Surgery

Question 1

features of exomphalos/omphalocele?

Answer 1

protrusion of abdominal contents through umbilical ring, covered with transparent sac formed by amniotic membrane and peritoneum
often assoc. with other major congenital abnormalities

Question 2

features of gastroschisis?

Answer 2

bowel protrusion through defect in anterior abdo wall, adjacent to umbilicus, no covering sac
not associated with other congenital abnormalities
much greater risk than exomphalos of dehydration and protein loss as lacks protective sac covering, so must wrap abdomen in several layers of clingfilm to minimise fluid and heat loss

Question 3

gastroschisis management?

Answer 3

wrap abdomen in several layers of clingfilm to minimise fluid and heat loss
pass NGT and aspirate frequently
IV infusion of dextrose
colloid support?-replace protein loss
repair surgically with primary closure of abdomen
if large lesion, may have to enclose intestine in silastic sac sutured to edges of abdominal wall, and contents gradually returned into peritoneal cavity.

Question 4

presentation of pyloric stenosis?

Answer 4

usually between 2 and 7wks of age, irrespective of gestational age, with:
non-bilious projectile vomiting-vomiting increases in frequency and forcefulness over time, typically occurs 30mins after feeding
hunger after vomiting until dehydration leads to loss of interest in feeding
weight loss if delayed presentation

investigations-hypochloraemic metabolic alkalosis with low plasma Na+ and K+

Question 5

how is pyloric stenosis diagnosed?

Answer 5

test feed-baby given milk feed which will calm hungry infant and allow examination: visible gastric peristalsis-wave moving from L to R across abdomen, and pyloric mass-olive, palpable in RUQ.
stomach may be overdistended with air and will require NG aspiration to empty to allow palpation
US can be used if diagnosis in doubt-shows thickened and elongated pylorus.

Question 6

pyloric stenosis mangement?

Answer 6

correct fluid and electrolyte abnormalities-need IV fluids
definitive tment=surgery=pyloromyotomy-hypertrophied pylorus is divided down to but not including the mucosa
PO child can usually be fed within 6hr and discharged within 2 days of surgery.

Question 7

who is pyloric stenosis more common in?

Answer 7

boys-4 times more common than girls, part. first borns

maternal FH

Question 8

surgical differentials for presentation of acute abdo pain in children?

Answer 8

acute appendicitis
intest obstruction including intussuception
inguinal hernia
peritonitis-*note risk in infants with ascites due to nephrotic syndrome or liver disease
inflamed Meckel diverticulum
pancreatitis
trauma

Question 9

intra-abdominal medical causes of acute abdominal pain?

Answer 9

non-specific abdo pain and mesenteric adenitis
gastroenteritis
urinary: UTI, acute pyelonephritis, hydronephrosis, renal calculus
HSP
DKA
sickle cell disease
hepatitis
IBD
constipation
recurrent abdo pain of childhood
gynaecological
psychological
lead poisoning
acute porphyria
unknown

Question 10

extra-abdominal causes of acute abdominal pain?

Answer 10

URTI
lower lobe pneumonia
torsion of testis
hip and spine

Question 11

importance of urine sample test in acute abdomen presentation in children?

Answer 11

exclude UTI, glycosuria and ketones-DKA

white cells in urine may be present in acute appendicitis as inflamed appendix may be adjacent to ureter or bladder.

Question 12

signs o/e of acute appendicitis?

Answer 12

flushed face with oral fetor
low-grade fever 37.2-38 degrees C
abdo pain aggravated by movement e.g. walking, coughing, jumping, bumps on car journey
persistent tenderness with guarding in RIF
Rovsing’s sign-palpating LIF increases pain felt in RIF

can occur at any age but uncommon under 3yrs
must ensure rpted observation and clinical r/v as progressive condition, can help distinguish from non specific abdo pain-mesenteric adenitis

Question 13

problems associated with diagnosis of acute appendicitis in pre-school children?

Answer 13

signs easy to underestimate at this age

perforation may be rapid as omentum less well developed and fails to surround inflamed appendix.

Question 14

define non-specific abdo pain

Answer 14

abdo pain which resolves in 24-48hr

less severe pain than that in appendicitis, variable RIF tenderness

Question 15

features of mesenteric adenitis?

Answer 15

less severe pain than in appendicitis, variable RIF tenderness
often URTI with cervical lymphadenopathy
definitive diagnosis only by laparotomy or laparoscopy where large mesenteric nodes seen and appendix is normal.

Question 16

define intussusception

Answer 16

invagination of proximal bowel into a distal segment, usually ileum passing into caecum through ileo-caecal valve
peak presentation between 3mnths and 2yrs

Question 17

commonest cause of intestinal obstruction in infants after neonatal period?

Answer 17

intussusception

Question 18

most serious complication of intussusception?

