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Phase 3a Paediatrics > Surgery > Flashcards

Surgery Flashcards

1
Q

What is exomphalos?

A

When the abdominal contents protrudes through the umbilical ring and is covered with a transparent sac (aminotic membrane and peritoneum)

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2
Q

What is gastroschisis

A

When the bowel protrudes through a defect in the anterior abdo wall, adjacent to the umbilicus, with no covering sac

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3
Q

What causes ventral body wall defects?

A

Increased risk with conditions related to placental insufficiency

  • materal illness and infection
  • drugs, alcohol, smoking
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4
Q

Which tests can detect a ventral body wall defect?

A
  • increased alpha-fetoprotein
  • abnormal US
  • both in second trimester
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5
Q

How would exomphalos present?

A
  • 4-12 cm abdo wall defect
  • central, epigastric or hypogastric
  • 75% have associated defects
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6
Q

How would gastroschisis present?

A
  • opening > 5cm
  • Right side of umbilical cord
  • 15% have associated defects
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7
Q

What investigations would you perform on suspected ventral body wall defect?

A
  • MSAFP (maternal serum alpha-fetoprotein)
  • karyotyping, strong link between exomphalos and chromosomal abnormalities
  • imaging
    • US
    • ?MRI (liver abnormalities)
  • Amniocentesis(diagnostic test carried out during pregnancy to assess whether the unborn baby could develop a genetic or chromosomal condition)
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8
Q

How would you manage exomphalos?

A
  • surgery +/- silo
  • if sac ruptures manage same as gastroschisis
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9
Q

How would you manage gastroschisis?

A
  • wrap baby in clingfilm to minimise fluid and heat loss
  • wrap cord in clingfilm to make sure its kept moist for plastic closure
  • NG tube
  • plastic closure - gradual decompression of abdo contents from silo into abdo (better because no GA)
  • primary closure
  • gastric function to comense over several weeks, if not functioning by 6/52 then re-think
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10
Q

What are the risk factors for NEC?

A
  • prematurity
  • low birth weight
  • preterm infants fed cows milk formula
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11
Q

How and when does NEC present?

A
  • usually in the first 2/52
  • stop tolerating feeds
  • bile stained vomit, fresh blood in stools
  • distended stomach
  • shock
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12
Q

What are the X-ray features of NEC?

A
  1. distended loops of bowel
  2. thickening bowel wall with intramural gas
  3. gas in portal tract
  4. bowel perforation in progressive disease
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13
Q

What is the management of NEC?

A
  • stop oral feeding - parenteral nutrition (PPN, TPN, NGT)
  • artifical vent, circulatory support
  • surgery
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14
Q

Common hernias in children

A

indirect inguinal (through the deep ring)

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15
Q

Inguinal hernias aetiology

A
  • more common in boys
  • patent processus vaginalis
  • common in prematurity
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16
Q

Inguinal hernia presentation

A
  • swelling in groin or scrotum on crying or straining (increase in intra-abdo pressure, can be recreated on examination by asking pt to cough or pressing on abdo)
  • thickening of spermatic cord (round ligament in females)
  • irreducible lump (firm and tender)
  • unwell (vomiting and irritable)
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17
Q

Inguinal Hernia tx

A
  • most irreducible hernias can be reduced by opiod analgesia and gentle compression
  • surgery
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18
Q

What causes a hydrocele?

A

Patent processus vaginalis allows peritoneal fluid to track down around testis

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19
Q

How does a hydrocele present?

A
  • presents at birth or in early childhood after an infection
  • Generally asymptomatic scrotal swelling
  • bilateral bluish colour
  • non-tender and transilluminate
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20
Q

Hydrocele tx

A
  • spontaneous resolution
  • sugery if persists past 18-24 months of age
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21
Q

Define vomiting

A

forceful ejection of gastric contents

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22
Q

Define posseting

A

non-forceful return of small amounts of milk, often accompanied by return of swallowed air (wind). common.

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23
Q

Define regurgitation

A

frequent non-forceful return of large amounts of milk

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24
Q

Common causes of vomiting in infants

A
  1. GOR
  2. feeding problems
  3. infection (gastroenteritis, resp/urinary tract, otitis media, whooping cough, meningitis)
  4. dietary protein intolerances
  5. intestinal obstruction (pyloric stenosis, atresia, intussusception, malrotation, volvulus, hirschsprungs)
  6. metabolic errors
  7. congential adrenal hyperplasia
  8. renal failure
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25
Q

Common causes of vomiting in pre-school children

A
  1. infection (gastroenteritis, resp/urinary tract, otitis media, whooping cough, meningitis)
  2. appendicitis
  3. intesinal obstruction (intussusception, malrotation, volvulus, adhesions, foreign body)
  4. increase intracranial pressure
  5. coeliac
  6. renal failure
  7. metabolic errors
  8. testicular torsion
26
Q

Common causes of vomiting in school aged children and adolescents

A
  1. infection (gastroenteritis, pyelonephritis, septicaemia, meningitis,)
  2. peptic ulcer/ H. pylori infection
  3. appendicitis
  4. migraine
  5. increased intracranial pressure
  6. coeliac
  7. renal failure
  8. DKA
  9. alcohol/drug ingestion
  10. cyclical vomiting syndrome
  11. bulimia/anorexia
  12. pregnancy
  13. testicular torsion
27
Q

What would bile stained vomit be a red flag for?

A

intestinal obstruction

28
Q

What would haematemesis be a red flag for?

A
  • oesophagitis
  • peptic ulcer
  • oral/nasal bleeding
29
Q

What would projectile vomiting (in first few weeks of life) be a red flag for?

A

pyloric stenosis

30
Q

What would paroxysmal coughing then vomiting be a red flag for?

