WordPress.com



2419356743065Malrotation / Volvulus<3/12Double bubbleBird’s beak00Malrotation / Volvulus<3/12Double bubbleBird’s beak40259006742429Epidemiology: malrotation occurs in 1:500; 90% of complications occur in 1st yr, 75% volvulus present in 1st few months of life; 66% within 1/12; 2:1 M:FPathology: irreversible ischaemia after a few hoursSymptoms: sudden onset constant pain; bilious vomiting, abdominal distension shock and peritonitisInvestigation: AXR shows show double bubble sign, paucity of gas with air bubbles in duodenum and stomach, loop of bowel overriding liver, obstruction; upper GI contrast series (narrowing of contrast at obstruction site = bird’s beak); USSManagement: emergent OT00Epidemiology: malrotation occurs in 1:500; 90% of complications occur in 1st yr, 75% volvulus present in 1st few months of life; 66% within 1/12; 2:1 M:FPathology: irreversible ischaemia after a few hoursSymptoms: sudden onset constant pain; bilious vomiting, abdominal distension shock and peritonitisInvestigation: AXR shows show double bubble sign, paucity of gas with air bubbles in duodenum and stomach, loop of bowel overriding liver, obstruction; upper GI contrast series (narrowing of contrast at obstruction site = bird’s beak); USSManagement: emergent OT154813067430652286004756150Appendicitis00Appendicitis15487654754879Epidemiology: most common surgical emergency in children; peak age 9-12yrs; M > F; less specific symptoms in children; rapid progression in <2yrs; perforation rate 80% if <4yrs, 10- 20% in adolescentsSymptoms: classical story present in only 50%; nausea, vomiting and anorexia in >80%; vomiting more common in younger childrenPaediatric appendicitis score: migration of pain, anorexia, nausea and vomiting, fever, cough / percussion / hopping tenderness, RIF tenderness, WCC >10; >6 = 93% sensitive, 70% specific; <2 = not appendicitisInvestigation: clinical diagnosis; 10% have normal WCC; WCC <10 has strong negative predictive valure; USS = 85% sensitivity, >95% specificity; CT = 94% sensitivity, 95% specificity00Epidemiology: most common surgical emergency in children; peak age 9-12yrs; M > F; less specific symptoms in children; rapid progression in <2yrs; perforation rate 80% if <4yrs, 10- 20% in adolescentsSymptoms: classical story present in only 50%; nausea, vomiting and anorexia in >80%; vomiting more common in younger childrenPaediatric appendicitis score: migration of pain, anorexia, nausea and vomiting, fever, cough / percussion / hopping tenderness, RIF tenderness, WCC >10; >6 = 93% sensitive, 70% specific; <2 = not appendicitisInvestigation: clinical diagnosis; 10% have normal WCC; WCC <10 has strong negative predictive valure; USS = 85% sensitivity, >95% specificity; CT = 94% sensitivity, 95% specificity2286002346325Necrotising Enterocolitis00Necrotising Enterocolitis39960552343785Epidemiology: usually affects prems / LBW, but can also occur in full termRisk factors: congenital heart disease, sepsis, respiratory distressSymptoms: non-specific, abdominal distension, tenderness, pneumoperitoneum, sepsis, feeding intolerance, bloody stoolsInvestigation: septic screen; X-table AXR (dilated loops of bowel, abnormal gas pattern, pneumatosis intestinalis, hepatic portal air, perf air seen above liver)Management: bowel rest, aggressive IV fluids, broad spectrum antibiotics, ICU00Epidemiology: usually affects prems / LBW, but can also occur in full termRisk factors: congenital heart disease, sepsis, respiratory distressSymptoms: non-specific, abdominal distension, tenderness, pneumoperitoneum, sepsis, feeding intolerance, bloody stoolsInvestigation: septic screen; X-table AXR (dilated loops of bowel, abnormal gas pattern, pneumatosis intestinalis, hepatic portal air, perf air seen above liver)Management: bowel rest, aggressive IV fluids, broad spectrum antibiotics, ICU15481302346325002286001140460By Age Group00By Age Group154813011417300-3/12m: necrotising enterocolitis, malrotation, incarcerated hernia, testicular torsion3/12 – 3yr: intussusception, testicular torsion, gastro, constipation, UTI, Henoch-Schonlein Purpura, trauma, volvulus, appendicitis, toxic megacolon, vaso-occlusive crisis3-15yrs: appendicitis, DKA, vaso-occlusive crisis, toxic ingestion, testicular torsion, ovarian torsion, ectopic preg, trauma, toxic