Surgery Flashcards
What is phimosis?
Inability to retract the skin covering the head (glans) of the penis. This is otherwise known as the foreskin.
In what age children is phimosis considered to be normal?
<2 years
What is balanoposthitis?
Inflammation of the head of the penis
Also known as balanitis
Which faiths undergo circumcision for religious/cultural reasons?
Jewish and Islamic faiths
What are some medical indicaitons for circumicision?
Balanitis xerotica obliterans (BXO) causing true phimosis
Recurrent balanitis
Paraphimosis
What is balanitis xerotica obliterans?
Whitish patches on the genitals
Lichen sclerosis affecting the penis
Gives rise to progressive scarring
What is paraphimosis?
It is when the foreskin of a penis becomes trapped behind the glans penis, and cannot be reduced. If this condition persists for several hours or there is any sign of a lack of blood flow, paraphimosis should be treated as a medical emergency, as it can result in gangrene.
What is the underlying anatomical problem with an inguinal hernia?
The processus vaginalis remains patent
How can you differentiate between a inguinal hernia and a hydrocele?
See if you can ‘get above it’
What are some of the complications of an inguinal hernia?
How may the child present if these complications arise?
The contents of the hernia may become irreducible (incarcerated), causing pain and sometimes intestinal obstruction or damage to the testis (strangulation)
Infant may be irritable and may vomit
What is the approach taken with management of an inguinal hernia?
Children presenting in the first few months of life are at the highest risk of strangulation == hernia should be repaired urgently.
Children > 1 year - lower risk. Surgery may be performed electively.
How do you distinguish between a femoral and an inguinal hernia?
=
What is the difference between a direct and an indirect inguinal hernia? Which is more common in children?
Indirect - passes through the inguinal canal. Is found lateral to the inferior epigastric vessels.
Direct - bulges through weakened fascia of the abdominal wall. Is found medial to the inferior epigastric vessels.
Most common in children is indirect, secondary to patent processus vaginalis.
How can testicular torsion present clinically?
What must if be differentiated from?
Sudden onset acute pain
Pain can be in the groin, ABDOMEN or scrotum
Can have redness and oedema of the scrotal skin
It must be differentiated from an incarcerated hernia, torted hydatid of Morgagni and epididymo orchitis.
What characteristics of the testes lead to an increased risk of testicular torsion?
Undescended testis
Testis lying transversely on it’s attachment to the spermatic cord (aka ‘clapper bell’ testis)
Undescended testis is a risk factor for tumour development in the undescended testis and also the normal descended testis
What is the management of testicular torsion?
Surgical exploration in acute scrotal presentation is mandatory unless torsion can be excluded with CERTAINTY
The testis is fixed, along with the contralateral testis - as there is an increased risk of contralateral torsion
What (non surgical) test can help you to differentiated between testicular torsion and epididymo-orchitis?
Urine microscopy
What are the 3 categories you can split causes of an acute abdomen up into?
Intra-abdominal: Surgical
Intra-abdominal: Medical
Extra-abdominal
What blood test should be requested if you are querying pancreatitis?
Think of the PANCREAS mneumonic
Essential = amylase
FBC (for WBC), Ca2+, U+Es for renal function, LFTs, Albumin, Blood glucose
What are your differentials for vomiting in a 2 year old?
-
What are your differentials for vomiting in a 3 month old child?
-
What are some differentials of acute abdominal pain in children? (Intra-abdominal, surgical)
- Appendicitis
- Pancreatitis
- Bowel obstruction (including intussusception)
- Inguinal hernia
- Peritonitis
- Inflamed Meckel’s diverticulum
What are some differentials of acute abdominal pain in children? (Intra-abdominal, medical)
- Gastroenteritis URINARY: - UTI - Acute pyelonephritis - Renal calculus
- Henoch-Schonlein purpura
- DKA
- Sickle cell disease
- Hepatitis
- IBD
- Constipation
- Recurrent abdominal pain of childhood
- Ovarian pathology or gynae problems in pubertal females
What are some differentials of acute abdominal pain in children? (Extra-abdominal)
- Upper resp tract infection
- Lower lobe pneumonia
- Torsion of the testis
- Hip and spine
In children, who can peritonitis be seen in?
Can be seen in patients with ascites from nephrotic syndrome or liver disease
What are the clinical things/features in the history that MAY be associated with abdominal pain due to appendicitis in children?
Pain worse on coughing, walking, jumping, bumps in the road during car journey. Children typically can’t hop on the right leg due to the pain.
MAY have guarding in the right iliac fossa (however with retrocaecal appendix localised guarding may be absent and in a pelvic appendix there may be few abdominal signs)
Also, the pain is initially central and colicky but then may localised to the right iliac fossa
What clinical features (except from abdominal pain) may a child with appendicitis present with?
Fever
Vomiting (once or twice but marked and persistent vomiting is unusual)
Anorexia
In what age group of children is appendicitis rare?
How may appendicitis present in pre-school children?
Less than 3 years = rare. So in this age range the presentation is more often perforation.
