Y4 Paediatrics > Surgery > Flashcards

Surgery Flashcards

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1
Q

How might peritonitis present?

A

Abdominal pain - widespread at start, may be localised depending on cause
vomiting and nausea
infection symptoms

guarding, rebound tenderness, rigid abdomen, mass

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2
Q

How might you investigate suspected peritonitis?

A
  • urine - Urinalysis and microscopy if indicated, pregnancy test
  • blood - FBC, U&E and creatinine, amylase, glucose, sickle cell status if indicated. Arterial blood gas, LFT. Bone profile (Ca and PO 4 )
  • CXR - pneumoperitoneum
  • AXR - dilated bowel
  • USS - (Pyloric stenosis, intussusception, ovarian pathology)
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3
Q

How might peritonitis be treated?

A
  • abx - cephalosporin
  • surgical washout
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4
Q

What is the pathophysiology of appendicitis?

A

inflammationof theappendix which is a small, thin tube sprouting from thecaecum which becomes inflamed due to infection trapped in the appendix by obstruction - usually by a faecolith or lymphoid hyperplasia

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5
Q

What features in the history may suggest appendicitis?

A

central abdominal pain which later radiates to the right iliac fossa
low-grade pyrexia
minimal vomiting
anorexia

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6
Q

What examination findings would you expect in acute appendicitis?

A
  • tenderness in Mcburney’s point which is a localised area 1/3 distance from ASIS to umbilicus
  • Rovsing’s sign
  • rebound tenderness and percussion tenderness which suggest rupturing of appendix
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7
Q

What are some complications in appendicitis?

A
  • inflammation -> gangrene -> rupture -> peritonitis
  • appendicular mass
  • surgical complications
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8
Q

What differentials must you keep in mind when considering appendicitis?

A
  • ectopic pregnancy
  • ovarian cysts
  • Meckel’s diverticulum
  • mesenteric adenitis
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9
Q

What investigations would you carry out in suspected appendicitis?

A
  • clinical presentation usually
  • CRP raised
  • CT scan
  • USS to exclude ovarian and gynaecological pathology
  • if investigations negative diagnostic laparoscopy
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10
Q

How would you manage appendicitis?

A

laparoscopic appendicectomy with prophylactic abx
- abdominal lavage if perforated
- if abscess suspected IV abx first then surgery 4-6w later

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11
Q

What is biliary atresia?

A

congenital condition where section of bile duct is narrowed or absent resulting in cholestasis where bile cannot be transported from liver to the bowel

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12
Q

What is the classical history of biliary atresia?

A

*presents shortly after birth with significant jaundice, persistent jaundice (>2w)
- white to light yellow stool
- dark urine
- growth and appetite disturbances
*may be healthy babies with pale stool and dark urine

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13
Q

What are some examination findings in biliary atresia?

A
  • jaundice
  • hepatosplenomegaly
    abnormal growth
    cardiac murmurs - if associated syndromes
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14
Q

What are some associated complications with biliary atresia?

A
  • Unsuccessful anastomosis formation
  • Progressive liver disease
  • Cirrhosis with eventual hepatocellular carcinoma
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15
Q

How is biliary atresia investigated?

A
  • levels of conjugated > unconjugated bilirubin
  • serum alpha-1-antitrypsin
  • USS biliary tree and GB
  • percutaneous liver biopsy
  • LFT
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16
Q

What procedure if carried out to treat biliary atresia?

A

Kasai portoenterostomy - EARLY
*attaching section of small intestine to opening of liver, where bile duct normally attaches

done early as over 100 days may cause permanent liver damage - transplant before 12m may be needed

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17
Q

What is the pathophysiology of Hirschsprung’s disease?

A

congenital condition where nerve cells of myenteric plexus are absent in distal bowel and rectum - absence of parasympathetic ganglion cells hence doesn’t relax hence with lack of this stimulation bowel looses motility and cannot pass food along its length

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18
Q

What does the pathophysiology of Hirschsprung’s mean for the neonate?

A

tonic state of bowel means bowel obstruction
which may lead to enterocolitis, perforation, sepsis and even death

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19
Q

How does hirschsprung’s present?

A

*within 2 days
failure to pass meconium, abdominal distension, bilious vomiting

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20
Q

How would you examine a patient with suspected hirschsprung’s?

