Paediatric Surgery Flashcards
Management of appendicitis
Fluid resuscitation bolus 10-20ml/kg 0.9NaCl
Opiate analgesia
Antibiotics
Surgery
Aetiology of indirect inguinal hernia
Wide patent processes vaginalis permits passage of bowel into inguinal canal/scrotum
Presentation of inguinal hernia in child
Groin pain, unsettled infant, groin swelling (intermittency/variation in size, +/- reducible), obstruction causing vomiting, colicky abdominal pain, dehydration
Groin swelling that cannot get above extending from inguinal ring to scrotum/labia
Increase in abdominal pressure e.g. Palpating/cough/laugh may evoke a reduced hernia
Management of paediatric inguinal hernia
Reducible hernia: elective hernia tony at next available opportunity, safety net tell patient signs of inarceration/obstruction
Irreducible: consider need for IV resuscitation if dehydrated, timely manual reduction if no signs of peritonitis or sepsis followed by repair within 24-48h after settling of swelling. Emergency surgery if failure of manual reduction, clinical deterioration, peritonism or sepsis
Features of hydrocele
Bluefish hue Can get above mass (I.e. Scrotal) Non tender Non reducible Transilluminates
Management of hydrocele
80% boys have at birth, 90% will resolve spontaneously by 2y therefore:
Defer elective surgery until after 2y
Same procedure as a herniotomy
Simple aspiration contrindicated
Differential diagnosis for acute scrotum in a child
Testicular torsion (commonest in pubertal)
Torsion of testicular appendages
Epididymoorchitis (commonest prepubertal)
Benign idiopathic scrotal oedema
Incarcerated inguinal hernia
Rare:HSP, leukaemia
Surgical referral guidelines for acute scrotum
Any boy with high suspicion of testicular torsion
Any boy whom an alternative diagnosis to testicular torsion cannot be made with confidence
Features of testicular torsion
Abrupt onset, unilateral, severe testicular pain
Abdominal pain, nausea,vomiting
Wide based gait, normal abdominal exam, erythematous oedematous hemiscrotum, absent cremasteric reflex, firm diffusely tender testicle, affected testicle sitting higher in scrotum or bell clapper (transverse lie) of scrotum - right testis usually slightly higher
Management of testicular torsion
Manual de torsion if emergency surgery unavoidably delayed (e.g. Presentation in remote setting) - successful in 70%, only a time buying procedure, definitive treatment still surgery
Surgical de torsion
Clinical presentation of Epididymo-orchitis
Testicular pain (less severe than than torsion events)
+/- Lower urinary tract symptoms
Inflamed hemiscrotum
Normal testis
Prehn’s manoeuvre positive (pain relieved by elevation of scrotum above pubis symphysis)
Management of Epididymo-orchitis
If diagnosis certain:
Antibiotics
Analgesia
Oral fluids
Clinical features of pyloric stenosis
Increasing frequency projectile vomiting, non bile stained, postprandial
Feeds readily after vomiting
+/- failure to thrive/weight loss
+/- dehydration, sepsis
Visible peristalsis left to right across epigastrium
Pyloric mass typically olive shaped in RUQ adjacent to liver edge
Management of pyloric stenosis
Not surgical emergency, dehydration may become medical emergency
Immediate: nil by mouth, fluid bolus
Correction of hydration and electrolyte disturbance, aim to correct over 24-48h
Surgical management: pyloromyotomy after electrolyte and acids base disturbance has been corrected
Differentials for acute abdomen in a child
Non specific abdominal pain Appendicitis UTI Mesenteric adenitis Gastroenteritis Pneumonia Midgut malrotation with volvulus Intussusception Irreducible/incarcerated inguinal hernia Testicular torsion Meckels diverticulitis/ bleeding diverticulitis Bacterial enterocolitis Pancreatitis
What is an omphalocele (exomphalos)
A midline abdominal wall defect at the base of the umbilical cord, containing umbilical contents under a membrane of amnion and peritoneum (abdominal contents protrude into the umbilical cord)
Immediate and definitive management of omphalocele
Sterile wrap of bowel
NG tube to decompress stomach
Stabilise airway and ensure adequate ventilation
Establish IV access
DEFINITIVE:
surgery: primary closure if
Abnormalities associated with omphalocele
Aneuploidy (T18, T13) Additional GI anomalies Cardiac defects (in up to 50%) GU anomalies Orofacial clefts Neural tube defects Diaphragm defects Polyhydramnios IUGR
What is gastroschisis
A full-thickness paraumbilical abdominal wall defect associated with evisceration of bowel without any covering membrane (to the R of the midline)
