MRCPCH GUIDE Surgery

Appendicitis is the most common condition for which emergency abdominal surgery is required
in childhood. Its symptomatology and management are similar to those in adults although in the
very young child there may be difficulty in making the appropriate diagnosis. Classically the
condition presents with pain, vomiting and fever. In the preschool child the diagnosis is also
difficult and a high perforation rate is encountered. The preschool child may present with
anorexia, listlessness, fever, vomiting and diarrhoea. The mortality rate for children with
appendicitis ranges from 0.1-1%. A child with appendicitis typically prefers to lie still due to
peritoneal irritation.
Bile stained vomiting occurs due to bowel obstruction distal to the ampulla of vater. Causes
include duodenal or jejunal atresia, strangulated hernia, meconium ileus secondary to cystic
fibrosis, Hirschprungs disease and malrotation of the gut with volvulus. Gastro-oesophageal
reflux is not a recognised cause of bile stained vomiting.
Exomphalos occurs when the contents of the gut herniate into the umbilical cord. The
incidence of exomphalos is approximately 1 in 5000 in the UK. It is associated with Edwards
syndrome, Pataus syndrome and Beckwith-Wiedemann syndrome. Associated abnormalities
occur in up to 40% of cases.

Oesophageal atresia is linked to the VACTERL association- Vertebral, Anorectal, Cardiac,
TracheoEsophageal fistula, Renal and Limb abnormalities. Polyhydramnios is a recognised
feature. A tracheo-oesophageal fistula accompanies at least 96% of cases of oesophageal
atresia.
Indications for adeno-tonsillectomy include obstructive sleep apnoea and repeated episodes of
tonsillitis resulting in failure to thrive or time lost from school. Recurrent ear infections with
middle ear effusion would be an indication for adenoidectomy but there would be no indication
for the tonsils to also be removed.

Intussusception most commonly occurs at the terminal ileum (ie, ileocolic). The telescoping
proximal portion of bowel (ie, intussusceptum) invaginates into the adjacent distal bowel (ie,
intussuscipiens).
The mesentery of the intussusceptum is compressed, and the ensuing swelling of the bowel
wall quickly leads to obstruction. Venous engorgement and ischemia of the intestinal mucosa
cause bleeding and an outpouring of mucous, which results in the classic description of
"redcurrant jelly" stool.

Most cases (90%) are idiopathic, with no identifiable lesion acting as the lead point or
pathological apex of the intussusceptum.

Intussusception is the predominate cause of intestinal obstruction in persons aged 3 months to
6 years. Recurrence is observed in 3-11% of cases.

Conservative treatment with barium (or air or saline) enema is effective in up to 80% of
children presenting with intussusception unless diagnosis and treatment is delayed. There are
few reported complications although recurrence occurs in approximately 10% of patients.
In pyloric stenosis, volume depletion and H
+
/Cl
-
loss occur.
Loss of H
+
stimulates more carbonic anhydrase activity to attempt to replace the lost H
+
which
results in more HCO
3
-
as well. If dudodenal secretion and renal excretion of bicarbonate are not
able to correct this rise in plasma HCO
3
-
then hypochloraemic alkalosis develops. Raised
haematocrit
Pyloric stenosis has a male to female preponderance of 4: 1. The cause of the condition is
unclear although a reduced number of cases occur in babies with blood group A and there is
also a strong familial pattern of inheritance. A thickening of the pyloric muscle results in
gastric outlet obstruction with resulting vomiting.
Symptoms of projectile vomiting occurring 10-20 min after a feed develop between the second
and fourth week of life, although they can occasionally occur either sooner or at up to 4
months of age. With progressive vomiting the infants loose weight and may eventually become
dehydrated and alkalotic. On clinical examination gastric peristaltic activity may be seen, and
palpation of the right upper quadrant of the abdomen during a test feed will reveal the pyloric
tumour in most cases. If the mass cannot be felt diagnosis can be aided by a barium meal by
ultrasound.

Indications for tonsillectomy
Absolute indications: Enlarged tonsils that cause upper airway obstruction, severe dysphagia,
sleep disorders, or cardiopulmonary complications; peritonsillar abscess unresponsive to
medical management and drainage; tonsillitis resulting in febrile convulsions; tonsils requiring
biopsy to define tissue pathology
Relative indications: Three or more tonsil infections per year despite adequate medical
therapy; persistent foul taste or breath due to chronic tonsillitis; chronic or recurrent
tonsillitis.