Surgery Flashcards
What findings of appendicitis may lead to incorrect diagnosis?
- diarrhoea, tender RIF –> sounds like gastroenteritis
- WBC common in urine as inflamed appendix may be next to ureter or bladder
What is an appendicular mass?
Omentum and small bowel adhere to appendix
Fever and palpable mass
Conservative treatment with fluids, analgesia and Abx - may need surgery
What is an appendicular abscess?
Shown on USS, CT or worsening CRP
Per cutaneous or open drainage
What are causes of acute abdomen in infants?
Intestinal obstruction and intussusception Gastroenteritis Constipation Meckel's diverticulum Malrotation Incarcerated hernia Hirschprung's disease UTI
What are the causes of acute abdominal pain in pre-school children?
Gastroenteritis Appendicitis Constipation UTI Intussusception Volvulus Mesenteric lymphadenitis Henoch-Schonlein purpura
What are the causes of acute abdomen in pre-pubescent children?
Gastroenteritis Appendicitis Constipation UTI Trauma Pneumonia Henoch-Schonlein purpura Mesenteric lymphadenitis
What are the causes of acute abdomen in teenagers?
Appendicitis Gastroenteritis Constipation Dysmenorrhea Mittelschmerz PID Ectopic pregnancy Ovarian/testicular torsion Diabetic ketoacidosis
What are the clinical features of inguinal hernia?
BOYS>girls
INDIRECT>direct
Decent of testis preceded by some peritoneum which normally obliterates
Intermittent swelling in groin on crying or straining
What are the consequences of an inguinal hernia?
Irreducible - lump is firm and tender, infant unwell with irritability and vomiting
Can normally be reduced after opioid analgesia and compression
Can cause strangulation of bowel and damage to testes
What are the clinical features of intestinal obstruction?
May be recognised antenatally on USS
Persistent vomiting - bile stained if obstruction is below ampulla of Vater
Meconium may be initially passed but then delay of stools
Abdominal distension >the more distal the obstruction is
What are causes of intestinal obstruction?
Small bowel obstruction
- Atresia/stenosis of duodenum - associated with Down’s
- Atresia/stenosis of jejunum/ileum - multiple sections
- Malformation or volvulus –> infarction of midgut
- Meconium ileus/plug - almost all have CF
Large bowel obstruction
- Hirschsprung disease - no passing of meconium which causes blockage
- Rectal atresia - can have fistula so to bladder or vagina
How does intussusception present?
Invagination of proximal bowel into distal segment (most commonly ileum into caecum or colon through ileocaecal valve)
Occurs between 2 months and 2 years
Paroxysmal, severe colicky pain and pallor
Sausage-shaped mass palpable in abdomen
Red currant jelly stool
Abdominal distension
How is intussusception investigated and treated?
AXR - distended small bowel and absence of gas in distal colon
Abdominal USS
Rectal air insufflation
Surgery
Complications - stretching and constriction of mesenteric –> venous obstruction, engorgement and bleeding, perforation, peritonitis and necrosis
What is pyloric stenosis?
Hypertrophy of the pyloric muscle causing gastric outlet obstruction
Presents at 2-7 weeks old, more common in boys and firstborns
Vomiting (non-bile stained) - increases in forcefulness until it becomes projectile –> alkalosis due to loss of stomach acid (low chloride and potassium)
Hunger after vomiting
Weight loss
How is pyloric stenosis diagnosed and treated?
Mass palpable in RUQ
USS
Metabolic alkalosis
?jaundice
Correct fluid and electrolyte imbalances
Pyloromyotomy (muscle but not mucosa is cut)
What are causes of acute scrotum and the age variances?
Testicular torsion - Common in infants and adolescents
Hydatid torsion - common around 10
Epididymitis - common in infants and toddlers
What are the clinical features of appendicitis?
- anorexia
- vomiting or diarrhoea a couple of times
- central colicky pain –> right iliac fossa - worse on movement
- flushed face
- low grade fever (37.2-38)
- tenderness with guarding in RIF (McBurney’s point)
- rebound tenderness
- obturator sign (internal rotation of flexed right thigh –> pain)
- faecoliths (on AXR) and perforation more common in young children
How is testicular torsion caused and how is it treated?
