Surgery Flashcards
Describe the pathophysiology of appendicitis.
It is typically caused by direct luminal obstruction, usually secondary to a faecolith or lymphoid hyperplasia, impacted stool or, rarely, an appendiceal or caecal tumour.
Describe how a child with appendicitis would present.
It is typically caused by direct luminal obstruction, usually secondary to a faecolith (Fig. 1) or lymphoid hyperplasia, impacted stool or, rarely, an appendiceal or caecal tumour.
What is Roving’s sign?
RIF fossa pain on palpation of the LIF
What is Psoas sign?
RIF pain with extension of the right hip
Specifically suggests an inflamed appendix abutting psoas major muscle in a retrocaecal position
What is the gold standard, creative treatment for appendicitis?
Laparoscopic appendicectomy
Name some complications associated with appendicitis.
- Perforations
- Surgical site
- Appendix mass
- Pelvic abscess
Describe the pathophysiology of pyloric stenosis.
Pyloric stenosis is characterised by progressive hypertrophy of the pyloric muscle, causing gastric outlet obstruction
Name 2 risk factors of pyloric stenosis.
- Male
- FH
Describe how a child with pyloric stenosis would present.
Pyloric stenosis presents at around 4-6 weeks of age with non-bilious vomiting after every feed. Vomiting is very forceful, and is typically described as projectile. Despite this, babies will continue to feed hungrily. Haematemesis has also been reported. Weight loss and dehydration are very common at presentation, ranging from mild dehydration to hypovolaemic shock.
On examination, there may be visible peristalsis and a palpable olive-sized pyloric mass, best felt during a feed
What will the blood gas of a child with pyloric stenosis show?
Blood gases will typically show a hypokalaemia, hypochloraemic metabolic alkalosis
What investigation should be preformed in suspected pyloric stenosis?
A test feed should be performed with a NG tube in situ and the stomach aspirated. Whilst the child is feeding, the examiner should palpate for a pyloric mass and observe for visible peristalsis.
What is the imaging modality of choice for a child with suspected pyloric stenosis?
Ultrasound is the imaging modality of choice. An ultrasound of the abdomen will demonstrate hypertrophy of the pyloric muscle, with wall thickness >3mm, length >15mm and diameter >11mm
What is the surgical management of pyloric stenosis?
Ramstedt’s pyloromyotomy
If billous vomiting is present, what is an important differential to consider?
Malrotation
In pyloric stenosis, ow many hours after surgery can the baby resume feeding?
6 hr
What is Hirschsprung’s disease?
It is a congenital aganglionic megacolon disease, is a congenital disease in which ganglionic cells fail to develop in the large intestine. This commonly presents as delayed or failed passage of meconium around birth.
Describe how a child with Hirschsprung disease would present.
The most common clinical feature at presentation is abdominal distension and bilious vomiting with failure to pass meconium
Name the 3 sub-types of Hirschsprung disease.
short-segment, long-segment, and total colonic aganglionosis disease.
Describe the pathophysiology of Hirschsprung disease.
Hischsprung’s disease is where ganglionic cells of the myenteric and submucosal plexuses in the bowel aren’t present proximally from the anus to a variable length along the large intestine.
The aganglionic segment remains in a tonic state leading to failure in peristalsis and bowel movements.
Name 3 risk factors of Hirschsprung disease.
- Male
- Chromosomal abnormalities i.e. Down syndrome
- FH
What is the gold standard for diagnosis of Hirschsprung disease?
Rectal suction biopsy
What are the rectal suctions biopsy guidelines?
Delayed passage of meconium (more than 48 hours after birth in term babies)
Constipation since first few weeks of life
Chronic abdominal distension plus vomiting
Family history of Hirschsprung’s disease
Faltering growth in addition to any of the previous features.
Describe the initial management of Hirschsprung disease.
Initial management would involve IV antibiotics, nasogastric tube insertion and bowel decompression.
Name some complications of hirschprung disease.
- Hirschsprung associated enterocolitis (HAEC)
- Enterocolitis
- Constipation
- Parianal abscess
- Faecal soiling
- Adhesions
What is Hirschsprung associated enterocolitis (HAEC)?
It is the main cause of mortality of patients with Hirschsprung’s disease. Stasis of faeces leads to bacterial overgrowth, particularly of Clostridium difficile, Staphylococcus aureus, and anaerobes, within the colon. This often presents as fever, vomiting, diarrhoea, abdominal tenderness, and eventually sepsis if not recognized early enough. The emergency treatment for suspected enterocolitis is with fluid resuscitation, bowel decompression and broad-spectrum IV antibiotics
What is Intussusception?
