Paediatric Surgery https://www.ummchealth.com/Health_Care_Services/Surgery/Children/Surgery_default.aspx.

Paediatric Surgery

Learning Outcomes By the end of the session you should be able to;
Recognise children presenting with common surgical conditions Implement initial investigation and management strategies Explain the condition and its management to parents Answer questions on a range of surgical topics

Case 1 You are called to see a 9 day old 29 weeker currently on NICU with abdominal distension Emergency C-section at 29 weeks for maternal pre-eclampsia Birth weight 1100g Breathing spontaneously since birth, NG fed Deteriorated over the last 18 hours, with vomiting and occasional apnoeas What would you want to do next? Full examination and initial investigations

What do you think about the obs? What investigations are needed?
Case 1 On examination; Obs: T 37.8 HR 108 RR 64 Abdominal distension Unsettled on abdominal palpation Bloody stools in the nappy What do you think about the obs? What investigations are needed? What do you think about the obs? Low-grade pyrexia, bradycardic and tachypnoeic What investigations would you want to do? Bloods inc. FBC, U+E, CRP, clotting, venous blood gas, cultures CXR and AXR Stool sample What if you struggled to get venous blood? Capillary sample – best from the heel in neonates, toes in toddlers and fingers in older children.

Case 1 VBG: lactic acidosis Bloods: Hb 19 WCC 21 plt 526 Ur 9.8 CRP 34 INR 1.4 CXR: unremarkable AXR: …

What signs can you see on the AXR?
Distended bowel loops with prominent intra-luminal gas Prominant intra-mural gas (a.k.a. pneumatosis) Can you see any free air? No, there is no obvious pneumoperitoneum How might we identify free air? Football sign on supine films and lateral decubitus views of the abdomen. What are your differentials? Sepsis Haemolytic disease of the newborn Malrotation and volvulus Hirschsprung’s colitis Pseudomembranous colitis Apnoea of prematurity NEC

Case 1: Necrotising Enterocolitis
Most common GI emergency in neonates Premature and low birth weight at highest risk Only 10% of cases occur in term babies Pathophysiology remains unclear High rates of morbidity and mortality Necrotising enterocolitis is the most common GI emergency occurring in neonates and can be especially distressing for parents as it tends to affect premature, low birth weight children who have survived the initial post-natal period and than have to face the high morbidity and mortality associated with NEC. NEC rarely affects term babies, approximately 10% of cases, and is often associated with an underlying disorder - such as polycythaemia, peri-natal asphyxia, respiratory distress, congenital abnormalities. The pathophysiology of NEC is unclear – it appears to follow serious intestinal injury to the immature gut.

Typically presents at 3-10 days of life with; Abdo distension Bilious vomiting Bloody stools Erythema Bradycardia Shock Apnoea Resp distress Initial management; NBM NGT & IVI IV abx TPN Oxygen Surgical r/v What management would you want to initiate? NBM (gut rest) NGT on free drainage (decompress the stomach) IV antibiotics Supportive treatment as required – O2, IV fluids, parenteral nutrition Surgical review Over half of infants will recover with supportive treatment, IV antibiotics for days and TPN. What antibiotics? Ampicillin and gentamicin or cefotaxime, plus metronidazole. These cover gram+ve, gram-ve and anaerobes. 20-40% of infants will require surgery to remove the necrotic bowel with formation of a stoma. Indications for surgery include perforation or deterioration despite medical management. Breast milk is 3-10x more protective than formula milk.

Complications; Perforation Short bowel syndrome Strictures Fistulae Abscesses Recurrence 75% of children survive Mortality is higher in infants weighing <1500g Breast milk is protective Complications of NEC include initial complications such as shock, sepsis and DIC during the acute illness, as well as long term complications associated with bowel inflammation (stricutres and fistulae) and short bowel syndrome. Breast milk is 3-10x more protective than formula milk. Probiotics are also now commonly used to further decrease the risk.

