Paediatric surgery Flashcards
What are the top 5 causes for vomiting in a baby?
Over feeding Posetting GORD Pyloric stenosis Obstruction
What are the most common causes of bilious vomit in a baby?
Malrotation +/- volvulus (until proven otherwise)
NEC
Atresia
Hirschsprung’s disease
Meconium ileus
What are the symptoms of malrotation and what is the diagnostic test of choice and management?
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
What are the features of NEC? and management:
Abdominal distension Blood in the stool Feeding intolerance Vomiting - usually bilious Pyrexia
*stopping feeds
* IV fluids
* IV antibiotics
*Stool cultures
*TPN
+/-
*surgical intervention
What are the most common differentials to abdominal pain in children?
Acute appendicitis Mesenteric adenitis Constipation Gastroenteritis UTI
What are some of the features seen on x-ray with a child with appendicitis?
Scoliosis Faecolith Absent right psoas shadow Small bowel dilation \+/- Signs of perforation - Rigler's sign
List some risk factors for intussusception:
Recent viral illness
HSP
Lymphoma
Cystic fibrosis
What sign is seen on ultrasound of intussusception? and what is the gold standard investigation?
Target sign / Dohunt sign
Air/ Barium enema
What is the treatment for intussusception?
Catheter with air inflation under fluoroscopy guidance - only used if no indication of perforation
If contraindicated or risk of perforation then:
- Laparoscopic surgery
What is the management of incarcerated inguinal hernia?
Resuscitate
Reduce
Repair
What are the risk factors for hernias?
Prematurity
Low birth weight
**elective surgery is done very soon following birth in premature
How are umbilical hernias managed?
Observation until 5 years old. after which surgery is completed.
In trauma, what volume of fluid required would be enough to initiate calling a surgeon?
> 40ml/kg of fluid resuscitation = surgeon to be called
What is the calculation to work out rough weight of the child?
Age + 4 x 2
What are the indications for a head CT in a child?
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
What are the risk factors, and signs and symptoms of intussusception?
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
What is the management of intussusception?
Medical:
- IV fluids
- NG tube
- IV antibiotics
- NBM
- Catheter with air compression guided by fluoroscopy
Surgical:
- Laparotomy (manual reduction)
What is the condition called when the abdominal contents comes out in the sac, and list some other features seen with it:
Exomphalos/ Omphalocele
- liver may herniate as well
- hernia of umbilical cord
- bowel function usually normal
What is called when there is herniation of the abdominal contents out with the sac and list some other features seen with it?
Gastroschisis
- lateral to umbilicus
- bowel function not normal - may be inflamed
- risk of obstruction
Fixed with Silo
What is the major complication that can occur with Hirschsprung disease?
Necrotising enterocolitis
What is the definitive surgical management for Hirschsprung disease?
Removal of the aganglionic bowel and attach it to the anal sphincter
When cant a transcutaneous bilirubin meter not be used to measure bilirubin levels?
<24 hours
What is the typical blood gases of pyloric stenosis?
Alkalosis
Hypokalaemia
Hypochloraemia
What are the symptoms of GORD in a infant?
Regurgitation
- often mistaken for vomiting
- effortless vomiting
Feeding difficulties
Cough / wheezing
Hoarseness of voice
Abdominal pain
- especially post-prandial
Haematemesis
*Sandifer syndrome
What are the differentials for GORD?
Over-feeding
Gastritis
Pyloric stenosis
Hiatus hernia
Cow’s milk protein intolerance
What are the investigations into GORD?
Bloods:
- FBC
- U&Es
- ABG (if pyloric stenosis suspected)
Orifices:
- pH studies
- endoscopy
X-rays:
- barium enema (for obstructions)
- Abdominal USS (stenosis)
What is the management for GORD?
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
List some complications of GORD:
Oesophagitis
- which can lead to stenosis
Tooth enamel damage
Sandifer syndrome
- torticollis like syndrome that occurs with hyperextension
Faltering growth
List some differentials for vomiting in an infant:
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
What is the diagnostic criteria for infantile colic and how is it treated?
> 3 hours of crying per day for >3 days per week
- usually worse in evenings
Treatment:
- Simethicone
- Exclude cow’s milk from diet
What are the symptoms of pyloric stenosis and what investigations should be undertaken?
- 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)
What is the management of pyloric stenosis?
Medical:
- IV rehydration + K+ rebalance
- NG tube - remove aspirates every 4 hours
Surgical:
- Ramstedt’s pyloromtomy
*recommence feds after 6 hours
With regard to inguinal hernias and transillumination what is an important factor to remember in children?
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.
In a child presenting with an inguinal hernia in the first 6 months of life when should it be repaired?
