GI (Surgical)

Question 1

What is the most common cause of an acute surgical abdomen in a child? Explain what it is

Answer 1

Appendicitis (inflammation of the appendix caused be feacoliths)

Question 2

In what age range of children is appendicitis more common in?

Answer 2

It can occur in children of any age but it is very rare in children under the age of 3

Question 3

What is different about some of the symptoms in a child with appendicitis and what are they?

Answer 3

The presentation is unlikely to be as barn door as it is in most adults 
ANOREXIA, VOMITING and irritability might be predominate symptoms 
ABDO PAIN is likely to be a symptom but might not be as localised to RIF as in adult 
BOWEL CHANGES (diarrhoea OR constipation)

Question 4

What clinical signs might a child with appendicitis have and how is it best to illicit these?

Answer 4

Appendicitis 
-Guarding of the abdomen 
-Rebound tenderness
-TEMP - Usually only low grade (<38)
It can every difficult to ascertain where the child is having pain. Asking the child to stand or hop on their Right leg can be a good way of seeing whether the pain is on that side

Question 5

What are some common complications of appendicitis?

Answer 5

• Perforation - happens in about 1/3 cases in children
• Can be rapid as the omentum is less well developed
• This will lead to peritonitis and clinical shock

Question 6

What investigations might you require to confirm a diagnosis of appendicitis?

Answer 6

• Sometimes it is obvious and ix might not be necessary - clinical diagnosis.
• USS can confirm
• CRP initially
• FBC - look for WCC and in particular neutrophils
• LFTs and U&Es should also be got as standard

Question 7

How should appendicitis be managed?

Answer 7

• Appendicectomy-laparoscopic (keyhole)

- Cover with Cef(uroxime) + Met

Question 8

What is another surgical abdominal condition that is commonly mistaken for appendicitis?
How does it present?
What causes it?
Treatment?

Answer 8

MESENTERIC ADENITIS

Presentation

• Non-specific abdominal pain that is less severe (even sometimes tenderness in the RIF)
• Quite often it is accompanied by a URTI with cervical lymphadenopathy

Cause
-swollen large mesenteric lymph nodes

Treatment

• normally just supportive-fever and pain
• some of these children the pain does not resolve and an appenidectomy is performed

Question 9

What is intussusception and how does this affect the bowel?

Answer 9

• When the bowel telescopes in on itself
• Can cause compression>obstruction>ischaemia and bowel necrosis
• can also cause perforation/peritonitis/sepsis/haemorrhage

Question 10

Where is the most common location of intusussception?

Answer 10

The terminal ileum invaginating into the cecum

Question 11

What is the common age range for intussusception?

Answer 11

• Between 3 months and 2 years (age where they put everything in their mouths>Peyers patches)
• Most common cause of bowel obstruction after the neonatal period
• M>F

Question 12

What complications can occur with intussusception?

Answer 12

The condition of itself is serious and need urgent treatment but tangling of the mesentery can also lead to venous outflow obstruction which can lead to PERFORATION, PERITONITIS, HAEMORRHAGE

Question 13

What are the symptoms in intussusception?

Answer 13

Intussuseption causes severe colicky pain

• episodic high pitched crying (every 10/20 mins)
• pale around the lips and mouth during episodes
• draw their knees up to their chest
• they will recover between waves of pain but will remain lethargic
• won’t want to eat (anorexia)
• bile stained vomiting

Question 14

What signs are assosiated with intussusception?

Answer 14

SYMPTOMS INTUSSUSEPTION
SIGNS INTUSSUSCEPTION 
-Sausage shaped mass felt in RUQ abdomen 
-Absent of bowel in RLQ (Dance's sign)
-Neurological signs 
	○ Lethargy 
	○ Hypotonia 
	○ Sudden alterations of consciousness may occur 
-Abdominal distension 
-Dehydration/shock
-Late mucoid and bloody redcurrant stools appear later (around 25% children- ischeamia)
-Late pyrexia

Question 15

What are some causes of intussusception?

Answer 15

Usually there is no identified cause (90%) - can be associated with a viral prodrome where it is thought that Peyer’s patches cause the bowel to invaginate

• in 10% it is caused by something
  
  • e.g. Meckel’s diverticulum (75%) or Henoch-Schonlein purpura (3%)

Question 16

What investigations should be done in child in whom you suspect intussusception?

Answer 16

INTUSSUSEPTION
USS done to confirm - target lesions/psuedokidney)

• AXR - might be able to see intussusception and might see obstruction (distended small bowel and absence of air on large bowel)
• FBC might show neutrophilia
• Us and Es might reflect dehydration

Question 17

How should intussusception be managed?

