Surgery Flashcards
General surgery + head injury
Acute abdomen differentials
Surgical: appendicitis, intestinal obstruction, inguinal hernia, peritonitis, inflamed Meckel diverticulum, pancreatitis, trauma
Medical: non-specific abdo pain, gastroenteritis, UTI/pyelo/hydronephrosis, HSP, DKA, sickle cell, hepatitis, IBD, constipation, gynae (pubertal age), psychological, lead poisoning, acute porphyria (rare)
Extra-abdominal: URTI, LL pneumonia, testicular torsion, hip/spine pain
Appendicitis
Uncommon <3y, commonest surgical cause of abdo pain
CF: anorexia, vomiting, abdo pain (central + colicky [midgut] then localises to RIF, aggravated by movement), persistent tenderness + guarding in RIF (tho in retrocaecal appendix may have no guarding), pelvic appendix may have no abdo signs.
Ix: nothing consistently helps diagnosis, but US abdomen may show thickened non-compressible appendix + increased blood flow, may show abscess. In young children may have faecoliths on XR
Assess regularly as progressive, <5y more likely to have rapid perforation as the momentum is less well-developed
M: laparoscopic appendicectomy, if perforation fluid resuscitations + IV Abx. If no signs of peritonitis may opt for conservative with Abx + appendicectomy when acute inflammation resolved
Head injury
Primary damage: focal contusions/lacerations, diffuse axonal injury, BV injury (EDH [arterial], SDH [venous], SAH), penetrating injury
Secondary damage: cerebral oedema, hypotension, hypoxia, seizures, hypoglycaemia
Criteria for urgent CT:
- Any one of: suspect NAI, post-traumatic seizure, GCS<14/<15 2h post injury, suspected skull #, focal neuro signs, <12m with a bruise or swelling that’s more than 5cm
- Any two of: witnessed LoC >5m, abnormal drowsiness, 3+ episodes of vomiting, dangerous mechanism of injury, amnesia >5m
Management:
- Poorly responsive/inadequate breathing: CT + intubate
- Admit + observe for at least 6h if have any of above features
- Avoid secondary damage, minimise RICP, may need surgical evacuation of ICH, may need intubation + ventilation to control BP+CO2 (as these affect cerebral perfusion)
- Rehab: cognitive, behavioural + mental health problems
Herniae
Protrusion of a tissue/organ outside the walls of its containing cavity
Inguinal: v common, usually herniation of momentum through deep inguinal ring due to persistence of the processes vaginalis (indirect); sometimes direct due to weak tissues (herniates directly through Hesselbach’s triangle, esp in premature). CF lump in groin/scrotum/labia, may be intermittent and visible on straining, sometimes thickened cord structures palpable in groin, most reducible. Comps include incarceration (irreducible, pain, sometimes causes obstruction), strangulation (damage to testis, tender lump, vomiting) - plan surgery for when oedema reduced, or if irreducible/strangulated emergency surgery due to risk of loss of gonad. This involves ligation + division of the processus vaginalis (cf adults-mesh reinforcement of abdo wall)
Umbilical: v common, usually go by 3-4y, if not surgical repair
Epigastric
Diaphragmatic-see neonatal
Hirschsprung’s disease
Absence of the myenteric + submucosal plexuses of the rectum and a variable distance of colon – narrow contracted segment – most just rectosigmoid but some can be whole colon
Ep: M>F, Down syndrome is a RF
CF:
- Neonatal (usual): intestinal obstruction, failure to pass meconium in first 24h, distension, bile stained vomiting. DRE may cause release of liquid stool with temporary sx improvmeent
- Life-threatening Hirschsprung enterocolitis in first few weeks
- Later: chronic profound constipation, abdo distension, growth failure
Ix: rectal biopsy (absent ganglion cells + large AChE positive nerve trunks), anorectal manometry/barium studies for length of aganglionic segment but not diagnosis
M: colostomy then anastomosis of normal bowel to the anus
Intussusception
Invagination of proximal bowel into a distal segment ‘telescoping’, most commonly ileum into caecum through ICV
