Paeds Surgery Flashcards
What is a infantile haemangioma?
A birthmark made up of blood vessels which develops from 4-6 weeks of life
Who are infantile haemangiomas more common in?
Caucasian premature girls
What is a superficial haemangioma?
It is a haemangioma that is on the surface of the skin and bright red/purple
What are deep haemangiomas?
Haemangioma in the fat layer- purple,blue or even skin colour if deep enough under the skin layer
Mixed haemangioma
Both superficial and deep components
What are the 3 phases of infantile haemangioma?
- rapidly growing phase(first few weeks or months)
- plateau phase- at 8 months
- involution phase-after 1 year they start to turn from red, purple to grey
Where are haemangiomas more common?
- scalp
- face
- neck
How do they initially present?
As a single red bruise/bump
When do we worry about internal haemangiomas?
When there are 6 skin haemangiomas and more
What is the typical size and shape of haemangiomas?
Vary from oval and round and 1mm to 20 cm
What special investigations do you do?
- Skin biopsy
- Doppler US
- MRI can make diagnosis if atypical looking
What is the treatment of haemangiomas dependant on?
- age
- size of the lesion
- how rapidly it’s growing
- the location(if it threatens life-airway and liver)
- complications
What is the treatment options for haemangiomas?
- observation
- propanolol(A b-blocker that vasocontricts and causes a colour change and softening of haemangioma within 24 hours)
- surgery
- Laser therapy
- oral corticosteroids
- Intralesional corticosteroids
- Topical steroids
What are the complications of haemangiomas?
Complications occur in 25% of pts
- inteference with organ function eg. eyes,and diaper area
- ulceration-the skin around a haemangioma is raw and shiny and can scar easily and can get infections easily
- Bleeding if cut or injured
What are the adverse reactions of propanolol?
- Hypotension
- Hypoglycaemia
- bradycardia
- bronchospasm
What is omphacocele?
It is congenital herniation of the abdominal contents through the umbilical ring
How does omphalococele develop?
By the intra-abdominal contents not closing into the abdomen at the 11-1th week of development
What is the hernia covered with?
Peritoneum/whartons jelly and transparent amniotic membrane
How can exomphalos be classified?
Minor: less than 5cm in sheath diameter
Major: More than 5 cm in sheath diameter
What is the presentation of babies with exomphalos?
They present with asoociated abnormalities, a defect through the umbilical ring, bowel covered in a membrane,
What is Beckwith Wiedeman syndrome?
- Hypoglycaemia
- Exomphalos
- Macroglossia(large tongue)
- macrosomia(large baby)
- organomegaly
- increased risk of nephroblastoma/hepatoblastoma
What chromosomal abnormalities does exomphalos present with?
Trisomy 13,18,21
What other congenital anomalies does omphalocele present with?
- prematurity
- malrotation in 100%
- cardiac and urogenital problems
What is the initial management of exomphalos?
Put in an IV line to combat the hypoglycameia(12-15% dextrose maintenance fluid)
What is the initial mamagement of a baby with exomphalos?
- Keep baby warm
- normal feeds unless going into theatre
- give antibiotics(penicllin and gentamycin)
- cover the abdominal contents with silk tie
What surgical options are there with exomphalos?
Primary closure:
Done under general anaesthesia in theatre
The membrane is removed and the contents reduced and sheath closed then skin closed
What is the delayed secondary closure for exomphalos?
This is when the baby has a ruptured sac or the sheath is too big. A silastic sac is placed over the aread and reduced twice a day until 3-10 days later
What does non-operative management of exomphalos consist of?
It is reserved for patients with cardiac issues that are not fit for surgery
We wait for the membrane to completely dry out and granulation tissue forms
The agents used for this include:
1% mercurochrome
H&E stain
Gentian violet(dye used to treat ringworms/athletes foot etc.)
Complications of exomphalos?
Infection and septic complications
Rupture of the sac
Hypoglycaemia
What is gastroschisis?
congenital condition where the abdominal contents are protruding outside of the anterior abdominal wall-lateral to the umbilical ring.
Not covered in a membrane
What are the risk factors for gastroschisis?
- Young mother <20 years old
- Drug abuse-Tik(vasoconstrictor)
- cigarette smoker
What is the clinical presentation of a baby with gastroschisis?
- They present with protruding bowel
- No membrane surrounding the bowel
- To the right of the umbilicus with an opening of 1-2 cm
What is the initial management of a patient with gastroschisis?
ABCDE!