A

whooping cough

31
Q

What would abdo tenderness/pain on movement with vomiting be a red flag for?

A

surgical abdomen

32
Q

What would abdo distension with vomiting be a red flag for?

A

intestinal obstruction

33
Q

What would hepatosplenomegaly with vomiting be a red flag for?

A

chronic liver disease

34
Q

What would blood in stool with vomiting be a red flag for?

A
  • intussusception
  • gastroenteritis
35
Q

What would severe dehydration, shock and vomiting be a red flag for?

A
  • severe gastroenteritis
  • systemic infection
  • DKA
36
Q

What would bulging fontanelle, seizures and vomiting be a red flag for?

A

increased intracranial pressure

37
Q

What would failure to thrive and vomiting be a red flag for?

A
  • GOR
  • coeliac
  • chronic GI condition
38
Q

What is GOR

A

involuntary passage of gastric contents into oesophagus

39
Q

What causes GOR

A
  • inappropriate relaxation of LOS because of function immaturity
  • risks
    • fluid diet
    • mainly horizontal posture
    • short intra-abdo length of oesophagus
40
Q

In which cases is severe reflux more common?

A
  • cerebral palsy
  • preterm
  • post surgery for oesophageal atresia or diaphragmatic hernia
41
Q

GOR complications

A
  • failure to thrive (most infants put weight on normally)
  • oesophagitis
    • haematemesis
    • discomfort on feeding
    • heartburn
    • IDA
  • recurrent pulmonary aspiration
    • recurrent pneumonia
    • cough or wheeze
    • apnoea (preterm)
  • dystonic neck posturing
  • Apparent life threatening events
42
Q

GOR investigations

A
  • normally a clinical diagnosis
  • Ix necessary if atypical hx, complications or failure to respond to tx
  • 24h oesophageal pH monitoring (quantify degree of acid reflux)
  • 24h impedance monitoring (measure weak acid or non acidic reflux)
  • endoscopy w/ oesophageal biopsies (identify oesophagitis and exclude other causes)
  • upper GI contrast (exclude anatomical abnormalities, identify malrotation
43
Q

GOR management

A
  • normally resolves by 12 months of age because
    • maturation of LOS
    • assumption of upright position
    • more solids in diet
  • uncomplicated
    • add thickening agents to feeds (nestargel, carobel)
    • feeding position help
  • more significant
    • acid suppression with either H2 receptor antagnoists (rantidine) or PPI (omeprazole) which decrease volume of gastric contents and treat acid related oesophagitis
    • gastric emptying enhancing drugs (domperidone) poor evidence
  • surgery
    • if compliations unresponsive to medical tx or oesophageal stricture
    • Nissen fundoplication
44
Q

What is a pyloric stenosis?

A

hypertrophy of pyloric muscle causing gastric outlet obstruction

45
Q

Pyloric stenosis epidemiology

A

boys

maternal family hx

46
Q

pyloric stenosis presentation

A

2-7 weeks of age

  • vomiting (increasing in frequency and forcefulness over time -> projectile
  • hunger post vomiting until dehydration leads to loss of interest in feeding
  • weight loss
  • hypochloraemic metabolic alkalosis
    • loss of hydrochloric acid
    • loss of sodium and potassium (sodium retained in collecting ducts -> metabolic alkalosis)
47
Q

Pyloric stenosis examination findings

A
  • gastric peristalsis seen as wave right L -> R
  • palpable pyloric mass RUQ, like an olive
48
Q

Pyloric stenosis management

A
  1. IV fluid (0.45% saline and 5% dextrose with potassium supplements) to correct any fluid or electrolyte imbalance
  2. pyloromyotomy = division of hypertrophied muscle down to mucosa
    • feed w/in 6h
    • discharge w/in 2 days
49
Q

What is intussusception?

A

invagination of proximal bowel into a distal segment

(most commonly ileum -> caecum via ileocaecal valve)

50
Q

Peak age of intussuception

A

3 months - 2 years

51
Q

What is the commonest cause of intestinal obstruction in infants after the neonatal period?

A

intussusception

52
Q

Presentation of intussusception

A
  • paroxysmal, severe colicky pain and pallor
    • during pain draws up legs
    • especially pale around mouth
    • recovers initially between pain but becomes more lethargic
  • refuse feeds, vomit (may be bile stained)
  • sausage shaped abdo mass
  • redcurrent jelly stool (occurs later)
  • shock
53
Q

What is the main serious complication of intussusception?

A

venous obstruction (stretching and constriction of mesentery) ->bleeding, fluid loss, bowel perforation, peritonitis, necrosis

54
Q

Investigations for intussusception

A

x-ray

  • distended small bowel
  • no gas distal colon or rectum

USS

  • confirm diagnosis and check response to Tx
55
Q

Tx for intussusception

A
  • IV FLUID RESUSCITATION
    • to avoid hypovolaemic shock
  • rectal air insufflation (75% successful)
  • operative reduction
    • in pt where rectal air insufflation unsuccessful
    • in pt with peritonitis
56
Q

What is a Meckels Diverticulum?

A

ileal remnant of vitello-intestinal duct

contains ectopic gastric mucosa or pancreatic tissue

57
Q

What is the indicence of meckels diverticulum?

A

2%

58
Q

Meckels diverticulum treatment

A

surgical resection

59
Q

Meckels diverticulum presentation

A
  • asymptomatic
  • severe rectal bleeding (not bright red not melaena)
  • intussusception
  • volvulus
  • diverticulitis
60
Q

Meckels diverticulum investigation

A

technetium scan increased uptake (by ectopic gastric mucosa)

61
Q
A

Phase 3a Paediatrics (2 decks)

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