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Year 4 Paediatrics > Paediatric Surgery > Flashcards

Paediatric Surgery Flashcards

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1
Q

Give 5 causes of acute scrotal pain

A 
Testicular Torsion
Irreducible Hernia
Torsion of Testicular Appendage
Epididymo-Orchitis
Testicular/Epididymal Rupture
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2
Q

How does Torsion of Testicular Appendage present?

A

Prepubertal child
Minimal pain at rest
Tenderness of upper pole
Blue dot on upper hemiscrotum

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3
Q

How does a Testicular/Epididymal Rupture present?

A

Pain and swelling may be delayed
Tender on palpation
Bruised appearance

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4
Q

Give four causes of non painful testicular swellings in Children

A

Hydrocoele
Varicocoele
Idiopathic Scrotal Oedema (can extend into groin)
Tumour/Leukaemia

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5
Q

Name five red flags for acute scrotal pain/swelling

A 
Severe Sudden Pain
Impaired Gait
High Riding
Non Reducible
Irritable
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6
Q

How should Acute Scrotal Pain/Swelling be investigated?

A

Irreducible hernia and Torsion need to be excluded first
USS and Doppler
Urinalysis MC and S

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7
Q

If suspecting that’s the Acute scrotum will require surgical management, how should you prepare?

A

Fasting/Clear Fluids
Consider NG tube if bowel obstruction
Adequate pain relief

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8
Q

How is a Hydrocoele managed?

A

90% resolve within first two years

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9
Q

How is a Varicocoele managed?

A

Outpatient surgery

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10
Q

How is Torsion of Testicular Appendage managed?

A

Supportive only

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11
Q

Give 5 causes of Acute Pancreatitis

A 
Abdominal Trauma
Systemic Infection (Mumps, Rubella)
Medications (Azathioprine, Steroids)
Metabolic (CF)
Hereditary
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12
Q

How would Acute Pancreatitis present?

A

Abdominal Pain
Vomiting
Abdominal Tenderness
Guarding

Maybe lying on side with hips flexed

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13
Q

How would Acute Haemorrhagic Pancreatitis present?

A

Life threatening shock
ARDS
DIC
Grey Turners and Cullens Sign

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14
Q

What investigations would you do for Acute Pancreatitis?

A

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)

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15
Q

How is Acute Pancreatitis managed?

A

IV Hydration
Pain Control
Bowel Rest

If complicated - surgery

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16
Q

How is Chronic Pancreatitis managed?

A

Could consider Pancreatectomy

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17
Q

When does Orchitis occur in isolation?

A

Only normally with Mumps

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18
Q

What is Mumps?

A

Unilateral or bilateral orchitis with fever, 4-8d after Parotitis
Self resolving but can lead to atrophy and infertility

Notifiable disease

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19
Q

Describe the pathophysiology of Epididymorchitis

A

Extension of infection from Lower Urinary Tract, either Enteric or STI (In older children)

UTI - E.Coli, Proteus Saprophyticus, Klebsiella
STI - N.Gonorrhoea, Chlamydia

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20
Q

How does Epididymitis present?

A

Unilateral scrotal pain and associated swelling
Dysuria
Discharge
Fever

?Reactive Hydrocoele, Prehn’s Sign

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21
Q

How should Epididymitis be investigated?

A

Urine dipstick MC and S
If relevant, first catch NAAT
FBC and CRP
USS (will require renal USS if second episode)

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22
Q

How is Epididymitis managed?

A

Bed rest and scrotal support

Empirical Antibiotics - Enteric requires Ofloxacin, STI requires Ceftriaxone Doxycycline and potentially Azithromycin

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23
Q

Testicular Torsion occurs when spermatic cord twists within Tunica Vaginalis. Describe the pathophysiology

A

Impaired arterial flow, venous return and subsequent venous congestion and oedema

More vulnerable if bell clapped (lacks attachment to tunica)

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24
Q

What is an extravaginal torsion?

A

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

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25
Q

Give three risk factors for Testicular Torsion

A

Age 12-25
Previous Torsion
Undescended Testes

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26
Q

What are the clinical features of Testicular Torsion?

