Paediatric Surgery Flashcards
Acute abdominal pain Appendicitis Head injury Herniae Hirschprung’s Disease Intussusception Neonatal intestinal obstruction Pyloric stenosis Testicular torsion Volvulus (118 cards)
1
Q
A child presents with acute abdominal pain.
What questions will you ask?
A
- Pain -> SQUITARS
- Have they noticed any lumps or bumps in the abdomen? (hernia)
- Nausea/vomiting? Is vomit bilious?
- Bowels - any change? Any blood? What’s normal?
- Urinary - any change? Any blood? Any other symptoms e.g. pain on urination. Ask about stream.
- Gynae - in older girls, ask about periods if they have started.
- Testicular - any pain or anything abnormal?
- Trauma? Overdose/poisoning/drugs?
- Is everyone well at home? Any recent illness in family/school?
- Development - any concerns?
- Are they sexually active (older child)
- Travel hx
- Social - how is school?
2
Q
An 11 year old girl presents tummy pain that started centrally but moved to the RIF.
They are not eating or drinking and have pain on any kind of movement.
What is my number 1 differential?
A
Appendicitis
3
Q
An 11 year old girl presents tummy pain that started centrally but moved to the RIF.
They are not eating or drinking and have pain on any kind of movement.
As she is female, what additional test would we do to rule out differentials that we wouldn’t do in a boy?
A
Pregnancy test
4
Q
An 11 year old girl presents tummy pain that started centrally but moved to the RIF.
They are not eating or drinking and have pain on any kind of movement.
What examination findings might we have?
A
- Appearance - painful to walk, don’t want to move, look unwell. Knees flexed helps pain.
- Palpation - generalised tenderness/RIF tenderness.
- Positive Rovsing’s sign (palpate LLQ -> pain felt in RLQ)
- Positive psoas stretch
- Guarding
- Mild fever
5
Q
An 11 year old girl presents tummy pain that started centrally but moved to the RIF.
They are not eating or drinking and have pain on any kind of movement.
What investigations would you like to do?
A
- Urine dip and culture
- Bloods - FBC (WCC), U&Es (vomiting -> electrolyte imbalance and dehydration), amylase (if even a tiny bit possible that it’s pancreatitis)
finish later
6
Q
A 1 year old boy is brought in with bilious vomiting and one episode of blood in the stool.
O/E you find a sausage shaped mass in the RUQ.
What are your differentials? Put them in order of suspicion.
A
Intussusception Hernia Cow’s milk allergy Volvulus Meckels diverticulum
7
Q
A 1 year old boy is brought in with bilious vomiting and one episode of blood in the stool.
O/E you find a sausage shaped mass in the RUQ.
What investigation is most appropriate here initially?
What do you think you’ll see?
A
USS abdomen
Target sign
8
Q
A 1 year old boy is brought in with bilious vomiting and one episode of blood in the stool.
O/E you find a sausage shaped mass in the RUQ.
How is this condition managed?
A
Intussusception is managed with reduction by air insufflation, or surgery if peritonitic.
9
Q
You overhear some surgeons talking about a child with an acute abdomen.
Like a good little medical student you start to form a list of differentials in your head (neerrrrrrd). What makes your list?
A
GI: Gastroenteritis Infantile Colic Appendicitis Mesenteric adenitis Intussusception Meckel’s diverticulum Constipation Hernia
GU:
- UTI
- Testicular torsion
- Pregnancy/Ectopic (older girls obvs)
- PID
- Ovarian torsion
- Menarche
Other:
- Henoch-Schönlein purpura
- Haemolytic uraemic syndrome
- Lower lobe pneumonia
- Trauma
- DKA
- Sickle cell crisis
- Psychogenic
10
Q
What is testicular torsion?
A
Spermatic cord twits and cuts off it’s blood supply, and can lead to testicular death.
It is a MEDICAL EMERGENCY.
11
Q
What is contained within the spermatic cord, and why is torsion so bad?
