Paediatric Surgery Flashcards
What are the medical causes of abdominal pain?
Constipation UTI Coeliac, IBD, IBS Mesenteric adenitis Abdominal migraine Pyelonephritis Henoch-Schonlein Purpur Tonsilitis DKA Infantile colic
What are causes of abdominal pain specific to adolescent girls?
Dysmenorrhoea Mittelschmerz Ectopic pregnancy PID Ovarian torsion Pregnancy
What are surgical causes of abdominal pain?
Appendicitis - central, spreads to RIF
Intussusception - colicky, non-specific, redcurrant jelly stools
Bowel obstruction - pain, distention, absolute constipation and vomiting
Testicular torsion - sudden onset, unilateral testicular pain, nausea and vomiting
What are the red flags for serious abdominal pain?
Persistent or bilious vomiting Severe chronic diarrhoea Fever Rectal bleeding Weight loss, faltering growth Dysphagia Nighttime pain Abdominal tenderness
What are some initial investigations for abdominal pain?
Anaemia - IBD, coeliac Raised inflammatory markers Raised anti-TTG, anti-EMA - coeliac Raised faecal calprotectin - IBD Positive urine dipstick - UTI
What is the management of recurrent abdominal pain?
Non-organic/functional Distractions Probiotics Avoid NSAIDs Address psychological triggers
How can an acute attack of abdominal migraine be treated?
Low stimulus environment
Paracetamol, ibuprofen
Sumatriptan
What are the causes of scrotal pain and/or swelling?
Testicular torsion Irreducible hernia Torsion of testicular appendage Epididymo-orchitis Testicular or epididymal rupture
What are the features of testicular torsion?
Usually pubertal, rarely neonates Usually sudden severe pain May radiate to iliac fossa Swelling Nausea and vomiting Impaired gait High riding testis Tender on palpation Some discolouration Cremasteric reflex absent
What are non painful scrotal swellings?
Hydrocele
Varicocele
Idiopathic scrotal oedema
Tumour/leukaemia
What are the features of hydrocele vs varicocele?
Hydrocele - soft, non tender, scrotal swelling which is transilluminable
Usually due to patent processus vaginalis
Varicocele (enlargement of veins) - peri-pubertal
Bag of worms, predominantly left sided, refer to surgical outpatients
What is the management of testicular torsion?
Urgent surgical review if suspected
Fasting and clear fluids
Consider NG tube if bowel obstruction suspected
Provide adequate analgesia
What are red flags for vomiting in children?
Bacterial gastroenteritis Concussion Meningitis Appendicitis Pyloric stenosis Intussusception Intestinal malrotation Small bowel atresia
What are common differentials for vomiting in children?
Viral gastroenteritis Giardiasis Migraine Motion/travel sickness Labyrinthitis GORD Cyclic vomiting Constipation UTI
What are the signs of clinical dehydration?
Appears to be unwell Decreased urine output Skin colour unchanged Warm extremities Altered responsiveness
Sunken eyes Dry mucous membranes Tachycardia Tachypnoea Normal peripheral pulses Normal CRT Reduced skin turgor Normal BP
What are the signs of clinical shock?
Decreased level of consciousness
Cold extremities
Pale or mottled skin
Tachypnoea Tachycardia Weak peripheral pulses Prolonged CRT Hypotension
What children are at increased risk of dehydration?
Children < 1 year
Infants low birth weight
Children had >6 or more diarrhoea stools in last 24 hours
Children vomited 3 or more times in past 24 hours
Children not been offered or not been able to tolerate fluids
Infants who have stopped breastfeeding during illness
Children with signs of malnutrition
What are the features of hypernatraemic dehydration?
Jittery movements Increased muscle tone Hyperreflexia Convulsions Drowsiness or coma
When should a stool sample following diarrhoea in children be done?
Suspect sepsis
Blood or mucus in stool
Child immunocompromised
Consider if:
recently been abroad
diarrhoea not improved by day 7
Uncertain about diagnosis of gastroenteritis
What is the management of dehydration in children following vomiting or diarrhoea?
For children with no evidence of dehydration - continue breastfeeding, encourage fluids, fruit juices, carbonated drinks
If dehydration suspected - give 50ml/kg low osmolarity oral rehydration solution over 4 hours
Continue breastfeeding
Consider supplementing with usual fluids
What is diurnal and enuresis incontinence?
Diurnal incontinence - urinary incontinence in the day
Enuresis - at night
Enuresis not usually diagnosed until age 7
What are the types of urinary incontinence?
Primary - never achieved urinary continence for >6 months
Secondary incontinence - children developed incontinence after period of at least 6 months of urinary control
What are causes of enuresis?
