Paediatric Surgery

Question 1

When is the peak incidence of appendicitis?

Answer 1

10-20 years old

Question 2

What is classic abdo pain presentation in appendicitis?

Answer 2

Central abdominal pain which moves to the right iliac fossa

Question 3

What are some clinical signs of appendicitis seen on abdominal examination?

Answer 3

Tenderness and guarding in right iliac fossa (especially McBurney’s point), rovsings sign

Question 4

What are some signs suggestive of peritonitis from ruptured appendix on abdominal examination?

Answer 4

Percussion tenderness, rebound tenderness

Question 5

What are some key differential diagnoses for appendicitis particularly in paediatric cases?

Answer 5

Ectopic pregnancy, meckels diverticulum, mesenteric adenitis, ovarian cyst/torsion, appendix mass, constipation, UTI

Question 6

What is meckels diverticulum?

Answer 6

A malformation of the distal ileum which is usually asymptomatic but can bleed, become inflamed, rupture or lead to a volvulus or intussusception

Question 7

What is mesenteric adenitis?

Answer 7

Inflamed abdominal lymph nodes presenting as abdominal pain, usually in younger children. Often associated with tonsillitis or URTI

Question 8

What is an appendix mass?

Answer 8

When the omentum surrounds and sticks to an inflamed appendix

Question 9

Is a appendiceal mass treated surgically?

Answer 9

No this is managed conservatively with antibiotics and appendicectomy is considered once the acute condition has resolved

Question 10

What is biliary atresia?

Answer 10

A congenital condition where a section of the bile duct is either absent or narrowed

Question 11

With biliary atresia, what type of bilirubin will build up?

Answer 11

Conjugated

Question 12

What is the management of biliary atresia?

Answer 12

Surgery (kasai portoenterostomy)- attaching a section of small bowel to the liver where the bile duct normally attached

Question 13

What is kernicterus?

Answer 13

Accumulation of bilirubin in the brain which is neurotoxic leads to irreversible neurological damage

Question 14

What causes pyloric stenosis?

Answer 14

Hypertrophy of the pyloric sphincter leading to a narrowing of the pylorus preventing stomach content travelling to duodenum as normal

Question 15

Why do you get projectile vomiting with pyloric stenosis?

Answer 15

There is powerful peristalsis of the stomach as it is trying harder to push stomach content through narrowed pylorus, this becomes so powerful it ejects the food into the oesophagus, and out of the mouth quite forcefully

Question 16

When and how will pyloric stenosis present in children?

Answer 16

Usually in the first few weeks of life with a hungry baby that is thin, pale and generally failing to thrive. History of projectile non-bilious vomiting

Question 17

What can be seen on abdominal examination of an infant with pyloric stenosis?

Answer 17

A firm olive shaped mass in epigastrium may be felt (hypertrophy of pylorus), if after feeding peristalsis may be visible

Question 18

What investigation can be done for pyloric stenosis to visualise the thicken pylorus?

Answer 18

Abdominal ultrasound

Question 19

What is the treatment for pyloric stenosis?

Answer 19

Laparoscopic pyloromyotomy - incision made in smooth muscle of pylorus to widen the lumen allowing easier passage of stomach contents to duodenum

Question 20

What is Hirschsprung’s disease?

Answer 20

Congenital condition where nerve cells of the myenteric plexus are absent in the distal bowel and rectum. This aganglionic bowel cannot perform peristalsis

Question 21

What is the pathophysiology of hirschsprungs and how does this link to development?

Answer 21

Pathophysiology is the absence of parasympathetic ganglionic cells. These migrate down the gut during development, in hirschsprungs they dont migrate all the way down so a section of colon at the end is left without them

Question 22

How does the normal and aganglionic bowel appear in hirschsprungs?

Answer 22

The aganglionic bowel cannot relax causing it to become constricted and causes the proximal normal bowel to become distended and full of faeces

Question 23

What are some conditions/syndromes associated with hirschsprungs?

Answer 23

Downs syndromes, neurofibromatosis, waardenburg syndrome, multiple endocrine neoplasia type 2

Question 24

What can affect the age of presentation for hirschsprungs?

Answer 24

Extent of bowel affected, severity can vary between individuals

Question 25

How can hirschsprungs present?

Answer 25

Acute intestinal obstruction or gradually developing symptoms Delay in passing meconium, chronic constipation, abdo pain and distention, vomiting, poor weight gain and failure to thrive

Question 26

What is hirschsprung-associated enterocolitis and how will this present?

Answer 26

Inflammation and obstruction of the intestine. Typicallly presents 2-4 weeks after birth with fever, abdominal distention, diarrhoea and features of sepsis

Question 27

How do you manage hirschsprungs-associated enterocolitis?

Answer 27

Antibiotics, fluid resuscitation and decompression of the bowel

Question 28

What is the gold standard investigation for diagnosing hirschsprungs?

Answer 28

Rectal suction biopsy

Question 29

What is the definitive management of hirschsprungs?

Answer 29

Surgical removal of aganglionic bowel section

Question 30

What is intussusception?

Answer 30

Where one section of the bowel telescopes into itself. This narrows the lumen at the folded which can obstruct the passage of faeces

Question 31

Who typically presents with intussusception?

