Surgery Flashcards
Causes of acute abdo pain in children - medical? (15)
Non-specific abdo pain Gastroenteritis Urinary tract - UTI, pyelonephritis, hydronephosis, renal calculus HSP DKA Sickle cell disease Hepatitis IBD Constipation Functional/recurrent abdo pain of childhood Gynae Psychological Lead poisoning Acute porphyria Unknown
Causes of acute abdo pain in children - surgical? (7)
Acute appendicitis Intestinal obstruction Inguinal hernia Peritonitis Inflamed Meckel diverticulum Pancreatitis Trauma
Causes of acute abdo pain in children - extra-abdominal?
URTI
Lower lobe pneumonia
Torsion of testis
Hip/spine
Ix for acute abdo pain?
- Urine dip → UTI/DKA
- Pregnancy test (maybe)
- Bloods – U&Es, FBC, LFTs, glucose, calcium
- Group and save
- Urinalysis
- ECG
- O2 saturation
- Radiology
S+S of appendicitis?
Sx:
- Anorexia
- Vomiting (usually only few times) or diarrhoea (not sig amounts)
- Abdo pain – initially central and colicky but then localising to RIF
Signs:
- Flushed face
- Low-grade fever 37.2-38 degrees
- Abdo pain aggravated by movement
- Persistent tenderness with guarding in RIF (McBurney’s point) – pos absent in retrocaecal appendix
- Rebound tenderness
- Obturator sign – internal rotation of a flexed right thigh will give pain if there is an inflammatory mass overlying obturator space (pelvic appendicitis)
- Rovsing sign – pain in RLQ when palpate LLQ → indicates peritoneal irritation
- May be few abdo signs in pelvic appendix
- Appendicitis progressive therefore clinical review every few hours essential to diagnosis
Ddx of appendicitis? (9)
- Gastroenteritis – N&V and diarrhoea
- Constipation
- PID
- Volvulus
- Hirschprung’s disease
- Intussusception
- Ovarian cysts
- Pregnancy
- Mesenteric adenitis
Ix for appendicitis? (3)
- No lab test/ imaging consistently helpful in making diagnosis
- Bloods: FBC, CRP, LFTs, amylase and lipase – useful if aetiology unclear
- USS – may support clinical diagnosis
- Laparoscopy if available
What is an appendicular mass?
- Complication of appendicitis
- Omentum and small bowel adhere to appendix
- Usually presents with fever and palpable mass
- Initial treatment = fluids, analgesia and abx but urgent surgical intervention may be required if mass enlarges or pt’s condition deteriorates
- Recovery following conservative treatment usually by appendectomy
Diagnosis and treatment of appendicular abscess?
- Can be shown by USS or CT
- 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
S+S of intestinal obstruction? (6)
- Persistent, bile-stained vomiting – non bilious if before ½ duo
- Delayed or absent passage of meconium
- Abdo distention - depends on location
- Abdo pain usually colicky then constant – child can’t sit still
- Tenderness - minimal and diffuse or localised and severe
- Auscultation - High pitched hyperactivity = mechanical obstruction - Over time waves and bowel sounds disappear
Causes of intestinal obstruction? (10)
- NEC
- Small bowel atresia
- Volvulus and malrotation
- Imperforate anus
- Gastroschisis / exomphalus
- Duodenal atresia/stenosis
- Meconium ileus (consider CF)
- Prenatal perforation (rare)
- Hirschprungs disease (common)
- Functional obstruction - defect in nn growth into myenteric plexi of bowel
Ix for intestinal obstruction?
AXR CXR - pos for perforation FBC, U&E’s, Creatinine Glucose Urinalysis ABG Stool for occult blood
Peak age of intussusception?
3m-2y
–> Commonest cause of obstruction in infants after neonatal period
Presentation of intussusception? (6)
Pain - severe, colicky Vomiting Mass Redcurrant jelly stool Abdo distension Shock
Ix for intussusception? (2)
AXR
- Distended small bowel and absence of gas in distal colon/rectum
USS
- Helpful to diagnose/check response to treatment
Management of intussusception?
