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4.4. Child Health > Surgery > Flashcards

Surgery Flashcards

1
Q

What is Balanitis (BXO), how does it present and what is its DDx?

A

Balanitis xerotica obliterans = keratinisation of the tip of the foreskin causing scaring and the prepuce remains non-retractile

Peak incidence 9-11y

S+S = irritation, dysuria, haematuria, local infection, prepuce will appear as a white/fibrotic/scarred preputial tip

DDx = Phimosis, balanitis, buried penis, zoon plasma cell balanitis

Mx = circumcision

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2
Q

What is Cryptorchidism, how does it present and what is its DDx?

A

Failure of testicular descent into the scrotum

  • True undescended testis = testis absent from scrotum but lies along the line of testicular descent
  • Ectopic testis = testis found away from the normal path of decent
  • Ascending testis = testis previously identified in the scrotum undergoes a secondary ascent out of the scrotum

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

S+S = not palpable in scrotum

DDx = normal retractile testis, true undescended testis , ectopic testis, absent testis, bilaterally impalpable testes

Mx = wait 6m (can migrate), if not orchidopexy

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3
Q

What is congenital diaphragmatic hernia, how does it present and what is its DDx?

A

Congenital birth defect = opening in the diaphragm allowing herniation of abdo contents into the thorax (typically L sided) - leading to impaired lung devel

S+S = diff resus at birth, resp distress, bowel sounds in hemithorax, apex/heart sounds on R side, diminished air entry, cyanosis

Ix = x-ray (bowel in thorax)

Mx = thoracoabdominal incision, close incision/patch

DDx = bronchopulmonary sequestration, congenital cystic adenomatoid malformation, bronchogenic cysts, and enteric cysts

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4
Q

What is a hydrocele, how does it present and what is its DDx?

A

Abnormal collection of fluid between the visceral and parietal layers of the tunica vaginalis and/or along the spermatic cord

Processus vaginalis patent at birth allowing only fluid from the peritoneal cavity to pass down

S+S = painless swelling of one or both testicles

DDx = Spermatocele, varicocele, haematocele, inguinal hernia (bowel), testicular tumours

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5
Q

What is malrotation, how does it present and what is its DDx?

A

Absent attachment of the SI mesentery can cause mid-gut rotation or obstruction in the third-part of the duodenum by fibrotic bands

S+S = bilious vomiting, PR bleeding

DDx = Bowel Obstruction in the Newborn, congenital band, intestinal Volvulus, necrotizing enterocolitis, neonatal Sepsis, paediatric duodenal atresia

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6
Q

What is necrotising enterocolitis, how does it present and what is its DDx?

A

Typically occurs in 2-3w of life in low birth weight premature, after enteral feeds

Bowel ischemia (last place to be perfused - low end-diastolic flow then low perforation and poor devel), inflam, necrosis, potentially finally perforation

RF = prematurity, low birth weight/IUGR, formula feed, ibuprofen, PDA, Abx >10d, gastroschisis, sepsis, umbilical lines

S+S = poor feeding, distended tender abdo, decreased activity, blood in the stool, bilious vomiting, change in stool patterns, palpable bowel loops

Ix = AXR (pneumotosis intestinalis - gas in the bowel wall)

DDx = sepsis, anal fissure, infectious enterocolitis, Hirschsprung disease

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7
Q

What is a Trachea-oesophageal fistula, how does it present and what is its DDx?

A

Congenital birth defect

Connection between the oesophagus and the trachea

S+S = copious salivation associated with choking, coughing, vomiting, and cyanosis coincident with the onset of feeding
- if oesophageal atresia present = polyhydramnios, vomiting post feed, cyanotic ep, drooling

DDx = laryngo-tracheoesophageal cleft, oesophageal webs, oesophageal stricture, oesophageal diverticulum, tubular oesophageal duplications, congenital short oesophagus, and tracheal agenesis/atresia

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8
Q

What is the aetiology and pathophysiology of Pyloric stenosis?

