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Yr4 - Paeds > Surgery > Flashcards

Surgery Flashcards

(72 cards)

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1
Q

Define Hirschsprung’s disease

A

Congenital disease in which ganglionic cells fail to develop in the large intestine
- commonly presents as delayed or failed passage of meconium

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2
Q

Epidemiology of Hirschsprung’s disease

A

1 in 1,500-1,700
90% present in neonatal period
High incidence in males
Genetic component - those that encode proteins for the RET signalling pathway and endothelin type B receptor pathway

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3
Q

Types of Hirschsprung’s disease

A

Short segment - 85%
Long segment - 10%
Total colonic aganglionosis disease

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4
Q

Pathophysiology of Hirschsprung’s disease

A

Ganglionic cells of myenteric and submucosal plexuses aren’t present proximally from anus
- due to arrest of neuroblast
Tonic state -> failure in peristalsis and bowel movements
- accumulation of faeces in rectosigmoid region
- functional obstruction
-> bowel dilation, abdo distention, bacterial proliferation, Hirschsprung’s enterocolitis

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5
Q

Risk factors for Hirschsprung’s disease

A

Males
Chromosomal abnormalities
FHx

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6
Q

Clinical features of Hirschsprung’s disease

A

Failure to pass meconium - within 48 hrs of birth
Abdo distention
Bilious vomiting

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7
Q

Differential diagnosis of Hirschsprung’s disease

A

Meconium plug syndrome
- symptoms resolve after passage of plug
Meconium ileus
- distal small bowel impacted by meconium
- differentiated by radiograph or barium enema
Intestinal atresia
- complete obstruction due to congenital malformation
Intestinal malrotation
- midgut volvulus -> bilious vomiting and abdo distention
Anorectal malformation
- differentiated by physical examination
Constipation
- diagnosis of exclusion

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8
Q

Ix for Hirschsprung’s disease

A 
Plain abdo x-ray
Contrast enema
- short transition zone between proximal end of colon and narrow distal end of colon
Rectal suction biopsy - gold standard
- submucosa tested for ganglionic cells
- stained for acetylcholinesterase
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9
Q

Indications for rectal suction biopsy

A

Delayed passage of meconium - more than 48 hrs in term babies
Constipation since first few weeks of life
Chronic abdo distension and vomiting
FHx of Hirschsprung’s disease
Faltering growth in addition to any previous features

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10
Q

Management of Hirschsprung’s disease

A 
Initial
- IV abx
- NG tube insertion
- bowel decompression
Definitive
- surgery - resect aganglionic section of bowel and connect unaffected bowel to the dentate line
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11
Q

Complications of Hirschsprung’s disease

A

Hirschsprung associated enterocolitis

  • stasis of faeces leads to bacterial overgrowth
  • C. diff, S. aureus
  • present with fever, vomiting, diarrhoea, abdo tenderness and sepsis
  • fluid resuscitation, bowel decompression and broad spectrum IV abx
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12
Q

Define intussusception

A

Movement or telescoping of one part of the bowel into another

  • proximal bowel segment to as the intussusceptum
  • distal segment is called the intussuscipiens
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13
Q

Epidemiology of intussusception

A

Peak incidence between 5-7 months
- rare after 2 years
Boys twice as likely to be affected

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14
Q

Pathophysiology of intussusception

A

Telescoping of one bowel segment into another

  • can lead to intestinal obstruction
  • 90% of cases are of the ileo-colic type - distal ileum passess into the caecum through the ileo-caeceal valve
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15
Q

Risk factors for intussusception

A 
Most cases are idiopathic
25% have underlying pathology - should be suspected in older child or high recurrence rate
- meckel diverticulum
- polyps
- lymphoma and other tumors
- post op
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16
Q

Clinical features of intussusception

A 
Sudden onset inconsolable crying episodes
- pallor
- knees drawn up to chest
- return to normal self inbetween episodes
Vomiting and abdo pain
Distension
Palpable sausage-shaped abdo mass
Signs of peritonism
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17
Q

DDx for intussusception

A 
Colic 
- excessive crying and drawing up of legs in otherwise well infant
Testicular torsion
 Appendicitis
- tends to be older children
- pain may localise to right iliac fossa
Gastroenteritis
Volvulus
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18
Q

Investigations for intussusception

A

AXR - may confirm diagnosis but not recommended due to low sensitivity
- distended small bowel loops
- curvilinear outline of intussusception
- absence of bowel gas in distal colon
Abdo USS - high sensitivity
- doughnut/target sign on transverse plane
- pseudokidney sign on longitudinal plane
Contrast enema
- contraindicated if evidence of peritonitis or perforation

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19
Q

Mx of intussusception

A 
Supportive
- fluid resuscitation
- NG tube
Non-operative reduction
- air or contrast enema 
- contraindicated in perforation, peritonitis or uncorrected shock
Surgical reduction
- if enema contraindicated or unsuccessful
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20
Q