Within 2 weeks
- ideally as soon as possible
What is Paraphimosis and how does this compare to phimosis?
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
What are the suggested aetiologies behind NEC? and where is most commonly affected?
Toxins and bacteria
- introduction of feeds
Mucosal intestinal barrier
- premature leakage of contents
Milk formula
- caesin based
Intestinal blood flow
- decreased blood flow affecting
What is the pathology of Hirschsprung disease?
Absence of the parasympathetic ganglion cells
Why does a psoas sign exist in acute appendicitis?
Retrocaecal position of the appendix
- causing compression against the psoas muscle as it moves.
If a male comes in with abdominal pain where is a very important place to always examine?
Testes
- often refers to abdomen
What is the definitive management of testicular torsion?
Orchiopexy bilaterally
What signs may be seen in torsion of appendage differentiating it from testicular torsion?
Less severe pain
- lack of N&V
Blue dot may be seen on the Testicle
Cremaster reflex is still intact
What is the definition of a hernia?
The protrusion or displacement of an organ out with its wall or cavity containing it.
What in a baby is typically the cause of a hydrocele?
Patent tunica vaginalis causing peritoneal fluid to leak into the the space
- typically caused by viral illness which seems to cause reactive peritoneal fluid
When are Umbilical hernias are operated on?
> 4 years old
Exceedingly large
*they rarely strangulate
What is an x-ray option you can do in baby you suspect has a perforation?
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
What is the main worrying diagnosis of bilious vomiting in a baby and what is the number one invetgiation that should be done?
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
What is the natural progress of pyloric stenosis if it is left untreated?
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.
What examination must ALWAYS be done when a male child presents with abdominal pain?
As well as the abdominal exam a child must always have their testicles examined.
PR exam should always be considered as well
Highlight some of the clinical differences between appendicitis and mesenteric adenitis:
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
Why might appendicitis present with urological symptoms? including swollen testes?
if the position is retrocaecal it can irritate the bladder, and colon presenting with symptoms similar to UTI.
If you have a child in with vomiting and you are waiting on a surgical consult what should you do in the meantime?
Start broad spectrum antibiotics
The next main differential to a surgical matter is sepsis.
When is vomiting always considered a surgical Emergancy?
If it is bilious this is a surgical Emergancy until proven otherwise.
What is a very important test to always get in the setting of excessive vomiting?
ABG/ VBG/ CVG
this will immediately tell you if they are alkalotic, acidotic and what their lactate is
What is the normal rotation of the mid-gut during embryological development?
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.
What are the rules of 2 in Merkel’s diverticulum?
<2 years old usually symptoms
2 feet from caecum
2 inches long
2 types of mucosa involved
- gastric
- Jejunal
What are the major pathologies which can occur with Meckel’s diverticulum? and what investigations should be done - noting the definitive diagnosis:
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)
What is the fluid is given to neonates?
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
What is the fluid given for maintenance fluid to a child (after neonatal period)?
- 9% Saline + 5% dextrose
- K+ is added and calculated in
What is the normal fluid resuscitation dose and which children would receive a smaller amount and what is this dosage?
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
What are the two types of epithelium that occur in Merkel’s diverticulum?
Gastric
Pancreatitis
What is the name of the procedure done for malrotation and what organ should be removed during it and why?
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.
What are the clinical findings in pyloric stenosis?
RIGHT upper quadrant mass
Peristalsis from left to right
Signs of dehydration
What bloods must be done in a paediatric patient presenting with abdominal pain?
FBC U&Es CRP LFTs Amylase Glucose
What infections may pre-dispose the child to intussusception?
Henock Scholien
URTI
*these cause enlargement of Peyer’s patches
Cystic fibrosis
Merkels diverticulum
How can you differentiate pityriasis alba from vitiligo?
It is just areas of lightened skin not complete loss of pigmentation like in vitiligo
What is the underlying pathology of the metabolic alkalosis seen in pyloric stenosis?
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
What is the name of the operation for pyloric stenosis?
Ramstedt’s pyloromyotomy
What are some differentials for intussusception?
Colic
Gastroenterisits
Meckel’s diverticulum
Volvulus
Testicular torsion
Appendicitis
**take these in context of childs age and symptoms
What are your two major investigations into intusuception?
US
Air contrast enema
What is the name of the surgery conducted for biliary atresia?
Kasia - Porto- Enterostomy
Hepatoportoenterostomy
*Part of the duodenum is removed and used to make a biliary tract
How is biliary atresia diagnosed?
Bloods:
- LFTs - conjugated bilirubin
X-rays:
- US of liver + biopsy
- HIDA scan
*thing such as alpha -1 antitrypsin and CF should be ruled out