A

Abdominal examination: grossly distended abdomen, faecal mass in the left lower quadrant, tympanic percussion note

Digital rectal examination: increased anal sphincter tone, empty rectal vault, withdrawal of the examining finger leads to a gush of liquid stool and flatus known as the “blast sign” due to dramatic rectal decompression

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21
Q

What is a complications of Hirschsprung’s?

A

Hirschsprung-associated enterocolitis
- inflammation and obstruction of intestine caused by overgrowth of c.diff, s.aureus

  • 3D Dysmotility, Dysbiosis of the gut microbiome, Defective intestinal barrier function and mucosal immune response
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22
Q

How does Hirschsprung-associated enterocolitis present?

A

fever, abdominal distention, foul smelling diarrhoea often with blood, sepsis

*life-threatening as toxic megacolon and perforation risk

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23
Q

How might you investigate Hirschsprung’s?

A

rectal biopsy with acetylcholinesterase (AChE) staining - Absence of colonic ganglion cells
OR suction rectal biopsy
abdominal XR - intestinal obstruction and demonstrating HAEC

FBC, sepsis screen, electrolytes, TFT, ABG

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24
Q

How is hirschsprung’s managed?

A

intravenous broad-spectrum antibiotics (e.g. metronidazole), fluid resuscitation, routine colonic irrigation, nasogastric/orogastric bowel decompression and making the patient nil-by-mouth for complete bowel rest