Complications of intussusception

A

Obstruction
Perforation
Bowel necrosis
Dehydration and shock

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21
Q

Epidemiology of pyloric stenosis

A

1 in 500-1000 live births

4 males for every female

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22
Q

Pathophysiology of pyloric stenosis

A

Characterised by progressive hypertrophy of pyloric muscle

  • causing gastric outlet obstruction
  • aetiology unknown
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23
Q

Risk factors for pyloric stenosis

A

Male

Fhx

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24
Q

Clinical features of pyloric stenosis

A 
Presents around 4-6 weeks of age
Non-bilious vomiting after every feed - projectile
Weight loss and dehydration
Visible peristalsis
Palpable olive-sized pyloric mass
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25
DDx of pyloric stenosis
``` Gastroenteritis GORD Over-feeding Sepsis UTI Food allergy ```
26
Investigations for pyloric stenosis
Test feed with NG tube in situ and stomach aspirated USS - hypertrophy of pyloric muscle Blood gases show - hypokalaemia, hypochloremic metabolic alkalosis
27
Mx of pyloric stenosis
Peri-operatively - correct underlying metabolic abnormalities - 10-20ml/kg fluid boluses for acute hypovolaemia - stop oral feeding - NG tube passed and aspirated at 4 hourly intervals Surgery - Ramstedt's pyloromyotomy
28
Complications of pyloric stenosis
``` Pre-operative - hypovolaemia - apnoea - secondary to hypoventilation associated with metabolic acidosis Post-op - wound dehiscence - infection - bleeding - perforation - incomplete myotomy ```
29
Define appendicitis
Inflammation of the appendix
30
Epidemiology of appendicitis
Most commonly in 2nd or 3rd decade | Overall lifetime risk of 7-8%
31
Pathophysiology of appendicitis
Direct luminal obstruction - secondary to faecolith or lymphoid hyperplasia Commensal bacteria in the appendix multiplies leading to acute inflammation Reduced venous drainage and localised inflammation -> increased pressure -> ischaemia -> necrosis -> perforate
32
Risk factors for appendicitis
``` FHx Ethnicity - more common in caucasians - ethnic minorities at greater risk of perforation Environmental - summer ```
33
Clinical features of appendicitis
Abdo pain - peri-umbilical - dull and poorly localised - migrates to right iliac fossa - sharp pain Vomiting Anorexia Nausea Diarrhoea Constipation Rebound tenderness Percussion pain over McBurney's point Gurading Rovsing's sign - RIF pain on palpation of LIF Psoas sign - RIF pain with extension of right hip
34
DDx of appendicitis
``` Gynae - ovarian cyst - ectopic pregnancy - pelvic inflammatory disease Renal - ureteric stones - UTI - pyelonephritis GI - IBD - Meckel's diverticulum - diverticular disease Uro - testicular torsion - epididymo-orchitis ```
35
Ix for appendicitis
``` Clinical diagnosis Urinalysis - exclude other cause Routine bloods - FBC and CRP Imaging - not essential - USS - 1st line - CT - good sensitivity and specificity ```
36
Mx of appendicitis
Laparoscopic appendectomy | - appendix sent for histopathology to look for malignancy
37
Complications of appendicitis
Perforation Surgical site infection Appendix mass Pelvic abscess
38
Define balanitis xerotica obliterans (BXO)
Tight foreskin due to lichen sclerosis atrophicus
39
Epidemiology of balanitis xerotica obliterans
95% of pathological phimosis due to BXO | Peak incidence is 9-11 years
40
Pathophysiology of balanitis xerotica obliterans
Keratinisation of the tip of the foreskin causes scaring | Prepuce remains non-retractile
41
Clinical features of balanitis xerotica obliterans
``` Ballooning foreskin during micturition - normal phenomena non-retractile foreskin ages 2-4 years - self-resolving as prepuce becomes more mobile with age Scaring of urethral meatus - irritation - dysuria - haematuria - local infection ```
42
Mx of balanitis xerotica obliterans
Circumcision | - send foreskin off to histopathology to confirm diagnosis
43
Complications of balanitis xerotica obliterans
Meatal stenosis Phimosis Erosions of glans and prepuce - can extend to urethra
44
Complications of circumcision for balanitis xerotica obliterans
Bleeding Infection Post op swelling
45
Define cryptorchidism
Congenital absence of one or both testes in scrotum | - due to failure of testes to descend during development
46
Epidemiology of cryptorchidism
Found in 6% of newborns | 1.5-3.5% of males at 3 months
47
Categories of cryptorchidism
True undescended testes - testis absent from scrotum but lies along line of testicular descent Ectopic testis - testis found away from normal path of descent Ascending testis - testis previously identified in the scrotum and undergoes secondary ascent out of scrotum
48
Pathophysiology of cryptorchidism