The movement or ‘telescoping’ of one part of the bowel into another. The proximal bowel segment is referred to as the intussuceptum whilst the distal segment as intussucipiens.
What is the peak incidence of Intussusception?
5-7 months
What is the most common type of intussusception?
oleo-colic type
Name some risk factors of developing intussusception.
Meckel diverticulum (most common) Polyps Henoch-Schönlein purpura Lymphoma and other tumors Post-operative
Describe how a child with intussusception would present.
The parent will report their child as having a sudden onset of inconsolable crying episodes. Pallor can be observed and in an attempt to alleviate pain the child may draw up their knees to their chest.
In-between episodes the parents will normally report the child returns to their normal self. With a delayed presentation the child can appear lethargic and anorexic.
In the later stages passed stools can appear to have a characteristic red-current consistency due to the presence of blood and mucus.
Describe the findings you would expect on an examination of a child with intussusception.
Distention
A palpable ‘sausage-shaped’ abdominal mass which can be found in the right upper quadrant (ileo-ceceal type)
Signs of peritonism
Presence of bowel sounds
What is the preferred method of diagnosis in intussusception?
Abdo USS
Name 2 methods of managing intussusception.
- Nonoperative reduction
2. Surgical reduction
Name some complications of intussusception.
- Obstruction
- Perforation
- Dehydration/ shock
What sign is seen on abdominal ultrasound in intussusception?
Target sign
What is cryptorchidism?
failure of testicular descent into the scrotum
Name the 3 categories of cryptorchidism.
True undescended testis: where testis is absent from the scrotum but lies along the line of testicular descent
Ectopic testis: where the testis is found away from the normal path of decent
Ascending testis: where a testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum.
Describe the pathophysiology of cryptorchidism.
Under normal embryological development the testis descends from the abdomen to the scrotum, pulled by the gubernaculum, within the processes vaginalis. This process is incomplete in the context of true undescended testis; or tracks to an abnormal position in an ectopic testis.
Name some risk factors of cryptorchidism.
prematurity,
low birth weight,
having other abnormalities of genitalia (i.e. hypospadias)
having a first degree relative with cryptorchidism.
What is the preferred method of imaging in cryptorchidism?
No imaging modality has been shown to be of benefit in the diagnosis of undescended testis. Both USS and MRI have been showed to have low sensitivity and be poor at locating the testis and therefore plays no role in the pre-operative management of these patients.
Describe the timeline of the definitive management of cryptorchidism.
At birth – review at 6-8 weeks of age
At 6-8 weeks – if fully descended, no further action. If unilateral, re-examine at 3 months
At 3 months – If testis is retractile, advise annual follow up (due to risk of ascending testis). If undescended, refer to paediatric surgery/urology for definitive intervention – ideally occurring 6 – 12 months of age.
Name 3 complications of undefended testis.
- Impaired fertility
- Testicular cancer
- Torsion
What is hypospadias?
a congenital defect causing the urethral meatus to be located at an abnormal site, usually on the under side of the penis rather than at the tip.
Name the 3 key features of hypospadias.
1) Ventral opening of the urethral meatus
2) Ventral curvature of the penis or “Chordee”
3) Dorsal hooded foreskin
What are the aims of urethroplasty?
Bringing the meatus to the glans of the penis
The chordee is corrected to straighten the penis
The dorsal foreskin is managed with either circumcision or reconstruction, depending on anatomy, parental and surgical preference.
What is blanitis xerotica obliterans?
eratinisation of the tip of the foreskin causes scaring and the prepuce remains non-retractile.
Describe how a child with ‘Balanitis xerotica obliterans would present.
Ballooning of the foreskin during micturition is a common presentation. BXO presents with scaring of the urethral meatus presents with irritation, dysuria, haematuria and local infection.
What will be seen on examination of BXO?
a BXO-affected prepuce will appear as a white, fibrotic and scarred preputial tip
Describe how to manage BXO.
Circumcision
Describe the pathophysiology of testicular torsion.
Torsion occurs when a mobile testis rotates on the spermatic cord. This leads to reduced arterial blood flow, impaired venous return, venous congestion, resultant oedema and infarction to the testis if not corrected.
Males with a horizontal lie to their testes, often termed a ‘bell-clapper deformity’, are more prone to developing testicular torsion. In this anatomical variant, the testis lacks a normal attachment to the tunica vaginalis and is therefore more mobile, increasing the likelihood of it twisting on the cord structures.
Name some risk factors of testicular torsion.
