Surgery

Question 1

what gender is most affected by appendicitis ?

Answer 1

males

Question 2

does visceral or parietal peritoneum cause referred pain?

Answer 2

visceral peritoneum

Question 3

what signs would be present for pelvic appendix ?

Answer 3

pain initially felt in RLQ, no visceral symptoms and pain on urination, may cause suprapubic pain (5). May present with profuse diarrhoea and pelvic pain.

Question 4

what signs would be present for retrocaecal appendix ?

Answer 4

Pain may localise to psoas muscle, the flank or right upper quadrant

Question 5

what signs would be present for retroileal appendix ?

Answer 5

May cause testicular pain due to irritation of the spermatic artery or ureter

Question 6

if a child with suspected appendicitis has been suffering from symptoms for >48hrs what is likely to have happened?

Answer 6

perforated appendix

Question 7

state some DD for appendicitis?

Answer 7

gastroenteritis 
acute mesenteric adenitis
constipation 
crohns 
intussusception 
UTI
ectopic pregnancy 
ovarian torsion 
basal pneumonia and pleurisy

Question 8

what is the risk scoring used for appendicitis in children?

Answer 8

Paediatric Appendicitis Score (PAS)

Question 9

what investigations can be done for appendicitis ?

Answer 9

FBC, U&Es, CRP, ESR, pregnancy test

urine dipstick

Question 10

what is the PAS score out of?

Answer 10

out of 10

Question 11

what does a PAS score of <4 show?

Answer 11

low likelihood of appendicitis

Question 12

what does a PAS score of 4-6 show?

Answer 12

indicates further monitoring is needed and should be used alongside clinical judgement

imaging will be helpful

Question 13

what does a PAS score of >6 show?

Answer 13

child is referred to the surgical team for blood tests

doesn’t confirm acute appendicitis

Question 14

what are some complications of appendicitis?

Answer 14

perforation 
appendix mass 
abscess
generalised peritonitis 
sepsis 
death

Question 15

is appendix perforation common in children?

Answer 15

yes

- up to 97%

Question 16

what is the initial management of appendicitis ?

Answer 16

immediate hospital admission
IV access
fluid resuscitation
contact surgical team to discuss IV antibiotics

Question 17

what is the gold standard surgical management of appendicitis ?

Answer 17

laparoscopy

Question 18

for uncomplicated cases, how long do patients stay in hospital for?

Answer 18

discharged after 24-36hrs

Question 19

What does a palpable mass at McBurneys point in the RLQ suggest?

Answer 19

appendix perforation

Question 20

Vomiting before the onset of pain is a feature of what appendix orientation?

Answer 20

retrocaecal

Question 21

what gender is most affected by pyloric stenosis?

Answer 21

males

Question 22

at what age does pyloric stenosis present at?

Answer 22

4-6weeks

Question 23

what is the vomiting described as for pyloric stenosis?

Answer 23

projectile

Question 24

on examination what could be found for pyloric stenosis?

Answer 24

visible peristalsis and a palpable olive-sized pyloric mass, best felt during a feed

Question 25

what are the DD for pyloric stenosis?

Answer 25

``` Gastroenteritis Gastro-oesophageal reflux, including Sandifer syndrome Over-feeding Sepsis UTI Food allergy ```

Question 26

what is Sandifer syndrome?

Answer 26

combination of gastro-oesophageal reflux disease with spastic torticollis and dystonic body movements with or without hiatal hernia

Question 27

what investigation should be done for pyloric stenosis?

Answer 27

test feed with NG tube in situ US for pyloric muscle hypertrophy >3mm thickness, >15mm length, >11mm diameter

Question 28

what do blood gases for pyloric stenosis usually show?

Answer 28

hypokalaemia, hypochloraemic metabolic alkalosis from vomiting

Question 29

what is the management for pyloric stenosis?

Answer 29

10-20ml/kg fluid bolus NG tube and aspirate contents rehydration 150ml/kg/day

Question 30

what surgery is done for pyloric stenosis?

Answer 30

Ramstedt’s pyloromyotomy

Question 31

what are complications of pyloric stenosis?

Answer 31

``` Hypovolaemia Apnoea Wound dehiscence Infection Bleeding Perforation Incomplete myotomy ```

Question 32

How many hours after surgery can the baby resume feeding?

