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