17: SURGERY

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CHAPTER 17 SURGERY

PAEDIATRIC PROBLEMS

HERNIA AND HYDROCELE

These usually present in the first year of life as a swelling in the groin. They may present after an episode of crying or coughing.

An obstructed hernia is tender and it is impossible to palpate above it, unlike other causes of a groin swelling:

• incompletely descended testicle

• inguinal lymphadenopathy

• groin abscess.

Referral to a paediatric surgeon is indicated. Admit to hospital any patient with a suspected obstructed hernia.

UNDESCENDED TESTES

Incompletely descended testes are seen in 0.5–0.7% of boys at 1 year of age.

Referral to a paediatric surgeon is indicated after age 1 at the first presentation, regardless of degree of maldescent.

PHIMOSIS

The foreskin is usually non-retractile until the age of 5 years. A tight meatus and spraying urinary stream may suggest the need for circumcision.

Recurrent balanitis is best treated with improved hygiene and intermittent oral antibiotics. Circumcision is indicated for persistent cases.

UMBILICAL GRANULOMA

Pyogenic granuloma of the umbilical remnant is a common problem at the 6–8-week check.

The application of silver nitrate, or alternatively ligation, are effective, simple measures.

UMBILICAL HERNIAE

The true umbilical hernia, or protruding umbilicus, usually resolves spontaneously and surgical referral should only be considered if it persists over the age of 2 years. Strangulation is very rare in these cases.

Supraumbilical and epigastric herniae should be referred, as trapping of bowel or omentum is more common.

INTUSSUSCEPTION

Intussusception is most common under the age of 2 years and presents as severe colic, vomiting and pallor, often with blood in the stool.

Admission to hospital is clearly indicated.

LEG PROBLEMS

Some normal conditions cause parental anxiety. These include: bow legs, flat feet, knock knees, in- and out-toeing and walking on tiptoes. As long as there is no pain or limp, and the examination reveals a full range of pain-free movement, the parents should be reassured that all is well.

LIMP

A persistent limp is usually pathological and referral to an orthopaedic surgeon is indicated. The acute onset of a limp with pain in the hip requires an urgent orthopaedic opinion to exclude septic arthritis and slipped femoral epiphysis.

BREAST LUMPS

All breast lumps cause anxiety in the patient until a firm diagnosis is made.

Refer patients with breast lumps to a surgeon with an interest in treating breast cancer.

LUMPY BREASTS

Anxiety about cancer in a woman with lumpy or large breasts poses a difficult problem. If normal on clinical examination, mammography may be useful.

PAINFUL BREASTS

Cyclical mastalgia in the absence of lumps can be treated by:

• reassurance that there are no lumps

• evening primrose oil, 2–3 capsules tds (only available OTC)

• furosemide 40 mg daily for premenstrual fluid retention.

GALLSTONES

The symptoms of gallstones are often confused with gastric problems. Most gallstones are asymptomatic.

HERNIAE IN THE GROIN

Inguinal herniae are usually found by the patient as a painless swelling in the groin. Occasionally they present in the early stages as groin pain. Femoral herniae tend to be more painful.

Management

Referral.

Femoral herniae need referring for elective surgery.

Femoral and indirect inguinal herniae can strangulate, causing abdominal pain, abdominal swelling, vomiting and absolute constipation (obstruction). Give iv pain relief and admit the patient directly to hospital.

Conservative management.

If the hernia is an easily reducible inguinal hernia, some relief can be obtained by the provision of a truss (prescribable on the NHS). Surgery may not be necessary. Encourage the patient to avoid straining and to lose weight if appropriate.

SCROTAL SWELLINGS

TESTICULAR PAIN

ANAL FISSURE

Diagnosis

History and examination.

The patient experiences sharp anal pain on defaecation. An anal fissure can mimic some of the symptoms of piles, but appears as a sore-looking crack in the skin at the anal margin. If present, an anal fissure often makes digital rectal examination extremely painful.

