Paeds surgery Flashcards
Omphalocele vs Gastroschisis
Unlike omphalocele, Gastroschisis NOT HAVE a protective sac and the viscera are in acute danger
Tell me a sentence about each one
1) Omphalocele
2) Gastroschisis
3) Esophageal atresia
4) Imperforate anus
5) Congenital diaphragmatic hernia(CDH)
Look it up in paeds surgery note
Intussusception
- definition
- age range
Intussusception occurs when a proximal part of the bowel invaginates into a distal part, leading to a mechanical obstruction and bowel ischemia.
May occur at any age, but most commonly between 2 months and 2 years of age
One of the most common causes of bowel obstruction in childhood
Late sign of Intussusception
“Currant jelly stool” (usually a late sign): may be noticed in passed stool or during digital rectal examination
Intussusception-USS sign
Target sign
The most common site of Intussusception
Ileocecal invagination
Terminal ileum involving the ileocecal valve and extending into the ascending colon
Triad of Intussusception
Less than 15% of patients with intussusception present with the classic triad of abdominal pain, a palpable sausage-shaped abdominal mass, and blood per rectum!
Treatment of choice
Air (pneumatic) enema: treatment of choice
Contrast or pneumatic enema using ultrasound or fluoroscopy (best confirmatory test): interruption of contrast or air at site of invagination
The most common cause of SBO in children
Intussusception, alongside incarcerated hernia, is one of the most common causes of bowel obstruction in children! It is the most common cause of bowel obstruction in the first two years of life!
Osgood-Schlatter disease
- define
- clinical features
- cause
- treatment
Osgood-Schlatter disease is an avascular necrosis thought to arise from overuse of the quadriceps muscle during periods of growth.
This causes a traction apophysitis at the tibial insertion of the quadriceps tendon.
The most common symptom is anterior knee pain that worsens with exercise.
A tibial bump may be felt and can often be seen on x-ray. Treatment is usually conservative. Surgical excision is only necessary in severe and treatment-resistant cases.
What is the surgery for cryptorchidism, when should it be done
Surgery is recommended between 6–18 months of age.
Orchidopexy: exposure and fastening of the testicle to the scrotum
What are the complications of cryptorchidism
Testicular cancer
Infertility
Testicular torsion
Inguinal hernia
Treatment for hydrocele
Usually resolves spontaneously within 6 months of birth
Surgery- if within one year does not resolve
SCFE
- which age group
- risk factors
Slipped capital femoral epiphysis (Juvenile femoral head detachment…)
Peak incidence: 10–16 years (often occurs during a growth spurt)
Risk factors–>
Trauma
Obesity
Family history
Treatment of SCFE-3
Avoid weight bearing before stabilization
Urgent surgical internal fixation with pinning of the femoral head
Prophylactic fixation of the contralateral hip
Complications of SCFE
Avascular necrosis of the femoral head
Early hip osteoarthritis
Chondrolysis
Absent cremasteric reflex
High riding testicle
Why is the cremasteric reflex absent
Testicular torsion
Absent cremastertic reflex as the result of swelling obstructing the genital branch from the genitofemoral nerve.
Prehn sign: negative
Testicular torsion
Prehn sign: positive
Epididymitis
Very tender (difficult examination)
Positive Prehn sign
Positive cremasteric reflex
That is?
Epididymitis
Differential diagnosis of scrotal pain
Testicular torsion
Epididymitis
Testicular cancer
Torsion of testicular appendage (hydatid of Morgagni)
Blue-dot sign
Torsion of testicular appendage (hydatid of Morgagni)
The hydatid of Morgagni (appendix of the testes) is an embryological remnant on the upper pole of the testes or at the epididymis (the remnant of the Müllerian duct). This hydatid of Morgagni has the potential to rotate. The resultant symptoms resemble acute testicular torsion
Treatment for testicular torsion
Testicular torsion is a medical emergency and should be treated upon suspicion within 6 hours of the onset of symptoms to prevent loss of the testis.