Answer 31

6 months to 2 years old (peak incidence 5-7 months), more common in boys

Question 32

What can be found on abdominal examination with intussusception?

Answer 32

Distention, a palpable mass where bowel is folded, this is sausage shaped and commonly in right upper quadrant.

Question 33

Where is the most common location for intussusception to occur?

Answer 33

The distal ileum telescopes into the caecum through the ileocaecal valve

Question 34

Although most cases are idiopathic, what are some pathological causes of intussusception?

Answer 34

Meckel diverticulum, polyps, HSP, tumours, post-operative

Question 35

How will a child with intussusception present in earlier stages?

Answer 35

History of sudden onset inconsolable crying episodes but normal in between these, child may draw their knees to chest to alleviate pain.

Question 36

How will a child with intussusception present in later stages?

Answer 36

Lethargy, anorexia, red-currant jelly stools (due to presence of blood and mucus), features of obstruction (vomiting and abdo pain)

Question 37

What would be seen on abdominal USS with intussusception?

Answer 37

Target sign

Question 38

How do we treat intussusception?

Answer 38

Air enema If contraindication to air enema then it cam be manually reduced in surgery

Question 39

What are the three main complications of intussusception?

Answer 39

Bowel obstruction, perforation and dehydration+shock

Question 40

Undescended testes in older children or after puberty hold a higher risk of what?

Answer 40

Testicular cancer, testicular torsion and infertility

Question 41

Where do the testes develop in utero?

Answer 41

In the abdomen

Question 42

How often do boy have testes which have not descended from the abdomen by birth?

Answer 42

5% of boys

Question 43

What are some risk factors for cryptorchidism?

Answer 43

FHx, low birth weight, small for gestational are, prematurity, maternal smoking during pregnancy

Question 44

If a boy is born and found to have an Undescended testes, what would be the management?

Answer 44

Watching and waiting, in most cases the testes descend in the first 3-6 months

Question 45

What would be the management of a boy who is 6 months old and their testes have yet to descend?

Answer 45

should be seen by paediatric urologist and undergo orchidopexy (surgical correction)

Question 46

In prepubescent boys, is it normal for the testes to move into the inguinal canal when cold or from the cremasteric reflex?

Answer 46

This is retraction testicles and is a normal variant which resolves through puberty. If they fully retract or failure to descend orchidopexy may be required

Question 47

What happens in testicular torsion?

Answer 47

The spermatic cord and its contents twist within the tunica vaginalis, cutting off the blood supply to the testes

Question 48

When is the peak incidence of testicular torsion?

Answer 48

In neonates and adolescents between 12-25

Question 49

What are risk factors for testicular torsion?

Answer 49

Age (12-25), previous testicular torsion, bell-clapper deformity, FHx, Undescended testes

Question 50

What is the clinical presentation of testicular torsion?

Answer 50

Sudden onset severe unilateral testicular pain, tests will sit in high position with scrotum appearing swollen and tender

Question 51

What examination findings are seen with testicular torsion?

Answer 51

Absent cremasteric reflex, negative Phren’s sign

Question 52

How does the presentation of epididymo-orchitis compare to that of testicular torsion?

Answer 52

Normally more associated with gradual onset of pain and can be associated with lower urinary tract symptoms and pyrexia

Question 53

How would torsion of the hydatid of margagni present?

Answer 53

Sudden onset pain, usually in younger age group than for testicular torsion, scrotum is less erythematous with normal lie of testis, blue dot sign

Question 54

What investigations can or should be done for testicular torsion?

Answer 54

If suspecting torsion patient should go straight to theatres for scrotal exploration, this should not be delayed for other investigations

Question 55

What are typical signs of intestinal obstruction?

Answer 55

Vomiting, absolute constipation, abdominal distention and abdominal pain Tinkling bowel sounds (early) or absent (late)

Question 56

What are some causes of intestinal obstruction in children?

Answer 56

Intussusception, volvulus, strangulated inguinal hernia, hirschprungs, meconium ileus, oesophageal/duodenal atresia, imperforate anus, malrotation

Question 57

What would AXR show for a child with intestinal obstruction?

Answer 57

Dilated loops of bowel proximal to obstruction, collapsed loops distal, absence of air in rectum

Question 58

What is the management of intestinal obstruction in children?

Answer 58

Refer to paediatric surgery as emergency, insert NG tube to drain stomach to help vomiting. IV fluids to correct dehydration and electrolyte imbalances

Question 59

What is a hernia?

Answer 59

The protrusion of viscus through a defect of the walls of its containing cavity

Question 60

Are direct or indirect inguinal hernias more common in children? Why?

Answer 60

Indirect, incomplete closure of the processes vaginalis after the descent of the testes

Question 61

What features of a scrotal swelling would suggest an inguinal hernia?

Answer 61

If the scrotal mass is reducible but you cant get above it, it generally doesn’t transilluminate, has a positive cough reflex

Question 62

Are inguinal hernia more likely to be right sided or left sided?

Answer 62

70% are right sided

Question 63

How will examination differ if an inguinal hernia becomes strangulated?

Answer 63

Irreducible, tender and may be clinical features of bowel obstruction

Question 64

What are some complications of inguinal hernias?

Answer 64

Recurrence, strangulation, incarceration and bowel obstruction