surgical Flashcards
ddx neonatal bilious vomiting
Surgical
a. Malrotation with midgut volvulus
b. Intestinal atresia
c. Meconium ileus
d. Necrotising enterocolitis
e. Hirschsprung’s disease
Non-surgical
a. Sepsis
b. Meningitis
c. Omphalitis
d. Reflux
exomphalos vs gastroschisis
exomphalos:
- herniation through defect at base of umbi
- therefore protected by sac (membrane) continuous with umbi
- poor outcome 10% survival
- more associated with genetics - BW, T13, T18
- if liver in sac, less likely aneuploidy risk
gastroschisis:
- herniation through abdo wall defect, usually to right of umbi
- no protective sac
- better outcome 90% survival
- AFP high
- cord paraumbi
consequences of CDH and long-term
pulmonary hypoplasia and pul HTN
malrotation
dextrocardia
long-term:
reflux, CLD, obstruction, recurrence of hernia
treatment of CDH
supportive: NGT
ventilate: HFOV vs CV, ECMO
treat pul HTN: NO, open PDA
surgical
what is diaphragmatic eventration
part of the diaphgram didnt muscularise good -> moves paradoxically
most is whatever, doesnt need repair
which TOF kind most common
type C = oesophageal atresia with distal TOF
types of TOF
A = atresia only B = atresia + prox TOF C = atresia + distal TOF D = atresia + both TOF E = h type = TOF no atresia
presence of air in stomach/bowel with a TOF must mean what type?
distal fistula present
how may TOFs present
US scan - polyhydramnios cant swallow fluid
birth - cant feed, vomiting/coughing, resp distress, infections, frothy mucous
which TOF type can present later?
H - no atresia, so stuff could go down to GI (or resp)
which type of TOF has worst prognosis?
A - pure atresia
pyloric stenosis
- age
- biochemical finding
- 2-6 weeks
- hypokalaemic hypochloraemic met alkalosis (vomit up Cl and H2O, kidneys conserve Na/H2O and kick out H/K)
exam thoughts: pyloric atresia = what condition?
= EB
when does malrotation present?
most within first year
most in D1-D3 of life
most common type of intestinal atresia
duodenal
duodenal atresia radiological finding
double bubble
duodenal atresia - vomit colour and distension: comment
no distension
bilious if distal to ampulla - most common
exam thoughts: duodenal atresia = what syndrome
T21
duodenal atresia have to screen for what and why
a/w congenital abnormalities echo - CHD renal USS cxr - TOF annular pnacreas
jejunoileal atresia - what kind of thing has gone wrong i.e. pathology
vascular shit
non-operative Mx for mec ileus
NAC - water soluble enema
NEC - clinical triad
bilious asps/vomiting
abdo distension
blood in stool
pathogenesis of NEC
invasion of bad bacteria into wall
bad bacteria form gas + inflammation
ischaemic necrosis of wall
risk factors for NEC
VLBW
aggressive enteral feeding
formula feeding
prolonged abx
NEC - some possible axr findings
i. Dilated loops of bowel consistent with ileus
ii. Pneumatosis intestinalis (hallmark of NEC) = bubbles of gas in the small bowel wall
iii. Pneumoperitoneum = occurs with perforation; gas outlining both sides of the bowel wall
v. Portal venous gas
classic exam finding of intestinal perf
blue-black discolouration of abdominal wall
most common cause of neonatal obstruction
Hirschprung’s
where in the colon is most Hirschprung disease
80% rectosigmoid
Hirschprung’s - most common associated gene
RET protooncogene
Hirschprungs - how can they present
no mec in 48h bilious vomits abdo distension enterocolitis / obstruction / perf FTT constipation squirt sign
age of umbi hernia surgery vs inguinal
umbi: 2-3yo - 9/10 resolve spontaneously before then
inguinal: 6:2 rule <6 weeks within 2 days, if <6 months within 2 weeks, if >6 months within 2 months
meckel’s - rule of 2s
i. Most common in children under 2
ii. 2 times more common in males
iii. Contains 2 types of tissue (pancreatic + gastric)
iv. 2 inches long
v. Found within 2 feet of the ileocaecal valve
vi. Occurs in 2% of the population
age of intussusception
3mo-2yo
classic triad intussusception
abdo pain
red currant jelly stool
sausage shaped mass
examples of pathological lead points in intussusception
i. Meckel’s diverticulum
ii. Polyps
iii. Henoch-Schonlein purpura
iv. Duplication cyst
v. Other
1. Intestinal lymphoma (>6 months)
3. Adenovirus or rotavirus infection
4. Celiac disease
5. CF
US finding of intussusception
target sign
paraphimosis vs phimosis
phimosis cant retract - foreskin will balloon. physiological or there’s been scarring e.g. circumcision, recurrent balanitis
paraphimosis - can’t put back a retracted foreskin
hypospadias - what
urethral meatus opens on underside of penis, and usually a/w chordee (bands pulling penis into curve) or hooded dorsal foreskin
exam thoughts - priapism = what disease
1/3 sickle cell develop priapism
when is foreskin fully retractable
3yo
inguinal hernia age
greatest in 1st year of life
when do most congenital UDT descend and why? so when do you need to refer for orchidopexy?
3mo - testosterone surge by 2mo
so it wont descend after 4mo and need to refer
orchidopexy by 6-12mo
male newborn with bilaterally UDT - exam thoughts - think of what??
is it even a boy tho? could be virilised female with CAH
whats the risks of a UDT
testicular cancer
torsion
infertility
hernia - 90% have an associated patent tunica vaginalis
age groups of
appendage torsion
testicular torsion
E-O
hydrocele
varicocele
idiopathic scrotal oedema
appendage torsion - pre-pubertal
testicular - neonatal and adolescents
E-O - rare pre-puberty until has UTI with genitourinary issue!! usually adolescent with STI
hydrocele - infants
varicocele - peri-pubertal
idiopathic scrotal oedema - 3-7yo
mumps orchitis occurs how long after parotitis
Mumps orchitis occurs 4-6days after parotitis**
main complications of varicocele
impaired fertility in 10-15%
pathophys of a non reactive hydrocoele
when to surgery and why
a. The patent processus vaginalis is narrow and enables peritoneal fluid, but not abdominal contents, into the cord structures
b. Patent processus vaginalis often closes on its own, in the first 18 months of life
surgery only if >2yo
exam thoughts: mec ileus = what?
90% = cystic fibrosis!!