Immediate surgical exploration of the scrotum with reduction (untwisting) and orchidopexy
Orchidopexy of the contralateral side is recommended
VUR- test of choice
Voiding cystourethrogram is the diagnostic test of choice for demonstrating urinary reflux and the severity of the disease.
What are the 2 most important risk factors for DDH
Family history and breech presentation
At which age does Barlow’s and Ortalani’s disappear
6 months +
Early and late signs of Hirschsprung’s disease
Early
Delayed passage of meconium
Distal intestinal obstruction: abdominal distention and bilious vomiting
Tight anal sphincter with explosive release of stools and air upon removal of the finger
Failure to thrive/poor feeding
Late
Chronic constipation with possible inability to pass gas
Gold standard diagnostic test for Hirschsprung’s disease
Rectal biopsy
Differential diagnosis of intestinal obstruction in neonates
Hirschsprung's disease Intestinal neuronal dysplasia (IND) Meconium ileus Meconium plug syndrome Congenital hypothyroidism
Complications for Hirschsprung’s disease
Hirschsprung enterocolitis (→ toxic megacolon)
Define Perthes disease
-peak age
Legg-Calvé-Perthes disease (LCPD, or Perthes disease) refers to idiopathic, avascular necrosis of the femoral head.
Peak incidence: 4–10 years
FABER test for Perthes test
FABER (Flexion, ABduction, and External Rotation) test elicits pain.
DDx for paediatric limp
Transient synovitis Septic arthritis Slipped capital epiphysis Legg-Calve-Perthes Developmental dysplasia of the hip HSP ARF NAI Trauma Malignancy
4–10 years of age
URI in recent weeks
Afebrile
Transient hip pain
What?
Transient synovitis
Acute onset of pain and fever.
Fever > 38.5° C
Child may refuse to bear weight
Laboratory ↑ CRP/ESR WBC > 50000 in synovial fluid Imaging Effusion on ultrasound Widened joint space on x-ray though unremarkable in early stages
Septic arthritis
10–16 years of age
Acute on chronic dull pain with antalgic gait
Afebrile
Vague hip and knee pain
Imaging: x-ray shows displacement of the femoral head
SUFE/SCFE
4–10 years of age
Insidious onset, pain may fluctuate with activity
Afebrile
Vague hip and knee pain
Legg-Calvé-Perthes disease
Asymptomatic during infancy
Inability to abduct the hip, hip pain, and limp later develop if uncorrected
Not clear but breech delivery, family history, and oligohydramnios seem to play a role
DDH
Transient synovitis
- what are the clinical features
- treatment
Transient synovitis (also known as toxic synovitis)
Nonspecific inflammation and hypertrophy of the synovial membrane
Unilateral and transient hip or groin pain
Recent upper respiratory tract infection in up to 50% of the patients
Treatment: conservative (i.e., NSAIDs)
Perthes severity classification(extra info)
Lateral pillar classification
What is the Kocher criteria
- what is it used for
- what are the things in the criteria
Distinguishes septic arthritis from transient synovitis in a child with an inflamed hip.
Non-weight-bearing
Temp > 38.5°C / 101.3°F
ESR > 40mm/hr
WBC > 12,000 cells/mm3
What is Meckel diverticulum
A Meckel diverticulum is the most common congenital anomaly of the gastrointestinal tract and is caused by an incomplete obliteration of the omphalomesenteric duct.
It is generally about 2 inches long and located 2 feet proximal to the ileocecal valve.