A
Vas deferens Lymphatic vessels Testicular artery and nerves Cremasteric artery and nerve Panpiniform plexus of veins
Its bad because twisting cuts of the only blood supply to the testicle, plus it is extremely painful.
12
Q
Who is testicular torsion most common in?
A
Neonates and adolescents
13
Q
How should we examine a child with an acute abdomen?
A
As usual:
- General - do they look unwell? Can you see a rash?
- ABCDE - haemodynamic status, temperature?
- Can the child be distracted from the pain?
- Ask the child to point with one finger to the pain?
- Ask to suck in abdomen then blow it out.
- Abdo examination as usual
- Rectal/genital examination only if absolutely necessary.
14
Q
What are some specific pitfalls to watch out for in a child with an acute abdomen?
A
- It is often hard to diagnose/exclude serious conditions in children
- Always consider gynae issues/pregnancy in girls and testicular issues in boys
- Consider illicit drug use
- Consider possibility of child abuse
15
Q
What head injuries might we see in a child?
A
- Skull fractures
- Cerebral lacerations
- Cerebral contusions
- Shearing injuries
- Haemorrhage following head injury
16
Q
How common are childhood head injuries, and how commonly are they associated with long term complications?
A
Very common, and rarely.
17
Q
How do children commonly get head injuries? How else can they get them?
A
Falling when playing etc.
Motor vehicle crashes
Pedestrian/bicycle accidents
Sports injury
Child abuse
18
Q
What are the symptoms of head injury in a child?
A
- Scalp swelling
- Loss of consciousness
- Headache
- Vomiting
- Seizures
- Concussion
19
Q
When should we perform tests on a child with a head injury?
A
If there is:
- recurrent vomiting
- seizure
- LoC
- Headache of worsening severity
- Behavioural changes
- Motor/speech difficulty
- CSF rhinorrhoea/otorrhoea
- Under 6 months
- Fall from height over 5 foot/high velocity hit
- Parental concern over how child is acting
20
Q
What is important to establish from the hx of a child with a head injury?
A
The timeline and how it happened.
When any symptoms occured gives a good clue as to what damage has been done.
Also important for suspected non-accidental injury.
21
Q
Do we image every child with a head injury?
A
No - we do a CT if there are concerns about serious brain injury.
22
Q
Which imaging modality is best of children with ?serious brain injury following head trauma/
A
CT Head
23
Q
If after a head injury it isn’t clear if a CT is needed, what can we do?
A
Keep ‘em in for observation for 4-6 hours. If they develop symptoms, scan them. If not, send them home with safetynet of watching for symptoms for 12 hours after injury
24
Q
What can we advise parents to do for minor head injuries when at home?
A
Rest
Analgesia
Ice on any swelling
Apply pressure to a bleed
25
Which type of hernia is common in children, and which demographic is it most common in?
Inguinal hernia.
Common in preterm infants and male infants.
26
How does an inguinal hernia present in a child?
Groin swelling that is usually reducible.
| May have an impulse when infant coughs.
27
How should congenital inguinal hernias be managed?
Once detected, send for surgical outpatient referral urgently.
28
Are direct or indirect inguinal hernias more common in children?
Indirect (protrusion through inguinal ring passes along inguinal canal through abdominal wall lateral to inferior epigastric vessels, instead of driectly protruding through weakness medial to the vessels)
29
What is the difference between omphalocele and gastroschisis?
Exomphalos aka omphalocele is a congenital herniation of abdominal contents into the umbilical cord with a peritoneal and amnion membrane covering.
Gastroschisis is a congenital abdominal wall defect usually to the right of the umbilicus, and there is no covering membrane.
30
How common is gastroschisis?
1 in 10,000 births
31
How common is exomphalos?
2.5 in 10,000 births
32
How can we diagnose/suspect gastroschisis or exomphalos before the baby is born?
On the foetal anomaly scan.
