Paediatrics Flashcards
A baby is born with a solitary mass over the right buttock.
Teratoma
A sacrococcygeal teratoma is a solid tumour found in new-borns, with girls being affected more than boys. It is a mixed germ cell tumour and may be associated with gastrointestinal or genital urinary symptoms.
A young child presents with fevers and a mass in the femur is noted and a diagnosis of malignancy is made. This malignancy is 30 times more common in white children compared to black children.
Ewing’s sarcoma
Ewing’s sarcoma is a tumour of the bone. It is usually found in long bones, particularly the femur. It may present with pain, fever and tenderness and sometimes pathological fractures. There is a poor prognosis.
It is 30 times more common in white children than black children.
A child of Nigerian parents presents with a unilateral tender cervical node. A diagnosis of malignancy is made with this malignancy being seven times more common in black children compared with white children.
Burkitt’s nasopharyngeal carcinoma
This genetic predisposition is contrary to the Burkitt’s nasopharyngeal carcinoma which is more common in black children than white (by sevenfold). This tumour has been associated with the Epstein-Barr virus and children present with sore throats, unilateral tenderness, cervical lymphnodes, trismus and weight loss.
An 8-month-old boy is referred with a unilateral swelling in the groin. On examination the right testis is fully descended but the left scrotum is rather underdeveloped and empty. On the medial aspect of the inguinal region was a smooth oval swelling which could be gently pushed into the upper scrotum.
Undescended testis
Undescended testes are commonly noticed by parents or found on routine infant checks. If there is tension in the spermatic cord when the testis is pushed gently into the scrotum, orchidopexy is necessary (best performed at around 2 years of age). Retractile testes, in contrast, are commonly palpable in the inguinal region initially, but come down very easily into the scrotal base with no tension. Orchidopexy is not indicated in these boys (referral to a paediatric surgeon recommended if there is any uncertainty).
A 2-year-old boy who had been born prematurely presents with a right-sided intermittent inguinal swelling. He is otherwise asymptomatic. On examination, both testes are fully descended. There were no obvious inguinal swellings evident but the spermatic cord on the right appeared thickened.
Indirect inguinal hernia
Inguinal hernias are commoner in boys born prematurely and the commonest type by far in children is the indirect hernia, caused by persisting patency of the processus vaginalis. Hernias are not always apparent on clinical examination but a thickened cord may be palpated. If this sign is present, together with a reliable parental history, herniotomy should be performed. The other groin should always be examined for contralateral hernia (bilateral hernias are commoner in premature babies).
A 6-month-old boy is noted to have a swelling in the left scrotum, which varies in size throughout the day. On examination there is a non-tender left scrotal swelling which transilluminates brightly. A normal testis is just palpable despite the swelling.
Hydrocoele
A hydrocoele is caused by the passage of peritoneal fluid down a patent processus vaginalis into the scrotum. The fluid may pass back into the peritoneal cavity and therefore variation in size of the hydrocoele is typical. It is often transilluminable. The processus vaginalis may close spontaneously and surgery is delayed until the child is around 3-years-old (unlikely to close spontaneously after this age).
A 4-month-old boy presents with irritability and unilateral testicular swelling. His temperature is 38°C and the testis is enlarged, red, firm and tender. Ward testing of his urine shows protein, nitrites and leucocytes (subsequent microbiology report shows growth of coliforms).
Epididymo-orchitis
Urinary tract infection (UTI) in boys may present with epididymo-orchitis. Prompt treatment with intravenous antibiotics is required and the urinary tract should be investigated as an outpatient (ultrasound scan of the renal tract, followed by micturating cystourethrogram). Untreated UTI in small children may lead to renal cortical scarring. It is important to note that if testicular torsion cannot be excluded by clinical examination or if there is any uncertainty, scrotal exploration should be performed.
A 6-week-old baby who had been born prematurely developed abdominal distension, irritability and bilious vomiting. Groin examination had been overlooked but abdominal x ray showed gas in the scrotum.
