Surgery Flashcards
1
Q
T or F: Umbilical hernias tend to close on their own.
A
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
2
Q
Surgical abdo. What do you do? CT or Fluids + analgesia?
A
Fluids + Analgesia
Stabilization first.
3
Q
Most common cause of testicular pain in M > 12 y.o.
A
Testicular Torsion
4
Q
List dx that transilluminate in scrotum:
A
- Hydrocele
- Inguinal Hernia
5
Q
BB with acute scrotal swelling. Transilluminate. Testes red, irritable. Mild tachycardia. Afebrile. Dx?
a. testicular torsion
b. epididymitis
c. inguinal hernia
d. acute hydrocele
A
Inguinal Hernia vs. Hydrocele
- can transilluminate in BB since thin bowel wall
- makes sense w/ acute, irritable, tachy
6
Q
What is the risk of a communicating hydrocele?
A
Direct Hernia
7
Q
When to refer a communicating hernia
A
18 mon
- should resolve otherwise before then by itself
8
Q
New hydrocele in teenager. R/O
A
Tumour
Trauma
Infection
9
Q
When do you US a hydrocele?
A
confirm testis if > 6 mo.
can’t tell if hernia
R/O testicular tumour (teenager)
scrotal pain
10
Q
What is the key to dx of hydrocele
A
Transillumination
11
Q
When do you refer or correct a non communicating hydrocele?
A
- large, tense, bothersome
12
Q
T or F: most hernia are direct (bulge through abdo wall)
A
False.
99% Inguinal (through PV)
13
Q
T or F: most hernia appear in 1st year of life.
A
True
14
Q
Describe a clinical hallmarks for hernia:
A
Smooth
Firm mass
Lateral to pubic tubercle
Enlarge w/ abdo pressure w/ discomfort
15
Q
What’s the diff between incarcerated vs. strangulated hernia?
A
Incarcerated= obstruction signs. Organ contained. Overlying red skin.
Strangulated: ischemic contacts.
16
Q
How do you treat torsion of appendix testis?
A
Bed rest x 24 hr
NSAID x 3-5 d
Will resolve in 3-10d
17
Q
13 y.o. 3d gradual pain. Tenderness of superior pole. Bluish discolouration at the tip. Next step?
A
Supportive care
+ Reassurance.
= Bed rest x 24 hr
NSAID x 3-5 d
Will resolve in 3-10d
18
Q
3 month old. Pale. Intermittent vomiting. Tachy. Next:
- AXR
- Air enema floor
- UGI
- Contrast
A
Air enema fluoroscopy
- Intussusception most common intestinal obstruction btwn 3 mo.-3 y.o.; rare in NICU
- colicky sudden pain, lethargic. vomiting then bilious.
19
Q
T or F: Intussusception most common cause of obstruction in neonates.
A
False.
MOST common in 3 mo. - 3 y.o.!
20
Q
T21 baby with non bilious vomiting after feed. Risk of?
A
Duodenal Atresia.
Test: XR
21
Q
What are the most common aetiologies of intussusception?
A
90%= idiopathic
Other:
- correlation w/ adenovirus
- Lymphoid nodular hyperplasia (Swollen Peyer patches)
- Lead point (Meckel diverticulum, Intestinal polyp, neurofibroma)
22
Q
What is the US finding of intussusception?
A
Doughnut/Target
23
Q
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
A
MRI
or US
24
Q
What is diaphragm eventration?
A
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
25
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
26
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
27
T or F: appendicitis is a clinical diagnosis.
True!
"febrile bowel obstruction"= perf appy until proven otherwise.
28
Peak age for appendicitis:
11-12 y.o.
29
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
30
What are RF for pyloric stenosis:
- *first born
- M
- bottle fed
- *erythro or azithro if < 2 wk old
- *(+) FHX
31
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.)
32
Pyloric stenosis presents with:
Non bilious
+ Projectile emesis
+ Dehydration
33
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
34
What is the sign on U/S for pyloric stenosis?
"target" sign
- length > 14mm
- thick > 3mm
35
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
36
List two complications of pyloric stenosis OR:
- mucosal perforation
| - incomplete pyloromyotomy
37
What is the most common area for intussusception:
- oleo-colic
- ileo-ileocolic
- jejunoileal
- coli-colic
- ileocolic w/ lead point
Ileo-Colic
38
Ages for intussusception:
3 mo- 3 y.o.
| peak at 9-12 months
39
What is the most common pathological lead point in intussusception
Mickey Diverticulum
Other: polyp, intestinal duplication, Henoch-Schonlein purpura, Appendix etc.
40
Are young or old more likely to have lead point in intussusception?
Old
- W/U for other lead point (i.e. lymphoma, polyp etc.)
