In a child 3 months to 12 years of age who is afebrile and well-appearing, it is reasonable to consider withholding empiric treatment if urine analysis (UA) is mildly positive or equivocal e.g.: leukocyte esterase (LE0 only, low WBC count) while awaiting culture results. Conversely, if the history is very consistent with UTI and positive UA, start treatment empirically.

Positive leukocyte esterase: very sensitive, but less specific for true infection (false positives are common)
Note: if no WBC on microscopy, more likely to be a false positive
Positive nitrite: high specificity for UTI, but lower sensitivity i.e. positive nitrite means likely UTI, but negative nitrite does not rule out UTI

Can also see positive nitrite in contaminated specimen if left at room temperature for too long
• Positive blood and protein: not specific for UTI
• Microscopy:>10 WBC/mm3 is suggestive of UTI

Management
– A single isolated UTI (in girls) may be managed expectantly.
– > 2 UTI’s (or 1 in males) in a 6 month period should prompt further testing.
– Voiding cystourethrograms show the greatest anatomical detail and is the ideal first line test in males; isotope cystography has a lower radiation dose and is the first line test in girls.
– USS should also be performed.
– Renal cortical scintigraphy should be performed when renal scarring is suspected.

The short gastric arteries branch from the splenic artery near the splenic hilum to travel back in the gastrosplenic ligament to supply the fundus of the stomach. Therefore, these may be injured in this case.
The splenic artery courses deep to the stomach to reach the hilum of the spleen. It doesn’t travel in the gastrosplenic ligament although it does give off branches that do.
The middle colic artery is a branch of the superior mesenteric artery that supplies the transverse colon.
Gastroepiploic artery is the largest branch of the splenic artery that courses between the layers of the greater omentum to anastomose with the right gastroepiploic.
Left gastric artery, a branch of the coeliac trunk. It supplies the left half of the lesser curvature.

Bile leak may be classified into a minor leak with low output drainage (<300 ml of bile/24 hours) or leaks due to major bile duct injury with high output drainage (>300 ml/24 hours).

The majority of minor bile leak results from Strasberg type A injuries with intact biliary-enteric continuity and includes leaks from cystic duct (CD) stump (55%-71%) or small (less than 3 mm) subsegmental duct in gall bladder (GB) bed (16%) and minor ducts like cholecystohepatic duct or supravesicular duct of Luschka (6%). An injury to the supravesicular duct occurs if the surgeon dissects into the liver bed while separating the gall bladder. This duct does not drain the liver parenchyma.
A leak from the cystic duct stump may occur from clip failure due to necrosis of the stump secondary to thermal injury/pressure necrosis or when clips are used in situations where ties are appropriate (acute cholecystitis) and in a significant majority from distal bile duct obstruction caused by a retained stone and resultant blow out of the cystic stump.
Strasberg type C and type D injuries usually present with a minor leak as well. The former results when an aberrant right hepatic duct (RHD) or right posterior sectoral duct (RPSD) is misidentified as the CD and divided because of the anomalous insertion of CD into either of these ducts.
Type D injuries are lateral injuries to the extrahepatic ducts (EHD) caused by cautery, scissors or clips.

High output biliary fistulas are the result of major transactional injury of EHD (Strasberg type E). Here the common bile duct (CBD) is misidentified as the CD and is clipped, divided and excised. This not only results in a segmental loss of the EHD but often associated with injury or ligation of right hepatic artery as well. Such devastating injuries are peculiar to LC and have been described by Davidoff as “classic laparoscopic biliary injury”.

Early recognition is the most important part of the management of bile leak due to iatrogenic injuries.
Unfortunately, most of the bile duct injuries are not recognized preoperatively. Optimal management of BDI detected postoperatively requires good coordination between the radiologist, endoscopists and an experienced hepatobiliary surgeon.

There is a scope of re-laparoscopy, within 24 hours of surgery, in situations where a low output fistula (<300 ml/day) is confirmed (by reviewing the operative video), to be because of a slipped CD clip. Through lavage, clipping or tying the CD stump with an endoloop may be a simple solution. Such an approach is not useful after 24 hours as inflammatory adhesions and oedema will make the job difficult. If low output controlled biliary fistula is detected after 24 hours, a wait and watch policy should be followed as many of the minor leaks will close within 5 to 7 days. If the leak fails to resolve or if the drainage amount is >300 ml/day (high output), an ERCP should be performed both to delineate the biliary tree and some therapeutic interventions if indicated.

This is a case of a high-velocity injury and, therefore, requires surgical fixation.

Bony injury resulting in a fracture may occur due to trauma (excessive force applied to bone), stress (repetitive low-velocity injury), or underlying pathology (abnormal bone which fractures during normal use or following minimal trauma).

