Pediatric Surgery Flashcards
A 3 year old boy is referred to the clinic with a scrotal swelling. On examination, the mass does not transilluminate and it is impossible to palpate normal cord above it. What is the most likely diagnosis?
Hydrocele Direct inguinal hernia Indirect inguinal hernia Femoral hernia Lymphatic malformation
This is likely to be an indirect hernia. In children these arise from persistent processus vaginalis and require herniotomy.
A male infant, born at term appears well following delivery. Six hours later, he is noted to have bilious vomiting by the paediatricians. On examination, he seems well and his abdomen is soft and non tender. What is the best course of action?
Arrange an abdominal x-ray Undertake a test feed Perform serial abdominal examinations Arrange an upper GI contrast study Arrange a laparotomy
Arrange an upper GI contrast study
Bilious vomiting in neonates is a surgical emergency and is intestinal malrotation and volvulus until otherwise proven. It is investigated with an upper GI contrast study. Contrast should be seen to exit the stomach and the location of the DJ flexure is noted (it lies to the left of the midline). If this is not the case, or the study is inconclusive, a laparotomy is performed.
A 6 day old baby was born prematurely at 33 weeks. He has been suffering from respiratory distress syndrome and has been receiving ventilatory support on NICU. He has developed abdominal distension and is increasingly septic. Ultrasound of the abdomen shows free fluid and evidence of small bowel dilatation. His blood pressure has remained labile despite inotropic support. What is the best course of action?
Laparoscopy Laparotomy Contrast enema Upper GI contrast study MRI abdomen
Laparotomy
He has necrotising enterocolitis and whilst this is often initially managed medically a laparotomy is required if the situation deteriorates.
A female infant is born by cesarean section at 38 weeks gestation for foetal distress. The attending paediatricians notice that she has a single palmar crease and a mongoloid slant to her eyes. Soon after the birth the mother tries to feed the child who has a projectile vomit about 10 minutes after feeding. On examination she has a soft, non distended abdomen. What is the most likely cause?
Pyloric stenosis Duodenal atresia Milk allergy Meconium ileus Anal atresia
Duodenal atresia
Proximally sited atresia will produce high volume vomits which may or may not be bile stained. Abdominal distension is characteristically absent. Whilst under resuscitated children may be a little dehydrated they are seldom severely ill. The presence of Trisomy 21 (palmar and eye signs) increases the likelihood of duodenal atresia.
What is the most common abdominal emergency in children under 1 year of age?
Appendicitis Intussusception Intestinal malrotation Pyloric stenosis Mid gut volvulus
Intussusception
The commonest emergency in this age group is inguinal hernia followed by intussusception. Appendicitis is commoner in those older than 1 year of age.
The parents of a 1 year old child are concerned after he develops a lump in his neck. On examination, there is a swelling in the subcutaneous tissue of the posterior triangle which transilluminates. What is the most likely cause?
Brachial cyst Branchial sinus Cystic hygroma Lipoma Pharyngeal pouch
Cystic hygroma
This is a classical description. Collection of dilated lymphatic sacs which are fluctuant and brilliantly transilluminable. Recurrence following surgical excision is not uncommon.
A 14 month old child is admitted with colicky abdominal pain and on investigation is found to have an ileo-ileal intussusception. What is the best course of action?
Attempt hydrostatic reduction with barium enema Attempt pneumatic reduction with air insufflation Undertake a laparotomy Undertake a colonoscopy Undertake a flexible sigmoidoscopy
Undertake a laparotomy
Ileo-ileal intussusception are far less common than the ileo-colic variant. However, where they occur, they require surgery and are not amenable to pneumatic reduction.
At what age should children with otherwise uncomplicated umbilical hernias be considered for surgery?
Within the first few days of life 6 months of age 12 months of age 18 months of age After 3 years of age
After 3 years of age
Many umbilical hernias will close in the first year of life. Defer surgery until the child is 3 years or older
A 2 month old baby presents with jaundice. He has an elevated conjugated bilirubin level. Diagnosis is confirmed by cholangiography during surgery. What is the best course of action?
Insertion of PTC Choledochoduodenostomy ERCP Roux-en-Y portojejunostomy Liver transplant
Roux-en-Y portojejunostomy
This child has biliary atresia. The aim is to avoid liver transplantation (however, most will come to transplant in time).
A neonate born at term has an episode of bilious vomiting and on investigation is found to have a DJ flexure displaced to the right. What procedure are they most likely to require?
Ladds procedure Gastrojejunostomy Kasai procedure Duoduodenostomy Ramstedts procedure
Intestinal malrotation with volvulus is treated with a Ladd’s procedure
A 2 week old baby is referred to the surgical team by the paediatricians. They are concerned because the child has a painful area of macerated tissue at the site of the umbilicus. On examination, a clear- yellowish fluid is seen to be draining from the umbilicus when the baby cries. What is the most likely diagnosis?
Omphalitis Umbilical granuloma Persistent vitello-intestinal duct Patent urachus Isolated cellular remnants
A patent urachus will present with umbilical urinary discharge. The skin may become macerated if not properly cared for. The discharge is most likely to be present when intra-abdominal pressure is raised. It is associated with posterior urethral valves.
