Paediatric Surgery
Notes from HMRI Paeds Update from Dr Bowkett
Vomiting baby
Check for hernia with inspection and palpation
Ask for bile yellow, green or orange vomit
Look and feel for sausage re: intussusception
If sick > hospital
If well but bile consider malrotation
Bile
Yellow = rapid exit
Green = mixed with acid
Orange = blood
Malrotation
The narrow base of the mesentery
Intussusception
Breastfeeding protective
Main cause is inflamed Peyer’s patches
Symptoms
6-7 months commonly
colicky pain 80%
Recent URTI 25%
Screaming and pallor
Blood and mucous in stools 55%
Lethargy 70%
Vomiting 90%
Diarrhoea 30%
Signs of intussusception
Mass 70% - often non-tender
Blood in stools 55%
Tender 40%
Dehydration 15%
Pyloric Stenosis
Usually boys
Usually 6 weeks
No weight gain over 2 to 3 weeks with or without vomiting then consider
The sensitive sign is to watch for gastric peristalsis
Hernia
Female infant, swelling groin is 90% hernia + ovary contained
If ovary out, leave it alone
Tenderness, vomiting + hernia = refer urgency
If the hernia not reducible consider urgent referral
If trying to reduce gentle and short attempt
Hernia guide
Easily reducible and non-tender and no vomiting or irritability then
<3 months = see that week and operate within 2 weeks
3 to 6 months = see in 3 weeks and operate within 6 weeks
6 to 12 months = see within 4 weeks and operate within 8 weeks
Hydrocoele
See around 18 months and operate at 2 years
If irritability consider concurrent hernia
Hydrocoele are slow to progress in size
Progression tension, separate from testicle and thickening above the hydrocoele are signs to consider hernia
Undescended testicle
Pain = urgent
Neither palpable = urgent
One palpable in the scrotum and hypospadias = urgent
Otherwise no longer than 6 months
Hard firm scrotum in first months on life
Usually non-tender
Can look black or blue
Child well
= neonatal torsion = emergency as other side can also go
Testicular torsion
Painful scrotum nearly always needs to be explored
Anorexia and vomiting = likely serious ischaemia
A child can appear very well
Non-specific abdominal pain
Localised away from the midline
Night pain
Nausea vomiting bile
= Early ultrasound
Can signify ureteric obstruction, chronic appendicitis, torsion, crohn’s
Always check scrotum in boys with non midline abdo pain as can be referred
Appendicitis
Pain localised, constant, colicky
Distension
Tachycardia
5 years and under
Rectal seldom required
Diarrhoea can occur if retroilial
Dysuria
Bile vomiting
Constipation diet causes faecolith
Bruised scrotum
Consider child abuse
HSP (look at legs)
