Paediatric Surgery Flashcards
Calculate estimated weight of a child
Weight = 2 x (AGE +4)
Estimated blood volume of a child
80mls per kg
Urine output of a child
0.5-1ml/kg/hour
Insensible fluid loss of a child
20ml/kg/day
Systolic blood pressure of a child
80 + (2 x age)
Respiratory rate of a 3 year old
25-30
Heart rate of child less than 1
100-160
Systolic blood pressure of 4 year old
80-100
WHO recommended paracetamol dose for child
20 mg/kg 4-6 hrly
WHO recommended ibuprofen dose for child
10mg/kg 8 hourly
Resuscitation fluid for child
20 ml/kg bolus 0.9% NaCl
Maintenance fluid for child
0.9% NaCl 5% Dextrose +/- 0.15%KCl
4/kg for first 10kg
2ml/kg for second 10kg
1 ml/kg for every kilo after
Replacement fluid for child
0.9%NaCl, 10mmol KCl ml for ml (400ml bag)
Signs of deterioration
Feed refusal Colour Temperature Change in tone Bile vomits
Abdominal pain closer to the umbilicus is indicative of?
Funtional cause
Not surgical concern
Which dermatome relates to the umbilicus?
T10
Where are young children most likely to point referring to abdominal pain?
Umbilicus
Should be cautious
Two types of pain to distinguish in abdominal pain
Constant vs Colic
When assessing pain on movement what should be asked in abdominal pain history?
Pain worsening in car/speed bumps
What colour of vomit is important in surgical causes of abdominal pain?
Green bile
3 features to be noted in abdominal examination
General appearance of child
Temperature
Rebound tenderness (assess by asking to cough) and guarding
4 investigations for abdominal pain
Urine
Electrolytes
Full blood count
X-ray
Murphy’s triad for appendicitis
Pain
Fever
Vomiting
Which point will be tender in appendicitis?
McBurney’s point
1/3 between ASIS and umbilicus
Complications of appendicitis
Abscess
Mass
Peritonitis
General presentation of child with appendicitis
Moderate temperature
Vomiting
Looks unwell
Unusual over 4 years old
Presentation of non-specific abdo pain
Generalised, central Constant Not made worse by movement No GI disturbance No temperature Site and severity can vary - functional
What condition can non-specific abdo pain mimic?
Early appendicitis
In which group of patients is non-specific abdo pain more common?
Young girls
Differential diagnoses for abdominal pain
Mesenteric adenitis Pneumonia Pyloric stenosis Malrotation Intussusception Gastroschisis Exomphalos
Features of pain in appendicitis
Periumbilical pain radiating to right iliac fossa
Worse on coughing and over speed bumps
Children cannot hop on right foot
Why does the pain radiate to the right iliac fossa in appendicitis?
Localised Partietal peritoneal inflammation
Other common features of appendicitis
Mild pyrexia - not as high as mesenteric adenitis
May have loose stool
Anorexia - lose appetite
Which form of appendicitis has fewer signs?
Retrocaecal
Examination of appendicitis
Abdo exam
Digital rectal - boogy sensation if pelvic abscess in case of pelvic appendix
Diagnosis of appendicitis
Raised inflammatory markers
History and examination findings
Urine analysis to exclude UTI, renal colic and pregnancy
Ultrasound - presence of free fluid
Management appendicitis
Appendectomy - laparoscopic
Prophylactic IV antibiotics
Broad spectrum antibiotics if mass present
Perforated appendicitis needs abdominal lavage
Presenting features of mesenteric adenitis
High temperature
Abdominal pain
URTI
Not unwell
Pneumonia can cause referred pain to which site>
Right iliac fossa
Pyloric stenosis usually presents in which stage of life?
4-16 weeks of life
Pyloric stenosis is more common amongst which group of patients?
Male babies
What causes pyloric stenosis?
Hypertrophy of the circular muscles of the pylorus
Presenting features of pyloric stenosis
Non bilous projectile vomiting Weight loss Palpable mass upper abdomen possible Dehydration and constipation possible Alkalosis, hypochloraemia, hypokalaemia
When does vomiting occur in pyloric stenosis?
30 mintues after feed
How is pyloric stenosis diagnosed?
Test feed - observe for mass and visible peristalsis
Ultrasound
Management of pyloric stenosis
IV fluid bolus for acute hypovolaemia Feed by NG tube Rehydration with crystalloid Regular blood gases and U&Es Periumbilical pyloromyotomy - Ramstedt's Must have electrolytes corrected first
Presentation of malrotation
3 day old baby with bilious vomiting
Fairy liquid green
What colour of vomit is associated with malrotation?