There may also be a prenatal rise in alpha-foetoprotein.
33
What are the differentials for exomphalos and gastroschisis?
- Physiological bowel herniation
- Umbilical hernia (frequent in prem babies)
- Extrophy of bladder
34
What investigations can we do for exomphalos and gastroschisis?
Karyotyping as exomphalos has a strong link with chromosomal abnormalities.
35
How is exomphalos managed?
If the sac is intact, cover sac with non-adherent gauze and replace contents and close abdomen surgically.
If the sac ruptures, manage as gastroschisis.
36
How is gastroschisis managed?
-Plastic closure can sometimes be achieved.
-In most cases, primary closure of the defect is main objective.
If the intestines are inflammed, may need to leave for a while before putting them back inside.
Supportive Rx alongside surgery e.g. parenteral feeding, IV fluids, O2.
37
What complications can occur secondary to exomphalos and gastroschisis?
Failure to thrive or poor nutritional status as metabolic drain.
Hepatomegaly/cholestasis if long term parenteral feeding.
Large defects may be harder to close and require longer hospital stay.
Intestinal atresia.
Trauma to the liver.
Short bowel syndrome.
38
What is intussusception?
A paediatric condition in which one segment of bowel invaginates into another segment distal to it, causing obstruction.
39
Describe the epidemiology of intussusception.
M:F 3:2
66% are under age 1, majority are by age 3.
It is the most common cause of intestinal obstruction in under 3s.
40
How does intussusception present?
```
Colicky abdominal pain every 10-20 minutes.
Sudden onset.
Early vomiting
Lethargy, hypotonia, alt consciousness
Irritability
Sweatng
Redcurrent stools later on
```
41
What signs are present in intussusception?
Palpable sausage shaped mass
Abscence of bowel in RLQ
Signs of shock and dehydration
Pyrexia (late)
42
What is pyloric stenosis?
Pyloric muscle hypertrophy resulting in narrowing of the pyloric canal, which can then become easily obstructed.
43
When does pyloric stenosis present?
Between 2 and 8 weeks of life.
44
How common is pyloric stenosis?
Occurs in 1 in 500 live births.
45
Is pyloric stenosis more common in males or females?
M:F 4:1
46
How does pyloric stenosis present?
Projectile non-bilious vomiting starting between 2 and 8 weeks of life, usually 30-60 minutes after a feed.
47
What other symptoms might an infant with pyloric stenosis present with after a few days?
Persistent hunger, dehydration, weight loss, lethargy, infrequent or absent bowel movements.
48
Can an enlarged pylorus be palpated on examination?
Can be palpated as an "olive" shape in the RUQ or epigastrium.
49
A 4 week old infant presents with projectile vomiting. What are you differentials?
Pyloric stenosis, feeding problem or milk intolerance, GOR, gastroenteritis, duodenal atresia, oesophageal atresia, intestinal malrotation.
50
What investigations are done with suspected pyloric stenosis?
Serum electrolyes, ABG (metabolic acidosis). USS.
51
How does pyloric stenosis appear on USS?
Thickened pyloric muscle and pyloric volume.
52
With which genetic conditions is pyloric stenosis associated?
Turner syndrome, and Trisomy 18
53
How is pyloric stenosis managed?
Surgery
54
What pre-operative management is done for pyloric stenosis?
Correct dehydration and electrolye imbalance.
55
What surgery is used to treat pyloric stenosis?
Pyloromyotomy (Ramstedt's or laparoscopic)
56
What complications are associated with pyloric stenosis?
Vomiting -> dehydration, weight loss, electrolyte disturbance.
57
What complications are associated with surgery for pyloric stenosis?
Mucosal perforation, bleeding, persistent vomiting.
58
What is the prognosis like for pyloric stenosis?
Excellent provided diagnosis and treatment is not delayed, and dehydration is not prolonged.
59
What is a volvulus?
A complete twisting of a loop of intestine around its mesenteric attachment site.
