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Paediatrics > Paediatric Surgery > Flashcards

Paediatric Surgery Flashcards

1
Q

What are the medical causes of abdominal pain?

A 
Constipation
UTI
Coeliac, IBD, IBS
Mesenteric adenitis
Abdominal migraine
Pyelonephritis
Henoch-Schonlein Purpur
Tonsilitis
DKA
Infantile colic
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2
Q

What are causes of abdominal pain specific to adolescent girls?

A 
Dysmenorrhoea
Mittelschmerz
Ectopic pregnancy
PID
Ovarian torsion
Pregnancy
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3
Q

What are surgical causes of abdominal pain?

A

Appendicitis - central, spreads to RIF
Intussusception - colicky, non-specific, redcurrant jelly stools
Bowel obstruction - pain, distention, absolute constipation and vomiting
Testicular torsion - sudden onset, unilateral testicular pain, nausea and vomiting

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4
Q

What are the red flags for serious abdominal pain?

A 
Persistent or bilious vomiting
Severe chronic diarrhoea
Fever
Rectal bleeding
Weight loss, faltering growth
Dysphagia 
Nighttime pain
Abdominal tenderness
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5
Q

What are some initial investigations for abdominal pain?

A 
Anaemia - IBD, coeliac 
Raised inflammatory markers
Raised anti-TTG, anti-EMA - coeliac 
Raised faecal calprotectin - IBD
Positive urine dipstick - UTI
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6
Q

What is the management of recurrent abdominal pain?

A 
Non-organic/functional
Distractions
Probiotics
Avoid NSAIDs
Address psychological triggers
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7
Q

How can an acute attack of abdominal migraine be treated?

A

Low stimulus environment
Paracetamol, ibuprofen
Sumatriptan

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8
Q

What are the causes of scrotal pain and/or swelling?

A 
Testicular torsion
Irreducible hernia
Torsion of testicular appendage
Epididymo-orchitis
Testicular or epididymal rupture
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9
Q

What are the features of testicular torsion?

A 
Usually pubertal, rarely neonates
Usually sudden severe pain
May radiate to iliac fossa
Swelling
Nausea and vomiting
Impaired gait
High riding testis
Tender on palpation
Some discolouration
Cremasteric reflex absent
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10
Q

What are non painful scrotal swellings?

A

Hydrocele
Varicocele
Idiopathic scrotal oedema
Tumour/leukaemia

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11
Q

What are the features of hydrocele vs varicocele?

A

Hydrocele - soft, non tender, scrotal swelling which is transilluminable
Usually due to patent processus vaginalis

Varicocele (enlargement of veins) - peri-pubertal
Bag of worms, predominantly left sided, refer to surgical outpatients

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12
Q

What is the management of testicular torsion?

A

Urgent surgical review if suspected
Fasting and clear fluids
Consider NG tube if bowel obstruction suspected
Provide adequate analgesia

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13
Q

What are red flags for vomiting in children?

A 
Bacterial gastroenteritis
Concussion
Meningitis
Appendicitis
Pyloric stenosis
Intussusception
Intestinal malrotation
Small bowel atresia
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14
Q

What are common differentials for vomiting in children?

A 
Viral gastroenteritis
Giardiasis
Migraine
Motion/travel sickness
Labyrinthitis
GORD
Cyclic vomiting
Constipation
UTI
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15
Q

What are the signs of clinical dehydration?

A 
Appears to be unwell
Decreased urine output
Skin colour unchanged
Warm extremities
Altered responsiveness
Sunken eyes
Dry mucous membranes
Tachycardia
Tachypnoea
Normal peripheral pulses
Normal CRT
Reduced skin turgor
Normal BP
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16
Q

What are the signs of clinical shock?

A

Decreased level of consciousness
Cold extremities
Pale or mottled skin

Tachypnoea
Tachycardia
Weak peripheral pulses
Prolonged CRT
Hypotension
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17
Q

What children are at increased risk of dehydration?