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25
What is the definitive management for Hirschsprung's?
surgical removal of the aganglionic segment, followed by a pull-through of the proximal healthy bowel down to the anal canal with preservation of sphincter function + washout to prevent HAEC
26
What are some pads causes of intestinal obstruction?
meconium ileus hirschsprung's oesophageal atresia duodenal atresia intussusception imperforate anus malrotation strangulated hernia
27
How might intestinal obstruction present?
- persistent vomiting - maybe bilious bright green bile (distal to the ampulla of Vater) - abdominal pain with distension - failure to pass stools or wind
28
What are the common principles of managing intestinal obstructions?
- referral to paediatric surgical unit - NBM and insertion of NGT to help drain stomach and stop vomiting - IV fluids to correct dehydration and electrolyte imbalances to keep them hydrated while waiting for definitive management
29
What is intussusception?
- telescoping or invagination of one part of the bowel into another bowel, ie bowel folds inwards - this thickens size of bowel and narrows the lumen at folded area leading to palpable mass in the abdomen and obstruction to faecal passage
30
What are some common causes of intussusception?
henoch-schonlein purpura, cystic fibrosis, intestinal polyps, Meckel diverticulum (most common)
31
How might intussusception present?
*infants 6 months to 2 years - parent report child - sudden onset of inconsolable crying episodes - concurrent viral upper respiratory infections preceding illness - severe, colicky abdominal pain - later stages - redcurrant jelly stool (blood and mucus) - older children - vomiting and abdominal pain *intestinal obstruction presentation
32
What is the classic text-book presentation of intussusception?
- RUQ mass on palpation - sausage shaped - redcurrant jelly stool
33
What are some complications associated with intussusception?
- obstruction (common cause of this in children is intussusception) - perforation as it invaginates further, stretching and constricting blood supply, venous congestion - dehydration and shock due to third spacing fluid loss within intussusception —> hypovolaemic shock
34
How would you investigate intussusception?
- USS doughnut or target sign - contrast enema - AXR for obstruction
35
What is the management for intussusception?
- non-operative - fluid resuscitation, NGT insertion to decompress obstructed bowel - therapeutic enema to reduce the telescoping - surgical reduction - surgical resection if bowel gangrene
36
What is the pathophysiology of pyloric stenosis?
hypertrophy (thickening) and therefore narrowing of pylorus is called pyloric stenosis this prevents food travelling from stomach to the duodenum *pyloric sphincter is a ring of smooth muscle that forms the canal between the stomach and duodenum
37
Why doesn't pyloric stenosis present at birth?
not seen from birth as sphincter continues to grow after birth, hence classically presenting around 3-6 weeks
38
What is the classic history of pyloric stenosis?
- projectile vomiting of non-billions milk content - failure to thrive
39
What is the classic examination finding in pyloric stenosis?
- peristalsis seen in observing abdomen - firm, round mass can be felt in upper abdomen, feels like large olive—> hypertrophic muscle of pylorus - best felt after feed
40
What are some other differentials to consider when thinking pyloric stenosis?
- raised intracranial pressure - differential for projectile vomiting - meningitis - vomiting in baby so LP done to rule out, much more acute in presentation - gastroenteritis - GORD - over-feeding - sepsis - UTI - food allergy - malrotation if bilious vomiting
41
How might to investigate pyloric stenosis?
- test feeding performed with NGT and stomach aspirated - LP to rule out meningitis and CT head to rule out raised ICP - blood gas analysis - hypochloraemic (low chloride) metabolic alkalosis due to vomiting HCl - hypokalaemia as kidneys exchange potassium to retain protons to compensate - USS - hypertrophy of pyloric muscle, doughnut or target sign
42
How might you manage pyloric stenosis (non-surgical)?
- non surgical: stop feeds, correct metabolic abnormalities, NGT, blood gases etc
43
What is the definitive management of pyloric stenosis?
laparoscopic pyloromyotomy (Ramstedt’s pyloromyotomy) *resume feeding after 6h unless mucous membrane perforation *Post–operative vomiting is common after surgery, due to gastric distension and dysmotility, and is not necessarily a sign of incomplete myotomy
44
What are some post-op complications for pyloric stenosis?
- Wound dehiscence - Infection - Bleeding - Perforation of mucous membranes - Incomplete myotomy
45
What is a volvulus? and what does it lead from?
- intestinal malrotation is a birth defect, this happens when the intestinal tract doesn’t form as it should - this presents as a volvulus when baby is born
46
What is the pathophysiology of intestinal malrotation and volvulus?
lack of intestinal fixation to the retro-peritoneum and a narrow midgut mesenteric base that predisposes to a twisting of the small bowel in the form of midgut volvulus
47
How does a volvulus present?
bilious vomiting abdominal pain and cramping D+C rectal bleed or bloody stool *could be intermittent obstruction distention, tenderness, drawing up legs, failure to thrive, tachycardia, body stools
48
What investigations would you undertake for a suspected volvulus?
- upper GI contrast studies - CT abdomen with contrast - abdominal XR - FBC - blood gas - flexible sigmoidoscopy
49
How is a volvulus managed?
NGT decompression, IVF, prophylaxis abx surgical management - Ladd's procedure to divide lands bands and widen base of mesentery - appendicectomy - ileostomy if necrotic
50
What is the normal descent of testes? and what is cryptorchidism?
- normal - testes develops in the abdomen and gradually migrates down through the inguinal canal and into scrotum before birth - testis pulled by gubernaculum within processes vaginalis *failed to reach the bottom of the scrotum by 3 months of age
51
What are the 3 types of failure of descent of testes?
- true undescended - absent from scrotum but lies along line of testicular descent (incomplete processes vaginalis) - ectopic - testis found away from normal path of descent (abnormal position of processes vaginalis) - ascending - testis previously identified in the scrotum undergoes secondary ascent out of the scrotum
52
What are some risk factors for cryptorchidism?