A premature infant (30-week gestation) presents with distended and tense abdomen. She is passing blood and mucus per rectum, and she is also manifesting signs of sepsis. What is the most likely underlying explanation?
Viral gastroenteritis Necrotising enterocolitis Meconium ileus Intestinal volvulus Ileal atresia
Necrotising enterocolitis is more common in premature infants. Mesenteric ischemia causes bacterial invasion of the mucosa leading to sepsis. Terminal ileum, caecum and the distal colon are commonly affected. The abdomen is distended and tense, and the infant passes blood and mucus per rectum. X -Ray of the abdomen shows distended loops of intestine and gas bubbles may be seen in the bowel wall.
A 1 day old child is born by emergency cesarean section for foetal distress. On examination, he has decreased air entry on the left side of his chest and a displaced apex beat. Abdominal examination demonstrates a scaphoid abdomen but is otherwise unremarkable. What is the most likely cause?
Pyloric stenosis Congenital diaphragmatic hernia Tracheo-oesophageal fistula Ileal atresia Meconium ileus
Congenital diaphragmatic hernia
Displaced apex beat and decreased air entry are suggestive of diaphragmatic hernia. The abdomen may well be scaphoid in some cases. The underlying lung may be hypoplastic and this correlates directly with prognosis.
A 10 year old boy is shot in the abdomen with an airgun pellet. He is concerned that he will get into trouble and the injury remains concealed for 10 days. Imaging using CT scanning shows it to be lodged in the left lobe of the liver. On examination, his abdomen is soft and non tender and he seems well. What is the best course of action?
Operate and remove the pellet on the next emergency list Operate and remove the pellet on the next elective operating list Do not operate and review the patient several weeks later Extract the pellet using interventional radiology techniques Perform an MRI scan
Do not operate and review the patient several weeks later
Given that the child is well, the risks of removing the pellet are not outweighed by the benefits and it should be left in situ at this stage.
A 4 year old boy is brought to the clinic. He gives a history of difficult, painful defecation with bright red rectal bleeding. What is the most likely diagnosis?
Crohns disease Ulcerative colitis Anal fissure Haemorrhoids Juvenile polyp
Anal fissure
Painful rectal bleeding in this age group is typically due to a fissure. Treatment should include stool softeners and lifestyle advice
A 1-day-old baby girl is noted to become profoundly cyanotic whilst feeding and crying. A diagnosis of congenital heart disease is suspected. What is the most likely cause?
Transposition of the great arteries Coarctation of the aorta Patent ductus arteriosus Hypoplastic left heart Ventricular septal defect
Transposition of the great arteries
Congenital heart disease
Cyanotic: TGA most common at birth, Fallot’s most common overall
Acyanotic: VSD most common cause
A 4 week old baby is developing well and develops profuse and projectile vomiting after feeds. He has been losing weight and the vomit is described as being non bilious. What is the most likely underlying pathology?
Duodenal atresia Ileal atresia Hypertrophy of the pyloric sphincter Achalasia cardia Intestinal malrotation
Hypertrophy of the pyloric sphincter
A history of projective vomiting and weight loss is a common story suggestive of pyloric stenosis. The vomit is often not bile stained. Diagnosis is further suggested by hypochloraemic metabolic alkalosis and a palpable tumour on test feeding.
A newborn baby boy presents with gross abdominal distension. He is diagnosed with cystic fibrosis and his abdominal x ray shows distended coils of small bowel, but no fluid levels. Which of the following interventions is the usual first line treatment?
Laparotomy and removal of meconium Administration of sodium picosulphate orally Enemas with N- acetyl cysteine Laparotomy and small bowel resection Colonoscopy
Enemas with N- acetyl cysteine
The most likely diagnosis here is meconium ileus. The first line treatment for uncomplicated cases is enemas of either dilute gastrograffin or N-acetyl cysteine. It’s important to ensure the child is adequately hydrated first. They are contra indicated if there is a suspected underlying perforation.
A male infant is born prematurely at 26 weeks gestation by emergency cesarean section. Following the birth he develops respiratory distress syndrome and is ventilated. He begins to improve twelve days after birth. Then he becomes unwell and develops abdominal distension and passes bloody stools and vomits a small quantity of bile stained vomit. What is the most likely cause?
Ileal atresia Hirschprungs disease Pyloric stenosis Necrotising enterocolitis Meconium ileus
Necrotising enterocolitis often has a delayed presentation and affected infants will typically pass bloody stools. Plain films may show air in the intestinal wall (Pneumatosis).
A 1 month old baby girl presents with bile stained vomiting. She had an exomphalos and a congenital diaphragmatic hernia. What is the most likely underlying explanation?
Duodenal atresia Intestinal malrotation Duplication cysts Annular pancreas Ileal atresia
Intestinal malrotation
Exomphalos and diaphragmatic herniae are commonly associated with malrotation.
A 7 month old girl presents with vomiting and diarrhoea. She is crying and drawing her legs up. There is a a sausage shaped mass in the abdomen. What is the most likely diagnosis?
Mesenteric cyst Intussusception Colonic cancer Small bowel tumour Internal hernia
Intussusception
In a child of this age the history of colicky pain and the presence of a sausage shaped mass are strongly suggestive of an ileo-colic intussusception.
