Surgery Flashcards
features of exomphalos/omphalocele?
protrusion of abdominal contents through umbilical ring, covered with transparent sac formed by amniotic membrane and peritoneum
often assoc. with other major congenital abnormalities
features of gastroschisis?
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
gastroschisis management?
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.
presentation of pyloric stenosis?
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+
how is pyloric stenosis diagnosed?
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.
pyloric stenosis mangement?
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.
who is pyloric stenosis more common in?
boys-4 times more common than girls, part. first borns
maternal FH
surgical differentials for presentation of acute abdo pain in children?
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
intra-abdominal medical causes of acute abdominal pain?
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
extra-abdominal causes of acute abdominal pain?
URTI
lower lobe pneumonia
torsion of testis
hip and spine
importance of urine sample test in acute abdomen presentation in children?
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.
signs o/e of acute appendicitis?
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
problems associated with diagnosis of acute appendicitis in pre-school children?
signs easy to underestimate at this age
perforation may be rapid as omentum less well developed and fails to surround inflamed appendix.
define non-specific abdo pain
abdo pain which resolves in 24-48hr
less severe pain than that in appendicitis, variable RIF tenderness
features of mesenteric adenitis?
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.
define intussusception
invagination of proximal bowel into a distal segment, usually ileum passing into caecum through ileo-caecal valve
peak presentation between 3mnths and 2yrs
commonest cause of intestinal obstruction in infants after neonatal period?
intussusception
most serious complication of intussusception?
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.
presentation of intussusception?
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
cause of intussusception?
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
investigation and management of intussusception?
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.
what examination must always be performed in the presentation of a boy or young man with inguinal or lower abdo pain of sudden onset?
genitalia:
must exclude testicular torsion-EMERGENCY
management of testicular torsion?
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.
features o/e of testicular torsion?
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.
usual presentation of small bowel malrotation?
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
what may contribute to bowel obstruction in malrotation?
Ladd bands-may cross the duodenum
why should congenital inguinal hernias be surgically repaired soon after diagnosis?
note indirect-result of persistent processus vaginalis
surgery due to risk of strangulation
which infants are particularly affected by inguinal hernias?
much more frequent in boys and are particularly common in premature infants
how might an inguinal hernia be made visible in an infant?
by asking them to cough or by pressing on the abdomen
when is surgery performed for inguinal hernias in infants?
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
why are undescended testes more common in premature infants?
as descent through inguinal canal occurs in 3rd trimester
investigation of choice for impalpable testis?
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
classification of cryptorchidism?
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
problems assoc. with undescended testis?
infertility
malignancy
surgery for undescended testis?
orchidopexy via an inguinal incision
define a meckel’s divericulum?
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
