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Flashcards in Paediatric surgery Deck (101):

Common causes of surgical abdominal pain in children?

testicular torsion
hypertrophic pyloric stenosis


Most common cause of vomiting and abdominal pain in children?



what is the typical risk factor for malrotation/volvulus in a neonate

narrow mesentary between iliocaecal valve and DJ flexure prone to twisting of gut around superior mesenteric vessels


complications of malrotation?

arterial ischaemia


why do we take out the appendix out of kids who have surgery for malrotation?

to prevent them from developing appendicitis in the LUQ where the caecum usually goes after repacking of bowel during the surgery


commonest intestinal obstruction presentation?

hypertrophic pyloric stenosis


age and sex of a patient we normally see with hypertrophic pyloric stenosis?

male + 3 week old


what is the metabolic derangement typical of hypertrophic pyloric stenosis?

metabolic alkalosis

vomit out HCL, K+ --> alkalosis


what is the paradoxical change in the urine of a child with hypertrophic pyloric stenosis, and why does it occur?

acidic urine

--> body's compensation for keep on throwing out HCL from vomiting--> kidneys throw out HCL to try and conserve Na+


how do we calculate the size of the ETT for a child?

age/4 + 4


what surgical procedure do we do for malrotation and volvulus?

ladd's procedure


an infant comes into ED with bilious vomiting. what ix do you order and why

upper GI contrast study to exclude malrotation


what are some clinical presentation features of a child with hypertrophic pyloric stenosis?

More common in boys

Hereditary component- 20% of cases (usually from mother's side)

Appetite preserved! Hungry child!

projectile vomiting



what ix to order with hypertrophic pyloric stenosis?

1. U/s

2. Blood test (gas/UEC)
Metabolic alkalosis due to reduced Cl- and K+

3. urine sample
Paradoxical acidic urine


define intussusception

invagination of proximal into distal bowel


what is a common cause of intussusception?

enlarged peyer's patches in terminal ileum


what is the peak of age seen for intussusception cases?



how do we treat intussusception?

Gas reduction enema under fluoroscopy

or for more severe cases- laparotomy


what are common pathological lead points in older children who get intussusception?

merkel's diverticulum


when is the peak incidence of appendicitis?

10-12yrs of age


how might retrocaecal appendicitis present clinically?

vague non-localising RIF pain with deep RIF tenderness, often without guarding


what is a key differential for pelvic appendicitis?



how might pelvic appendicitis present clinically?

vague lower abdominal pain and tenderness
urinary symptoms
no guarding


what is an external angular dermoid cyst? What does it feel like? When does it present?

embryological abnormality- usually on the top of eyebrow

anomaly of fusion between the fronto-nasal and maxillary processes during formation of the head and face

Often feels bony because it lies under the periosteum

usually presents around 3-12 months


what is another name for strawberry naevus?

congenital haemangioma


when might we surgically treat a strawberry naevus

if it blocks the visual axis; if it is on the eyebrow causing secondary blindness


what does the 'setting sun eyes' sign refer to?

can see the sclera from the side when normally you shouldn't be able to

indicates ophthalmoplegia due to increased ICP and is associated with perinaud's syndrome

extremely rare sign


what might you think if you saw a lump around the lower back to bottom (coccyx) in a newborn?

sacrococcylgeal teratoma


why do we surgically fix cleft palate around 6-9 months?

Because having a cleft palate will affect the voice we need to surgically correct it.

6-9months is when the baby begins to develop their voice and so this is the best time to perform the procedure


what is virchow's lymph node? what is its significance?

sentinel lymph node at the end of the thoracic duct
--> situated above left clavicle

an enlarged virchow's lymph node is always malignant.

may indicate cancer from bowel/pancreas/lung/stomach/lymphoma


what are the 2 types of lymphomas that can cause virchow's lymph node in a child?

hodgkin disease or neuroblastoma


what do you think if there are more than 3 malformations in a newborn?

multiple malformation syndrome


how do we investigate intussusception in a child?


but gold standard= contrast enema study under fluoroscepy as it can also be therapeutic. Contraindication would be perforation though


tell me about sacrococcygeal teratomas?