What else would you want to know?
Case 2 A 9 week old boy is admitted to A+E with; Vomiting Lethargy and decreased GCS Weight loss He was born at term. No intra-uterine, peri- or immediate post-natal problems. What else would you want to know? What more would you want to know? More about the vomiting – always been a sickly baby but worse over the last 2 weeks. Now vomiting around minutes after every feed. Always just milk, getting more and more forceful. Tends to miss mums back and hit the floor behind her. Other symptoms – still greedy for feeds but not really keeping much down, drowsy for the last 12 hours only, no fevers and not hot to touch, reduced urine output and stools today only, no cough, cold or coryza. The midwife mentioned last week that he had lost a bit of weight but not sure how much.

Case 2 On examination; Obs: T 36.5 HR 140 RR 36 Drowsy but rousable
Thin  skin turgor, dry mucous membranes Palpable mass in the epigastrium What is the mass in the abdomen? Hypertrophied pylorus muscle – tends to be described as olive shaped. What could you do if there was no mass palpable on initial examination? Palpate during a test feed – the pylorus contracts and becomes easier to feel. What if there was still no palpable mass what other investigations might you do? Abdo USS with or without test feeding. What other investigations would you want and what would you expect them to show? Bloods – inc U+E and a VBG. What’s the diagnosis? Pyloric stenosis

Case 2: Pyloric Stenosis
Hypertrophy and hyperplasia of pylorus and antrum Affects 1 in 500 births Most common in first born males Presents at 2-8 weeks of age Typically projectile vomits after feeds, dehydration and weight loss Infantile hypertrophic pyloric stenosis affects 1 in 500 births. First born males are the most at risk, with most presenting between 2 and 8 weeks of age, though late presentation my occur up to around 6 months.

On examination they may be small for their age and dehydrated Visible stomach peristalsis Palpable pylorus in RUQ/epigastrium VBG shows hypochloraemic, hypokalaemic metabolic alkalosis USS shows hypertrophic pylorus and long, narrow pyloric canal

Initial management is correction of fluid balance and electrolyte disturbance Once acid-base balance is restored surgical pyloromyotomy is undertaken This may be open (Ramstedt’s procedure) or laparoscopic Prognosis is excellent, unless profoundly acidotic at presentation or treatment is delayed Initial management of patients is with IV fluids, to gently correct the fluid depletion and electrolyte disturbance. This usually takes hours and can be a distressing time for parents as they feel their child is not being treated, simply having repeated capillary blood sampling. It is therefore important to explain that without this correction periods any surgery would be higher risk. Laparoscopic repair is associated with shorter time to enteral feeding (around 18 hours as opposed to 23 hours with open procedures). Post-op IV fluids continued until the child is able to tolerate oral intake – children should remain NBM for the first hours post-op, and then feeds should be gradually be reintroduced, encouraging parents to offer smaller volumes more often. It may take hours for vomiting to settle down. How are maintenance fluid requirements calculated? 100ml/kg for first 10kg 50ml/kg for the second 10kgs 20ml/kg for every other kg >20kg Otherwise 4ml/kg/hr, then 2ml/kg/hr, then 1ml/kg/hr Complications of pyloric stenosis include those related to dehydration and severe electrolyte disturbance, and those related to surgical intervention, such as perforation, bleeding and infection. Prognosis is excellent, and recurrence is rare.

Case 3 A 10 month old presents with abdominal distension and FTT
He usually opens his bowels every other day, and his stools are small, firm balls He has previously tried treatment for constipation will little effect On further questioning his mum says he has had problems with constipation since birth Is there anything else you would want to enquire about? When he passed meconium, usually passed within the first 24 hours of life. He didn’t pass meconium until after 48 hours

Case 3 Obs stable and apyrexial
On examination his abdomen is distended and tympanic Distended bowel loops are palpable AXR shows faecal loading and distended large bowel loops Would you perform a rectal examination? Rectal examinations are rarely performed in children, but it can be useful in certain circumstances.

