Paediatric Surgery Flashcards
Acute abdominal pain Appendicitis Head injury Herniae Hirschprung’s Disease Intussusception Neonatal intestinal obstruction Pyloric stenosis Testicular torsion Volvulus
A child presents with acute abdominal pain.
What questions will you ask?
- Pain -> SQUITARS
- Have they noticed any lumps or bumps in the abdomen? (hernia)
- Nausea/vomiting? Is vomit bilious?
- Bowels - any change? Any blood? What’s normal?
- Urinary - any change? Any blood? Any other symptoms e.g. pain on urination. Ask about stream.
- Gynae - in older girls, ask about periods if they have started.
- Testicular - any pain or anything abnormal?
- Trauma? Overdose/poisoning/drugs?
- Is everyone well at home? Any recent illness in family/school?
- Development - any concerns?
- Are they sexually active (older child)
- Travel hx
- Social - how is school?
An 11 year old girl presents tummy pain that started centrally but moved to the RIF.
They are not eating or drinking and have pain on any kind of movement.
What is my number 1 differential?
Appendicitis
An 11 year old girl presents tummy pain that started centrally but moved to the RIF.
They are not eating or drinking and have pain on any kind of movement.
As she is female, what additional test would we do to rule out differentials that we wouldn’t do in a boy?
Pregnancy test
An 11 year old girl presents tummy pain that started centrally but moved to the RIF.
They are not eating or drinking and have pain on any kind of movement.
What examination findings might we have?
- Appearance - painful to walk, don’t want to move, look unwell. Knees flexed helps pain.
- Palpation - generalised tenderness/RIF tenderness.
- Positive Rovsing’s sign (palpate LLQ -> pain felt in RLQ)
- Positive psoas stretch
- Guarding
- Mild fever
An 11 year old girl presents tummy pain that started centrally but moved to the RIF.
They are not eating or drinking and have pain on any kind of movement.
What investigations would you like to do?
- Urine dip and culture
- Bloods - FBC (WCC), U&Es (vomiting -> electrolyte imbalance and dehydration), amylase (if even a tiny bit possible that it’s pancreatitis)
finish later
A 1 year old boy is brought in with bilious vomiting and one episode of blood in the stool.
O/E you find a sausage shaped mass in the RUQ.
What are your differentials? Put them in order of suspicion.
Intussusception Hernia Cow’s milk allergy Volvulus Meckels diverticulum
A 1 year old boy is brought in with bilious vomiting and one episode of blood in the stool.
O/E you find a sausage shaped mass in the RUQ.
What investigation is most appropriate here initially?
What do you think you’ll see?
USS abdomen
Target sign
A 1 year old boy is brought in with bilious vomiting and one episode of blood in the stool.
O/E you find a sausage shaped mass in the RUQ.
How is this condition managed?
Intussusception is managed with reduction by air insufflation, or surgery if peritonitic.
You overhear some surgeons talking about a child with an acute abdomen.
Like a good little medical student you start to form a list of differentials in your head (neerrrrrrd). What makes your list?
GI: Gastroenteritis Infantile Colic Appendicitis Mesenteric adenitis Intussusception Meckel’s diverticulum Constipation Hernia
GU:
- UTI
- Testicular torsion
- Pregnancy/Ectopic (older girls obvs)
- PID
- Ovarian torsion
- Menarche
Other:
- Henoch-Schönlein purpura
- Haemolytic uraemic syndrome
- Lower lobe pneumonia
- Trauma
- DKA
- Sickle cell crisis
- Psychogenic
What is testicular torsion?
Spermatic cord twits and cuts off it’s blood supply, and can lead to testicular death.
It is a MEDICAL EMERGENCY.
What is contained within the spermatic cord, and why is torsion so bad?
Vas deferens Lymphatic vessels Testicular artery and nerves Cremasteric artery and nerve Panpiniform plexus of veins
Its bad because twisting cuts of the only blood supply to the testicle, plus it is extremely painful.
Who is testicular torsion most common in?
Neonates and adolescents
How should we examine a child with an acute abdomen?
As usual:
- General - do they look unwell? Can you see a rash?
- ABCDE - haemodynamic status, temperature?
- Can the child be distracted from the pain?
- Ask the child to point with one finger to the pain?
- Ask to suck in abdomen then blow it out.
- Abdo examination as usual
- Rectal/genital examination only if absolutely necessary.
What are some specific pitfalls to watch out for in a child with an acute abdomen?
- It is often hard to diagnose/exclude serious conditions in children
- Always consider gynae issues/pregnancy in girls and testicular issues in boys
- Consider illicit drug use
- Consider possibility of child abuse
What head injuries might we see in a child?
- Skull fractures
- Cerebral lacerations
- Cerebral contusions
- Shearing injuries
- Haemorrhage following head injury
How common are childhood head injuries, and how commonly are they associated with long term complications?