A

Children < 1 year
Infants low birth weight
Children had >6 or more diarrhoea stools in last 24 hours
Children vomited 3 or more times in past 24 hours
Children not been offered or not been able to tolerate fluids
Infants who have stopped breastfeeding during illness
Children with signs of malnutrition

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18
Q

What are the features of hypernatraemic dehydration?

A 
Jittery movements
Increased muscle tone
Hyperreflexia
Convulsions
Drowsiness or coma
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19
Q

When should a stool sample following diarrhoea in children be done?

A

Suspect sepsis
Blood or mucus in stool
Child immunocompromised

Consider if:
recently been abroad
diarrhoea not improved by day 7
Uncertain about diagnosis of gastroenteritis

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20
Q

What is the management of dehydration in children following vomiting or diarrhoea?

A

For children with no evidence of dehydration - continue breastfeeding, encourage fluids, fruit juices, carbonated drinks

If dehydration suspected - give 50ml/kg low osmolarity oral rehydration solution over 4 hours
Continue breastfeeding
Consider supplementing with usual fluids

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21
Q

What is diurnal and enuresis incontinence?

A

Diurnal incontinence - urinary incontinence in the day
Enuresis - at night

Enuresis not usually diagnosed until age 7

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22
Q

What are the types of urinary incontinence?

A

Primary - never achieved urinary continence for >6 months

Secondary incontinence - children developed incontinence after period of at least 6 months of urinary control

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23
Q

What are causes of enuresis?

A

Maturational delay
Uncompleted toilet training
Functionally small bladder
Difficulties arousal from sleep

Conditions that increase urine volume - diabetes, renal failure
Increase bladder irritability
Structural abnormalities e.g. ectopic ureter
Abnormal sphincter weakness e.g. spina bifida

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24
Q

What are common causes of diurnal incontinence?

A 
Bladder irritability
Relative weakness of detrusor muscle
Constipation
Urethrovaginal reflux or vaginal voiding 
Structural abnormalities
Abnormal sphincter weakness
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25
Q

What are red flag signs of urinary incontinence?

A 
Signs or concerns of sexual abuse
Excessive thirst, polyuria, weight loss
Prolonged primary diurnal incontinence
Any neurologic signs
Physical signs of neurologic impairment
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26
Q

What are appropriate investigations for urinary incontinence?

A 
Focused history
Physical examination
Bladder diary
Urinalysis
USS of urinary tract
Urodynamic studies
MRI spinal cord
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27
Q

How do the testes normally develop?

A

In the abdomen

Gradually migrate down through inguinal canal and into the scrotum

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28
Q

What is the risk of cryptorchidism in older children?

A

Higher risk of testicular torsion, infertility and testicular cancer.

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29
Q

What are the risk factors for undescended testes?

A 
Family history 
Low birth weight
Small for gestational age
Prematurity
Maternal smoking during pregnancy
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30
Q

What is the management of undescended testes?

A

Watching and waiting in newborns, most will descend within 3-6 months
If not descended by 6 months - seen by urologist
Orchidopexy - surgical correction between 6-12 months of age

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31
Q

What is retractile testicles?

A

Normal for those who have not reached puberty for testes to move out of scrotum and into inguinal canal when cold/cremasteric reflex

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32
Q

What is hypospadias?

A

Urethral meatus is abnormally displaced to the ventral side - underside of penis
Congenital condition affecting babies from birth

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33
Q

What is epispadias?

A

Meatus is displaced to the dorsal side - top of the penis

Foreskin abnormally formed to match position of meatus

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34
Q

What is the management of hypospadias?

A

Referral to urologist
Do not circumcise until indicated okay
Surgery within 3- 4 months of age, correct and straighten penis

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35
Q

What are the complications of hypospadias?

A

Difficulty directing urination
Cosmetic and psychological concerns
Sexual dysfunction

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36
Q

What are the features of appendicitis?

