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Child health > Surgery - acute abdomen > Flashcards

Surgery - acute abdomen Flashcards

1
Q

What are the clinical features of appendicitis? (How common and Symptoms)

A

Very uncommon <3 years, otherwise commonest childhood abdo pain that requires surgical intervention. Can occur from 1-100 year olds

Symptoms

Anorexia
Vomiting (few times)
Abdo pain, initially central and colicky, then localising to right iliac fossa

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2
Q

What are the signs of acute appendicitis?

A

Flushed face with oral fetor
Low-grade fever (37.2-38°C)
Abdo pain aggravated by movement (walk, cough, bumps on the road during car journey)

Persistent tenderness with guarding in the right iliac fossa (McBurney’s point)

Signs are easy to underestimate in pre-school age group

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3
Q

Why may appendicitis present with white blood cells or organisms in the urine and thus lead to a misdiagnosis of UTI?

A

Inflamed appendix may be adjacent to the ureter or bladder

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4
Q

Which clinical examination and investigatins are required in acute abdominal pain?

A

Full examination
Includes gynae examination in girls
Testicular examination in boys (referred)

Investigations depend on age and presentation:
Capillary blood glucose
FBC
CRP
LFTs
Urine dipstick
U&amp;Es
Renal function
Amylase
Stool sample with diarrhoea
Blood cultures
Imaging (AXR/US of abdo/testis, erect CXR - gas) may be required, but not always

Laparoscopy

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5
Q

Which are very common causes of acute abdominal pain? At which age are they common?

A 
UTI
Acute appendicitis (>3 years)
Mesenteric adenitis
Gastro-enteritis
Constipation
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6
Q

Which are less common causes of acute abdo pain?

A 
Lower lobe pneumonia
Strangulated hernia
Diabetic ketoacidosis
Intussusception
Intestinal obstruction
Henoch Schönlein Purpura
Pancreatitis
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7
Q

What are the causes of acute abdominal pain in <1 year olds?

A

Medical:
gastroenteritis
Constipation
UTI

Surgical:
intussusception
volvulus
incarcerated hernia

Other:
Hirschprung’s disease

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8
Q

What are the causes of acute abdominal pain in 2-5 year olds?

A

Medical:
gastroenteritis
constipation
UTI

Surgical:
Appendicitis
Intussusception
Volvulus
Trauma
Other:
Henoch-schonlein purpura
DKA
Mesenteric lymphadenitis
Sickle cell crisis
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9
Q

What are the causes of acute abdominal pain in 6-11 year olds?

A

Medical:
gastroenteritis
constipation
UTI

Surgical:
appendicitis
trauma

Other:
Mesenteric adenitis
Abdominal migraine
Henoch schonlein purpura
DKA
Sickle cell crisis
Lower lobe pneumonia
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10
Q

What are the causes of acute abdominal pain in 12-18 year olds?

A

Medical:
gastroenteritis
constipation

Surgical:
appendicitis
trauma
testicular torsion
ovarian torsion
Other:
Dysmenorrhoea
Ectopic pregnancy
Mittelschmerz (ovulation)
PID
Threatened abortion
DKA
IBD
Adrenal crisis
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11
Q

In which cases can acute appendicitis be easily misdiagnosed?

A

Can present atypically with diarrhoea/tender RIF - misdiagnosed as gastroenteritis

Can present atypically with tender RIF/ abnormal urine dipstick - misdiagnosed as UTI

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12
Q

List differentials for paediatric acute appendicitis (vague symptoms)

A 
Ovarian cyst/torsion (12-18)
PID (12-18)
Pregnancy (12-18)
Ectopic pregnancy (12-18)
Testicular torsion
Renal calculi
Mesenteric adenitis
Right LL pneumonia
Volvulus
Intussusception
Constipation
Gastroenteritis
UTI
Pyelonephritis

Hirschprungs disease in infants

HSP (henoch schonlein purpura)
HUS (haemolytic uraemic syndrome)

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13
Q

What are the differentials for acute appendiceal abscess or mass?