megacolon, constipation, gastro, UTI, pneumonia, pancreatitis, cholecystitis, renal stones, HSP, IBD, mesenteric adenitis000-3/12m: necrotising enterocolitis, malrotation, incarcerated hernia, testicular torsion3/12 – 3yr: intussusception, testicular torsion, gastro, constipation, UTI, Henoch-Schonlein Purpura, trauma, volvulus, appendicitis, toxic megacolon, vaso-occlusive crisis3-15yrs: appendicitis, DKA, vaso-occlusive crisis, toxic ingestion, testicular torsion, ovarian torsion, ectopic preg, trauma, toxic megacolon, constipation, gastro, UTI, pneumonia, pancreatitis, cholecystitis, renal stones, HSP, IBD, mesenteric adenitis398780692150Paediatric Abdominal Pain00Paediatric Abdominal Pain246380539750Paediatric Abdominal Pain00Paediatric Abdominal Pain 15716259519285Pathology: in terminal ileum on antimesenteric side; incidence 1%; 75% are asymptomatic; 60% complications occur <2yrs (rare >10yrs)Complications: haemorrhage, perforation, intussusception, malrotation, infection, Littre’s hernia00Pathology: in terminal ileum on antimesenteric side; incidence 1%; 75% are asymptomatic; 60% complications occur <2yrs (rare >10yrs)Complications: haemorrhage, perforation, intussusception, malrotation, infection, Littre’s hernia2603509521190Meckel’s Diverticulum00Meckel’s Diverticulum2603507546340Pyloric Stenosis1-2/1200Pyloric Stenosis1-2/1215716257543799Epidemiology: 3/1000; 4:1 M:F (male 1:150, female 1:750); uncommon <2/52 or >6/12 (usually between 2-8/52); most common in 1st born males; 50% familialPathology: marked hypertrophy and hyperplasia of pylorus narrowing of gastric antrumAssessment: non-bilious projectile vomiting of feeds; maybe small amount of blood; feeds after vomit; upper abdominal distension with peristaltic wave (from LR) and succussion splash after feeding; palpable olive shaped mass >1cm in RUQ; dehydration, weight loss, but infant appears wellInvestigation: hypochloraemic (Cl <100, Na <130) hypokalaemic metabolic alkalosis (present in <10% if diagnosed <1/12); USS (sensitivity 97%, specificity 100%); Barium mealManagement: IV fluids; treat electrolyte problems; OT00Epidemiology: 3/1000; 4:1 M:F (male 1:150, female 1:750); uncommon <2/52 or >6/12 (usually between 2-8/52); most common in 1st born males; 50% familialPathology: marked hypertrophy and hyperplasia of pylorus narrowing of gastric antrumAssessment: non-bilious projectile vomiting of feeds; maybe small amount of blood; feeds after vomit; upper abdominal distension with peristaltic wave (from LR) and succussion splash after feeding; palpable olive shaped mass >1cm in RUQ; dehydration, weight loss, but infant appears wellInvestigation: hypochloraemic (Cl <100, Na <130) hypokalaemic metabolic alkalosis (present in <10% if diagnosed <1/12); USS (sensitivity 97%, specificity 100%); Barium mealManagement: IV fluids; treat electrolyte problems; OT2603506089650Hirschprung’s Disease00Hirschprung’s Disease15716256089014Epidemiology: 1/5000; 4:1 M:FPathology: absence of parasympathetic cells from myenteric plexus from anus proximally; 25% rectum only, 50% rectum and sigmoid only; proximal bowel hypertrophies and distendsSymptoms: acute obstruction in neonatal period, or chronic constipation in older; failure to pass meconium within 48hrsManagement: needs OT00Epidemiology: 1/5000; 4:1 M:FPathology: absence of parasympathetic cells from myenteric plexus from anus proximally; 25% rectum only, 50% rectum and sigmoid only; proximal bowel hypertrophies and distendsSymptoms: acute obstruction in neonatal period, or chronic constipation in older; failure to pass meconium within 48hrsManagement: needs OT260350452755Intussusception3-18/12MeniscusDanceTarget00Intussusception3-18/12MeniscusDanceTarget15716252592705Epidemiology: most common cause of intestinal obstruction 3/12 - 6yrs; rare <3/12; 4:1 M:F; 66% <1yr; diagnosis delayed / missed in 60%; usually 3-18/12; mortality 1-3% with treatment, 100% without; peaks during GI viral illness seasonsPathology: commonly at ileocaecal valve; often associated with adenovirus infection; idiopathic in 90%; some due to Meckel’s diverticulm, polyps, lymphoma, HUS; inflammed Peyer patch at ileocolic region most common cause; mesentry obstructs venous return bowel ischaemiaAssessment: episodic severe distress, pale faced crying, palpable sausage-shaped