It is seen in 2% of the general population and is more common in males
What are the rule of two’s with Meckel’s diverticulum
The rule of two’s: Meckel diverticulum occurs in 2% of the population, 2% are symptomatic, mostly in children < 2 years, affects males twice as often as females, is located 2 feet proximal to the ileocecal valve, is ≤ 2 inches long, and can have 2 types of mucosal lining(Pancreatic and gastric–> that the two types of cells)
Meckel’s diverticulum-True or false
True diverticulum
What is the most common presentation of Meckel’s diverticulum
Painless lower gastrointestinal bleeding (most common presentation)
Haematochezia
However many of the kids are asymptomatic
What imaging would you do for Meckel’s scan
Meckel scintigraphy scan (Meckel scan): a noninvasive nuclear medicine imaging technique using radiolabelled technetium (99mTc), which is preferentially absorbed by the gastric mucosa and can identify ectopic gastric mucosa
Double bubble sign
Duodenal atresia
Malrotation procedure
Ladd’s procedure
NEC- what will you see on AXR
1) Dilated bowels
2) Edematous walls
3) Mostly ominously air(pneumatosis intestinalis)
Painless GI bleeding
Meckel’s diverticulum
The most common cause of gastric outlet obstruction in paeds
- When is the peak incidence
HPS(hypertrophic pyloric stenosis)
Peak incidence: 3–6 weeks of age (rarely presents after 12 weeks of age)
HPS leads to what electrolyte disturbance
Constant vomiting leads to hypokalemia and hypochloremic metabolic alkalosis
What sign can be seen in a baby who has HPS
An enlarged, thickened, “olive-shaped”, non-tender pylorus (diameter of 1–2 cm) should be palpable in the epigastrium
Which abx ingestion linked with HPS
Macrolide antibiotics
Erythromycin and azithromycin
State the clinical features of a baby who has HPS
Frequent regurgitation progressing to projectile, nonbilious vomiting immediately after feeding
An enlarged, thickened, “olive-shaped”, non-tender pylorus (diameter of 1–2 cm) should be palpable in the epigastrium
A peristaltic wave, moving from left to right, may be evident in the epigastrium
“Hungry vomiter”: demands re-feeding after vomiting, demonstrates a strong rooting and sucking reflex, irritable
If left untreated: dehydration, weight loss, failure to thrive
Differential diagnosis of newborn vomiting
1) HPS
2) Benign GERD
3) GERD
4) Midgut volvulus or intestinal malrotation
5) Gastroenteritis
6) Congenital adrenal hyperplasia with salt loss
State some treatments for GERD(conservative)
https://www.rch.org.au/clinicalguide/guideline_index/Gastrooesophageal_reflux_in_infants/
What is the treatment of choice for HPS
Ramstedt pyloromyotomy
Definition for intussusception and main site it occurs at
Intussusception is the invagination (telescoping) of a proximal segment of bowel into the distal bowel lumen. The commonest site is a segment of ileum moving into the colon through the ileo-caecal valve. This process leads to bowel obstruction, venous congestion and bowel wall ischaemia. Perforation can occur and lead to peritonitis and shock.
Triad of intussusception
The triad of intermittent abdominal pain, palpable abdominal mass and red currant jelly stools occurs in only 1/3 of children
Most cases are idiopathic (90%)
Vomiting is usually a prominent feature (but bile stained vomiting is a late sign and indicates a bowel obstruction)
Management of intussusception
Do History and examination
ABCD
Involve the surgical team early
Keep nil orally
Pass nasogastric tube if bowel obstruction or perforation on AXR, or if planning transfer by air
Children with intussusception can decompensate while undergoing an ultrasound and/or air enema. Ensure medical or nursing escorts are capable of providing resuscitation if needed
Blood group and hold prior to theatre
Treatment for intussusception
Contrast / gas enema–> The enema may be used diagnostically and therapeutically in consultation with a surgical team
There is a small risk of bowel perforation and bacteraemia during the gas enema.
Testicular torsion is USS needed for diagnosis
An ultrasound is not recommended prior to referral
Chaperone for scrotal exam
Absent cremasteric reflex
Acute scrotal pain ddx-5
Testicular Torsion
Incarcerated Hernia
Torsion of Testicular appendage
Epididymo-orchitis
Testicular or Epididymal rupture
Hydrocele
Varicoceole
Idiopathic scrotal oedema
Tumour/ Leukaemia
Hydrocele is?