Case 3 What is the likely diagnosis? Hirschsprung’s disease

Case 3: Hirschsprung’s Disease
Absence of myenteric and submucosal ganglia cells in the rectum, and sometimes colon Due to failure of neural crest cells to migrate during weeks 8-12 of development Results in an aganglionic section that is unable to relax Affects 1 in 5000 live births, boys more at risk Hirschsprung’s disease is a congenital absence of parasympathetic ganglia cells in the myenteric and submucosal plexi of the rectum and sometimes colon. This is due to failure of neural crest cells to migrate with the vagal nerve cells to the rectum and colon at 8-12 weeks of gestation. The small bowel is very rarely involved. The results in an aganglionic segment that is unable to relax, leading to a functional colonic obstruction. This then causes proximal dilatation of the normal bowel.

Presents with; Abdo distension Vomiting Delayed meconium Constipation Poor nutrition FTT AXR shows faecal loading and dilated bowel loops Barium enema shows a dilated proximal segment Rectal biopsy is definitive Hirschsprung’s may present in the neonatal period with abdominal distension, vomiting and delayed passage of meconium after 48 hours. When asked retrospectively over half of Hirschsprung’s patients did not pass meconium within the first 36 hours of life. If not picked up during the neonatal period children present with chronic constipation which is resistant to the usual treatments, abdominal pain and distension and failure to thrive. If no diagnosed early most cases are picked up within the first 12 months, and almost everyone is diagnosed by 2 years. Rectal biopsy, usually suction biopsy, is taken from 2-2.5cm above the dentate line. The specimen is sent for histology to look for the presence or absence of ganglionic cells in the myenteric plexus. Multiple biopsies are taken to reduce the risk of inadequate samples or false negatives.

Surgical management may involve; Removal of segment with end-end anastomosis Removal of aganglionic segment and colostomy to allow decompression of the dilated bowel Complications include; Soiling Incontinence Enterocolitis Constipation Obstruction Stricture Most patients eventually acquire normal bowel habits, though it may not be until adolescence Surgical management is dependent of age, length and position of aganglionic segment and degree of pre-operative decompression – it may involve removal of the segment with end to end anastomosis or, if there is gross dilatation of the proximal segment, temporary colostomy. The most serious complication of Hirschsprung’s disease is enterocolitis which presents with pain, fever and bloody diarrhoea. If left untreated it may progress to sepsis, transmural intestinal necrosis and perforation. It should be treated with broad spectrum antibiotics and IV fluid resuscitation. If not treated early the mortality rates may be as high as 35%.

Case 4 An 8 month old presents acutely with; Obs: T 37.1 HR 155 RR 35
Intermittent crying and drawing up of legs Vomiting Lethargy Obs: T 37.1 HR 155 RR 35 What would you look for on examination? What investigations would you want? What would you look for on examination? Sausage-shaped mass in the RUQ or epigastrium Recurrent-jelly stools (late sign) What investigations would you want? Bloods including FBC and U+Es (may show neutrophilia and dehydration) AXR (may show dilated proximal bowel and multiple fluid levels) Abdo USS (may show ‘target’ sign) Air or barium enema (may show a crescent sign and filling defect) What are the differentials? Intususception Malrotation/volvulus Obstruction Colick

Case 4: Intussusception
Invagination of proximal into distal bowel Most commonly ileo-caecal The bowel wall distends, causing obstruction Left untreated the lymphatic and venous obstruction may lead to ischaemia Usually affect boys, aged 5-10 months >90% of the cases follow a non-pathological lead point such as a viral illness or a hypertrophic Peyer’s patch in response to infection. The other 10% have pathological lead points such as a Meckel’s diverticulum, intestinal polyps and Peutz-Jeughers syndrome.

Case 4: Intussusception
Examination may reveal sausage-shaped mass in the RUQ and redcurrent-jelly stool Abdo USS shows a target sign Treatment includes; Urgent surgical referral NBM, drip and suck Air enema Surgery may be required Indications for surgery include; Peritonitis Perforation Prolonged history (>24 hours) High likelihood of a pathological lead-point (e.g. In older children) Failed air enema Why is surgery indicated if there is a prolonged history? The risk of ischaemia and necrosis is higher, the longer the disease has been on going. If air enema is performed in the presence of necrosis there is a risk of perforation. Around 5% of cases recur, and without treatment 100% of cases are fatal. Mortality is around 1% with treatment.

