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Surgery Flashcards

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1
Q

What findings of appendicitis may lead to incorrect diagnosis?

A
  • diarrhoea, tender RIF –> sounds like gastroenteritis

- WBC common in urine as inflamed appendix may be next to ureter or bladder

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2
Q

What is an appendicular mass?

A

Omentum and small bowel adhere to appendix
Fever and palpable mass
Conservative treatment with fluids, analgesia and Abx - may need surgery

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3
Q

What is an appendicular abscess?

A

Shown on USS, CT or worsening CRP

Per cutaneous or open drainage

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4
Q

What are causes of acute abdomen in infants?

A 
Intestinal obstruction and intussusception
Gastroenteritis
Constipation
Meckel's diverticulum
Malrotation
Incarcerated hernia
Hirschprung's disease
UTI
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5
Q

What are the causes of acute abdominal pain in pre-school children?

A 
Gastroenteritis
Appendicitis
Constipation
UTI
Intussusception
Volvulus
Mesenteric lymphadenitis
Henoch-Schonlein purpura
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6
Q

What are the causes of acute abdomen in pre-pubescent children?

A 
Gastroenteritis
Appendicitis
Constipation
UTI
Trauma
Pneumonia
Henoch-Schonlein purpura
Mesenteric lymphadenitis
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7
Q

What are the causes of acute abdomen in teenagers?

A 
Appendicitis
Gastroenteritis
Constipation
Dysmenorrhea
Mittelschmerz
PID
Ectopic pregnancy
Ovarian/testicular torsion
Diabetic ketoacidosis
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8
Q

What are the clinical features of inguinal hernia?

A

BOYS>girls
INDIRECT>direct
Decent of testis preceded by some peritoneum which normally obliterates
Intermittent swelling in groin on crying or straining

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9
Q

What are the consequences of an inguinal hernia?

A

Irreducible - lump is firm and tender, infant unwell with irritability and vomiting
Can normally be reduced after opioid analgesia and compression
Can cause strangulation of bowel and damage to testes

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10
Q

What are the clinical features of intestinal obstruction?

A

May be recognised antenatally on USS
Persistent vomiting - bile stained if obstruction is below ampulla of Vater
Meconium may be initially passed but then delay of stools
Abdominal distension >the more distal the obstruction is

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11
Q

What are causes of intestinal obstruction?

A

Small bowel obstruction

  • Atresia/stenosis of duodenum - associated with Down’s
  • Atresia/stenosis of jejunum/ileum - multiple sections
  • Malformation or volvulus –> infarction of midgut
  • Meconium ileus/plug - almost all have CF

Large bowel obstruction

  • Hirschsprung disease - no passing of meconium which causes blockage
  • Rectal atresia - can have fistula so to bladder or vagina
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12
Q

How does intussusception present?

A

Invagination of proximal bowel into distal segment (most commonly ileum into caecum or colon through ileocaecal valve)

Occurs between 2 months and 2 years

Paroxysmal, severe colicky pain and pallor
Sausage-shaped mass palpable in abdomen
Red currant jelly stool
Abdominal distension

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13
Q

How is intussusception investigated and treated?

A

AXR - distended small bowel and absence of gas in distal colon
Abdominal USS

Rectal air insufflation
Surgery

Complications - stretching and constriction of mesenteric –> venous obstruction, engorgement and bleeding, perforation, peritonitis and necrosis

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14
Q

What is pyloric stenosis?

A

Hypertrophy of the pyloric muscle causing gastric outlet obstruction
Presents at 2-7 weeks old, more common in boys and firstborns

Vomiting (non-bile stained) - increases in forcefulness until it becomes projectile –> alkalosis due to loss of stomach acid (low chloride and potassium)
Hunger after vomiting
Weight loss

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15
Q

How is pyloric stenosis diagnosed and treated?

A

Mass palpable in RUQ
USS
Metabolic alkalosis
?jaundice

Correct fluid and electrolyte imbalances
Pyloromyotomy (muscle but not mucosa is cut)

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16
Q

What are causes of acute scrotum and the age variances?

A

Testicular torsion - Common in infants and adolescents
Hydatid torsion - common around 10
Epididymitis - common in infants and toddlers

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17
Q

What are the clinical features of appendicitis?

