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Paediatrics > Surgery > Flashcards

Surgery Flashcards

1
Q

Features of appendicitis?

A

Uncommon <3 years as lumen wider and well drained.
Usually secondary to obstruction or lymphoid hyperplasia.
Peak incidence is 10-20 years of age.
More common in male sex.

Central abdo pain later radiating to RIF (more severe on movement).
Visceral to parietal peritoneum inflammation.
Low grade pyrexia
N+V
Diarrhoea or constipation
Anorexia (reduced appetite)
Tachycardia
Signs of dehydration
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2
Q

Atypical pain and symptoms of appendicitis?

A

Pelvic appendix - pain initially felt in RLQ, no visceral symptoms and pain on urination may cause suprapubic pain. May present with profuse diarrhoea and pelvic pain.

Retrocaecal appendix - 15% - pain localises to psoas muscle, flank or right upper quadrant.

Retroilial appendix - may cause testicular pain due to irritation of spermatic artery or ureter.

Vomiting before onset of pain

Diarrhoea - tends to be soft stools and small volume and frequent rather than watery

Fever - >38 degrees not common but may present when perforation occurs.

If perforated:

  • generalised abdominal pain
  • high heart rate
  • temp >38
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3
Q

What do you find on examination in appendicitis?

A

Tender McBurney’s point (1/3 distance from ASIS to umbilicus).
Guarding to RIF.
Rebound tenderness and percussion tenderness indicates peritonitis
Rosving’s sign - palpation of left iliac fossa (LIF) causes pain in RIF.

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4
Q

Diagnosis of appendicitis?

A

Increased inflammatory markers - CRP
Urine analysis to exclude pregnancy, renal colic, UTI
USS if pelvic organ pathology suspected.
CT

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5
Q

Features of appendix mass in appendicitis?

A

Signs of appendicitis with palpable mass in RIF.
When momentum and/or bowel surround and stick to inflamed appendix.
Typically managed conservatively with supportive treatment and antibiotics, with appendicectomy once acute condition has resolved.

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6
Q

What do score ranges in the paediatric appendicitis score?

A

<4 - low risk - find other cause

4-6 - further monitoring needed. Imaging would help - USS or MRI

> 6 - high risk - surgical team referral for blood tests to obtain WBC.

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7
Q

Management of appendicitis?

A

IV access, fluid resuscitation.
Contact surgical team to discuss IV abx, whether to make child NMB and if surgical intervention is needed.

Appendicectomy:
- laparoscopic treatment as fewer risks and faster recovery

Complications - bleeding, infection, pain, scars, damage to bowel, bladder or other organs, removal of normal appendix, anaesthetic risk, DVT/PE

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8
Q

Complications of appendicitis?

A 
Appendix mass
Abscess
Generalised peritonitis
Sepsis
Death
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9
Q

What is Hirschsprung’s disease and what features?

A

Aganglionic segment of bowel due to developmental failure of parasympathetic Auerbach (myenteric) and Meissner (submucosal) plexuses.

Neonatal - failure or delay to pass meconium

Older children - constipation, abdominal distension, bilious vomiting

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10
Q

What associations are there with Hirschsprung’s disease?

A

3 times more common in males

Down’s syndrome

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11
Q

Diagnosis and management of Hirschsprung’s disease?

A

Full thickness rectal biopsy will show no ganglion cells.

Rectal washouts initially.
Anorectal pull through procedure (removes affected bowel and reconnect bowels together).

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12
Q

What is Intussusception and features?

A

Invagination of one portion of bowel into lumen of adjacent bowel, most commonly ileo-caecal region.

6-18 months
M>F

  • Paroxysmal abdominal colic pain - child draws knees up and turns pale.
  • Episodic crying
  • Vomiting becomes bilious when obstruction occurs.
  • Blood stained stool - red-current jelly is late sign.
  • Sausage-shaped mass in RUQ.
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13
Q

Diagnosis and management of intussusception?

A

Ultrasound - may show target-like mass

Adequate resuscitation
Reduction by air insufflation under radiological control.

If this fails - surgery is performed.

Supportive - oxygen, morphine, naloxone (in case of overdose), prophylactic antibiotics, cannula

Risk of perforation -> use cannula for immediate decompression of air in abdomen.

