Paediatrics Flashcards
A baby is born with a solitary mass over the right buttock.
Teratoma
A sacrococcygeal teratoma is a solid tumour found in new-borns, with girls being affected more than boys. It is a mixed germ cell tumour and may be associated with gastrointestinal or genital urinary symptoms.
A young child presents with fevers and a mass in the femur is noted and a diagnosis of malignancy is made. This malignancy is 30 times more common in white children compared to black children.
Ewing’s sarcoma
Ewing’s sarcoma is a tumour of the bone. It is usually found in long bones, particularly the femur. It may present with pain, fever and tenderness and sometimes pathological fractures. There is a poor prognosis.
It is 30 times more common in white children than black children.
A child of Nigerian parents presents with a unilateral tender cervical node. A diagnosis of malignancy is made with this malignancy being seven times more common in black children compared with white children.
Burkitt’s nasopharyngeal carcinoma
This genetic predisposition is contrary to the Burkitt’s nasopharyngeal carcinoma which is more common in black children than white (by sevenfold). This tumour has been associated with the Epstein-Barr virus and children present with sore throats, unilateral tenderness, cervical lymphnodes, trismus and weight loss.
An 8-month-old boy is referred with a unilateral swelling in the groin. On examination the right testis is fully descended but the left scrotum is rather underdeveloped and empty. On the medial aspect of the inguinal region was a smooth oval swelling which could be gently pushed into the upper scrotum.
Undescended testis
Undescended testes are commonly noticed by parents or found on routine infant checks. If there is tension in the spermatic cord when the testis is pushed gently into the scrotum, orchidopexy is necessary (best performed at around 2 years of age). Retractile testes, in contrast, are commonly palpable in the inguinal region initially, but come down very easily into the scrotal base with no tension. Orchidopexy is not indicated in these boys (referral to a paediatric surgeon recommended if there is any uncertainty).
A 2-year-old boy who had been born prematurely presents with a right-sided intermittent inguinal swelling. He is otherwise asymptomatic. On examination, both testes are fully descended. There were no obvious inguinal swellings evident but the spermatic cord on the right appeared thickened.
Indirect inguinal hernia
Inguinal hernias are commoner in boys born prematurely and the commonest type by far in children is the indirect hernia, caused by persisting patency of the processus vaginalis. Hernias are not always apparent on clinical examination but a thickened cord may be palpated. If this sign is present, together with a reliable parental history, herniotomy should be performed. The other groin should always be examined for contralateral hernia (bilateral hernias are commoner in premature babies).
A 6-month-old boy is noted to have a swelling in the left scrotum, which varies in size throughout the day. On examination there is a non-tender left scrotal swelling which transilluminates brightly. A normal testis is just palpable despite the swelling.
Hydrocoele
A hydrocoele is caused by the passage of peritoneal fluid down a patent processus vaginalis into the scrotum. The fluid may pass back into the peritoneal cavity and therefore variation in size of the hydrocoele is typical. It is often transilluminable. The processus vaginalis may close spontaneously and surgery is delayed until the child is around 3-years-old (unlikely to close spontaneously after this age).
A 4-month-old boy presents with irritability and unilateral testicular swelling. His temperature is 38°C and the testis is enlarged, red, firm and tender. Ward testing of his urine shows protein, nitrites and leucocytes (subsequent microbiology report shows growth of coliforms).
Epididymo-orchitis
Urinary tract infection (UTI) in boys may present with epididymo-orchitis. Prompt treatment with intravenous antibiotics is required and the urinary tract should be investigated as an outpatient (ultrasound scan of the renal tract, followed by micturating cystourethrogram). Untreated UTI in small children may lead to renal cortical scarring. It is important to note that if testicular torsion cannot be excluded by clinical examination or if there is any uncertainty, scrotal exploration should be performed.
A 6-week-old baby who had been born prematurely developed abdominal distension, irritability and bilious vomiting. Groin examination had been overlooked but abdominal x ray showed gas in the scrotum.
Incarcerated inguinal hernia
The differential diagnosis of neonates with small bowel obstruction includes
Malrotation Meconium ileus Ileal atresia Ileal duplication cyst and Incarcerated inguinal hernia. Upper gastrointestinal contrast study is extremely useful in the investigation of bilious vomiting, particularly if malrotation is suspected - volvulus and total gut necrosis is a serious risk with devastating consequences if missed.
Examination of the groin is paramount and it is usually possible to reduce incarcerated hernias (sedation may be necessary). Incarceration is more common in premature babies as are bilateral hernias.
Inguinal hernias in children always require herniotomy.
