Surgery Flashcards
What is epididymitis?
Inflammation/infection of the epididymis
What is orchitis?
Inflammation/ infection of the testes
What is the cause of epididymo-orchitis?
E. Coli
Chlamydia trachomatis
Neisseria gonorrhoea
Mumps
What is the usual presentation of epididymitis/orchitis?
Usually gradual onset over minutes/hours rather than the rapid onset you would see with torsion
Usually is unilateral
Testicular pain and tenderness
Dragging/ heavy sensation
Urethral discharge (chlamydia/gonorrhoea)
Tender on palpation, particularly over epididymis
Erythema to scrotum.
What is the management of epididymitis/orchitis?
Admit and treat if septic but otherwise can be treated as an outpatient
ABx following local guidelines
Tight underwear for scrotal support
Abstain from intercourse
Confirm diagnosis through US (this helps exclude torsions and tumours)
What is acute pancreatitis?
Inflammation of the pancreas Pancreatic enzymes (amylase/lipase) attack the pancreatic tissue
What are the causes of acute pancreatitis?
Alcohol
Gallstones
Post ERCP
What scoring system is used for the severity of pancreatitis?
Glasgow score <2= mild 2= moderate >2= severe Consider intensive care Intervention/review when score is >1
What are the complications of acute pancreatitis?
Pancreatitic necrosis
Infection in necrotic areas
Pseudocysts
Chronic pancreatitis
What is the management of acute pancreatitis?
Patients can become extremely sick very quickly
Escalate care according to Glasgow score
Careful monitoring
IV fluids
Analgesia
Endoscopic drainage if large pseudocusts
Antibiotics only if evidence of infected pancreatic necrosis
Surgery to remove infected pancreatic necrosis
What is Hirschsprung’s disease?
This is a congenital condition where the nerve cells in the myenteric plexus are absent in the distal bowel and rectum.
What is the myenteric plexus?
The myenteric plexus is also known as the Auerbach plexus and is the enteric nervous system (brain of the gut).
It runs all away along the bowel in the bowel wall and is a complex web of neurones, ganglions, receptors, synapses and neurotransmitters. It is responsible for stimulating peristalsis of the large bowel. Without the stimulation the bowel loses its motility and stops it from being able to move food along its length.
What is the key pathophysiology in Hirschsprung’s disease?
The absence of parasympathetic ganglion cells. In fetal development, these cells start higher up and migrate gradually to the distal colon and rectum. Hirschsprung’s is where the ganglion cells do not travel the whole way down and there is a section without parasympathetic ganglion cells. The length without the innervation varies.
What is it called when the entire colon has an absence of parasympathetic ganglion cells?
Total colonic aganglionosis.
What is the problem with the absence of parasympathetic ganglion cells?
This part of the bowel will not relax and become constricted. The proximal bowel will dilate and become obstructed.
What are the genetic associations with Hirschsprung’s?
There are a number of genes which have a modifying
effect and an increased risk.
Family history puts them at increased risk
Usually occurs in isolation, however there are a few associated conditions
Down’s syndrome, Waardenburg (pale blue eyes, patches of white hair, hearing loss), neurofibromatosis, multiple endocrine neoplasia type 2.
What is the presentation of Hirschsprung’s disease?
The presentation really depends on the severity and the age.
It may present as acute intestinal obstruction or gradually developing symptoms.
Delay passing meconium (>24 hrs) Poor weight gain/failure to thrive Vomiting Abdo pain and distension Chronic constipation since birth
What is Hirschsprung’s associated enterocolitis?
This is inflammation and obstruction
20% of neonates with Hirschsprung’s
Presents within 2-4 weeks of birth and presents with abdominal distension, fever, diarrhoea which often has blood, features of sepsis.
How serious is Hirschsprung’s associated enterocolitis?
It is life threatening and can lead to toxic megacolon and perforation.
What is the treatment of Hirschsprung’s associated enterocolitis?
ABx, fluid resuscitation, decompression obstructed bowel
What is the management of Hirschsprungs?
Abdominal x Ray Rectal biopsy- confirm diagnosis Fluid rescuscitation Management of intestinal obstruction IV ABx HAEC Surgical resection of bowel is the definitive management
How does small bowel obstruction present?
Presents with persistent vomiting, which is bile stained unless the obstruction is above the ampulla of vater.
Meconium may or may not be passed, subsequently it’s passage is usually delayed or absent with no transition to normal stool
High lesions present soon after birth, lower obstruction may not present for some days.
What is small bowel obstruction caused by?
Atresia or stenosis of the duodenum
1/3rd have Down syndrome and also associated with other congenital malformations.
Atresia/stenosis of the jejunum/ileum
Malrotation with volvulus (May lead to infarction of the entire midgut)
Meconium ileus
Meconium plug
How would you manage SBO in a child?
Depends on the cause
Correct fluid and electrolyte depletion
Meconium plug pass spontaneously
Meconium ileus May be dislodged using gastro gaff in contrast medium (otherwise will require surgery p)
Atresia/stenosis/malrotation are treated surgically!
What are the causes of LBO?
Hirschsprung’s disease and rectal atresia.
What is the pathophysiology behind pyloric stenosis?
Thickening of the pyloric musculature which leads to narrowing of the gastric antrum and subsequent disruption of gastric outflow.
This causes forceful vomiting of gastric contents, that will not become bilious.
The loss of hydrogen and chloride ions orally produces a hypochloraemic metabolic alkalosis that in turn causes potassium ions to move intracellularly (as K+ ions move in, H+ ions can move out) and leads to hypokalaemia.
What are the risk factors for pyloric stenosis?
Male sex
Family history