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14
Q

Features of neonatal intestinal obstruction?

A

Bilious vomiting.
Absent or delayed passage of meconium.
Abdominal distension
Polyhydramnios in utero.

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15
Q

Examples of small bowel obstruction and examples of each?

A

Meconium ileus:

  • associated with cystic fibrosis.
  • presents in first 24-48 hours of life - abdo distension, bilious vomiting
  • diagnose with air fluid levels on AXR, sweat test to confirm CF.
  • manage with surgical decompression.

Duodenal atresia:
- associated with Down’s syndrome, diagnosed antenatally on USS, surgical repair required.

Midgut volvulus and malrotation:
- Failure of midgut rotation in utero, results in incomplete obstruction and intermittent pain, or may present acutely with volvulus.

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16
Q

Examples of large bowel obstruction and features of each?

A

Hirschsprung disease

Anorectal atresia:
- surgical management includes colostomy until a pull-through procedure can be performed. Some children remain faecally incontinent after repair.

17
Q

Features of pyloric stenosis?

A

Weeks 2-4
Caused by hypertrophy of circular muscles of pylorus.

  • Projectile non-bilious vomiting, typically 30 minutes after feed.
  • Infant remains hungry.
  • Weight loss.
  • Mild jaundice.
  • Constipation and dehydration.
  • Palpable mass may be present in upper abdomen (used to diagnose).
  • Hypochloraemic, hypokalaemic alkalosis.
18
Q

How to diagnose and manage pyloric stenosis?

A

USS
Examination - feel to pyloric lump during test feed.
Biochemical features.

Adequate fluid resuscitation first (baby will be dehydrated)
Definitive treatment - laparoscopic Ramstedt’s operation (pyloromyotomy).

Alternative treatment - atropine sulphate for 4-6 weeks.

19
Q

Causes of bilious vomiting in neonates?

A 
Duodenal atresia
Malrotation with volvulus
Jejunal/ilieal atresia
Meconium ileus
Necrotising enterocolitis
20
Q

Features, diagnosis and management of malrotation with volvulus?

A

3-7 days after birth, usually caused by incomplete rotation during embryogenesis.
Can cause peritonism and haemodynamic instability.

Diagnose with upper GI contrast study - shows DJ flexure is more medially placed.

Surgical management - Lads’s procedure.

21
Q

Management of umbilical hernia?

A

Usually self-resolve, but if large or symptomatic perform elective repair at 2-3 years of age.
If small and asymptomatic, perform elective repair at 4-5 years of age.

22
Q

Features and treatment of gastroschisis?

A

Congenital defect in anterior abdominal wall just lateral to umbilical cord.
Associated with socio-economic deprivation (maternal age <20, maternal alcohol/tobacco use)

Treat ASAP and whilst waiting, bowel should be protected with cling-film.

23
Q

Features and management of exomphalos?

A

Contents protrude through anterior abdominal wall but covered in amniotic sac formed by amniotic membrane and peritoneum.

Stages repair is preferred, as returning abdominal contents can cause respiratory insufficiency or inability to close abdomen, both of which can result in death.
Gradual closure allows pulmonary system to adapt to the increased abdominal contents over 6-12 months.

No need for cling-film covering as peritoneum will already be protecting bowel in exomphalos.

24
Q

Features of phimosis and management?

A

Non-retractable foreskin with healthy tissue underneath.

No need for treatment, will most likely correct itself.

25
Q

Balantis Xerotica Obliterans (males)/ Lichen Sclerosis (females)

A

Inflammation of glans with white plaque
May be itchy and can cause significant scarring
Management - steroids, foreskin meatoplasty, or circumcision.

26
Q

Features of diaphragmatic hernia?

A

Herniation of abdominal viscera into chest cavity due to incomplete formation of diaphragm.
Most are left sided, and often pulmonary hypoplasia.
Diagnosed antenatally allowing for early management

Early intubation and NG tube aspiration (to avoid inflation of bowel), and then surgical repair once stable enough.

Features - dyspnoea, tachypnoea at birth, pulmonary hypoplasia, compression of lung due to presence of abdominal contents in thoracic cavity.