Very common, and rarely.
How do children commonly get head injuries? How else can they get them?
Falling when playing etc.
Motor vehicle crashes
Pedestrian/bicycle accidents
Sports injury
Child abuse
What are the symptoms of head injury in a child?
- Scalp swelling
- Loss of consciousness
- Headache
- Vomiting
- Seizures
- Concussion
When should we perform tests on a child with a head injury?
If there is:
- recurrent vomiting
- seizure
- LoC
- Headache of worsening severity
- Behavioural changes
- Motor/speech difficulty
- CSF rhinorrhoea/otorrhoea
- Under 6 months
- Fall from height over 5 foot/high velocity hit
- Parental concern over how child is acting
What is important to establish from the hx of a child with a head injury?
The timeline and how it happened.
When any symptoms occured gives a good clue as to what damage has been done.
Also important for suspected non-accidental injury.
Do we image every child with a head injury?
No - we do a CT if there are concerns about serious brain injury.
Which imaging modality is best of children with ?serious brain injury following head trauma/
CT Head
If after a head injury it isn’t clear if a CT is needed, what can we do?
Keep ‘em in for observation for 4-6 hours. If they develop symptoms, scan them. If not, send them home with safetynet of watching for symptoms for 12 hours after injury
What can we advise parents to do for minor head injuries when at home?
Rest
Analgesia
Ice on any swelling
Apply pressure to a bleed
Which type of hernia is common in children, and which demographic is it most common in?
Inguinal hernia.
Common in preterm infants and male infants.
How does an inguinal hernia present in a child?
Groin swelling that is usually reducible.
May have an impulse when infant coughs.
How should congenital inguinal hernias be managed?
Once detected, send for surgical outpatient referral urgently.
Are direct or indirect inguinal hernias more common in children?
Indirect (protrusion through inguinal ring passes along inguinal canal through abdominal wall lateral to inferior epigastric vessels, instead of driectly protruding through weakness medial to the vessels)
What is the difference between omphalocele and gastroschisis?
Exomphalos aka omphalocele is a congenital herniation of abdominal contents into the umbilical cord with a peritoneal and amnion membrane covering.
Gastroschisis is a congenital abdominal wall defect usually to the right of the umbilicus, and there is no covering membrane.
How common is gastroschisis?
1 in 10,000 births
How common is exomphalos?
2.5 in 10,000 births
How can we diagnose/suspect gastroschisis or exomphalos before the baby is born?
On the foetal anomaly scan.
There may also be a prenatal rise in alpha-foetoprotein.
What are the differentials for exomphalos and gastroschisis?
- Physiological bowel herniation
- Umbilical hernia (frequent in prem babies)
- Extrophy of bladder
What investigations can we do for exomphalos and gastroschisis?
Karyotyping as exomphalos has a strong link with chromosomal abnormalities.
How is exomphalos managed?
If the sac is intact, cover sac with non-adherent gauze and replace contents and close abdomen surgically.
If the sac ruptures, manage as gastroschisis.
How is gastroschisis managed?
-Plastic closure can sometimes be achieved.
-In most cases, primary closure of the defect is main objective.
If the intestines are inflammed, may need to leave for a while before putting them back inside.
Supportive Rx alongside surgery e.g. parenteral feeding, IV fluids, O2.
What complications can occur secondary to exomphalos and gastroschisis?
Failure to thrive or poor nutritional status as metabolic drain.
Hepatomegaly/cholestasis if long term parenteral feeding.
Large defects may be harder to close and require longer hospital stay.
Intestinal atresia.
Trauma to the liver.
Short bowel syndrome.
What is intussusception?
A paediatric condition in which one segment of bowel invaginates into another segment distal to it, causing obstruction.
Describe the epidemiology of intussusception.
M:F 3:2
66% are under age 1, majority are by age 3.
It is the most common cause of intestinal obstruction in under 3s.
How does intussusception present?
Colicky abdominal pain every 10-20 minutes. Sudden onset. Early vomiting Lethargy, hypotonia, alt consciousness Irritability Sweatng Redcurrent stools later on
What signs are present in intussusception?
Palpable sausage shaped mass
Abscence of bowel in RLQ
Signs of shock and dehydration
Pyrexia (late)
What is pyloric stenosis?
Pyloric muscle hypertrophy resulting in narrowing of the pyloric canal, which can then become easily obstructed.
When does pyloric stenosis present?
Between 2 and 8 weeks of life.
How common is pyloric stenosis?
Occurs in 1 in 500 live births.
Is pyloric stenosis more common in males or females?
M:F 4:1
How does pyloric stenosis present?
Projectile non-bilious vomiting starting between 2 and 8 weeks of life, usually 30-60 minutes after a feed.
What other symptoms might an infant with pyloric stenosis present with after a few days?
Persistent hunger, dehydration, weight loss, lethargy, infrequent or absent bowel movements.