mass (RIF / RUQ; present in 2/3), red-current jelly stool (in 50%; late sign), diarrhoea (30%); triad of colicky abdominal pain, vomiting and bloody stools seen in 20%; vomiting occurs late (after 6-12hrs, may be bilious)Investigation: USS (sensitivity 96%, specificity 97%) – donut sign, target lesion; AXR normal in 25%, but maybe target sign (soft tissue mass in RUQ, in 40%), Dance sign (no air in RLQ), meniscus sign (crescent of gas in colon), perforation, obstruction; positive FOB / fecal guaiacIndications for air enema: <24hrs duration, no peritonism / toxicity, no blood on PRManagement: IV fluids; NG if vomiting; air enema works in 75% (5-10% recur, usually in 1st 24-48hrs); if air enema not work, needs OT; air enema allows better control over colonic pressure, and avoids spillage of barium if perforation; with barium increased risk of perforation but decreased risk of recurrence00Epidemiology: most common cause of intestinal obstruction 3/12 - 6yrs; rare <3/12; 4:1 M:F; 66% <1yr; diagnosis delayed / missed in 60%; usually 3-18/12; mortality 1-3% with treatment, 100% without; peaks during GI viral illness seasonsPathology: commonly at ileocaecal valve; often associated with adenovirus infection; idiopathic in 90%; some due to Meckel’s diverticulm, polyps, lymphoma, HUS; inflammed Peyer patch at ileocolic region most common cause; mesentry obstructs venous return bowel ischaemiaAssessment: episodic severe distress, pale faced crying, palpable sausage-shaped mass (RIF / RUQ; present in 2/3), red-current jelly stool (in 50%; late sign), diarrhoea (30%); triad of colicky abdominal pain, vomiting and bloody stools seen in 20%; vomiting occurs late (after 6-12hrs, may be bilious)Investigation: USS (sensitivity 96%, specificity 97%) – donut sign, target lesion; AXR normal in 25%, but maybe target sign (soft tissue mass in RUQ, in 40%), Dance sign (no air in RLQ), meniscus sign (crescent of gas in colon), perforation, obstruction; positive FOB / fecal guaiacIndications for air enema: <24hrs duration, no peritonism / toxicity, no blood on PRManagement: IV fluids; NG if vomiting; air enema works in 75% (5-10% recur, usually in 1st 24-48hrs); if air enema not work, needs OT; air enema allows better control over colonic pressure, and avoids spillage of barium if perforation; with barium increased risk of perforation but decreased risk of recurrence53892454686301639570453390034874204533902787654801870Foreign Body Ingestion00Foreign Body Ingestion15900404799964Coins in oesophagus circular (coronal plane), in trachea longitudinal (sagittal plane); if past pylorus of stomach, likely to pass spontaneously (unless high risk); 80% occur in children (other stat said 80% aged 18-48yrs); usually distal in adults; 97% distal meat impactions in adults have pathological conditions so all need Ba swallow studySites of narrowing: Pyriform fossa, tonsil, posterior tongue cricopharyngeus C6 (most common site in children) thoracic inlet T1 in oesophagus Aortic arch T4 in oesophagus Lower oesophageal sphincter T10 in oesophagus Pylorus – if past here, usually OK Ileocecal valve Meckel’s diverticulum Sites of previous surg / abnormalities Symptoms in children: refuse to eat, gagging, drooling, vomiting, stridorSymptoms: pain on swallowingComplications: aspiration, perforation (crepitus, mass, fever, regional lymphadenopathy, decreased neck mvmt), haemorrhage, dyspnoea, abscessHigh risk objects: sharp (perforation will occur in 35%) button batteries (asymptomatic in >90%; complications rare if passed oesophagus (66% pass oesophagus in 48hrs); perforation can occur in <6hrs; damage due to pressure necrosis and leakage of alkali and electrical injury; heavy metal toxicity unlikely unless case damaged / GI transit time significantly prolonged) irregular edges / >5-6cm long / >2cm wide / packaged drug ingestion Do CXR/AXR if: high risk object or symptomatic Saltwater fish are radio-opaque and will not spontaenously dissolve; freshwater radiolucent and may spontaneously resolve if smallDo repeat XR if: FB in oesophagus (give food and drink, observe, repeat @24hrs – unless button battery) High risk object (daily until past duodenum)Do CT if: evidence of perforation and/or infection00Coins in oesophagus circular (coronal plane), in trachea longitudinal (sagittal plane); if past