital condition affecting babies from birth

Answer 9

Meatus is displaced to the dorsal side - top of the penis | Foreskin abnormally formed to match position of meatus

Answer 10

Referral to urologist Do not circumcise until indicated okay Surgery within 3- 4 months of age, correct and straighten penis

Answer 11

Difficulty directing urination Cosmetic and psychological concerns Sexual dysfunction

Answer 12

Central abdominal pain, moves to RIF On palpation - tenderness at McBurney's point - one third from ASIS to umbilicus ``` Loss of appetite Low grade pyrexia Nausea, vomiting Rovsing's - palpation of LIF causes pain in RIF Guarding on palpation ``` Rebound tenderness Percussion tenderness - ruptured, peritonitis

Answer 13

Clinical presentation Raised inflammatory markers CT, USS in females to exclude ovarian and gynaecological pathology Diagnostic laparoscopy

Answer 14

Ectopic pregnancy in those childbearing, check serum or urine bHCG Ovarian cysts - pelvic and iliac fossa pain Meckel's diverticulum - malformation of distal ileum, can cause volvulus or intussusception Mesenteric adenitis - inflamed abdominal lymph nodes, often associated with tonsillitis or URTI Appendix mass - omentum surrounds and sticks to inflamed appendix

Answer 15

Removal by surgery | Laparoscopic surgery

Answer 16

``` Bleeding, infection, pain, scars Damage to bowel, bladder, other organs Removal of normal appendix Anaesthetic risks VTE, DVT, PE ```

Answer 17

Section of the bile duct either narrowed or absent Results in cholestasis - bile cannot be transported from liver to bowel Prevents conjugated bilirubin in bile being excreted

Answer 18

Type 1 - common duct obliterated Type 2 - atresia of cystic duct Type 3 - atresia of left and right ducts

Answer 19

In first few weeks of life Jaundice beyond physiological two weeks Dark urine, pale stools Appetite and growth disturbance Hepatomegaly, splenomegaly Abnormal growth Cardiac murmurs if associated cardiac abnormalities present

Answer 20

``` Serum bilirubin, conjugated and total LFTs - usually raised Serum alpha-1 antitrypsin deficiency may cause neonatal cholestasis Sweat chloride test - CF USS of biliary tree and liver Percutaneous liver biopsy ```

Answer 21

Surgical intervention - Kasai portoenterostomy - attaching section of small intestine to opening of liver Often require full liver transplant to resolve condition Dissection of abnormalities into distinct ducts, anastomosis creation Antibiotic coverage and bile acid enhancers following surgery

Answer 22

Unsuccessful anastomosis Progressive liver disease Cirrhosis with eventual hepatocellular carcinoma

Answer 23

In 2nd - 4th week of life

Answer 24

Narrowing of pylorusand hypertrophy of the pyloric sphincter | Ring of smooth muscle that forms the canal between stomach and duodenum

Answer 25

``` Hungry baby Thin, pale, failure to thrive Projectile vomiting Peristalsis after feeding Large olive mass in upper abdomen ```

Answer 26

Hypochloraemic (low chloride) hypokalaemic metabolic acidosis As baby vomiting HCl

Answer 27

Diagnosis with abdominal USS Treatment - laparoscopic pyloromyotomy - Ramstedt's operation Incision made in smooth muscle of pylorus to widen canal

Answer 28

Congenital Absent nerve cells in myenteric plexus in distal bowel and rectum Absence of parasympathetic ganglion cells Aganglionic sections do not relax, become constricted Loss of movement of faeces and obstruction in the bowel, proximal to this becomes distended and full

Answer 29

Down's Neurofibromatosis Waardenburg syndrome Multiple endocrine neoplasia type II

Answer 30

Acute intestinal obstruction shortly after birth, or more gradual symptoms Delay in passing meconium - more than 24 hours Abdo pain, distention Vomiting Poor weight gain Failure to thrive

Answer 31

HAEC Inflammation and obstruction occurring in those with the condition ``` Within 2-4 weeks of birth Fever Abdominal distention Blood diarrhoea Sepsis ``` Can lead to toxic megacolon and perforation

Answer 32

Urgent antibiotics Fluid resuscitation Decompression of obstructed bowel

Answer 33

Abdominal x-ray Rectal biopsy to confirm diagnosis, histology shows absence of ganglionic cells Initial fluid resuscitation and management of obstruction Rectal washouts, bowel irrigation Surgery to affected segment

Answer 34

