Paediatric Surgery Flashcards
When is the peak incidence of appendicitis?
10-20 years old
What is classic abdo pain presentation in appendicitis?
Central abdominal pain which moves to the right iliac fossa
What are some clinical signs of appendicitis seen on abdominal examination?
Tenderness and guarding in right iliac fossa (especially McBurney’s point), rovsings sign
What are some signs suggestive of peritonitis from ruptured appendix on abdominal examination?
Percussion tenderness, rebound tenderness
What are some key differential diagnoses for appendicitis particularly in paediatric cases?
Ectopic pregnancy, meckels diverticulum, mesenteric adenitis, ovarian cyst/torsion, appendix mass, constipation, UTI
What is meckels diverticulum?
A malformation of the distal ileum which is usually asymptomatic but can bleed, become inflamed, rupture or lead to a volvulus or intussusception
What is mesenteric adenitis?
Inflamed abdominal lymph nodes presenting as abdominal pain, usually in younger children. Often associated with tonsillitis or URTI
What is an appendix mass?
When the omentum surrounds and sticks to an inflamed appendix
Is a appendiceal mass treated surgically?
No this is managed conservatively with antibiotics and appendicectomy is considered once the acute condition has resolved
What is biliary atresia?
A congenital condition where a section of the bile duct is either absent or narrowed
With biliary atresia, what type of bilirubin will build up?
Conjugated
What is the management of biliary atresia?
Surgery (kasai portoenterostomy)- attaching a section of small bowel to the liver where the bile duct normally attached
What is kernicterus?
Accumulation of bilirubin in the brain which is neurotoxic leads to irreversible neurological damage
What causes pyloric stenosis?
Hypertrophy of the pyloric sphincter leading to a narrowing of the pylorus preventing stomach content travelling to duodenum as normal
Why do you get projectile vomiting with pyloric stenosis?
There is powerful peristalsis of the stomach as it is trying harder to push stomach content through narrowed pylorus, this becomes so powerful it ejects the food into the oesophagus, and out of the mouth quite forcefully
When and how will pyloric stenosis present in children?
Usually in the first few weeks of life with a hungry baby that is thin, pale and generally failing to thrive. History of projectile non-bilious vomiting
What can be seen on abdominal examination of an infant with pyloric stenosis?
A firm olive shaped mass in epigastrium may be felt (hypertrophy of pylorus), if after feeding peristalsis may be visible
What investigation can be done for pyloric stenosis to visualise the thicken pylorus?
Abdominal ultrasound
What is the treatment for pyloric stenosis?
Laparoscopic pyloromyotomy - incision made in smooth muscle of pylorus to widen the lumen allowing easier passage of stomach contents to duodenum
What is Hirschsprung’s disease?
Congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum. This aganglionic bowel cannot perform peristalsis
What is the pathophysiology of hirschsprungs and how does this link to development?
Pathophysiology is the absence of parasympathetic ganglionic cells. These migrate down the gut during development, in hirschsprungs they dont migrate all the way down so a section of colon at the end is left without them
How does the normal and aganglionic bowel appear in hirschsprungs?
The aganglionic bowel cannot relax causing it to become constricted and causes the proximal normal bowel to become distended and full of faeces
What are some conditions/syndromes associated with hirschsprungs?
Downs syndromes, neurofibromatosis, waardenburg syndrome, multiple endocrine neoplasia type 2
What can affect the age of presentation for hirschsprungs?
Extent of bowel affected, severity can vary between individuals
How can hirschsprungs present?
Acute intestinal obstruction or gradually developing symptoms
Delay in passing meconium, chronic constipation, abdo pain and distention, vomiting, poor weight gain and failure to thrive
What is hirschsprung-associated enterocolitis and how will this present?
Inflammation and obstruction of the intestine.
Typicallly presents 2-4 weeks after birth with fever, abdominal distention, diarrhoea and features of sepsis
How do you manage hirschsprungs-associated enterocolitis?
Antibiotics, fluid resuscitation and decompression of the bowel
What is the gold standard investigation for diagnosing hirschsprungs?
Rectal suction biopsy
What is the definitive management of hirschsprungs?
Surgical removal of aganglionic bowel section
What is intussusception?
Where one section of the bowel telescopes into itself. This narrows the lumen at the folded which can obstruct the passage of faeces
Who typically presents with intussusception?