pylorus of stomach, likely to pass spontaneously (unless high risk); 80% occur in children (other stat said 80% aged 18-48yrs); usually distal in adults; 97% distal meat impactions in adults have pathological conditions so all need Ba swallow studySites of narrowing: Pyriform fossa, tonsil, posterior tongue cricopharyngeus C6 (most common site in children) thoracic inlet T1 in oesophagus Aortic arch T4 in oesophagus Lower oesophageal sphincter T10 in oesophagus Pylorus – if past here, usually OK Ileocecal valve Meckel’s diverticulum Sites of previous surg / abnormalities Symptoms in children: refuse to eat, gagging, drooling, vomiting, stridorSymptoms: pain on swallowingComplications: aspiration, perforation (crepitus, mass, fever, regional lymphadenopathy, decreased neck mvmt), haemorrhage, dyspnoea, abscessHigh risk objects: sharp (perforation will occur in 35%) button batteries (asymptomatic in >90%; complications rare if passed oesophagus (66% pass oesophagus in 48hrs); perforation can occur in <6hrs; damage due to pressure necrosis and leakage of alkali and electrical injury; heavy metal toxicity unlikely unless case damaged / GI transit time significantly prolonged) irregular edges / >5-6cm long / >2cm wide / packaged drug ingestion Do CXR/AXR if: high risk object or symptomatic Saltwater fish are radio-opaque and will not spontaenously dissolve; freshwater radiolucent and may spontaneously resolve if smallDo repeat XR if: FB in oesophagus (give food and drink, observe, repeat @24hrs – unless button battery) High risk object (daily until past duodenum)Do CT if: evidence of perforation and/or infection2787653921760Incarcerated Hernia00Incarcerated Hernia15900403919220Epidemiology: hernias occur in up to 5%; more common in prems; incarceration occurs in 1/3, usually in 1st year (most common >2/12)Management: reduce (may need sedation); once reduced, needs follow up with paediatric surgeon in 24-48hrs; up to 1/3 recur00Epidemiology: hernias occur in up to 5%; more common in prems; incarceration occurs in 1/3, usually in 1st year (most common >2/12)Management: reduce (may need sedation); once reduced, needs follow up with paediatric surgeon in 24-48hrs; up to 1/3 recur15900402215515Usually resolves by 1yr; may begin at 1/52; often resolves with solids foods and sitting positionInvestigation: barium swallow (to exclude hiatus hernia, webs, stenosis, stricture, vascular ring, gastric outlet obstruction, malrotation), pH monitoringManagement: burping, small volume feeds, thicken feeds, gaviscon; ranitidine/omeprazole if oesophagitis; OTComplications: oesophagitis (irritability, loss of appetite, haematemesis, malaena, peptic stricture), FTT, resp probs (asthma, pneumonia, apnoea, ALTEs, recurrent cough, stridor), family dysfunction00Usually resolves by 1yr; may begin at 1/52; often resolves with solids foods and sitting positionInvestigation: barium swallow (to exclude hiatus hernia, webs, stenosis, stricture, vascular ring, gastric outlet obstruction, malrotation), pH monitoringManagement: burping, small volume feeds, thicken feeds, gaviscon; ranitidine/omeprazole if oesophagitis; OTComplications: oesophagitis (irritability, loss of appetite, haematemesis, malaena, peptic stricture), FTT, resp probs (asthma, pneumonia, apnoea, ALTEs, recurrent cough, stridor), family dysfunction2787652218689GORD00GORD278765504825Colic00Colic1590040502285Definition: excessive unexplained paroxysms of crying in healthy infant (crying >3hrs per day, >3 days per week, for >3/52); starts in 1st week, peaks in 2nd month, resolves by 3-4 monthsEpidemiology: incidence 13%Symptoms: flushed face, circumoral pallor, clenched fists, tense abdomen, draw up legs, cold feetInvestigation: examine baby; assess caretaker mental health (risk factor for NAI)Term babies should regain birth weight by 1/52Management: instruct in proper feeding practices; 1/52 trial of hypoallergic milk if severe; reassurance00Definition: excessive unexplained paroxysms of crying in healthy infant (crying >3hrs per day, >3 days per week, for >3/52); starts in 1st week, peaks in 2nd month, resolves by 3-4 monthsEpidemiology: incidence 13%Symptoms: flushed face, circumoral pallor, clenched fists, tense abdomen, draw up legs, cold feetInvestigation: examine baby; assess caretaker mental health (risk