Maturational delay
Uncompleted toilet training
Functionally small bladder
Difficulties arousal from sleep
Conditions that increase urine volume - diabetes, renal failure
Increase bladder irritability
Structural abnormalities e.g. ectopic ureter
Abnormal sphincter weakness e.g. spina bifida
What are common causes of diurnal incontinence?
Bladder irritability Relative weakness of detrusor muscle Constipation Urethrovaginal reflux or vaginal voiding Structural abnormalities Abnormal sphincter weakness
What are red flag signs of urinary incontinence?
Signs or concerns of sexual abuse Excessive thirst, polyuria, weight loss Prolonged primary diurnal incontinence Any neurologic signs Physical signs of neurologic impairment
What are appropriate investigations for urinary incontinence?
Focused history Physical examination Bladder diary Urinalysis USS of urinary tract Urodynamic studies MRI spinal cord
How do the testes normally develop?
In the abdomen
Gradually migrate down through inguinal canal and into the scrotum
What is the risk of cryptorchidism in older children?
Higher risk of testicular torsion, infertility and testicular cancer.
What are the risk factors for undescended testes?
Family history Low birth weight Small for gestational age Prematurity Maternal smoking during pregnancy
What is the management of undescended testes?
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
What is retractile testicles?
Normal for those who have not reached puberty for testes to move out of scrotum and into inguinal canal when cold/cremasteric reflex
What is hypospadias?
Urethral meatus is abnormally displaced to the ventral side - underside of penis
Congenital condition affecting babies from birth
What is epispadias?
Meatus is displaced to the dorsal side - top of the penis
Foreskin abnormally formed to match position of meatus
What is the management of hypospadias?
Referral to urologist
Do not circumcise until indicated okay
Surgery within 3- 4 months of age, correct and straighten penis
What are the complications of hypospadias?
Difficulty directing urination
Cosmetic and psychological concerns
Sexual dysfunction
What are the features of appendicitis?
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
How is appendicitis diagnosed?
Clinical presentation
Raised inflammatory markers
CT, USS in females to exclude ovarian and gynaecological pathology
Diagnostic laparoscopy
What are key differentials of appendicitis?
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
What is the management of appendicitis?
Removal by surgery
Laparoscopic surgery
What are the complications of appendicectomy?
Bleeding, infection, pain, scars Damage to bowel, bladder, other organs Removal of normal appendix Anaesthetic risks VTE, DVT, PE
What is biliary atresia?
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
What are the types of biliary atresia?
Type 1 - common duct obliterated
Type 2 - atresia of cystic duct
Type 3 - atresia of left and right ducts
What is the presentation of biliary atresia?
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
What are the investigations of biliary atresia?
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
What is the management of biliary atresia?
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
What are the complications of biliary atresia?
Unsuccessful anastomosis
Progressive liver disease
Cirrhosis with eventual hepatocellular carcinoma
When does pyloric stenosis present?
In 2nd - 4th week of life
What is pyloric stenosis?
Narrowing of pylorusand hypertrophy of the pyloric sphincter
Ring of smooth muscle that forms the canal between stomach and duodenum
What is the presentation of pyloric stenosis?
Hungry baby Thin, pale, failure to thrive Projectile vomiting Peristalsis after feeding Large olive mass in upper abdomen
What does blood gas analysis show in pyloric stenosis?
Hypochloraemic (low chloride) hypokalaemic metabolic acidosis
As baby vomiting HCl
What is the management of pyloric stenosis?
Diagnosis with abdominal USS
Treatment - laparoscopic pyloromyotomy - Ramstedt’s operation
Incision made in smooth muscle of pylorus to widen canal
What is the pathophysiology of Hirschsprung’s disease?
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
What syndromes can Hirschsprung’s be associated with?
Down’s
Neurofibromatosis
Waardenburg syndrome
Multiple endocrine neoplasia type II
What is the presentation of Hirschsprung’s?
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
What is Hirschsprung-associated enterocolitis?
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
What is the management of HAEC?
Urgent antibiotics
Fluid resuscitation
Decompression of obstructed bowel
What is the management of Hirschsprung’s disease?
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
What are causes of intestinal obstruction?
Meconium ileus Hirschsprung's Oesophageal atresia Duodenal atresia Intussusception Imperforate anus Malrotation Strangulated hernia
What is the presentation of intestinal obstruction?
Persistent vomiting
May be bilious
Abdominal pain
Distention
Failure to pass stools or wind - absolute constipation
Abnormal bowel sounds - high pitched and tinkling
How can intestinal obstruction be diagnosed?
Abdominal x-ray
Shows dilated loops of bowel proximal to obstruction
Collapsed loops of bowel distal
Absence of air in rectum
What is the management of intestinal obstruction?
Paediatric surgery referral
NBM
NG tube
IV fluids
What is meconium ileus?
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
What are signs and symptoms of meconium ileus?
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
What is the management of meconium ileus?