Age (most common 12-25yrs)
Previous testicular torsion*
Family history of testicular torsion
Undescended testes
Describe how patients with testicular torsion would present.
Patients will generally present with sudden onset severe unilateral testicular pain. This is often associated with nausea and vomiting, secondary to the pain. Referred abdominal pain can also occur.
Describe how patients with testicular torsion would present on examination.
On examination, the testis will have a high position* (compared the contralateral side) with a horizontal lie. It can also appear swollen and will be extremely tender.
Classically, the cremasteric reflex is absent and pain continues despite elevation of the testicle, termed a negative Prehn’s sign (whilst in epididymo-orchitis, Prehn’s test is often positive).
Describe how testicular torsion is diagnosed.
The diagnosis of testicular torsion is a clinical one, therefore any suspected cases should be taken straight to theatre for scrotal exploration.
Describe the surgical management of testicular torsion.
If torsion is confirmed intra-operatively, the cord and testis will be untwisted and both testicles fixed to the scrotum, termed bilateral orchidopexy (prevent further any further torsion episodes).
Describe the bimodal age distribution of epididymitis.
The condition has a bimodal age distribution, occurring most commonly in males aged 15-30yrs and then again in males >60yrs.
Name 2 of the most common causative organisms of epididymitis.
N. gonorrhoeae and C. trachomatis
*In males who practice anal intercourse, enteric organisms such as E. coli are also a common cause
Describe how a patient with epididymitis would present.
unilateral scrotal pain and associated swelling. Fever and rigors can also be present.
What is Prehn’s sign?
Prehn’s sign can be used to further assess for suspected cases of epididymitis. The patient is supine and the scrotum is elevated by the examiner. In cases where the pain is relieved by elevation (a positive Prehn’s sign), this is suggestive of epididymitis.
Unfortunately, Prehn’s sign is unreliable; whilst it has good sensitivity, it has relatively poor specificity, therefore is not used routinely in clinical practice.
Describe how epididymitis should be investigated.
All suspected cases should have a urine dipstick performed (checking for evidence of infection), with a low-threshold for sending for urine culture (MC&S).
For suspected non-enteric epididymitis, first-void urine should be collected and sent for Nucleic Acid Amplification Test (NAAT), to assess for N. gonorrhoeae, C. trachomatis, and M. genitalium. Further STI screening may be warranted, dependent on the history.
What is blanitis xerotica obliterans?
eratinisation of the tip of the foreskin causes scaring and the prepuce remains non-retractile.
Describe how a child with ‘Balanitis xerotica obliterans would present.
Ballooning of the foreskin during micturition is a common presentation. BXO presents with scaring of the urethral meatus presents with irritation, dysuria, haematuria and local infection.
What will be seen on examination of BXO?
a BXO-affected prepuce will appear as a white, fibrotic and scarred preputial tip
Describe how to manage BXO.
Circumcision
Describe the pathophysiology of testicular torsion.
Torsion occurs when a mobile testis rotates on the spermatic cord. This leads to reduced arterial blood flow, impaired venous return, venous congestion, resultant oedema and infarction to the testis if not corrected.
Males with a horizontal lie to their testes, often termed a ‘bell-clapper deformity’, are more prone to developing testicular torsion. In this anatomical variant, the testis lacks a normal attachment to the tunica vaginalis and is therefore more mobile, increasing the likelihood of it twisting on the cord structures.
Name some risk factors of testicular torsion.
Age (most common 12-25yrs)
Previous testicular torsion*
Family history of testicular torsion
Undescended testes
Describe how patients with testicular torsion would present.
Patients will generally present with sudden onset severe unilateral testicular pain. This is often associated with nausea and vomiting, secondary to the pain. Referred abdominal pain can also occur.
Describe how patients with testicular torsion would present on examination.
On examination, the testis will have a high position* (compared the contralateral side) with a horizontal lie. It can also appear swollen and will be extremely tender.
Classically, the cremasteric reflex is absent and pain continues despite elevation of the testicle, termed a negative Prehn’s sign (whilst in epididymo-orchitis, Prehn’s test is often positive).
Describe how testicular torsion is diagnosed.
The diagnosis of testicular torsion is a clinical one, therefore any suspected cases should be taken straight to theatre for scrotal exploration.
Describe the surgical management of testicular torsion.
If torsion is confirmed intra-operatively, the cord and testis will be untwisted and both testicles fixed to the scrotum, termed bilateral orchidopexy (prevent further any further torsion episodes).
Describe the bimodal age distribution of epididymitis.
The condition has a bimodal age distribution, occurring most commonly in males aged 15-30yrs and then again in males >60yrs.