Answer 32

6hrs

Question 33

what is cryptorchidism ?

Answer 33

congenital absence of one or both testes in the scrotum

Question 34

what are the three types of cryptorchidism?

Answer 34

true undescended testis ectopic testis ascending testis

Question 35

during embryology, what pulls the testis down from the abdomen ?

Answer 35

gubernaculum within the processes vaginalis

Question 36

what causes bilateral cryptorchidism ?

Answer 36

hormonal causes such as androgen insensitivity syndrome or disorder of sex development must also be excluded.

Question 37

what are risk factors of cryptorchidism?

Answer 37

prematurity, low birth weight, having other abnormalities of genitalia (i.e. hypospadias) having a first degree relative with cryptorchidism.

Question 38

how many undescended testis are palpable ?

Answer 38

80%

Question 39

what are some DD of cryptorchidism?

Answer 39

``` normal retractile testis true undescended testis ectopic testis absent testis bilateral impalpable testes ```

Question 40

what are the two locations of ectopic testis ?

Answer 40

prepenile | femoral

Question 41

what are the three locations of true cryptochidism testis ?

Answer 41

abdominal inguinal suprascrotal

Question 42

what is the management of cryptochidism at birth?

Answer 42

review at 6-8weeks

Question 43

what is the management of cryptochidism at 6-8weeks?

Answer 43

if fully descended, no further action. If unilateral, re-examine at 3 months

Question 44

what is the management of cryptochidism at 3months?

Answer 44

If testis is retractile, advise annual follow up (due to risk of ascending testis). If undescended, refer to paediatric surgery/urology for definitive intervention – ideally occurring 6 – 12 months of age.

Question 45

what is the surgery preformed for cryptorchidism when the testes are palpable ?

Answer 45

orchidopexy

Question 46

what are three complications of undescended testis?

Answer 46

impaired fertility testicular cancer torsion

Question 47

what is the incidence of hypospadias?

Answer 47

1 in 300

Question 48

is the incidence of hypospadias increasing or decreasing ?

Answer 48

increasing

Question 49

what are three key features of hypospadias?

Answer 49

1) Ventral opening of the urethral meatus 2) Ventral curvature of the penis or “Chordee” 3) Dorsal hooded foreskin

Question 50

what are the different locations of hypospadias ?

Answer 50

``` glandular coronal shaft scrotal perineal ```

Question 51

what is a diagnosis that must not be missed with hypospadias?

Answer 51

congenital adrenal hyperplasia

Question 52

what investigations can be done if there are concerns over disorder of sex development?

Answer 52

``` Detailed history and examination Karyotype Pelvic ultrasound scan Urea and Electrolytes Endocrine hormones: Testosterone, 17 alpha-hyroxyprogesterone, LH, FSH, ACTH, renin, aldosterone ```

Question 53

what is the treatment for hypospadias?

Answer 53

Urethroplasty

Question 54

what are long term complications of surgery to correct hypospadias?

Answer 54

urethral fistulas | urethral stenosis

Question 55

what is BXO?

Answer 55

balanitis xerotica obliterates

Question 56

what happens during BXO?

Answer 56

where keratinisation of the tip of the foreskin causes scaring and the prepuce remains non-retractile

Question 57

what age is most affected by BXO?

Answer 57

9-11 years

Question 58

with what symptoms does BXO present?

Answer 58

scaring of the urethral meatus presents with irritation, dysuria, haematuria and local infection. in extreme cases of scarring patients can present with urinary obstruction and retention.

Question 59

what is the management of BXO?

Answer 59

circumcision | - the foreskin is sent off to histopathology in order to confirm the diagnosis

Question 60

what are complications of untreated BXO?

Answer 60

meatal stenosis phimosis erosions of glands and prepuce

Question 61

What is the mean age for when first foreskin retraction occurs?

Answer 61

10.4 years

Question 62

What percentage of pathological phimosis is due to the process ‘Balanitis xerotica obliterans?'

Answer 62

95%

Question 63

At what age is it normal phenomena to have non-retractile foreskin?

Answer 63

2-4years