Paediatric Surgery Flashcards
Give 5 causes of acute scrotal pain
Testicular Torsion Irreducible Hernia Torsion of Testicular Appendage Epididymo-Orchitis Testicular/Epididymal Rupture
How does Torsion of Testicular Appendage present?
Prepubertal child
Minimal pain at rest
Tenderness of upper pole
Blue dot on upper hemiscrotum
How does a Testicular/Epididymal Rupture present?
Pain and swelling may be delayed
Tender on palpation
Bruised appearance
Give four causes of non painful testicular swellings in Children
Hydrocoele
Varicocoele
Idiopathic Scrotal Oedema (can extend into groin)
Tumour/Leukaemia
Name five red flags for acute scrotal pain/swelling
Severe Sudden Pain Impaired Gait High Riding Non Reducible Irritable
How should Acute Scrotal Pain/Swelling be investigated?
Irreducible hernia and Torsion need to be excluded first
USS and Doppler
Urinalysis MC and S
If suspecting that’s the Acute scrotum will require surgical management, how should you prepare?
Fasting/Clear Fluids
Consider NG tube if bowel obstruction
Adequate pain relief
How is a Hydrocoele managed?
90% resolve within first two years
How is a Varicocoele managed?
Outpatient surgery
How is Torsion of Testicular Appendage managed?
Supportive only
Give 5 causes of Acute Pancreatitis
Abdominal Trauma Systemic Infection (Mumps, Rubella) Medications (Azathioprine, Steroids) Metabolic (CF) Hereditary
How would Acute Pancreatitis present?
Abdominal Pain
Vomiting
Abdominal Tenderness
Guarding
Maybe lying on side with hips flexed
How would Acute Haemorrhagic Pancreatitis present?
Life threatening shock
ARDS
DIC
Grey Turners and Cullens Sign
What investigations would you do for Acute Pancreatitis?
Amylase (peaks after 48h and remains elevated for 4d)
Lipase (more specific and remains elevated for 8-14d)
USS (focally diffused/enlarged)
ERCP (if suspected biliary abnormalities)
How is Acute Pancreatitis managed?
IV Hydration
Pain Control
Bowel Rest
If complicated - surgery
How is Chronic Pancreatitis managed?
Could consider Pancreatectomy
When does Orchitis occur in isolation?
Only normally with Mumps
What is Mumps?
Unilateral or bilateral orchitis with fever, 4-8d after Parotitis
Self resolving but can lead to atrophy and infertility
Notifiable disease
Describe the pathophysiology of Epididymorchitis
Extension of infection from Lower Urinary Tract, either Enteric or STI (In older children)
UTI - E.Coli, Proteus Saprophyticus, Klebsiella
STI - N.Gonorrhoea, Chlamydia
How does Epididymitis present?
Unilateral scrotal pain and associated swelling
Dysuria
Discharge
Fever
?Reactive Hydrocoele, Prehn’s Sign
How should Epididymitis be investigated?
Urine dipstick MC and S
If relevant, first catch NAAT
FBC and CRP
USS (will require renal USS if second episode)
How is Epididymitis managed?
Bed rest and scrotal support
Empirical Antibiotics - Enteric requires Ofloxacin, STI requires Ceftriaxone Doxycycline and potentially Azithromycin
Testicular Torsion occurs when spermatic cord twists within Tunica Vaginalis. Describe the pathophysiology
Impaired arterial flow, venous return and subsequent venous congestion and oedema
More vulnerable if bell clapped (lacks attachment to tunica)
What is an extravaginal torsion?
Attachment between scrotum and tunica Vaginalis is not fully formed and entire testes and tunica Vaginalis can tort
Can occur in utero, so should be checked at birth
Give three risk factors for Testicular Torsion
Age 12-25
Previous Torsion
Undescended Testes
What are the clinical features of Testicular Torsion?
Sudden onset unilateral scrotal pain
Nausea and vomiting
Referred abdominal pain
Absent Cremasteric Reflex
How would you manage Testicular Torsion?
Immediate surgical exploration within 6 hours
Analgesia, Abx, Fluids
Bilateral Orchidopexy
What is Balanitis Xerotica Obliterans?