Summary Preterm/<1500g 1st born males NEC Pyloric Stenosis
Presents with abdo distension/vomiting/apnoea Intra-mural gas is pathognomic Breast milk is protective Pyloric Stenosis 1st born males Presents with projectile vomiting/weight loss Blood gas showsCl, K metabolic alkalosis Olive-shaped mass in epigastrium

Summary Absent ganglionic cells in myenteric plexus
Hirschsprungs Absent ganglionic cells in myenteric plexus Presents by delayed meconium/constipation/FTT Barium enema shows dilated proximal segment Excision of aganglionic segment Intussusception Boys, aged 5-10 months Invagination of proximal into distal bowel Presents with spasmic abdo pain/mass/red jelly stools Managed with air enema or resection

Questions

Questions 6 MCQs 3 EMQs 6 Clinical Images 30 seconds per mark
Discussion of answers IBD

Questions: MCQs Tracheo-oesophageal fistula is not commonly associated with... a. Horseshoe kidney b. Cleft lip c. AV septal defects d. Imperforate anus An enlarged Peyer’s patch is often involved in the pathophysiology of which condition? a. Pyloric stenosis b. Hirschsprung’s c. Intussusception d. Meconium ileus IBD

Questions: MCQs 3. When is meconium usually passed by? a. 12 hours of age b. 24 hours of age c. 36 hours of age d. 48 hours of age 4. Meckel’s diverticulum is... a. Present in 20% b. Associated with CF c. Seen on DEXA scan d. Vitelline duct remnant IBD

Questions: MCQs 5. Umbilical hernias should be repaired.. a. Within 48 hours b. At 3-4 months c. At 4-5 years d. At years 6. A 7 year old presents with 36 hours of testicular pain. On examination a pea-sized blue swelling is seen. a. Testicular torsion b. Hydrocele c. Torted hydatid d. Inguinal hernia

Questions: EMQ 1 Select the most likely diagnosis.
a. Hypospadias b. Epispadias c. Balanitis d. Priapism e. Phimosis f. Cryptorchidism g. Epididymitis h. Testicular torsion 1. A 14 year old presents with dysuria, frequency and scrotal pain and swelling for 48 hours. 2. A ventral meatus and deficient foreskin is noticed during the post-natal baby check.

a. Hypospadias b. Epispadias c. Balanitis d. Priapism e. Phimosis f. Cryptorchidism g. Epididymitis h. Testicular torsion 3. A common condition that increases the risk of testicular cancer and infertility. 4. A 3 year old presents with inflammation of the glans and purulent discharge.

a. Oesophageal stricture b. Appendicitis c. Hirschsprung’s disease d. Pyloric stenosis e. Mesenteric adenitis f. Tracheo-oesophageal fistula g. UTI h. GOR 1. A 6 week old presents choking and coughing during feeds, abdominal distension and 2 episodes of LRTI. 2. A 3 year old presents with regurgitation of undigested food. He was treated for bleach ingestion 1 week ago.

a. Oesophageal stricture b. Appendicitis c. Hirschsprung’s disease d. Pyloric stenosis e. Mesenteric adenitis f. Tracheo-oesophageal fistula g. UTI h. GOR 3. A 9 year old presents with a 5 day history of cough and corya and 1 day of RIF pain. She is eating and drinking as normal. Apyrexial. 4. A 7 week old presents with vomiting after feeds. He is resistant and arches to feeding.

Questions: Image 1 What’s the diagnosis?

Questions: Image 2 What’s the diagnosis?
What initial management should be started?

Questions: Image 3 What can be seen within the highlighted area?

Questions: Image 4 A baby presents with respiratory distress, feeding difficulties and ‘frothing’ at a few hours old. What’s the diagnosis? (Look carefully!)