27
Q

Investigations of undescended testis?

A

Bilateral - investigations to rule out congenital adrenal hyperplasia.
USS +/- MRI
Laparoscopy
Endocrine investigations.

28
Q

Management of undescended testis?

A

Watching and waiting.
If not descended by 6 months, should be seen by paediatric urologist.
Orchidopexy - surgical correction of undescended testes, should be carried out between 6-12 months of age.

Orchidotomy if unilateral intraabdominal testis not responsive to orchidopexy.

29
Q

Meckels diverticulum features?

A

Remnany of vitellointestinal duct, and contains ectopic ileal, gastric or pancreatic mucosa.

Rule of 2s:

  • 2% population
  • 2 feet from ileocaecal valve
  • 2 inches long
  • Female:male 2:1

Asymptomatic usually.
Abdominal pain mimicking appendicitis.
Rectal bleeding.
Intestinal obstruction - secondary to omphalomesenteric band (most commonly), volvulus and intussusception.

30
Q

Diagnosis and management of Meckel’s diverticulum?

A

Meckel scan

Removal if narrow neck or symptomatic.
Options are between wedge excision or formal small bowel resection and anastomosis.

31
Q

Features, diagnosis and management of tracheo-oesophageal fistula?

A

Copius salivation associated with chocking, coughing and vomiting.
Cyanosis when feeding.

Detected antenatally on US or MRI - shows polyhydramnios.
Chest XR
Consider endoscopy or bronchoscopy

Surgical correction with resection of fistula and anastomosis of any discontinuous segments.

32
Q

Features of necrotising enterocolitis?

A

Part of bowel becomes necrotic, leading to perforation.
Less common in babies fed by breast milk feeds.

Intolerance to feeds
Abdominal discolouration
Perforation
Peritonitis
Generally unwell
Tender abdomen
Absent bowel sounds
Blood in stools
Peritonitis and shock if perforation has occurred.
33
Q

Investigations of necrotising enterocolitis?

A

Metabolic acidosis on blood gas.
Thrombocytopenia
AXR:
- dilated bowel loops (often asymmetrical in distribution)
- Bowel wall oedema
- Pneumatosis intestinalis (intramural gas)
- Portal venous gas
- Pneumoperitoneum resulting from perforation
- Air both inside and outside bowel wall (Rigler sign)
- Air outlining the falciform ligament (football sign)

34
Q

Management of necrotising enterocolitis?

A

Immediate referral to surgical team
Stablise patient
Surgery required to remove dead bowel tissue
May be left with temporary stoma if significant bowel is removed.

35
Q

Features of hypospadias?

A

Urethral meatus to be located at abnormal site, usually under-side of penis rather than at the tip.
Further towards glans in 90% of cases.

Ventral opening of urethral meatus
Ventral curvature of penis or “chordee” - where head of penis bends downwards
Dorsal hooded foreskin.

36
Q

Classification of hypospadias?

A 
Glandular
Coronal
Shaft (distal, mid, proximal)
Scrotal
Perineal
37
Q

Investigations of hypospadias?

A 
Detailed history and examination
Karyotype
Pelvic ultrasound scan
U&amp;Es
Endocrine hormones - testosterone, 17 alpha-hydroxyprogesterone, LH, FSH, ACTH, renin, aldosterone.
38
Q

Management of hypospadias?

A

Mild cases - no treatment required.
Referral to urology for surgical correction.
Surgery usually performed before 2 years of age:
- important child not circumcised prior to surgery as foreskin may be used in corrective procedure.

Corrective surgery:

  • Urethroplasty - using graft of foreskin
  • Brings meatus to glans of penis
  • Chordee is corrected to straighten penis
  • dorsal foreskin managed with either circumcision or reconstruction, depending on anatomy, parental and surgical preference.
39
Q

Complications of hypospadias and surgery?

A

Urethral catheter:

  • may block, become displaced or kinked
  • can cause pain and bladder spasms - spasms treated with anticholinergics such as oxybutynin.

Bleeding and infection

Longer term complications:

  • urethral fistula
  • meatal or urethral stenosis

Cosmetic and psychological concerns

Sexual dysfunction

Paediatrics (15 decks)

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