A

Aetiology = unknown

Path = progressive hypertrophy of the pyloric muscle, causing gastric outlet obstruction

More common in boys

Hypochloremic, hypokalemic metabolic alkalosis, with paradoxical aciduria

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9
Q

How does pyloric stenosis present?

A

4-6 weeks of age

  • projectile non-bilious vomiting after every feed
  • Haematemesis
  • Weight loss and dehydration
  • Visible peristalsis
  • Palpable olive-sized pyloric mass
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10
Q

Outline how pyloric stenosis should be investigated?

A

Test feed:

  • NG tube in situ and the stomach aspirated
  • Palpate for a pyloric mass and observe for visible peristalsis during

USS = hypertrophy of the pyloric muscle, with wall thickness >3mm, length >15mm and diameter >11mm

Dynamic scan - while swallowing

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11
Q

Describe the Mx of pyloric stenosis

A

Correct fluid or electrolyte abnormalities

Ramstedt’s pyloromyotomy (incision is made in the longitudinal and circular muscles of the pylorus)

Babies can resume feeding after 6h, although there may be some residual vomiting

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12
Q

What is the pathophysiology and aetiology of an acute appendicitis?

A

Inflam of the appendix

Aetiology =

  • Faecolith = stony mass of faeces
  • Lymphoid hyperplasia
  • Impacted stool
  • Caecal tumour
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13
Q

How does an acute appendicitis present?

A
  • Abdominal pain = initially dull peri-umbilical localising to the RIF (sharp), aggravated by movement
  • Vomiting
  • Anorexia
  • Nausea
  • Diarrhoea
  • Constipation
  • Tachycardia
  • Tachypnoeic
  • Pyrexia
  • Rebound tenderness
  • Percussion pain over McBurney’s point
  • Guarding = if perforated

Rovsing’s sign: RIF fossa pain on palpation of the LIF

Psoas sign: RIF pain with flexion of the right hip (inflamed appendix abutting psoas major muscle in a retrocaecal position)

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14
Q

How should a suspected acute appendicitis be investigated?

A

Urinalysis = exclude UTI, renal, urological cause

Pregnancy test

Routine bloods = FBC, CRP

Pelvic exam in females of reproductive age = gynaecological pathology

Trans-abdominal US = most useful in children (less abdo fat)

CT scan = used in older pts

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15
Q

How should an acute appendicitis be managed?

A

Abx = in uncomplicated cases

Laparoscopic appendicectomy = appendix sent to histopathology

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16
Q

Describe the pathophysiology of an inguinal hernia

A

Abdo contents enter the inguinal canal

DIRECT = bowel enters inguinal canal “directly” through a weakness in wall, Hesselbach’s triangle

INDIRECT = bowel enters the inguinal canal via the deep inguinal ring, patent processus vaginalis

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17
Q

How can you differentiate between an indirect and direct inguinal hernia?

A

Indirect hernias will be lateral to the inferior epigastric vessel

Direct hernias will be medial to the inferior epigastric vessels

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18
Q

How does an inguinal hernia present?

A

Lump in groin = will disappear with minimal pressure

Discomfort which can worsen with activity or standing

Incarcerated = painful, tender, erythematous

Strangulated = pain out of proportion to clinical signs

19
Q

How should an inguinal hernia be investigated?

A

Exam = reduce hernia, place pressure over deep inguinal ring (mid-point of the inguinal ligament), before asking the patient to cough, protrusion = direct

Explorative surgery = definitive diagnosis

US = to exclude other pathology

20
Q

How should an inguinal hernia be managed?