Answers

Questions: MCQs Tracheo-oesophageal fistula is not commonly associated with... a. Horseshoe kidney b. Cleft lip c. AV septal defects d. Imperforate anus Oesophageal atresia and tracheo-oesophageal fistula usually occur together (only 10% of children have an isolated OA and isolated TOF is very rare). OA and TOF are associated with other malformations in over 50% of the cases, the most common of which are the VACTERL conditions; vertebral anomalies (fused vertebrae or hemivertebra), anorectal anomalies (imperforate anus), cardiac anomalies (all types), TOF (and OA), renal tract abnormalities (all types) and limb anomalies (hypoplastic thumbs). Oesophageal atresia and tracheo-oesophageal fistula usually occur together (only 10% of children have an isolated OA and isolated TOF is very rare). OA and TOF are associated with other malformations in over 50% of the cases, the most common of which are the VACTERL conditions; Vertebral anomalies (fused vertebrae or hemivertebra) Anorectal anomalies (imperforate anus) Cardiac anomalies (all types) TOF (and OA) Renal tract abnormalities (all types) Limb anomalies (hypoplastic thumbs) Cleft lip and palate are common problems presenting in paeds surgery – around 1 in 1000 live births are affected. Cleft lip is obvious at birth but cleft palate may present with feeding difficulties and nasal regurgitation of milk.

Questions: MCQs An enlarged Peyer’s patch is often involved in the pathophysiology of which condition? a. Pyloric stenosis b. Hirschsprung’s c. Intussusception d. Meconium ileus Intussusception in younger children is usually associated with a viral gastroenteritis where the enlarged Peyer’s patches (immune tissue) act as a lead point for the proximal bowel to telescope into the distal bowel. In older children and adults pathological lead points are more common, such as a meckels diverticulum. Intussusception in younger children is usually associated with a viral gastroenteritis where the enlarged Peyer’s patches (immune tissue) act as a lead point for the proximal bowel to telescope into the distal bowel. In older children and adults pathological lead points are more common, such as a meckels diverticulum.

Questions: MCQs 3. When is meconium usually passed by? a. 12 hours of age b. 24 hours of age c. 36 hours of age d. 48 hours of age IBD

Questions: MCQs 4. Meckel’s diverticulum is... a. Present in 20% b. Associated with CF c. Seen on DEXA scan d. Vitelline duct remnant Meckel’s diverticulum is persistence of the embryonic vitelline duct which usually disappears during late fetal development. It is present in 2% of the population and is usually asymptomatic. It can present with rectal bleeding, umbilical discharge and bowel obstruction. It can be seen using a T99 isotope scan, known as a Meckel’s scan, and should to resected if symptomatic. Meckel’s diverticulitis or perforation is often indistinguishable from acute appendicitis. Meckel’s diverticulum is persistence of the embryonic vitelline duct which usually disappears during late fetal development. It is present in 2% of the population and is usually asymptomatic. It can present with rectal bleeding, umbilical discharge and bowel obstruction. It can be seen using a T99 isotope scan, known as a Meckel’s scan, and should to resected if symptomatic. Meckel’s diverticulitis or perforation is often indistinguishable from acute appendicitis.

Questions: MCQs 5. Umbilical hernias should be repaired..
a. Within 48 hours b. At 3-4 months At 4-5 years d. At years Umbilical hernias are common, particularly in Afro-Caribbean children. Complications are very rare, and they often close spontaneously within the first few years of life. In the UK they are usually repaired at 4-5 years of age just before the child starts school. Umbilical hernias are common, particularly in Afro-Caribbean children. Complications are very rare, and they often close spontaneously within the first few years of life. In the UK they are usually repaired at 4-5 years of age just before the child starts school.

Questions: MCQs a. Testicular torsion b. Hydrocele
6. A 7 year old presents with 36 hours of testicular pain. On examination a pea-sized blue swelling is seen. a. Testicular torsion b. Hydrocele c. Torted hydatid d. Inguinal hernia Testicular pain is relatively common in childhood, especially around the age of 12 years. In all children the priority must be to exclude testicular torsion. A blue or black swelling is indicative of a torted hydatid of Morgani, an embryological remnant of the upper pole of the testes. Pain from a torted hydatid is usually less severe than in testicular torsion, and onset is more gradual. If there is any doubt about the diagnosis scrotal exploration should be performed. Testicular pain is relatively common in childhood, especially around the age of 12 years. In all children the priority must be to exclude testicular torsion. A blue or black swelling is indicative of a torted hydatid of Morgani, an embryological remnant of the upper pole of the testes. Pain from a torted hydatid is usually less severe than in testicular torsion, and onset is more gradual. If there is any doubt about the diagnosis scrotal exploration should be performed.