-treatment?
collection fluid in scrotum due to patent processus vaginalis
Resorb and tunica vaginalis closes spontaneously in the first year- 90% by 2 years
Consider surgical referral for repair if present after 2 years of age
Hirschsprung’s disease
- what?
- where does it happen the most
- age group
(congenital aganglionic megacolon)
the rectosigmoid region, which fails to relax leading to functional intestinal obstruction.
Hirschsprung’s disease- what the newborn not do
The first sign of the disease is often when a newborn fails to pass meconium within 48 hours after birth and/or shows symptoms of gastrointestinal obstruction (e.g., bilious vomiting and abdominal distention).
What is the severe complication of Hirschsprung’s disease
-what will you get in it
Hirschsprung’s enterocolitis
A severe complication of the disease is Hirschsprung enterocolitis, which presents with abdominal pain, fever, and foul-smelling and/or bloody diarrhea. If not treated promptly, this condition can progress to e.g., toxic megacolon or sepsis.
Which genetic syndrome kids are a risk of Hirschsprung’s disease
Down syndrome
Gold standard for Hirschsprung’s disease
Rectal biopsy–> Absence of ganglion cells in an adequate tissue sample
Differential diagnosis of intestinal obstruction in neonates
Hirschsprung’s disease
Intestinal neuronal dysplasia (IND)–> too much ganglion cells(hyperganglionosis) as compared to aganglion in HD
Meconium ileus–> Delayed passage of meconium(could be CF)
Meconium plug syndrome
Congenital hypothyroidism
Treatment of Hirschsprung’s disease
Surgical treatment is usually performed in two stages:
1) First stage: diverting colostomy to relieve the dilated bowel.
2) Second stage:
- Resection of the aganglionic segment
- Anastomoses of the normal ganglionic colon segment to either the distal modified rectum or normal (unmodified) distal rectum.
- Preservation of internal anal sphincter function is of the utmost importance.
Hirschsprung’s enterocolitis
-presentation and treatment
Hirschsprung enterocolitis (→ toxic megacolon)
Presentation
Abdominal pain
Fever
Foul-smelling and/or bloody diarrhea
Further complications: If not treated early, sepsis, transmural intestinal necrosis, and perforation are possible.
Management: IV fluid resuscitation, broad-spectrum IV antibiotics (anaerobic and aerobic coverage), rectal irrigations, with a possible colostomy
Another common ddx for appendicitis in children
Meckel’s diverticulum
Meckel’s diverticulum presents with hematochezia why?
ectopic tissue–> Pancreatic and gastric–> if they are active they will start producing enzymes–> hence they start bleeding–> Haematochezia
Gastric mucosa is the most common heterotopic mucosa (∼ 60%). Other types include pancreatic, colonic, and duodenal mucosa.
IX for intussuscpetion-4-why?
- Plain Abdo Xray to rule out perforation or obstruction . look for target sign
- USS abdo - ix of choice if suggestive hx but no palpable mass
- Blood tests: glucose, FBC, U&Es , group and hold
- Air enema - both diagnostic and therapeutic
Management of intussusception-6
- Secure IV access for all patients who are suspected to have intussusception
- Most children will require fluid resuscitation with IV boluses of 20mls/kg normal saline before radiological investigations
- Give adequate analgesia (usually morphine)
- Keep nil orally
- Pass nasogastric tube if bowel obstruction or perforation on AXR
- Consider IV antibiotics before air enema (discuss with surgeons)
Congenital undescended testes
Review in 12 weeks after birth–>
1) If not come down–> orchidopexy at 6-12 months age
2) if by then it has come down–> yearly review
When would you be worried about undescended testes
6 months