A

Central abdominal pain, moves to RIF
On palpation - tenderness at McBurney’s point - one third from ASIS to umbilicus

Loss of appetite
Low grade pyrexia
Nausea, vomiting
Rovsing's - palpation of LIF causes pain in RIF
Guarding on palpation

Rebound tenderness
Percussion tenderness
- ruptured, peritonitis

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37
Q

How is appendicitis diagnosed?

A

Clinical presentation
Raised inflammatory markers
CT, USS in females to exclude ovarian and gynaecological pathology

Diagnostic laparoscopy

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38
Q

What are key differentials of appendicitis?

A

Ectopic pregnancy in those childbearing, check serum or urine bHCG

Ovarian cysts - pelvic and iliac fossa pain

Meckel’s diverticulum - malformation of distal ileum, can cause volvulus or intussusception

Mesenteric adenitis - inflamed abdominal lymph nodes, often associated with tonsillitis or URTI

Appendix mass - omentum surrounds and sticks to inflamed appendix

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39
Q

What is the management of appendicitis?

A

Removal by surgery

Laparoscopic surgery

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40
Q

What are the complications of appendicectomy?

A 
Bleeding, infection, pain, scars
Damage to bowel, bladder, other organs 
Removal of normal appendix
Anaesthetic risks
VTE, DVT, PE
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41
Q

What is biliary atresia?

A

Section of the bile duct either narrowed or absent
Results in cholestasis - bile cannot be transported from liver to bowel

Prevents conjugated bilirubin in bile being excreted

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42
Q

What are the types of biliary atresia?

A

Type 1 - common duct obliterated
Type 2 - atresia of cystic duct
Type 3 - atresia of left and right ducts

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43
Q

What is the presentation of biliary atresia?

A

In first few weeks of life
Jaundice beyond physiological two weeks
Dark urine, pale stools
Appetite and growth disturbance

Hepatomegaly, splenomegaly
Abnormal growth
Cardiac murmurs if associated cardiac abnormalities present

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44
Q

What are the investigations of biliary atresia?

A 
Serum bilirubin, conjugated and total
LFTs - usually raised
Serum alpha-1 antitrypsin deficiency may cause neonatal cholestasis
Sweat chloride test - CF
USS of biliary tree and liver
Percutaneous liver biopsy
45
Q

What is the management of biliary atresia?

A

Surgical intervention - Kasai portoenterostomy - attaching section of small intestine to opening of liver
Often require full liver transplant to resolve condition
Dissection of abnormalities into distinct ducts, anastomosis creation
Antibiotic coverage and bile acid enhancers following surgery

46
Q

What are the complications of biliary atresia?

A

Unsuccessful anastomosis
Progressive liver disease
Cirrhosis with eventual hepatocellular carcinoma

47
Q

When does pyloric stenosis present?

A

In 2nd - 4th week of life

48
Q

What is pyloric stenosis?

A

Narrowing of pylorusand hypertrophy of the pyloric sphincter

Ring of smooth muscle that forms the canal between stomach and duodenum

49
Q

What is the presentation of pyloric stenosis?

A 
Hungry baby
Thin, pale, failure to thrive
Projectile vomiting
Peristalsis after feeding
Large olive mass in upper abdomen
50
Q

What does blood gas analysis show in pyloric stenosis?

A

Hypochloraemic (low chloride) hypokalaemic metabolic acidosis
As baby vomiting HCl

51
Q

What is the management of pyloric stenosis?

A

Diagnosis with abdominal USS

Treatment - laparoscopic pyloromyotomy - Ramstedt’s operation

Incision made in smooth muscle of pylorus to widen canal

52
Q

What is the pathophysiology of Hirschsprung’s disease?

A

Congenital
Absent nerve cells in myenteric plexus in distal bowel and rectum
Absence of parasympathetic ganglion cells

Aganglionic sections do not relax, become constricted
Loss of movement of faeces and obstruction in the bowel, proximal to this becomes distended and full

53
Q

What syndromes can Hirschsprung’s be associated with?