- common in adolescents
- pain may be in scrotum, groin or lower abdomen
- previous self-limiting episodes
- acute onset pain and swelling
- absent cremasteric reflexes
- must be relieved within 6-12hrs via surgery to both testes
What is torsion of testicular appendage?
- torsion of hydatid of Morgagni (embryological remnant on upper pole of testes)
- presents just prior to puberty
- pain increases over 1-2 days
- blue dot sign
What are other causes of acute scrotum?
- viral/bacterial epididymo-orchitis (UTI, STI, mumps, operation, medication)
- epididymitis
- UTI
- incarcerated inguinal hernia
- idiopathic scrotal oedema
What is volvulus and how does it present?
malrotation is abnormality of bowel during development
volvulus is complication and occurs when blood supply is cut off
bloody/dark red stools, constipation, distended abdomen, pain/tenderness, N+V, pulling up of legs
BILIOUS VOMITING
How is volvulus investigated and managed?
Generally, diagnosis made clinically
FBC - shows severity, sepsis, venous oozing
U+E - hydration status, sepsis, acidosis
AXR
Surgery - caecum on L and duodenum on R
What is balanitis and what are the causes?
inflammation of end of penis, may also involve foreskin
commonly
What causes pathological phimosis?
Whitish scarring of foreskin rare before 5yo
Due to Balanitis Xerotica Obliterans (BXO) which can cause urethral meatal stenosis
What causes cervical lymphadenopathy in children?
Acute causes
- transient response to local or generalised infection
- viral URTI or streptococcal pharyngitis (acute bilateral)
- streptococcal or staphyloccal infection (acute unilateral)
Chronic causes
- cat scratch diseae
- mycobacterial infection
- toxoplasmosis
- neuroblastoma and leukaemia 6yo
What else causes neck swelling?
- mumps (swelling crosses angle of jaw)
- thyroglossal cyst (moves up with swallowing or tongue protrusion)
- brachial cleft cyst (lower ant border of SCM)
- sternomastoid tumour (can be moved horizonally but not vertically)
- cervical ribs
- cystic hygroma (multiloculated, diffuse, transilluminates)
- laryngocele (becomes larger with valsalva manouvere, stridor)
- dermoid cyst (midline)
What are cleft lip and palate?
Cleft lip - failure of frontonasal and maxillary processes to fuse
Cleft palate - failure of fusion of palatine process and nasal septum
What are common problems with cleft lip and palate?
feeding problems - inadequate suck
ear infections - acute otitis media
speech and language problems
dental health
What other conditions are associated with or cause cleft lip/palate?
anti-convulsant therapy
isotretinoin
Patau syndrome
Pierre Robin syndrome - abnormally small lower jaw with tongue falling backwards into throat
How do diaphragmatic hernias develop?
Failure of one or both pleuroperitoneal membranes to close –> continuous peritoneal and pleural cavities along post body wall
Abdominal viscera can enter pleural cavity
Which organs normally enter a diaphragmatic hernia?
Usually hernia is on left side so: intestinal loops stomach spleen liver
Pushes heart anteriorly and compresses lungs –> hypoplastic
What are presenting features of a diaphragmatic hernia?
cyanosis tachypneoa tachycardia chest wall asymmetry absent breath sounds over one side of chest bowel sounds audible over chest wall
What are signs of a serious head injury?
Witnessed LOC >5 mins Amnesia >5 mins >3x vomiting NAI Seizure w/o epilepsy GCS
What is a hydrocele?
Patent processus vaginalis which is too narrow for hernia but allows peritoneal fluid to track down around testes
Non-tender and transilluminate
If >18 months consider surgery
How do the intestines rotate in utero?
Fixes at duodenojujunal flexure and ileocaecal region
How does malrotation present?
GREEN BILIOUS VOMITING
What is necrotising enterocolitis?
Pseudomonas aeruginosa invasion of ischaemic bowel wall, mostly terminal ileum and ascending colon
Occurs in premis in first weeks of life esp. if only bottle fed
How does NEC present?
feeding intolerance delayed gastric emptying abdo distension ileus erythema bilious vomiting PR blood
Intramural air on AXR
How is NEC treated?
