Flashcards in Surgery ||| Deck (93):
What are the symptoms (3) and signs (3) of acute appendicitis?
3. Abdominal pain, initially central and colicky, then localising to the right iliac fossa
2. Abdominal pain aggravated by movement
3. Persistent tenderness with guarding in the right iliac fossa (McBurney's point)
What is the ddx of acute appendicitis (6)?
1. Intestinal obstruction incl intussusception
2. Inguinal hernia
4. Inflamed Meckel's diverticulum
What are the late presentations/complications of acute appendicitis (3)?
1. Appendix mass
2. An abscess
How is an appendix mass without/with signs of generalised peritonitis managed?
Conservative management with iv Abx with appendicectomy performed after several weeks.
If symptoms progress, laparotomy is indicated
What sign is consistent with peritonitis?
How is peritonitis with acute appendicitis managed?
iv Abx prior to laparotomy
What is the most common cause of intestinal obstruction in infants after the neonatal period?
What is the peak age of presentation of intussusception?
3 months-2 years
What is the presentation of intestinal obstruction (5)?
1. Severe colicky pain
2. Vomiting - may be bile stained
3. Abdominal distension
5. Diarrhoea early on, or constipation later on
What is the presentation of intussusception (5)?
1. Paroxysmal, severe colicky pain with pallor - during episodes of pain, the child is pale and draws up legs. There is recovery and play inbetween episodes
2. May refuse feeds, vomit, which can be bile stained depending on site of lesion
3. A sausage-shaped mass - often palpable in the abdomen
4. Passage of redcurrant jelly stool comprising blood-stained mucus
5. Abdominal distension and shock
What is intussusception?
What part of the bowel does intussusception most commonly occur in?
Ileum passing into the caecum through the ileocaecal valve
The invagination of proximal bowel into a distal segment
What investigations can be done for the diagnostic work up for intussusception (2)?
1. Abdo x-ray - may show distended SI and absence if gas in distal colon or rectum
2. Abdo USS - helpful to confirm diagnosis
How is intussusception managed (3)?
1. Immediate fluid resuscitation
2. Rectal air insufflation in order to reduce intussusception, if there are no signs of peritonitis
3. If rectal air insufflation fails, operative reduction
What is malrotation of the SI?
What are its 2 presentations/consequences?
During rotation of the small bowel in fetal life, if the mesentery is not fixed at the duodenojejunal flexure or in the ileocaecal region, its base is shorter than normal and is predisposed to volvulus.
2. Obstruction with a compromised blood supply
What is the presentation of malrotation and at what age does it occur?
Obstruction with bilious vomiting in the first few days of life
What investigations are done in the diagnostic work up of malrotation (2)?
1. Urgent upper GI contrast study
-to assess intestinal rotation
2. Urgent laparotomy
-if signs of vascular compromise are present
What is the danger with malrotation leading to volvulus?
When a volvulus occurs, the superior mesenteric arterial blood supply to the SI and proximal LI are compromised so need correction to avoid infarction of these areas
What is the management of malrotation leading to volvulus?
Urgent surgical correction - untwisting of volvulus
Malrotation is not corrected but the mesentery broadened.
What investigation does any child with bilous vomiting require and why?
Urgent upper GI contrast study to assess internal rotation
How do the clinical features of volvulus differ according to the anatomical abnormality?
- predominant symptoms may be those of a small bowel obstruction (nausea, vomiting and lack of stool or flatus), because the obstructing point is close to the ileocecal valve and small intestine.
- although abdominal pain may be present, symptoms of constipation may be more prominent
What is Meckel diverticulum?
An ileal remnant of the vitello-intestinal duct, which contains ectopic gastric mucosa or pancreatic tissue
What is the clinical presentation of Meckel's (3)?
1. Most asymptomatic
But may present as:
2. Severe rectal bleeding which is classically neither bright red nor true melaena
3. Acute reduction in haemoglobin
What are the complications of Meckel's (4)?
3. Diverticulitis - inflammation of diverticulum mimics appendicitis
4. Ulcers in SI due to release of gastric acid, leading to pain and bleeding
What is necrotising enterocolitis (NEC)?
At what age group is it typically seen in?
Necrotising enterocolitis (NEC) is a serious illness in which tissues in the intestine become inflamed and start to die.
First few weeks of life
What group of neonates are particularly vulnerable to NEC?
