Paediatric surgery Flashcards
What are the symptoms of acute appendicitis?
- anorexia
- vomiting
- abdominal pain (central and colicky then RIF localised)
What are the signs of acute appendicitis?
- fever
- abdominal pain (aggravated by movement)
- persistent tenderness with guarding in RIF (McBurney’s point)
nb may be absent localised guarding in retrocaecal appendix and few abdo signs in pelvic appendix
Why is perforation of the appendix more rapid in preschool children?
The omentum is less well developed and fails to surround the appendix
What investigations would you do in acute appendicitis?
- FBC for neutrophilia
- Urine dip for presence of WBC/ organisms
- USS - thickened non-compressible appendix with increased blood flow
NB none are consistently helpful in making the diagnosis
What are the differential diagnoses for acute appendicitis?
- gastroenteritis
- constipation
- pyelonephritis
- UTI
- HSP
- Intersusception
- Meckel’s diverticulum
Pregnancy/testicular torsion/ ectopic …
What is the management for acute appendicitis?
- Appendectomy
- Treat shock if present
- If guarding consistent with perforation, give IV antibiotics prior to surgery
- Can manage conservatively if no palpable mass in RIF or signs of generalised peritonitis with IV antibiotics and an appendectomy after several weeks
What are the surgical causes of acute abdominal pain?
- acute appendicitis
- intestinal obstruction inc intussusception
- inguinal hernia
- peritonitis
- inflamed Meckel’s diverticulum
- pancreatitis
- trauma
What is intussusception?
the invagination of proximal bowel into a distal segment
What part of the bowel is commonly involved in intussusception?
Ileum passing into caecum through ileocaecal valve
What is the peak age of presentation of intussusception?
3 months to 2 years but can occur at any age
What are the clinical presentations of intussusception?
- paroxysmal, severe colicky pain with pallor
- anorexia
- vomiting
- sausage-shaped mass in abdomen
- redcurrant jelly stool
- abdominal distension
- shock
- lethargy
Causes of intusussception
- idiopathic
- viral infection
- Meckel’s diverticulum
- polyps
Management of intussusception
- IV fluid and resuscitation (shock v high risk)
- IV antibiotics if suspected peritonitis (penicillin, gentamicin and metronidazole
- NG tube and gastric emptying
- rectal air enema (75% success rate)
- surgery if that fails/peritonitis/perforation
What is the most serious complication of intussusception?
stretching and constriction of the mesentery resulting in venous obstruction, causing engorgement and bleeding from the bowel mucosa, fluid loss and subsequently bowel perforation, peritonitis and gut necrosis.
What is malrotation?
an abnormality that occurs during rotation of the small bowel in a foetus
What is volvulus?
a complication of malrotation, occuring when the bowel twists, so the superior mesenteric artery blood supply to the small intestine and proximal large intestine is compromised
What are the two presentations of malrotation
- obstruction
- obstruction with a compromised blood supply
When does malrotation usually present and how?
in first 1-3 days of life with intestinal obstruction from Ladd bands obstructing the duodenum or volvulus
Clinical presentation of volvulus?
- dark green, bilious vomiting
- abdominal pain, colicky, paroxysmal
- tenderness (peritonitis)
- constipation
Investigations for intestinal rotation?
- upper gastrointestinal contrast study to assess intestinal rotation
- abdo xray/uss
Management of volvulus?
- urgent laparotomy if signs of vascular compromise
- appendix generally removed to avoid diagnostic confusion in future
What are Ladd bands?
peritoneal bands that may cross the duodenum, often anteriorly
What is a Meckel diverticulum?
An ileal remnant of the vitello-intestinal duct which contains ectopic gastric mucosa or pancreatic tissue.
Around 2% of individuals have it.
Clinical presentation of Meckel diverticulum
- Most are asymptomatic
- May present with severe rectal bleeding, neither bright red nor true melaena
- Acute reduction in haemoglobin
- Abdominal pain mimicking appendicitis
- May present as intussusception, volvulus or diverticulitis
Investigations of Meckel diverticulum
- FBC - anaemia
- a technetium scan will demonstrate increased uptake by ectopic gastric mucosa in 70% of cases
Treatment of Meckel diverticulum
Surgical resection
Complications of a Meckel’s diverticulum
May present as intusussception, volvulus or diverticulitis
What is necrotising enterocolitis?
An infection of the gut seen in premature infants, as a result of bacterial invasion and ischaemic injury
Risk factors of NEC
- prematurity
- preterm infants fed cow’s milk formula instead of breast milk
- ischaemic injury and bacterial invasion
Clinical presentation of NEC
- feed intolerance
- vomiting, may be bile stained
- distended abdomen
- fresh blood in stool
- shock
Investigations for NEC
- abdo XRAY: distended loops of bowel and thickening of the bowel wall with intramural gas. May be gas in portal venous tract
Management of NEC
- early recognition
- stop oral feeding, parental feeding
- treat shock
- triple antibiotic therapy
- may require mechanical ventilation
- surgery for bowel perforation
Complications of NEC
- bowel perforation
- 20% morbidity and mortality
- development of strictures
- malabsorption
- greater risk of a poor neurodevelopmental outcome
What is pyloric stenosis?
hypertrophy of the pyloric muscle causing gastric outlet obstruction
Epidemiology of pyloric stenosis
- presents at 2-8 weeks
- irrespective of gestational age
- M:F = 4:1
- more common in firstborn
- may be a FH, especially on the mother’s side
Clinical presentation of pyloric stenosis
- vomiting, increased forcefulness and frequency ending up in projectile vomiting
- dehydration
- decreased interest in feeding
- weight loss
- hypochloraemic metabolic alkalosis
- olive shaped mass in RUQ
Investigations for pyloric stenosis
- bloods esp u&e for hypokalaemia, hyponaturaemia and high urea
- test feed: gastric peristalsis L to R waves
- USS
- stomach might need to be emptied by an NG tube
Management for pyloric stenosis
- correct fluid and electrolyte disturbance with IV fluids
- pyloromyotomy
- child can be usually fed within 6 hours and discharged within 2 days of surgery
