Surgery - acute abdomen Flashcards
What are the clinical features of appendicitis? (How common and Symptoms)
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
What are the signs of acute appendicitis?
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
Why may appendicitis present with white blood cells or organisms in the urine and thus lead to a misdiagnosis of UTI?
Inflamed appendix may be adjacent to the ureter or bladder
Which clinical examination and investigatins are required in acute abdominal pain?
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&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
Which are very common causes of acute abdominal pain? At which age are they common?
UTI Acute appendicitis (>3 years) Mesenteric adenitis Gastro-enteritis Constipation
Which are less common causes of acute abdo pain?
Lower lobe pneumonia Strangulated hernia Diabetic ketoacidosis Intussusception Intestinal obstruction Henoch Schönlein Purpura Pancreatitis
What are the causes of acute abdominal pain in <1 year olds?
Medical:
gastroenteritis
Constipation
UTI
Surgical:
intussusception
volvulus
incarcerated hernia
Other:
Hirschprung’s disease
What are the causes of acute abdominal pain in 2-5 year olds?
Medical:
gastroenteritis
constipation
UTI
Surgical: Appendicitis Intussusception Volvulus Trauma
Other: Henoch-schonlein purpura DKA Mesenteric lymphadenitis Sickle cell crisis
What are the causes of acute abdominal pain in 6-11 year olds?
Medical:
gastroenteritis
constipation
UTI
Surgical:
appendicitis
trauma
Other: Mesenteric adenitis Abdominal migraine Henoch schonlein purpura DKA Sickle cell crisis Lower lobe pneumonia
What are the causes of acute abdominal pain in 12-18 year olds?
Medical:
gastroenteritis
constipation
Surgical: appendicitis trauma testicular torsion ovarian torsion
Other: Dysmenorrhoea Ectopic pregnancy Mittelschmerz (ovulation) PID Threatened abortion DKA IBD Adrenal crisis
In which cases can acute appendicitis be easily misdiagnosed?
Can present atypically with diarrhoea/tender RIF - misdiagnosed as gastroenteritis
Can present atypically with tender RIF/ abnormal urine dipstick - misdiagnosed as UTI
List differentials for paediatric acute appendicitis (vague symptoms)
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)
What are the differentials for acute appendiceal abscess or mass?
Meckel’s diverticulum
Crohn’s disease
How is the late presentation of appendicitis explained and how is it managed?
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
What are the symptoms and signs of intestinal obstruction?
Abdominal pain
Persistent vomiting
Signs:
Bile-stained vomit
Jaundice if high intestinal obstruction
Abdominal distension
Auscultation - increased bowel sounds
In suspected intestinal obstruction (infant), how can malrotation volvulus be diagnosed?
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
What is the age group and the clinical features of intussusception?
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
Why does upper intestinal obstruction cause bilious vomiting?
Enzymes secreted by gall bladder go up into the gallbladder and digest it
What has to always be assessed for in intussusception, malrotation, and strangulated inguinal hernia?
Dehydration and shock (vomiting)
What is intussusception?
Invagination of proximal bowel into distal segment
Most commonly ileum into caecum (through ileocaecal valve)
Why is prompt diagnosis and immediate treatment of intusussception necessary?
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
What is the management of intussusception?
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
How is intussusception diagnosed?
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
Which investigation is required in bilious vomiting?
Ugent upper GI contrast study to assess intestinal rotation
Unless there are signs of vascular compromise - requires urgent laparotomy
