Surgery - Acute Abdomen

Question 1

How should you calculate a fluid bolus in children?

Answer 1

20mls/kg of 0.9% normal saline

Question 2

How should you estimate weight in children?

Answer 2

<9 years is 2(age+4)

>9 years is 3 x age

Question 3

How should you estimate blood volume in children?

Answer 3

80mls/kg

Question 4

How should you estimate maintenance fluids in children?

Answer 4

4mls/kg/hr for first 10kg
2mls/kg/hr or the next 10kg
1ml/kg/hr for every kg after

Question 5

What are the clinical features of acute appendicitis?

Answer 5

anorexia
vomiting
abdominal pain (aggravated by movement)
fever
tenderness with guarding in right iliac fossa

Question 6

What are the differential diagnosis of acute appendicitis?

Answer 6

ovarian cyst 
ovarian torsion 
pregnancy 
ectopic pregnancy 
pelvic inflammatory disease
renal calculi 
mesenteris 
lymphadenitis 
mittelschmerz
pneumonia 
lymphoma 
volvulus 
typhlitis

Question 7

What are the 3 ways in which acute appendicitis presents?

Answer 7

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

Question 8

What atypical presentation gets mistaken for a UTI?

Answer 8

tender RIF

abnormal urine dipstick

Question 9

How does late appendicitis present?

Answer 9

presence of an appendix mass, abscess, perforation presents with generalised guarding consistent with perforation, fluid resuscitation and IV antibiotics are given before laparotomy

Question 10

How is and appendicular mass managed?

Answer 10

conservative management with intravenous antibiotics with appendectomy being performed after several weeks if symptoms progress laparotomy is indicated

Question 11

How does intestinal obstruction present?

Answer 11

persistent vomiting (may be bile stained) abdominal distention pain irritability

Question 12

What is malrotation?

Answer 12

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

Question 13

How is malrotation managed?

Answer 13

urgent upper GI contrast study is indicated if there is bilious vomiting treatment is with surgical correction

Question 14

How does malrotation present?

Answer 14

bilious vomiting
abdominal pain
tenderness from peritonitis ischaemic bowel

Question 15

What is intussusception?

Answer 15

invagination of the proximal bowel into a distal segment

common cause of intestinal obstruction infants after the neonatal period

Question 16

How does intussusception present?

Answer 16

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

Question 17

How is intussusception managed?

Answer 17

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

Question 18

At what age does intussusception present?

Answer 18

usually between 3 months and 2 years

Question 19

What are the clinical features of volvulus?

Answer 19

crying/pain no/little passing of urine and faeces crampsvomiting (green) signs of dehydration

Question 20

What does the colour of vomit mean in terms of the anatomical abnormality?

Answer 20

vomit is bile stained unless the obstruction is above the ampulla of Vader worrying feature that always needs investigating

Question 21

How is volvulus managed?

Answer 21

surgical emergency as SMA blood supply is compromised untwisting of volvulus in surgery is needed

Question 22

When does necrotising enterocolitis?

Answer 22

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

Question 23

What are the clinical features of NEC?

Answer 23

feed intolerance vomiting may be bile stained distended abdomen stool sometimes contains fresh blood shock mechanical ventilation may be required

Question 24

What are the radiological features of NEC?

Answer 24

air under the diaphragm air in portal tract
distended bowel loops
thickening of bowel wall with intramural air

Question 25

How is NEC managed?

Answer 25

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

Question 26

What are the atresias that can present in the newborn period?

Answer 26

oesophageal atresia
duodenal atresia
jejunum or ileal atresiarectal atresia (absence of an anus)

Question 27

How do different atresias present?

Answer 27

signs of obstruction - vomiting (can be bile stained), abdominal distention, pain

Question 28

How does a duodenal atresia present on an X-ray?

Answer 28

‘double bubble’ appearance on a X-ray from distention of the stomach and duodenal cap

Question 29

What are the clinical features of meckels diverticulum?

Answer 29

abdo pain
mimicking appendicitis
lower GI bleed
(life threatening) obstruction