Surgery Flashcards
T or F: Umbilical hernias tend to close on their own.
True.
- 95% of < 1cm close w/in 5 y.o.
- No sx unless does not go way by 4 y.o., strangulated,or progressively larger after 1-2 y.o.
- Note: defect > 2cm less likely to close on their own
Surgical abdo. What do you do? CT or Fluids + analgesia?
Fluids + Analgesia
Stabilization first.
Most common cause of testicular pain in M > 12 y.o.
Testicular Torsion
List dx that transilluminate in scrotum:
- Hydrocele
- Inguinal Hernia
BB with acute scrotal swelling. Transilluminate. Testes red, irritable. Mild tachycardia. Afebrile. Dx?
a. testicular torsion
b. epididymitis
c. inguinal hernia
d. acute hydrocele
Inguinal Hernia vs. Hydrocele
- can transilluminate in BB since thin bowel wall
- makes sense w/ acute, irritable, tachy
What is the risk of a communicating hydrocele?
Direct Hernia
When to refer a communicating hernia
18 mon
- should resolve otherwise before then by itself
New hydrocele in teenager. R/O
Tumour
Trauma
Infection
When do you US a hydrocele?
confirm testis if > 6 mo.
can’t tell if hernia
R/O testicular tumour (teenager)
scrotal pain
What is the key to dx of hydrocele
Transillumination
When do you refer or correct a non communicating hydrocele?
- large, tense, bothersome
T or F: most hernia are direct (bulge through abdo wall)
False.
99% Inguinal (through PV)
T or F: most hernia appear in 1st year of life.
True
Describe a clinical hallmarks for hernia:
Smooth
Firm mass
Lateral to pubic tubercle
Enlarge w/ abdo pressure w/ discomfort
What’s the diff between incarcerated vs. strangulated hernia?
Incarcerated= obstruction signs. Organ contained. Overlying red skin.
Strangulated: ischemic contacts.
How do you treat torsion of appendix testis?
Bed rest x 24 hr
NSAID x 3-5 d
Will resolve in 3-10d
13 y.o. 3d gradual pain. Tenderness of superior pole. Bluish discolouration at the tip. Next step?
Supportive care
+ Reassurance.
= Bed rest x 24 hr
NSAID x 3-5 d
Will resolve in 3-10d
3 month old. Pale. Intermittent vomiting. Tachy. Next:
- AXR
- Air enema floor
- UGI
- Contrast
Air enema fluoroscopy
- Intussusception most common intestinal obstruction btwn 3 mo.-3 y.o.; rare in NICU
- colicky sudden pain, lethargic. vomiting then bilious.
T or F: Intussusception most common cause of obstruction in neonates.
False.
MOST common in 3 mo. - 3 y.o.!
T21 baby with non bilious vomiting after feed. Risk of?
Duodenal Atresia.
Test: XR
What are the most common aetiologies of intussusception?
90%= idiopathic
Other:
- correlation w/ adenovirus
- Lymphoid nodular hyperplasia (Swollen Peyer patches)
- Lead point (Meckel diverticulum, Intestinal polyp, neurofibroma)
What is the US finding of intussusception?
Doughnut/Target
Older infant. Resp symp. CXR show diaphragmatic hernia or diaphragmatic eventration. What is MOST dx test:
a. Sx exploration
b. diaphragm fluoroscopy
c. U/S
d. MRI
MRI
or US
What is diaphragm eventration?
abN elevation of diaphragm.
- uncommon
- congenital or acquired (injury to phrenic nerve from traumatic birth or Sx)
- US tell this vs. CDH
- most asymptomatic and do no need repair
List key traits of Gastroschisis:
- usually periumbilical (R of)
- NO membranous sac
- 1/10= intestinal ATRESIA
- other malformation rare
- TX: ABC (no CPAP, if need to = intubate), OGT to LIS, cover gut, examine gut, bolus + fluids + Abx
Which of the following is TRUE regarding paediatric appendicitis?
a. incidence of perforated appendicitis in kids < 2 rare
b. routine imaging recommended
c. peak incidence 6-8 y.o.
d. pt w/ perforated appendicitis may be treated w/ abx alone.
Pt w/ perf appy may be tx w/ Abx alone.
- 1/4 of appy= perf
- peak: 11-12 y.o.
- clinical dx; decision for imaging based on Sx
T or F: appendicitis is a clinical diagnosis.
True!
“febrile bowel obstruction”= perf appy until proven otherwise.
Peak age for appendicitis:
11-12 y.o.