Most 3m - 2y, but can be any age, usually no underlying cause (but viral infection may enlarge Peyer’s patches - point of the intussusception); if >2y more common to find a lead point like Meckel’s or polyp
CF: pain (severe, colicky, child pale+draws up legs, between episodes recovers), refuses feeds, vomiting (bile stained if after AoV), sausage-shaped mass in abdomen, redcurrant jelly stool (late sign), abdo distension + shock
AXR: distended SB, absence of gas in distal colon/rectal, outline of the intussusception
Abdominal US: target/doughnut sign
M: IV fluid resuscitation as fluid pooling in gut causes hypovolaemia, reduction via rectal air insufflation (unless peritonitis, works for 75%), or surgery (if unsuccessful or peritonitis)
Comps: stretched + constricted mesentery - venous obstruction - engorgement + mucosal bleeding - perforation, peritonitis, gut necrosis
Neonatal intestinal obstruction
SBO: antenatally or p/w persistent bile stained vomiting (unless above AoV), absent meconium, doesn’t transition to normal stool. Causes include duodenal atresia/stenosis (1/3 have DS), other atresia, malrotaiton + volvulus, meconium ileus, meconium plug
LBO: Hirschsprung , rectal atresia (anus at abnormal site)
Pyloric stenosis
Hypertrophy of pyloric muscle (nr exit of stomach) - gastric outlet obstruction
Ep: 2-8w of age (irrespective of gestational age), M>F, may have a FH
CF: vomiting increasing in freq then projectile, hunger after vomiting then dehydration, weight loss, hypochloraemic hypokalaemia hyponatraemic metabolic alkalosis, may see a wave of gastric peristalsis, pyloric mass in RUQ
US confirms diagnosis, may need NG tube to remove air distension, test feed
M: rehydration + electrolyte balance, pyloromyotomy (divide the hypertrophied muscle up to but not including the mucosa). Post-op can feed after 6h and discharge after 2d
Testicular torsion
Commonest post-pubertal but can be any age. Higher risk if undescended or ‘clapper bell’ testis (testis lies transversely on attachment to spermatic cord)
CF: severe pain in groin/lower abdomen, red + oedematous scrotal skin
M: treat within hours to lower loss risk. Any acute scrotum needs surgical exploration unless certain not torsion, and they will alway fixate the contralateral testis due to the higher risk of torsion. If perinatal torsion (presents neonatally) then testicular loss almost inevitable
Volvulus
Intestinal obstruction + compromised SMA supply to the SB/proximal LB
M: urgent untwisting, duodenum mobilised, bowel placed in non-rotated position with DJ flexure on right + cecum and appendix on left, mesentery broadened, appendix removed
Balanitis
Acute, persistent or recurrent inflammation of the glans penis
Commonest cause in boys is non-specific dermatitis with a red glans penis/shaft, may get non-retractile foreskin from adhesions (phimosis) causing poor hygiene + irritation. Predisposes to colonisation with candida [red, spares meatus, itchy papule, white DC]/staph/strep [painful, oedema, erosions, purulent exudate]
-Can also be due to other infection, other skin conditions like contact dermatitis, trauma
M: gently clean + dry, avoid soaps, written info, hydrocortisone cream, remove triggers, imidazole cream for candida/flucloxacilin for bacterial
Circumcision may be indicated if not responding/BXO causing a true phimosis/prophylaxis of UTI esp with congenital uropathy like posterior urethral valves
Comps: phimosis, cellulitis, meatal stenosis, stricture
Diaphragmatic hernia
Herniation (usually left) of abdo contents through diaphragm foramen
CF: displaced apex + HS (to right), poor air entry into left chest, pneumothorax in normal lung from resuscitation
XR C+A: loops of bowel in left chest, displaced mediastinum
M: stabilise by passing large NG tube + suction to stop intrathoracic bowel distension, repair hernia surgically
Comp: pulmonary hypoplasia (usually permanent as has been compressed throughout pregnancy)
Hydrocele