An 8-month-old girl presents with a two day history of episodic abdominal pain. She had recently been passing loose stools and fresh blood had been seen in the last nappy. A tender mass was palpable in the right hypochondrium.
Intussusception
Intussusception affects older babies and toddlers, the classic presentation being that of episodic abdominal pain, ‘redcurrant jelly’ stool and sausage shaped mass.
A 3-year-old girl presents with a five day history of poorly localised abdominal pain. She was vomiting and had diarrhoea. She was febrile and her abdomen was distended. She did not co-operate well with abdominal examination but the right side appeared to be tender.
Perforated appendicitis
Appendicitis can occur in any age and may lead to diagnostic difficulty in small children. Perforation is common and may give rise to inflammatory mass and secondary small bowel obstruction.
An 8-year-old boy with cerebral palsy who had previously undergone an open fundoplication for gastro-oesophageal reflux presents with bilious vomiting. His abdomen was distended and minimally tender. Plain abdominal x ray showed multiple dilated small bowel loops.
Adhesional
Adhesional bowel obstruction may follow any abdominal procedure.
The risk following Nissen fundoplication is approximately 5%.
Small bowel obstruction in Crohn’s can be caused by extreme bowel wall thickening or strictures.
Antenatal history should be obtained as intestinal atresia and meconium ileus may be associated with dilated bowel and polyhydramnios (amniotic fluid swallowed in utero cannot get past the point of obstruction).
Necrotising enterocolitis typically occurs in premature babies and may lead to perforation, inflammatory mass and obstruction.
A four-year-old child is admitted to the Emergency Department. The child has been rushed to the unit by her grandparents who are looking after the child, as the parents are at a friend’s wedding overseas, and cannot be contacted.
The child is examined and investigations are performed. A provisional diagnosis of a possible ruptured appendix is made, and the surgical team are called. After further review, the surgical team request to speak to the child’s parents in order to obtain their authority to perform surgery. The child continues to deteriorate.
What is the most appropriate action in this case?
(Please select 1 option)
The surgeon accepts authorisation from the grandparents who state that they do not have parental responsibility
The surgeon asks that, as the parents are unable to be contacted, a call is made to social services
The surgeon declines to take the child to theatre, as they are unable to obtain parental authorisation
The surgeon performs surgery without authorisation in the child’s best interests
The surgeon speaks with the charge nurse in the Emergency Department who signs the consent form
The surgeon performs surgery without authorisation in the child’s best interests
A person with parental responsibility for them may give authorisation for treatment of a child who lacks capacity. In this scenario, the child’s parents are unavailable. The child is deteriorating, and it is an emergency situation. The surgeon may consider the views of the grandparents and staff caring for the child, but may lawfully act in the child’s best interest and treat the child in an emergency without authorisation.
This is consistent with the common law principles of the doctrine of necessity set out in the case of Re F [1990] 2 AC 1 and is consistent with ethical guidance published by the GMC in its booklet Consent: patients and doctors making decisions together at paragraph 79:
“When an emergency arises in a clinical setting and it is not possible to find out a patient’s wishes, you can treat them without their consent, provided the treatment is immediately necessary to save their life or to prevent a serious deterioration of their condition.”
A 4-day-old male baby is brought to the paediatric acute surgical ward with mild abdominal distension, bilious vomiting, refusing to feed, and failure to pass meconium after birth. Abdominal examination is unremarkable.
Plain abdominal x ray reveals dilated loops of bowel with fluid levels. A barium enema demonstrates a ‘conical appearance’ in the distal segment of the colon. The parents have been informed that the baby requires a rectal biopsy.
From the options below choose the one which you think is the most likely diagnosis in this patient.
(Please select 1 option)
Anal atresia
Hirschsprung’s disease
Intestinal atresia
Meconium ileus
Necrotising enterocolitis
Hirschsprung’s disease
Hirschsprung’s disease is the absence of ganglion cells (congenital aganglionosis) in the neural plexus of the intestinal wall. The disease begins with the anus, which is always involved, and continues proximally for a variable distance. Both the myenteric (Auerbach) and submucosal (Meissner) plexus are absent, resulting in reduced bowel peristalsis and function.
Hirschsprung’s disease is more common in male than female babies. The delayed passage of meconium together with distension of abdomen following feeds and bilious vomiting are the usual clinical features.
Other pertinent clinical features include abdominal distension (which may cause the baby to breathe fast and grunt when breathing), constipation, and reduced feeding.
Plain abdominal x ray may demonstrate dilated loops of bowel with fluid levels.
Barium enema demonstrates a ‘conical appearance’ in the affected part due to the dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend.
The diagnosis, however, is frequently confirmed by rectal biopsy.
Rectal manometry is also an useful investigation which is performed in certain centres.