How does the paradoxical acuduria occur in pyloric stenosis?
- urine initially reflect primary process (low Cl with high bicarb)
= then more dehydrated over time
= aldosterone= Na retained and K and H excreted in urine
= urinary paradoxical acuduria
What are RF for pyloric stenosis:
- *first born
- M
- bottle fed
- *erythro or azithro if < 2 wk old
- *(+) FHX
T or F: pyloric stenosis is most common from 2 wk-2 month old?
True.
2-to-2
RARE after 12 weeks esp (3 mon.)
Pyloric stenosis presents with:
Non bilious
+ Projectile emesis
+ Dehydration
What is the lytes + gas pattern for pyloric stenosis?
Vomit= lose HCL
= Hypochloremic
Metabolic alkalosis
+/- Hypokalemic
= renal try to compensate for H+ loss by preserving Na and excrete K= low K
= urine initially reflect primary process (low Cl with high bicarb)
= then more dehydrated over time
= aldosterone= Na retained and K and H excreted in urine
= urinary paradoxical acuduria
What is the sign on U/S for pyloric stenosis?
“target” sign
- length > 14mm
- thick > 3mm
How do you treat pyloric stenosis:
Rehydrate + Stabilize
- IV bolus NS until U/O
- Change to dextrose + K after (0.45NS if < 4 week or 0.9NS if > 4 wk)
OR
- Pyloromyotomy
List two complications of pyloric stenosis OR:
- mucosal perforation
- incomplete pyloromyotomy
What is the most common area for intussusception:
- oleo-colic
- ileo-ileocolic
- jejunoileal
- coli-colic
- ileocolic w/ lead point
Ileo-Colic
Ages for intussusception:
3 mo- 3 y.o.
peak at 9-12 months
What is the most common pathological lead point in intussusception
Mickey Diverticulum
Other: polyp, intestinal duplication, Henoch-Schonlein purpura, Appendix etc.
Are young or old more likely to have lead point in intussusception?
Old
- W/U for other lead point (i.e. lymphoma, polyp etc.)
What is the gold standard test to for intussusception?
U/S= doghnut/target sign
but air anema dx + tx
Pain
+ Palpable sausage abdo mass
+ Bloody or currant jelly stool. Dx?
Intussusception
Classic Triad
List one contraindication to enema (air, water, contrast) in intussusception cases:
Free air/ pneumoperitoneum.
Other: Peritonitis, persistent low BP
These pt= OR reduction
Recurrence rate of intussusception?
10%
2 y.o. M w/ large bloody painless stool. Dx?
Meckel diverticulum
List a ddx for Meckel diverticulum:
- colonic polyp
- intussusception
- bleeding esophageal varices
what is the most common congenital anomaly of the GI tract?
Meckel’s diverticulum
List the Rule of 2’s of Meckel’s Diverticulum
2% of pop 2X M > F ppt by 2 y.o. 2 inches long 2 feet proximal to ileoceccal valve 2 types of mucosa (gastric, pancreatic)
what is the test to order in Meckel’s diverticulum:
Radionuclide Scan (Technetium-99 scan)
What is a Meckel’s diverticulum
abnormal embryonic out pouching of bowel on small intestine
What is the MOST appropriate next step in newborn baby w/ resp distress where you are thinking CDH?
a. immediate NG or OG
b. fluid resus
c. echo
d. prep OR for Sx
e. start inhaled NO
Immediate NG or OG
- want to avoid stomach expanding with cry/gasp causing mediastinal shift
Which CDH complication after birth challenges mngmt?
PPHN
- pul hypoplasia + surfactant deficient and poor LV
= hypoxemia + hypercarbia + acidosis
= pul arterial vasoconstriction = pul HTN= fetal circulation and R - L shunt
If you have an antenatal dx of CDH what should you do w/ airway?
INTUBATE on 1st brith + NG to decompress stomach.
- mechanical vent \+/- HFO \+/- inotropes \+/- iNO \+/- ECMO
When do you repair CDH?
if stable over initial 24-48hr= Sx (primary repair if small defect vs. patch)
Otherwise depend on ABC settings.
How can you tell an EA vs. EA with TEF on XR?
NG/OG stuck.
BUT air getting into abdo = air getting in through fistula!
Most IMPORTANT maneuver to confirm dx of EA-TEF:
- contrast esophagogram
- urgent bronch
- CT chest
- attempt NG
- U/S neck/chest
Attempt NG 8-10Fr.
- NG usually block at 10cm
Major anomaly occurs MOST frequently w/ EA-TEF?