60
What is a midgut rotation?
Twisting of the entire midgut around the axis of the superior mesenteric artery.
61
Why does volvulus occur?
The gut rotates between weeks 4 and 12 of gestation to end up fixed to the posterior abdominal wall - if this process arrests at any point, fixation to the abdo wall is impaired which increases the risk for volvulus.
62
How common is malrotation?
Occurs in 1 in 500 live births.
63
When does volvulus/malrotation present?
Within the first month of life (80%), and another 10% within the first year of life.
64
When does volvulus classically present?
In infancy or early childhood.
65
Are volvulus and malrotation the same thing?
No they are 2 separate things.
66
How are volvulus and malrotation different in presentation?
Malrotation may be asymptomatic and found incidentally. Malrotation causes intermittent symptoms of intestinal obstruction, but volvulus causes complete obstruction.
67
An infant is brought into A+E with bilious vomiting. What is the top differential?
Volvulus
68
If volvulus presents later in life than 2 months, what symptoms might they have?
Bilious and non-bilious vomiting, failure to thrive, anorexia, constipation, bloody stools, and intermittent apnoea.
69
Can volvulus occur before birth?
Yes, it can rarely occur, and can even more rarely lead to intrauterine death.
70
If volvulus is not treated surgically immediately, what can happen?
Intestinal necrosis can occur within several hours.
71
How does volvulus present?
Bilious vomiting, metabolic acidosis, lactataemia, oliguria, hypotension, and shock.
72
What can be found on examination of a child with volvulus?
A palpable abdominal mass, or acute abdomen with distension if ischaemia develops, or peritonitis if perforates.
73
What bloods need to be done if an infant has bilious vomiting ?volvulus?
FBC to assess severity, U+Es to monitor general condition, dehydration, sepsis, and acidosis.
74
What imaging can help diagnose volvulus?
AXR and Upper GI contrast series.
75
How does volvulus look on AXR?
Dilation of stomach and proximal duodenum with small amount of dital bowel gas = double-bubble sign.
76
How does upper GI contrast series diagnose volvulus?
Small amount of barium administered through NG tube or bottle, and shows patterns of dilation and obstruction.
77
How should volvulus be managed?
Surgically
78
What surgery is used to treat volvulus?
Ladd's procedure - volvulus is corrected by rotating small intestine anticlockwise, placing caecum in left abdomen.
79
How should an infant with volvulus who has had surgery be followed up?
Second-look laparoscopy to ensure the remaining bowel is viable.
80
What are the complications associated with volvulus?
If untreated, intestinal ischaemia, mucosal necrosis, and sepsis. Perforation peritonitis and death follow. Post-operatively, short-gut syndrome and nutritional problems can occur.
81
What is the most common area of bowel affected by intussusception?
Ileocaecal
82
Is intussusception common preterm?
No, it is rare preterm.
83
What is Dance's sign?
Absence of bowel in the RLQ seen sometimes in intussusception.
84
How do a child's stools look in the late stages of intussusception?
Mucoid and bloody redcurrent stools.
85
Are the majority of cases of intussusception associated with an underlying condition of the gut?
No - over 90% have a non-pathological lead point. 50% of these are viral in aetiology.
86
What viruses are associated with intussusception?
Rotavirus, adenovirus, and human herpesvirus 6
87
What is the leading pathological cause of intussusception? When does this tend to present?
Meckel's diverticulum - seen in older pts with this in PMHx.
88
What is the investigation of choice for intussusception?
Ultrasound or Bowel barium enema
89
What does ultrasound of intussusception look like?
Doughnut or target sign.
90
How should intussusception be managed?
Resuscitation ("drip and suck"). Radiological reduction if no sign of peritonitis/perforation/shock, with air or barium enema. Laparotomy is indicated if there is peritonitis/perforation/hx over 24 hours/pathological lead point/failed enema.
91
What are the complications of intussusception?
