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Paediatric surgery Flashcards

1
Q

What are the top 5 causes for vomiting in a baby?

A 
Over feeding 
Posetting 
GORD 
Pyloric stenosis 
Obstruction
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2
Q

What are the most common causes of bilious vomit in a baby?

A

Malrotation +/- volvulus (until proven otherwise)

NEC

Atresia

Hirschsprung’s disease

Meconium ileus

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3
Q

What are the symptoms of malrotation and what is the diagnostic test of choice and management?

A

Bilious vomit (in previous well baby)
Distended abdomen
PR bleeding
Vascular collapse

Barium swallow test

  • diagnostic test
  • D-J flexure sits to right of midline

Management:

  • IV fluids
  • IV antibiotics
  • NG tube

Surgical management

  • excision of necrotised bowel
  • stoma formation
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4
Q

What are the features of NEC? and management:

A 
Abdominal distension 
Blood in the stool 
Feeding intolerance 
Vomiting - usually bilious
Pyrexia

*stopping feeds
* IV fluids
* IV antibiotics
*Stool cultures
*TPN
+/-
*surgical intervention

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5
Q

What are the most common differentials to abdominal pain in children?

A 
Acute appendicitis 
Mesenteric adenitis 
Constipation 
Gastroenteritis 
UTI
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6
Q

What are some of the features seen on x-ray with a child with appendicitis?

A 
Scoliosis
Faecolith 
Absent right psoas shadow  
Small bowel dilation
\+/- 
Signs of perforation - Rigler's sign
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7
Q

List some risk factors for intussusception:

A

Recent viral illness

HSP

Lymphoma

Cystic fibrosis

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8
Q

What sign is seen on ultrasound of intussusception? and what is the gold standard investigation?

A

Target sign / Dohunt sign

Air/ Barium enema

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9
Q

What is the treatment for intussusception?

A

Catheter with air inflation under fluoroscopy guidance - only used if no indication of perforation

If contraindicated or risk of perforation then:
- Laparoscopic surgery

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10
Q

What is the management of incarcerated inguinal hernia?

A

Resuscitate
Reduce
Repair

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11
Q

What are the risk factors for hernias?

A

Prematurity

Low birth weight

**elective surgery is done very soon following birth in premature

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12
Q

How are umbilical hernias managed?

A

Observation until 5 years old. after which surgery is completed.

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13
Q

In trauma, what volume of fluid required would be enough to initiate calling a surgeon?

A

> 40ml/kg of fluid resuscitation = surgeon to be called

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14
Q

What is the calculation to work out rough weight of the child?

A

Age + 4 x 2

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15
Q

What are the indications for a head CT in a child?

A 
Loss of consciousness >5mins 
Retrograde or anterograde amnesia >5mins 
Abnormal drowsiness 
>3 episodes of vomiting 
Seizure 
GCS <14 in waiting room 
Tense fontanelle 
Focal neurology 
<1 year old with >5cm bruising on head 
Dangerous Mechanism of injury
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16
Q

What are the risk factors, and signs and symptoms of intussusception?

A

Commonly occurs from 3months - 2 years

Risk factors:

  • recent viral illness
  • Merkel’s diverticulum
  • cystic fibrosis

Symptoms:

  • sudden onset colicky pain
  • Redcurrant jelly stools
  • Bilious vomiting

Signs:

  • Sausage shaped mass in RUQ
  • Pallor
  • empty RLQ - Dance sign

Target sign seen on US

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17
Q

What is the management of intussusception?

A

Medical:

  • IV fluids
  • NG tube
  • IV antibiotics
  • NBM
  • Catheter with air compression guided by fluoroscopy

Surgical:
- Laparotomy (manual reduction)

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18
Q

What is the condition called when the abdominal contents comes out in the sac, and list some other features seen with it:

A

Exomphalos/ Omphalocele

  • liver may herniate as well
  • hernia of umbilical cord
  • bowel function usually normal
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19
Q

What is called when there is herniation of the abdominal contents out with the sac and list some other features seen with it?

