Week 5 - B - Common Surgical Problems in Neonates and Children - vomiting, abdo and scrotal pain/swelling, meconium ileus Flashcards
Describe the symptoms of pyloric stenosis? What happens to the fontanelles in this condition?
Child roughly 6 weeks of age
Child projectile vomits slightly after feeding - milky vomit
Child is therefore dehydrated and thin
Also has sunken fontanelles - sign of dehydration or malnutrition
On palpation what does the pyloric stenosis feel like? How is pyloric stenosis diagnosed? How is pyloric stenosis treated?
Hypertrophied pyloris feels like an olive on examination The stenosis is diagnosed via an USS and Ramsted’s pylormyotomy is used to treat the condition
IN pyloric stenosis is the child classically metabolic acidotic or alkalotic?
Due to the baby projectile vomiting all the acid in the stomach - the child is classically metabolically alkalotic in this condition - requires correcting
What is the most common cause of intestinal obstruction in children under 2years old? It happens when the small bowel swallows itself by invagination - known as telescoping of the bowel
This would intussusception
Describe the symptoms of intussusception?
Intusscsception is usually diagnosed by 2 years of age in children characterised by a pain coming and going in waves, children tend to vomit and have bloody redcurrant like faeces
The child also has a temperature and a sausgae shaped mass in the abdomen
Why is there redcurrant faeces in the childs nappy with this condition? How is this condition diagnosed? What is the lesion described as seen on this scan?
The redcurrant faeces are a sign that the bowel is sick and the mucosal wall is sloughing away The condition is diagnosed via an USS - can see telesoping of the bowel on ultrasound - known as a target lesion
What is the treatment of choice in children with intussusception? If this doesnt work what is carried out?
Use an air enema to try and correct the bowel - allows 80% of kids to avoid operation If this fails then surgery must be carried out
Classic story 6 year old boy complains of pain in lower right abdomen Didnt like the bumps on the roads and he is reluctant to stand up What is this classically a history of?
Classic history of appendicitis
Where does appendicitis pain usually begin? What is the most common point for appendicitis pain to begin at known as?
Pain for appendicitis usually begins in the umbilical region before spreading to the right iliac fossa
Pain is mot commonly felt in McBurney’s point - 1/3rd of the way from the anterior superior iliac spine to the umbilicus
Green bile vomiting What is this until proven otherwise? What would make you think pyloric stenosis if baby was vomiting?
Green bile vomiting - intestinal malrotation until proven otherwise Pyloric stenosis- vomit doesnt come from the intestine and therefore no bile to turn it green - hence the usually milky projectile vomit just after a feed
How is intestinal malrotation diagnosed?
Usually an Xray scan is used for diagnoses or an Upper GI contrast
What can occur due to intestinal malrotation in children?
Malrotation can lead to volvulus which can causes ischaemia of the bowel
Most common cause of acute scrotum - Pain at the top of the testicle, sometimes also a blue dot at this area, black mark in the testes when opened this is from a left over female part which can tort and hence turns black What is this?
This is torsion of the appendix testis Torsion of the Hydatid of Morgagni - pain felt over top area of testicle usually with a blue dot discoloration
a self-limiting condition characterised by marked oedema of the skin and dartos fascia without involvement of the deeper layers, testes, or epididymis - usually have widespread symmetrical erythema on scotum also What is this? Diagnosis is important to avoid unnecessary surgery
This would be acute idiopathic scotal oedema
unable to pull foreskin behind the glans penis in uncircumcised males, often reloves on its own as common congenital defect that resolves with age. WHat is this condition? If it fails to resolve on its own what is the treatment?
This is phimosis If the condition fails to resolve alone, steroids can be used to thin the prepuce in order to allow it to retract over the glans - topical steroids Also strecth foreskin in the bath for daily do both for 3 months
is a urologic emergency in which the retracted foreskin of an uncircumcised male cannot be returned to its normal anatomic position. What is this and why is it an emergency?
This is paraphimosis It is an emergency as it can cause gangrene of the glans of the penis which would require amputation - hence importance of diagnosing this condition
What is the emergency treatment of paraphimosis?
Squeeze the glans of the penis for p to 1 minute to cause the foreskin to return to the normal position - can hurt a lot so analgesia may be required - circumcision can be offered if problem continues
What is it known as when there is a meatus on the ventral aspect of the pens? What is it known as when there is a meatus on the dorsum of the penis?
Meatus on ventral aspect of penis - hypospadius
Meatus on dosrum of penis - epispadius
Accumulation of fluid due to a patent processus vaginalis?
Where does this fluid accumulate?
Loop of bowel going down into the scrotum causing the swelling, what is this known as?
What is it due to?
