what can cause acute abdominal pain
appendicitis most common. lower lobe pneum may cause pain referred to abdomen, primary peritonitis in nephrotic syndrome, DKA, UTI
symptoms appendicitis
anorexia, vomiting, abdominal pain- initially central then localises to RIF
signs appendicitis
tenderness with guarding RIF, flushed face, oral fetor, fever, abdominal pain aggravated by movement, Rovings sign
what is rovsings sign
if palpate left lower quadrant and it produces pain in the right lower quadrant
complications of appendicitis
abscess, perforation
what is complicated appendicitis
presence of appendix mass, abscess, perforation
if there is generalised guarding consistent with perforation what is the management
fluid resus, IV antibiotics, laparotomy
if there is a palpable RIF mass but no signs peritonitis what is the management
conservative- IV antibiotics
when is an appendicetomy done
after several weeks. if symptoms progress- laparotomy
what is intussusception
invagination of proximal bowel into distal segment. ileum passes through ileocaecal valve to the caecum
what is the commonest cause of intestinal obstruction in neonates
intussusception
age intussusception
3m-2y
complications intussusception
stretching and constriction of the mesentery, venous obstruction- engorgement and bleeding from bowel mucosa, fluid loss- perforation, peritonitis, gut necrosis
presentation intussusception
paroxysmal colicky pain which can recover in between but becoming more lethargic, vomiting, refusing feeds, sausage shaped mass, redcurrant jelly like stools, abdominal distension and shock
what may AXR show in intussusception
distended small bowel, absence of gas in distal colon
investigations in intussusception
AXR, abdominal US
management intussusception
reduction by rectal air enema- by radiologist. if fails- laparoscopy or laparotomy
how recurrent is intussusception
5%
what is meckel diverticulum
in 2% there is an ileal remnant of vitello intestinal duct containing ectopic gastric mucosa or pancreatic tissue
presentation meckel diverticulum
most asymptomatic. can present with severe rectal bleeding. neither bright red or true malaena.
investigation in meckel diverticulum
technetium scan
management meckel
surgical resection.
what happens in malrotation
during rotation of small bowel in fetal life if the mesentery is not fixed at the duodenojejunal flexure or in ileocaecal region base is shorter than normal and predisposed to volvulus
presentation malrotation
obstruction (due to Ladd bands) or with compromised blood supply (ischaemic bowel)
presentation malrotation
obstruction with bilious vomiting in first few days of life, or later on - volvulus. dark green vomiting
management malrotation
upper GI contrast, laparotomy if vascular compromise. operate- volvulus untwisted, mobilise duodenum, bowel placed in non rotated position.
what type of inguinal hernia is it almost always
indirect- due to patent processus vaginalis. more freq in boys
what type of infant is inguinal hernia common in
premature
presentation inguinal hernia
swelling in groin, scrotum, crying, straining. may be an irreducible lump in groin or scrotum. firm and tender lump.
when would the groin swelling become more visible
increase intra abdominal pressure- press on abdomen or ask them to cough
if the lump cant be reduced what happens (inguinal hernia)
emergency surgery as can lead to bowel strangulation and damage to testes
why would surgery be delayed by 24-48 hours
allow resolution of oedema
what is a hydrocele
patent processus vaginalis allows peritoneal fluid to track down and around the testis
features hydrocele
scrotal swelling, bilateral sometimes bluish discoloration, non tender, transilluminates
when is surgery necessary hydrocele
most resolve spontaneously. but if it is persistent past 18-24 months then need surgery
what is varicocele
varicosities of testicular veins - abnormal enlargement of pampiniform plexus
what is varicocele associated with
subfertility
symptoms varicocele
visible or enlarged palpable vein, aching sensation within scrotum, feeling of heaviness
management varicocele
obliteration testicular vein, surgery, laparoscopic
what happens in testicular torsion
spermatic cord twists cutting off blood supply
presentation testicular torsion
pain may be in scrotum, groin or lower abdomen. examine all young males with inguinal or lower abdominal pain
management testicular torsion
must be relieved within 6-12h for testicular viability. Doppler US to look at flow, surgery
why is fixation of contralat testicle in torsion surgery necessary
as may be predisposition to torsion eg bell clapper deformity
what is a risk factor for torsion
undescended testes
what is an undescended testis
has been arrested along its normal pathway of descent. present in 4% term births.
what is the term for bilateral undescended testes
cryptorchidism
in who is undescended testes more common
prem- as testicular descent occurs in 3rd trimester
in examination of undescended testis what is done
gently massage the contents of the inguinal canal to bring the testes down to a palpable position
classification undescended testis
retractile, palpable, impalpable
what is a retractile undescended testis
can be massaged down into bottom of scrotum but retracts back into inguinal region due to the cremasteric muscle
what is a palpable and impalpable testis
palpable- testis can be felt in the inguinal region but cant be manipulated into scrotum. impalpable- cant be felt- in the inguinal canal, intra abdominal or absent
investigations in undescended testis
ultrasound, hormonal- watch for rise in testosterone when inject HCG if bilateral impalpable, laparoscopy
what is the surgery for undescended testis
orchidopexy- move testis into scrotum and permanently fix it there
indications orchidopexy
fertility, malignancy, cosmetic, psychological
what is fertility reduced to in bilateral orchidopexy
50%
when is the risk of malignancy higher in undescended
if bilateral and intra abdominal