- Diagnosis of appendicitis in pre-school children is more difficult.
- Faecoliths are more common and can be seen on a plain abdominal x-ray
- Perforation may be rapid (because omentum is less well developed and fails to surround the appendix, and signs are easy to underestimate at this age)
Why is there not one lab investigation that is consistently useful in appendicitis?
What investigations can SUPPORT the diagnosis?
Because findings are not always positive, even if appendicitis is present. E.g
On FBC: Neutrophilia may or may not be present
On Urine dip: White cells may or may not be present
On US: Cannot always identify the appendix. However, the presence of free fluid should raise suspicion. May also show a thickened, non-compressible appendix with increased blood flow.
What is the management of appendicitis?
Management of appendicitis with perforation?
- Appendicectomy (open or laparoscopic)
- Administration of METRONIDAZOLE reduces wound infection rates.
- Patients with perforated appendicitis (typical around 15-20%) require copious abdominal lavage. They are given IV Abx and Iv fluids prior to appendicectomy.
When there is generalised guarding with appendicitis what is this suggestive of?
Perforation
How should a child be managed if there is a palpable mass in the right iliac fossa and there are no signs of generalised peritonitis?
Patients without peritonitis who have an appendix mass:
- Should receive broad-spectrum antibiotics
- Appendicectomy can be performed after several weeks
What is intussusception?
What is the peak age of presentation?
Where (in the bowel) does it most commonly occur?
Invagination of proximal bowel into a distal segment
Peak age = 3 months - 2 years
Most commonly involves the ileum passing into the caecum through the ileocaecal valve
What is the most serious complication of intussusception?
Mesentery can compress on blood vessels (venous obstruction)
This can lead to engorgement and bleeding from the bowel mucosa and consequently shock from fluid loss
Bowel can perforate and peritonitis and gut necrosis can occur
What management of intussusception is essential in order to avoid complications?
Early identification, fluid resus and urgent reduction of the intussusception
How does intussusception typically present?
- Paroxysmal, severe colicky pain
- May refuse feeds, may vomit (may become bile stained - dependent on the site of the intussusception)
- Sausage shaped mass
- Redcurrant jelly stool (blood stained mucus) presents late, and may follow a rectal examination
- Abdominal distension and shock
How may intussusception appear on abdominal x-ray?
Distended small bowel
Absence of gas in the distal colon or rectum
What other imaging is useful in the diagnosis of intussusception?
In what order are they carried out?
US and AIR CONTRAST enema
- US is useful at demonstrating free fluid indicating peritonitis. It can also show if the bowel is ischaemic (which is a CI to air reduction)
- Air contrast enema and attempts at radiological air reduction are usually performed following the ultrasound (provided that the patient is resuscitated, stable and there are no contraindications), even if the ultrasound scan is normal when there is a strong clinical suspicion of the diagnosis.
US can also help to monitor the response to treatment
How is an intussusception managed?
What are contraindications to the above management??
What is the management if this fails?
- Rectal air insufflation (usually attempted by a radiologist)
- This procedure should only be carried out once the child has been resuscitated and is under the supervision of a paediatric surgeon in case the procedure is unsuccessful or bowel perforation occurs. Successful 75% of the time
- Remaining 25% require operative reduction
Describe the abdominal pain that occurs in intussusception in more detail.
The pain is paroxysmal, severe and colicky
During the episodes of pain the child becomes PALE, especially around the mouth and draws up their legs
There is recovery between the painful episodes but the child be subsequently become lethargic
What is Hirschsprung’s disease?
The absence of ganglion cells from the myenteric and submucosal plexuses or part of the large bowel
What is pyloric stenosis?
At what age does it typically present and why?
Who is it more common in?
Hypertrophy of the pyloric muscle causing gastric outlet obstruction
Presents at 2-8 weeks of age (Can be up to 4 months of age)
This is because the pylorus is normal at birth snd hypertrophies as time progresses.
More common in boys and people with a family history
What is the typical presentation of pyloric stenosis?
- Vomiting, which increases in frequency and forcefulness over time, ultimately becoming projectile
- The vomiting typically occurs 30 minutes after a feed
- Hunger after vomiting until dehydration leads to loss of interest in feeding
- Weight loss if presentation is delayed
What is the blood gas of a baby with pyloric stenosis?
What may be seen later on?
Hypokalaemic, hypochloraemic, metabolic alkalosis
However, later in the clinical course of pyloric stenosis the dehydration worsens and lactic acidosis may be seen.
What may be seen on examination of a child with pyloric stenosis?
A palpable mass may be present in the upper abdomen (RUQ)- this is the hypertrophied pylorus - it is firm, mobile and olive shaped.
Gastric peristalsis may be seen as a wave moving from left to right across the abdomen (this represents intense contractions against an obstruction)
Fontanelle may be depressed as the patient is often malnourished and dehydrated.
How is diagnosis of pyloric stenosis commonly made?
What is this supported by? When is this an exception?
