Paediatric surgery and trauma Flashcards
Appendicitis
Commonest surgical emergency in children - lifetime risk 8.5% for boys and 6.7% for girls. obstruction of the lumen causes distension, ischemia, infection and inflammation
Stages of appendicitis
Acute>suppurative>Gangrenous>perforation> abscess
In older children adhesions may form between the appendix and the surrounding bowel and omentum
Symptoms of an appendicitis
Initially colicky abdominal pain which moves from the umbilicus to the RIF - this can vary on appendix position. Can also display anorexia or nausea after onset of pain. vomiting may happen but frequent bilious vomiting indicates bowel obstruction. mucusy Diarrhoea is also seen in children
Signs in appendicitis
Unwell, pale or flushed. movement is painful with explicit guarding of the right side. Mild pyrexia may be present but will be much higher if peritonitis is present. dehydrated. PR is generally not needed if there is a firm diagnosis
Investigations in acute appendicitis
50% of children will show raised WCC. Urine may be positive for blood and protein due to bladder irritation. AXR will revel a faecolith in 20% of cases. abdo USS can be very effective and specific depending on the centre
Management of acute appendicitis
Surgery should be performed immediately but if there is peritonitis adequate resuscitation should be performed first to stabilise the child.
Right Lanz incision is generally used in children as it has a better cosmetic result than Mcburney’s
Appendicitis in the young child
Can be hard meaning the disease may be very advanced on presentation – 80% are perforated by the time of operation. All attempts must be made to make sensitive examination possible so that signs are not missed
Intussusception
An invagination of bowel into itself - cutting off the blood supply causing necrosis.This can occur between 3months and 3yrs, most common between 3 and 10months – 2x risk in boys
Symptoms of intussusception
Sudden onset abdo pain causing screaming and leg flexion lasting 5-20mins. Vomiting is common, bile stained if persistent. half of cases have mucus and blood (red current jelly stool) passage PR.
Causes of intussusception
1/3 will have a preceeding viral illness (GI or URTI) which causes inflammation of the peyer’s patches in the terminal ileum
2% of cases start with appendix, meckels or polyp
Haematuria or rash could point to co-existing HSP
Investigation of intussusception
If diagnosis is not firm clinically then AXR or USS can be useful (target sign).
Contast enema can be used as well
Non-operative Treatment of intussusception
Air insufflation PR is cheap, safe and up to 95% effective. This has a 10% reccurance rate, and should be used cautiously if there is marked small bowel distension or rectum involvement - if there is reccurance air insufflation can be tried again
Operative treatment of intussusception
Surgical management should be used if other methods have failed, there is perforation or peritonism. Access is gained with a transverse right para-umbilical incision and resection is sometimes needed
Infantile hypertrophic pyloric stenosis
Most common surgical cause of vomiting - 0.01-0.025% incidence 5x risk for males but possibly greater genetic element for female patients
Olive sized pyloric tumour palpable in the upper right quadrant
Symptoms of pyloric stenosis
Frequent and projectile vomiting of milk from the first weeks of life - duration of vomiting controls level of dehydration – forceful, bile free vomit and visible peristalsis are pathognomonic
Pre-operative management of pyloric stenosis
Electrolyte balance and dehydration should be properly assessed and managed – classically will have metabolic alkalosis, hypochloremia, hyponatreamia, hypokalaemia. Initial management is rehydration
Operative management of pyloric stenosis
Pyloromyotomy - right transverse, upper abdominal incision – the pylorus is then debulked – feeding can be started the next morning starting with water. complications – vomiting (10%), wound infection or dehiscence
Investigations of pyloric stenosis
USS confirms the diagnosis in 95% of cases - lumen is <8mm.
Only needed when a pyloric tumour cannot be felt.
Barium meal can also be used
Testicular torsion - incidence and presentation
35% of acute scrotal presentations – total necrosis in 6hrs. Occurs most in first month of life and teenage years. sudden onset severe scrotal pain with N&V+low abdo pain
No fever or urinary symptoms
Torsion of the testicular appendages - presentation
42% of acute scrotal presentations – mullerian duct produce appendages which can tort giving rise to gradual (24hrs) scrotal pain without autonomic symptoms
Epididymo-orchitits (6)
Infection from blood or urinary reflux causing gradual onset of pain in pubertal/postpubertal boys – may have spread to the lower abdomen or loin, dysuria or discharge, tender & swollen epididymis, oedematous or erythematous scrotum – testicle is usually normal
Accounts for 10% of acute scrotal presentations
Idiopathic scrotal oedema
Common and likely unreported – onset and offset sudden
painless oedema of the scrotal skin with erythema
otherwise healthy and no treatment is required
Traumatic chest injuries in children
Rib cage is springy so organs can be damaged without fractures occuring – cannot assume the organs avoided damage just because no ribs were broken
Testicular torsion - examination and treatments
testicle is high, swollen and tender – reactive hydrocele and skin oedema gradually obscures the contents. Immediate surgery is needed to untort and fix (both testes) or remove dead one
Torsion of testicular appendages - exam and treatment
a small tender nodule may be palpated (blue dot sign) before oedema, and rarely, hydrocele develops – USS or surgery is needed to confirm
If clear can be managed conservatively or removed
Interssuspection - examination
In 60% of cases a sausage shaped abdominal mass is present in the upper right quadrant (or rarely around the anus). If advanced they may present with peritonitis and shock
Hypospadias
The urethra opens on the ventral surface and in severe cases can lead to ventral curvature (chordee). 3/1000 births and corrective surgery is performed before 2yrs using the foreskin for reconstruction.