Diagnosis involves not just evaluating the fracture, such as the site and type of injury, but also other associated injuries and distal neurovascular status. This may entail not just clinical examination but radiographs of proximal and distal joints. When assessing x-rays, it is important to assess for changes in the length of the bone, the angulation of the distal bone, rotational effects, and the presence of a foreign body such as glass.

The secretions of the adrenal glands by zone are:
Zona glomerulosa – aldosterone
Zona fasciculata – cortisol and testosterone
Zona reticularis – oestradiol and progesterone
Adrenal medulia – adrenaline, noradrenaline and dopamine.

Microscopic colitis is an inflammation of the large intestine (colon) that causes persistent watery diarrhoea. The disorder gets its name from the fact that it’s necessary to examine the colon tissue under a microscope to identify it, since the tissue may appear normal with a colonoscopy or flexible sigmoidoscopy. It is characterised by normal endoscopic appearances, microscopic features of colonic inflammation and thickening of the sub epithelial collagen layer. Features such as granulomas are absent. It is the normal endoscopic appearance that makes the other options less likely.

To determine compliance of the respiratory system, changes in transmural pressures (in and out) immediately across the lung or chest cage (or both) are measured simultaneously with changes in lung or thoracic cavity volume. Changes in lung or thoracic cage volume are determined using a spirometer with transmural pressures measured by pressure transducers. For the lung alone, transmural pressure is calculated as the difference between alveolar (pA; inside) and intrapleural (ppl; outside) pressure. To calculate chest cage compliance, transmural pressure is ppl (inside) minus atmospheric pressure (pB; outside). For the combined lung–chest cage, transmural pressure or transpulmonary pressure is computed as pA – pB. pA pressure is determined by having the subject deeply inhale a measured volume of air from a spirometer. Under physiological conditions the transpulmonary or recoil pressure is always positive; intrapleural pressure is always negative and relatively large, while alveolar pressure moves from slightly negative to slightly positive as a person breathes.

This may be a case of malignant melanoma. Excision biopsy is required to allow accurate histological assessment. If the diagnosis is confirmed, re-excision of margins may be required. Incisional or punch biopsy of lesions suspected to be melanoma is avoided.

Various options used for the treatment of skin lesions include:
1. Trucut biopsy
2. Punch biopsy
3. Excision biopsy
4. Wide excision biopsy
5. Incisional biopsy

Answer: Waterhouse- Friderichsen syndrome

Waterhouse-Friderichsen syndrome is a condition characterized by the abrupt onset of fever, petechiae, arthralgia, weakness, and myalgias, followed by acute haemorrhagic necrosis of the adrenal glands and severe cardiovascular dysfunction. The syndrome is most often associated with meningococcal septicaemia but may occur as a complication of sepsis caused by other organisms, including certain streptococcal species. This disorder may be associated with a history of splenectomy.

Fulminant infection from meningococcal bacteria in the bloodstream is a medical emergency and requires emergent treatment with vasopressors, fluid resuscitation, and appropriate antibiotics. Benzylpenicillin was once the drug of choice with chloramphenicol as a good alternative in allergic patients. Ceftriaxone is an antibiotic commonly employed today. Hydrocortisone can sometimes reverse the adrenal insufficiency. Amputations, reconstructive surgery, and tissue grafting are sometimes needed as a result of tissue necrosis (typically of the extremities) caused by the infection.

Answer: Meckel’s diverticulum

Meckel’s diverticulum is the most common congenital malformation of the gastrointestinal tract (present in 2%-4% of population) due to persistence of the congenital vitello-intestinal duct. Bleeding from Meckel’s diverticulum due to ectopic gastric mucosa is the most common clinical presentation, especially in younger patients, but it is rare in the adult population. This is due to the persistence of the proximal part of the congenital vitello-intestinal duct. It is a true diverticulum, typically located on anti-mesenteric border, and contains all three coats of intestinal wall with its separate blood supply from the vitelline artery. Meckel’s diverticulum is lined mainly by the typical ileal mucosa as in the adjacent small bowel. However, ectopic gastric, duodenal, colonic, pancreatic, Brunner’s glands, hepatobiliary tissue and endometrial mucosa may be found, usually near the tip. The main mechanism of bleeding is the acid secretion from ectopic mucosa, leading to ulceration of adjacent ileal mucosa. It is possible that the recurrent intussusception may cause trauma, inflammation, mucosal erosion and bleeding. The pathogenic role of Helicobacter pylori in the development of gastritis and bleeding in the ectopic gastric mucosa is still debatable. NSAIDs’ effect on the ectopic gastric mucosa is yet to be proved. Bleeding from Meckel’s diverticulum can cause the iron deficiency anaemia, but it may also cause megaloblastic anaemia due to the bacterial overgrowth and vitamin B12 deficiency as a result of the dilatation and stasis in adjacent obstructed ileal loop. The presence of bleeding with hypoalbuminemia and low ferritin due to ongoing slow unrecognized bleeding may lead to the diagnosis of inflammatory bowel disease.