prematurity, low birth weight, having abnormal genitalia, having first degree relatives with cryptorchidism, maternal smoking during pregnancy
53
How would you examine a presentation of cryptorchidism?
💁🏽‍♂️ lie child flat and keep relaxed - warm hands, palpate laterally with left hand, from inguinal ring and work along canal to pubic symphysis - from other hand palpate scrotum - should feel like enlarged lymph node, deeper location - if found check if it can be milked down to base, and if so diagnose retractile testis - if in groin along canal - inguinal undescended testis
54
What might b/L cryptorchidism indicate?
congenital adrenal hyperplasia
55
What are the differentials for cryptorchidism?
- normal retractile testis - in boys who have not reached puberty, its normal for testes to move out of scrotum into canal when cold or when cremasteric reflex activated - true undescended testis - ectopic testis - absent - BL impalpable testes
56
when would you worry about cryptorchidism?
unilateral - NICE CKS now recommend referral should be considered from around 3 months of age, with the baby ideally seeing a urological surgeon before 6 months of age bilateral - Should be reviewed by a senior paediatrician within 24hours as the child may need urgent endocrine or genetic investigation
57
What are some reasons for the correction of cryptorchidism?
Reduce risk of infertility Allows the testes to be examined for testicular cancer - 40 times as likely to develop testicular cancer (seminoma) Avoid testicular torsion Cosmetic appearance
58
How is cryptorchidism managed?
Orchidopexy at 6- 18 months of age - consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch Intra-abdominal testis should be evaluated laparoscopically and mobilised * After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy
59
What is testicular torsion?
- Mobile testis rotates on the spermatic cord - Leads to reduced arterial blood flow, impaired venous return, venous congestion, resultant oedema & infarction to the testis within hours
60
What is the pathophysiology of testicular torsion ?
- Males with a horizontal lie to their testes are more prone to developing testicular torsion - ‘bell-clapper deformity’ lacks normal attachment to tunica vaginalis hence more mobile - in neonates the attachment between scrotum and tunica vaginalis is not fully formed and entire testis and tunica vaginalis can tort - extra-vaginal torsion
61
How might testicular torsion present?
- Sudden onset severe unilateral testicular pain - associated N&V - referred abdominal pain
62
What are some examination findings for testicular torsion?
- testis will have a high position with a horizontal lie - try and confirm normal position with patient or parent - swollen and tender - cremasteric reflex is absent - negative Prehn’s sign - pain continues despite elevation of testicle
63
How might you investigate testicular torsion?
- clinical - straight to theatre - doppler ultrasound to investigate potential compromised blood flow - urine dipstick to assess for infection
64
How is testicular torsion managed?
- Surgical emergency – urgent surgical exploration of the testis within 4-6h window - Strong analgesia and anti-emetics pre=operatively - nil by mouth and maintenance fluids - Torsion in confirmed intra-operatively = bilateral orchidopexy - Testis is non-viable = an orchidectomy may be warranted
65
What is a hernia?
protrusion of viscus through a defect of walls of its containing cavity, inguinal hernia viscus if intra-abdominal contents like bowel, containing cavity is abdomen and protrusion is into the inguinal canal
66
What is the pathophysiology of the most common type of inguinal hernia?
- indirect inguinal hernias common in children where contents protrude through deep inguinal ring into inguinal canal, through superficial inguinal ring into groin - this is due to incomplete closure of out-pouching of peritoneum called processus vaginalis after descent of testes in utero
67
How might an inguinal hernia present?
- groin swelling - nausea, vomiting - constipation - inguinal/ inguino-scrotal mass that cannot ‘get above’ - reducible when lying flat - does not transilluminate - positive cough reflex - when strangulated, irreducible and tender tense lump with pain out of proportion to clinical signs + features of bowel obstruction
68
How is an inguinal hernia managed?
- surgical repair of hernia - herniotomy - performed on all full-term male infants with asymptomatic reducible inguinal hernias - emergency surgical repair in irreducible ones, to prevent bowel and testicular ischaemia
69
What is the pathophysiology of epididymorchitis?
Usually caused by local extension of infection from the lower urinary tract either via enteric or non-enteric organisms which spreads to epididymis and testicle * In younger boys, it can be caused by a urinary tract infection and may be linked to a structural problem in the genitourinary system - In older boys and teens, could be an STI, most often caused by gonorrhoea or chlamydia hence are bacterial infections - It’s most often seen in teen boys ages 14 and older or in younger children are at risk if they have had a urinary tract infection - mumps to TB?
70
How might epididymorchitis present?
- Pain and swelling in the testicles - nausea and vomiting - Fever - Feeling of heaviness in the testicles - Fluid leaking from the urethra - Blood in the semen - Lump in the testicles - Pain during urination or ejaculation
71
What are some examination findings seen in Epididymo-orchitis?
- red & swollen, very tender - reactive hydrocoele - urethral discharge - Cremasteric reflex which is intact in cases of epididymitis - Prehn’s sign (supine & scrotum is elevated by the examiner -> relieved by elevation)
72
How might Epididymo-orchitis be investigated?
- urine dip - infection - assess STI potential and do a screen - First-void urine should be collected and sent for NAAT for suspected non-enteric epididymitis - Routine bloods - Imaging – typically a clinical one, however USS of the testes can be useful to confirm the diagnosis & rule out any complication like an abscess
73
How is Epididymo-orchitis managed?
- antibiotics and analgesia - *If an enteric organism is suspected, fluoroquinolones are the preferred antibiotic, as they have excellent penetration into the testes* - If your teen has an STI, make sure they tell any sexual partners who had contact within 60 days before symptoms - chronic epididymitis that prove to be refractory to all other therapy and have a persistent pain, **orchiectomy** may be warranted in rare cases
74
Y4 Paediatrics
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