Surgery Flashcards
What are the usual causes of appendicitis?
Direct luminal obstruction usually secondary to a faecolith, lymphoid hyperplasia or impacted stool
What are the clinical features of appendicitis?
Abdominal pain - initially peri-umbilical and later migrates to RIF
Nausea and vomiting, anorexia, diarrhoea, constipation
Rebound tenderness, guarding
What is Rovsing’s sign?
RIF pain on palpation of the LIF
What is psoas sign?
RIF pain with extension of the right hip
What are some differentials of appendicitis in children?
UTI, pyelonephritis, IBD, Meckel’s diverticulum, testicular torsion, epididymo-orchitis, acute mesenteric adenitis, gastroenteritis, constipation, intussusception
What are some risk factors for pyloric stenosis?
Male gender (4x risk) Family history
What is pyloric stenosis?
Progressive hypertrophy of the pyloric muscle causing gastric outlet obstruction
What are the clinical features of pyloric stenosis?
Presents around 4-6 weeks
Non-bilious vomiting after every feed, usually projectile
Weight loss and dehydration
Visible peristalsis
Palpable olive-sized pyloric mass
What are some differentials of pyloric stenosis?
Gastroenteritis, GORD, overfeeding, sepsis, UTI, food allergy
How is pyloric stenosis investigated?
Test feed with an 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
Ultrasound of the pylorus - wall thickness >3mm, length >15mm and diameter >11mm
Blood gases - hypokalaemia, hypochloraemic metabolic alkalosis
What does the blood gas typically show in a baby with pyloric stenosis and why?
Hypokalaemic, hypochloraemic metabolic alkalosis
Due to loss of Hal with vomiting causing a chloraemia and metabolic alkalosis
Kidneys then change potassium to retain protons as a compensation, leading to hypokalaemia
How is pyloric stenosis managed?
Preoperatively - correct underlying metabolic abnormalities
Fluid boluses
Rehydration at 150ml/kg/day
Ramstedt’s pyloromyotomy (babies can resume feeding after 6 hours)
What are some complications of pyloric stenosis?
Hypovolaemia, apnoea secondary to hypoventilation associated with metabolic acidosis
Complications post op:
Wound dehiscence Infection Bleeding Perforation Incomplete myotome
What is Hirschsprung’s disease?
A congenital disease in which ganglionic cells fail to develop in the large intestine
What is the classical triad that 25% of patients with Hirschsprung’s disease have?
Failure to pass meconium, abdominal distension and bilious vomiting
What is the median age of presentation of Hirschsprung’s?
2 days old
What are the most common clinical features of Hirschsprung’s?
Failure to pass meconium in the first 48 hours, bilious vomiting and abdominal distension
What gene is strongly associated with Hirschsprung’s?
Receptor tyrosine kinase (RET) gene - a proto-oncogene on chromosome 10q11
What are the three main subtypes of Hirschsprung’s?
Short segment, long segment and total colonic agangliosis disease
Short term is the most common (85% of cases) - restricted to rectosigmoid portion of colon
What is the pathophysiology of Hirschsprung’s?
Arrest of the neuroblast, derived from neural crest cell migration in fetal development between week 8 and 12
Or normal cell migration occurs but the neuroblast fails to develop properly due to apoptosis, improper differentiation or failure in proliferation
The aganglionic segment remains in a tonic state - failure in peristalsis and bowel movements
What are the risk factors of Hirschsprung’s?
Male (4x risk), chromosomal abnormalities, family history
What are some differentials of Hirchsprung’s?
Meconium plug syndrome, meconium ileus, intestinal atresia, intestinal malrotation, anorectal malformation, constipation
How is Hirschsprung’s investigated?
Plain AXR
Contrast enema - short transition zone between proximal end of colon and narrow distal end of colon
Gold standard - rectal suction biopsy (submucosa tested for ganglionic cells) - biopsy stained for acetylcholinesterase
How is Hirschsprung’s managed?
IV antibiotics, NG insertion, bowel decompression
Surgery - resecting the ganglionic section of bowel and connecting the unaffected bowel to the dentate line
What are some complications of Hirschsprung’s?
Hirschsprung associated enterocolitis - stasis of faeces leads to bacterial overgrowth (C diff, staph aureus and anaerobes) - presents as fever, vomiting, diarrhoea, tenderness, sepsis
Complications of surgery - constipation, enterocolitis, perianal abscess, faecal soiling and adhesions
What are the terms used to describe the proximal bowel segment and distal bowel segment in intussusception?
Proximal = intussusceptum
Distal = intussucipiens
What is intussusception?
Movement or telescoping of one part of the bowel into another - 90% of cases are ileo-colic whereby the distal ileum passes into the caecum through the ileocaecal valve
When is the peak incidence of intussusception?
Between 5-7 months of age
Rare after 2 years
What are some risk factors for intussusception?
Rotaviruses, Meckel’s diverticulum, polyps, Henoch-Schonlein purpura, lymphoma, post op
What are the clinical features of intussusception?
Sudden onset inconsolable crying episodes
Drawing up legs to a alleviate pain
Pallor
Red-current stools due to presence of blood and mucus
Sausage shaped abdominal mass in RUQ
What are the differentials of intussusception?
Colic, testicular torsion, appendicitis, gastroenteritis, volvulus
How is intussusception investigated?
Abdominal ultrasound - doughnut/target sign
AXR (low sensitivity) - distended small bowel loops, may have Rigler’s sign if perforated
Contrast enema - contraindicated if peritonitis or perforation
How is intussusception managed?
Fluid resuscitation if shock or dehydration, NG tube insertion
Non operative reduction - air or contrast enema to reduce the intussuscepted bowel
Surgical reduction
What are some complications of intussusception?
Obstruction, perforation, dehydration and shock
What is cryptorchidism?
Failure of testicular descent into the scrotum
What are some risk factors for cryptorchidism?
Prematurity, low birth weight, genital abnormalities eg hypospadias, family history
What is the management of cryptorchidism?
At birth - review at 6-8 weeks
At 6-8 weeks - if unilateral, re examine at 3 months
At 3 months - if undescended, refer to paediatric surgery for definitive intervention ideally occurring at 6-12 months
Definitive intervention - open orchidopexy
What are some complications of cryptorchidism?
Impaired fertility, testicular cancer, torsion