Incarcerated inguinal hernia
The differential diagnosis of neonates with small bowel obstruction includes
Malrotation Meconium ileus Ileal atresia Ileal duplication cyst and Incarcerated inguinal hernia. Upper gastrointestinal contrast study is extremely useful in the investigation of bilious vomiting, particularly if malrotation is suspected - volvulus and total gut necrosis is a serious risk with devastating consequences if missed.
Examination of the groin is paramount and it is usually possible to reduce incarcerated hernias (sedation may be necessary). Incarceration is more common in premature babies as are bilateral hernias.
Inguinal hernias in children always require herniotomy.
An 8-month-old girl presents with a two day history of episodic abdominal pain. She had recently been passing loose stools and fresh blood had been seen in the last nappy. A tender mass was palpable in the right hypochondrium.
Intussusception
Intussusception affects older babies and toddlers, the classic presentation being that of episodic abdominal pain, ‘redcurrant jelly’ stool and sausage shaped mass.
A 3-year-old girl presents with a five day history of poorly localised abdominal pain. She was vomiting and had diarrhoea. She was febrile and her abdomen was distended. She did not co-operate well with abdominal examination but the right side appeared to be tender.
Perforated appendicitis
Appendicitis can occur in any age and may lead to diagnostic difficulty in small children. Perforation is common and may give rise to inflammatory mass and secondary small bowel obstruction.
An 8-year-old boy with cerebral palsy who had previously undergone an open fundoplication for gastro-oesophageal reflux presents with bilious vomiting. His abdomen was distended and minimally tender. Plain abdominal x ray showed multiple dilated small bowel loops.
Adhesional
Adhesional bowel obstruction may follow any abdominal procedure.
The risk following Nissen fundoplication is approximately 5%.
Small bowel obstruction in Crohn’s can be caused by extreme bowel wall thickening or strictures.
Antenatal history should be obtained as intestinal atresia and meconium ileus may be associated with dilated bowel and polyhydramnios (amniotic fluid swallowed in utero cannot get past the point of obstruction).
Necrotising enterocolitis typically occurs in premature babies and may lead to perforation, inflammatory mass and obstruction.
A four-year-old child is admitted to the Emergency Department. The child has been rushed to the unit by her grandparents who are looking after the child, as the parents are at a friend’s wedding overseas, and cannot be contacted.
The child is examined and investigations are performed. A provisional diagnosis of a possible ruptured appendix is made, and the surgical team are called. After further review, the surgical team request to speak to the child’s parents in order to obtain their authority to perform surgery. The child continues to deteriorate.
What is the most appropriate action in this case?
(Please select 1 option)
The surgeon accepts authorisation from the grandparents who state that they do not have parental responsibility
The surgeon asks that, as the parents are unable to be contacted, a call is made to social services
The surgeon declines to take the child to theatre, as they are unable to obtain parental authorisation
The surgeon performs surgery without authorisation in the child’s best interests
The surgeon speaks with the charge nurse in the Emergency Department who signs the consent form
The surgeon performs surgery without authorisation in the child’s best interests
A person with parental responsibility for them may give authorisation for treatment of a child who lacks capacity. In this scenario, the child’s parents are unavailable. The child is deteriorating, and it is an emergency situation. The surgeon may consider the views of the grandparents and staff caring for the child, but may lawfully act in the child’s best interest and treat the child in an emergency without authorisation.
This is consistent with the common law principles of the doctrine of necessity set out in the case of Re F [1990] 2 AC 1 and is consistent with ethical guidance published by the GMC in its booklet Consent: patients and doctors making decisions together at paragraph 79:
“When an emergency arises in a clinical setting and it is not possible to find out a patient’s wishes, you can treat them without their consent, provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition.”
A 4-day-old male baby is brought to the paediatric acute surgical ward with mild abdominal distension, bilious vomiting, refusing to feed, and failure to pass meconium after birth. Abdominal examination is unremarkable.