A teratoma arising from and attached to the tip of the sacrum or the front of the coccyx – a rare congenital anomaly arising in 1/40000 births (slightly more
frequently in females).

It is usually obvious at birth and may be so large as to cause obstetric difficulties.

The tumour is a mixture of solid and cystic areas arising from all embryonic layers. It is benign at birth but has a high risk (5‐35%) of turning malignant postnatally. This malignant degeneration is much less likely if removed
immediately after birth


how do cleft palates arise?

cleft palate- failure of the maxillary plates to fuse horizontally


what is the eponymous name for torsion of the testicular appendage?

hydatid of morgagni


at what age is torsion of the testicular appendage more common in males?

at less than 11 years


what are the two peaks of incidence for testicular torsion in boys?

babies and greater than 13 yrs


which boys are predisposed to testicular torsion?

boys with a bell clapper deformity--> longer mesentary--> testes heavier during puberty--> increased risk of torsion


what is the classic shape of bilateral hydrocoele?

dumbbell shaped because the pathology is WITHIN the TUNICA VAGINALIS (inside the peritoneal cavity)


what does it mean if a scrotum is symmetrically swollen?

oedema e.g. idiopathic oedema or nephrotic syndrome

it means the pathology is OUTSIDE the tunica vaginalis


how do we tell which types of scrotal conditions require surgical intervention?

the scrotum is a subcutaneous space containing two peritoneal cavities --left and right tunica vaginalis

if the pathology is within the peritoneal cavity- then it would be limited by the hemi-scrotal border- this requires surgery as it relates to the testes.

if the pathology is outside the peritoneal cavity- then often surgery is not needed as another cause exists e.g. nephrotic syndrome


what is the testicular appendage?

proximal remnant of the mullerian duct


what is the commonest cause of acute scrotum?

hydatid of morgani (testicular appendage) torsion


what is the name of the testicular mesentary



why do we use a midline incision for a surgery to take out a dead testis due to torsion?

we do a midline incision as we must also correct the long mesentary of the remaining viable testes, so that fertility is preserved. This is because the other testes is also at risk of torsion


how can we tell if a testes is enlarged/small? i.e. what is a rule of thumb

the testes should be the same size as the glans; so use the size of the glans as a control


when would you feel the classic 'bag of worms' sensation for a varicoele?

when the boy is vertical as the blood engorges the veins in the standing position

when the boy is lying down--> it won't feel like a bag of worms.

So mainly have a high clinical suspicion of varicoele if you see an asymmetrical scrotum, and confirm with the boy standing up


what are two common abdominal masses with malignant cause in an infant?

wilm's tumour


what does VATS stand for?

video-assisted thorascopic surgery


what are the 3 characteristics of hypospadias

1. insufficient foreskin on the ventral side
2. ectopic position of urethral meatus on the ventral side
3. Chordee


how might we assess the severity of hypospadias?

the more proximal the urethral opening= the more severe hypospadias


which penile conditions have a surgical indication for circumcision?

balanitis xerotica obliterans leading to pathological phismosis--> always requires circumcision

recurrent inflammation of glans and foreskin may warrant circumcision but not always


How might we surgically correct coarctation of the aorta?

1. Removal of the narrowed segment, ends sewn back together

2. Subclavian flap

2. Balloon dilatation


Why do we wait till over 6 months of age for surgical treatment of TOF? What do we do in the meantime?

We wait often because infants may be premature, have immature artery anatomy and are not good surgical candidates at ages younger than 6 months. In the meantime we can use palliative shunts which are provides stable pulmonary blood flow till the operation. Shunts are between subclavian artery and pulmonary artery


What does the surgical procedure for TOF involve?

Patch closure of VSD

Resection of right ventricular outflow tract


How might we clinically distinguish between intussusception and gastroenteritis in an infant aged between 3-18 months?

Early vomiting
Spasmodic pain
Abdominal mass and distension


Little diarrhea

These clinical signs suggest intussusception rather than gastroenteritis


How might we best determine whether a child has guarding on abdominal exam?

Gentle palpating and percussion tenderness! Do not do rebound tenderness!!!!


How can we differentiate appendicitis and mesenteric adenitis in an older child?