- skeletal
- genitourinary
- CVS
- neurologic
- GI
CVS
In VACERL W/U- CVS anomalies most common + life threatening
Prem w/ polyhydraminos. Infant choking/cyanotic w/ feeding + oral secretion
Esophageal atresia.
Most common TEF:
Type C.
Proximal EA w/ distal fistula formation btw teach-distal esophagus.
PPT: fetal polyhydraminos b/c can’t swallow AF.
T or F: 90% of TEF have EA.
True.
List three associated conditions:
- VACTERL= X linked, vertebral, anal, cardiac, TEF, renal, limb, hydrocephalus
- T13, T18, T21
- CHARGE (coloboma, heart, atresia of nasal chonanae, retardation (Growth/IQ), GU hypoplasia, ear
List two complications of TEF repair:
anastomotic leak
recurrent fistula
1 wk old infant w/ 24h hx vomiting, less stool, low U/O. lethargic. Vomit yellow-green and some streak of blood. Dehydrated. BW done. Next appropriate TEST:
a. AXR
b. CT abdo
c. US abdo
d. Upper GI series
e. Contrast enema
Not wrong to do XR to R/O obstruction
MOST appropriate= Upper GI to R/O mid-gut volvulus as LIFE threatening and TIME sensitive.
Bilious emesis in neonate ddx:
- malrotation +/- midgut volvulus
- intestinal atresia
- Ileus
- Hirschsprung dx
The gold standard for Malrotation w/ midgut volvulus is U/S.
False.
ANSWER= Upper GI series
US= may show inversion of SMA/SMV relationship (so that SMA on R and SMV on L)
New baby with vomiting. Only small mec. Distended. Large gas + stool after DRE. Likely dx?
Hirschsprung’s
What is Hirschsprung’s Disease?
failure of neural crest to migrate during intestinal development
List one association w/ Hirschsprung Dx
T21
List cardinal signs of Hirschsprung Disease:
- Failure to pass mec <24h
- Abdo distension
- Vomiting
+/- explosive gas and stool after DRE
+/- enterocolitis signs (fever, V, distension, lethargy)
What is the gold standard to dx Hirschsprung? Findings?
Rectal Bx
- No ganglion cells
- Hypertrophic nerves
- Increased acetylcholinesterase staining
What is an imaging test you can do in Hirschsprung?
Contrast enema
Sigmoid > rectum.
Funnelling = Transition zone
When do you use anorectal manometry in suspected Hirschsprung?
Older kids/infants
= recto-inhibitory reflex
How do we treat Hirschsprung?
- NS rectal decompression via saline irrigation
+/- IV ABX if enterocolitis - Sx (pull-through)
- +/- rare emergency colostomy if BAD enterocolitis
Pt with hirschsprung disease present with fever, diarrhea, foul stool. What Dx to consider?
Enterocolitis!!
- admit
- ABX
- rectal irrigation
- dilate bowel
Which is the following feature to BEST distinguish omphalocele from gastroschisis:
- location of umbilical cord relative to abdo wall defect
- co-existent intestinal obstruction
- co-existent intestinal malrotation
- prenatal dx
Location of umbilical cord relative to abdo wall defect
- thru umbilicus= omphalocele
- R of umbilicus= gastroschisis
Most common cardiac malformation associated w/ omphalocele:
a. Ebstein’s anomaly
b. VSD
c. ASD
d. TOF
e. Hypoplastic L heart syn
TOF
Cardiac anomaly most common w/ omphalocele; of that TOF most common.
T or F: highest rate of inguinal hernia occur in prem infants.
True
What is risk factor for inguinal hernia?
Prematurity
Male
When do you refer for inguinal hernia?
Immediately.
high risk ASAP (esp prem)
What is the ONLY indication for CONTRALATERAL exploration during hernia repair?
PREM infant
List 2 post-op inguinal hernia complications:
- Scrotal Swelling/hematoma
- Wound infection
Other
- recur 1%
- iatrogenic cryptorchidism
- infertility (due to vas deferens injury)
- testicular atrophy
What is the MAIN indication for orchidopexy?
INFERTILITY risk
T or F: spontaneous descend of testes after 9 month rare?
True
When to refer for Sx if undescended testis?
9 month
T or F: you should always do US for undescended testes?
False.
- may consider to confirm presence if b/l and DSD suspicion
Refer earlier for undescended testes if:
- M but b/l non palpable
- unilateral w/ hypospadias
- DSD suspicion