Questions: EMQ 1 A 14 year old presents with dysuria, frequency and scrotal pain and swelling for 48 hours. g. Epididymitis Epididymitis is inflammation of the epididymis that is usually associated with UTI as infected urine refluxes down the vas deferens. In sexually active patients epipdidymo-orchitis may be caused by chlamydia and gonorrhoea. Urine should be sent for culture, and STI screen performed if appropriate, before starting antibiotics. Epididymitis is inflammation of the epididymis that is usually associated with UTI as infected urine refluxes down the vas deferens. In sexually active patients epipdidymo-orchitis may be caused by chlamydia and gonorrhoea. Urine should be sent for culture, and STI screen performed if appropriate, before starting antibiotics.

Questions: EMQ 1 A ventral meatus and deficient foreskin is noticed during the post-natal baby check. Hypospadias Hypospadius is characterised by an abnormal position of the external urethral meatus on the ventral surface of the penis. It is graded and managed according to severity – the further away from its correct position the more severe the hypospadias. Hypospadius is characterised by an abnormal position of the external urethral meatus on the ventral surface of the penis. It is graded and managed according to severity – the further away from its correct position the more severe the hypospadias.

Questions: EMQ 1 A common condition that increases the risk of testicular cancer and infertility. f. Cryptorchidism The testes descend via the inguinal canal into the scrotum during the first trimester. Cryptorchidism, or undescended testes, is seen in around 3% of term babies at birth, the risk is higher in premature infants. The majority descend spontaneously within the first 6 months, however if they haven’t descended by then the child should be referred to a paediatric surgeon. It is important to repair undescended testes as their is a risk of infertility and a 10-fold increased risk of testicular cancer. The testes descend via the inguinal canal into the scrotum during the first trimester. Cryptorchidism, or undescended testes, is seen in around 3% of term babies at birth, the risk is higher in premature infants. The majority descend spontaneously within the first 6 months, however if they haven’t descended by then the child should be referred to a paediatric surgeon. It is important to repair undescended testes as their is a risk of infertility and a 10-fold increased risk of testicular cancer.

Questions: EMQ 1 A 3 year old presents with inflammation of the glans and purulent discharge. c. Balanitis Balanitis is acute inflammation of the glans and foreskin, often associated with purulent discharge. It is most common between 2-5 years of age. UTI is the most common cause and should be treated with oral antibiotics. Balanitis is acute inflammation of the glans and foreskin, often associated with purulent discharge. It is most common between 2-5 years of age. UTI is the most common cause and should be treated with oral antibiotics.

Questions: EMQ 2 A 6 week old presents choking and coughing during feeds, abdominal distension and 2 episodes of LRTI. f. Tracheo-oesophageal fistula Isolated TOFs present with choking and coughing during feeds, abdominal distension and recurrent LRTIs. Symptoms are often present from birth but diagnosis is often not made until later in childhood. Investigation includes oesophageal contrast injection with x-ray imaging and bronchoscopy. Treatment is with surgical division of the TOF via a neck incision. Isolated TOFs present with choking and coughing during feeds, abdominal distension and recurrent LRTIs. Symptoms are often present from birth but diagnosis is often not made until later in childhood. Investigation includes oesophageal contrast injection with x-ray imaging and bronchoscopy. Treatment is with surgical division of the TOF via a neck incision.

Questions: EMQ 2 A 3 year old presents with regurgitation of undigested food. He was treated for bleach ingestion 1 week ago. Oesophageal stricture Ingestion of caustic materials such as bleach may cause both acute and chronic issues – acutely you need to give supportive treatment such as IV fluids and an antidote if available (check TOXBASE), and perform endoscopy to assess to severity of the oesophageal injury. Any acute injury may then contract on healing, causing oesophageal strictures. These occur relatively acutely may require feeding gastrostomy insertion if they are very tight. Treatment is with serial oesophageal dilatations, but if these are not successful oesophageal replacement may be necessary. This is usually done with gastric transposition or colonic replacement. Ingestion of caustic materials such as bleach may cause both acute and chronic issues – acutely you need to give supportive treatment such as IV fluids and an antidote if available (check TOXBASE), and perform endoscopy to assess to severity of the oesophageal injury. Any acute injury may then contract on healing, causing oesophageal strictures. These occur relatively acutely may require feeding gastrostomy insertion if they are very tight. Treatment is with serial oesophageal dilatations, but if these are not successful oesophageal replacement may be necessary. This is usually done with gastric transposition or colonic replacement.