- Put in a nasogastric tube
- Give feeds TPN and nil by mouth
- IV fluids- normal fluids plus 10% extra of neonatalyte
- If the baby presented to the hospital late give 10-20ml/kg IV crystalloid (NaCl 0.9%) to combat the dehydration
- Protect the bowel by covering it with plastic eg clingwrap
- Avoid ischaemia of the bowel by making sure the mesentery does not coil
- enlarge to opening by injecting local anaesthetic and cutting 1cm left laterally - Transfer the baby to a tertiary hospital ASAP
What is the definitive management of gastroschisis?
- Primary reduction and surgical closure of the sheath is recommended
- Delayed Secondary closure can be done if the abdomen of the baby is too small for the abdominal contents to fit- in this case a silo bag is placed and the closure re-attempted at 5-10 days later
- The baby must be TPN because the bowel activity only begins 2-4 weeks after the ileus - If there is atresia then repair of that 3 weeks is expected
What are the complications of gastroschisis?
Death
Central venous line infection
Necrotizing enterocolitis
Define a hernia
It is the protrusion of an organ through its cavity when a defect occurs in its cavity wall
Inguinal hernia?
It is the out-pouching of abdminal contents out of the inguinal canal
What is the prossesus vaginalis?
It is the embryonic outpouching of peritoneum along the pathway of the testicles. It is 20% as adults, 40% for 2 year olds and 80% at birth
What causes groin hernias 99% of the time?
Opened processus vaginalis
What other contents other than abdominal contents do groin hernias have?
Ovaries in girls and someimes bladder
What is a fluid hernia/hydrocele?
The fluid from the abdomen collecing in the testicles
Is the incidence of bilateral hernias more common in girls or boys?
Girls- 75%
How does a baby with a hernia present with?
Increasing inguinal mass with coughing/vasalva
Relaible hx from mom
Bowel obstruction symptoms- constipation and vomiting
What are the clinical findings on inspection of an inguinal hernia?
- There is a swelling in the groin that is either reducible/not reducible
- red, swollen, tender
- transillumination if hydrocele
What are the clinical signs on palpation of an inguinal hernia?
- silk sign where it feels like silk when you rub the processus vaginalis
- palpation of bowel in the inguinal canal
- swelling
- cannot get above the mass (for a hydrocele you can get above the mass)
- swollen lymphnodes as masses below the inguinal canal
What are the clinical signs that you would auscultate for in an inguinal hernia?
Gurgling sounds
What is the diff diagnosis of inguinal hernia?
- Hydrocele
- varicocele
- Testicular torsion
- undescended testes
- Buried testes
- Hydrocele of the cord
What is an incarcerated/obstructed hernia?
It is a hernia where the abdominal contents continue to be outside the abdominal cavity
What is an irreducible hernia?
It is a hernia that ca be pushed back into the cavity
How do incarcerated hernias present?
- pain
- swelling in inguinal canal
- vomiting
- cannot get above the mass
- sudden onset
What is a strangulated hernia?
It is a hernia that is obstructed where ischaemia and necrosis occur
What are the clinical signs of a strangulated hernia?
It is an emergency- painful,redness, oedema above the mass, tenderness
This requires resuscitation and surgery ASAP
What complications can inguinal hernias cause?
- incarcerated hernia
- strangulated hernia
- speticaemia and septic shock
- full thickness necrosis
- testicular infarction in 10% of obstructed hernias
What is the operation of choice in children with an uncomplicated hernia?
Herniotomy
Is age important when deciding when to do the herniotomy?
No it isn’t because the younger the child is(neonates) the higher the risk of complications
What is the Mx of an incarcerated hernia?
- Conservative treatement first to prevent possible infection, haematoma,recurrent hernia and damage to the vas dederens
- Give 1mg/kg of ketamine as sedation
- Resuscitation and nasogastric tube is commenced
- Once reduced wait 24-48 hours to do the surgery
What is the Mx of patients with a strangulated hernia?
- Active resusciation is NB- electrolyte correction, IV fluids,broad spectrum Antibiotics
- Resection of ischaemic bowel and a primary anastomses
- Herniotomy
- ICU postoperatively
Surgical complications for herniotomy:
- wound infection
- haematoma
- recurrence especially in patients with connective tissue disorders
- injury to bladder and vas deferens
What is corrected gestational age?
It is the gestational age plus the age since birth
What is a hydrocele?
It has the same congenial defects as an inguinal hernia, an open processus vaginalis but the opening is too small to allow anything but fluid to go through
What is the clinical picture of someone with a hydrocele?
- asymptomatic swelling
- you can palpate the spermatic cord above it
- transilluminates
- cystic
- non tender and non reducible
When do congenital hydroceles close?
