Surgical Paediatrics

Question 1

6 week old baby vomiting, mass in abdomen which fluctuates in size
What should you be thinking?

Answer 1

Pyloric stenosis

Question 2

Projectile vomiting, soon after feeding, baby hungry, milky vomit. Very dehydrated, metabolically upset, thin, sunken fontanelle.
What should you be thinking?

Answer 2

Pyloric stenosis

Question 3

How can you diagnose pyloric stenosis simply?

Answer 3

Make diagnosis with fingertips – feel something hard just to the left of the umbilicus – feel like an olive (feel with your left hand).

Question 4

What imaging is used to diagnose pyloric stenosis?

Answer 4

USS – if you can see the pylorus, then it’s abnormal. 4mm and above is going high.

Question 5

What should you think about before operating to correct pyloric stenosis?

Answer 5

Have to fix the metabolic upset before you operate – metabolic alkalosis, treat with fluid resuscitation.

Question 6

What is the surgery for treatment of pyloric stenosis?

Answer 6

Make an incision deep into the pylorus, then spread it open – Ramstead pyloral myotomy. Can also do laparoscopically.

Question 7

6 month old baby – vomiting for 2 days, temperature, seem to be in pain, abdominal mass (sausage shape). Pain comes in waves.
What should you be thinking?

Answer 7

Intussusception

Question 8

Red current jelly in nappy

What is this a sign of?

Answer 8

Intussusception

Sign that the inside mucosal layer is sloughing off

Question 9

What imaging is used in intusussception?

Answer 9

USS - target lesion

Bright bit is mucosa and dark bit is muscle

Question 10

Treatment of intussusception?

Answer 10

Air enema reduction – put tube into bottom, blow up balloon, and pump air around the colon.

Question 11

Child stooped holding onto abdomen

What should you be thinking?

Answer 11

Appendicitis

Question 12

What can you ask to see if there is peritonitis?

Answer 12

What was their journey like to the hospital? “I had to slow down on the corners and bumps in the road” or “the bumps are really sore” – indicates peritonitis. You can also ask the child to jump – causes pain. Can use the jump test for safety netting.

Question 13

What are the two types of pain in appendicitis?

Answer 13

Not just appendix which is inflamed – visceral pain, i.e. in the middle of their abdomen. Only when the peritoneum (parietal pain) gets inflamed does the pain become localized.

Question 14

How can you diagnose appendicitis?

Answer 14

Diagnose with fingertips (USS to confirm) – on USS if you can see the appendix then it is inflamed.

Question 15

Baby vomiting mossy green bile

What should you be thinking?

Answer 15

Malrotation

Question 16

Which artery is commonly affected in malrotation?

Answer 16

Superior mesenteric artery

Question 17

How do you investigate malrotation?

Answer 17

Do an upper GI contrast with follow through.

Question 18

Top of testicle painful on prodding with pen

What should you be thinking?

Answer 18

Appendage on testicle - remnant of female embryology

Question 19

Odematous, diffusely red scrotum

What should you be thinking?

Answer 19

Idiopathic scrotal oedema. May be allergic, not very sore, doesn’t need an operation.

Question 20

Mucosa pouting on penis - treatment?

Answer 20

Use some steroid and ask the parents do dab the area with some tissue paper when he’s peed. Ask them to have a daily bath and stretch the area. Ask them to rub in steroid – will slightly loosen the collagen. Will get some opening of the foreskin.

Question 21

Mucosa scarred on penis

Treatment?

Answer 21

Requires circumcision – may go into urethra and cause urethral stenosis.

Question 22

What is parathenosis?

Answer 22

Foreskin is constricting the band, causing obstruction with oedema. Treatment – grab it and squeeze it really hard.

Question 23

Hypospadias

• What is it?
• Treatment?

Answer 23

Birth abnormality of the urethra where the urinary opening is not at the usual location on the head of the penis
Doesn’t require circumcision – instead they require surgery to move the hole along the anterior surface of the penis – required use of the foreskin.

Question 24

How can you exmaine for an undescended testicle?

Answer 24

If you take some soap and run it along the groin, then take your finger and feel along the inguinal canal – as you sweep down, you will feel the testicle flip under your finger. If you cannot feel the testicle, then you can do an operation to go and search – if not in the groin, then it will be in the abdomen. Testicle might be absent.