Accumulation of fluid is in the tunica vaginalis due to a patent processus vaginalis - this is known as a hydrocele
Inguinal hernia is when the bowel descends into the scrotum - this is also due to a aptent processus vaginalis but this time there is not only fluid in the scrotum
How is it possible to tell the difference between a hydrocele and a inguinal hernia?
The hydrocele will be transilluminable and the inguinal hernia will not be
Is the inguinal hernia likely to be direct or indirect if extending into the scrotum? Describe the difference between these two hernias?
If extending into the scrotum - likely to be an indirect inguinal hernia which lie lateral to the inferior epigastric vessel
Direct is medial to the inferior epigastric vessels
If the scrotum appears empty, what may this be? What is the treatment?
This may be a sign of an undescended testicle - cryptoorchidism - orchidopexy is the treatment option where the undescended testicle is surgical fixed in the scrotum
What is gas in the gut wall seen on xray known as?
This is pneumatosis intestinalis
What is pneumotosis intestinalis pathognomonic for?
Air in the gut wall is pathognomonic for necrotiing entercolitis (NEC) The diagnosis of NEC is usually confirmed by the presence of gas or air bubbles in the wall of the intestine on an abdominal X-ray
Necrotising enterocolitis (NEC) is the most common gastrointestinal condition in premature neonates, and continues to have significant mortality and morbidity. - Necrotizing enterocolitis (NEC) is a medical condition primarily seen in premature infants, where portions of the bowel undergo ischemic necrosis (tissue death) of the intestinal mucosa What is the single biggest risk factor for the condition and how does this cause it?
Prematurity is the chief risk factor for necrotizing entercolotiis Causes the symptoms as the gut wall isnt as strong as in a mature infant - therefore if there is a reduced oxygen supply the weak bowel wall is more susceptible to bacteria which can damage the intestinal tissue leading to NEC
On a plain radiograph in the NEC, there may be air on both sides of the bowel secondary to bowel perforation causing a sign to be seen on xray What is this sign known as? The sign is seen on a radiograph of the abdomen when the air is present on both sides of the intestine, i.e. when there is air on both the luminal and peritoneal side of the bowel wall.
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What is the mainstay of treatments for necrotizing entercoloitis?
Stop oral feeding Give broad spectrum antibiotics
Your newborn will usually have his first bowel movements a day or two after his birth. This first poo is called meconium and its arrival is a good sign. It shows that your newborn’s digestion is working normally. These first poos, which your babywill produce for a few days, have a black, almost tar-like consistency.If not had it by 48 hours then worrying What is failure to present stool in the 1st 2 days of like known as?
This is known as meconium ileus
What is the main cause of meconium ileus in children?
Meconium ileus is most commonly caused by Cystic Fibrosis
What is the mode of inheritance of cystic fibrosis? What is the most common mutation in cystic fibrosis?
The mode of inheritance is autosomal recessive Most common mutation is delta F508 gene of the CFTR on the long arm of chromosome 7
If a patient presents with cystic fibrosis and you are only looking to see if they have the Delta F508 gene mutation, what test can be done? What test can be carried out if looking for multiple genes?
Sanger sequencing if looking for a specific gene Next generation sequencing if looking for a mutation over multiple genes
What are other symptoms of cystic fibrosis? What is the sweat test chloride level that is supportive of CF?
Steatorrhea Meconium ileus Recurrent pneumonia + clubbing At older ages male infertility Chloride level greater than 60mmol/l supports the diagnosis of CF
Jejunal Atresia is a birth defect in which the fold of the stomach membrane needed to connect the small intestine to the back wall of the abdomen is, in part, absent. As a result, a portion of the small intestine (the jejunal) twists about one of the arteries to the colon. This twisting may be so severe that the artery in question is completely blocked (atresia). Which artery does the intestine spiral around?
The jejenum spirals around the marginal artery (of drummond)
Jejunal atresia is a birth defect in a newborn characterized by partial or complete absence of the membrane connecting the small intestines to the abdominal wall (the mesentery). It causes a portion of the small intestines (the jejunum) to twist around an artery that supplies blood to the colon (the marginal artery). What maes up the marginal artery?
The marginal artery of Drummond, also known as the marginal artery of the colon, is a continuous arterial circle or arcade along the inner border of the colon formed by the anastomoses of the terminal branches of the superior mesenteric artery (SMA) and inferior mesenteric artery (IMA).
What is the curling of the jejunum around the marginal artery sometimes compared to?
It is sometimes compared to an apple peel appearance
What are symptoms of jejunal atresia?
vomiting a bitter, yellow-green secretion of the liver (bile); an expanded or swollen upper middle part of the abdomen just below the breastbone (epigastric distension); and an absence of stools after birth.
