Surgery 4

Question 1

What are the common conditions that get confused with appendicitis?

Answer 1

Gastroenteritis- vomiting often precedes pain
UTI- WBC can be in urine in appendicitis too. USS will differentiate
Retrocaecal appendix (15%)- pain will localise to psoas muscle, can localise to rectum or bladder

Question 2

What is an appendicular mass?

Answer 2

the omentum and small bowel adhere to the appendix- presents with a fever and a palpable mass
initial treatment is usually conservative with fluids, analgesia and antibiotics but urgent surgical intervention may be required if the mass
enlarges or the patient’s condition deteriorates recovery following conservative treatment is usually by appendectomy

Question 3

What is an appendicular abscess?

Answer 3

can be shown by ultrasound or CT scan and the initial treatment is by percutaneous or open drainage, but open drainage also enables appendectomy
a worsening CRP with a good history is a sure signal of rupture and abscess formation

Question 4

How does a volvulus present?

Answer 4

complication of malrotation and occurs when the bowel twists so the blood supply to that part of the bowel is cut off 
o	Bloody or dark red stools
o	Constipation
o	Distended abdomen
o	Pain or tenderness of the abdomen
o	Nausea or vomiting- which is often bilious
o	Failure to thrive
o	Shock

Question 5

What are the red flags for vomiting?

Answer 5

Bile-stained- intestinal obstruction
Haematesmesis- oesophagitis, peptic ulceration, oral/nasal bleeding
Vomiting at end of coughing- whooping cough (pertussis)
Abdo tenderness- surgical abdomen
Abdo distension- intestinal obstruction, strangulated hernia
Hepatosplenomegaly- chronic liver disease
Blood in the stool- intussusception, gastroenteritis
Severe dehydration (shock)- infection, DKA, gastroenteritis
Bulging fontanelle or seizures- raised ICP
FTT- GORD, coeliac

Question 6

What are the investigations for a volvulus?

Answer 6

FBC, WCC (sepsis), low hb (venous oozing)
U+Es to assess hydration
Hyponatraemia, hyperkalaemia, metabolic acidosis, increased urea and creatinine, hypochloraemia and lactic acidosis can occur in such cases
Contrast studies are best for diagnosing

Question 7

What is the management for a volvulus?

Answer 7

Surgery- rotating the small intestine in an anti- clockwise direction-with the caecum being placed on the left side and the duodenum directed down to the right
• Initial management should include fluid resuscitation

Question 8

What is necrotising enterocolitis?

Answer 8

Mainly affects preterm infants
pseudomonas aeruginosa is thought to be the cause- it is associated with bacterial invasion of ischaemic bowel wall
Most common GI emergency in neonates
Mostly affects the terminal ileum and proximal ascending colon

Question 9

How does necrotising enterocolitis present?

Answer 9

o	Feeding intolerance
o	Delayed gastric emptying
o	Abdominal distension and tenderness
o	Ileus
o	Erythema
o	Apnoea
o	Lethargy
o	Decreased peripheral perfusion
o	Shock
o	Cardiovascular collapse
o	Hypoglycaemia
o	Bilious vomiting
o	Abdominal distension
o	Blood per rectum
o	Free abdominal air
o	Systemic shock

Question 10

What are the characteristic X-ray signs of necrotising enterocolitis?

Answer 10

Distended loops of bowel and thickening of the bowel wall with intramural gas
The disease may progress to perforation and x-ray will show gas under the diaphragm, transillumination of the abdomen and intraperitoneal fluid

Question 11

What are the investigations for necrotising enterocolitis?

Answer 11

o	FBC
o	Blood cultures
o	U&E’s
o	ABG
o	Imaging  x-ray +/- ultrasound

Question 12

What is the management of necrotising enterocolitis?

Answer 12

stop oral feeding and give broad spectrum antibiotics to cover both aerobic and anaerobic organisms
• Parenteral nutrition is always needed and artificial ventilation and circulatory support are often needed
• The disease has significant morbidity and mortality and the long-term sequelae include development of strictures and malabsorption if extensive bowel resection has been necessary

Question 13

How do bowel atresias present?

Answer 13

o	Bilious vomiting
o	Prematurity
o	Polyhydramnios
o	Low birth weight
o	Jaundice
o	Abdominal distension
o	Failure to pass meconium
Dehydration, poor urine output, tachycardia and neurological involvement

Question 14

What do bowel atresias look like on imaging?

Answer 14

• Plain abdominal radiograph will show a dilated gas bubble and massively dilated proximal bowel with a gasless abdomen distal to the obstruction- contrast studies will clearly show the anomaly

Question 15

What are the types of testicular torsion?

Answer 15

o An extravaginal torsion (5%) usually manifests in the neonatal period and most commonly develops prenatally in the spermatic cord, proximal to the attachment of the tunica vaginalis
o An intravaginal torsion (16%) occurs within the tunica vaginalis and usually in older children (13 years typically)

Question 16

How does testicular torsion present?

Answer 16

• Presentation is typically a firm, hard scrotal mass which does not transilluminate in an otherwise asymptomatic newborn male
The scrotal skin characteristically fixes to the necrotic gonad- in older boys the presentation is sudden onset of severe testicular pain followed by inguinal or scrotal swelling- pain may lessen as necrosis becomes more complete, in some patients scrotal trauma or scrotal disease may precede the presentation
a physical examination will reveal a swollen and tender, high riding testis
there will be an absent cremasteric reflex

Question 17

How quickly must torsion of the testes be managed?

Answer 17

Within 6–12 h of the onset of symptoms for there to be a good chance of testicular viability
surgical exploration is mandatory unless torsion can be excluded, if torsion is confirmed, fixation of the contralateral testis is essential because there may be an anatomical predisposition to torsion, for example the ‘bell clapper’ testis – where the testis is not anchored properly

Question 18

What are the causes of epididymo-orchitis?

Answer 18

o Urine infection: bacterial infections (E.coli) can tract down the vas deferens to cause an acute epididymo-orchitis, this can happen at any age and is the most common cause over 3½, this is because partial blockage of urine becomes more common with age
o STI: a common cause in young men with chlamydia and gonorrhoeal infection being most common
o Mumps: can occur in 1 in 5 cases but is now uncommon due to the MMR vaccination
o Operation: any operation in this area can cause this
o Medication: particularly amiodarone

Question 19

What are the symptoms of epididymo-orchitis?

Answer 19

Acute- testes swell rapidly, scrotum becomes enlarged, tender, red and painful
Dysuria, fever. discharge

Question 20

What causes balanitis?

Answer 20

o Poor hygiene- combined with a tight foreskin this can lead to irritation by smegma (a cheesy-like substance which forms under the foreskin if the glans is not cleaned), this is the most common cause
o Infection (not STI): candida is a common infection and is more likely if there is alreadyinflammation, the patient has diabetes or there is phimosis
o STI: less likely in children but should be considered
o Allergy or irritants
o Skin condition

Question 21

How does balanitis xerotica obliterans present?

Answer 21

Involves glans penis and causes urethral meatal stenosis

Burning, pruritus, hypoesthesia, dysuria, painful erection and these occur over months to years.

Question 22

How is balanitis managed?

Answer 22

Avoid soaps when inflammation is present
o Anti-yeast cream of anti yeast tablets
o Antibiotics
o A mild steroid cream

Question 23

What is the management for hydrocele?

Answer 23

The majority resolve spontaneously as the processus continues to obliterate- but surgery is considered if it persists beyond 18–24 months of age
• A hydrocele of the cord forms a non-tender mobile swelling in the spermatic cord