24. Surg 5 Flashcards
What is occurring? Is it serious?
Where is it from?
Likely cuase of the abdominal distension is a bowel obstruction - this is serious.
The redness suggests peritonitis secondary to perforation
Proximal dilation fo small bowel above the blockage is most prominent when obstruction is in the ileum - duodenal or jejunal obstruction would cause less distension (less bowel involved)
This baby- might have meconium ileus
What causes meconium ileus? What causes the perforation associated with it?
Cystic fibrosis - sticky mucous/meconium
In meconium ileus caused by CF, the proximal ileum above the blockage becomes so dilated that secondary volvulus is common. Local volvulus leads to ischaemia in twisted mesentery and perforation of necrotic bowel
What does the x ray show?
Erect view - dilated stomach containing a fluid level in the body of the stomach.
To the right of the spine is a second area of dilated gut with a second fluid level- the dilated proximal duodeum.
No gas distal to the duodenum is seen- this is the typical picture of the “double-bubble” seen in duodenal atresia (absence/narrowing/closure)
Do babies with duodenal atresia have other anomalies? How is duodenal atresia fixed?
About 30% of babies with duodenal atresia have down’s syndrome- may be other anomalies such as anorectal malformation, oesophageal atresia and Hirschsprung disease.
In this case, contrast has been passed into the stomach: what does it show? What is the diagnosis?
The body of the stomach is not dilated, consistent with very recent onset of obstruction, as there has been no time for proximal dilation.
The contrast is seen in the 1st and 2nd parts of the duodenum and appears to suddenly pass to the right (S shape), rather than crossing the spine to the left to reach the duod-jejunal flexure
Dx: malrotation of small bowel, cause by abnormal alignment of midgut after small bowel returns to abdominal cavity from the physiological hern ia in the cord at 10 wks gestation
Why is the baby with malrotation and volvulus normal at birth?
Before birth, amniotic fluid is swallowed, but peristalsis is not very active. Breast milk stimulates vastly enhanced peristalsis, which probably triggers the twist - the small bowel not fixed by the narrow base of the mesentery.
Malrotation commonly presents a few days after birth when volvulus occurs.
What’s wrong here and waht is the treatment?
Malrotation - the narrow base of mesentery is obvious with a cork screw twist of the gut. Gut still looks healthy.
operation = Ladd’s operation, untwisting of gut, then mesentery is opened and teased apart until the caecum and all colon is in the left upper quadrant, and the proximal jejunum is in the right uppper quadrant. Adhesions usualy hold it there (no sutures needed)
What’s going on here?
How would you suspect it?
arterial occlusion and ischaemia of midgut due to malrotation.. leads to death or years of parenteral nutrition- why we need to know about it.
Malrotation suspected if:
morphologically normal baby begins feeding without trouble, but a few days after birth suddenly vomits green bile, with no accompanying symptoms of malaise or sepsis.
If plain x ray shows no obvious small bowel obstructio, malrotation is very likely, and needs urgent referral.
What is this called?
Why is the umbilical cord on the left?
What is the structure that is blind ending and is overlying the left costal margin?
What is the greatest risk for this baby’s life?
Gastroschisis- eviscerated bowel
The likely cause is rupture of the physiological hernia of the umbilical cord at its base
Left hemiscrotum is empty - blind ending tube is left spermatic cord and testis. When the physiological hernia ruptured, the left gubernaculum was torn> testicle prolapsed into amniotic cavity.
Greatest risk to baby’s life is evaporative heat loss from the exposed bowel. Solidification of subcutaneous fat in the limbs - called sclerema - is a premortem sign of hypothermia.
What first aid is required for a baby with gastroschisis?
ABCs, then heat and water loss from exposed bowel needs to be attended to - cover with cling wrap.
Other managment: IV fluids and glucose, nil orally, NGT to keep somach and gut empty, put baby in incubator to keep warm, NETS and surg reg
What’s going on here? Will there be other anomalies?
exomphalos/omphalocele - failure of normal folding of embryonic disc into 3D embryo
exomphalos is associated wiht lots of other anomalies, many of which may be fatal, as it is such a fundamental error of embryogenesis
what’s going on here and what might be wrong if the baby weighed 4.6kg?
Smaller exomphalos (exomphalos minor or hernia of the cord)
If weighs 4.6 kg, may have Beckwith-Wiedemann syndrome, where abnormal insulin-like hormones in the fetus cause overgrowth of viscera, predisposing to persistence of the physiological hernia (usuallly closes at 10wks)
What’s going on here
2 things - umbilicus: mucosa is present at base of umbilical cord, consistent with the persistence of one of the two structures which pass through the umbilicus before birth and have a mucosal lining - the vitello-intestinal duct (bw dev gut and yolk sac) and the urachus (the initial connection bw the embryonic urinary tract and the extra-intestinal duct.
Scrotum- anocutaneous fistula contains visible meconium- anorectal malformation
What is this?
prolapsing mucosa with a central l=umen suggests vitello-intestinal duct.
Excoriation is caused by chemical irritation from the small bowel fluid
What is this?
severe anomaly of lower abdominal wall closure, with exomphalos and caudal exposure of the midgut cetnrally and the bladder on either side.
knownas cloacal exstrophy - most severe anomaly in paed surgery - baby has no fusion of pelvis at pubic symphysis, major disruption to dev of GIT, urinary and genital tracts
How is Hirschsprung disease treated
excision of the aganglionic distal gut and anastomosis of the ganglionated proximal gut to the upper anal canal.
What is wrong with the proportions of this baby? what is the likely cause of resp distress?
Scaphoid/flat abdomen - classic sign of diaphragmatic hernia- gut prolapsed into chest> lung dev deficient so resp distress
What is wrong?
bowel loops visible extending from the abdomen into chest cavity, almost taking up whole left hemichest - lungs hypoplastic and compressed.
(diaphragmatic hernia)