Answer 17

INTUSSUSEPTION IS AN EMERGENCY
1. Resuscitation- Drip and suck method of resuscitation fluids (NG tube and IV fluids AND ANTIBIOTICS)
2. Then treat with an AIR ENEMA – put a catheter into the rectum, pass air into the bowel, see how far it goes (done by radiologist)
○ This works best for ileocolic intussusception
○ Lots of children wont tolerate-need sedation
○25% will need further surgery
○ If long history-bowel might be perforated
- Antibiotics and morphine

Question 18

What is pyloric stenosis?

Answer 18

Thickening of the pyloric muscle meaning food cannot properly leave the stomach and gets regurgitated up food pipe

Question 19

Who does pyloric stenosis occur in?

Answer 19

• NOT at birth- around 2-7 weeks (takes time for muscle to hypertrophy)
• More common in First-Born Males
• More common in those with FH (particularly on mother’s side)

Question 20

How does pyloric stenosis present? (symptoms)

Answer 20

SYMPTOMS OF PYLORIC STENOSIS

• NON BILIOUS projectile vomiting
  
  • White/yellow- just milk/digested milk
  • Doesn’t have to be projectile-early stages
  • Vomiting frequency/projectililty will increase over time - Not feeding (still hungry after so lose interest)
• Failure to thrive

Question 21

What are some of the clinical SIGNS of pyloric stenosis?

Answer 21

SIGNS OF PYLORIC STENOSIS

• VISIBLE PERISTALSIS on the surface of the child’s abdomen
• olive shaped mass
• signs of dehydration
• METABOLIC ALKALOSIS (hypochloraemic (Cl-)/hypokalaemia (K+)/ Hyponatreamic (Na+)

Question 22

How should we investigate a child with pyloric stenosis?

Answer 22

PYLORIS STENOSIS

• USS-hypertrophic pylorus (looks like a donut), measurements of >3mm in thickness and 15mm in length are diagnostic
• CapGas to check for metabolic alkalosis
• TEST FEED- observe for vomiting, visible peristalsis and olive shaped mass
• AXR- can also be useful and show enlarged stomach as air is trapped behind it

Question 23

How should pyloric stenosis be managed?

Answer 23

PYLORIC STENOSIS

1. Resuscitate with fluids and correct electrolyte imbalances (0.45% saline with 5% dextrose and potassium supplementation)
2. Surgical management - pyloromyotomy

Question 24

What is duodenal atresia?

What is the treatment?

Answer 24

• This is when the duodenum does not form properly and contents cannot pass through
• Drip and suck (IV fluids and NG decompression) then SURGERY

Question 25

When does duodenal atresia present? | How common is it?

Answer 25

- This is a problem with the development of the tubes and so it will present in the neonatal period(usually antenatal) - It's the most common cause of obstruction in neonates

Question 26

How does duodenal atresia present?

Answer 26

- Baby of a few days old vomiting profusely after every feed and will soon stop feeding - vomit MAY BE billious (85%-because atresia is distil to ampulla) - Usually the baby will have passed its meconium (every distal to blockage will be passed) - this can make the obstructive picture more difficult to interpret - however NO MORE stool will be passed after the first meconium

Question 27

How should we investigate duodenal atresia?

Answer 27

USS | AXR - classical DOUBLE BUBBLE SIGN - very distended stomach and proximal duodenum (deflated rest of bowel)

Question 28

Is duodenal atresia associated with any other conditions?

Answer 28

1/3 cases of DA will have T21 (downs syndrome)

Question 29

What is an oesophageal atresia? | whats it assosistaed with?

Answer 29

- Malformation of the oesophagus meaning food can't pass down - nearly always associated with fusion/malformation of the trachea (TOF)

Question 30

What pregnancy complication is oesophageal atresia associated with?

Answer 30

Polyhydramnios - this is because the baby has not been swallowing fluid

Question 31

What other malformations is oesophageal atresia associated with?