``` Meconium ileus Hirschsprung's Oesophageal atresia Duodenal atresia Intussusception Imperforate anus Malrotation Strangulated hernia ```

Answer 35

Persistent vomiting May be bilious Abdominal pain Distention Failure to pass stools or wind - absolute constipation Abnormal bowel sounds - high pitched and tinkling

Answer 36

Abdominal x-ray Shows dilated loops of bowel proximal to obstruction Collapsed loops of bowel distal Absence of air in rectum

Answer 37

Paediatric surgery referral NBM NG tube IV fluids

Answer 38

Small bowel obstruction caused by unusually thick and sticky meconium Mostly caused by cystic fibrosis; chloride trapped in cell, prevents water from thinning out secretions Can also be due to very low birthweight or gastrointestinal malformations

Answer 39

Signs of intestinal obstruction Meconium peritonitis - abdominal tenderness, increased swelling of abdomen, infection, low BP - small flecks calcified can be seen on abdominal x-ray

Answer 40

Drip and suck Agents to soften meconium mixed with contrast enema Surgery to resolve obstruction, resection

Answer 41

Bowel invaginates or telescopes into itself

Answer 42

Thickened overall size of bowel and narrowed lumen Leads to palpable mass Obstruction to faeces

Answer 43

6 months - 2 years | Boys

Answer 44

``` Concurrent viral illness Henoch-Schonlein purpura Cystic fibrosis Intestinal polyps Meckel diverticulum ```

Answer 45

``` Severe colicky abdo pain During paroxysmal pain, infant will draw knees up and turn pale Pale, lethargic, unwell child Redcurrant jelly stool - late sign RUQ mass on palpation - sausage shaped Vomiting Intestinal obstruction ``` Often have viral URTI preceding illness Absolute constipation

Answer 46

Ultrasound scan | Contrast enema

Answer 47

Therapeutic enemas can try to reduce it - contrast, water or air pumped into colon to force it out Surgical reduction If bowel becomes gangrenous or perforated, surgical resection required

Answer 48

Obstruction Gangrenous bowel Perforation Death

Answer 49

When the spermatic cord and contents twist within tunica vaginalis Compromises blood supply to testicle

Answer 50

Attachment between scrotum and tunica vaginalis not fully formed Entire testis and tunica vaginalis can tort

Answer 51

Age - 12-15 years Previous testicular torsion Family history Undescended testes

Answer 52

Sudden onset severe unilateral testicular pain Associated nausea and vomiting Testis in high position Absent cremasteric reflex Negative Prehn's sign - pain continues despite elevation of testicle

Answer 53

Clinical diagnosis Theatre for scrotal exploration Doppler ultrasound Urine dipstick any infection

Answer 54

Surgery within 4-6 hours Strong analgesia, anti-emetics Bilateral orchidopexy - cord and testis untwisted, both testicles fixed to scrotum If testis non-viable - orchidectomy warranted

Answer 55

Inflammation of the epididymis Caused by extension of infection from lower urinary tract, bladder or urethra

Answer 56

Sexual transmission | N gonorrhoeae

Answer 57

Can occur as a complication of mumps viral infection Unilateral or bilateral orchitis Fever Usually self resolves, can lead to testicular atrophy and infertility

Answer 58

``` MSM Multiple sexual partners Known contact of gonorrhoea Recent instrumentation Catheterisation Bladder outlet obstruction ```

Answer 59

Unilateral scrotal pain Swelling Fever, rigors Associated symptoms e.g. dysuria, storage LUTS, urethral discharge On examination affected side red and swollen Tender on palpation Intact cremasteric reflex Positive Prehn’s sign

Answer 60

Urine dipstick First void urine Routine bloods USS doppler to rule out any complication e.g. abscess

Answer 61

Appropriate antibiotics Sufficient analgesia Bed rest Scrotal support Enteric - levofloxacin STI - ceftriaxone Abstain from sexual activity

Answer 62