A

Down’s
Neurofibromatosis
Waardenburg syndrome
Multiple endocrine neoplasia type II

54
Q

What is the presentation of Hirschsprung’s?

A

Acute intestinal obstruction shortly after birth, or more gradual symptoms
Delay in passing meconium - more than 24 hours
Abdo pain, distention
Vomiting
Poor weight gain
Failure to thrive

55
Q

What is Hirschsprung-associated enterocolitis?

A

HAEC
Inflammation and obstruction occurring in those with the condition

Within 2-4 weeks of birth
Fever
Abdominal distention
Blood diarrhoea
Sepsis

Can lead to toxic megacolon and perforation

56
Q

What is the management of HAEC?

A

Urgent antibiotics
Fluid resuscitation
Decompression of obstructed bowel

57
Q

What is the management of Hirschsprung’s disease?

A

Abdominal x-ray
Rectal biopsy to confirm diagnosis, histology shows absence of ganglionic cells
Initial fluid resuscitation and management of obstruction

Rectal washouts, bowel irrigation
Surgery to affected segment

58
Q

What are causes of intestinal obstruction?

A 
Meconium ileus
Hirschsprung's
Oesophageal atresia
Duodenal atresia
Intussusception
Imperforate anus
Malrotation
Strangulated hernia
59
Q

What is the presentation of intestinal obstruction?

A

Persistent vomiting
May be bilious
Abdominal pain
Distention
Failure to pass stools or wind - absolute constipation
Abnormal bowel sounds - high pitched and tinkling

60
Q

How can intestinal obstruction be diagnosed?

A

Abdominal x-ray
Shows dilated loops of bowel proximal to obstruction
Collapsed loops of bowel distal
Absence of air in rectum

61
Q

What is the management of intestinal obstruction?

A

Paediatric surgery referral
NBM
NG tube
IV fluids

62
Q

What is meconium ileus?

A

Small bowel obstruction caused by unusually thick and sticky meconium

Mostly caused by cystic fibrosis; chloride trapped in cell, prevents water from thinning out secretions

Can also be due to very low birthweight or gastrointestinal malformations

63
Q

What are signs and symptoms of meconium ileus?

A

Signs of intestinal obstruction
Meconium peritonitis - abdominal tenderness, increased swelling of abdomen, infection, low BP
- small flecks calcified can be seen on abdominal x-ray

64
Q

What is the management of meconium ileus?

A

Drip and suck
Agents to soften meconium mixed with contrast enema
Surgery to resolve obstruction, resection

65
Q

What is intussusception?

A

Bowel invaginates or telescopes into itself

66
Q

What are the findings in intussusception?

A

Thickened overall size of bowel and narrowed lumen
Leads to palpable mass
Obstruction to faeces

67
Q

Who is intussusception most common in?

A

6 months - 2 years

Boys

68
Q

What conditions is intussusception associated with?

A 
Concurrent viral illness
Henoch-Schonlein purpura
Cystic fibrosis
Intestinal polyps
Meckel diverticulum
69
Q

What is the presentation of intussusception?

A 
Severe colicky abdo pain
During paroxysmal pain, infant will draw knees up and turn pale
Pale, lethargic, unwell child
Redcurrant jelly stool - late sign
RUQ mass on palpation - sausage shaped
Vomiting
Intestinal obstruction

Often have viral URTI preceding illness
Absolute constipation

70
Q

How is intussusception diagnosed?

A

Ultrasound scan

Contrast enema

71
Q

What is the management of intussusception?

A

Therapeutic enemas can try to reduce it - contrast, water or air pumped into colon to force it out

Surgical reduction

If bowel becomes gangrenous or perforated, surgical resection required

72
Q

What are the complications of intussusception?

A

Obstruction
Gangrenous bowel
Perforation
Death

73
Q

What is testicular torsion?