Name 2 of the most common causative organisms of epididymitis.
N. gonorrhoeae and C. trachomatis
*In males who practice anal intercourse, enteric organisms such as E. coli are also a common cause
Describe how a patient with epididymitis would present.
unilateral scrotal pain and associated swelling. Fever and rigors can also be present.
What is Prehn’s sign?
Prehn’s sign can be used to further assess for suspected cases of epididymitis. The patient is supine and the scrotum is elevated by the examiner. In cases where the pain is relieved by elevation (a positive Prehn’s sign), this is suggestive of epididymitis.
Unfortunately, Prehn’s sign is unreliable; whilst it has good sensitivity, it has relatively poor specificity, therefore is not used routinely in clinical practice.
Describe how epididymitis should be investigated.
All suspected cases should have a urine dipstick performed (checking for evidence of infection), with a low-threshold for sending for urine culture (MC&S).
For suspected non-enteric epididymitis, first-void urine should be collected and sent for Nucleic Acid Amplification Test (NAAT), to assess for N. gonorrhoeae, C. trachomatis, and M. genitalium. Further STI screening may be warranted, dependent on the history.
What is blanitis xerotica obliterans?
eratinisation of the tip of the foreskin causes scaring and the prepuce remains non-retractile.
Describe how a child with ‘Balanitis xerotica obliterans would present.
Ballooning of the foreskin during micturition is a common presentation. BXO presents with scaring of the urethral meatus presents with irritation, dysuria, haematuria and local infection.
What will be seen on examination of BXO?
a BXO-affected prepuce will appear as a white, fibrotic and scarred preputial tip
Describe how to manage BXO.
Circumcision
Describe the pathophysiology of testicular torsion.
Torsion occurs when a mobile testis rotates on the spermatic cord. This leads to reduced arterial blood flow, impaired venous return, venous congestion, resultant oedema and infarction to the testis if not corrected.
Males with a horizontal lie to their testes, often termed a ‘bell-clapper deformity’, are more prone to developing testicular torsion. In this anatomical variant, the testis lacks a normal attachment to the tunica vaginalis and is therefore more mobile, increasing the likelihood of it twisting on the cord structures.
Name some risk factors of testicular torsion.
Age (most common 12-25yrs)
Previous testicular torsion*
Family history of testicular torsion
Undescended testes
Describe how patients with testicular torsion would present.
Patients will generally present with sudden onset severe unilateral testicular pain. This is often associated with nausea and vomiting, secondary to the pain. Referred abdominal pain can also occur.
Describe how patients with testicular torsion would present on examination.
On examination, the testis will have a high position* (compared the contralateral side) with a horizontal lie. It can also appear swollen and will be extremely tender.
Classically, the cremasteric reflex is absent and pain continues despite elevation of the testicle, termed a negative Prehn’s sign (whilst in epididymo-orchitis, Prehn’s test is often positive).
Describe how testicular torsion is diagnosed.
The diagnosis of testicular torsion is a clinical one, therefore any suspected cases should be taken straight to theatre for scrotal exploration.
Describe the surgical management of testicular torsion.
If torsion is confirmed intra-operatively, the cord and testis will be untwisted and both testicles fixed to the scrotum, termed bilateral orchidopexy (prevent further any further torsion episodes).
Describe the bimodal age distribution of epididymitis.
The condition has a bimodal age distribution, occurring most commonly in males aged 15-30yrs and then again in males >60yrs.
Name 2 of the most common causative organisms of epididymitis.
N. gonorrhoeae and C. trachomatis
*In males who practice anal intercourse, enteric organisms such as E. coli are also a common cause
Describe how a patient with epididymitis would present.
unilateral scrotal pain and associated swelling. Fever and rigors can also be present.
What is Prehn’s sign?
Prehn’s sign can be used to further assess for suspected cases of epididymitis. The patient is supine and the scrotum is elevated by the examiner. In cases where the pain is relieved by elevation (a positive Prehn’s sign), this is suggestive of epididymitis.
Unfortunately, Prehn’s sign is unreliable; whilst it has good sensitivity, it has relatively poor specificity, therefore is not used routinely in clinical practice.
Describe how epididymitis should be investigated.
All suspected cases should have a urine dipstick performed (checking for evidence of infection), with a low-threshold for sending for urine culture (MC&S).
For suspected non-enteric epididymitis, first-void urine should be collected and sent for Nucleic Acid Amplification Test (NAAT), to assess for N. gonorrhoeae, C. trachomatis, and M. genitalium. Further STI screening may be warranted, dependent on the history