Plain abdominal x ray reveals dilated loops of bowel with fluid levels. A barium enema demonstrates a ‘conical appearance’ in the distal segment of the colon. The parents have been informed that the baby requires a rectal biopsy.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Anal atresia
Hirschsprung’s disease
Intestinal atresia
Meconium ileus
Necrotising enterocolitis
Hirschsprung’s disease
Hirschsprung’s disease is the absence of ganglion cells (congenital aganglionosis) in the neural plexus of the intestinal wall. The disease begins with the anus, which is always involved, and continues proximally for a variable distance. Both the myenteric (Auerbach) and submucosal (Meissner) plexus are absent, resulting in reduced bowel peristalsis and function.
Hirschsprung’s disease is more common in male than female babies. The delayed passage of meconium together with distension of abdomen following feeds and bilious vomiting are the usual clinical features.
Other pertinent clinical features include abdominal distension (which may cause the baby to breathe fast and grunt when breathing), constipation, and reduced feeding.
Plain abdominal x ray may demonstrate dilated loops of bowel with fluid levels.
Barium enema demonstrates a ‘conical appearance’ in the affected part due to the dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend.
The diagnosis, however, is frequently confirmed by rectal biopsy.
Rectal manometry is also an useful investigation which is performed in certain centres.
Surgery is the treatment of choice where the abnormal aganglionic section of colon is removed. The surgery is frequently a two-stage procedure with a colostomy being performed as a first stage, and a definitive procedure (end-to-end anastomosis of the unaffected segments of colon) being performed later in the first year of life.
A 10-month-old male baby with haemophilia is brought to the emergency department by his parents with a 36 hour history of intermittent episodes of inconsolable crying and vomiting. The parents say the baby’s stools are mixed with blood.
On examination, a sausage-shaped mass is palpable over the right side of abdomen. Per rectal examination reveals an empty rectum but blood is noticed on the glove of the examining finger.
From the options below choose the one which you think is the most likely diagnosis in this patient:
(Please select 1 option)
Infantile hypertrophic pyloric stenosis
Intestinal atresia
Intussusception
Meckel’s diverticulum
Meconium ileus
Intussusception
Intussusception is caused due to invagination of a segment of bowel into its adjoining lower segment. Mesentery and vessels may also become involved with the intraluminal loop and squeezed within the engulfing segment.
Although the precise aetiology is not clear intussusception is known to occur with greater frequency in children who have undergone recent abdominal surgery, either intraperitoneal or retroperitoneal operations. It may be due to early adhesions or focal oedema of the bowel wall, creating a lead point for the intussusception.
Intussusception is more common in boys and usually occurs under the age of 1.
Intussusception is associated with
Haemophilia Henoch-Schonlein purpura Haemangiomas and Gastrointestinal lymphomas. Clinical features of this condition include severe colicky abdominal pain (causing intermittent inconsolable cries with the child drawing up the legs) and vomiting. Between attacks, the infant may appear in good health.
The infant may pass redcurrant jelly stools and a sausage shaped mass is palpable on abdominal examination. Rectal examination may reveal blood.
The treatment plan, in the absence of signs of peritonism, should be to reduce the intussusception by using either a barium or air enema.
Ten per cent recur within 24 hours and so all patients should be admitted and observed.
If this fails or if there are signs of peritonism then surgery is indicated.
A 6-month-old baby presents with vomiting, blood-stained stools and irritability.
On examination he has a tense abdomen and draws his knees up with palpation.
What is the most appropriate action you should take for this baby?
(Please select 1 option)
Abdominal x ray
Check serum amylase
Give antibiotics
Refer to surgeons
Suppositories to relieve constipation
Refer to surgeons
This child has features to suggest intusussception.
The most appropriate course of action is to refer immediately for surgery.
Approaches to relieve the intusussception will initially entail attempts at air reduction and, if this fails, surgery.
Risk factors for intusussception include viral infection and intestinal lymphadenopathy.