What are the signs of NEC (5)?
1. Feed intolerance
2. Vomiting - may be bile stained
3. Distended abdomen
4. Stool contains fresh blood
5. Can progress to shock
What are the characteristic x-ray features of NEC?
Distended loops of bowen and thickening of the bowel wall with intramural gas
There may be gas in the portal venous tract
What is the main complication of NEC?
what is the management of NEC (4)?
1. Stop oral feeding
2. give broad spectrum Abx to cover both aerobic and anaerobic organisms
3. Parenteral nutrition is always needed
4. Mechanical ventilation (difficult to breathe due to pain and abdo distension) and circulatory support often required
What are the indications for surgery in NEC?
What is bowel atresia? Which parts of the bowel can it occur in?
Narrowing of the bowel
Duodenum, jejunum or ileum
What are the clinical/radiological features of bowel atresia?
Abdominal x-ray shows intestinal obstruction
What are the clinical signs of early compensated shock (4)?
1. normal bp
4. cold peripheries
What are additional clinical signs relating specifically to shock from dehydration (3)?
1. over 10% loss of body weight
2. profound metabolic acidosis
3. failure to feed and drink while severely ill
What are the clinical signs of late or uncompensated shock (2)?
1. Falling bp
2. Increasing lactic acidosis
What is the management of shock (6)?
1. Fluid resuscitation with 0.9% saline
if there is no improvement:
2. tracheal intubation and mechanical venilation
3. invasive monitoring of bp
4. inotropic support
5. correction of haematological, biochemical and metabolic derangements
6. support for renal failure
What is an inguinal hernia?
A persistently patent processus vaginalis which emerges from the deep inguinal ring through the inguinal canal.
Are inguinal hernias usually direct or indirect?
How does a hernia present as?
A lump in the groin which may extend into the scrotum or labium
Usually asymptomatic but may be visible during straining
What is a complication of a hernia? How does it present in an infant (2)?
-the contents of the hernia may become irreducible, causing pain and sometimes intestinal obstruction or damage to the testes (strangulation)
What is a hydrocele? How is it different to an inguinal hernia?
A collection of fluid in the scrotum.
Similar anatomy to an inguinal hernia but the processus vaginalis, although patent, is not sufficiently wide to form an inguinal hernia.
What are the key signs in examination to differentiate between a hernia from a hydrocele (2)?
1. The ability to 'get above' a hydrocele
2. Hydroceles usually illuminate
How is an inguinal hernia managed?
Reduction by 'taxis' with good analgesia
Then later when it is a suitable time:
Surgery - ligation and division of the processus vaginalis
If reduction is not possible, then emergency surgery required
What is a varicocele?
What are its clinical features (5)?
What is a complication of a varicocele?
A scrotal swelling comprising dilated (varicose) testicular veins
1. Usually asymptomatic
2. May cause a dull ache
3. Blue colour
4. On examination, feels like a 'bag of worms'
5. Testis may be smaller or softer than normal
What is important to remember to do regarding an examination of undescended testis? Why?
Warm environment with warm hands - helps to distinguish between undescended testis and retractile testes
What are the characteristics of:
1. palpable undescended testes
2. non-palpable undescended testes
1. Palpable undescended testis is usually seen or felt in the groin but cannot be manipulated into the scrotum
2. Non-palpable undescended testis may be in the inguinal canal but cannot be identified, or it may be intra-abdominal or absent.
What is the worry regarding bilateral impalpable testis?
That it may be a disorder of sex development.
Need to establish karyotype.
Regarded as a medical emergency.
What is the management of undescended testis?
Orchidopexy - a surgical placement of the testis in the scrotum
What are the risks of operating (3) vs not operating (3) on an undescended testicle?
Risks of operating:
1. testicular atrophy (blood supply cannot sustain testicle in new position
2. testicle can move back up
3. infection/bleeding etc
Risks of not operating:
1. increased risk of torsion and trauma
2. reduced fertility
3. increased risk of malignancy in the future
What are possible causes of acute scrotum (5)?
1. Torsion of the testis
2. Torsion of appendix testis
4. Idiopathic scrotal oedema
5. Trauma to scrotum
What investigation is mandatory for any acute scrotal presentation?
What ddx do you need to exclude in an acute scrotum?
How does torsion of the testis present (2)?
What is a risk factor for torsion of the testis?
