Surgery - Acute Abdomen Flashcards
How should you calculate a fluid bolus in children?
20mls/kg of 0.9% normal saline
How should you estimate weight in children?
<9 years is 2(age+4)
>9 years is 3 x age
How should you estimate blood volume in children?
80mls/kg
How should you estimate maintenance fluids in children?
4mls/kg/hr for first 10kg
2mls/kg/hr or the next 10kg
1ml/kg/hr for every kg after
What are the clinical features of acute appendicitis?
anorexia
vomiting
abdominal pain (aggravated by movement)
fever
tenderness with guarding in right iliac fossa
What are the differential diagnosis of acute appendicitis?
ovarian cyst ovarian torsion pregnancy ectopic pregnancy pelvic inflammatory disease renal calculi mesenteris lymphadenitis mittelschmerz pneumonia lymphoma volvulus typhlitis
What are the 3 ways in which acute appendicitis presents?
1) right iliac fossa - ANT to bowel tenderness, guarding, easy to diagnose
2) right iliac fossa - POST to bowel vague deep tenderness, guarding, hard to diagnose
3) pelvis vague suprapubic tenderness commonly perforated and hard to diagnose, late presentation
What atypical presentation gets mistaken for a UTI?
tender RIF
abnormal urine dipstick
How does late appendicitis present?
presence of an appendix mass, abscess, perforation presents with generalised guarding consistent with perforation, fluid resuscitation and IV antibiotics are given before laparotomy
How is and appendicular mass managed?
conservative management with intravenous antibiotics with appendectomy being performed after several weeks if symptoms progress laparotomy is indicated
How does intestinal obstruction present?
persistent vomiting (may be bile stained) abdominal distention pain irritability
What is malrotation?
uncommon but important to diagnose
Intestinal malrotation is a developmental anomaly of intestinal fixation and rotation caused by a disruption in the normal embryologic development of the bowel
How is malrotation managed?
urgent upper GI contrast study is indicated if there is bilious vomiting treatment is with surgical correction
How does malrotation present?
bilious vomiting
abdominal pain
tenderness from peritonitis ischaemic bowel
What is intussusception?
invagination of the proximal bowel into a distal segment
common cause of intestinal obstruction infants after the neonatal period
How does intussusception present?
severe colicky pain with pallormay refuse feeds/vomit (can be bile stained)
sausage shaped mass often palpable
passage of redcurrant jelly stool comprising blood stained mucus
abdominal distention and shock
How is intussusception managed?
shock is important complication and requires urgent treatment
reduction is attempted by rectal air insufflation unless peritonitis is present
surgery if reduction with air is unsuccessful or for peritonitis
At what age does intussusception present?
usually between 3 months and 2 years
What are the clinical features of volvulus?
crying/pain no/little passing of urine and faeces crampsvomiting (green) signs of dehydration
What does the colour of vomit mean in terms of the anatomical abnormality?
vomit is bile stained unless the obstruction is above the ampulla of Vader worrying feature that always needs investigating
How is volvulus managed?
surgical emergency as SMA blood supply is compromised untwisting of volvulus in surgery is needed
When does necrotising enterocolitis?
typically seen in the first few weeks of life bowel of preterm infant is vulnerable to ischaemic injury and bacterial invasion (both risk factors for NEC) more likely if fed on cows milk rather than bread milk
What are the clinical features of NEC?
feed intolerance vomiting may be bile stained distended abdomen stool sometimes contains fresh blood shock mechanical ventilation may be required
What are the radiological features of NEC?
air under the diaphragm air in portal tract
distended bowel loops
thickening of bowel wall with intramural air
How is NEC managed?
stop oral feeding
broad spectrum abx
parenteral nutrition
mechanical ventilation and circulatory support often needed
surgery is performed for bowel perforation
significant morbidity and mortality
What are the atresias that can present in the newborn period?
oesophageal atresia
duodenal atresia
jejunum or ileal atresiarectal atresia (absence of an anus)
How do different atresias present?
signs of obstruction - vomiting (can be bile stained), abdominal distention, pain
How does a duodenal atresia present on an X-ray?
‘double bubble’ appearance on a X-ray from distention of the stomach and duodenal cap
What are the clinical features of meckels diverticulum?
abdo pain
mimicking appendicitis
lower GI bleed
(life threatening) obstruction