Answer 31

``` VACTERL (congenital malformations) ALWAYS LOOK! V - Vertebral A - Anal abnormalities (e.g. atresia) C - cardiac malformations (e.g. VSD) T - Tracheosophageal fistular ( TOF) E - Esophageal altresìa R - Renal L -Limb (absent radius) ```

Question 32

How does oesohageal atresia present?

Answer 32

OSOPHAGEAL ALTRESIA - Persistent drooling and excessive saliva after birth - child unable to swallow spit. - Inability to feed - cyanotic episodes/coughing /choking (might be cos its going down wrong way)

Question 33

How is oesophageal atresia investigated?

Answer 33

A feeding tube is passed and then we x-ray to see if it has reached the stomach

Question 34

How do we managed oesophageal atresia?

Answer 34

OSOPHAGEAL ALTRESIA | -Constant suction in oesophageal pouch to clear saliva - -Followed by SURGERY

Question 35

How does malrotation and volvulus occur?

Answer 35

- When the fetal bowel is developing it grows faster than the space in the abdominal cavity. - Therefore the bowel grows outside the body and before it goes back in it rotates in 2 very specific axis before re-inserting (270 degrees anticlockwise around theSUPERIOR MESENTERIC ARTERY, 90, then 180) - Brings ceacum to right lower quadrant - Can get twisted and affect the blood supply (volvulus)

Question 36

Who does malrotation and volvulus usually occur in?

Answer 36

- Volvulus secondary to malrotation can occur in someone of any age but more likely in neonates - More common in boys

Question 37

How does malrotation and volvulus present?

Answer 37

VOLVULUS - Billious vomiting - Abdo pain/tenderness - Peritonitis/shock (can lead to death)

Question 38

What imaging should be ordered for a suspected case of malrotation and volvulus? what would you see?

Answer 38

AXR (contrast) - no bowel gas seen and characteristic corkscrew jejunum (duodenum and proximal jejunum also dont cross midline-go inferior instead

Question 39

How should malrotation and volvulus be managed?

Answer 39

Urgent surgical intervention (LADDS PROCEEDURE untwist, remove ladds bands and appendix, reposition)

Question 40

What is an inguinal hernia and what are the types?

Answer 40

-Protrusion of bowel into the inguinal canal DIRECT -poking through the posterior wall of the canal -rare in children (unless complex needs/connective tissue problem) - INDIRECT - entering through the deep inguinal ring) - more common in children and usually due to patent ductus vaginalis

Question 41

In which children are inguinal hernias more common?

Answer 41

Males (almost exclusively) Pre-term (also more common on the RHS)

Question 42

How will an inguinal hernia present?

Answer 42

○ Intermittent swelling in scrotum or groin ○Swelling might be made larger by crying, coughing, running around ○ It is usually not painful but it might be tender to the touch

Question 43

When you examine a possible hernia what should you be looking for?

Answer 43

- Reducibility - if the lump cannot be reduced then risk that it is strangulated - more urgent - Always try and feel for the testicle in the scrotum - Ask the child to cough or bear down - Assess for tenderness

Question 44

How should an inguinal hernia be managed?

Answer 44

NEONATAL INGUINAL HERNIAS>SURGERY 1. Give opioid analgesics and try to reduce hernia (most will be reducible with pain killers) 2. Once the lump has been reduced it should be operated on (wait for 24-48 hours for the oedema to go down) 3. If the lump absolutely cannot be reduced (incarcerated) then it need to be operated on urgently Risk of strangulation> may lead to ischemia

Question 45

What needs to be checked in the external genitalia in a newborn boy examination?

Answer 45

Check for presence of testicles in scrotum

Question 46

If the testes are not in the scrotum in a newborn what should you do?

Answer 46

- Feel up and along the inguinal canal and see if you can find them. - If found a) are they in the rightt path or are they ectopic b) if in right path can you drag them down into the scrotum?

Question 47

Describe the descent of the testes

Answer 47

- start abdomen around the kidneys - from the third month of pregnancy up until term the testes should begin descending - abdo>inguinal canal >scrotum - they should take with them a layer of peritoneum that will become the tunica vaginalis.

Question 48

What % will have cryptorchidism at birth? Who is it most common in? When will majority resolve?

Answer 48

- 4% of males will have cryptorchidism at birth - more common in preterm because the majority of descent will occur in the third trimester - Majority will correct themselves by 3 months

Question 49

If the testes cannot initially be felt in the scrotum what are the three possibilities?

Answer 49

-RETRACTILE - felt higher up an able to manipulate down into scrotum (pulled back up by cremasteric muscle, less worrying as will usually settle) -PALPABLE -feel but can't manipulate it down - (remember it may be ectopic and not in inguinal canal) -IMPALPABLE- might not be able to feel it at all (might be in abdomen)

Question 50

When should we escalate cryptorchidism?

Answer 50

CHRYPTORCHIDISM - If bilateral refer to pediatrics (sexual development) within 24 hours - If unilateral-do follow up at 3 months (if still not descended refer to surgeons before they are 6 months) *surgery will probs happen after 1 year

Question 51

What are some possible complications with cryptorchidism?