1. Very painful usually in groin/lower abdomen
2. redness and oedema of the scrotal skin
What is torsion of appendix testis?
How does it present (3)?
Torsion of the testicular appendage, which is a Mullerian (paramesonephric) remnant usually located on upper pole of testis.
1. Pain evolves over a few days but not as dramatic as testicular torsion
2. Blue dot may be seen through the scrotal skin
3. Pain may be able to be controlled with analgesia.
What is epididymo-orchitis?
What age group is it most common in?
Inflammation of the epididymis and/or testis
Infants and small children
What age group is torsion of the testis most common in?
What age group is torsion of the appendix testis most common in?
What investigations should be done for epididymo-orchitis (3)?
1. Surgical exploration
2. Doppler ultrasound of flow pattern in the testicular bv - may allow differentiation of epididymitis from torsion of testis
3. Urine sample to identify an associated UTI
Why is surgical exploration in acute scrotum necessary?
To identify torsion of the testis - needs to be treated within hours to lower the risk of testicular loss.
What is balanoposthitis/balanitis? How does it present?
Is the infection usually bacterial/viral? How is it managed?
Skin infection/irritation of head of penis
Extensive redness, purulent discharge
Bacteria - Abx
What balanitis xerotica obliterans (BXO)? What can it lead to?
How is it managed?
Chronic inflammatory skin disease that leads to progressive scarring of the penis which can extend onto the glans, into the meatus and into the urethra. It can lead to phimosis
What are the medical indications of male circumcision (4)?
1. BXO causing a true phimosis
2. Recurrent balanoposthitis
3. Prophylaxis or recurrent UTI
4. If access to urethra is required reliably for intermittent catheterization
What are the complications of male circumcision (3)?
1. Post-op bleeding
2. Infection in skin margin
3. Ulceration of exposed granular skin
How does fusion of the labia minora present? How is it managed?
Superficial fusion of the labia minora with a translucent/blueish area of flimsy tissue between the labia
If no symptoms, no specific treatment is required
-topical corticosteroids or oestrogens can be helpful to lyse the adhesions
What is pyloric stenosis? At what age does it present at?
In pyloric stenosis, there is hypetrophy of the pyloric muscle causing gastric outlet obstruction.
It presents at 2-8 weeks of age
Clinical features of pyloric stenosis (3)?
1. Vomiting - increases in frequency and forcefulness overtime, ultimately becoming projectile
2. Hunger after vomiting until dehydration leading to loss of interest in feeding
3. Weight loss if presentation is delayed
What happens to the fluid and electrolyte balance in pyloric stenosis?
Hypochloraemia metabolic alkalosis with a low plasma sodium and potassium due to vomiting stomach contents
How is pyloric stenosis diagnosed (4)?
1. Unless immediate fluid resuscitation is required - a test feed is performed
2. Baby given milk feed which calms the hungry infant, allowing examination
3. The pyloric mass, which feels like an olive is usually palpable in the right upper quadrant
4. Ultrasound exam
How is pyloric stenosis managed (2)?
1. Correct any fluid and electrolyte balance with iv fluids
2. Pyloromyotomy via an open procedure or laparoscopically
What is the malformation causing a cleft lip and cleft palate?
Cleft lip - failure of fusion of frontonasal and maxillary processes
Cleft palate - failure of fusion of the palatine processes and nasal septum
What other syndromes are cleft lip and palate associated with?
Trisomy 13 - Patau syndrome
Van der Woude Syndrome
X-linked mental retardation
What are the issues relating to cleft lip and palate (3)?
What are the infants prone to getting in the long term?
1. Difficulty feeding
2. Coughing and choking while feeding
3. Secretory otitis media
Acute otitis media
What is a diaphragmatic hernia and how does it present?
Left-sided herniation of abdominal contents through the posterolateral foramen of the diaphragm
Failure to respond to resuscitation or respiratory distress
How is a diaphragmatic hernia managed (3)?
1. Vigorous resuscitation
2. Diagnosis confirmed by chest and abdominal x-ray
A large NG tube passed and suction applied to prevent distension of intrathoracic bowel
3. After stabilisation, hernia is repaired surgically
What are the 3 presentations of trachea-oesophageal fistula and how common are each of them?
