Week 5 - B - Common Surgical Problems in Neonates and Children - vomiting, abdo and scrotal pain/swelling, meconium ileus

Question 1

Describe the symptoms of pyloric stenosis? What happens to the fontanelles in this condition?

Answer 1

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

Question 2

On palpation what does the pyloric stenosis feel like? How is pyloric stenosis diagnosed? How is pyloric stenosis treated?

Answer 2

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

Question 3

IN pyloric stenosis is the child classically metabolic acidotic or alkalotic?

Answer 3

Due to the baby projectile vomiting all the acid in the stomach - the child is classically metabolically alkalotic in this condition - requires correcting

Question 4

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

Answer 4

This would intussusception

Question 5

Describe the symptoms of intussusception?

Answer 5

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

Question 6

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?

Answer 6

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

Question 7

What is the treatment of choice in children with intussusception? If this doesnt work what is carried out?

Answer 7

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

Question 8

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?

Answer 8

Classic history of appendicitis

Question 9

Where does appendicitis pain usually begin? What is the most common point for appendicitis pain to begin at known as?

Answer 9

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

Question 10

Green bile vomiting What is this until proven otherwise? What would make you think pyloric stenosis if baby was vomiting?

Answer 10

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

Question 11

How is intestinal malrotation diagnosed?

Answer 11

Usually an Xray scan is used for diagnoses or an Upper GI contrast

Question 12

What can occur due to intestinal malrotation in children?

Answer 12

Malrotation can lead to volvulus which can causes ischaemia of the bowel

Question 13

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?

Answer 13

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

Question 14

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

Answer 14

This would be acute idiopathic scotal oedema

Question 15

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?

Answer 15

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

Question 16

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?

Answer 16

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

Question 17

What is the emergency treatment of paraphimosis?

Answer 17

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

Question 18

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?

Answer 18

Meatus on ventral aspect of penis - hypospadius

Meatus on dosrum of penis - epispadius

Question 19

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?

Answer 19

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

Question 20

How is it possible to tell the difference between a hydrocele and a inguinal hernia?

Answer 20

The hydrocele will be transilluminable and the inguinal hernia will not be

Question 21

Is the inguinal hernia likely to be direct or indirect if extending into the scrotum? Describe the difference between these two hernias?

Answer 21

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

Question 22

If the scrotum appears empty, what may this be? What is the treatment?

Answer 22

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

Question 23

What is gas in the gut wall seen on xray known as?

Answer 23

This is pneumatosis intestinalis

Question 24

What is pneumotosis intestinalis pathognomonic for?

Answer 24

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

Question 25

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?

Answer 25

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

Question 26

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.

Answer 26

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Question 27

What is the mainstay of treatments for necrotizing entercoloitis?

Answer 27

Stop oral feeding Give broad spectrum antibiotics

Question 28

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?

Answer 28

This is known as meconium ileus

Question 29

What is the main cause of meconium ileus in children?

Answer 29

Meconium ileus is most commonly caused by Cystic Fibrosis

Question 30

What is the mode of inheritance of cystic fibrosis? What is the most common mutation in cystic fibrosis?

Answer 30

The mode of inheritance is autosomal recessive Most common mutation is delta F508 gene of the CFTR on the long arm of chromosome 7

Question 31

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?

Answer 31

Sanger sequencing if looking for a specific gene Next generation sequencing if looking for a mutation over multiple genes

Question 32

What are other symptoms of cystic fibrosis? What is the sweat test chloride level that is supportive of CF?

Answer 32

Steatorrhea Meconium ileus Recurrent pneumonia + clubbing At older ages male infertility Chloride level greater than 60mmol/l supports the diagnosis of CF

Question 33

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?

Answer 33

The jejenum spirals around the marginal artery (of drummond)

Question 34

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?

Answer 34

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).

Question 35

What is the curling of the jejunum around the marginal artery sometimes compared to?

Answer 35

It is sometimes compared to an apple peel appearance

Question 36

What are symptoms of jejunal atresia?

Answer 36

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.