Surgery Flashcards
ACUTE ABDOMEN: Know the common causes in different age groups
Intussusception: Most commonly seen between 5 - 12 months of age
Appendicitis: Uncommon in children < 5 years
Pyloric stenosis: Presents in infants < 3 months
NEC and Hirschsprung’s disease seen in neonates.
ACUTE ABDOMEN: Outline the principles of resuscitation in patients with shock.
Fluids
- Fluid bolus 20 ml/kg warmed saline
- Reassessment and calculation of maintenance, if required
- Monitor fluid input/output
ACUTE ABDOMEN: Describe the clinical features and differential diagnosis of acute appendicitis.
Clinical features:
- RIF pain (initially central and colicky)
- Anterior abdominal wall signs: Tenderness (rebound), guarding, may prefer to lie still with flexed knees
- Vomiting/nausea
- Anorexia
- Mild fever
- +/- Urinary/bowel symptoms
- Pyuria and bacteraemia may be present on urinalysis
Differential diagnosis:
- Intestinal obstruction: Intussusception, volvulus, adhesion
- NEC
- Colic
- Constipation
- Mesenteric adenitis
- DKA
ACUTE ABDOMEN: Be aware of the common pitfalls in acute appendicitis
- Atypical presentation:
- Diarrhoea, tender RIF
- Tender RIF, abnormal urine dipstick
- Possible incorrect diagnosis of UTI
- Avoid commencing abx unless dysuria is present, as this may mask the symptoms of appendicitis
ACUTE ABDOMEN: Understand some of the late presentation of appendicitis and their management
Late presentation of appendicitis:
- Appendicular mass1
- Abscess2
- Perforation → peritonitis → bacteraemia
Management:
- If signs of perforation are present then urgent fluid resuscitation and preparation for surgery is required
- Abscesses may be treated by CT-guided drainage
- Surgery is indicated by appendicular masses if the mass enlarges, small bowel obstruction occurs or the patient becomes more toxic
1: An appendicular mass is an inflammatory tumour consisting of the inflamed appendix, its adjacent viscera and the greater omentum. A RIF can be palpated
2: A pus-containing appendiceal mass
ACUTE ABDOMEN: Describe the clinical features and abdominal signs on intestinal obstruction
Clinical features:
- Vomiting: Bilious/faecal
- (Absolute) constipation
- Discomfort/distress
- Dehydration
- ‘Red current jelly’ stools in intussusception
Abdominal signs:
- Abdominal distention
- Tinkling bowel sounds
- Absent if perforation occurs
- Sausage shaped mass in the RIF in intussusception
ACUTE ABDOMEN: Be aware of the diagnostic workup of potentially dangerous conditions like malrotation, intussusception; fluid management and treatment
Malrotation
Diagnosis:
- Bilious vomiting
- Usually presents within the first 3 days of life, due to obstruction of the duodenum by Ladd’s bands but may present later in life as a volvulus causing obstruction and ischaemic bowel
Management
- Pass NG tube to allow decompression and provide fluids
- Emergency surgical decompression if blood is present in stools
- Ladd procedure1 and appendectomy2 performed, as SMA may become compromised (leading to ischaemia)
Intussusception
Diagnosis
- Clinical signs: Vomiting (may be bilious), refusing feeds, sausage shaped mass, constipation, red current jelly stools, paroxysmal severe colicky pain with pallor, abdominal distension and shock
- Most commonly seen between 3 months - 2 years
- Abdominal US: Target sign
- Abdominal X-ray: Distended small bowel, absence of gas in the distal colon
Management
- IV fluid resuscitation *as shock is an important side effect*
- Rectal air insufflation - unless peritonitis is present
- Surgical correction
1: Ladd procedure: Excision of Ladd’s bands which are anchoring the abnormally positioned intestines
2: Appendectomy is also performed as the appendix would otherwise be left in an unusual postion, causing difficulties diagnosing appendicitis
ACUTE ABDOMEN: Outline the age at presentation and clinical features of intussusception
Age at presentation:
Generally, seen between 3 months and 2 years of age
Clinical features
- Paroxsymal, colicky abdominal pain with associated pallor
- Sausage shaped mass in the abdomen
- Vomiting (may be bilious - depending upon the location of the obstruction)
- Refusing feeds
- Abdominal distension
- ‘Red current jelly’ stools as a late sign - associated with ischaemia
- Shock (as fluid accumulates within the intestines)
ACUTE ABDOMEN: Understand the importance of prompt diagnosis and subsequent treatment
Prompt diagnosis is required as intestinal perfusion can be rapidly compromised - sequelae include necrosis and perforation.
Shock can also develop as a consequence of intussusception.
Subsequent treatment
- Pass NG tube and provision of IV fluids
- Air enema reduction
- Surgical correction if above is unsuccessful or there are signs of peritonitis
ACUTE ABDOMEN: Describe the clinical features of volvulus in relation to the anatomical abnormality
Volvulus occurs due to intestinal malformation. A shortened root of the mesentery and loss of intestinal fixation allows the intestines to twist.
A closed-loop obstruction occurs leading to vomiting, abdominal pain/distension and constipation. The bowel may become ischaemic.
In older children Ladd’s bands may cause intermittent intestinal obstruction.
ACUTE ABDOMEN: Understand that bilious vomiting in a child is worrying feature and always requires investigation
- Upper GI contrast imaging (barrium meal/swallow/follow through) should be performed
- Abdominal X-ray
ACUTE ABDOMEN: Describe the initial management of a child with volvulus
- NG tube insertion and fluid resuscitation
- Analgesia
- ?Antibiotics
- Imaging - Upper GI constrast imaging, AXR
- Arrange for immediate laparotomy
ACUTE ABDOMEN: Describe the epidemiology, clinical and radiological features of necrotising enterocolitis (NEC)
Epidemiology
- Most commonly seen in premature neonates
- Risk factors include IUGR and hypoxia
Clinical features
- Systemic illness: Temperature instability, lethargy, apnoeas
- Bilious vomiting/aspirate from NG tube
- Poor feeding
- Abdominal distension with tense, shiny skin seen over the abdomen
- Blood in stools/vomit
- Thrombocytopenic (DIC)
- Sepsis
Radiological features
- Intramural gas
- Bowel distension
- Pneumoperitoneum if perforation has occurred
ACUTE ABDOMEN: Outline the medical management and indications for surgery in NEC
Medical management
- NG tube insertion to allow for decompression
- Stop milk feeds for 10 - 14 days
- Fluid resuscitation
- IV abx
- Mechanical ventilation
- Continuous monitoring for signs of sepsis
Indications for surgery
- Perforation1
- Deterioration despite medical treatment
- GI obstruction
1: Detected by AXR or transillumination of the abdomen
ACUTE ABDOMEN: Be aware of bowel atresias in the new-born period and their clinical/radiological features
Bowel atresias:
Clinical features:
- Bilious vomiting
- Faltering growth/weight loss
- No passage of stool/meconium within 24 hours
- Oesophageal atresia: Persistent drooling and salivation, cough/choking during feeding and cyanotic episodes
- Duodenal/jejunal/ileal atresia: Features of obstruction
Radiological features:
- Oesophageal atresia: Absent stomach bubble on antenatal USS, polyhydramnios, unable to pass NG tube into the stomach - seen on AXR,
- Duodenal atresia: ‘Double bubble’ sign on AXR, represents dilatation of the stomach and proximal duodenum