A

Sudden onset unilateral scrotal pain
Nausea and vomiting
Referred abdominal pain
Absent Cremasteric Reflex

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27
Q

How would you manage Testicular Torsion?

A

Immediate surgical exploration within 6 hours

Analgesia, Abx, Fluids

Bilateral Orchidopexy

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28
Q

What is Balanitis Xerotica Obliterans?

A

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

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29
Q

How does BXO present?

A

Ballooning of foreskin in Micturition

Irritation, dysuria, haematuria from scarring

OE - white fibrotic and scarred with difficulty in meatus visualisation

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30
Q

How is BXO managed?

A

Circumcision and subsequently histopathology to confirm diagnosis

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31
Q

What is Cryptorchidism?

A

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)

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32
Q

What diagnosis would you consider with bilateral Cryptorchidism?

A

Androgen Insensitivity or Disorder of Sex Development

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33
Q

Give three risk factors for Cryptorchidism

A

Prematurity
Low Birth Weight
FH

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34
Q

How should you examine an undescended teste?

A

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

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35
Q

If you suspected that Disorder of Sex Development was the cause of Cryptorchidism, how would you manage?

A

Senior paediatrician referral within 24 hours (at risk from salt losing crisis in CAH)

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36
Q

How would you manage Cryptorchidism?

A

Continue to review, if undescended at 6-12m then operate
Palpable - Orchidopexy via Groin Incision
Non Palpable - 2 stage procedure for Intra-abdominal

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37
Q

What are the complications with Undescended Testes?

A

Impaired Fertility (due to temperature difference impairing spermatogenesis)
Torsion
Testicular Cancer

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38
Q

What is Hirschsprung’s disease?

A

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

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39
Q

What are the three types of Hirschsprung?

A

Short Segment (85%) - Aganglionosis restricted to rectosigmoid

Long Segment (10%) - Aganglionosis spreads to splenic flexure

Total Colon (may also involve small bowel)

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40
Q

Describe the pathophysiology of Hirschsprungs

A

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

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41
Q

What is the classical triad of Hirschsprungs?

A

Failure to pass Meconium after 48 hours
Abdominal Distension
Bilious Vomiting

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42
Q

What would you see OE in Hirschsprungs?

A

Dilation of proximal bowel (palpated mass in LLQ)

Empty rectal vault

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43
Q

Give two differentials for Hirschsprungs and how you would rule them out

A

Meconium Plug
Meconium Ileus

Water Soluble Enema

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44
Q

What investigations would you do in Hirschsprungs?

A 
Contrast Enema (Distinguishes transition zone and rectal diameter)
Rectal Suction Biopsy (Gold Standard)
45
Q

What is a Rectal Suction Biopsy?

A

Simple bedside procedure with antibiotic cover
Submucosa tested for Aganglionic cells
Biopsy stained with acetylcholinesterase

46
Q

How is Hirschsprungs managed?

A

Initial - IV Abx, NG, Bowel Decompression

Definitive - Surgery (resection of aganglionic bowel and connecting it to dentate line)

47
Q

One of the main complications of Hirschsprungs is Hirschsprung Associated Enterocolitis. How does it present?

A

Fever, Vomiting, Diarrhoea, Abdominal Tenderness

Managed with bowel decompression and broad spectrum abx

48
Q

Define Intussusception

A

Telescoping of one part of bowel into another

Proximal bowel is intussusceptum while distal is intussucipiens

49
Q

Describe the pathophysiology of intussusception

A

90% Ileocolic

Normally idiopathic but underlying pathologies can create a lead point:
Rotavirus, Meckels, Polyps, Lymphoma

50
Q

How does a child with Intussusception present?

A

Sudden onset inconsolable crying
Draw knees to chest
Vomiting
Later - Red Currant Jelly Stools (Blood and Mucous)

51
Q

What would you see OE of a child with Intussusception?

A

Palpable sausage mass in RUQ
Peritonism
Presence of bowel sounds

52
Q

How would you investigate Intussusception and what would you see?

A

AXR - distended small bowel loops (any perforation - riglers)

Abdo USS - high sensitivity, doughnut/target on transverse plane

Contrast Enema (can be therapeutic)

53
Q

How is Intussusception managed?