Under normal embryological development testes descends from abdomen to scrotum pulled by gubernaculum within processes vaginalis
49
Risk factors for cryptorchidism
Prematurity Low birth weight Having other abnormalities of genitalia Having 1st degree relative with cryptorchidism
50
DDx of cryptorchidism
Normal retractile testis - testis seen intermittently in scrotum and with minimal traction can be pulled to base of scrotum True undescended testis - testicle located along the normal decent pathway but cannot be manipulated to base of scrotum Ectopic testis - testis present but not along normal path of descent Absent testis Bilaterally impalpable testes
51
Ix of cryptorchidism
If DSD suspected or undescended testis associated with hypospadias or bilateral undescended testes - urgent referral to senior paediatrician within 24 hrs - maybe presentation of congenital adrenal hyperplasia - risk of salt-losing crisis No imaging modality shown to benefit diagnosis
52
Mx of cryptorchidism
At birth - review at 6-8 weeks of age At 6-8 weeks - if fully descended no further action, if unilateral re-examine at 3 months At 3 months - testis retractile advise annual follow-up, if undescended refer to paed surgery/urology for definitieve intervention
53
Complications of cryptorchidism
Impaired fertility - testis 2-3⁰C warmer can effect spermatogenesis Testicular cancer - 2-3 times more common in hx of undescended testis Torsion
54
Define hypospadias
Congenital defect causing urethral meatus to be located at an abnormal site - usually on the side rather than at the tip
55
Epidemiology of hypospadias
Incidence around 1 in 300 male births
56
Pathophysiology of hypospadias
Occurs due to arrest of penile development
57
Clinical features of hypospadias
``` Diagnosis made on examination Hx of abnormal urinary flow 3 key features - ventral opening of urethral meatus - ventral curvature of penis - dorsal hooded foreskin ```
58
Classification of hypospadias
Related to site of urethral meatus - glandular - coronal - shaft - distal, mid or proximal - penoscrotal - scrotal - perineal
59
Ix for hypospadias
Only if concerned about DSD - detailed hx and examination - karyotype - pelvic USS - U+Es - endocrine hormones
60
Mx of hypospadias
Urethroplasty - bringing meatus to glans of penis - chordee is corrected to straighten penis - dorsal foreskin managed with circumcision or reconstruction
61
Complications of hypospadias
Post-op - pain, bleeding and infection Urethral fistula Meatal or urethral stenosis
62
Pathophysiology of mesenteric adenitis
Symptoms caused by inflammation of mesenteric lymph nodes secondary to recent infection which causes mild peritoneal irritation
63
Epidemiology of mesenteric adenitis
Most common in children < 15 years old
64
Clinical features of mesenteric adenitis
``` Abdominal pain in right lower quadrant - no peritonism High fever Symptoms of URT infection of tonsillitis Patients do not look as unwell as those with appendicitis ```
65
DDx of mesenteric adenitis
``` Appendicitis PID Pancreatitis Ectopic pregnancy Neoplasia Diverticulitis Intussusception Cystic ovaries IBD Torsion of testes IBS Stones ```
66
Mx of mesenteric adenitis
No specific management - symptoms self-limiting Analgesia Treat causal infection if known
67
Define Meckel diverticulum
Remnant of the vitellointestinal duct - embryological structure that connects the midgut to the yolk sac - may contain aberrant tissue - gastric, pancreatic or jejunal
68
Pathophysiology of Meckel diverticulum
Most asymptomatic Haemorrhage - aberrant secretion of gastric acid causing ulceration and subsequent bleeding in the adjacent ileum Obstruction - diverticulum act as fulcrum for volvulus formation - recurrent inflammation causes stricture formation Inflammation - diverticulitis - secondary to bacterial infection
69
Epidemiology of Meckel diverticulum
Rule of 2s - 2% of the population - 2:1 male:female - 2 years old or younger - 2 feet from the ileocecal valve - 2 inches long
70
Clinical features of Meckel diverticulum
Haemorrhage - bleeding per rectum - frank or mixed with stool - ensure no haemodynamic compromise Obstruction - absolute constipation - absence of flatus - bilious vomiting and abdo distention/tenderness Inflammation - pain originating in periumbilical region and radiating to RLQ
71
Ix for Meckel diverticulum
Blood only necessary if bleeding PR - FBC shows reduced Hb and haematocrit Imaging - obstruction - AXR or CT - dilated bowel loops proximal to any obstruction - haemorrhage - Technetium-99m pertechnetate scintigraphy
72
Mx of Meckel diverticulum
Definitive treatment = surgical excision - patient is NBM and IV maintenance fluids Adjunctive therapy dependent on complication - bleeding - blood transfusion - obstructed - NG tube

Yr4 - Paeds (16 decks)

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