Management

• The patient should avoid constipation with a high-fibre diet ± a bulking laxative.

• Stool-softeners often allow the fissure to heal.

• Steroid/local anaesthetic suppositories, e.g. Scheriproct, inserted before passing a stool, will allow the bowels to be opened less painfully.

• Glyceryl trinitrate ointment applied to the anal margins helps relieve sphincter muscle spasm pain.

• The anal fissure that is severe, or will not heal with suppositories and laxatives, may require surgical referral for an anal stretch or partial internal sphincterotomy.

HAEMORRHOIDS

Piles, or haemorrhoids, are one of the commonest causes of rectal bleeding.

Diagnosis

History.

• The nature of the rectal bleeding. With haemorrhoids this is usually bright red, painless and often drips into the toilet pan or is seen on the toilet paper. It is not mixed with the stool, but more often streaked on the surface of the stool.

• Anal irritation.

• Prolapsed or external piles, which can be felt by the patient as lumps outside the anus. These may be confused with anal skin tags.

Examination.

• External piles and skin tags, which are obvious on inspection of the anal margin. Thrombosed piles are acutely tender, hard, purple lumps.

• Internal piles, which can be seen on passing a proctoscope, and look like small purple bulges about 4 cm (1.5 in.) inside the anal margin.

• A mass higher up in the rectum, by performing a digital rectal examination.

• An abdominal mass, by palpating the abdomen.

Investigations.

Investigations are unnecessary for piles.

Caution is needed in attributing new rectal bleeding to piles in patients aged over 40. Consider referral for colonoscopy in all cases, as large bowel cancer and piles are both common and can coexist.

Management

• Advise the patient to avoid constipation, straining at stool and sitting for too long.

• A laxative and/or a bulking agent, e.g. ispaghula husk granules, often help to prevent the piles worsening.

• Steroid/local anaesthetic ointment or suppositories are useful for anal irritation or soreness, and also for healing an anal fissure.

• Injection of piles with oily phenol is easy and will symptomatically cure about 50% of cases. This can be done in general practice or by referral to surgical outpatients.

• Consider referral for haemorrhoidectomy for third-degree piles, painful piles, heavy bleeding or failure of phenol injection.

PROSTATISM

APPENDICITIS

Appendicitis presents about two or three times a year to the GP with the average list of 2000 patients. Pain in the right iliac fossa due to other causes is far more frequent.

Diagnosis

History.

Pain in the abdomen is often the first symptom. It is usually in the right iliac fossa, having moved there from the centre of the abdomen over the preceding 24 hours. In the early stages this is often the only symptom and can be quite severe before the other symptoms (e.g. vomiting, fever) arise.

A concomitant URTI with abdominal pain suggests mesenteric adenitis in a child.

Diarrhoea is unusual in appendicitis, and suggests gastroenteritis.

Examination.

Patients with appendicitis requiring hospital treatment will be mildly pyrexial and tender in the right iliac fossa, with guarding and rebound tenderness and quiet bowel sounds. They will also usually have a tachycardia, halitosis and dry lips.

The milder case may only have slight tenderness in the abdomen and no other symptoms.

Rectal examination confirms tenderness high on the right.

Management

Admit as a surgical emergency with a view to appendicectomy. If there is doubt in the GP’s mind as to the severity of the case, it should be discussed with the surgical registrar.

In mild cases it is acceptable to treat in general practice. If appendicitis is suspected but the patient is not unwell, it is reasonable to treat with metronidazole and a cephalosporin in conjunction with some mild analgesia. It is important to review the patient for signs of worsening over 24–48 hours.

Grumbling appendix.

Repeated attacks of appendicitis that settle down with conservative measures are due to a ‘grumbling appendix’. Referral to surgical outpatients is advised for consideration for an interval appendicectomy, i.e. between the attacks.

Related

Churchills Pocketbook of General Practice