A

Surgical repair = open or laparoscopic

21
Q

Outline the pathophysiology of testicular torsion

A

Twisting of spermatic cord structures and subsequent loss of the blood supply to the ipsilateral testicle = surgical emergency

Rate of testicular viability decreases significantly after 6 hours from onset of symptoms

Twisting of the testicle causes venous occlusion and engorgement as well as arterial ischemia and infarction of the testicle

Bell-clapper deformity (commonly adolescents) = attachment of tunica vaginalis to the testicle is inappropriately high, spermatic cord can rotate within it = intravaginal torsion

Extravaginal torsion (commonly neonates) = tunica vaginalis is not yet secured to the gubernaculum and, therefore, the spermatic cord, as well as the tunica vaginalis, undergo torsion as a unit

22
Q

What are the signs and symptoms of testicular torsion?

A

Sudden onset (may be related to trauma) of severe unilateral scrotal pain

Followed by inguinal and/or scrotal swelling

Nausea

Vomiting

Absence of cremasteric reflex

Abnormal testicular direction

Painful urination

Scrotal erythema

23
Q

How should testicular torsion be investigated?

A

Surgical exploration

Scrotal exam = diff due to pain and scrotal oedema

TWIST scoring = testis swelling (2 points), hard testis (2), absent cremasteric reflex (1), nausea/vomiting (1), high-riding testis (1)

Urinalysis = exclude UTI

24
Q

Outline the management of testicular torsion

A

If Hx/exam strongly suggest testicular torsion, pt should go directly to surgery

Orchiopexy = testis is anchored to the scrotal wall

Orchietomy = if the testis is necrotic

25
Q

Give a DDx for paediatric lumps of the neck

A

Ix if = >2w, >2cm, >2 regions affected

  • Kawasaki Disease = unilateral, >15mm, painful nodes
  • Viral infections (EBV, CMV)
  • Bacterial infections (strep, staph)
  • Malignancy (lymphoma, leukaemia)
  • Juvenile chronic arthritis, SLE, atopic eczema
  • Lipoma
  • Dermoid cyst
  • Sebaceous cyst
  • Thyroid (moves on swallow)
  • Branchial cyst
  • TB
  • Abscess
  • Cystic hygroma
26
Q

How long should children fast for prior to surgery?

A

Solids = 6h

Liquids = 2 h

Baby on breast milk = 4h

27
Q

What is tongue tie (ankyloglossia)?

A

Unusually short, thick or tight band of tissue (lingual frenulum) tethers the bottom of the tongue’s tip to the floor of the mouth

Congenital

Doesn’t effect speech but can effect feeding

Mx = watch and wait (may loosen over time, resolving), if not surgery

28
Q

What is a thyroglossal cyst?

A

The thyroid gland is connected to the tongue during development via the thyroglossal duct

If the duct doesn’t close/atrophy, collects fluid, creates cyst (midline)

Painless unless infected (abscess)

Mx = sistrunks procedure (GA, remove cyst, thyroglossal tract, part of hyoid bone)

29
Q

What is gastroschisis vs an omphalocoele?

A

Gastroschisis

  • Failure of abdo wall to close = bowel outside
  • Can have associated bowel atresia, absorption problems (dependent on parenteral nutrition)
  • Mx = bowel in silo, held upright, gravity pushes bowel inside, 3-4d surgical closure of defect

Omphalocoele

  • Persistent physiological gut herniation
  • Surrounded by peritoneum
  • Major (with liver), minor (just bowel)
  • Prone to hypoglycaemia (check BM)
30
Q

What factors can be used to differentiate testicular torsion from torted hydatid of Morgagni from epididymo-orchitis?

A

0-10mins, loss of cremasteric reflex = torsion

0-8hrs with worse pain after 1-2d, blue dot = torted hydatid of Morgagni

Dysuria first then pain + swelling after 2-3d, urine dip = epididymo-orchitis

31
Q

What is the aetiology and pathophysiology of paediatric intussusception?

A

Segment of intestine “telescopes” inside of another, causing an intestinal obstruction (blockage) - most commonly ileum passing into the caecum through the ileocaecal value

Tends to happen between 3-18m

Causes typically unknown

Complication = venous obstruction, engorgement, bleeding, fluid loss, bowel perforation, peritonitis, gut necrosis

32
Q

How does intussusception present?

