Paeds surgery Flashcards
Inguinal hernia pathophysiology
failure of oblitration of processus vaginalis
- with hernation of abdominal contents into peritoneal sac
Types of inguinal hernia
Direct (directly through the fascia)
Indirect (through deep inguinal ring)
M:F of inguinal hernia
9:1
Right to left ratio of inguinal hernia
3:1
Mx of inguinal hernia
herniotomy - high ligation of processus
When to manage inguinal hernia in prematures
before d/c from NICU
When to manage inguinal hernia in infants
within 1 mo
When to manage inguinal hernia in children
elective
Hydrocele
fluids enter peritoneal sac, but too narrow for abdo content to do so
How to differentiate between a hydrocele and hernia
Hydrocele:
- slow to fill, slow to empty
- can get above the swelling
- it transilluminates
Cryptorchidism
undescended testes
Mx of unilateral /bilateral undescended testes (UDT) that is palpable
orchidopexy
Mx of unilateral UDT which is impalpable
laproscopy
orchidopexy
Mx of bilateral UDT which is impalpable
make sure it’s a boy!
Hypertrophic pyloric stenosis Dx
- test feed clinically
- VBG:
metabolic hypochloraemic alkalosis - U/S
How to test feed for Hypertrophic pyloric stenosis
- Pass a nasogastric tube
- Examine from the LEFT
- Feed/put air down NG tube
- Watch for visible peristalsis
- Feel for the tumour
Phimosis
inability to retract foreskin
Definite indications for circumcision
-
pathological phimosis
- BXO
BXO
Balanitis Xerotica Obliterans
lichen sclerosis of male genitalia; stenosis of foreskin making harder to pee
Intussusception
Most common abdo pain in 3 months - 2 yrs
Telescoping of bowel into more distal bowel
Sx of intussusception
Partially formed stool Redcurrent jelly stool Vomiting (clear then becomes more bilious) Colic abdo pain Mass Infarction Peritonitis
Ix for intussusception
- Abdo US (diagnostic)
- AXR
- if in doubt, contrast enema
Abdo US findings for intussusception
Transverse = Doughnut / target sign
Longitudinal = tubular mass
AXR findings for intussusception
Dilated proximal bowel
Multiple fluid levels
Mx of intussusception
Drip and suck resus
Air enema < 120 mmHg
Laparotomy reduction/resection
Types of intussusception
Primary
Secondary
Primary Intussusception pathophysiology
Secondary to lymphoid hyperplasia of Peyer’s patches in terminal ileum following a viral infection
Secondary intussusception
secondary to pathological lead point eg Meckel’s diverticulum
- suspect in older children and recurrent episodes
Normal rotation of gut
In utero, gut returns to abdo cavity at 10 wks and rotates 270 degrees counterclockwise
Abnormal rotation of gut in utero
<270 degrees rotation
Consequence of Abnormal rotation of gut in utero
- shortness base of the mesentery
- predisposes to mid-gut volvulus
Malrotation presentation
- presents within 1st yr
- sudden onset bile stained vomiting
- abdo pain
Ix for malrotation
AXR
Upper GI contrast
AXR findings of malrotation
double bubble
small amount of air distally
not good for Dx
Upper GI contrast finding of malrotation
corkscrew appearance due to obstruction of flow of contrast
Mx of malrotation
Ladds procedure:
- urgent laprotomy
- division of adhesional bands allowing widening of small mesentery
Extra abdominal causes of abdo pain
Hernia Testes Hip Vertebrae URT LRT
Differentials for RIF pain
Appendicitis
Mesenteric adenitis
Psoas abscess
Apparently pneumonia too but meh
Mesenteric adenitis
Central abdo pain and URTI
Inflamed abdominal lymph node
Differentials for sudden severe testicular pain
Testicular torsion
Hydatid of morgagne
Epididymo-orchitis
Idiopathic scrotal oedema
Mx of testicular torsion
Emergency surgical scrotal exploration
Bilateral orchidopexy
Hydatid of morgagne
Torsion of small outpouching of testes
May see small dark blue spot
Hirschsprung’s disease pathophysiology
- Neural crest cells dont migrate fully to form the myenteric plexus, which supplies the intestine.
- also absence of ganglion cells-> persistent overstimulation of nerves in the affected region, resulting in contraction
Sx of hirchsprung’s disease
- vomiting
- constipation (failure of passing meconium)
- explosive stool
Dx of hirchsprung
- suction biopsy at the distal end; no ganglion cells
Mx of Hirchsprung disease
- Rectal washouts initially,
- Anorectal pull through procedure
Gastroschisis
defect lateral to umbilicus
abdo content outside abdo, and not covered by peritoneum
Omphalocele/exomphalos
defect within umbilicus
abdo content outside abdo
but COVERED by peritoneum
ass with trisomies
What is meconium ileus
Delayed passage of meconium
Meconium ileus cause
Majority cystic fibrosis
Meconium ileus mx
Initially: PR contrast ( may dislodge meconium plugs) + NG N acetyl cysteine
Surgery
Necrotising enterocolitis risk factor
Prematurity
Necrotising enterocolitis presentation
Abdo distension
Bloody stool
Septic
Necrotising enterocolitis mx
Total bowel rest
TPN