Surgery is the treatment of choice where the abnormal aganglionic section of colon is removed. The surgery is frequently a two-stage procedure with a colostomy being performed as a first stage, and a definitive procedure (end-to-end anastomosis of the unaffected segments of colon) being performed later in the first year of life.
A 10-month-old male baby with haemophilia is brought to the emergency department by his parents with a 36 hour history of intermittent episodes of inconsolable crying and vomiting. The parents say the baby’s stools are mixed with blood.
On examination, a sausage-shaped mass is palpable over the right side of abdomen. Per rectal examination reveals an empty rectum but blood is noticed on the glove of the examining finger.
From the options below choose the one which you think is the most likely diagnosis in this patient:
(Please select 1 option)
Infantile hypertrophic pyloric stenosis
Intestinal atresia
Intussusception
Meckel’s diverticulum
Meconium ileus
Intussusception
Intussusception is caused due to invagination of a segment of bowel into its adjoining lower segment. Mesentery and vessels may also become involved with the intraluminal loop and squeezed within the engulfing segment.
Although the precise aetiology is not clear intussusception is known to occur with greater frequency in children who have undergone recent abdominal surgery, either intraperitoneal or retroperitoneal operations. It may be due to early adhesions or focal oedema of the bowel wall, creating a lead point for the intussusception.
Intussusception is more common in boys and usually occurs under the age of 1.
Intussusception is associated with
Haemophilia Henoch-Schonlein purpura Haemangiomas and Gastrointestinal lymphomas. Clinical features of this condition include severe colicky abdominal pain (causing intermittent inconsolable cries with the child drawing up the legs) and vomiting. Between attacks, the infant may appear in good health.
The infant may pass redcurrant jelly stools and a sausage shaped mass is palpable on abdominal examination. Rectal examination may reveal blood.
The treatment plan, in the absence of signs of peritonism, should be to reduce the intussusception by using either a barium or air enema.
Ten per cent recur within 24 hours and so all patients should be admitted and observed.
If this fails or if there are signs of peritonism then surgery is indicated.
A 6-month-old baby presents with vomiting, blood-stained stools and irritability.
On examination he has a tense abdomen and draws his knees up with palpation.
What is the most appropriate action you should take for this baby?
(Please select 1 option)
Abdominal x ray
Check serum amylase
Give antibiotics
Refer to surgeons
Suppositories to relieve constipation
Refer to surgeons
This child has features to suggest intusussception.
The most appropriate course of action is to refer immediately for surgery.
Approaches to relieve the intusussception will initially entail attempts at air reduction and, if this fails, surgery.
Risk factors for intusussception include viral infection and intestinal lymphadenopathy.
An otherwise healthy 7-year-old boy presents with an asymptomatic 1 × 1 cm firm oval swelling in the submandibular region. Which of the following is the most likely cause? (Please select 1 option) Acute follicular tonsillitis Branchial cyst Chronic lymphadenitis Salivary duct calculus Thyroglossal cyst
Chronic lymphadenitis
Cervical lymphadenopathy is very common in children. This is usually related to a previous mild upper respiratory viral infection. Most enlarged glands will resolve with time.
Diseases of the lymph nodes include acute lymphadenitis (inflammation arising from an acute infection) and chronic lymphadenitis, frequently associated with hyperplasia of the node.
Nodes may be enlarged secondary to malignant infiltration. This is rare in children. Tuberculosis must always be considered.
In this case, as the child is well, it is unlikely that a follicular tonsillitis is the cause.
The lymphadenopathy related to glandular fever may last for some months after the acute illness.
A thorough history and examination needs to be undertaken with particular reference to more extensive lymphadenopathy, hepatosplenomegaly and possible mediastinal masses.
First line investigations would include blood tests to exclude blood dyscrasias, as well as blood tests for inflammatory markers, for example:
erythrocyte sedimentation rate (ESR)
C- reactiveprotein (CRP)
antistreptolysin-O test (ASOT) titres, and
Paul Bunnell test (glandular fever).
If clinically there are signs of bacterial infection then the treatment of choice would be a course of antibiotics.
Salivary gland calculi are rare in childhood and a thyroglossal cyst should be in the midline.
Which of the following is an indication for surgical treatment of hiatus hernia with gastro-oesophageal reflux in children?
(Please select 1 option)
Anaemia
Duodenal ulceration
Hiatus hernia still present after the age of 2 years
Recurrent chest infection
Vomiting
Recurrent chest infection
Indications for surgical operation in children with hiatus hernia include persistent symptoms such as oesophagitis and recurrent chest infection.
Vomiting is not in itself an indication for surgery as it is not an unusual symptom and is one which may settle with appropriate treatment.