Questions: EMQ 2 A 9 year old presents with a 5 day history of cough and corya and 1 day of RIF pain. She is eating and drinking as normal. e. Mesenteric adenitis Mesenteric adenitis is often one of the key differentials for children presenting with ?appendicitis. They tend to have a viral prodrome – either URTI or D+V – following by central or RIF pain. Unlike appendicitis they tend to remain relatively well and their appetite is maintained. They also have a relatively long lead up prior to admission, which is again uncommon in acute appendicitis. Simple analgesia is required. If there is any doubt the child should be admitted for a period of observation and blood tests, and perhaps an abdo USS. If their condition does not deteriorate it is less likely to be appendicitis. Mesenteric adenitis is often one of the key differentials for children presenting with ?appendicitis. The tend to have a viral prodrome – either URTI or D+V – following by central or RIF pain. Unlike appendicitis they tend to remain relatively well and their appetite is maintained. They also have a relatively long lead up prior to admission, which is again uncommon in acute appendicitis. If there is any doubt the child should be admitted for a period of observation and blood tests, and perhaps an abdo USS. If their condition does not deteriorate it is less likely to be appendicitis. Simple analgesia is required.

Questions: EMQ 2 A 7 week old presents with vomiting after feeds. He is resistant and arches to feeding. h. GOR Although this child is the correct age for pyloric stenosis his resistance to feeds and arching fit more with a diagnosis of gastro-oesophageal reflux. Babies with pyloric stenosis tend to be hungry and keen to feed despite vomiting. Although this child is the correct age for pyloric stenosis his resistance to feeds and arching fit more with a diagnosis of gastro-oesophageal reflux. Babies with pyloric stenosis tend to be hungry and keen to feed despite vomiting.

Questions: Image 1 What’s the diagnosis? Omphalocele
Omphalocele is seen is 1 in 3000 live births and is hernia of the abdominal contents into the umbilical cord, covered by a thin sac composed of peritoneum and amnion. It is usually diagnosed intra-uterine. Treatment is with closure of the defect. It is associated with other abnormalities, such as trisomy 13/18/21, Turner’s syndrome and cardiac defects, in around 50% of cases. Omphalocele is seen is 1 in 3000 live births and is hernia of the abdominal contents into the umbilical cord, covered by a thin sac composed of peritoneum and amnion. It is usually diagnosed intra-uterine. It is associated with other abnormalities, such as trisomy 13/18/21, Turner’s syndrome and cardiac defects, in around 50% of cases. Treatment is with closure of the defect.

Questions: Image 2 What’s the diagnosis? Small bowel obstruction
What initial management should be started? NBM, drip and suck This x-ray shows centrally located loops of distended bowel, consistent with small bowel obstruction. Initial management is conservative with NBM, IV fluids and NGT on free drainage to decompress the stomach. If it does not resolve spontaneously laparotomy is required. This x-ray shows centrally located loops of distended bowel, consistent with small bowel obstruction. Initial management is conservative with NBM, IV fluids and NGT on free drainage to decompress the stomach. If it does not resolve spontaneously laparotomy is required.

Questions: Image 3 What can be seen within the highlighted area?
Faecal loading The abdo x-ray shows faecal loading and some large bowel dilatation secondary to chronic constipation. The abdo x-ray shows faecal loading and some large bowel dilatation secondary to chronic constipation.

Questions: Image 4 A baby presents with respiratory distress, feeding difficulties and ‘frothing’ at a few hours old. What’s the diagnosis? Oesophageal atresia Note the NG tube doubled back on itself. Note the NG tube doubled back on itself.

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