Location of pain in m.adenitis is variable and less specific, and high fever maybe present


What are the ddx for children with suspected appendicitis?

Top ddx is mesenteric adenitis

Other ddx is
Meckel diverticulitis
Testicular torsion
Inguinal hernia that is strangulated
Acute pyelonephritis or renal colic
sickle cell anemia
RLL pneumonia


what is the anaesthetic used for inhaled induction?

NO and sevoflurane


What is the name of the surgery for undescended testes?



Why and when would we surgically treat undescended testes?

Undescended testes carry the risk of testicular malignancy and infertility. surgery usually occurs around 1 yr of age as testes are unlikely to descend spontaneously after this time


why can't infants with hypospadias be circumcised?

the foreskin is often used for reconstructive surgery


what is the difference between phismosis and paraphismosis?

pathological phismosis= Inability to retract foreskin

paraphismosis=Foreskin gets trapped in retracted position


most common reason for an indirect inguinal hernia?

Failure of obliteration of the processus vaginalis


when do we see smegma in a baby boy?

1-3yrs old


what are the usual pathogens causing balanitis?

bowel flora or E.coli


how does paraphismosis occur?

retracted foreskin compresses venous return so the glans swell and becomes acutely painful and red


how can we tell the difference between true hypospadias and disorders of sexual development causing hypospadias appearing ambiguous genitalia?

if there is a fused scrotum with palpable descended testes= true hypospadias


what are the possible causes of intoeing in a child?

metatarsus adductus, internal tibial torsion, internal femoral torsion


what is a cystic hygroma?

lymphatic malformation (block in the lymphatic system during development) causing a diffuse swelling/lump


what is the difference between being born with a haemangioma and developing a haemangioma in the first few weeks of infancy?

babies born with a haemangioma--> unlikely to self resolve; permanent

babies who develop a haemangioma during infancy e.g. strawberry naevus--> lesion will self-involute with time


what is the main trigger for sternocleidoid muscle tumour?

breech delivery


what does the submental lymph nodes drain?

teeth so dental caries can cause submental lymphadenopathy


what are some causes of a midline neck lump?

thyroglossal cyst
submental lymph node
congenital dermoid cyst (midline fusion defect)
bacterial lymphandenitis


what exactly is a sternocleidoid muscle tumour?

torn SCM muscle causing scarring --> lump forms --> can result in torticollis


what is the tell tale pathognomic sign of infected thyroglossal cyst?

the erythematous 'smile' of the mid-line neck lump, and not clearly circular like an infected lymph node


a boy presents with a purplish lump on the side of his neck? what is your number 1 differential?

MAC (mycobacterium avium complex) adenopathy


what are some ddx for cervical lymphadenopathy?

bacterial lymphadenitis (most common)
haematological malignancy
infected lymph node
Kawasaki's disease
MAC adenopathy


what causes a tongue tie?

short lingual frenulum


what are some anatomical cutaneous clues on a newborn which may indicate possible spina bifida?

midline lump on back
a hairy patch on the midline back
/dark pigmented naevus

--> if you see this- consider referral to neurosurg


what does plagiocephaly mean?

flattened occiput of head --> causing abnormal head shape. Not normally pathological and positional related


what does craniosyntosis refer to?

premature fusion of the sutures causing abnormal head shape in baby


what is the main cause of labial adhesions during infancy?

low oestrogen


in what group of children with abdo pain may you consider cholelithesis as a possible ddx?

older adolescents

children with chronic haemolytic disorders like thalassemia and spherocytosis


how soon does surgery have to be performed for a child with an inguinal hernia?

the younger the child, generally the earlier the hernia should be repaired.
- think 6/2 approach

e.g. 6 week old= op within 2 days
6 months old= op with 2 weeks
6 yrs old= op within 2 months

if the hernia is incarcerated- then urgent surgical intervention is indicated.


what is the pathognomic sign of faecal mass causing abdominal mass on examination?

abdominal mass indents upon compression


what are some complications of an incarcerated inguinal hernia in a child?