6 months to 2 years old (peak incidence 5-7 months), more common in boys
What can be found on abdominal examination with intussusception?
Distention, a palpable mass where bowel is folded, this is sausage shaped and commonly in right upper quadrant.
Where is the most common location for intussusception to occur?
The distal ileum telescopes into the caecum through the ileocaecal valve
Although most cases are idiopathic, what are some pathological causes of intussusception?
Meckel diverticulum, polyps, HSP, tumours, post-operative
How will a child with intussusception present in earlier stages?
History of sudden onset inconsolable crying episodes but normal in between these, child may draw their knees to chest to alleviate pain.
How will a child with intussusception present in later stages?
Lethargy, anorexia, red-currant jelly stools (due to presence of blood and mucus), features of obstruction (vomiting and abdo pain)
What would be seen on abdominal USS with intussusception?
Target sign
How do we treat intussusception?
Air enema
If contraindication to air enema then it cam be manually reduced in surgery
What are the three main complications of intussusception?
Bowel obstruction, perforation and dehydration+shock
Undescended testes in older children or after puberty hold a higher risk of what?
Testicular cancer, testicular torsion and infertility
Where do the testes develop in utero?
In the abdomen
How often do boy have testes which have not descended from the abdomen by birth?
5% of boys
What are some risk factors for cryptorchidism?
FHx, low birth weight, small for gestational are, prematurity, maternal smoking during pregnancy
If a boy is born and found to have an Undescended testes, what would be the management?
Watching and waiting, in most cases the testes descend in the first 3-6 months
What would be the management of a boy who is 6 months old and their testes have yet to descend?
should be seen by paediatric urologist and undergo orchidopexy (surgical correction)
In prepubescent boys, is it normal for the testes to move into the inguinal canal when cold or from the cremasteric reflex?
This is retraction testicles and is a normal variant which resolves through puberty. If they fully retract or failure to descend orchidopexy may be required
What happens in testicular torsion?
The spermatic cord and its contents twist within the tunica vaginalis, cutting off the blood supply to the testes
When is the peak incidence of testicular torsion?
In neonates and adolescents between 12-25
What are risk factors for testicular torsion?
Age (12-25), previous testicular torsion, bell-clapper deformity, FHx, Undescended testes
What is the clinical presentation of testicular torsion?
Sudden onset severe unilateral testicular pain, tests will sit in high position with scrotum appearing swollen and tender
What examination findings are seen with testicular torsion?
Absent cremasteric reflex, negative Phren’s sign
How does the presentation of epididymo-orchitis compare to that of testicular torsion?
Normally more associated with gradual onset of pain and can be associated with lower urinary tract symptoms and pyrexia
How would torsion of the hydatid of margagni present?
Sudden onset pain, usually in younger age group than for testicular torsion, scrotum is less erythematous with normal lie of testis, blue dot sign
What investigations can or should be done for testicular torsion?
If suspecting torsion patient should go straight to theatres for scrotal exploration, this should not be delayed for other investigations
What are typical signs of intestinal obstruction?
Vomiting, absolute constipation, abdominal distention and abdominal pain
Tinkling bowel sounds (early) or absent (late)
What are some causes of intestinal obstruction in children?
Intussusception, volvulus, strangulated inguinal hernia, hirschprungs, meconium ileus, oesophageal/duodenal atresia, imperforate anus, malrotation
What would AXR show for a child with intestinal obstruction?
Dilated loops of bowel proximal to obstruction, collapsed loops distal, absence of air in rectum
What is the management of intestinal obstruction in children?
Refer to paediatric surgery as emergency, insert NG tube to drain stomach to help vomiting. IV fluids to correct dehydration and electrolyte imbalances
What is a hernia?
The protrusion of viscus through a defect of the walls of its containing cavity
Are direct or indirect inguinal hernias more common in children? Why?
Indirect, incomplete closure of the processes vaginalis after the descent of the testes
What features of a scrotal swelling would suggest an inguinal hernia?
If the scrotal mass is reducible but you cant get above it, it generally doesn’t transilluminate, has a positive cough reflex
Are inguinal hernia more likely to be right sided or left sided?
70% are right sided
How will examination differ if an inguinal hernia becomes strangulated?
Irreducible, tender and may be clinical features of bowel obstruction
What are some complications of inguinal hernias?
Recurrence, strangulation, incarceration and bowel obstruction