Fairy liquid green
Investigation for malrotation
Upper GI contrast study
Management of malrotation
Urgent laparotomy
When can babies resume feeding after pyloromyotomy?
6 hours
Why is vomiting common after pyloromyotomy?
Distension and dysmotility
Complications of pyloric stenosis
Hypovolaemia
Apnoea
Post operative Infection Bleeding Perforation Incomplete myotomy Wound dehiscence
Intussusception most commonly occurs at what age?
3-9 month old babies
What is intussusception?
Invagination of one part of bowel into lumen of adjacent bowel
What area is intussusception most likely to occur?
Ileocaecal
Presentation of intussusception
3 day history of viral illness (Paroxysmal) Intermittent colic Dying spells Bilious vomiting Red currant jelly stools 4 second capillary refill Sausage shaped mass RUQ
What sign will infant display during paroxysm in intussusception?
Draws knees up and turns pale
Investigation for intussusception
Ultrasound - Target sign
What sign on US indicates intussusception?
Target mass
Management of intussusception
Pneumatic reduction (air enema) Laparotomy
Indication for laparotomy in intussusception
Pneumatic reduction fails or child has peritonitis
What is gastroschisis?
Congenital abdominal wall defect
Gut eviscerated and exposed
Atresia associated
Management of gastroschisis
May attempt vaginal delivery and newborn to theatre ASAP
Primary or delayed closure
Total Parenteral Nutrition
How does exomphalos (omphalocele) differ to gastroschisis?
Abdominal contents protrude through anterior abdominal wall but enclosed in amniotic sac
Anomalies associated with exomphalos
Beckwith Weideman
Cardiac and kidney malformations
Down’s syndrome
Management of exomphalos
Primary/delayed closure
Casearean to keep amniotic sac intact
Staged repair where primary closure difficult- intraabdominal pressure
Sac is allowed to granuloate and epithelialise - forms a shell
As infant grows contents can fit in abdominal cavity and shell removed, abdomen closed
Hirschsprung’s disease
Congenital Aganglionic megacolon
Ganglionic cells fail to develop in large intestine
Delayed or failed passage of meconium within 48 hours of birth
Triad for hirschsprung’s disease
Abdominal distension
Bilious vomiting
Failure to pass meconium
Male to female ratio for hirschsprung’s disease
4 to 1
Genetic associations with Hirschsprung’s disease
Receptor Tyorisine Kinase Gene (RET)
Chromosome 10q11
and
Endothelin Type B receptor pathway
Conditions associated with Hirschsprung’s
Trisomies -Down Syndrome
3 subtypes of hirschsprung’s disease
Short segment
Long segment
Total colonic aganglionosis
Which subtype fo hirschsprung’s disease is most common?
Short segment
Result of anganglionosis in Hirschsprung’s disease
Failure of bowel movement and peristalsis
Accumulation of faeces will not trigger opening of sphincter
Proximal bowel dilatation leads to abdominal distension
Bacterial proliferation can lead to Hirschsprung’s enterocolitis - complications of which can be sepsis and death
Risk factors for hirschsprungs
Male
Chromosomal Abnormalities
Family history
Clinical features of hirschrpung’s
Abdominal distension Bilious vomiting Failure to pass meconium Dilation of bowel - mass in left lower abdomen Empty rectal vault
Differentials for hirschsprungs
Meconium plug syndrome Meconium ileus Intestinal atresia Intestinal malrotation Anorectal malformation Constipation
Investigations for hirschsprungs
Contrast enema
Short transition zone between proximal and distal colon
Rectal suction biopsy- tested for acetylcholinesterase
NICE Rectal suction biopsy guidelines
Delayed passage of meconium
Constipation since first few weeks of life
Chronic abdominal distension and vomiting
FH of hirschsprung’s
Faltering growth
Management of hirschsprungs
IV antibiotics
NG tube
Bowel decompression
Surgery - Swenson, Soave, Duhamel pull through : resect aganglionic bowel, connect unaffected to dentate
Complications of hirschsprungs
Hirschsprung associated Enterocolitiis (HEC)
Of surgery - constipation, enterocolitis, perianal abscess, faecal soiling and adhesions.
Which bacteria are associated with Hirschsprung Enterocolitis
C difficile
Staph aureus