Duodenal atresia presentation and diagnosis
Abdominal distension present at birth and progressive
Bilious vomiting beginning in first 24 hours of life
“Double bubble” sign on abdominal x-ray (dilation of stomach and proximal duodenum with gas)
Management of duodenal atresia
Initial:
Withhold feeds, NG tube for decompression, fluid resuscitation, correct metabolic anomalies, broad spectrum Abx (ampicillin + gentamycin)
Surgical repair
VACTERL associated congenital anomalies
Vertebral defects Anal atresia Cardiac defects Tracheo-oesophageal fistula + Esophageal atresia Renal defects Limb hypoplasia
Causes of meconium retention
Hirschsprung disease Meconium plug syndrome Meconium ileus Anorectal malformations Intestinal atresia
Presentation and diagnosis of oesophageal atresia
Usually picked up on antenatal USS (polyhydramnios, small stomach, etc.)
Post-natal:
Excessive drooling/mucousy
Need for suction and resuscitation at birth
Cyanosis during feeds
Rattling respiration, frothy white bubbles of mucus in nostrils/lips within minutes of birth
Try to introduce an OG tube - arrests 10cm from lips
Thoracic/Abdo xray: air in stomach and small bowel (=TOF) - allows to assess for associated anomalies e.g. vertebral or rib, right-sided aortic arch
Management of oesophageal atresia
Echo: identify any cardiac lesions
Renal USS: exclude bilateral renal agenesis (if patient has not passed urine)
Early genetic consultation
Early complete correction (TOF division, reconstruction of end-to-end oesophagus)
Varicocele (definition, epidemiology, aetiology)
A collection of dilated, tortuous veins in the pampiniform plexus surrounding the spermatic cord
present in 10-25% of adolescents, 85-95% are left sided due to L spermatic vein entering left renal vein at right angle whereas R enters IVC at more obtuse angle
Secondary causes: IVC obstruction (thrombosis, abdominal mass e.g. retroperitoneal tumour, lymphadenopathy)
Presentation of varicocele
May be asymptomatic OR dull ache/fullness in scrotum upon standing
Examination: visible distention around spermatic cord on standing (grade III) palpable “bag of worms” in scrotum (grade I if only with valsalva)
Indications for IVC ultrasonography in setting of varicocele
Suspicion of IVC obstruction: Right-sided varicocele, acute onset, persistence in supine position (grade III)
Management of varicocele
Usually conservative
Surgical ligation or testicular vein embolisation, indications:
Affected testicle volume less than unaffected (>10-15% or 2mL difference)
Symptomatic varicocele (pain, heaviness, swelling)
bilateral varicoceles
Types of testicular cancers
Testicular Germ cell tumours (95%)
Seminoma
Nonseminomatous germ cell tumours (embryonal carcinoma, teratoma, choriocarcinoma/trophoblastic tumour, yolk sac/endodermal sinus tumour, mixed germ cell tumours)
Sex cord-stromal tumours:
Leydig cell tumours (2%) sertoli cell tumours, granulosa cell tumours, mixed types
Testicular cancer: epidemiology, risk factors, presentation and diagnosis
Most common solid malignancy in 15-35y/o males, 5 year survival >95%
Risk factors: cryptorchidism and orchipexy (both ipsilateral and contralateral testes at risk), abnormal testicular development, family history, HIV/AIDS (causes seminoma)
Symptoms: painless swelling of one testis, dull/heavy ache in lower abdo/scrotum, acute abdominal or scrotal pain, gynaecomastia (due to bHCG release) - more systemic symptoms possible if metastatic
Examination: seminoma - ovoid, painless, rubbery mass, embryonal carcinoma or teratocarcinoma - irregular mass with indiscreet borders +/- LN in abdo
AFP and bHCG raised in most NSGCT, AFP never raised in seminoma (bHCG sometimes is)
Scrotal USS - non-cystic masses, CT abdo/pelvis ?mets
Radical inguinal orciectomy - provide histological proof that primary tumour
Management of testicular cancer
offer pre-treatment cryopreservation
Orchiectomy usually curative for early stage seminoma
If regional LN involvement: RT or cisplatin based chemo
Advanced stage disease: chemo (cisplatin if good risk)
Chordee (definition, presentation, management)
Curvature of the head of the penis at the junction of the head and the shaft
Most obvious when erect
Caused by fibrous tissue along the usual course of the corpus spongiosum, or different lengths of the two corpora
DOES NOT CAUSE PAIN
Monitoring if mild, surgery at 6-18 months if not resolved
Cryptorchidism definition and presentation
A testis which has failed to descend spontaneously into the scrotum by 4 months post-term - may be absent or undescended.
