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