Stop oral feeding
Broad spectrum Abx
Parenteral nutrition
Development of strictures and malabsorption
What is a sacrococcygeal teratoma?
thought to be derived from primitive streak and is benign
presents on antenatal screening
What causes supparative adenitis/lympadenitis?
Small, palpable cervical, axillary and inguinal nodes
URTI with sore throat, earache, coryza or impetigo
Fever, irritability and anorexia
Contact with KITTEN
How does TOF present?
Maternal polyhydramnios
Absent gas on prenatal USS
Secretions –> rattling respiration, coughing, choking
What are the types of TOF?
Type A - proximal is blind ending, distal is TEF
Type B - blind ending proximal and distal
Type C - Oesophagus communicates but is intact
Type D - proximal TEF and blind ending distal
Type E - proximal and distal TEF without connection
How are undescended testes classified?
Retractile - can be manipulated into bottom of scrotum but then retract as pulled up by cremasteric muscle
Palpable - can be palpated in groin but not manipulated
Impalpable - may be in inguinal canal, intra-abdominal or absent
How are undescended testes investigated and managed?
USS - identifies bilateral impalpable testis in inguinal region
Laparoscopy
Fertility - need to be cooler than body
Malignancy
How do gastroschisis and exomphalos present?
Exomphalus - contents of abdomen (bowel +/- liver) herniate into umbilical cord through umbilical ring
viscera are covered by peritoneum and amnion
Gastroschisis - defect to right of umbilical cord abdo contents (only small intestine) herniate into amniotic sac no covering membrane
What is urachus?
Joining of urinary bladder of fetus to umbilical cord
Child will leak urine from umbilical cord
What is umbilical granuloma?
Inflammatory process at umbilicus causes excess granulation tissue
Silver nitrate cauterisation is the treatment
What is bladder exstrophy?
Part of bladder is present outside body due to failure of abdominal wall to close
What anorectal malformations exist?
- membrane over anal opening
- imperforate anus (rectum not connected to anus)
- rectum may be connected to part of urinary or reproductive system via fistula
- anal stenosis
- rectum may be connected to another part of the skin
What conditions are associated with anorectal malformations?
Associated with Trisomy 18 and diabetic mothers
Vertebral - hypoplastic vertebrae and scoliosis
Anorectal atresia
Cardiovascular - ASD, VSD and tetralogy of Fallot
TOF
Esophageal and duodenal atresia
Renal - one umbilical vein
Limb defects - hypoplastic thumbs, extra digits
How are anorectal malformations treated?
Low anomalies - anoplasty with serial dilators
High anomalies - temporary colostomy and then new anus
How do atresias of the bowel present?
BILIOUS VOMITING Prematurity Polyhydramnios Low birth weight Failure to pass meconium
What are indications for circumcision?
With age, most foreskins become retractible
- pathological phimosis - white scarring (BXO)
- recurrent balanoposthitis - redness and inflammation of foreskin
- recurrent UTIs
How do labial adhesions present?
Tend to be noticed by parents, urine pooling in vagina
Membrane between labia minora starting at back and working forwards
Need to rule out sex abuse
Oestrogen cream will help separate
How does Meckels diverticulum present?
Located in distal ileum within 1m of ileocaecal valve
PAINLESS RECTAL BLEEDING - ectopic mucosal tissue leads to GI bleeding
What are complications of Meckels?
- bowel obstruction - abdo pain, vomiting, may mimick appendicitis
- diverticulitis - acute inflammation
- umbilical abnormalities - fistulas, cysts, sinuses and fibrous bands from diverticulum to umbilicus
What is a varicocele?
Abnormal dilation of testicular veins in pampiniform venous plexus caused by reflux
Cause reduction of testicular function –> infertility
MORE COMMON ON LEFT
How does a varicocele present?
Increases in incidence after puberty
Scrotum ‘feels like bag of worms’ and hangs lower when standing
Identified with Doppler and USS
Which imaging techniques are indicated in different situations?
MRI - better at differentiating soft tissue, brain tumours,
CT - better for bony structures, lung and chest