Duodenal ulceration is rare in children and not associated with hiatus hernia.
Regarding paediatric umbilical hernias, which of the following statements is correct?
(Please select 1 option)
All require repair in order to prevent complications
Are found in up to 15% of infants
Are often symptomatic
Have a greater incidence in the Caucasian population
The inferior epigastric artery is at risk during repair
Are found in up to 15% of infants
Umbilical hernias are seen in one in six children, and resolve in at least 90% of children by the age of 3 or 4.
There is an increased incidence in Afro-Caribbeans; incarceration is rare.
Repair involves suture of the fascial defect, and the inferior epigastric vessels are not encountered.
Regarding childhood circumcision, which of the following is correct?
(Please select 1 option)
Balanitis xerotica obliterans is a relative contraindication
Balanitis xerotica obliterans may involve the urethral meatus
It is indicated when hypospadias is present
It is routinely performed for phimosis
Postoperative bleeding is rarely associated with the frenular vessels
Balanitis xerotica obliterans may involve the urethral meatus
Circumcision is contraindicated in hypospadias, as the prepucial skin may be utilised in the repair.
Phimosis may resolve with conservative management (1% topical hydrocortisone), but if balanitis xerotica obliterans (white scarring, which can also affect the urethral meatus) is present, circumcision is mandatory.
Frenular vessels or the dorsal vein are frequent culprits in postoperative bleeding.
Which of the following is correct regarding undescended testes in boys?
(Please select 1 option)
Are always approached using an inguinal incision
Are bilateral in 50% of cases
Ectopic testes may be found in the perineum
Require orchidopexy when the child is approximately 4-years-old
Usually require a two-stage procedure
Ectopic testes may be found in the perineum
Unilateral undescended testis is the commonest. The testis may be intra-abdominal (impalpable) or palpable at or near the external ring.
Ectopic sites include the perineum and thigh.
Orchidopexy is performed around the age of 2, and either an inguinal or scrotal approach used depending on the position of the testis.
Regarding childhood acute appendicitis, which of the following is correct?
(Please select 1 option)
Appendix mass should not be managed conservatively
Does not occur below the age of two
Faecoliths are rare
Laparoscopic appendicectomy is possible
Rarely presents with bilious vomiting and abdominal distension
Laparoscopic appendicectomy is possible
Acute appendicitis can occur at any age. Small children often cannot localise pain, and may present with
Vomiting
Diarrhoea
Abdominal distension.
Faecoliths are sometimes encountered, and laparoscopic appendicectomy is possible.
Appendix mass associated with delayed presentation is usually managed conservatively, and some advocate interval appendicectomy at least six weeks later.
Which of the following is correct regarding congenital diaphragmatic hernia?
(Please select 1 option)
Is usually right sided
May be associated with hepatic hypoplasia
May be diagnosed antenatally
Repair is required within the first 48 hours
Repair is typically approached using a thoracic incision
May be diagnosed antenatally
Congenital diaphragmatic hernia occurs in 1 in 2000 live births and is frequently diagnosed on antenatal ultrasound scans.
Left-sided (Bochdalek) defects are commonest, and pulmonary hypoplasia is a common cause of death.
In babies, repair is usually delayed for at least 48 hours, until the ventilatory status is stable. It is repaired using a left upper quadrant abdominal incision.
Which of the following is correct concerning Hirschsprung’s disease?
(Please select 1 option)
Causes functional bowel obstruction due to stricturing
Is associated with Down syndrome
Is commoner in girls
Is not associated with enterocolitis
Usually involves the entire colon
Is associated with Down syndrome
Hirschsprung’s disease is caused by aganglionosis of the Auerbach’s and Meissner’s plexi in the bowel.
It is commoner in males and Down syndrome is present in 5% of cases.
Hirschsprung’s frequently presents with delayed (more than 48 hours) passage of meconium and constipation, and less commonly with enterocolitis.
Rectosigmoid involvement predominates, but ganglia are sometimes absent throughout the entire colon.
In pyloric stenosis, which of the following is correct?
(Please select 1 option)
Babies usually present with hyperchloraemic metabolic alkalosis
Projectile bilious vomiting is characteristic
Ramstedt’s pyloroplasty is performed
The pyloric canal is lengthened
The pylorus is palpable in 50% of cases
The pyloric canal is lengthened
Pyloric stenosis presents with milky projectile vomiting.
The muscular hypertrophy causes increase in diameter and length of the pylorus and 85% of these are palpable.
Vomiting results in hypochloraemic metabolic alkalosis, sometimes with hypokalaemia. When this has been corrected with judicious fluid resuscitation, Ramstedt’s pyloromyotomy is performed.