50% close by the age of 2 and so there is no reason to operate prior to this age
What is a hernia?
It is the protrusion of an organ through its cavity as a result of a defect in the wall of the cavity eg. umbiical hernia
What is a umbilical hernia?
It is the protrusion of abdominal contents through the umbilical ring due to the incomplete closure during development
In which patients do umbilical hernias usually present in?
3-5% in black children
Name 3 clinical pictures of a patient with umbilical hernia?
- easily reducible
- gurgling sounds when reducing
- obvious protrusion/bulge through the umbilicus
What associated symptoms does umbilical hernias present with?
Trisomy 13, 18
Beckwith Wiedemann syndrome
What is the Mx of umbilical hernias?
Most closes spontaneously by 3 years
If not closed by 3 then do surgery
If it is still 2 cm at 2 years it will not close spontaneously
What is the differential diagnosis of an umbilical hernia?
- para-umbilical hernia
2. rectus sheath diastatis
What is a para-umbilical hernia?
- occurs at a defect in the linear alba, above the umbilicus
- The defect is elliptical in shape
- It is surgically repaired because it seldom closes spontaneously
- There is a higher risk of intestinal obstruction
Name 4 discharges that can come out of the umbilicus?
- mucus
- pus from infection
- faeces
- urine which is clear
In which patientsis bowel incarceration more common in?
- patients who have pica and eat sand
2. pregnant girls
What is omphalitis?
Omphalitis is the infection of the umbilical cord. It can be prevented by using antiseptic spirits until it dries out
What are the causative organisms of omphalitis?
- staphylococccus
- haemolytic streptococcus
- fungal infections
What is the clinical picture of a baby with omphalitis?
- pus draining from the umbilicus
- cellulitis, oedema and erythema surrounding the umbilicus
- foul smelling umbilicus
Name 6 complications as a result of omphalitis?
- septicaemia because babies have a high incidence of becoming septicaemic
- cellulitis to the abdominal wall
- umbilical gangrene
- necrotising fasciitis
- abscesses(infection spreads along congenital tract)
- umbilical vein thrombosis which ca cause portal vein obstruction and portal hypertension
What is the Mx of omphalitis?
- IV fluids
- Electrolyte correction
- Broad sprectrum antibiotics
- surgical debridement of necrotizing fasciitis
What is a umbilical granuloma?
A red granuloma of the umbilicus that occurs as a result of a low grade infection and it drains a little pus
What is the treatment of an umbilical granuloma?
- You can use a topical table salt
- You can silver nitrate and tied off at its narrow base
- surgery if it does not respond to conservative treatment
What is a umbilical mucosal polyp?
- It looks cherry red
- It is a mucousal remnant that has a mucousal discharge
What is the Mx of a mucosal polyp?
Surgical excision
What is a vitello-intestinal duct remnant?
This is when there is still communication between the small bowel and the umbilicus which drains faeces
What is the pathophysiology of how vitello-intestinal duct occurs?
It occurs when at 7 weeks there in still communication between the umbilicus and and the small bowel.
There is usually a fibrous meckels band that surrounds the umbilicus and the small bowel and cysts may form
What is meckel’s diverticulum?
It is intestinal remnant of the vitello-intestinal duct
What is the rule of 2’s associated with meckel’s diverticulum?
- only 2% of the population
- 2% are symptomatic
- 2-3 times more common in boys
- can contain 2 types of mucosa
- 2 feet from the ileocaecal valve
- 2 inches long in adults
What special investigations would you do in a meckels diverticulum?
-scintigraphy(Tc 99)
What is the management of meckel’s diverticulum?
surgical excision and repair
What are the complications of meckel’s diverticulum?
- lead point in intussusception in 20%
- rectal bleeding in 40% due to peptic ulceration
- diverticulitis in 15%
- Intestinal obstruction/volvulus in 7%
What is a patent urachus?
When urine drains from the umbilicus
What should we exclude if a baby presents with a patent urachus?
That they have a bladder neck obstruction associated with posterior urethral valves
It is treated with surgical excision and repair
What is hypertrophic pyloric stenosis?
It is thickening of the pyloric muscles that leads to stomach outlet obstruction
What is the clinical picture of these patients?
They are usually first born caucasian male around 6 weeks old
What is the most important feature of neonates with HPS?
They present with:
- continuous vomiting of stomach contents
- dehydration
- metabolic derangements
- malrotation
What is the clinical Hx you will hear from the mom?
- Baby is vomiting non bile stained, projectile contents
- That it started at 2-3 weeks
- 5-20% have a family history
Why do 15% of babies present with haematemesis?