A

Gastroschisis

  • lateral to umbilicus
  • bowel function not normal - may be inflamed
  • risk of obstruction

Fixed with Silo

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20
Q

What is the major complication that can occur with Hirschsprung disease?

A

Necrotising enterocolitis

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21
Q

What is the definitive surgical management for Hirschsprung disease?

A

Removal of the aganglionic bowel and attach it to the anal sphincter

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22
Q

When cant a transcutaneous bilirubin meter not be used to measure bilirubin levels?

A

<24 hours

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23
Q

What is the typical blood gases of pyloric stenosis?

A

Alkalosis
Hypokalaemia
Hypochloraemia

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24
Q

What are the symptoms of GORD in a infant?

A

Regurgitation

  • often mistaken for vomiting
  • effortless vomiting

Feeding difficulties

Cough / wheezing

Hoarseness of voice

Abdominal pain
- especially post-prandial

Haematemesis

*Sandifer syndrome

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25
Q

What are the differentials for GORD?

A

Over-feeding

Gastritis

Pyloric stenosis

Hiatus hernia

Cow’s milk protein intolerance

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26
Q

What are the investigations into GORD?

A

Bloods:

  • FBC
  • U&Es
  • ABG (if pyloric stenosis suspected)

Orifices:

  • pH studies
  • endoscopy

X-rays:

  • barium enema (for obstructions)
  • Abdominal USS (stenosis)
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27
Q

What is the management for GORD?

A

Advice:

  • avoid over feeding (smaller portions)
  • Sit more upright
  • Thicker feeds

Medical:
1st line: Gaviscon
2nd line: Ranitidine or Omeprazole

*should not be used long term due to poor Ca2+ absorption

Surgical:
- Nissans fundoplication

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28
Q

List some complications of GORD:

A

Oesophagitis
- which can lead to stenosis

Tooth enamel damage

Sandifer syndrome
- torticollis like syndrome that occurs with hyperextension

Faltering growth

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29
Q

List some differentials for vomiting in an infant:

A

Infection
- acute vomiting

Pyloric stenosis

  • Acute
  • poor weight gain
  • projectile vomiting

Infantile colic

  • Chronic
  • Inconsolable crying
  • Usually resolved by 4 months

Cow’s milk protein intolerance

  • abdominal pain
  • eczema
  • flatulence
  • bloody stools

Intestinal obstruction/ malrotation

  • acute on chronic
  • bilious vomiting

Raised intercranial pressure
- chronic

30
Q

What is the diagnostic criteria for infantile colic and how is it treated?

A

> 3 hours of crying per day for >3 days per week
- usually worse in evenings

Treatment:

  • Simethicone
  • Exclude cow’s milk from diet
31
Q

What are the symptoms of pyloric stenosis and what investigations should be undertaken?

A
  • Effortless projectile vomit
  • Dehydration (dry nappies)
  • Weight loss
  • Constipation

Signs:

  • peristalsis visible over stomach area
  • Olive mass felt

Investigations:

  • ABG
  • U&Es
Test fed -  No.1 
Abdominal US 
Contrast studies (string sign)
32
Q

What is the management of pyloric stenosis?

A

Medical:

  • IV rehydration + K+ rebalance
  • NG tube - remove aspirates every 4 hours

Surgical:
- Ramstedt’s pyloromtomy

*recommence feds after 6 hours

33
Q

With regard to inguinal hernias and transillumination what is an important factor to remember in children?

A

Normally in an adult only a hydrocele will transluminate helping to differentiate it from bowel.

However in children the bowel can also transluminate. due to the liquid diet.

34
Q

In a child presenting with an inguinal hernia in the first 6 months of life when should it be repaired?

A

Within 2 weeks

- ideally as soon as possible

35
Q

What is Paraphimosis and how does this compare to phimosis?

