Pediatric Surgery

Question 1

Discuss the presentation and management of pyloric stenosis

Answer 1

Demographics: 
- Aged 2-8
Symptoms: 
- acute, progressive non-bilious vomiting
- abdominal pain
- palpable pyloric olive
- visible gastric motility waves
- gastric distension
- hypovolemic
Investigations: 
- ultrasound showing thickened pyloric sphincter (>3mm, >14mm, >15mm)
- upper GI series
Treatment: 
- IV fluid resuscitation to treat metabolic alkalosis
- Ramsted’s pyloromyotomy

Question 2

Discuss the presentation and management of Meckel’s Diverticulum

Answer 2

Demographics:
- 2% of population, 2% are symptomatic, 2x more likely in males, 2 blood supplies, 2 types of ectopic mucosa, 2 feet from ilealcecal junction
- present under age of 4
Symptoms/Signs:
- bleeding (ulceration from mucosa, rectal bleeding, severe anemia)
- inflammation (pain, vomiting)
- obstruction (nausea/vomiting, abdominal pain and distension, constipation) which can lead to intussusception or volvulus
Investigations:
- Technetium 99m
Treatment:
- surgical resection

Question 3

What is the embryological mechanism of Meckel’s diverticulum?

Answer 3

Proximal portion of omphalomesenteric canal remains open forming a diverticulum on the mesenteric side of distal small intestine.

Question 4

What is the embryological mechanism for malrotation and volvulus? Differentiate between the two.

Answer 4

• Malrotation occurs due to the angle of Treitz and cecum lie next to each other
• Volvulus occurs when small bowel twists around the super mesentaric artery leading to small bowel ischemia and necrosis.

Question 5

Discuss the presentation and management of volvulus

Answer 5

Demographic:
- present within the first month of life
Symptoms:
- previously healthy child that develops bilious vomiting and feeding difficulties
- abdominal distention with tenderness and/erythema
- rectal bleeding
Investigations:
- Upper GI series
Treatment:
- IV fluid resuscitation, antibiotics
- surgery (division of Ladd bands, rotation, appendectomy)
Chronic presentation: chronic vomiting, hematemesis, intermittent abdominal pain, diarrhea or constipation, failure to thrive

Question 6

Discuss the diagnosis and management of intestinal atresia

Answer 6

Demographics: 
- usually syndrome (Downs)
- present within first few days of life
Symptoms: 
- distended abdomen
- bilious vomiting
- did not pass meconium
- hyperbilirubinia leading to jaundice
Investigations: 
- abdominal x-ray
- upper GI series
Treatment: 
- NG tube suction
- IV fluid resuscitation, antibiotics
- surgery (removal or anastamosis)

Question 7

What is the embryological mechanism of intestinal atresia?

Answer 7

Have interruption of mesenteric blood supply -> ischemia and necrosis of fetal intestine -> resorption of distal and proximal ends

Question 8

Differentiate between an inguinal hernia and other scrotal pathology

Answer 8

Inguinal hernia
- cannot palpate superior to the testis
- is reducible
Hydrocele
- can palpate testis above mass
- trans-illuminates

Question 9

Discuss the presentation and management of an umbilical hernia

Answer 9

Demographics: 
- occur before the age of 5 as this is when the rectus abdominus fascia closes
Symptoms/Signs: 
- asymptomatic
- may interfere with feeding
- reducible mass, 
Treatment: 
- rarely becomes incarcerated and will close on its by age 5, so just require observation.
Indications for surgery: 
- strangulated/incarcerated
- symptomatic
- significant behavioural problems
- proboscoid
- fascia defect not decreasing in size

Question 10

Discuss the presentation and management of appendicitis

Answer 10

Demographics: 
- Between 15-30 most common
Symptoms: 
- visceral dull
- aching umbilical pain -> somatic, sharp RLQ pain
- fever/chills
- nausea/vomiting
- anorexia
- diarrhea
- tenderness at McBurney’s point
- + Rovsing’s sign/obturator sign/psoas sign
- peritoneal signs
Investigations: 
- ultrasound
- CT
- b-HCG to r/o pregnancy
- u/a to r/o UTI
Treatment: 
- IV fluid resuscitation
- antibiotics (ceftriaxone and metronidazole)
- appendectomy

Question 11

List the complications of appendicitis

Answer 11

Rupture and peritonitis (require laporotomy)
Bowel perforation (require laporotomy)
Phlegmon (require IV antibiotics first)
Abscess (require IV antibiotics first)

Question 12

Discuss the presentation and management of intussusception

Answer 12

Demographics: 
- occur between 3-9 months of age
Symptoms: 
- abdominal pain
- non-bilious vomiting
- rectal bleeding (red currant jelly)
- abdominal distention
Investigations: 
- ultrasound to show pseudo-kidney or doughnut sign
Treatment: 
- colon or air enema
- surgery

Question 13

List the risks of intussusception

Answer 13

In those <3months or >3 years must consider

• Meckel’s diverticulum
• Lymphoma
• Duplication cyst of the terminal ileum

Question 14

Discuss the presentation and management of Hirschsprung’s disease

Answer 14

Demographics: 
- Present mainly in neonatal period
- with male more common
- majority being sporadic 
Symptoms: 
- delayed passage of meconium (>48hrs)
- bilious vomiting
- abdominal distention
- explosive diarrhea on rectal exam
Delayed presentation: 
- chronic abdominal pain
- constipation
- malnutrition
- failure to thrive
Investigations: 
- Contrast enema
- manometry showing internal sphincter tone elevation and absence of relaxation of with rectal distention
- biopsy showing absence of ganglion cells
Treatment: 
- IV fluid resuscitation
- antibiotics
- rectal washout
- surgical resection of aganglionic colon with anastomosis 1cm above dentate line

Question 15

Calculate the fluid requirements for a 24kg 8 year old with moderate dehydration

Answer 15

Bolus: 480mL in 20 minutes (20ml/kg)
Maintenance: 64mL/hr with 20mEq/L of K (4/2/1 rule)
Deficit: 1440mL (peds 5, 10, 15 for deficit x kg x 1000)

Order: 480mL bolus of NS over 20 minutes with 124mL/hr of D5NS for first 8 hours and then 94mL/hour of D5NS for 16 hours. After 24 hours begin at 64mL/hour of D5NS with 20mEq/L of K