Because of the old milk curd irrititating the gastric mucosa and oesophagitis from secondary gastro-oesophageal reflux
What are the metabolic abnormalities associated?
- hypokalaemia
- hypochloraemia
- metabolic alkalosis(pH is above 7,45)
What are other clinical signs and symptoms does the baby present with?
- oliguria
- small hard stools(hunger stools)
- malnutrition as a late sign and anaemia
- 2% are jaundiced because of impaired glucoronyl transferase activity
- large distended abdomen with palpable ‘olive’ or ‘tumour’
How would you palpate the pyloric tumour or olive of the baby?
I would stand on the left and have the baby lie on their right. Then I would make sure the baby is relaxed and not crying and give test feed water. If I can palpate the olive sized tumour on the border of the rectus sheath then I can diagnose it as HPS
What special investigations do you do with pyloric stenosis?
- Abdominal Xray
- Ultrasound is the first line
- Barium meal
What do you see on ultrasound to diagnose HPS?
You would see a thickened pyloric canal >3 mm >15mm long
What signs would you find on barium meal of HPS?
- string sign which as the contrast goes through the narrow pylorus
- mammary sign
What is the initial management of Hypertrophic Pyloric Stenosis?
First start by correcting the dehydration and the electrolyte abnormalities:
- Nasogastric tube drainage
- Give 0,9% of NaCl 10/20 ml/kg until the baby passes at least 1ml/kg of urine
- Then give maintenance fluid of about 0,45% of NaCl and 5% of dextrose at 130-150% of normal infusion rate
- Add KCl once the urine output is achieved
- Then do blood gas: hypochloraemia and hypokalaemia and metabolic alkalosis
- Do a U&E: low sodium, low potassium, low chloride and raised serum rate
Why is 0,45% of NaCl used and not 0,9%?
This is to prevent brain oedema and pontine demyelonosis as shifting the sodium too rapidly can lead to it
What is the surgical management of HPS?
Pyolorotomy- 24 -72 hours after correcting electrolytes
This is because post-operative apnea and myocardial suppression happen
What are the complications of surgery in HPS?
- Wound sepsis
- poor wound healing
- duodenal perforation
What is the post-operative management of a baby who had a pyolorotomy?
- The baby usually feeds 24-48 hours after surgery
- Give zinc and vitamin C supplementation to help with wound healing
- Baby is usually discharged 1-5 days post surgery
Define volvulus?
Volvulus is when there is obstruction due to twisting of the stomach or intestine
What is midgut volvulus?
obstruction caused by twisting of the midgut(2nd part of the duodenum/ampula of vater) to the mid transverse colon
How does volvulus occur embryologically?
This happens when there is disruption in the normal 270 degree anti-clockwise rotation of the midgut around the Superior mesenteric artery axis
What is the difference between malrotation and non-rotation?
Malrotation is when the caecum is still in the superior right quadrant-more dangerous than non-rotational
Non-rotation is when the caecum is in the middle of the bowel-less dangeous than malrotation
What is the incidence of midgut volvulus?
- 3% of people has malrotation of the intestines
- 75% of the patients will present within the first month after birth
What are Ladds bands?
They are congenital peritoneum bands that obstruct the duodenum and can cause ischaemia
What is the early clinical presentation of midgut volvulus?
-sudden onset of bilous vomit in a previously well child
What are the late clinical signs of midgut volvulus?
- abdominal distension
- blood passed per rectum if ischaemia is now occuring
- peritonitis
How do older children present with malrotation?
- Failure to thrive
- chronic bilous or non-bilous vomiting
What other associated abnormalities is malrotation associated with?
- exomphalos
- gastroschisis
- situs inversus(heart on the right, polysplenism or asplenism, major blood vessels on the wrong side
What are the other causes of congenital GIT vomiting?
- oesophageal atresia
- duodenal atresia
- jejunal atresia
- hirschsprungs disease
- imperforate anus
What is the gold standard investigation for midgut volvulus?
-Contrast meal
What do you expect on AXR of midgut volvulus?
- distended stomach and duodenum but sometimes xray can be normal
- No distal gas
On contrast meal for midgut volvulus what signs can you expect?
-Any abnormal C-loop such as a birds beak, pigtail or corkscrew appearance
Give examples of acquired causes of vomiting?
- Obstruction-pyloric stenosis, intussusception, tumours, ingested foreign bodies
- Inflammation-appendicitis, crohns disease, ulcerative colitis, pancreatitis, cholecystitis
- Trauma- bowel injury, pancreatic injury,head injury
What other investigations other than AXR and meal contrast can you do?