A

When the spermatic cord and contents twist within tunica vaginalis
Compromises blood supply to testicle

74
Q

What is neonatal testicular torsion?

A

Attachment between scrotum and tunica vaginalis not fully formed
Entire testis and tunica vaginalis can tort

75
Q

What are the risk factors for testicular torsion?

A

Age - 12-15 years
Previous testicular torsion
Family history
Undescended testes

76
Q

What are the clinical features of testicular torsion?

A

Sudden onset severe unilateral testicular pain
Associated nausea and vomiting
Testis in high position
Absent cremasteric reflex
Negative Prehn’s sign - pain continues despite elevation of testicle

77
Q

What are the investigations for testicular torsion?

A

Clinical diagnosis
Theatre for scrotal exploration
Doppler ultrasound
Urine dipstick any infection

78
Q

What is the management of testicular torsion?

A

Surgery within 4-6 hours
Strong analgesia, anti-emetics
Bilateral orchidopexy - cord and testis untwisted, both testicles fixed to scrotum

If testis non-viable - orchidectomy warranted

79
Q

What is epididymitis?

A

Inflammation of the epididymis

Caused by extension of infection from lower urinary tract, bladder or urethra

80
Q

What is the most common cause of epididymitis in young adult males?

A

Sexual transmission

N gonorrhoeae

81
Q

What is mumps orchitis?

A

Can occur as a complication of mumps viral infection

Unilateral or bilateral orchitis
Fever
Usually self resolves, can lead to testicular atrophy and infertility

82
Q

What are the risk factors for epididymitis?

A 
MSM
Multiple sexual partners 
Known contact of gonorrhoea 
Recent instrumentation 
Catheterisation 
Bladder outlet obstruction
83
Q

What are the clinical features of epididymitis?

A

Unilateral scrotal pain
Swelling
Fever, rigors
Associated symptoms e.g. dysuria, storage LUTS, urethral discharge

On examination affected side red and swollen
Tender on palpation
Intact cremasteric reflex
Positive Prehn’s sign

84
Q

What are the investigations of epididymitis?

A

Urine dipstick
First void urine
Routine bloods
USS doppler to rule out any complication e.g. abscess

85
Q

What is the management of epididymitis?

A

Appropriate antibiotics
Sufficient analgesia
Bed rest
Scrotal support

Enteric - levofloxacin
STI - ceftriaxone

Abstain from sexual activity

86
Q

What are the risk factors for an umbilical hernia?

A 
Prematurity 
Low birth weight
Down’s
Ehlers Danlos
Hypothyroidism
87
Q

What are the risk factors for an inguinal hernia?

A 
Premature
Low birth weight 
Males 
Connective tissue disorders
Patients with conditions which raise intraabdominal pressure
88
Q

What can cause an umbilical hernia?

A

Umbilical ring allows passage of vessels through abdominal wall between mother and fetus.

After birth, remains until spontaneous closure by 5
Failure or delay leads to formation of hernia

89
Q

What is the presentation of umbilical hernias?

A

Reducible
Painless bulge
At umbilicus
More prominent on straining or crying

Needs urgent assessment with symptoms of incarceration or strangulation

90
Q

What are the differentials for an umbilical hernia?

A

Epigastric herniation
Herniation of the umbilical cord
Exomphalos minor

91
Q

What can cause inguinal hernias?

A

Processus vaginalis does not close

Enables intra abdominal contents to herniate through deep inguinal ring, inguinal canal and superficial inguinal ring

92
Q

How do inguinal hernias present and what is it important to look out for?

A

Bulge in the groin
Scrotal swelling, often only visible on straining or crying

Incarcerated if irreducible
Unilateral swollen erythematous labia can be a torted ovary which has passed through a patent processus vaginalis

93
Q

What is peritonitis?