1. Atresia with fistula between distal oesophagus and trachea (86%)
2. Atresia without fistula (8%)
3. H-type fistula without atresia (4%)
How does a trachea-oesophageal fistula present?
Antenatal - associated with polyhydramnios or an absent stomach bubble on antenatal USS
1. Persistent salivation and drooling from the mouth
2. Coughing and choking when feeding
3. Cyanotic episodes
4. Aspiration of feeds
What is the basic management of trachea-oesophageal fistula (2)?
1. Continuous suction applied to a tube passed into the oesophageal pouch to reduce aspiration of saliva and secretions pending transfer to a neonatal surgical unit
2. Surgical correction of fistula
What are the clinical features of exomphalos?
What anomalies are associated with it?
The abdominal contents protrude through the umbilical ring, covered with a transparent sac formed by the amniotic membrane and peritoneum
Congenital heart abnormalities and chromosomal abnormalities
What are the clinical features of gastroschisis?
The bowel protrudes through a defect in the anterior abdominal wall adjacent to the umbilicus and there is no covering sac
What is a rectal atresia? How are the classified?
How is it managed?
Absence of the anus at the normal site
Classified as high or low, depending on whether the bowel ends above or below the levator ani muscle
What are high rectal atresias associated with?
fistula to bladder or urethra in boys, or adjacent to the vagina or to the bladder in girls
What is the initial evaluation of a child with a minor head injury (5)?
2. Reduced responsiveness/breathing inadequately?
3. GCS <14/ <15 2h after injury? post-traumatic seizure? Fracture?
4. LOC >5min? Abnormal drowsiness? >3 episodes of vomiting? Amnesia lasting>5min?
5. If any were yes -> CT scan
If no, no imaging required
What are the indications for admission and imaging in a child with a minor head injury (3)?
1. Unresponsive, responsive only to pain, breathing inadequately
2. Suspicion of non-accidental injury, post-traumatic seizure, GCS <14 or <15 2h after injury, suspected open or depressed skull fracture, sign of basal skull fracture (panda eyes), focal neurological signs
3. Witnessed LOC >5min, abnormal drowsiness, >3 discrete episodes of vomiting, dangerous mechanism of injury, amnesia lasting >5 min
What other injuries can occur with a head injury (2)?
1. Neck injury - most common are fracture of upper 2 cervical vertebrae
2. Neck injury can also lead to spinal cord damage although rare in children, and usually only with significant trauma
What are the possible ddx of an abdominal solid tumour (4)?
1. Wilm's tumour
3. Sacrococcygeal teratoma
4. Hepatoblastoma/hepatocellular carcinoma
Where does a neuroblastoma arise from?
What are its clinical features (common (6) and uncommon (5))?
Arise from neural crest tissue in the adrenal medulla and sympathetic nervous system
1 Abdominal mass
3. Weight loss
5. Bone pain
2. Cervical lymphadenopathy
4. Periorbital bruising
5. Skin nodules
What are the common clinical associations of neuroblastoma (2)?
1. Large tumour mass crossing the midline and enveloping major blood vessels and lymph nodes
2. Paravertebral tumours may invade though the adjacent intervertebral foramen and cause spinal cord compression
Where do Wilm's tumours arise from?
What are its clinical features (common (2) and uncommon (4))?
Originate from embryonal renal tissue
1. Large abdominal mass
1. Abdominal pain
3. Anaemia (haemorrhage into mass)
What is a sacrococcygeal teratoma?
A benign teratoma that develops at the base of the coccyx (tailbone) and is thought to be derived from the primitive streak
What are the ddx of cervical lymphadenopathy?
1. Infection (3)
2. Malignancy (3)
3. Other (2
Cervical lymphadenopathy is not a diagnosis, it is a sign
What are the investigations for cervical lymphadenopathy (5)?
1. FBC, blood film and ESR, plasma viscosity or CRP
LFTs: liver infiltration.
2. Infection swabs from primary infection site for culture and sensitivities
3. Biopsy for large nodes
4. Viral titres - e.g. Epstein-Barr virus, HIV, hepatitis.
5. Investigations for TB, syphilis serology, toxoplasma screen
What is suppurative adenitis?
Which areas are most commonly affected?
A long term skin disease characterized by the occurrence of inflamed and swollen lumps.These are typically painful and break open releasing fluid or pus.
The areas most commonly affects are the underarms, under the breasts, and groin. After healing scar tissue remains.