A
  • anorexia
  • vomiting or diarrhoea a couple of times
  • central colicky pain –> right iliac fossa - worse on movement
  • flushed face
  • low grade fever (37.2-38)
  • tenderness with guarding in RIF (McBurney’s point)
  • rebound tenderness
  • obturator sign (internal rotation of flexed right thigh –> pain)
  • faecoliths (on AXR) and perforation more common in young children
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18
Q

How is testicular torsion caused and how is it treated?

A
  • common in adolescents
  • pain may be in scrotum, groin or lower abdomen
  • previous self-limiting episodes
  • acute onset pain and swelling
  • absent cremasteric reflexes
  • must be relieved within 6-12hrs via surgery to both testes
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19
Q

What is torsion of testicular appendage?

A
  • torsion of hydatid of Morgagni (embryological remnant on upper pole of testes)
  • presents just prior to puberty
  • pain increases over 1-2 days
  • blue dot sign
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20
Q

What are other causes of acute scrotum?

A
  • viral/bacterial epididymo-orchitis (UTI, STI, mumps, operation, medication)
  • epididymitis
  • UTI
  • incarcerated inguinal hernia
  • idiopathic scrotal oedema
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21
Q

What is volvulus and how does it present?

A

malrotation is abnormality of bowel during development
volvulus is complication and occurs when blood supply is cut off

bloody/dark red stools, constipation, distended abdomen, pain/tenderness, N+V, pulling up of legs
BILIOUS VOMITING

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22
Q

How is volvulus investigated and managed?

A

Generally, diagnosis made clinically
FBC - shows severity, sepsis, venous oozing
U+E - hydration status, sepsis, acidosis
AXR

Surgery - caecum on L and duodenum on R

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23
Q

What is balanitis and what are the causes?

A

inflammation of end of penis, may also involve foreskin

commonly

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24
Q

What causes pathological phimosis?

A

Whitish scarring of foreskin rare before 5yo

Due to Balanitis Xerotica Obliterans (BXO) which can cause urethral meatal stenosis