- IV fluid rescus likely to be needed immediately (often pooling in gut)
- Unless peritonitis, reduction of intussusception by rectal air insufflation
- → Only carried out once child has been resuscitated and under supervision of paediatric surgeon in case unsuccessful or bowel perforation occurs
- Sucess rate = 75%
- Remaining 25% require operative reduction
- Recurrence occurs in <5% but more frequent after hydrostatic reduction
Complications of intussusception? (3)
- Shock and dehydration
- Stretching and constriction of mesentery → venous obstruction → engorgement and bleeding from bowel mucosa, fluid loss and subsequently bowel perforation, peritonitis and gut necrosis
- Metabolic acidosis
What is volvulus?
Loop of intestine twists around self and mesentery → bowel obstruction
Clinical features of volvulus? (7)
- Bilious vomiting
- Bloody/ dark red stools
- Constipation + cramps (crying, pulling legs up)
- Distended abdo
- Tender abdo
- Dehydration – dry nappies, sunken fontanelle
- Ischaemia → acute abdo + peritonitis → raised HR, shock, hypovolaemia
Management of volvulus? (3)
Surgery
- Rotate volvulus (Ladds procedure, not laparoscopic)
- Bowel straightened, infarcted bowel removed
Fluid resuscitation
NG tube to drain stomach and bowel contents pre-op
RFs for NEC? (4)
- Preterm
- Low birthweight
- Cow’s milk formula
- Patent ductus arteriosus
Most common location of NEC? (2)
Terminal ileum
Proximal ascending colon
S+S of NEC? (7)
- Usually in first 2w
- Distension + tenderness
- Vomiting – bilious
- Bloody mucoid stool
- ↓ Bowel sounds, palpable mass
- May rapidly become shocked and require artificial ventilation
- Stop tolerating feeds
Xray findings in NEC? (4)
- Distended loops of bowel
- Thickened bowel wall
- Intramural gas and gas in portal tract
- If perforation may see free air in abdo
Management of NEC?
- Triple Abx therapy (broad spec)
- Nil by mouth
- Parental nutrition needed
- If complications (perforation or stenosis > surgery may be required to remove non-functioning bowel)
- Artificial ventilation and circulatory support often needed
Clinical features of bowel atresia?
- Bilious vomiting
- Prematurity
- Polyhydramnios
- Low birth weight
- Additional early signs = jaundice, abdo distension and failure to pass meconium
- Signs of continuous fluid loss such as dehydration, poor urine output, tachycardia and neurological involvement
What is Meckel’s diverticulum?
Ileal remnant of vitello-intestinal duct
- Contains ectopic gastric mucosa or pancreatic tissue
- 2cm long, 2% population, 2 feet from ileocaecal valve
What is a
a) Indirect inguinal hernia?
b) Hydrocele?
Both from failure of processes vaginalis (tongue of peritoneum) to obliterate after testicular descent
a) Processus vaginalus intact, bowel can enter inguinal canal
b) Processus vaginalus incompletely obliterated, leaving thin tract - peritoneal fluid can tract down into scrotum around testis
Which side is inguinal hernia more common?
RHS
RF for inguinal hernia? (2)
Boy
Premature
Clinical features of inguinal hernia?
- Intermittent swelling in groin/scrotom on crying/straining
- May become visible on raising IAP (press on abdo/cough)
- Diagnosis relies on hx and identification of thickening of spermatic cord (round lig in girls)
- May present as irreducible lump → firm & tender
- → Infant may be unwell with irritability/ vomiting
Management of inguinal hernia?
- Incarceration/strangulation in 12-16% → surgery ASAP
- Most ‘irreducible’ can be reduced following opioids and sustained gentle compression
- Surgery delayed 24-48h to allow reduction of odema
- If not- risk of strangulation → operate immediately
Clinical features of hydrocele?
- Asymptomatic scrotal swellings
- Often bilateral
- Sometimes blueish discolouration
- May be tense or lax
- Transilluminate
- Some not evident at birth but present early childhood after viral/GI illness
Management of hydrocele?
- Majority resolve spontaneously as processus continues to obliterate
- Surgery considered if persists >18-24m old
Ddx of acute scrotum? (3)
- Testicular torsion
- Hyatid torsion
- Epididymo-orchitis
How quickly must testicular torsion be operated on to prevent testicular necrosis?
6-12h after onset of sx
Clinical features of testicular torsion?
- Pain in scrotum, groin or lower abdo
- May be hx of previous self-limiting episodes
- More common in L testis
- Red, swollen testis, retracted upwards, decreased cremasteric reflex
- In newborn → red, firm hard scrotal mass + doesn’t transilluminate
Management of testicular torsion?
