Surgery Flashcards
What is exomphalos?
When the abdominal contents protrudes through the umbilical ring and is covered with a transparent sac (aminotic membrane and peritoneum)
What is gastroschisis
When the bowel protrudes through a defect in the anterior abdo wall, adjacent to the umbilicus, with no covering sac
What causes ventral body wall defects?
Increased risk with conditions related to placental insufficiency
- materal illness and infection
- drugs, alcohol, smoking
Which tests can detect a ventral body wall defect?
- increased alpha-fetoprotein
- abnormal US
- both in second trimester
How would exomphalos present?
- 4-12 cm abdo wall defect
- central, epigastric or hypogastric
- 75% have associated defects
How would gastroschisis present?
- opening > 5cm
- Right side of umbilical cord
- 15% have associated defects
What investigations would you perform on suspected ventral body wall defect?
- 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)
How would you manage exomphalos?
- surgery +/- silo
- if sac ruptures manage same as gastroschisis
How would you manage gastroschisis?
- 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
What are the risk factors for NEC?
- prematurity
- low birth weight
- preterm infants fed cows milk formula
How and when does NEC present?
- usually in the first 2/52
- stop tolerating feeds
- bile stained vomit, fresh blood in stools
- distended stomach
- shock
What are the X-ray features of NEC?
- distended loops of bowel
- thickening bowel wall with intramural gas
- gas in portal tract
- bowel perforation in progressive disease
What is the management of NEC?
- stop oral feeding - parenteral nutrition (PPN, TPN, NGT)
- artifical vent, circulatory support
- surgery
Common hernias in children
indirect inguinal (through the deep ring)
Inguinal hernias aetiology
- more common in boys
- patent processus vaginalis
- common in prematurity
Inguinal hernia presentation
- 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)
Inguinal Hernia tx
- most irreducible hernias can be reduced by opiod analgesia and gentle compression
- surgery
What causes a hydrocele?
Patent processus vaginalis allows peritoneal fluid to track down around testis
How does a hydrocele present?
- presents at birth or in early childhood after an infection
- Generally asymptomatic scrotal swelling
- bilateral bluish colour
- non-tender and transilluminate
Hydrocele tx
- spontaneous resolution
- sugery if persists past 18-24 months of age
Define vomiting
forceful ejection of gastric contents
Define posseting
non-forceful return of small amounts of milk, often accompanied by return of swallowed air (wind). common.
Define regurgitation
frequent non-forceful return of large amounts of milk
Common causes of vomiting in infants
- GOR
- feeding problems
- infection (gastroenteritis, resp/urinary tract, otitis media, whooping cough, meningitis)
- dietary protein intolerances
- intestinal obstruction (pyloric stenosis, atresia, intussusception, malrotation, volvulus, hirschsprungs)
- metabolic errors
- congential adrenal hyperplasia
- renal failure
Common causes of vomiting in pre-school children
- infection (gastroenteritis, resp/urinary tract, otitis media, whooping cough, meningitis)
- appendicitis
- intesinal obstruction (intussusception, malrotation, volvulus, adhesions, foreign body)
- increase intracranial pressure
- coeliac
- renal failure
- metabolic errors
- testicular torsion
Common causes of vomiting in school aged children and adolescents
- infection (gastroenteritis, pyelonephritis, septicaemia, meningitis,)
- peptic ulcer/ H. pylori infection
- appendicitis
- migraine
- increased intracranial pressure
- coeliac
- renal failure
- DKA
- alcohol/drug ingestion
- cyclical vomiting syndrome
- bulimia/anorexia
- pregnancy
- testicular torsion
What would bile stained vomit be a red flag for?
intestinal obstruction
What would haematemesis be a red flag for?
- oesophagitis
- peptic ulcer
- oral/nasal bleeding
What would projectile vomiting (in first few weeks of life) be a red flag for?
pyloric stenosis
What would paroxysmal coughing then vomiting be a red flag for?
whooping cough
What would abdo tenderness/pain on movement with vomiting be a red flag for?
surgical abdomen
What would abdo distension with vomiting be a red flag for?
intestinal obstruction
What would hepatosplenomegaly with vomiting be a red flag for?
chronic liver disease
What would blood in stool with vomiting be a red flag for?
- intussusception
- gastroenteritis
What would severe dehydration, shock and vomiting be a red flag for?
- severe gastroenteritis
- systemic infection
- DKA
What would bulging fontanelle, seizures and vomiting be a red flag for?
increased intracranial pressure
What would failure to thrive and vomiting be a red flag for?
- GOR
- coeliac
- chronic GI condition
What is GOR
involuntary passage of gastric contents into oesophagus
What causes GOR
- inappropriate relaxation of LOS because of function immaturity
- risks
- fluid diet
- mainly horizontal posture
- short intra-abdo length of oesophagus
In which cases is severe reflux more common?
- cerebral palsy
- preterm
- post surgery for oesophageal atresia or diaphragmatic hernia
GOR complications
- 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
GOR investigations
- 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
GOR management
- 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
What is a pyloric stenosis?
hypertrophy of pyloric muscle causing gastric outlet obstruction
Pyloric stenosis epidemiology
boys
maternal family hx
pyloric stenosis presentation
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)
Pyloric stenosis examination findings
- gastric peristalsis seen as wave right L -> R
- palpable pyloric mass RUQ, like an olive
Pyloric stenosis management
- IV fluid (0.45% saline and 5% dextrose with potassium supplements) to correct any fluid or electrolyte imbalance
- pyloromyotomy = division of hypertrophied muscle down to mucosa
- feed w/in 6h
- discharge w/in 2 days
What is intussusception?
invagination of proximal bowel into a distal segment
(most commonly ileum -> caecum via ileocaecal valve)
Peak age of intussuception
3 months - 2 years
What is the commonest cause of intestinal obstruction in infants after the neonatal period?
intussusception
Presentation of intussusception
- 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
What is the main serious complication of intussusception?
venous obstruction (stretching and constriction of mesentery) ->bleeding, fluid loss, bowel perforation, peritonitis, necrosis
Investigations for intussusception
x-ray
- distended small bowel
- no gas distal colon or rectum
USS
- confirm diagnosis and check response to Tx
Tx for intussusception
- 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
What is a Meckels Diverticulum?
ileal remnant of vitello-intestinal duct
contains ectopic gastric mucosa or pancreatic tissue
What is the indicence of meckels diverticulum?
2%
Meckels diverticulum treatment
surgical resection
Meckels diverticulum presentation
- asymptomatic
- severe rectal bleeding (not bright red not melaena)
- intussusception
- volvulus
- diverticulitis
Meckels diverticulum investigation
technetium scan increased uptake (by ectopic gastric mucosa)
