Surgery - Pediatric Surgery Flashcards
SUR - 9.1
In case of infantile and paediatric inguinal hernia which statement is correct?
1) The main symptom is usually a painless swelling in the inguinal region, which is easily reduced or can be repositioned into the abdominal cavity (reduction).
2) In case of an unsuccessful reduction (incarcerated hernia) in boys, usually an urgent operation is needed.
3) In childhood, stating the diagnosis of an inguinal hernia equals setting the indication for the operation.
4) In setting the diagnosis of an inguinal hernia, the doctor often relies only on parents.
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
E) all of the answers are correct
EXPLANATION
Inguinal hernia is the most common disease requiring surgery in infancy and childhood. The leading symptom is a swelling in the inguinal region (in boys along the funiculus to the testis), which often does not cause any symptoms and can be easily manipulated into the abdominal cavity (hernia reduction). Pain, swelling, hyperaemia in the inguinal region combined with optional vomiting may hint to incarceration which needs immediate surgical treatment. The symptoms of an inguinal hernia are often not detectable to the examining physician in the office, thus the diagnosis is deduced from the parental anamnesis. An inguinal hernia does not resolve spontaneously, needs operative treatment, which can be done as a day surgery intervention. In the case of premature infants an early operation should be sought as the chance of incarceration is higher.
SUR - 9.2
Which statement is correct?
1) Neonatal and infantile congenital hydrocele do not require any operation under 1 year of age.
2) There is no hydrocele in girls.
3) If next to a hydrocele an inguinal hernia is detected, the operation is recommended regardless of age.
4) Double-sided hydrocele causes often pain and other severe symptoms.
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
B) 1st and 3rd answers are correct
EXPLANATION
A childhood hydrocele is a serous fluid accumulation, which is located in the partially of totally open processus vaginalis peritonei (sac). This lesion does not cause any pain or symptoms. In case of a congenital form the sac closes in the first 1-1,5 years in 95-97% of the cases, the fluid is reabsorbed from the processus. Thus a congenital hydrocele needs only observation in most cases. If the connection to the abdominal cavity is wide, an inguinal hernia can also be suspected and the operation is recommended because of the risk of incarceration. The same applies for one or two sided hydroceles. Hydroceles forming in later age (above 2-3 years) need operative treatment regardless of age. Hydrocele in girls (so called Nuck’s cyst) is rarity.
SUR - 9.3
In distinguishing hydrocele and inguinal hernia, the following(s) may be useful:
1) Anamnestic data
2) Physical examination
3) Ultrasound scan
4) X-ray
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
E) all of the answers are correct
EXPLANATION
In setting the diagnosis of a hydrocele a detailed anamnesis and careful physical examination are crucial. With their help, the diagnosis can usually be set, and the intervention can be avoided in the first and second year of life. In dubious cases, mostly with a simultaneous hernia, ultrasonography could help. A native abdominal X ray is only rarely needed. It may help in differentiating hydrocele and incarcerated hernia if sonography is not available
SUR - 9.5
When does scrotal pain in an infant or child mean an imminent indication for operation?
1) If there is parenchymal bleeding in the testis because of blunt trauma
2) If scrotal pain is accompanied by abdominal pain
3) In case of orchido-epididymitis
4) If a testicular torsion cannot be ruled out based on the clinical symptoms, physical examination and/or Doppler sonography scan
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
D) only 4th answer is correct
EXPLANATION
In boys sudden onset scrotal pain, which may radiate to the inguinal, lower abdominal region, is a characteristic symptom of testicular torsion. It starts often with lower abdominal pain. The scrotum will soon swell, the testicle enlarges and in case of complete torsion (360 degrees), the testicle may necrotise in 4-6 hours. Manual derotation of the testicle may be attempted but in every cases, in which testicular torsion cannot be ruled out either with physical examination or with a doppler ultrasound scan, immediate operation is recommended (exploration of the testis).
