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Paediatrics > Surgery > Flashcards

Surgery Flashcards

1
Q

What are the usual causes of appendicitis?

A

Direct luminal obstruction usually secondary to a faecolith, lymphoid hyperplasia or impacted stool

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2
Q

What are the clinical features of appendicitis?

A

Abdominal pain - initially peri-umbilical and later migrates to RIF

Nausea and vomiting, anorexia, diarrhoea, constipation

Rebound tenderness, guarding

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3
Q

What is Rovsing’s sign?

A

RIF pain on palpation of the LIF

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4
Q

What is psoas sign?

A

RIF pain with extension of the right hip

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5
Q

What are some differentials of appendicitis in children?

A

UTI, pyelonephritis, IBD, Meckel’s diverticulum, testicular torsion, epididymo-orchitis, acute mesenteric adenitis, gastroenteritis, constipation, intussusception

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6
Q

What are some risk factors for pyloric stenosis?

A 
Male gender (4x risk)
Family history
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7
Q

What is pyloric stenosis?

A

Progressive hypertrophy of the pyloric muscle causing gastric outlet obstruction

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8
Q

What are the clinical features of pyloric stenosis?

A

Presents around 4-6 weeks

Non-bilious vomiting after every feed, usually projectile

Weight loss and dehydration

Visible peristalsis

Palpable olive-sized pyloric mass

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9
Q

What are some differentials of pyloric stenosis?

A

Gastroenteritis, GORD, overfeeding, sepsis, UTI, food allergy

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10
Q

How is pyloric stenosis investigated?

A

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

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11
Q

What does the blood gas typically show in a baby with pyloric stenosis and why?

A

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

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12
Q

How is pyloric stenosis managed?

A

Preoperatively - correct underlying metabolic abnormalities

Fluid boluses

Rehydration at 150ml/kg/day

Ramstedt’s pyloromyotomy (babies can resume feeding after 6 hours)

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13
Q

What are some complications of pyloric stenosis?

A

Hypovolaemia, apnoea secondary to hypoventilation associated with metabolic acidosis

Complications post op:

Wound dehiscence
Infection
Bleeding
Perforation
Incomplete myotome
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14
Q

What is Hirschsprung’s disease?

A

A congenital disease in which ganglionic cells fail to develop in the large intestine

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15
Q

What is the classical triad that 25% of patients with Hirschsprung’s disease have?

A

Failure to pass meconium, abdominal distension and bilious vomiting

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16
Q

What is the median age of presentation of Hirschsprung’s?

A

2 days old

17
Q

What are the most common clinical features of Hirschsprung’s?

A

Failure to pass meconium in the first 48 hours, bilious vomiting and abdominal distension

18
Q

What gene is strongly associated with Hirschsprung’s?

A

Receptor tyrosine kinase (RET) gene - a proto-oncogene on chromosome 10q11

19
Q

What are the three main subtypes of Hirschsprung’s?

A

Short segment, long segment and total colonic agangliosis disease

Short term is the most common (85% of cases) - restricted to rectosigmoid portion of colon

20
Q

What is the pathophysiology of Hirschsprung’s?

A

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

21
Q

What are the risk factors of Hirschsprung’s?

A

Male (4x risk), chromosomal abnormalities, family history

22
Q

What are some differentials of Hirchsprung’s?

A

Meconium plug syndrome, meconium ileus, intestinal atresia, intestinal malrotation, anorectal malformation, constipation

23
Q

How is Hirschsprung’s investigated?

A

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

24
Q

How is Hirschsprung’s managed?

A

IV antibiotics, NG insertion, bowel decompression

Surgery - resecting the ganglionic section of bowel and connecting the unaffected bowel to the dentate line

25
Q

What are some complications of Hirschsprung’s?

A

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

26
Q

What are the terms used to describe the proximal bowel segment and distal bowel segment in intussusception?

A

Proximal = intussusceptum

Distal = intussucipiens

27
Q

What is intussusception?

A

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

28
Q

When is the peak incidence of intussusception?

A

Between 5-7 months of age

Rare after 2 years

29
Q

What are some risk factors for intussusception?

A

Rotaviruses, Meckel’s diverticulum, polyps, Henoch-Schonlein purpura, lymphoma, post op

30
Q

What are the clinical features of intussusception?

A

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

31
Q

What are the differentials of intussusception?

A

Colic, testicular torsion, appendicitis, gastroenteritis, volvulus

32
Q

How is intussusception investigated?

A

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

33
Q

How is intussusception managed?

A

Fluid resuscitation if shock or dehydration, NG tube insertion

Non operative reduction - air or contrast enema to reduce the intussuscepted bowel

Surgical reduction

34
Q

What are some complications of intussusception?

A

Obstruction, perforation, dehydration and shock

35
Q

What is cryptorchidism?

A

Failure of testicular descent into the scrotum

36
Q

What are some risk factors for cryptorchidism?

A

Prematurity, low birth weight, genital abnormalities eg hypospadias, family history

37
Q

What is the management of cryptorchidism?

A

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

38
Q

What are some complications of cryptorchidism?

A

Impaired fertility, testicular cancer, torsion

Paediatrics (7 decks)

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