A

Paraphimosis:
- circumferential tightening of the foreskin when retracted causing restriction of blood flow to the penile glands causing swelling.

Phimosis

  • tight foreskin which is unable to be retracted. urine can often get stuck between the skin and glans causing UTIs
  • may be normal up till 2 years
36
Q

What are the suggested aetiologies behind NEC? and where is most commonly affected?

A

Toxins and bacteria
- introduction of feeds

Mucosal intestinal barrier
- premature leakage of contents

Milk formula
- caesin based

Intestinal blood flow
- decreased blood flow affecting

37
Q

What is the pathology of Hirschsprung disease?

A

Absence of the parasympathetic ganglion cells

38
Q

Why does a psoas sign exist in acute appendicitis?

A

Retrocaecal position of the appendix

- causing compression against the psoas muscle as it moves.

39
Q

If a male comes in with abdominal pain where is a very important place to always examine?

A

Testes

- often refers to abdomen

40
Q

What is the definitive management of testicular torsion?

A

Orchiopexy bilaterally

41
Q

What signs may be seen in torsion of appendage differentiating it from testicular torsion?

A

Less severe pain
- lack of N&V

Blue dot may be seen on the Testicle

Cremaster reflex is still intact

42
Q

What is the definition of a hernia?

A

The protrusion or displacement of an organ out with its wall or cavity containing it.

43
Q

What in a baby is typically the cause of a hydrocele?

A

Patent tunica vaginalis causing peritoneal fluid to leak into the the space
- typically caused by viral illness which seems to cause reactive peritoneal fluid

44
Q

When are Umbilical hernias are operated on?

A

> 4 years old

Exceedingly large

*they rarely strangulate

45
Q

What is an x-ray option you can do in baby you suspect has a perforation?

A

Left lateral sign
- get them to lie on their left and the air will accumulate to allow you to see any air

*left lateral decubitus

46
Q

What is the main worrying diagnosis of bilious vomiting in a baby and what is the number one invetgiation that should be done?

A

Volvulus
- due to mid-gut rotation

Abdominal contrast study is needed
- this is going to rule out multiple pathologies including: meconium aspirate, volvulus, intestinal atresia, Hirschsprung disease

47
Q

What is the natural progress of pyloric stenosis if it is left untreated?

A

Death occurs due to respiratory arrest.

the severe metabolic alkalosis drives down the respiratory rate so far.

  • if the child goes on a respiratory during this stage they will not come off.
  • this is why the bloods must be perfect before the operation.
48
Q

What examination must ALWAYS be done when a male child presents with abdominal pain?

A

As well as the abdominal exam a child must always have their testicles examined.

PR exam should always be considered as well

49
Q

Highlight some of the clinical differences between appendicitis and mesenteric adenitis:

A

Adenitis:

  • higher fever
  • felt unwell prior to onset of abdominal pain
  • abdominal pain doesn’t move
  • Patient looks more flushed

Appendicitis:

  • lower fever
  • abdominal pain prior to feeling ill
  • abdominal pain migrates
  • patient looks more pale

**note that mesenteric adenitis can become appendicitis due to obstruction of of the lumen

50
Q

Why might appendicitis present with urological symptoms? including swollen testes?

A

if the position is retrocaecal it can irritate the bladder, and colon presenting with symptoms similar to UTI.

51
Q

If you have a child in with vomiting and you are waiting on a surgical consult what should you do in the meantime?

A

Start broad spectrum antibiotics

The next main differential to a surgical matter is sepsis.

52
Q

When is vomiting always considered a surgical Emergancy?

A

If it is bilious this is a surgical Emergancy until proven otherwise.

53
Q

What is a very important test to always get in the setting of excessive vomiting?

A

ABG/ VBG/ CVG

this will immediately tell you if they are alkalotic, acidotic and what their lactate is

54
Q

What is the normal rotation of the mid-gut during embryological development?

