Introduction to Paediatric Surgery

Question 1

How is fluid given to children?

Answer 1

Crystalloid fluid is used for resuscitation and is given as a 20ml/kg bolus of 0.9% NaCl. Maintenance fluid can be given as 0.9% NaCl or 5% dextrose and is given as follows:
•4ml/kg for first 10kg of child’s weight
•2ml/kg for second 10kg of child’s weight
•1ml/kg for every kg thereafter

Question 2

What are the non-specific red flags of an ill child?

Answer 2

Feed refusal (especially in babies)
Bile vomits (green)
Paleness
Tone (a floppy baby is a sick baby)
Temperature

Question 3

What are the symptoms of appendicitis?

Answer 3

Classically, appendicitis is associated with Murphy’s triad of pain, vomiting and fever.
Tenderness over McBurney’s point
Pain exacerbated by rebound- which is elicited by a car going over speed bumps so it is more appropriate to ask if this happens than to elicit the rebound pain on examination.
Appendicitis is unusual >4 years of age and clues to diagnosis include a moderate temperature, vomiting and a child who looks unwell

Question 4

What are the common complications of appendicitis?

Answer 4

Abscess
Mass formation
Peritonitis

Question 5

Where is McBurney’s point?

Answer 5

1/3 of the way from the umbilicus to the anterior superior iliac spine

Question 6

What are the features of non-specific abdominal pain?

Answer 6

Short duration
Central 
Constant
Not exacerbated by movement
No GIT disturbance
No temperature
Girls > boys

Question 7

What other diagnoses can be made in paediatric abdominal pain?

Answer 7

Mesenteric adenitis- high temperature, URTI common, not unwell
Pneumonia- right middle lobe can have referred pain to right iliac fossa, generally appear less well than abdominal signs indicate

Question 8

In what populations is pyloric stenosis most common?

Answer 8

Weeks 4-16 of life

Boys > girls 5:1

Question 9

What are the symptoms of pyloric stenosis?

Answer 9

Non-bilious projectile vomiting
Weight loss
Hypochloraemia, hypokalaemia and alkalosis

Question 10

How is pyloric stenosis managed?

Answer 10

Test feed
IV fluid
Ultrasound
Periumbilical pyloromyotomy

Question 11

What is the classical history associated with malrotation?

Answer 11

The classic history is of a three day old baby presenting with bilious vomiting- reported as “fairy liquid” green in appearance. Diagnosis is malrotation and volvulus until proved otherwise

Question 12

How is malrotation investigated and treated?

Answer 12

Investigation- urgent GI contrast study

Management- urgent laparotomy

Question 13

What is intussusception?

Answer 13

Intussusception is when one part of the bowel slides inside another bit

Question 14

At what age is intussusception most common?

Answer 14

6-12 months

Question 15

What are the symptoms of intussusception?

Answer 15

Three day history of viral illness
Intermittent colic 
Dying spells 
Bilious vomiting 
Prolonged capillary refill time

Question 16

How is intussusception investigated and managed?

Answer 16

Investigated with a ultrasound of the abdomen

Treated with pneumostatic reduction (air enema) or laparotomy

Question 17

What is the incidence of umbilical hernias?

Answer 17

1:6 babies

Question 18

What are the risk factors for umbilical hernias?

Answer 18

Low body weight
Trisomy 21
Hypothyroidism
Mucopolysaccharidosis

Question 19

How do umbilical hernias close?

Answer 19

Usually close spontaneously by 4

Can be closed surgically if there are complications

Question 20

What is gastroschisis?

Answer 20

An abdominal wall defect that leaves the gut eviscerated and exposed through the umbilicus. 10% of cases have an associated atresia

Question 21

How is gastroschisis managed?

Answer 21

Management is with delayed closure- can be surgical if large defect

Question 22

What are the survival rates of gastroschisis and when does it become fatal?

Answer 22

Survival rates are 90%+, with the condition only becoming fatal if short gut occurs- when the umbilicus causes ischaemia of a large portion of bowel and the baby is only left with a small part of the bowel

Question 23

What is exomphalos?

Answer 23

An umbilical defect where the herniating mass is covered in the three layers of the umbilical cord. It is a marker of poor embryological development and so has a number of associated anomalies

Question 24

What anomalies can be associated with exomphalos?

Answer 24

Cardiac anomalies
Chromosomal- trisomy 13, 18 (both lethal) and 21
Renal 
Neurological
Beckwith-Weideman syndrome

Question 25

What is the post-natal fatality rate associated with exomphalos?

Answer 25

25%