Answer 51

- Reduced fertility - for maximal spermatogenesis testicles should be a couple of degrees below body temp - Abdominal testicles are more likely to become MALIGNANT

Question 52

How is cryptorchidism managed?

Answer 52

Cryptorchidism ○ Found: Orchidoplexy via inguinal incision ○ Can't find: Exploratory Laparoscopy (ExLap) - USS can be done but is not that useful for abdominal testis - Hormonal assays are useful especially if the testes are impalpable bilaterally (IM injection to trigger testosterone)

Question 53

Who is more likely to get testicular torsion?

Answer 53

- Bell-Clapper testes - horizontal lay/not fixed in place - Also more likely if hx of cryptorchidism (undescended testicle - Peak in infancy and adolescence

Question 54

How does torsion present?

Answer 54

- Sudden onset testicular/abdominal pain - Abdominal pain - Vomiting - like in appendicitis picture might be slightly less obvious in paediatric patient

Question 55

What would be some examination findings with torsion?

Answer 55

- Testicle might be high, swollen, oedematous - Pain and tender testicle - Absent cremastueric reflex - Negative Phrens sign (pain not relieved by elevating testicle) - Painful abdomen but this is usually not tender

Question 56

How should torsion be investigated?

Answer 56

- If it is obvious- REFER SURGERY IMMEDIATELY | - If less clear can get USS scanning (with doppler)

Question 57

How is torsion managed?

Answer 57

- Surgically with detorsion of the testis | - Even if some doubt-surgical exploration is usually done because there is a chance of saving a testicle

Question 58

What is biliary atresia? What causes it? What happens if its untreated?

Answer 58

Absence/ blockage of bile duct (mostly extra-hepatic billiary tree). Rare, but most common cause of surgically treated jaundice in neonates Genetics and environment (toxins, viral) if left untreated build up of bile> can leak into blood> conjugated bile> jaundice

Question 59

How does biliary atresia present?

Answer 59

BILIARY ATRESIA - NORMAL at birth and meconium passed - Jaundice at two or three weeks after birth (with pale stools and dark urine (obstructive pattern) - Hepatomegaly will occur and then splenomegaly (d/t portal hypertension) - Can be easily mistaken for neonatal hepatitis

Question 60

How should you investigate suspected biliary atresia? What are some important conditions to rule out?

Answer 60

BILARY ATRESIA - serum bilirubin (union and con) CONJUGATED HIGH - DIAGNOTSIC:cholioangograohy (x rays with contrast) - Liver biopsy will show extra-hepatic obstruction - fasting abdo USS (Bilary tree and liver) - LFTs raised but cannot differentiate between other causes - Rule out Anti1 antitrypsin and cystic fibrosis (sweat test)

Question 61

How is biliary atresia treated?

Answer 61

BILIARY ATRESIA - CORRECT COMPLICATIONS (Vit A, D, E and K) and cholangitis - SURGERY Kasai procedure/hepato-porto-enterostomy (small bowel used to mimic ducts) - Required ASAP (60 days) to improve survival - Normally will still need liver transplant (around 2 years) because of chronic liver disease

Question 62

What is the surgical sieve?

Answer 62

VITAMIN CDEF Vascular, Inflammatory / Infective, Trauma, Autoimmune, Metabolic, Iatrogenic, Neoplastic, Congenital, Degenerative, Endocrine and Functional.

Question 63

What conditions are assosiated with malrotation?

Answer 63

Malrotation can be a feature in - exomphalos - congenital diaphragmatic hernia - intrinsic duodenal atresia

Question 64

What is Meckels diverticulum? | Epidemiology of Meckels diverticulum?

Answer 64

Meckels diverticulum - Most common congenital abnormality of the small intestine - Can also get ectopic gastric and pancreatic tissue - 2% population, 2 years, twice common in males

Question 65

how does Meckels diverticulum present?

Answer 65

- RLQ pain - Most common cause of dark red PR bleed in peads - Can cause intussusception/volvulus/obstruction

Question 66

What is Hirschsprung's disease?

Answer 66

This is an absence of ganglionic cells in the bowel - this could be just in a small section of the bowel or it could be over a much large proportion (in 10% the whole bowel is involved)

Question 67

Where in the bowel is most commonly affect by Hirschsprung's? What affect does this have on the bowel?

Answer 67

The rectum - then there is varying degrees of proximal extension The affected bowel is narrowed and contracted

Question 68

How and when does Hirschsprung's usually present?

Answer 68

- FAIL TO PASS MECONIUM IN THE FIRST 24 HOURS OF LIFE - Abdominal distension - Babies can develop BILE-STAINED VOMIT but this is a late sign - should have been identified before this

Question 69

What is a complication of Hirschsprung's?

Answer 69

Hirscprung related ENTEROCOLITIS (due to C.diff)- this occurs in severe Hirshprungs

Question 70

How should you investigate for Hirschsprung's?

Answer 70

- Full thickness rectal biopsy with AB cover (just in case of perforation)- lack of ganglionic cells under microscope - BARIUM enema with X ray- shows how long the aganglionic area is extending (agangionic segment will appear thin)

Question 71

How is Hirschsprung's treated?

Answer 71

- Initially colonic washouts - Then (6-9 months) PULL THROUGH proceedure colostomy followed by anastomosis of normally innervated bowel to the anus (colostomy might not be lifelong)