- Contrast enema- showing the caecum in the wrong position
2. ULtrasound or CT which shows a whirl-pool configuration of the SM artery or vein
What is the Mx of midgut volvulus?
- nasogastric tube decompression
- electrolyte correction
- IV fluids
- Surgery(laparotomy where the malrotation is fixed)
What are the complications of midgut volvulus?
- mortality
2. short bowel syndrome
What examination is very important to do before you discharge a baby from hopital?
An inspection of the anus to exclude anorectal malformations
What will you see on an antenatal ultrasound of a baby?
- polyhydroamnios
- distended bowel loops
- Associated with other VACTERL anomalies
What will you see on presentation of the baby with anorectal malformation?
- distended abdomen
- vomiting(bile stained)
- no anus or abnormal anus
- baby does not pass meconium after the first 24 hours of birth
What is a cloacal malformation?
When the urethra, the vagina, and rectum all drain into one opening instead of 3
What does VACTERL stand for?
Vertebral anomalies- butterfly vertebra, tethered spinal cord
Anorectal malformations
Cardiac anomalies
Tracheo-oesophageal fistula-with or without oesophaeageal atresia
Renal-single or dysplastic kidney, vesico-ureteric reflux
Limb-radial aplasia or polydactyly
What is the primary management of a baby with anorectal malformation?
- Start with nasogastric decompression
- IV fluid NaCl 0,9% 10-20 ml/kg bolus
- Maintenace fluid use neonatalyte
- Keep the patient warm
- colostomy if general surgeon around and cannot transfer immediately
- Double barrel sigmoid colostomy where a incision is made in the left iliac fossa and distal mucous fistula is brough and a proximal functional sigmoid
What is the surgical management of anorectal malformations?
- VACTERL workup(ECGS, Spinal Xrays, nasogastric tube on babygram, look at whether the baby is passing meconium or not anywhere on the perineum,MRI spine for tethered cord
- double barrel colostomy at presentation
- Definitive surgery by making a anus-PSARP and LAARP
- Colostomy closure 1-3 months after the anus is the correct size
What does PSARP and LAARP mean and where do we do them?
- Posterior sagittal anorectoplasty for lower lesions
2. laparoscopic assisted anorectoplasty for high lesions
What complications can occur in the acute setting of anorectal malformations?
respiratory problems because of the abdominal distension
bowel wall ischaemia and necrosis
leading to bowel perforation
and severe sepsis which can cause death
What is Hirschsprung’s disease?
The abnormal innervation of the distal bowel due to aganglionosis of the meissner and auerbach nerve plexuses(parasympathetic nerve system)
Proximal to the affected colon there is a megacolon
What is the incidence of of Hirschsprungs disease?
1: 5000
What is the anatomical distribution of Hirschsprung’s
70% is rectosigmoidal
20% in the long tranverse colon
10% includes the whole colon
What is the clinical presentation of Hirschsprung’s disease?
- vomiting post delivery
- Failure to pass meconium in the first 24 hours of life
- distended abdomen , tenderness and hirschsprung’s enterocolitis
- dehydration, metabolic derangements causd by the vomiting
- if the patient presents after 28 days theey usually present with abdominal distension, chronic constipation, failure to thrive,
What are the other associated abnormalities with Hirschsprung’s disease?
Trisomy 21(Down’s syndrome)
What is the differential diagnosis of Hirschsprung’s disease?
-Neonatal small left colon syndrome
-Associated with maternal DM
-Transition zone at splenic flexure
-meconium ileus
meconium plug syndrome
What special investigations would you do for Hirschsprung’s?
You would do an abdominal X-Ray:
- to confirm the suspicion of Hirschsprung’s disease
- it can show the transition zone
- you sometimes can see Hirschsprung’s enterocolitis
On chest X-Rays:
-look for pneumoperitoneum(free air in the abdomen)
Contrast enema :
-To check the elevel of the deformity
Histology:
-full thickness biopsy
What are the signs of pneumoperitoneum?
- football sign
- riglers sign (the presence of air on both sides of the bowel wall-intraluminally and peritoneally
- the liver is greyish due to the overlying air
- ligamentum teres is outlined with free air from both sides
What is the conservative RX of HD?
- rectal washout/ warm saline enemas 10-30ml 3 times a day if it is an uncomplicated HD
- If it is complicated then do a colostomy
What is the surgical management of HD?
You would do a transanal pull-through
What are the complications of Hirschsprung’s disease?
- chronic constipation
- Hirschsprung’s enterocolitis
- malnutrition
- bowel perforation
