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
What is the most common cause of acute bowel obstruction in children?
Pyloric stenosis
How would pyloric stenosis present?
Effortless, projectile vomiting which occur during or after feeds
The vomit is actually never bilious but may have blood
Depending on how long it has gone on for, the child may be dehydrated and constipated.
What would you see on examination of a child with pyloric stenosis?
Peristaltic waves moving from left to right
An olive shaped mass in the epigastrium.
What investigations should you do for a child you are suspecting pyloric stenosis in?
Bloods- carry out blood gases and U&Es
U and Es will show hypochloraemia hypokalaemia and metabolic alkalosis
An abdominal USS for diagnosis
What are the differential diagnoses for pyloric stenosis?
Over feeding GORD Duodenal atresia Gastroenteritis Food allergy
What is the management of pyloric stenosis?
IV access should be gained and fluid rescuscitation (if required) and maintenance therapy should be commenced.
Definitive treatment= ramstedts pyloromyotomy
What is intusussception?
Telescoping of a proximal bowel segment into the immediately distal part.
What causes intusussception?
Usually idiopathic
However in a small number of children it may be pathological- meckel diverticulum, polyps, peutz Jeghers, Henoch schonlein
What is the pathophysiology of intusussception?
Invagination causes obstruction of venous and lymphatic drainage
Bowel swelling and subsequent luminal narrowing
Swelling leads to arterial insufficiency
Potential infarction of the bowel.
What age is intusussception commonly seen in?
See most often in children between the ages of 3 months and 2 years and peaks in children around 6-9 months.
What are the risk factors for intusussception?
Male sex (2-3:1) Antecedent viral illness (weak)
What are the clinical features of intusussception?
Symptoms
Colicky abdominal pain which lasts 1-2 mins is common
Child will typically scream in pain and may bring their knees to their chest
Red currant jelly rectum bleeding
Early vomiting, becomes bilious
SIGNS
perforation is rare but still look for signs of sepsis and peritonism
Pallor common on insoeftjon
Palpate abdomen for sausage sized mass in the RUQ and empty RLQ (dance sign)
Relatively asymptomatic between bouts (10-20mins)
What investigations would you carry out if you were suspecting intusussception?
Bloods and baseline observations
Abdominal USS: target or doughnut sign
AXR: gives a picture of bowel obstruction with dilated bowel loops proximally and absence of gas distally, the leading edge of the obstruction has a rounded appearance typically.
Contrast enema is the gold standard for diagnosis.
What are the differentials for intusussception?
Cows milk protein intolerance (leads to bloody stools) Hernia (Gastric) volvulus Meckel diverticulum Appendicitis GE Cyclical vomiting syndrome
What is the gold standard investigation for intusussception?
Contrast enema
What is the management of intusussception?
Surgical patients so NBM and IV maintenance fluids should be commenced
NG tube to decompress the stomach and bowel (drip and suck)
Analgesia and anti emetics as required
No signs of peritonism= air/barium enema is the treatment of choice
Signs of peritonism= laparotomy is required
When is torsion of the testes most common?
Most common in post pubertal boys, but may occur at any age, including the newborn when it is present at birth.
How does testicular torsion present?
Usually very painful with redness and oedema of the scrotal skin, however the Pain may be localised to the groin or lower abdomen, therefore you must always examine the testes in a boy presenting with sudden knset pain in the groin, abdomen, scortum.
What are the risk factors for testicular torsion?
1) Undescended testes
2) Testes lying transversely on its attachment to the spermatic cord (clapper bell) testis.
Why do you have to fix the the contralateral testis in torsion of the testicles?
You have to fix both because of the risk of testicular torsion in the other undescended testes.
What type of pain is seen in testicular torsion?
Acute/sudden onset of unilateral testicular pain
Often triggered by activity
There is a 6 hour window after onset before damage from ischaemia is irreversible
What is the major complication of testicular torsion?
Subfertility/infertility
What would you find on examination of testicular torsion?
Acutely tender testicle (often difficult to examine due to the extent of tenderness)
Firm testicle
Absent cremasteric reflex
Abnormal lie- horizontal lie, rotated so that epididymis is not in normal posterior position, elevated (retracted) testicle
What is bell clapper deformity?
Normally the testicle is fixed posteriorly to the tunica vaginalis
Bell clapper is where this fixation is absent
Bell clapper allows the testicle to rate within tunica
As the testicle rotates it twists the vessels and cuts of its blood supply
How do you manage testicular torsion?
Urgent urology assessment is needed
Immediate surgical exploration is needed- untwist and then fix both testicles in position to prevent further episodes (orchiplexy)
Possible orchiectomy if delayed surgery or necrotic testicle is present
What is the normal descent of a testes?
It normally starts in the abdomen, they are retro peritoneum and then they travel down the processes vaginalis and then move down to the scrotum.
What do you do if you have a neonate with undescended testes at birth?
You need to leave it and wait, undescended testes are present in up to 5% of newborn term infants bur are more common in premature infants. By 3 months of age only 1% are still undescended.
How can you deliver testes?
Testes may need to be delivered by gentle pressure along the line of the inguinal canal to the scrotum.
What happens if the testis is impalpable?
It means the testes might be in the inguinal canal but cannot be identified or it may be intra abdominal or absent.
What happens if there are bilateral impalpable testes!
This is a medical emergency
Karyotype must be established to exclude disorders of sex development.
It may indicate congenital adrenal hyperplasia
What is the difference between a retractile testes and undescended testis?
A retractile testis can be manipulated into the scrotum with ease and without tension
Cremasteric reflex also pulls up the testis in a retractile testis.
Why do you have to fix the testis (orchidopexy)
Cosmetic- Psychological benefit
Reduced risk of torsion and trauma compared to groin location
Fertility- the testis need to be in the scrotum, below body temperature to allow spermatogenesis, probably marginal in unilateral but is important if bilateral
There is also some evidence that delaying orchidopexy beyond the first two years of life adversely affects testicular development.
Malignancy- increased risk in an undescended testis, greater if bilateral or intra abdominal. Placing the testis in the scrotum facilitates self examination but may not influence malignancy risk (person more likely to recognise a malignancy if its in their scrotum).
When would you do an orchidopexy?
Should be done around one year of age due to the fact after this spontaneous descent is unlikely and there is evidence that testicular growth, hormonal function and spermatogenesis is improved by operating at this early age rather than waiting until they are older.
What is the other name for undescended testes?
Cryptochidism
What are the risk factors for undescended testes?
Family history Low birth weight SGA Prematurity Maternal smoking during pregnancy
What are retractile testicles?
Normal variant in boys that have not reached puberty, it is where the testes move out of the scrotum and into the inguinal canal when it is cold or the cremasteric reflex is activated.
What is the the pathophysiology behind a hydrocele?
Same underlying anatomy as a hernia but the processus vaginalis, although patent, is not sufficiently wide enough to form an inguinal hernia.
Processus vaginalis is often patent at birth but it offen closes within months therefore hydroceles usually resolve spontaneously. Surgery considered after first two years of life.
How do you differentiate a hernia from a hydrocele?
The ability to get above a hydrocele
Hydroceles usually transilluminate
What is a varicocele?
Scrotal swelling which consists of dilated (varicose) testicular veins and occurs in up to 15% of boys, usually at puberty.
What side does a varicocele usually occur on and why?
More common on the left side because of the drainage of the gonadal vein into the left renal vein.
What may you feel on examination of someone with varicoceles?
Bag of worms
What is the management of varicocele?
Conservative if asymptomatic
Occlusion of the gonadal veins can be achieved by surgical ligation- through the groin laparoscopically or by radiological embolization.