A

Inflammation of the peritoneal cavity in reaction to infection or irritation
Can be primary/spontaneous bacterial peritonitis
Secondary - visceral disruption from perforation, abscess, injury
Tertiary - recurrent infection

94
Q

What are the risk factors for peritonitis?

A 
End stage liver disease
Low serum albumin
Nephrotic syndrome
Splenectomy
Peritoneal dialysis
GI haemorrhage
Prematurity
PPI use
95
Q

What are the features of peritonitis?

A

Ascites, abdo pain, fever
Sudden onset pain exacerbated by movement
Washboard rigidity
Pulse >100

96
Q

What are the complications of peritonitis?

A 
Loss of fluids
Electrolyte imbalance
Difficulty breathing
Peritoneal abscess
Sepsis
97
Q

What are the investigations and management for peritonitis?

A

Erect CXR for air under diaphragm
Serum amylase rule out pancreatitis
US/CT

IV fluids and electrolytes to reverse hypovolaemia
IV abx if infective
Surgery - laparotomy, washout

98
Q

What are the features of malrotation?

A

High caecum at midline
Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia

May be complicated by the development of volvulus

Upper GI contrast, USS

Treatment with laparotomy
If volvulus present or high risk of occurring - Ladd’s procedure - counterclockwise detorsion of bowel, surgical division of Ladd’s bands fibrous stalks of peritoneal tissue

99
Q

What can leave the bowel at high risk for volvulus?

A

At fourth week of gestation, GI system is straight tube centrally, the following 8 weeks the midgut rotates and becomes fixed to posterior abdominal wall

Arrest of this development at any stage narrows mesenteric base, risk of volvulus

100
Q

What is the presentation of malrotation?

A 
Can be asymptomatic
Intermittent symptoms of intestinal obstruction
Bilious vomiting
Presume to have volvulus unless proven otherwise
Failure to thrive
Anorexia
Constipation
Bloody stools 
Intermittent apnoea
Older children:
Cyclical vomiting
Recurrent abdo pain
protein-calorie malnutrition
Immunodeficiency
101
Q

What is the presentation of vovulus?

A

Similar presentation to malrotation, twists around mesenteric base
May lead to necrosis without surgery in hours
Rapid onset and bilious vomiting
Metabolic acidosis
Oliguria
Hypotension
Shock with advancing Ischaemia

Acute abdomen
Blood or sloughed tissue may pass per rectum
Tachycardia, hypovolaemia, septic shock

102
Q

What are differentials in the acute phase of volvulus or malrotation?

A 
Appendicitis
Cholecystitis 
Constipation
Duodenal atresia
GORD
Hirschsprung's
Pyloric stenosis
Meckel's diverticulum
NEC
103
Q

What are the investigations for malrotation/volvulus?

A

FBC
Raised WCC
CRP
U&Es
Plain radiographs; midgut volvulus - partial duodenal obstruction - double bubble sign
Contrast studies - dilatation of proximal duodenum shows birds beak

104
Q

What is the treatment for malrotation/volvulus?

A

Observation, GI decompression

Surgery, Ladd’s procedure

105
Q

What is Meckel’s diverticulum?

A

Most common congenital abnormality of the bowel
Most patients remain asymptomatic all their life
True diverticulum; results from failure of vitelline duct to obliterate during fifth week of fetal development

106
Q

What is the presentation of Meckel’s?

A 
Most often asymptomatic
Bright red blood in stools 
Intestinal obstruction, intractable constipation
<2 years
Nausea, vomiting, cramps
Diffuse abdominal tenderness
107
Q

What are the investigations for Meckel’s?

A

FBC
Technetium 99m pertechnetate Meckel’s scan
Plain abdo radiography
CT scan of abdomen and pelvis

Contrast enema
Mesenteric angiography
Surgical exploration

108
Q

What is the treatment of Meckel’s?

A

Does not require treatment if asymptomatic and an incidental finding

Excision of diverticulum and opposing region of ileum
Lysis of adhesions
Perioperative antibiotics

Paediatrics (17 decks)

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