Surgery Flashcards
what gender is most affected by appendicitis ?
males
does visceral or parietal peritoneum cause referred pain?
visceral peritoneum
what signs would be present for pelvic appendix ?
pain initially felt in RLQ, no visceral symptoms and pain on urination, may cause suprapubic pain (5). May present with profuse diarrhoea and pelvic pain.
what signs would be present for retrocaecal appendix ?
Pain may localise to psoas muscle, the flank or right upper quadrant
what signs would be present for retroileal appendix ?
May cause testicular pain due to irritation of the spermatic artery or ureter
if a child with suspected appendicitis has been suffering from symptoms for >48hrs what is likely to have happened?
perforated appendix
state some DD for appendicitis?
gastroenteritis acute mesenteric adenitis constipation crohns intussusception UTI ectopic pregnancy ovarian torsion basal pneumonia and pleurisy
what is the risk scoring used for appendicitis in children?
Paediatric Appendicitis Score (PAS)
what investigations can be done for appendicitis ?
FBC, U&Es, CRP, ESR, pregnancy test
urine dipstick
what is the PAS score out of?
out of 10
what does a PAS score of <4 show?
low likelihood of appendicitis
what does a PAS score of 4-6 show?
indicates further monitoring is needed and should be used alongside clinical judgement
imaging will be helpful
what does a PAS score of >6 show?
child is referred to the surgical team for blood tests
doesn’t confirm acute appendicitis
what are some complications of appendicitis?
perforation appendix mass abscess generalised peritonitis sepsis death
is appendix perforation common in children?
yes
- up to 97%
what is the initial management of appendicitis ?
immediate hospital admission
IV access
fluid resuscitation
contact surgical team to discuss IV antibiotics
what is the gold standard surgical management of appendicitis ?
laparoscopy
for uncomplicated cases, how long do patients stay in hospital for?
discharged after 24-36hrs
What does a palpable mass at McBurneys point in the RLQ suggest?
appendix perforation
Vomiting before the onset of pain is a feature of what appendix orientation?
retrocaecal
what gender is most affected by pyloric stenosis?
males
at what age does pyloric stenosis present at?
4-6weeks
what is the vomiting described as for pyloric stenosis?
projectile
on examination what could be found for pyloric stenosis?
visible peristalsis and a palpable olive-sized pyloric mass, best felt during a feed
what are the DD for pyloric stenosis?
Gastroenteritis Gastro-oesophageal reflux, including Sandifer syndrome Over-feeding Sepsis UTI Food allergy
what is Sandifer syndrome?
combination of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements with or without hiatal hernia
what investigation should be done for pyloric stenosis?
test feed with NG tube in situ
US for pyloric muscle hypertrophy >3mm thickness, >15mm length, >11mm diameter
what do blood gases for pyloric stenosis usually show?
hypokalaemia, hypochloraemic metabolic alkalosis
from vomiting
what is the management for pyloric stenosis?
10-20ml/kg fluid bolus
NG tube and aspirate contents
rehydration 150ml/kg/day
what surgery is done for pyloric stenosis?
Ramstedt’s pyloromyotomy
what are complications of pyloric stenosis?
Hypovolaemia Apnoea Wound dehiscence Infection Bleeding Perforation Incomplete myotomy
How many hours after surgery can the baby resume feeding?
6hrs
what is cryptorchidism ?
congenital absence of one or both testes in the scrotum
what are the three types of cryptorchidism?
true undescended testis
ectopic testis
ascending testis
during embryology, what pulls the testis down from the abdomen ?
gubernaculum within the processes vaginalis
what causes bilateral cryptorchidism ?
hormonal causes such as androgen insensitivity syndrome or disorder of sex development must also be excluded.
what are risk factors of cryptorchidism?
prematurity,
low birth weight,
having other abnormalities of genitalia (i.e. hypospadias)
having a first degree relative with cryptorchidism.
how many undescended testis are palpable ?
80%
what are some DD of cryptorchidism?
normal retractile testis true undescended testis ectopic testis absent testis bilateral impalpable testes
what are the two locations of ectopic testis ?
prepenile
femoral
what are the three locations of true cryptochidism testis ?
abdominal
inguinal
suprascrotal
what is the management of cryptochidism at birth?
review at 6-8weeks
what is the management of cryptochidism at 6-8weeks?
if fully descended, no further action. If unilateral, re-examine at 3 months
what is the management of cryptochidism at 3months?
If testis is retractile, advise annual follow up (due to risk of ascending testis). If undescended, refer to paediatric surgery/urology for definitive intervention – ideally occurring 6 – 12 months of age.
what is the surgery preformed for cryptorchidism when the testes are palpable ?
orchidopexy
what are three complications of undescended testis?
impaired fertility
testicular cancer
torsion
what is the incidence of hypospadias?
1 in 300
is the incidence of hypospadias increasing or decreasing ?
increasing
what are three key features of hypospadias?
1) Ventral opening of the urethral meatus
2) Ventral curvature of the penis or “Chordee”
3) Dorsal hooded foreskin
what are the different locations of hypospadias ?
glandular coronal shaft scrotal perineal
what is a diagnosis that must not be missed with hypospadias?
congenital adrenal hyperplasia
what investigations can be done if there are concerns over disorder of sex development?
Detailed history and examination Karyotype Pelvic ultrasound scan Urea and Electrolytes Endocrine hormones: Testosterone, 17 alpha-hyroxyprogesterone, LH, FSH, ACTH, renin, aldosterone
what is the treatment for hypospadias?
Urethroplasty
what are long term complications of surgery to correct hypospadias?
urethral fistulas
urethral stenosis
what is BXO?
balanitis xerotica obliterates
what happens during BXO?
where keratinisation of the tip of the foreskin causes scaring and the prepuce remains non-retractile
what age is most affected by BXO?
9-11 years
with what symptoms does BXO present?
scaring of the urethral meatus presents with irritation, dysuria, haematuria and local infection.
in extreme cases of scarring patients can present with urinary obstruction and retention.
what is the management of BXO?
circumcision
- the foreskin is sent off to histopathology in order to confirm the diagnosis
what are complications of untreated BXO?
meatal stenosis
phimosis
erosions of glands and prepuce
What is the mean age for when first foreskin retraction occurs?
10.4 years
What percentage of pathological phimosis is due to the process ‘Balanitis xerotica obliterans?’
95%
At what age is it normal phenomena to have non-retractile foreskin?
2-4years