Ischaemia, sepsis, necrosis, haemorrhage, perforation, peritonitis, failure of reduction.
92
How good is the prognosis for intussusception?
Excellent if treated promptly.
93
Why do congential diaphragmatic hernias occur?
Failure of the diaphragm to fuse properly during foetal development, which allows abdominal organs to migrate into chest cavity.
94
What are the 2 main problems with congenital diaphragmatic hernias?
Pulmonary hypertension and pulmonary hypoplasia.
95
Which side of chest cavity do most diaphragmatic hernias herniate into?
The left - 85% of the time.
96
How common are congenital diaphragmatic hernias?
Occur in 1 in 2500 births, accounting for 8% of all major congenital defects.
97
Why are left diaphragmatic hernias more common than right?
The liver plugs the hole through which the bowel could herniate.
98
What risk factors are there for congenital diaphragmatic hernias?
Majority are idiopathic, but a few familial clusters have been observed.
99
How are many congenital diaphragmatic hernias diagnosed?
Most are diagnosed prenatally on USS.
100
What signs are exhibited in a neonate with congenital diaphragmatic hernia?
- Cyanosis soon after birth
- Tachypnoea
- Tachycardia
- Chest wall asymmetry
- Absent breath sounds on one side of chest
- Bowel sounds audible in chest
- Abdomen feels less full...
101
What are the differentials for congenital diaphragmatic hernia?
- Pneumothorax
- Pleural effusion
- Aspiration syndromes
- Persistent newborn pulmonary HTN
102
If a neonate hasn't had congenital diaphragmatic hernia diagnosed in utero, how is it investigated after birth?
CXR or USS
103
What immediate care do neonates with congenital diaphragmatic hernias need?
- Resuscitation
- Resus should be done with head in up position rather than head down.
- Intubation and mechanical ventilation
104
What non-surgical management can be done for congenital diaphragmatic hernia?
Optimise oxygenation and avoid barotrauma.
105
What surgical management can be done for congenital diaphragmatic hernia?
Replacing abdominal organs within abdominal cavity and repairing the diaphragmatic defect.
106
When should surgical correction of congenital diaphragmatic hernia be performed?
Can be delayed for up to 7-10 days - usually until pulmonary arterial pressure have been maintained for 24-48 hours.
107
What complications are associated with congenital diaphragmatic hernia?
If sever CDH, chronic lung disease.
Hypoxaemia may cause nervous system damage e.g. cerebral palsy or hearing loss.
GOR is very common.
108
What is balanitis?
Inflammation of the glans penis.
May include the foreskin -> balanoposthitis.
109
Is balanitis more common in men or boys?
Men
110
What are the risk factors for balanitis?
Diabetes mellitus is the main risk factor.
Oral abx use
Poor hygiene in uncircumcised males
Immunosuppression
Chemical or physical irritation of glans
111
What can cause the inflammation in balanitis?
- Infection (bacterial most commonly, fungal usually just opportunistic)
- Dermatological causes
- Miscellaneous irritants or trauma
112
What dermatological causes are there for balanitis?
- Drug eruption
- Lichen sclerosus
- Balanitis xerotica obliterans
- Psoriasis
- Lichen planus
- Seborrhoeic dermatitis
- Pemphigoid/pemphigus
113
How does balanitis present?
- Sore, inflammed and swollen glans
- Non-retractile foreskin
- Ulceration, plaques
- Satellite lesions
- Dysuria
114
What investiagtions may be needed for a case of balanitis?
- Bloods/urine testing for diabetes
- Swab for culture if infection suspected
- If STI is suspected, ?abuse - swab.
115
How should balanitis be managed?
- Daily cleaning with warm water and gentle drying
| - Treat underlying cause
116
How can recurrent balanitis be managed?
Consider for circumcision
| Check for diabetes
117
What is testicular torsion?
Torsion of the spermatic cord - it is an emergency.
118
where?
https://patient.info/doctor/torsion-of-the-testis-pro