Ultrasound
Can be supported by a test feed: However, diagnosis cannot be made via a test feed if immediate fluid resuscitation is required - this means that the baby is given a milk feed, which calms the hungry infant and allows examination.
What is the management of pyloric stenosis?
a) Initially
b) Definitively
Initial priority = correction of fluid and electrolyte disturbance with IV fluids. Fluid status should be corrected over 24 hours.
Then once hydration and acid-base and electrolytes are normal, definitive treatment by pyloromyotomy can be performed
What is oesophageal atresia?
What is it associated with?
What may be seen on scans antenatally?
It is a congenital condition where the upper part of the oesophagus doesn’t connect with the lower part of the oesophagus - there is, instead, a blind ended pouch.
It is associated with trachea-oesophageal fistula.
It is associated with polyhydramnios during pregnancy or an absent stomach bubble on antenatal ultrasound screening
What is done is oesophageal atresia is suspected?
An NG tube is passed after birth and checked by x-ray to see if it reaches the stomach
How may oesophageal atresia present if it is not suspected at birth?
Hypersalivation and drooling at the mouth (as unable to swallow saliva)
Apnoeic episodes when feeding
Coughing and choking when feeding
Aspiration into the lungs of saliva, milk and acid secretions from the stomach
What is the VACTERL association?
Vertebral Anorectal Cardiac Tracheo- oEsophageal Renal radial Limb anomalies
How is oesophageal atresia managed?
Continuous suction is applied to a tube passed into the oesophageal pouch to reduce aspiration of saliva and secretions pending transfer to a neonatal surgical unit for correction
What are some long term complications of a fixed oesophageal atresia?
GOR, chronic cough
Sometimes oesophageal dilatation is required in infancy or childhood
What is volvulus?
Torsion of the colon around it’s mesenteric axis resulting in compromised blood flow and closed loop obstruction.
What is the problem in malrotation of the bowel?
The mesentery is not fixed at the duodeno-jejunal flexure or in the ileo-caecal region.
This results in it’s base being shorter than normal so predisposes it to volvulus.
The caecum is high and in the midline
When does malrotation of the bowel typically present?
With what symptoms?
Usually presents in the first 1-3 days of life
Clinical features:
- Bilous vomiting
- Abdominal pain
- Tenderness from peritonitis or ischaemic bowel
What does any child with dark green vomiting require?
Why?
An urgent upper GI contrast study
To assess intestinal rotation
UNLESS there are signs of vascular compromise present - then an urgent laparotomy is needed
When an infant suffers from volvulus what blood supply is affected?
What does this result in?
The superior mesenteric artery is affected
Blood supply to the small intestine and proximal large intestine is compromised and unless corrected it leads to infarction of these areas
How is volvulus treated?
At operation the volvulus is untwisted
The bowel is placed in the correct positioning
The malrotation is not ‘corrected’ but the mesentery is broadened
The appendix is usually removed to avoid diagnostic confusion should the child subsequently have symptoms suggestive of appendicitis
What is duodenal atresia associated with?
Down’s syndrome. 1/3 of children with duodenal atresias have Down’s.
How does duodenal atresia appear on abdominal x-ray?
Describe the reason for this
A ‘double bubble’ is seen
The air is trapped in the stomach and proximal duodenum, which are separated by the pyloric sphincter, creating the appearance of two bubbles visible on x-ray.
What are some differentials for bilous vomiting?
Duodenal atresia Malrotation with volvulus Jejunal/ileal atresia Meconium ileus Necrotising entercolitis
What is rectal atresia?
Absence of the anus at the normal site
Treatment is surgical
If an intracranial injury is identified, the aim of management is to avoid secondary damage to the brain. How is this done?
Maintaining the blood supply to the brain
AND
Minimising the damage from raised intra-cranial pressure
HOW:
- Surgical evacuation of intracranial haemorrhage
- Intubations and ventilation to control blood pressure and blood CO2 levels - both of which affect cerebral perfusion
What are the criteria which are the same as adults for an urgent (within 1 hour) CT scan in children with head injuries?
- Post-traumatic seizure
- GCS <15 2 hours after injury
- Sign of basal skull fracture (haemotympaneum, panda eyes, battle sign, CSF leak from nose/ears)
- Suspected open or depressed skull fracture
- Focal neurological deficit
What are the criteria which are slightly different to adults for an urgent (within 1 hour) CT scan in children with head injuries?
- GCS less that 14 on initial assessment or <15 in a child <1
- Suspicion of non-accidental injury
- <1 year old with a bruise, swelling or laceration >5cm on the head
- Tense fontanelle
What are the criteria in children, that if more than 1 is present should cause an urgent CT to be carried out?
- Loss of consciousness lasting more than 5 minutes (witnessed).
- Abnormal drowsiness.
- Three or more discrete episodes of vomiting.
- Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object).
- Amnesia (antegrade or retrograde) lasting more than 5 minutes
If a mass is palpable in intussusception where is it typically palpable?
In the right upper quadrant
It is a sausage shaped mass