- Surgical exploration mandatory unless torsion can be excluded
- Doppler USS can allow differentiation from epididymitis (yet not used to diagnose)
- Surgery within 6-12h
- If torsion confirmed, must fix both testis (anatomical predisposition)
Causes of epididymo-orchitis? (5)
- UTI
- STI
- Mumps
- Operation
- Medication (esp amiodarone)
What is balanitis?
Inflammation of the glans penis
- Due to irritation by environmental substances, physical trauma, and infection
- Usually affects boys <4y
- Uncommon in circumcised men
Clinical features of balanitis? (4)
- Small red erosions on glans (can be small patch or whole glans)
- Pain + redness of foreskin + penis
- Other rashes + foul smelling discharge
- Pain passing urine
Causes of balanitis? (4)
- Poor hygine + tight foreskin → most common
- Infection e.g. candida, STI
- Allergy or irritants
- Skin conditions
Management of balanitis?
- Washed daily in warm water no soap
- Swab to culture, check for DM
- Tropic corticosteroids
- Infection → antifungals/ abx
What is BXO?
Balanitis xerotica obliterans
- Skin condition affecting foreskin and penis → causes pathological phimosis
- Atrophic white patches on affected area + white ring hardened tissue stops retraction
- Can also cause urethral meatal stenosis
- Sx → burning, pruritis, dysuria, painful erection
- Circumcision only treatment
What % have non-retractable foreskin at
a) 1y
b) 4y
c) 16y?
a) 50%
b) 10%
c) 1%
Indications for circumcision? (3)
- Pathological phimosis
- Recurrent balanoposthitis – red/inflamed foreskin +/- discharge – usually responds to abx
- Recurrent UTIs and upper UT abnormality
What % have undescended testicle at birth and 3m?
4% at birth
- More common if preterm
1.5% by 3m (little change thereafter)
3 types of undescended testicle?
- Retractile (with age will go into scrotum - yet follow up)
- Palpable
- Impalpable
Ix for undescended testis? (3)
USS
- Performed with bilateral impalpable testes to verify internal pelvic organs
Hormonal
– For bilateral impalpable testes, presence of testicular tissue confirmed by rise in serum testosterone in response to IM HCG
Laparoscopy
- Ix of choice for impalpable testis
How does undescended testes affect fertility?
Fertility for unilat undescended testis nearly normal
Fertility only 50% for bilateral palpable undescended testis
Usually sterile if bilateral impalpable testis
What is pyloric stenosis and RFs?
Hypertrophy of pyloric muscle → gastric outlet obstruction
RFs:
- M> F x4
- More common in first borns
- May be FH – esp maternal side
Most common age of pyloric stenosis presentation?
2-7w (irrespective of gestational age)
Clinical features of pyloric stenosis?
- Vomiting – increases in freq and forcefulness over time
- → Eventually projectile
- Hunger after vomiting until dehydration → loss of appetite
- Wt loss if presentation delayed
- Hypochloraemic metabolic alkalosis with low Na and K due to vomiting
Ix for pyloric stenosis?
- Test feed (unless immediate fluid resus needed)
- Baby given milk – may see peristalsis from L→R across abdo
- Pyloric mass (feels like olive) usually palpable in RUQ
- If stomach overdistended with air → must be emptied by NG tube to allow palpation
- USS if diagnosis in doubt
Treatment of pyloric stenosis?
- Initial priority = correct fluid + electrolyte imbalance with IV fluids (0.45% saline and 5%dextrose with potassium supplements
- Once hydration, acid-base + electrolytes normal → pyloromyotomy
- → Division of hypertrophies muscle down to but not inc mucosa
- Open or peri-umbilical procedure or laparascopically
- Recovery fast – fed 6h later, discharged within 2d
Ddx of lymphadenopathy? (3 categories)
- Infection
- Viral URTI, Infectious mononucleosis (EBV, CMV), group A strep pharyngitis, acute bacterial lymphadenitis, Kawasaki disease, rubella, mumps, cat scratch disease, toxoplasmosis, TB - Malignancy
- Acute leukaemia, lymphoma, neuroblastoma, rhabdomyosarcoma - Other
- Thyroglossal cyst or brachial cleft cyst, cervical ribs, cystic hydroma, haemangioma, laryngocele, deroid cyst
What is lymphadenitis?