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25
What causes cervical lymphadenopathy in children?
Acute causes - transient response to local or generalised infection - viral URTI or streptococcal pharyngitis (acute bilateral) - streptococcal or staphyloccal infection (acute unilateral) Chronic causes - cat scratch diseae - mycobacterial infection - toxoplasmosis - neuroblastoma and leukaemia 6yo
26
What else causes neck swelling?
- mumps (swelling crosses angle of jaw) - thyroglossal cyst (moves up with swallowing or tongue protrusion) - brachial cleft cyst (lower ant border of SCM) - sternomastoid tumour (can be moved horizonally but not vertically) - cervical ribs - cystic hygroma (multiloculated, diffuse, transilluminates) - laryngocele (becomes larger with valsalva manouvere, stridor) - dermoid cyst (midline)
27
What are cleft lip and palate?
Cleft lip - failure of frontonasal and maxillary processes to fuse Cleft palate - failure of fusion of palatine process and nasal septum
28
What are common problems with cleft lip and palate?
feeding problems - inadequate suck ear infections - acute otitis media speech and language problems dental health
29
What other conditions are associated with or cause cleft lip/palate?
anti-convulsant therapy isotretinoin Patau syndrome Pierre Robin syndrome - abnormally small lower jaw with tongue falling backwards into throat
30
How do diaphragmatic hernias develop?
Failure of one or both pleuroperitoneal membranes to close --> continuous peritoneal and pleural cavities along post body wall Abdominal viscera can enter pleural cavity
31
Which organs normally enter a diaphragmatic hernia?
``` Usually hernia is on left side so: intestinal loops stomach spleen liver ``` Pushes heart anteriorly and compresses lungs --> hypoplastic
32
What are presenting features of a diaphragmatic hernia?
``` cyanosis tachypneoa tachycardia chest wall asymmetry absent breath sounds over one side of chest bowel sounds audible over chest wall ```
33
What are signs of a serious head injury?
``` Witnessed LOC >5 mins Amnesia >5 mins >3x vomiting NAI Seizure w/o epilepsy GCS ```
34
What is a hydrocele?
Patent processus vaginalis which is too narrow for hernia but allows peritoneal fluid to track down around testes Non-tender and transilluminate If >18 months consider surgery
35
How do the intestines rotate in utero?
Fixes at duodenojujunal flexure and ileocaecal region
36
How does malrotation present?
GREEN BILIOUS VOMITING
37
What is necrotising enterocolitis?
Pseudomonas aeruginosa invasion of ischaemic bowel wall, mostly terminal ileum and ascending colon Occurs in premis in first weeks of life esp. if only bottle fed
38
How does NEC present?
``` feeding intolerance delayed gastric emptying abdo distension ileus erythema bilious vomiting PR blood ``` Intramural air on AXR
39
How is NEC treated?
Stop oral feeding Broad spectrum Abx Parenteral nutrition Development of strictures and malabsorption
40
What is a sacrococcygeal teratoma?
thought to be derived from primitive streak and is benign presents on antenatal screening
41
What causes supparative adenitis/lympadenitis?
Small, palpable cervical, axillary and inguinal nodes URTI with sore throat, earache, coryza or impetigo Fever, irritability and anorexia Contact with KITTEN
42
How does TOF present?
Maternal polyhydramnios Absent gas on prenatal USS Secretions --> rattling respiration, coughing, choking
43
What are the types of TOF?
Type A - proximal is blind ending, distal is TEF Type B - blind ending proximal and distal Type C - Oesophagus communicates but is intact Type D - proximal TEF and blind ending distal Type E - proximal and distal TEF without connection
44
How are undescended testes classified?
Retractile - can be manipulated into bottom of scrotum but then retract as pulled up by cremasteric muscle Palpable - can be palpated in groin but not manipulated Impalpable - may be in inguinal canal, intra-abdominal or absent
45
How are undescended testes investigated and managed?
USS - identifies bilateral impalpable testis in inguinal region Laparoscopy Fertility - need to be cooler than body Malignancy
46
How do gastroschisis and exomphalos present?
Exomphalus - contents of abdomen (bowel +/- liver) herniate into umbilical cord through umbilical ring viscera are covered by peritoneum and amnion ``` Gastroschisis - defect to right of umbilical cord abdo contents (only small intestine) herniate into amniotic sac no covering membrane ```
47
What is urachus?
Joining of urinary bladder of fetus to umbilical cord Child will leak urine from umbilical cord
48
What is umbilical granuloma?
Inflammatory process at umbilicus causes excess granulation tissue Silver nitrate cauterisation is the treatment
49
What is bladder exstrophy?
Part of bladder is present outside body due to failure of abdominal wall to close
50
What anorectal malformations exist?
- membrane over anal opening - imperforate anus (rectum not connected to anus) - rectum may be connected to part of urinary or reproductive system via fistula - anal stenosis - rectum may be connected to another part of the skin
51
What conditions are associated with anorectal malformations?
Associated with Trisomy 18 and diabetic mothers Vertebral - hypoplastic vertebrae and scoliosis Anorectal atresia Cardiovascular - ASD, VSD and tetralogy of Fallot TOF Esophageal and duodenal atresia Renal - one umbilical vein Limb defects - hypoplastic thumbs, extra digits
52
How are anorectal malformations treated?
Low anomalies - anoplasty with serial dilators High anomalies - temporary colostomy and then new anus
53
How do atresias of the bowel present?
``` BILIOUS VOMITING Prematurity Polyhydramnios Low birth weight Failure to pass meconium ```
54
What are indications for circumcision?
With age, most foreskins become retractible - pathological phimosis - white scarring (BXO) - recurrent balanoposthitis - redness and inflammation of foreskin - recurrent UTIs
55
How do labial adhesions present?
Tend to be noticed by parents, urine pooling in vagina Membrane between labia minora starting at back and working forwards Need to rule out sex abuse Oestrogen cream will help separate
56
How does Meckels diverticulum present?
Located in distal ileum within 1m of ileocaecal valve PAINLESS RECTAL BLEEDING - ectopic mucosal tissue leads to GI bleeding
57
What are complications of Meckels?
- bowel obstruction - abdo pain, vomiting, may mimick appendicitis - diverticulitis - acute inflammation - umbilical abnormalities - fistulas, cysts, sinuses and fibrous bands from diverticulum to umbilicus
58
What is a varicocele?
Abnormal dilation of testicular veins in pampiniform venous plexus caused by reflux Cause reduction of testicular function --> infertility MORE COMMON ON LEFT
59
How does a varicocele present?
Increases in incidence after puberty Scrotum 'feels like bag of worms' and hangs lower when standing Identified with Doppler and USS
60
Which imaging techniques are indicated in different situations?
MRI - better at differentiating soft tissue, brain tumours, CT - better for bony structures, lung and chest

Paediatrics (14 decks)

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