A

Gut moves out of the peritoneal cavity and rotates 270 degrees.
the DJ should come to lie in the midline and the caecum in the right iliac fossa.

55
Q

What are the rules of 2 in Merkel’s diverticulum?

A

<2 years old usually symptoms

2 feet from caecum

2 inches long

2 types of mucosa involved

  • gastric
  • Jejunal
56
Q

What are the major pathologies which can occur with Meckel’s diverticulum? and what investigations should be done - noting the definitive diagnosis:

A

Haemorrhage (due to gastric secretions)

  • PR bleeding
  • mixed with stool

Volvulus
- increase risk of intussusception

Appendicitis
- tends to be more periumbilical/ umbilical area

Investigations:

  • FBC
  • U&ES
  • G&S/ CXM (if perfuse bleeding)

X-rays:
- Abdominal x-ray (obstruction)

Definitive diagnosis:
- Mekel’s scan (radioactive uptake of ectopic gastric tissue)

57
Q

What is the fluid is given to neonates?

A 
Dextrose 10% 
\+ 
Na2+ individually (3mmol/kg/day)
\+
K+ individually (2mmol/kg/day)

The exact amount of fluid actually varies depending on the exact age of the child

58
Q

What is the fluid given for maintenance fluid to a child (after neonatal period)?

A
  1. 9% Saline + 5% dextrose

- K+ is added and calculated in

59
Q

What is the normal fluid resuscitation dose and which children would receive a smaller amount and what is this dosage?

A

20mls/kg of 0.9% saline

10mls/kg of 0.9% saline is used in special cases including:

  • neonates
  • cardiac disease
  • DKA
  • trauma

2ml/kg of 10% dextrose in hypoglycaemic child

**if more than 3 boluses or 40mls/kg given then ICU should be contacted. there is a real risk of pulmonary overload

60
Q

What are the two types of epithelium that occur in Merkel’s diverticulum?

A

Gastric

Pancreatitis

61
Q

What is the name of the procedure done for malrotation and what organ should be removed during it and why?

A

Ladd’s procedure.

The appendix is always removed. this is because it will be in an abnormal position in when placed back into the abdomen - making future appendicitis difficult to diagnosis.

62
Q

What are the clinical findings in pyloric stenosis?

A

RIGHT upper quadrant mass

Peristalsis from left to right

Signs of dehydration

63
Q

What bloods must be done in a paediatric patient presenting with abdominal pain?

A 
FBC 
U&Es
CRP 
LFTs
Amylase 
Glucose
64
Q

What infections may pre-dispose the child to intussusception?

A

Henock Scholien
URTI
*these cause enlargement of Peyer’s patches

Cystic fibrosis
Merkels diverticulum

65
Q

How can you differentiate pityriasis alba from vitiligo?

A

It is just areas of lightened skin not complete loss of pigmentation like in vitiligo

66
Q

What is the underlying pathology of the metabolic alkalosis seen in pyloric stenosis?

A

Reduced Cl- results in increased HCO3- reabsorption from the kidneys increasing the base

Loss of H+

Loss of K+ triggers uptake of H+ into the cells

RAAS system

67
Q

What is the name of the operation for pyloric stenosis?

A

Ramstedt’s pyloromyotomy

68
Q

What are some differentials for intussusception?

A

Colic

Gastroenterisits

Meckel’s diverticulum

Volvulus

Testicular torsion

Appendicitis

**take these in context of childs age and symptoms

69
Q

What are your two major investigations into intusuception?

A

US

Air contrast enema

70
Q

What is the name of the surgery conducted for biliary atresia?

A

Kasia - Porto- Enterostomy
Hepatoportoenterostomy

*Part of the duodenum is removed and used to make a biliary tract

71
Q

How is biliary atresia diagnosed?

A

Bloods:
- LFTs - conjugated bilirubin

X-rays:

  • US of liver + biopsy
  • HIDA scan

*thing such as alpha -1 antitrypsin and CF should be ruled out

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