Lymphadenitis = inflammation and/or enlargement of lymph nodes
- Most due to benign, local or general infection
- Onset can be acute, sub-acute or chronic
- Small palpable cervical, axillary and inguinal nodes
Ix for lymphadenopathy?
- FBC and film
- Rule out infectious causes: monospot, CMV, EBV, toxoplasma, bartonella titres, TB skin test, anti-HIV test, CRP, ESR
- ECH if kawasaka suspected (autoimmune of blood vessels)
- LFTs, U&Es and urinalysis (systemic disorders)
- LDH, uric acid, ca, phosphate, Mg if malignancy suspected
- BM biopsy if malig suspected
- CT or USS guided lymph node biopsy
Most common cause of lymphadenopathy?
Transient response to benign local or generalised infection
What proportion of cleft lip and palate is each?
Half cleft palate
Quarter cleft lip
Quarter both
Problems from cleft lip and palate? (5)
May be detected antenatally
- Feeding problems – inadequate suck
- Ear infections and hearing impairment
- Speech and language problems (repaired before speech starts to develop)
- Dental health – change in structure
- Psychological issues
When is cleft lip/palate surgery undertaken?
- Cleft lip can be done in 1st week
- Cleft palate usually done at several months of age
Associated conditions/drugs with cleft lip and palate? (5)
- Anticonvulsant therapy
- Isotretinoin (acne treatment)
- Patau syndrome and other chromosomal disorders
- Maternal factors - smoking, alcohol, obesity, lack of folate & HTN
- Pierre Robin syndrome → rare condition where baby born with abnormally small lower jaw that causes their tongue to fall backwards in throat, causing breathing difficulties
3 types of diaphragmatic hernia?
Bochdalek
- > 90%
- Posterolateral, usually on the left
- In L → small and large bowel and solid intra-abdo viscera
Morgagni
- Less common
- Anterior – behind sternum, most slightly to R
- In R → liver and portion of large bowel
Hiatus
Nb if bilateral usually fatal
Signs of diaphragmatic hernia?
- Cyanosis shortly after birth
- Tachypnoea
- Tachycardia
- Asymmetry of chest wall
- Absent breath sounds on 1 side of chest (usually left)
- Bowel sounds audible over the chest wall
- Abdo feels ‘less full’ on palpation
- Shift of cardiac sounds
- Signs of pneumothorax
Management of diaphragmatic hernia?
Immediately after birth:
- Optomise oxygenation whilst avoiding barotrauma
- Stabilize baby before surgery
- Resuscitate if needed
- Intubate and artificially ventilate
- Place NG tube and suction to remove air from stomach to prevent further lung compression
- Continuous monitoring of O2, BP, perfusion – use drugs to maintain if needed
- Maintain glucose and Ca levels
Once stable:
- Surgical repair
2 pulmonary effects from diaphragmatic herniation?
Pulmonary hypoplasia Pulmonary HTN (decreased vasculature)
Types of trachea-oesophageal atresia?
Trachea-oesophageal atresia w/o fistula (8%)
Trachea-oesophageal atresia with fistula
- Proximal fistula 1%
- Distal fistula (84%)
- Prox + distal fistula (3%)
Trachea-oesophageal fistula w/o atresia (4%)
What abnormality throughout pregnancy is trachea-oesophageal atresia associated with?
Polyhydramnios
Clinical features of trachea-oesophageal atresia?
- Persistant salivation + drooling
- May → coughing and choking when fed and have cyanotic episodes
- May be aspiration into lungs of saliva (or milk) from upper airways and acid secretions from stomach
- Almost ½ have other congenital malformations eg VACTERL association
Diagnosis of trachea-oesophageal atresia? (3)
- If suspected – pass wide-calibre feeding tube and check by XRay to see if it reaches stomach
- CT scan – clear picture of type of malformation
- Oesophagoscopy and bronchoscopy
Management of trachea-oesophageal atresia? (2)
- Continuous suction applied to tube passed into oesophageal pouch to reduce aspiration
- Transfer to neonatal surgical unit for repair
Features of gastroschisis?