A

Meckel’s diverticulum

Crohn’s disease

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14
Q

How is the late presentation of appendicitis explained and how is it managed?

A

Appendicular mass. (Retroceacal appendicitis can also present late)

Managed with immediate laparoscopic appendicectomy

OR - since this is still researched

Conservative management with antibiotics and ultrasound guided percutaneous drainage. Depending on the recurrence rate after this (which is still controversial), patients may need interval surgery. In patients, conservative is SAFER

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15
Q

What are the symptoms and signs of intestinal obstruction?

A

Abdominal pain
Persistent vomiting

Signs:
Bile-stained vomit
Jaundice if high intestinal obstruction
Abdominal distension

Auscultation - increased bowel sounds

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16
Q

In suspected intestinal obstruction (infant), how can malrotation volvulus be diagnosed?

A

Imaging is the mainstay. Always if bilious vomiting.

Malrotation with volvulus:
Upper GI series
Absence of splenic and hepatic flexures

If abdominal distension and tenderness, barium enema is better - distinguishes malrotation from Hirschprung’s enterocolitis

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17
Q

What is the age group and the clinical features of intussusception?

A

0-6 years
Peak 3 months - 2 years

Refuse feeds

Signs:
Acutely unwell (pallor - around mouth)
Increasingly lethargic
Waves of abdominal pain
Often a palpable mass in RUQ (sausage shape)
Redcurrant jelly stool - blodd-stained mucus (DRE)
Bilious vomit (late)
Abdo distension
Shock
18
Q

Why does upper intestinal obstruction cause bilious vomiting?

A

Enzymes secreted by gall bladder go up into the gallbladder and digest it

19
Q

What has to always be assessed for in intussusception, malrotation, and strangulated inguinal hernia?

A

Dehydration and shock (vomiting)

20
Q

What is intussusception?

A

Invagination of proximal bowel into distal segment

Most commonly ileum into caecum (through ileocaecal valve)

21
Q

Why is prompt diagnosis and immediate treatment of intusussception necessary?

A

To avoid life-threatening complications:

Stretching and constriction of the mesentery can result in venous obstruction. Causes engorgement and bleeding from bowel mucosa. FLuid loss
Bowel perforation
Peritonitis
Gut necrosis

22
Q

What is the management of intussusception?

A

Fluid resuscitation, first, then
Air enema reduction (75% success)

there needs to be a paediatric surgeon, in case of failure, or if bowel perforation occurs.
Operative reduction is by manual squeezing of the colon to reduce intussusception

23
Q

How is intussusception diagnosed?

A

Investigations needed if bilious vomit

AXR may show distented small intestine and absence of air in distal colon/rectum
Sometimes the outline of intussusception can be seen
Abdo US can help

24
Q

Which investigation is required in bilious vomiting?

A

Ugent upper GI contrast study to assess intestinal rotation

Unless there are signs of vascular compromise - requires urgent laparotomy

25
Q

What is the management of volvulus?

A

Surgery recommended within 2 days of diagnosis OR immediately if severely twisted or blood supply cut off. In case of infarction, resection is required with reattachment.

Sigmoid: decompression with sigmoidoscope + flatus tube (allows rapid decompression of distended bowel)

Surgery:
Sigmoidectomy

Untwist duodenum (rotate anti-clockwise)
Mobilise duodenum and place bowel in unrotated position with duodeno-jejunal flexure on the right and the caecum and appendix on left

For cecal:
Cecoplexy or intestinal resection

26
Q

What are the types of volvulus? What are their features?

A

Volvulus is obstruction caused by rotation of bowel with its mesentery.

Sigmoid volvulus

Caecal volvulus
Midgut volvulus (small intestine - duodenum)
27
Q

What are the features of sigmoid volvulus?

A

Occurs with chronic constipation, such as in Hirschprung’s

Sudden onset colicky, lower abdo PAIN. Gross abdo distension (palpable mass, non-tender)

Constipation/blood in stools
Vomiting occurs late.
Signs of shock

AXR shows massively distended sigmoid, reaching the xiphisternum

28
Q

What are the features of cecal volvulus?