Normally there are adhesions between prelude and glans that break down as child ages
Keratinisation of the two of foreskin causing scarring and pathological phimosis
How does BXO present?
Ballooning of foreskin in Micturition
Irritation, dysuria, haematuria from scarring
OE - white fibrotic and scarred with difficulty in meatus visualisation
How is BXO managed?
Circumcision and subsequently histopathology to confirm diagnosis
What is Cryptorchidism?
Congenital absence of one or both testes in scrotum due to failure of developmental descent
Can be: True Undescended (lying along line of descent), Ectopic (Lying away from path of descent) or Ascending (previously descended)
What diagnosis would you consider with bilateral Cryptorchidism?
Androgen Insensitivity or Disorder of Sex Development
Give three risk factors for Cryptorchidism
Prematurity
Low Birth Weight
FH
How should you examine an undescended teste?
Palpate from Inguinal ring to Pubic symphysis
If found try to pull it down (if easy - retractile testes, if under tensions- high testes)
If unable to pull down - Inguinal Undescended Teste
If you suspected that Disorder of Sex Development was the cause of Cryptorchidism, how would you manage?
Senior paediatrician referral within 24 hours (at risk from salt losing crisis in CAH)
How would you manage Cryptorchidism?
Continue to review, if undescended at 6-12m then operate
Palpable - Orchidopexy via Groin Incision
Non Palpable - 2 stage procedure for Intra-abdominal
What are the complications with Undescended Testes?
Impaired Fertility (due to temperature difference impairing spermatogenesis)
Torsion
Testicular Cancer
What is Hirschsprung’s disease?
AKA Congenital Aganglionic Megacolon Disease
Ganglion is cells fail to develop in large intestine, commonly presenting as delayed Meconium passage
Associated with Receptor Tyrosine Kinase
What are the three types of Hirschsprung?
Short Segment (85%) - Aganglionosis restricted to rectosigmoid
Long Segment (10%) - Aganglionosis spreads to splenic flexure
Total Colon (may also involve small bowel)
Describe the pathophysiology of Hirschsprungs
Failure of neural crest cells to enter normally through vagus nerve
Aganglionic sections remain ‘tonic’ and faeces in rectum do not trigger sphincter relaxation
Stasis leads to Enterocolitis
What is the classical triad of Hirschsprungs?
Failure to pass Meconium after 48 hours
Abdominal Distension
Bilious Vomiting
What would you see OE in Hirschsprungs?
Dilation of proximal bowel (palpated mass in LLQ)
Empty rectal vault
Give two differentials for Hirschsprungs and how you would rule them out
Meconium Plug
Meconium Ileus
Water Soluble Enema
What investigations would you do in Hirschsprungs?
Contrast Enema (Distinguishes transition zone and rectal diameter) Rectal Suction Biopsy (Gold Standard)
What is a Rectal Suction Biopsy?
Simple bedside procedure with antibiotic cover
Submucosa tested for Aganglionic cells
Biopsy stained with acetylcholinesterase
How is Hirschsprungs managed?
Initial - IV Abx, NG, Bowel Decompression
Definitive - Surgery (resection of aganglionic bowel and connecting it to dentate line)
One of the main complications of Hirschsprungs is Hirschsprung Associated Enterocolitis. How does it present?
Fever, Vomiting, Diarrhoea, Abdominal Tenderness
Managed with bowel decompression and broad spectrum abx
Define Intussusception
Telescoping of one part of bowel into another
Proximal bowel is intussusceptum while distal is intussucipiens
Describe the pathophysiology of intussusception
90% Ileocolic
Normally idiopathic but underlying pathologies can create a lead point:
Rotavirus, Meckels, Polyps, Lymphoma
How does a child with Intussusception present?
Sudden onset inconsolable crying
Draw knees to chest
Vomiting
Later - Red Currant Jelly Stools (Blood and Mucous)
What would you see OE of a child with Intussusception?
Palpable sausage mass in RUQ
Peritonism
Presence of bowel sounds
How would you investigate Intussusception and what would you see?
AXR - distended small bowel loops (any perforation - riglers)
Abdo USS - high sensitivity, doughnut/target on transverse plane
Contrast Enema (can be therapeutic)
How is Intussusception managed?