A

May require NG decompensation and IV fluids

Air/ Contrast Enema

Failing the above, manual reduction via surgery and removal of necrotic bowel

54
Q

What happens if Intussusception is left untreated?

A

Obstruction
Perforation
Dehydration and Shock

55
Q

What is Pyloric Stenosis?

A

Progressive hypertrophy of pylorus causing outlet obstruction with unknown aetiology, within first 4-6 weeks of life

56
Q

How does Pyloric Stenosis present?

A

Non bilious projectile vomiting after feeds
Potentially Haematemesis
Weight loss and dehydration

57
Q

What would you see OE in Pyloric Stenosis?

A

Visible Peristalsis and Olive Shaped Mass in feeding

58
Q

Give four differentials for Pyloric Stenosis

A

Gastroenteritis
GORD
Food Allergy
Malrotation (Bilious)

59
Q

How would you investigate Pyloric Stenosis?

A

Test feed with NG

USS gold standard

Blood Gas (HYPOkalaemic, Hypochloraemic, metabolic alkalosis)

60
Q

What are the USS parameters for Pyloric Stenosis?

A

Wall thickness >3mm
Length>15mm
Diameter>11mm

61
Q

How is Pyloric Stenosis managed?

A

Rehydrate using UHL policy
Stop oral feeding and pass NG (aspirating four hourly)
Ramstedts Pyloromyotomy

62
Q

What is Ramstedt’s Pyloromyotomy?

A

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

63
Q

Describe the pathophysiology of Acute Appendicitis

A

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

64
Q

Give three risk factors for Acute Appendicitis

A

Family History
Caucasian
Summer Season

65
Q

Describe the classical presentation of Acute Appendicitis

A

Dull peri umbilical pain becoming sharp and migrating to RIF

Associated vomiting/anorexia/nausea

66
Q

Describe two clinical signs in Acute Appendicitis

A

Rovsing’s Sign - RIF pain on palpation of LIF

Psoas Sign - RIF pain on hip extension (if retrocaecal)

67
Q

Describe the atypical presentation of appendicitis in Children

A

Diarrhoea
Urinary Symptoms
Left sided pain

If <6y and pain ongoing >48h then likely perforated

68
Q

Appendicitis is generally a clinical diagnosis. What investigations could be done?

A

Urinalysis
Routine bloods (inc CRP)
hCG where appropriate
USS

69
Q

What is the scoring system for Appendicitis?

A

Shera Score

<3 is low risk, >3 is high risk

70
Q

How is Acute Appendicitis managed?

A

Laproscopic Appendicectomy (via Lanz Incision)

If abscess then give Abx first before Appendicectomy

Specimen sent for histopathology (check for Meckels)

71
Q

Name three complications of Appendicitis

A

Perforation
Appendiceal Mass
Pelvic Abscess

72
Q

Define Malrotation of the gut

A

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

73
Q

What is a consequence of Malrotation?

A

Results in a narrow based mesentery prone to volvulus

74
Q

How is Malrotation corrected?

A

Surgically corrected with Ladd’s Procedure (+ Appendicectomy)

75
Q

What is Volvulus secondary to Malrotation?

A

High intestinal obstruction at duodenal level, followed by necrosis of whole midgut

76
Q

How does Volvulus present in Children?

A

Bile stained vomit
Sunken tender abdomen (AKA Scaphoid)
Bloody stools
Circulatory Collapse

77
Q

How is suspected Volvulus investigated?

A

AXR (‘double bubble’ and gas elsewhere in abdomen)

Upper GI contrast study

78
Q

If in a reparative laparotomy for Malrotation the bowel is not viable, what should be done?

A

Second look laparotomy after 24 hours

Weigh up risks of massive intestinal necrosis, or short gut syndrome (+ lifelong TPN)

79
Q

Define Meckels Diverticulum

A

Ileal remnant of vitellointestinal duct, containing ectopic gastric mucosa or pancreatic tissue affecting 2% of population

80
Q

How does Meckels Diverticulum present?

A

Often asymptomatic

Severe rectal bleeding, intussusception, Volvulus, Diverticulitis

May mimic appendicitis

81
Q

How is Meckels Diverticulum investigated?