factor for NAI)Term babies should regain birth weight by 1/52Management: instruct in proper feeding practices; 1/52 trial of hypoallergic milk if severe; reassurance2787656373495Pancreatitis00Pancreatitis15900406370319Rare; 25% idiopathic; 35% systemic causes; 15% trauma; 10% structural abnormalities; 5% metabolic; 5% drugs; 2% hereditaryRisk factors = recent chemo, trauma, cystic fibrosis, FH pancreatitis; lipase 100% specificity, increases within hours, remains up 2/52, severity of rise doesn’t correlate with severity of disease. AXR may show sentinel loop; USS is imaging of choice00Rare; 25% idiopathic; 35% systemic causes; 15% trauma; 10% structural abnormalities; 5% metabolic; 5% drugs; 2% hereditaryRisk factors = recent chemo, trauma, cystic fibrosis, FH pancreatitis; lipase 100% specificity, increases within hours, remains up 2/52, severity of rise doesn’t correlate with severity of disease. AXR may show sentinel loop; USS is imaging of choice15900405581650Uncommon in children; more likely to be acalculous; stones secondary to haemolysis and TPN; causative organisms E coli and klebsiella; if cholecystitis, treat with ampicillin + gentamicin00Uncommon in children; more likely to be acalculous; stones secondary to haemolysis and TPN; causative organisms E coli and klebsiella; if cholecystitis, treat with ampicillin + gentamicin2787655584190Cholecysititis00Cholecysititis278765504190Foreign Body Ingestion (cntd)00Foreign Body Ingestion (cntd)1590040501014If button battery below diaphragm, can observe at home with FU XR at 4/7. Refer Surg if symptomatic / not progressing on serial XR. >85% batteries pass within 96hrs.Do urgent endoscopy if: symptomatic oesophageal FB with complete obstruction sharp object not beyond duodenum multiple FB button battery in oesophagus (ie. Within 6hrs; within 2hrs if 20mm lithium) perforation / haemorrhage / obstruction coin @ cricopharyngeus airway compromiseDo endoscopy if: symptomatic oesophageal FB with incomplete obstruction gastric button battery with no mvmt at 2-7/7 gastric coins with no mvmt at 2-3/52Or consider Foley catheter balloon retrieval; rigid is gold standard but requires GAUse dissolution techniques if: soft food bolus in oesophagus + normal lateral neck X-ray + presence of gag reflex + no suspicion of sharp object + no suspicion of perf Coke: relieves obstruction in 50%; may increase risk of perforation (not necessarily safe) Manual compression: if sensation of FB at cricopharyngeus; massage at thyroid / cricoid cartilage IV glucagon: if ?lower oesophagus; relaxes lower oesophageal sphincter; contraindicated in phaeochromocytoma Others: NaHCO3, tartaric acidPrognosis: 90-95% pass without problemComplications: mucosal erosion, perforation, peritonitis, mediastinitus, pneumothorax, pneumomediastinum, aorto-enteric fistula?benefit: glucagon, benzodiazepines, nifedipine00If button battery below diaphragm, can observe at home with FU XR at 4/7. Refer Surg if symptomatic / not progressing on serial XR. >85% batteries pass within 96hrs.Do urgent endoscopy if: symptomatic oesophageal FB with complete obstruction sharp object not beyond duodenum multiple FB button battery in oesophagus (ie. Within 6hrs; within 2hrs if 20mm lithium) perforation / haemorrhage / obstruction coin @ cricopharyngeus airway compromiseDo endoscopy if: symptomatic oesophageal FB with incomplete obstruction gastric button battery with no mvmt at 2-7/7 gastric coins with no mvmt at 2-3/52Or consider Foley catheter balloon retrieval; rigid is gold standard but requires GAUse dissolution techniques if: soft food bolus in oesophagus + normal lateral neck X-ray + presence of gag reflex + no suspicion of sharp object + no suspicion of perf Coke: relieves obstruction in 50%; may increase risk of perforation (not necessarily safe) Manual compression: if sensation of FB at cricopharyngeus; massage at thyroid / cricoid cartilage IV glucagon: if ?lower oesophagus; relaxes lower oesophageal sphincter; contraindicated in phaeochromocytoma Others: NaHCO3, tartaric acidPrognosis: 90-95% pass without problemComplications: mucosal erosion, perforation, peritonitis, mediastinitus, pneumothorax, pneumomediastinum, aorto-enteric fistula?benefit: glucagon, benzodiazepines, nifedipine ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download