- Bowel protrudes through defect in anterior abdo wall, adjacent to umbilicus
- No covering sac
- Not associated with other congenital abnormalities
- High risk of dehydration and protein loss
- → Abdo of affected infants wrapped in several layers of cling film to minimize fluid/ heat loss
- NG tube passed and aspirated often
- IV infusion of dextrose
- Colloid sipper often required to replace protein loss
- Repaired by surgery
- If not pos to do in 1 surgery, intestine enclosed in silastic sac sutured to edges of abdo wall and contents gradually returned to peritoneal cavity
Features of exompholos?
- Also called omphalocele
- Abdo contents protrude through umbilical ring into umbilical cord, covered with transparent sac formed by amniotic membrane and peritoneum
- Often associated with other major congenital abnormalities eg trisomy 13, 18, 21, Beckwith-Weidemann syndrome and others
- Minor = <4cm opening, only intestines
- Major >4cm, intestines + liver
Name 3 umbilical abnormalities?
Patent vitello-intestinal duct
Urachus
- leakage of urine out of umbilicus
Umbilical granuloma
- XS granulation tissue
Management of low and high anorectal malformations?
Low
- Anoplasty
High
- Initial colostomy
- Appropriate surgery to form anus
- Further surgery to remove colostomy
4 types of congenital neck cysts?
Thyroglossal duct cyst
Branchial cleft cyst
Dermoid cyst
Enlarged lymph nodes
What primary damage can occur from a head injury? (3)
Cerebral contusions/lacerations
Dural tears
Diffuse axonal damage
What secondary damage can occur from a head injury? (5)
Hypoxia from airway obstruction/inadequate ventilation
Hypoglycaemia/ hyperglycaemia
Reduced cerebral perfusion
- Hypotension from bleeding
- Raised ICP
Haematoma (extradural, subdural, intracranial)
Infection (from open wound or CSF leak)
What factors indicate a potentially serious head injury? (11)
LOC >5min
Amnesia >5min
Abnormal drowsiness
3 or more discrete episodes of vomiting
Clinical suspicion of NAI
Post traumatic seizure (no hx of epilepsy)
GCS <15 (<14 if <1y)
Suspicion of open/depressed skull injury/tense fontanelle
Sign of basal skull fracture (e.g. CSF leak from nose/ears)
<1y + bruise/swelling >5cm on head
Dangerous mechanism eg RTA, >3m fall
General management of head injury?
Mild → discharge home with written advice
Potentially severe → monitor to avoid secondary damage
Severe → resuscitate, CT scan + neurosurgical referral
What is a neuroblastoma?
Solid tumour arising from neural crest tissue in the adrenal medulla and sympathetic NS
- Biologically unusual as occasionally regresses
- Most common <5yo
Common clinical features of neuroblastoma?
Pallor Wt loss Abdo mass Hepatomegaly Bone pain Limp
–> If >2yo, most sx from metastatic disease
Diagnosis of neuroblastoma?
Characteristic clinical and radiological features with raised urinary catecholamine levels suggest neuroblastoma
- Confirmatory biopsy usually obtained
Management of neuroblastoma?
- Localised primaries w/o metastatic disease → often cured with surgery alone
- Metastatic disease → chemo, incl highdose therapy with autologous stem cell rescue, surgery and radiotherapy
- Risk of relapse high and prospect of cure for metastatic disease is little better than 30%
- Immunotherapy and use of longterm ‘maintenance’ treatment with differentiating agents (retinoic acid) are establishing role in those with high-risk disease
What is a saccrococcygeal teratoma?
- Teratoma located at base of coccyx thought to be derived from primitive streak
- Benign
- Most common tumour in newborns
- Treatment = surgical removal
What is Wilm’s tumour?
= Nephroblastoma
- Originates from embryonal renal tissue
- Commonest renal tumour of childhood
- > 80% of patients present <5yo
- Very rarely seen after 10yo
Common and uncommon presenting features of Wilm’s tumour?
Common
- Abdo mass
Uncommon
- Abdo pain
- Anorexia
- Anaemia (haemorrhage into mass)
- Haematuria
- HTN
Ix for Wilm’s tumour?
USS +/or CT/MRI usually characteristic
Management of Wilm’s tumour?
- Initial chemo followed by delayed nephrectomy, after which tumour is staged histologically and subsequent treatment planned
- Radiotherapy restricted to those with more advanced disease
- Prognosis good
- > 80% of all patients cured
- Cure rate for metastatic disease at presentation (~15%) is >60%, but relapse carries a poor prognosis