41
What is the gold standard test to for intussusception?
U/S= doghnut/target sign
but air anema dx + tx
42
Pain
+ Palpable sausage abdo mass
+ Bloody or currant jelly stool. Dx?
Intussusception
Classic Triad
43
List one contraindication to enema (air, water, contrast) in intussusception cases:
Free air/ pneumoperitoneum.
Other: Peritonitis, persistent low BP
These pt= OR reduction
44
Recurrence rate of intussusception?
10%
45
2 y.o. M w/ large bloody painless stool. Dx?
Meckel diverticulum
46
List a ddx for Meckel diverticulum:
- colonic polyp
- intussusception
- bleeding esophageal varices
47
what is the most common congenital anomaly of the GI tract?
Meckel's diverticulum
48
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)
```
49
what is the test to order in Meckel's diverticulum:
Radionuclide Scan (Technetium-99 scan)
50
What is a Meckel's diverticulum
abnormal embryonic out pouching of bowel on small intestine
51
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
52
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
53
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
```
54
When do you repair CDH?
if stable over initial 24-48hr= Sx (primary repair if small defect vs. patch)
Otherwise depend on ABC settings.
55
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!
56
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
57
Major anomaly occurs MOST frequently w/ EA-TEF?
- skeletal
- genitourinary
- CVS
- neurologic
- GI
CVS
In VACERL W/U- CVS anomalies most common + life threatening
58
Prem w/ polyhydraminos. Infant choking/cyanotic w/ feeding + oral secretion
Esophageal atresia.
59
Most common TEF:
Type C.
Proximal EA w/ distal fistula formation btw teach-distal esophagus.
PPT: fetal polyhydraminos b/c can't swallow AF.
60
T or F: 90% of TEF have EA.
True.
61
List three associated conditions:
1. VACTERL= X linked, vertebral, anal, cardiac, TEF, renal, limb, hydrocephalus
2. T13, T18, T21
3. CHARGE (coloboma, heart, atresia of nasal chonanae, retardation (Growth/IQ), GU hypoplasia, ear
62
List two complications of TEF repair:
anastomotic leak
| recurrent fistula
63
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.
64
Bilious emesis in neonate ddx:
1. malrotation +/- midgut volvulus
2. intestinal atresia
3. Ileus
4. Hirschsprung dx
65
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)
66
New baby with vomiting. Only small mec. Distended. Large gas + stool after DRE. Likely dx?
Hirschsprung's
67
What is Hirschsprung's Disease?
failure of neural crest to migrate during intestinal development
68
List one association w/ Hirschsprung Dx
T21
69
List cardinal signs of Hirschsprung Disease:
1. Failure to pass mec <24h
2. Abdo distension
3. Vomiting
+/- explosive gas and stool after DRE
+/- enterocolitis signs (fever, V, distension, lethargy)
70
What is the gold standard to dx Hirschsprung? Findings?
Rectal Bx
1. No ganglion cells
2. Hypertrophic nerves
3. Increased acetylcholinesterase staining
71
What is an imaging test you can do in Hirschsprung?
Contrast enema
Sigmoid > rectum.
Funnelling = Transition zone
72
When do you use anorectal manometry in suspected Hirschsprung?
Older kids/infants
= recto-inhibitory reflex
73
How do we treat Hirschsprung?
1. NS rectal decompression via saline irrigation
+/- IV ABX if enterocolitis
2. Sx (pull-through)
3. +/- rare emergency colostomy if BAD enterocolitis
74
Pt with hirschsprung disease present with fever, diarrhea, foul stool. What Dx to consider?
Enterocolitis!!
- admit
- ABX
- rectal irrigation
- dilate bowel
75
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
76
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.
77
T or F: highest rate of inguinal hernia occur in prem infants.
True
78
What is risk factor for inguinal hernia?
Prematurity
Male
79
When do you refer for inguinal hernia?
Immediately.
high risk ASAP (esp prem)
80
What is the ONLY indication for CONTRALATERAL exploration during hernia repair?
PREM infant
81
List 2 post-op inguinal hernia complications:
1. Scrotal Swelling/hematoma
2. Wound infection
Other
- recur 1%
- iatrogenic cryptorchidism
- infertility (due to vas deferens injury)
- testicular atrophy
82
What is the MAIN indication for orchidopexy?
INFERTILITY risk
83
T or F: spontaneous descend of testes after 9 month rare?
True
84
When to refer for Sx if undescended testis?
9 month
85
T or F: you should always do US for undescended testes?
False.
- may consider to confirm presence if b/l and DSD suspicion
86
Refer earlier for undescended testes if:
- M but b/l non palpable
- unilateral w/ hypospadias
- DSD suspicion