A

Usually young adults. Undeveloped mesentery.
Adhesions are main pathological cause

Often intermittent chronic symptoms:
Abdominal cramping/swelling
Nausea + vomiting
Slowly develop constipation

29
Q

What are the clinical features of midgut volvulus?

A

Mostly babies. Twisting of bowel around mesentery

ACUTE:
Usually 1st year of life (most significant to paeds)
Sudden onset bilious emesis
Diffuse abdominal tenderness (out of proportion to examination)

CHRONIC:
Recurrent abdominal pain
Malabsorption syndrome

30
Q

What are signs of worsening intestinal ischaemia?

A 
Signs of shock:
Decreased urine output
Hypotension
Elevated lactate
Base deficit

Peritonitis
Discolouration of skin

31
Q

What are the symptoms and signs of acute and chronic duodenal obstruction?

A 
Acute: (usually infants)
Forceful biliary/nonbiliary emesis
Abdominal distension possible
There can be passage of stool/meconium
Usually no signs of peritonitis or shock, unless volvulus further down
Chronic: (infancy to pre-school)
Usually bilious vomiting
May have failure to thrive
May have intermittent abdominal pain
Physical findings may be completely normal
There may be distension and tenderness
32
Q

What is the epidemiology of necrotising enterocolitis?

A

Mainly pre-term infants
Occurs in first few weeks of life

Pre-term infants fed cow’s milk formula are at higher risk

33
Q

How does necrotising enterocolitis present?

A

Poor feeding

Milk aspirated from stomach

Bilious/non-bilious emesis (possible)

Distended abdomen

Blood in stool/explosive diarrhoea

Rapidly becomes shocked/Respiratory distress with acidosis

34
Q

What are the feautes of necrotising enterocolitis on AXR? (mainstay)

A

Distended loops of bowel

Thickening of bowel wall with INTRAMURAL air (thumb printing)!

There may be gas in the portal tract

35
Q

What is the treatment of NEC? Indications for surgery?

A

Stop oral feed
Broad-spectrum antibiotics (cefotaxime)
Parenteral nutrition

Artificial ventilation
Circulatory support (often)

If bowel perforation: surgery
Resection of clearly necrotic bowel and creating proximal enterostomy

Also if there is air in the portal circulation on AXR

36
Q

What are the different types of bowel atresias in the newborn?

A

Oesophageal. Usually associated with tracheo-oesophageal fistulas.

Pyloric atresia (familial)

Duodenal atresia. Associated with Trisomy 21. Recanalisation of bowel by 9 weeks gestation fails.

Jejunal
ileal
and 
colon atresia: 
are not from a failure of recanalisation, but ischaemic injury (all supplied by superior mesenteric artery - SMA)
37
Q

How is oesophageal artresia diagnosed?

A

If suspected, a wide-calibre feeding tube is passed and checked by X-ray to see if it reaches the stomach

38
Q

What are the features on AXR of duodenal atresia (eg. in gestation). Clinical features?

A

“Double Bubble”

Swallowing of amniotic fluid which cannot pass through leads to inflation of stomach and duodenum. Mother may have polyhydramnios due to blockage.

Also seen on US.

There may be bilious vomiting in first few days of life. Swollen but soft abdomen.
May not pass meconium.

39
Q

What are the clinical features of pyloric atresia?

A

AXR - air filled stomach (distended), but no air in the rest of the abdomen

Vomiting
Distended abdomen

40
Q

What are the clinical features of jejuno-ileal atresia

A

Bilious emesis within first 24 hours of life.
Distended abdomen.
No bowel movements within first day.

AXR shows distension and air above atresia + distension

41
Q

What are the clinical features and complications of Meckel’s diverticulum?

A

Most asymptomatic
May have severe rectal bleeding (lower GI)
This may cause symptoms of anaemia (lethargy, pallor, failure to thrive)

Intussusception
Volvulus around a band
Diverticulitis (mimics appendicitis)

Child health (51 decks)

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