1. Bowel ischaemia --> perforation --> sepsis

2. Bowel obstruction

3. secondary atrophy of testis and necrosis


what are your differentials for a painless enlarged hemiscrotum?

indirect inguinal hernia
testicular tumour


what are some clinical features of an inguinal hernia on history and exam?

sudden appearance of a lump

intermittent presence

appears with increased abdominal pressure such as crying/straining/coughing

usually painless but may cause some discomfort

swelling may extend up to the external inguinal ring

'cant get above the swelling'

can be reduced; cough reflex

not an ectopic testes as testes present in the hemiscrotum

does not transilluminate


where do direct inguinal hernias normally present in the abdomen?

above the external inguinal ring


describe the process of 'scrubbing' for surgery?

1. Theatre attire, remove watches, phones, jewellery
2. Put on a mask
3. Make sure there is appropriately sized sterile gloves and apron opened for you on a nearby sterile table
4. Open scrub pack and use nail pick to clean under nails
5. Use elbows to apply iodine to hands and scrub hands/fingers thoroughly with scrub. Scrub up to forearms
6. Once hands are scrubbed, throw scrub into bin.
7. Apply more iodine and wash to elbows. Wash away the iodine with hands higher than elbows such that water drips off the elbow.
8. Repeat and rub iodine to forearms. Rinse.
9. Again rub iodine into hands and rinse.
10. Dry hands on already prepared towel. Use one hand/arm per side of towel or one hand per towel if 2 are present
11. pick up the gown carefully, ensuring the front is not touched, and the gown does not touch the floor. Slide arms into the apron until fingers reach the cuff. Someone will tie the back of the apron for you.
12. Put on sterile gloves. Palms up, typing to the cuff and fingers facing towards you.
13. Put second set of sterile gloves on.
14. ask someone to hold onto the cardboard part of the gown and turn. Tie the apron together.


describe the psoas sign and obturator sign of acute appendicitis

• Psoas sign: Pain on hip extension.
• Obturator sign: Pain on hip internal rotation.


when should suspected testicular torsion require surgical exploration before it becomes infarcted/necrosed?

surgical exploration within 8-12 hours


what is the embryological origin of testicular appendage?

mullerian duct


what is the management of torsion of the testicular appendage?

Torsion of these appendages is self‐limited and is best treated with nonsteroidal anti‐inflammatory medications and comfort measures such as restricted activity and warm compresses. Surgical exploration is indicated when the diagnosis of testicular torsion cannot be reliably excluded or when the symptoms are prolonged and fail to resolve spontaneously.


how do we manage paraphismosis?

Paraphimosis can usually be corrected without surgery:

Adequate analgesia +/- sedation should be given.

Liberally covering the entire foreskin and glans in topical anaesthetic cream & Gladwrap for 1 hour may be effective. Local infiltration of anaesthetic is best avoided as it increases the swelling.

The swollen area is gently but firmly compressed within one hand, for a few minutes, to squeeze out the oedema fluid. The glans may then be pushed back and the foreskin returned to the normal position.

If manual reduction fails, consult surgical registrar immediately. Surgical options include needle puncture to release oedema fluid or incision of the tight band of the foreskin.

Once reduced, a single episode of paraphimosis is not an indication for circumcision. If the child has significant phimosis then it should be treated as above.


how do we manage phismosis?

Application of topical steroid creams: 0.05% betamethasone cream should be used twice daily for 2 to 4 weeks.

Gently retract foreskin without causing any discomfort and apply a thick layer of cream to the tightest part of the foreskin.

Circumcision (if significant phimosis and steroid creams fail)


describe the mechanism of hypokalemic hypochloraemic alkalosis in pyloric stenosis?

profuse vomiting leads to loss of H+ and K+ and Na+

as a result the kidney tries to compensate by favouring Na+ retention, and hence, K+ and H+ loss at the kidneys increase at the respective Na+/K+ pump and Na+/H+ pump in the nephron.

With increased H+ loss--> there is reduced pH in the urine= paradoxical acidic urine


why is it important to correct electrolytes in an infant with pyloric stenosis prior to operation?

It is particularly important to fully correct serum bicarbonate before theatre because of the risk of hypoventilation/ apnoeas post-operatively in the setting of metabolic alkalosis.