Paediatric Surgery Flashcards
How does appendicitis present?
initially dull abdominal pain in the umbilical region that localises to the RIF
tenderness over McBurney’s point (1/3 of distance from ASIS to umbilicus)
Loss of appetite (anorexia)
Nausea and vomiting
Rovsing’s sign (palpation of the left iliac fossa causes pain in the RIF)
Guarding on abdominal palpation
Rebound tenderness and percussion tenderness - suggest peritonitis
how can appendicitis be diagnosed?
clinical diagnosis, supported by raised inflammatory markers
USS is often used in female patients to exclude ovarian and gynaecological pathology
DDx for appendicitis?
Ectopic Pregnancy
Ovarian Cysts
Meckel’s Diverticulum
Mesenteric Adenitis
Appendix Mass: when the omentum surrounds and sticks to the inflamed appendix
Appendicitis is managed with a laparoscopic appendicectomy - what are the complications of this procedure?
Bleeding, infection, pain and scars
Damage to bowel, bladder or other organs
Removal of a normal appendix
Anaesthetic risks
Venous thromboembolism
Intestinal obstruction is where a physical obstruction prevents the flow of faeces through the intestines, causing vomiting and absolute constipation (stool and flatus).
What can cause it?
Meconium ileus
Hirschsprung’s disease
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus
Malrotation of the intestines with a volvulus
Strangulated hernia
How may intestinal obstruction present?
Persistent vomiting- may be bilious
Abdominal pain and distention
Failure to pass stools or wind
Abnormal bowel sounds. These can be high pitched and “tinkling” early in the obstruction and absent later
How can intestinal obstruction be investigated and managed?
IX:
abdominal xray :
dilated loops of bowel proximal to the obstruction and collapsed loops of bowel distal to the obstruction
absence of air in the rectum
MX:
admit to paeds surgical ward
make NBM
drip and suck - give IV fluids and insert NG tube for decompression
Give some risk factors for inguinal hernias
Prematurity
Male sex (male:female ratio is approximately 8:1)
Family history
How do inguinal hernias present?
inguinal/inguino-scrotal mass that you cannot ‘get above’, is reducible when lying flat, does not transilluminate, and has a positive cough reflex
a hernia that has strangulated will present as an irreducible and tender tense lump
DDx for an inguinal hernia?
Hydrocele: possible to ‘get above’ a hydrocele, transilluminates, non-tender
Varicocele: scrotal heaviness, non-tender, ‘bag-of-worms’ sensation on palpation
How can inguinal hernias be diagnosed?
usually clinical diagnosis
if uncertainty:
USS
CT scan (mainly used in patients with features of obstruction or strangulation, or when there is uncertainty in the diagnosis)
How can inguinal hernias be managed?
Children presenting in the first few months of life are at the highest risk of strangulation and the hernia should be repaired urgently
Children over 1 year of age are at lower risk and surgery may be performed electively
For paediatric hernias a herniotomy without implantation of mesh is sufficient
Complications associated with inguinal hernias?
– Recurrence
– Strangulation
– Incarceration
– Bowel obstruction
What is epididymitis?
inflammation of the epididymis
bimodal age distribution, occurring most commonly in males aged 15-30yrs and then again in males >60yrs
presents as unilateral scrotal pain and associated swelling
What is a positive Prehn’s sign?
scrotal pain relieved on elevation of testes - suggestive of epididymitis
How should epididymitis be investigated?
urine dipstick +/- culture
NAAT if STI suspected
FBC and CRP
typically clinical dx but can use US Doppler
How should epididymitis be managed?
analgesia
Enteric organisms – Ofloxacin for 14 days or levofloxacin for 10 days
Sexually-transmited organisms – Ceftriaxone IM single dose and Doxycycline for 10-14 days
Complications of epididymitis?
Typically, symptoms improve within 48hours of starting antibiotics
Complications:
reactive hydrocele formation, abscess formation (rare), or testicular infarction (rare)
What is orchitis?
inflammation of the testes
Risk factors for testicular torsion?
Age (most common 12-25yrs)
Previous testicular torsion
Family history of testicular torsion
Undescended testes
Abnormal testicular lie e.g. bell clapper deformity
What features does testicular torsion present with?
Severe, sudden onset testicular pain
Can be spontaneous or precipitated by minor trauma
Typically affects adolescents and young males
On examination testis is tender and pain not eased by elevation
Absent cremasteric reflex
DDx for testicular torsion?
torsion of the hydatid of Morgagni
epididymo-orchitis
trauma
incarcerated inguinal hernia
renal colic
hydrocele
How should testicular torsion be managed?
urgent bilateral orchidopexy
4-6 hour window before significant ischaemic damage
What is volvulus?
a condition where the bowel twists around itself and the mesentery that it is attached to - leads to a closed loop bowel obstruction
Which volvulus tends to affect younger patients?
caecal volvulus
How does volvulus present?
Vomiting (particularly green bilious vomiting)
Abdominal distention
Diffuse abdominal pain
Absolute constipation and lack of flatulence
How is caecal volvulus managed?
usually surgical
laparotomy
Ileocaecal resection or right hemicolectomy