Answer 18

stretching and constriction of mesentery causing venous obstruction, leading to engorgement and bleeding from bowel mucosa, fluid loss and subsequent bowel perforation, peritonitis and gut necrosis.

Question 19

presentation of intussusception?

Answer 19

paroxysmal severe colicky abdo pain and pallor-during pain episodes, espec. around mouth, and pt draws up their legs, initially recovers between episodes but resultantly becomes increasingly lethargic
may refuse feeds, vomit-can become bile-stained
sausage-shaped mass, often palpable in abdomen
blood in stools-characteristic redcurrant jelly stool with blood-stained mucus, later sign in illness, may be found on DRE
abdo distension and SHOCK

Question 20

cause of intussusception?

Answer 20

usually no underlying intestinal cause found
may be related to viral infection causing enlargement of peyer’s patches which form lead point of intussusception
other identifiable lead points e.g. meckel diverticulum, more likely in children over 2

Question 21

investigation and management of intussusception?

Answer 21

usually need immediate fluid resuscitation due to fluid pooling in gut which can cause hypovolaemic shock
AXR-distended small bowel, and absence of gas in distal colon or rectum, sometimes can visualise outline of intussuception
abdo US-may show target like mass, can also check response to tment
unless signs of peritonitis, reduction of intussusception by rectal air insufflation usually tried by radiologist, only after child has been resuscitated, and under paed surgeon supervision
if unsuccessful, require operative reduction
recurrence more likely after hydrostatic reduction.

Question 22

what examination must always be performed in the presentation of a boy or young man with inguinal or lower abdo pain of sudden onset?

Answer 22

genitalia:

must exclude testicular torsion-EMERGENCY

Question 23

management of testicular torsion?

Answer 23

surgical: must relieve within 6-12hr of symptom onset for there to be good chance of testicular viability
must fixate CL testis as may be anatomical predisposition to torsion e.g. bell clapper testis-testis not anchored properly.

Question 24

features o/e of testicular torsion?

Answer 24

swollen and raised testis
ALWAYS tender on palpation, even if pt does not describe hx of testicular pain e.g. may complain of R lower abdo pain or inguinal pain.

Question 25

usual presentation of small bowel malrotation?

Answer 25

obstruction with bilious vomiting in 1st few days of life, but can be seen at later age
any child with dark green vomiting requires urgent upper GI contrast study to assess intestinal rotation unless signs of vasc compromise present-need urgent laparotomy

require urgent surgical correction

Question 26

what may contribute to bowel obstruction in malrotation?

Answer 26

Ladd bands-may cross the duodenum

Question 27

why should congenital inguinal hernias be surgically repaired soon after diagnosis?

Answer 27

note indirect-result of persistent processus vaginalis

surgery due to risk of strangulation

Question 28

which infants are particularly affected by inguinal hernias?

Answer 28

much more frequent in boys and are particularly common in premature infants

Question 29

how might an inguinal hernia be made visible in an infant?

Answer 29

by asking them to cough or by pressing on the abdomen

Question 30

when is surgery performed for inguinal hernias in infants?

Answer 30

surgery delayed for 24-48hrs to allow oedema to resolve
if cannot reduce, emergency surgery done due to risk of bowel strangulation and damage to testis
hernia assoc. with an undescended testis should be operated on early to minimise risks to testis

surgery performed via inguinal skin crease incision-ligation and division of processus vaginalis

Question 31

why are undescended testes more common in premature infants?

Answer 31

as descent through inguinal canal occurs in 3rd trimester

Question 32

investigation of choice for impalpable testis?

Answer 32

laparoscopy-must 1st check testis is not in the inguinal canal

others-US-used in those with bilateral impalpable testes to verify internal pelvic organs
hormonal-for bilateral impalpable testes-presence of testicular tissue can be confirmed by recording a rise in serum testosterone in response to IM injection of hCG

Question 33

classification of cryptorchidism?

Answer 33

retractile testis-can be manipulated into scrotum without tension but retract into inguinal region, pulled up by cremasteric muscle
with age, testis will reside permanently in scrotum
f/u advisable as rarely testis subsequently ascends into inguinal canal
palpable testis-testis palpated in groin but cannot be manipulated into scrotum, occasionally ectopic when lies outside normal line of descent-may be found in perineum or femoral triangle
impalpable-no testis felt, may be in inguinal canal, intra-abdominal or absent

Question 34

problems assoc. with undescended testis?

Answer 34

infertility

malignancy

Question 35

surgery for undescended testis?

Answer 35

orchidopexy via an inguinal incision

Question 36

define a meckel’s divericulum?

Answer 36

an ileal remnant of the vitello-intestinal duct which contains ectopic gastric mucosa or pancreatic tissue
may present with severe PR bleeding, intussuception, volvulus around a band, or diverticulitis which mimics appendicitis.
technetium scan-increased uptake my gastric mucosa

tment=surgical resection