Present as empty scrotal sac, unable to manually descend testis and have it remain in scrotum
Risk factors of cryptorchidism
2% of full-term 30% prem
RF: prematurity, SGA, birth weight
Acute idiopathic scrotal oedema
Definition, presentation, epidemiology, management
A rare cause for acute scrotum, acute onset of scrotal erythema (salmon pink or violaceous) and swelling +/- scrotal pain (without testicular pain)
bilateral in 50%
peak incidence 5-7y (only presents in prepubertal boys)
Analgesia if required, self-limiting over 48-72 hours
Features of torsion of testicular appendage
Less acute, less severe testicular pain that testicular torsion (often >6h) Normal testicular lie/orientation
Blue-dot sign is pathognomic (present in 25%)
Management of torsion of testicular appendage
If certain (e.g. blue-dot sign), non-operative management with analgesia + rest - should resolve within 48 hours Scrotal exploration if diagnosis cannot be made with certainty
Smegma:
What is it, how does it present, how is it managed
Accumulation of desquamated cells released as the foreskin separates from the glans in a prepubertal boy. Material accumulates below the adherent foreskin.
Yellow-tinged material - may be enough to produce a swelling, confused for dermoid cyst +/- erythema and irritation
NORMAL - do not excise, reassure and ensure good hygiene
Paraphimosis (definition and features)
Occurs when foreskin has been retracted over the glans and has become stuck behind the coronal groove - causing oedema of the foreskin and the glans
Swelling, pain of the penis, irritability in an infant
penile shaft will appear flaccid and unaffected
Blue or black colour of glans suggests ischaemia
Management of paraphimosis
Gentle manipulation of foreskin forwards under adequate analgesia (may required general)
Followed by topical corticosteroid (betamethasone) use QID to reduce constriction of foreskin
Risks/causes of paraphimosis
Partial phimosis, GU procedures, sexual activity, penile trauma, forgetting to replace the foreskin after cleaning, urination, cystoscopy or urinary catheterisation
Plasmodium falciparum
Definition and features of phimosis
The constriction of the foreskin with inability to retract over the glans (congenital or acquired)
Narrowed opening at tip of foreskin with inability to retract foreskin or visualise the urethral meatus
Poor hygiene e.g. smegma
may present with complications: urinary outlet obstruction (dribbling) or UTI
Epidemiology and causes of phimosis
Normal condition, usually resolves by 5y
Occurs due to natural adhesions between foreskin and glans OR
marked inflammation (e.g. balanitis), infection, skin splitting, balanitis xerotica obliterans
Complications of phimosis
balanitis urinary outlet obstruction UTI penile cancer increased risk of STIs paraphimosis
Management of phimosis
only required if complicated (balanitis, UTI, urinary outlet obstruction, BXO, suspicion of carcinoma)
Manage with topical betamethasone ointment to the tight, shiny part of the partly retracted foreskin QID (usually obviates the need for circumcision)
Balanitis definition and presentation
inflammation under the foreskin of the glans penis (balanoposthisis = inflammation of glans and foreskin)
Genital itching, pain, discharge, rash. Dysuria, crying in infants, relative phimosis
Erythema, oedema of foreskin
Exudate, foul odour
+/- inguinal lymphadenopathy
(inflammatory findings differentiate from physiologic smegma secretion)
Balanitis management
proper hygiene in infants will typically resolve in 3-5 days
If considerable erythema or swelling - oral penicillin, cephalexin or roxithromyxin
Risk factors for balanitis
phimosis
non-circumcised boys
irritant use
poor genital hygiene
Hypospadias definition and presentation
A congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral meatus