A

Sudden onset crying, severe abdo pain, comes and goes, 2-3m

In between episodes, the child will look very pale, tired and floppy

After 12 hours or so the pain becomes more constant, and the child will usually go off food and may vomit (dehydration = lethargy, floppy, sunken fontanelle, fewer wet nappies)

A lump in the abdomen

Stool mixed with blood and mucus (sometimes referred to as “currant jelly” stool because of its appearance)

33
Q

Outline how suspected intussusception should be investigated?

A

Palpation = swollen bowel

USS

AXR

34
Q

Describe how diagnosed intussusception should be managed

A

Dehydration = fluids

NG tube = drain off the stomach and bowel contents, and vent any air that has built up

Intussusception = air enema

Unsuccessful = GA laparoscopic

35
Q

Give a DDx for paediatric abdo pain

A 
Intussusception
Gastroenteritis 
Constipation
UTI
Appendicitis 
Abdominal migraine
Lower lobe pneumonia
Primary peritonitis - ascites from nephrotic syndrome/liver disease
DKA
Testicular pathology 
Ovarian pathology
MSK
Reflux
Factitious
Bowel Obstruction
Food allergy
Inguinal hernia
36
Q

Give a DDx for paediatric intestinal obstruction

A 
Meconium ileus
Meconium plug
Hirschsprung’s disease
Oesophageal atresia
Duodenal/jejunum/ileum atresia/stenosis
Intussusception
Imperforate anus
Malrotation of the intestines with a volvulus
Strangulated hernia
37
Q

Outline Hirschsprung’s Disease

A

Ganglionic cells fail to develop in the myenteric and submucosal plexus in the large intestine = obstruction

S+S = delayed or failed passage of meconium within 48h of birth, distention, bilious vomiting, constipation

Ix = AXR, contrast enema, rectal suction biopsy

Mx = IV antibiotics, nasogastric tube insertion, bowel decompression, surgery resecting the aganglionic section (Swenson, Soave, and Duhamel pull-through procedures)

38
Q

Outline paediatric malrotation and volvulus

A

Malrotation occurs when the intestine does not make the turns as it should

Malrotation causes the SI to twist around the SMA

S+S = vomiting bile, stomach pain, diarrhoea or constipation, bloody stools, distention, failure to thrive

Ix = AXR, CT, barium swallow/enema

Mx

  • Symptomatic malrotation = Ladd’s procedure
  • Volvulus = SI in an anticlockwise direction, caecum in L abdo, duodenum directed down R paravertebral gutte
39
Q

Outline paediatric anorectal abnormalities

A

Types = cloacal malformation, imperforate anus, rectal atresia and stenosis, fistula

S+S = lack of stool, stool coming from the vagina, stool in the urine, urine coming from the anus, constipation

40
Q

How does paediatric head injury present?

A

Scalp wound

LOC

Headache

Light-headedness

Confusion: disorientation, incoherent speech

N+V

Tinnitus

Seizures

Balance, coordination problems

Abnormal eye movements

Memory problems

Leaking of clear fluid from the ear or the nose

41
Q

How should a head injury be Ix?

A

x3 vomiting = CT head and cervical spine imaging

42
Q

Outline the Mx for a head injury?

A

A-E

GCS 8 or less, ensure there is early involvement of an anaesthetist or critical care physician to provide appropriate airway management

Manage pain effectively because it can lead to a rise in intracranial pressure (small dose IV morphine)

Discuss with a neurosurgeon if surgical abnormalities on imaging

43
Q

What are the possible complications from a head injury?

A

Permanent changes in their personality

Decreased physical ability

Decreased cognition

Seizures

Hydrocephalus

44
Q

List a DDx for head injury

A 
Stroke
Dementia
Brain Metastasis
Cerebral Aneurysms 
Hydrocephalus
Prion-Related Diseases

4.4. Child Health (37 decks)

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