Drip and suck
Agents to soften meconium mixed with contrast enema
Surgery to resolve obstruction, resection
What is intussusception?
Bowel invaginates or telescopes into itself
What are the findings in intussusception?
Thickened overall size of bowel and narrowed lumen
Leads to palpable mass
Obstruction to faeces
Who is intussusception most common in?
6 months - 2 years
Boys
What conditions is intussusception associated with?
Concurrent viral illness Henoch-Schonlein purpura Cystic fibrosis Intestinal polyps Meckel diverticulum
What is the presentation of intussusception?
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
How is intussusception diagnosed?
Ultrasound scan
Contrast enema
What is the management of intussusception?
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
What are the complications of intussusception?
Obstruction
Gangrenous bowel
Perforation
Death
What is testicular torsion?
When the spermatic cord and contents twist within tunica vaginalis
Compromises blood supply to testicle
What is neonatal testicular torsion?
Attachment between scrotum and tunica vaginalis not fully formed
Entire testis and tunica vaginalis can tort
What are the risk factors for testicular torsion?
Age - 12-15 years
Previous testicular torsion
Family history
Undescended testes
What are the clinical features of testicular torsion?
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
What are the investigations for testicular torsion?
Clinical diagnosis
Theatre for scrotal exploration
Doppler ultrasound
Urine dipstick any infection
What is the management of testicular torsion?
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
What is epididymitis?
Inflammation of the epididymis
Caused by extension of infection from lower urinary tract, bladder or urethra
What is the most common cause of epididymitis in young adult males?
Sexual transmission
N gonorrhoeae
What is mumps orchitis?
Can occur as a complication of mumps viral infection
Unilateral or bilateral orchitis
Fever
Usually self resolves, can lead to testicular atrophy and infertility
What are the risk factors for epididymitis?
MSM Multiple sexual partners Known contact of gonorrhoea Recent instrumentation Catheterisation Bladder outlet obstruction
What are the clinical features of epididymitis?
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
What are the investigations of epididymitis?
Urine dipstick
First void urine
Routine bloods
USS doppler to rule out any complication e.g. abscess
What is the management of epididymitis?
Appropriate antibiotics
Sufficient analgesia
Bed rest
Scrotal support
Enteric - levofloxacin
STI - ceftriaxone
Abstain from sexual activity
What are the risk factors for an umbilical hernia?
Prematurity Low birth weight Down’s Ehlers Danlos Hypothyroidism
What are the risk factors for an inguinal hernia?
Premature Low birth weight Males Connective tissue disorders Patients with conditions which raise intraabdominal pressure
What can cause an umbilical hernia?
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
What is the presentation of umbilical hernias?
Reducible
Painless bulge
At umbilicus
More prominent on straining or crying
Needs urgent assessment with symptoms of incarceration or strangulation
What are the differentials for an umbilical hernia?
Epigastric herniation
Herniation of the umbilical cord
Exomphalos minor
What can cause inguinal hernias?
Processus vaginalis does not close
Enables intra abdominal contents to herniate through deep inguinal ring, inguinal canal and superficial inguinal ring
How do inguinal hernias present and what is it important to look out for?
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
What is peritonitis?
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
What are the risk factors for peritonitis?
End stage liver disease Low serum albumin Nephrotic syndrome Splenectomy Peritoneal dialysis GI haemorrhage Prematurity PPI use
What are the features of peritonitis?
Ascites, abdo pain, fever
Sudden onset pain exacerbated by movement
Washboard rigidity
Pulse >100
What are the complications of peritonitis?
Loss of fluids Electrolyte imbalance Difficulty breathing Peritoneal abscess Sepsis
What are the investigations and management for peritonitis?
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
What are the features of malrotation?
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
What can leave the bowel at high risk for volvulus?
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
What is the presentation of malrotation?
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
What is the presentation of vovulus?
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
What are differentials in the acute phase of volvulus or malrotation?
Appendicitis Cholecystitis Constipation Duodenal atresia GORD Hirschsprung's Pyloric stenosis Meckel's diverticulum NEC
What are the investigations for malrotation/volvulus?
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
What is the treatment for malrotation/volvulus?
Observation, GI decompression
Surgery, Ladd’s procedure
What is Meckel’s diverticulum?
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
What is the presentation of Meckel’s?
Most often asymptomatic Bright red blood in stools Intestinal obstruction, intractable constipation <2 years Nausea, vomiting, cramps Diffuse abdominal tenderness
What are the investigations for Meckel’s?
FBC
Technetium 99m pertechnetate Meckel’s scan
Plain abdo radiography
CT scan of abdomen and pelvis
Contrast enema
Mesenteric angiography
Surgical exploration
What is the treatment of Meckel’s?
Does not require treatment if asymptomatic and an incidental finding
Excision of diverticulum and opposing region of ileum
Lysis of adhesions
Perioperative antibiotics