May require NG decompensation and IV fluids
Air/ Contrast Enema
Failing the above, manual reduction via surgery and removal of necrotic bowel
What happens if Intussusception is left untreated?
Obstruction
Perforation
Dehydration and Shock
What is Pyloric Stenosis?
Progressive hypertrophy of pylorus causing outlet obstruction with unknown aetiology, within first 4-6 weeks of life
How does Pyloric Stenosis present?
Non bilious projectile vomiting after feeds
Potentially Haematemesis
Weight loss and dehydration
What would you see OE in Pyloric Stenosis?
Visible Peristalsis and Olive Shaped Mass in feeding
Give four differentials for Pyloric Stenosis
Gastroenteritis
GORD
Food Allergy
Malrotation (Bilious)
How would you investigate Pyloric Stenosis?
Test feed with NG
USS gold standard
Blood Gas (HYPOkalaemic, Hypochloraemic, metabolic alkalosis)
What are the USS parameters for Pyloric Stenosis?
Wall thickness >3mm
Length>15mm
Diameter>11mm
How is Pyloric Stenosis managed?
Rehydrate using UHL policy
Stop oral feeding and pass NG (aspirating four hourly)
Ramstedts Pyloromyotomy
What is Ramstedt’s Pyloromyotomy?
Can be Laproscopic or through supraumbilical incision
Muscle divided down mucosa
Babies can resume feed after 6hrs
May be post op vomiting but this is due to distension
Describe the pathophysiology of Acute Appendicitis
Inflammation of the appendix, from direct luminal obstruction
Normally secondary to faecolith/lymphoid hyperplasia/impacted stool
Commensal bacteria multiply
Reduced venous drainage and increased inflammation result in ischaemia
Give three risk factors for Acute Appendicitis
Family History
Caucasian
Summer Season
Describe the classical presentation of Acute Appendicitis
Dull peri umbilical pain becoming sharp and migrating to RIF
Associated vomiting/anorexia/nausea
Describe two clinical signs in Acute Appendicitis
Rovsing’s Sign - RIF pain on palpation of LIF
Psoas Sign - RIF pain on hip extension (if retrocaecal)
Describe the atypical presentation of appendicitis in Children
Diarrhoea
Urinary Symptoms
Left sided pain
If <6y and pain ongoing >48h then likely perforated
Appendicitis is generally a clinical diagnosis. What investigations could be done?
Urinalysis
Routine bloods (inc CRP)
hCG where appropriate
USS
What is the scoring system for Appendicitis?
Shera Score
<3 is low risk, >3 is high risk
How is Acute Appendicitis managed?
Laproscopic Appendicectomy (via Lanz Incision)
If abscess then give Abx first before Appendicectomy
Specimen sent for histopathology (check for Meckels)
Name three complications of Appendicitis
Perforation
Appendiceal Mass
Pelvic Abscess
Define Malrotation of the gut
Failure of the physiological process that brings caecum to lie in RIF and duodenojejunal flexure on the left.
This causes the small bowel to lie on the right side, and the caecum to lie in RUQ
What is a consequence of Malrotation?
Results in a narrow based mesentery prone to volvulus
How is Malrotation corrected?
Surgically corrected with Ladd’s Procedure (+ Appendicectomy)
What is Volvulus secondary to Malrotation?
High intestinal obstruction at duodenal level, followed by necrosis of whole midgut
How does Volvulus present in Children?
Bile stained vomit
Sunken tender abdomen (AKA Scaphoid)
Bloody stools
Circulatory Collapse
How is suspected Volvulus investigated?
AXR (‘double bubble’ and gas elsewhere in abdomen)
Upper GI contrast study
If in a reparative laparotomy for Malrotation the bowel is not viable, what should be done?
Second look laparotomy after 24 hours
Weigh up risks of massive intestinal necrosis, or short gut syndrome (+ lifelong TPN)
Define Meckels Diverticulum
Ileal remnant of vitellointestinal duct, containing ectopic gastric mucosa or pancreatic tissue affecting 2% of population
How does Meckels Diverticulum present?
Often asymptomatic
Severe rectal bleeding, intussusception, Volvulus, Diverticulitis
May mimic appendicitis
How is Meckels Diverticulum investigated?
Technetium scan shows increased uptake by gastric mucosa
How is Meckels Diverticulum managed?