A

Technetium scan shows increased uptake by gastric mucosa

82
Q

How is Meckels Diverticulum managed?

A

Surgical resection

83
Q

Diaphragmatic hernias are often diagnosed in antenatal screening. How do they present?

A

Respiratory distress or poor response to rescucitation
On examination, apex beat is displaced to right
Poor air entry on left

84
Q

Where does a diaphragmatic hernia normally herniate?

A

Posterolateral foramen of diaphragm

Commonly on left

85
Q

How is a diaphragmatic hernia investigated?

A

CXR

AXR

86
Q

How is a Diaphragmatic Hernia managed?

A

Stabilised its NG and suction to prevent bowel distension in intrathoracic cavity
May require ET intubation and surfactant

Definitive surgical repair

87
Q

Give two complications of Diaphragmatic Hernia

A

Vigorous rescucitation may cause pneumothorax

Pulmonary Hypoplasia

88
Q

Umbilical hernia affects a significant proportion of children. Describe the pathophysiology.

A

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

89
Q

Give three risk factors for Umbilical Hernias

A

Premature
Ehlers Danlos
Hypothyroid

90
Q

How do Umbilical Hernias presents?

A

Reducible painless bulge at umbilicus, becoming more prominent on straining/crying

Incarcerated - painful and irreducible
Strangulated - Vomiting and constipation

91
Q

How would you manage an Umbilical Hernia ?

A

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

92
Q

What is an Epigastric Hernia?

A

Occurring in the midline, anywhere from Xiphoid Process to Umbilicus
Mostly preperitoneal fat

93
Q

How do Epigastric Hernias present?

A

Mass in Epigastric which commonly enlarges

Associated with abdominal wall pain and tenderness

94
Q

How should Epigastric Hernias be managed?

A

Do not repair on their own

Repair with elective day case

95
Q

What is the main differential for an Epigastric Hernia?

A

Divarification of Recti (Weakness in Linea Alba)

96
Q

Describe the anatomy of Inguinal Hernias

A

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)

97
Q

How do Inguinal Hernias present?

A

Bulge in groin or swelling in scrotum

Most commonly incarcerated in children

Torted ovary May pass through patent processus (swollen labia unilaterally)

98
Q

Inguinal Hernias are a clinical diagnosis. What can see OE?

A

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

99
Q

Any symptomatic Inguinal Hernias require immediate reduction. How are asymptomatic patients managed?

A

Neonates - before discharge
<6m - operation on next list
Older - elective

Can be Laproscopic or through groin incision

100
Q

State the three different types of Peritonitis

A

Primary - no underlying infective cause(eg Nephrotic)

Secondary - Bowel Perforation, Abscess formation, Ischaemic necrosis

Tertiary - recurrence of previously treated

101
Q

Name four risk factors for Peritonitis

A

End Stage Liver Failure
Serum Albumin <1.5
Nephrotic Syndrome
Peritoneal Dialysis

102
Q

Name four causes of Secondary Peritonitis

A

Hirschsprungs perforation
Necrotising Enterocolitis
Appendicitis
Intussusception

103
Q

What is the rule of 1/3s in Duodenal Atresia?

A

1/3 have trisomy 21
1/3 have cardiac anomalies
1/3 have associated malrotation

104
Q

How does Duodenal Atresia present?

A

Often an Antenatal diagnosis with Polyhydramnios/double bubble

Post natal bilious vomiting

105
Q

What investigation would you carry out for Duodenal Atresia?

A

AXR

Double bubble of gas in stomach and proximal duodenum

106
Q

How is Duodenal Atresia managed?

A

Duodenoduodenostomy

107
Q

Mechanical causes of bowel obstruction in Children can be remembered using (AIM)2. Describe this mnemonic

A 
Adhesions
Appendicitis
Intussusception
Incarcerated Hermia
Meckels
Midgut Volvulus
108
Q

Give three Non Mechanical (Ileus) causes of bowel obstruction in Children

A

Appendicitis
Reduced blood supply
Hypokalaemia
Meconium Ileus (can go on to form mechanical Volvulus)

Year 4 Paediatrics (15 decks)

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