``` Prematurity Low birth weight Down’s Ehlers Danlos Hypothyroidism ```

Answer 63

``` Premature Low birth weight Males Connective tissue disorders Patients with conditions which raise intraabdominal pressure ```

Answer 64

Umbilical ring allows passage of vessels through abdominal wall between mother and fetus. After birth, remains until spontaneous closure by 5 Failure or delay leads to formation of hernia

Answer 65

Reducible Painless bulge At umbilicus More prominent on straining or crying Needs urgent assessment with symptoms of incarceration or strangulation

Answer 66

Epigastric herniation Herniation of the umbilical cord Exomphalos minor

Answer 67

Processus vaginalis does not close | Enables intra abdominal contents to herniate through deep inguinal ring, inguinal canal and superficial inguinal ring

Answer 68

Bulge in the groin Scrotal swelling, often only visible on straining or crying Incarcerated if irreducible Unilateral swollen erythematous labia can be a torted ovary which has passed through a patent processus vaginalis

Answer 69

Inflammation of the peritoneal cavity in reaction to infection or irritation Can be primary/spontaneous bacterial peritonitis Secondary - visceral disruption from perforation, abscess, injury Tertiary - recurrent infection

Answer 70

``` End stage liver disease Low serum albumin Nephrotic syndrome Splenectomy Peritoneal dialysis GI haemorrhage Prematurity PPI use ```

Answer 71

Ascites, abdo pain, fever Sudden onset pain exacerbated by movement Washboard rigidity Pulse >100

Answer 72

``` Loss of fluids Electrolyte imbalance Difficulty breathing Peritoneal abscess Sepsis ```

Answer 73

Erect CXR for air under diaphragm Serum amylase rule out pancreatitis US/CT IV fluids and electrolytes to reverse hypovolaemia IV abx if infective Surgery - laparotomy, washout

Answer 74

High caecum at midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by the development of volvulus Upper GI contrast, USS Treatment with laparotomy If volvulus present or high risk of occurring - Ladd's procedure - counterclockwise detorsion of bowel, surgical division of Ladd's bands fibrous stalks of peritoneal tissue

Answer 75

At fourth week of gestation, GI system is straight tube centrally, the following 8 weeks the midgut rotates and becomes fixed to posterior abdominal wall Arrest of this development at any stage narrows mesenteric base, risk of volvulus

Answer 76

``` Can be asymptomatic Intermittent symptoms of intestinal obstruction Bilious vomiting Presume to have volvulus unless proven otherwise Failure to thrive Anorexia Constipation Bloody stools Intermittent apnoea ``` ``` Older children: Cyclical vomiting Recurrent abdo pain protein-calorie malnutrition Immunodeficiency ```

Answer 77

Similar presentation to malrotation, twists around mesenteric base May lead to necrosis without surgery in hours Rapid onset and bilious vomiting Metabolic acidosis Oliguria Hypotension Shock with advancing Ischaemia Acute abdomen Blood or sloughed tissue may pass per rectum Tachycardia, hypovolaemia, septic shock

Answer 78

``` Appendicitis Cholecystitis Constipation Duodenal atresia GORD Hirschsprung's Pyloric stenosis Meckel's diverticulum NEC ```

Answer 79

FBC Raised WCC CRP U&Es Plain radiographs; midgut volvulus - partial duodenal obstruction - double bubble sign Contrast studies - dilatation of proximal duodenum shows birds beak

Answer 80

Observation, GI decompression | Surgery, Ladd's procedure

Answer 81

Most common congenital abnormality of the bowel Most patients remain asymptomatic all their life True diverticulum; results from failure of vitelline duct to obliterate during fifth week of fetal development

Answer 82

``` Most often asymptomatic Bright red blood in stools Intestinal obstruction, intractable constipation <2 years Nausea, vomiting, cramps Diffuse abdominal tenderness ```

Answer 83

FBC Technetium 99m pertechnetate Meckel's scan Plain abdo radiography CT scan of abdomen and pelvis Contrast enema Mesenteric angiography Surgical exploration

Answer 84

Does not require treatment if asymptomatic and an incidental finding Excision of diverticulum and opposing region of ileum Lysis of adhesions Perioperative antibiotics