Surgical resection
Diaphragmatic hernias are often diagnosed in antenatal screening. How do they present?
Respiratory distress or poor response to rescucitation
On examination, apex beat is displaced to right
Poor air entry on left
Where does a diaphragmatic hernia normally herniate?
Posterolateral foramen of diaphragm
Commonly on left
How is a diaphragmatic hernia investigated?
CXR
AXR
How is a Diaphragmatic Hernia managed?
Stabilised its NG and suction to prevent bowel distension in intrathoracic cavity
May require ET intubation and surfactant
Definitive surgical repair
Give two complications of Diaphragmatic Hernia
Vigorous rescucitation may cause pneumothorax
Pulmonary Hypoplasia
Umbilical hernia affects a significant proportion of children. Describe the pathophysiology.
Umbilical ring allows passage of vessels between mother and foetus
After birth ring remains, spontaneously closing by 5y through abdominal muscle growth and fascia fusion
Failure or delay leads to formation
Give three risk factors for Umbilical Hernias
Premature
Ehlers Danlos
Hypothyroid
How do Umbilical Hernias presents?
Reducible painless bulge at umbilicus, becoming more prominent on straining/crying
Incarcerated - painful and irreducible
Strangulated - Vomiting and constipation
How would you manage an Umbilical Hernia ?
Reassure that complications are rare and it should reduce by child’s fourth birthday
If over 4 - refer to paediatric surgery for day case closure
What is an Epigastric Hernia?
Occurring in the midline, anywhere from Xiphoid Process to Umbilicus
Mostly preperitoneal fat
How do Epigastric Hernias present?
Mass in Epigastric which commonly enlarges
Associated with abdominal wall pain and tenderness
How should Epigastric Hernias be managed?
Do not repair on their own
Repair with elective day case
What is the main differential for an Epigastric Hernia?
Divarification of Recti (Weakness in Linea Alba)
Describe the anatomy of Inguinal Hernias
Processes Vaginalis lengthens through Inguinal canal allowing testes to descend
Gradually obliterates at 36-40 weeks with distal part persisting as Tunica Vaginalis (failure leads to hernias and hydrocoeles)
Left obliterates quicker than right (more common in right)
How do Inguinal Hernias present?
Bulge in groin or swelling in scrotum
Most commonly incarcerated in children
Torted ovary May pass through patent processus (swollen labia unilaterally)
Inguinal Hernias are a clinical diagnosis. What can see OE?
Shouldn’t be able to feel above
Silk Sheet Sign (roll structures on Pubic tubercle - if hernia it feels like silk sheets)
BEWARE IT MAY TRANSILLUMINATE
Any symptomatic Inguinal Hernias require immediate reduction. How are asymptomatic patients managed?
Neonates - before discharge
<6m - operation on next list
Older - elective
Can be Laproscopic or through groin incision
State the three different types of Peritonitis
Primary - no underlying infective cause(eg Nephrotic)
Secondary - Bowel Perforation, Abscess formation, Ischaemic necrosis
Tertiary - recurrence of previously treated
Name four risk factors for Peritonitis
End Stage Liver Failure
Serum Albumin <1.5
Nephrotic Syndrome
Peritoneal Dialysis
Name four causes of Secondary Peritonitis
Hirschsprungs perforation
Necrotising Enterocolitis
Appendicitis
Intussusception
What is the rule of 1/3s in Duodenal Atresia?
1/3 have trisomy 21
1/3 have cardiac anomalies
1/3 have associated malrotation
How does Duodenal Atresia present?
Often an Antenatal diagnosis with Polyhydramnios/double bubble
Post natal bilious vomiting
What investigation would you carry out for Duodenal Atresia?
AXR
Double bubble of gas in stomach and proximal duodenum
How is Duodenal Atresia managed?
Duodenoduodenostomy
Mechanical causes of bowel obstruction in Children can be remembered using (AIM)2. Describe this mnemonic
Adhesions Appendicitis Intussusception Incarcerated Hermia Meckels Midgut Volvulus
Give three Non Mechanical (Ileus) causes of bowel obstruction in Children
Appendicitis
Reduced blood supply
Hypokalaemia
Meconium Ileus (can go on to form mechanical Volvulus)