SUR - 9.6
Choose the true statement(s), which is (are) correct for intussusception in infancy and early childhood:
1) Sudden onset, spasmodic abdominal pain
2) Early onset, raspberry jam like stool
3) Its incidence is the greatest between 3-13 months of age
4) Meckel’s diverticulum does not play a role in intussusception
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
B) 1st and 3rd answers are correct
EXPLANATION
The invagination of the oral intestinal segment – mostly terminal ileum loop- into the lumen of the aboral (distal) intestine is called intussusception. This disease may cause ileus, intestinal necrosis, then perforation and peritonitis. Symptoms appear extreme sudden. Violent, periodic, spasmodic abdominal pain and vomiting are the early symptoms. A few hours later abdominal pain may reduce the patients turns lethargic, exsiccated, the intestines become paralytic. The raspberry jam like stool, mixed with undigested blood (the peeling of the mucosa) is a late sign, it usually refers necrosis of the intestinal wall. If we suspect this disease, often an invagination tumor can be felt through the abdominal wall or rectally with bimanual examination. It’s incidence is the highest between the 3rd and 13th month of life, usually accompanied by catarrhal airway symptoms. The increased intestinal peristalsis caused by accompanying mesenterial lymphadenitis, enteritis, and longer mesenterium than usual may be the causes for intussusception. If it presents itself at a later age (above 3 years), the clinical symptoms usually refers to a presence of a „leading point” (e.g. Meckel’s diverticulum, intestinal polyp, intestinal duplication, tumor, etc), which may need surgical removal.
SUR - 9.7
In case of infantile intussusception, which treatment(s) option(s) should be taken?
1) Hydrostatic desinvagination attempt (with ultrasound control)
2) In case of an unsuccessful desinvagination attempt operative treatment
3) In case of peritoneal symptoms, guarding, perforation immediate laparotomy
4) In case of bloody stool laparotomy is always needed
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
In case of a radiologically or clinically proved intussuscepted intestinal segment (intussusceptum), if there are no signs of peritonitis or perforation, an urgent hydrostatic desinvagination is attempted. This means applying lukewarm physiologic saline solution or contrast material, a high enema through the anus with controlled pressure (about a 100 H2Ocm) with which the intussusception can be resolved. The examination is carried out with an ultrasound scan in case of physiologic saline solution, in case of contrast material under fluoroscopy. In 90% of the cases intussusception can be resolved this way. A visible sign for this is that the intussusception disappears and the fluid floods the small intestine. In case of three unsuccessful attempts (either in narcosis or in sedation), or suspected perforation, peritonitis laparotomy in antibiotic protection is needed.
SUR - 9.8
In case of congenital hypertrophic pyloric stenosis:
1) The vomit is bloody from the strain.
2) It is characterised by gradually developing jet like vomiting.
3) The vomit is rather bilious.
4) It presents more often in boys.
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
C) 2nd and 4th answers are correct
EXPLANATION
A typical sign for congenital pyloric stenosis in mature new-borns and infants is jet like vomiting which appears gradually in 2-12 weeks of age, after every breast- feeding and may be typical even while feeding. The vomit contains undigested nourishment (mother’s milk or formula), not bilious. The disease is 3-4 times more often in boys.
SUR - 9.9
Congenital hypertrophic pyloric stenosis can be diagnosed by
1) Feeding test
2) Abdominal ultrasound scan
3) Upper gastrointestinal X-ray with contrast
4) Lab tests (full blood count, Astrup and electrolytes)
A) 1st, 2nd and 3rd answers are correct
B) 1st and 3rd answers are correct
C) 2nd and 4th answers are correct
D) only 4th answer is correct
E) all of the answers are correct
ANSWER
A) 1st, 2nd and 3rd answers are correct
EXPLANATION
Male gender, the typical symptoms in the typical age make the diagnosis likely. In uncertain cases the thickened, mobile, olive like pyloric tumor can be palpated through the abdominal wall during breastfeeding. The presence of binding gastric peristalsis (rolling ping-pong ball sign), then the anti-peristaltic waves can be observed on the abdominal wall. This is followed by jet like vomiting. The positivity of this examination (Feeding test) is a sure sign of pyloric stenosis. Nowadays an ultrasound scan is usually performed, which can also confirm the presence of thickened pyloric musculature with great accuracy. A stomach X ray is only performed for differential diagnosis. This comes with radiation but has a high specificity and sensitivity. The loss of chloride, and potassium, metabolic alkalosis as a result of protracted vomiting are only secondary laboratory signs.