Processus vaginalis is patent but not wide enough to form a hernia - usually asymptomatic but may appear blue, can usually feel the testis, but are able to ‘get above’ it (unlike hernias), should transluminate (unreliable af)
Usually spontaneous resolution as the PV closes, >2y may do surgery
Female version - hydrocele of the canal of Nuck
Malrotation
Rotation of SB, mesentery not fixed so base shorter than normal so predisposes to volvulus. May have Ladd bands crossing duodenum so further obstruction
CF: obstruction or volvulus. Bilious vomiting (dark green) in first few days - do urgent upper GI contrast study, or if vascular compromise urgent laparotomy (as otherwise get SB + prox colon infarction)
Can happen at any age
M: untwist volvulus, mobilise duodenum + place bowel in non-rotated position with DJ flexure on right and cecum + appendix on left, mesentery broadened so less chance of volvulus, usually remove appendix so less confusion from acute abdomen in future
Necrotising enterocolitis
RF: prematurity, cows milk feeds
Ischaemic bowel + bacterial invasion
CF: feed intolerance, vomiting (may have bile), abdo distension, fresh blood in stool, shock
XR: distended loops of bowel, thickened bowel wall, intramural gas, gas in portal venous tract, perforation
M: stop oral feeding, broad spectrum Abx, parenteral nutrition, surgery if perforated
Comps: strictures, malabsorption from extensive resection, poor neurodevelopment outcome. 20% mortality
Tracheo-oesophageal fistula
Airway anomaly
Aspiration
Undescended testes
Arrest along the normal pathway of descent, common esp in premature, should ideally pick up on NIPE (feel in scrotum/gentle pressure along line of inguinal canal to bring them there)
CF: palpable (felt in groin but cant move into scrotum), ectopic (palpable below external ring but outside scrotum), impalpable (may be in canal, abdomen or absent), b/l impalpable (may have disorder of sex development)
Imaging not helpful
M: orchidopexy (surgical placement of testis in scrotum, done for psychological + cosmetic, reduced risk of torsion + trauma, fertility [testis needs to be below body temp for spermatogenesis esp important if b/l], malignancy [esp if b/k, allows self examination]). If undescended at 3m refer to paediatric surgeon to be seen by 6m. Done before/around 1y as after this spontaneous descent unlikely. Absent testis-prosthesis. Laparoscopy to diagnose impalpable testis.
Retractile testis: can be easily manipulated into scrotum, cremaster muscle pulls up testis (light touch on abdo wall), FU recommended as some high testes need surgery to place them into scrotum
Varicocele
Scrotal swelling of dilated testicular veins, usually at puberty
Left side commoner - drainage of left gonadal vein into left renal vein which receives blood from left adrenals so has catecholamiens
CF: asymptomatic, dull ache, bluish colour, ‘bag of worms’, sometimes smaller/softer testis
M: conservative unless symptomatic (can occlude gonadal veins)
Meckel diverticulum
Remnant of vitello-intestinal duct in ileum, present in 2%. Has ectopic gastric/pancreatic tissue
Can inflame-PR bleeding with acute Hb reduction, intussusception, volvulus, divertilitis
Technetium scam may show increased uptake
M: surgical resection
Non-specific abdo pain
Pain for 24-48h, less severe than appendicitis, tender RIF may happen
often a/w URTI + cervical lymphadenopathy
if not resolving may do appendicectomy where may find large mesenteric nodes but remove appendix anywya
Acute scrotum differentials
Torsion of appendix testis (hydatid of Morgagni): a mullerian remnant, more in prepubertal boys and more common than TT. Pain over days, often need exploration + excision, may see a ‘blue dot’ through the scrotal skin
Epididymo-orchitis: infection more in younger/pre-existing abnormalities, often need exploration, Doppler US of blood vessels + urine to check for UTI. Empric Abx while wait for pus sample results
Idiopathic scrotal oedema: red + swelling beyond scrotum into thigh/perineum, normal non-tender testis, needs analgesia
Incarcerated inguinal hernia
Trauma