Abnormal dorsal hood of foreskin, chordee and appearance of 2 urethral openings (one in the correct position - blind-ending - and one anterior (glans/corona), middle (shaft) or posterior (scrotum/perineum)
Often associated with cryptorchidism, cardiac disease, imperforate anus, celft lip
Hypospadias prevalence and risk factors
1/300 live male births
RF: advanced maternal age, maternal DM, GA
Management of hypospadias
may not require surgery if only mild (distal meatus without significant chordee)
Surgery: uses foreskin to reconstruct the urethra, aim for meatus as close to tip as possible, usually performed at 6-18 months
Complications: urethral fistula, stricture, diverticulum
Complications of hypospadias
impaired urinary and sexual function
Impaired fertility
Psychosocial copmlications
Epispadias
Rare congenital defect, in which urethra opens on the dorsum of the glans, shaft or at the penopubic junction
Severe forms occur with bladder exstrophy
Present with incontinence, reflux, UTIs
Features of intussusception
Colicky pain with drawing up of knees, relief of pain with vomiting
+/- prodromal febrile illness +/- diarrhoea
typically inconsolable with shocked expression
mucoid, bloody, red currant jelly stools
Dance’s sign (RUQ sausage shaped mass)
USS: doughnut or sandwich sign
Management of intusussception
US guided air or saline reduction enema Admit IV fluid resuscitation, correct third space losses Nil by mouth, wide NG tube IV Abx, + analgesia
Complications of Cryptorchidism
reduced fertility (higher intra-abdominal temperature affects spermatogenesis) Testicular torsion
Management of cryptorchidism
Surgical delivery of the testis to the scrotum between 9-12 months of age (or ASAP if identified later)
Orchidopexy - day case
Later the operation, the more likely to impair spermatogenesis
Chance of preserving a torted testicle if surgical treatment performed within 6 hours v 12 hours
6 hours: 90%
12 hours: 50%
Direction of torsion in testicular torsion
2/3- medial torsion
1/3 - lateral torsion
Which ventral wall defect is associated with chromosomal anomalies, which chromosomal defect most common
Omphalocele more commonly than gastroschisis
- Beckwith Weiderman
T18 and T13 most common chromosomal defects (only in non-liver containing defects)
Definition of Hirschsprung Disease
AKA congenital aganglionic megacolon: motor disorder of the gut caused by failure of neural crest cells to migrate completely during intestinal developement, thus the aganglionic portion of the colon fails to relax, causing a functional obstruction
Epidemiology of Hirschsprung disease
1/5000 live births
Male:female 3:4
Majority diagnosed in neonatal period
Associated syndromes: Down syndrome, chromosomal anomalies, MEN2, Bardet-Biedl syndrome
Clinical features of Hirschsprung disease
Symptoms of distal intestinal obstruction:
- failure to pass meconium by 48h
- bilious vomiting
- abdominal distension
- Squirt/blast sign after DRE, temporarily relieving obstruction
May present with enterocolitis
- sepsis like picture
- fever, vomiting, diarrhoea
- abdominal distension - toxic megacolon
In less severe disease, present in older children with:
- Chronic constipation + FTT
Diagnosis of Hirschsprung disease
Rectal biopsy is gold standard (prove aganglionic)
Supported by:
- AXR: distal intestinal obstruciton
- contrast enema: cone-shaped transition zone or calibre change in rectosigmoid area
- Anorectal manometry: lack of relaxation of internal anal sphincter with balloon rectal distension
Management of Hirschsprung disease
Surgery to resect the affected segment and bring normal ganglionic bowel close to anus
Anal sphincter function is preserved
Characteristic radiological feature of pyloric stenosis
“String sign” on barium swallow
Thin contracted pyloric canal with “string” of barium passing through
Characteristic metabolic consequence of pyloric stenosis
Hypochloraemic hyokalaemia alkalosis
