43 Pediatrics Flashcards
what is considered within the foregut?
lungs, esophagus, stomach, pancreas, liver, gallbladder, bile duct, prox duodenum to ampulla
what is considered within the midgut?
duodenum distal to ampulla, small bowel, large bowel distal 1/3 of transverse colon
what is considered within the hindgut?
distal 1/3 of transverse colon to anal canal
how much does the midgut rotate and which direction?
270 deg counterclockwise
what is considered low birth weight?
<2500 g
how many weeks is considered premature?
<37 weeks
how does a baby get immunity at birth?
IgA from mother’s milk. IgG from placenta
what is a “trauma bolus” for kids?
20cc/kg x2, then give blood 10cc/kg
what is the best indicator for shock in kids and what is the HR for different ages?
tachycardia (neonate >150; 120; rest of kids >100)
what percentage of adult GFR are kids’ GFR? what does this mean for concentrating urine?
25%. means poor concentrating ability
why is alk phos higher in children compared to adults?
bone growth
what vessels are in the umbilicus?
2 arteries, 1 vein
what is the mivf rule for kids?
4cc/kg/hr for 1st 10kg, 2cc/kg/hr for 2nd 10kg, 1cc/kg/hr for everything after
in congenital cystic disease of the lung, how does pulmonary sequestration happen?
lung tissue has anomalous systemic arterial supply (thoracic aorta or abdominal aorta through inferior pulmonary ligament). they have either systemic venous or pulmonary vein drainage
in pulmonary sequestration of kids, where is venous drainage in extra-lobar pulmonary sequestion? intra-lobar?
extra-lobar: systemic venous (azygous system)
intra-lobar: pulmonary vein drainage
in pulmonary sequestration, do vessels in the lung communicate with tracheobronchial tree?
no
what is the most common presentation of pulmonary sequestration?
infection. also respiratory compromise or abnormal CXR
what is the treatment for pulmonary sequestration?
lobectomy
what is another name for emphysema in kids?
congenital lobar overinflation
what is the pathophysiology of congenital lobar overinflation?
cartilage fails to develop in bronchus, leading to air trapping with expiration.
in congenital lobar overinflation, what happens to vascular supply and the other lung lobes?
vascular supply and other lobes are normal (except compressed by hyperinflated lobe)
what should you watch for in congenitla lobar overinflation?
hemodynamic instability (same mxn as tension PTX) or respiratory compromise
which lobe is most commonly affected in congenital lobar overinflation?
LUL
what is treatment for congenital lobar overinflation?
lobectomy
where is the most common place for bronchiogenic cysts to occur?
mediastinum, posterior to the carina usually
are bronchiogenic cysts extra or intrapulmonary? what are they formed of?
extra-pulmonary. formed from bronchial tissue and cartilage wall
what is usually present with a bronchiogenic cyst?
mediastinal mass filled with milky fluid
what is a complication of bronchiogenic cyst?
compress adjacent structures or become infective. have malignant potential
can bronchiogenic cysts be intra-pulmonary?
occasionally
what is treatment for bronchiogenic cysts?
resection of cyst
what is the mcc of mediastinal masses in children? where are they located?
neurogenic tumors (neurofibroma, neuroganglioma, neuroblastoma). located posteriorly
what are the symptoms of mediastinal mass? does it matter where they are located?
respiratory symptoms, dysphagia common to all mediastinal masses regardless of location
what are the types of anterior mediastinal masses in children?
teratoma (most common type of anterior mass), T cell lymphoma, other germ cell tumors, thyroid cancer
what are the types of middle mediastinal masses in children?
T cell lymphoma, teratoma, cyst (cardiogenic or bronchiogenic)
what are the types of posterior mediastinal masses in children?
T cell lymphoma, neuroblastoma, neurogenic tumor
how common is thymoma in children?
very rare
what do you do for choledochal cyst in children? what are the risks?
need to resect. risk of cholangiocarcinoma, pancreatitis, cholangitis, obstructive jaundice
what causes choledochal cyst in children?
reflux of pancreatic enzymes into biliary system in utero
how many types of choledochal cysts? what percentage of all choledochal cysts are of each type?
5 types. I (85%), II (3%), III (1%), IV (10%), V (1%)
what is the most common type of choledochal cyst?
Type I. 85% of all choledochal cysts.
describe type I choledochal cyst. what is the treatment?
fusiform dilation of entire CBD, mildly dilated CHD, normal intrahepatic ducts. rx: resection, hepaticojejunostomy
describe type II choledochal cyst. what is the treatment?
true diverticulum that hangs off the CBD. rx: resection off CBD, may be able to preserve CBD and avoid hepaticojejunostomy
describe type III choledochal cyst. what is the treatment?
dilation of distal CBD; involves sphincter of oddi. rx: resection, choledochojejunostomy
describe type IV choledochal cyst. what is the treatment?
multiple cysts, both intrahepatic and extrahepatic. rx: resection; may need liver lobectomy, possible transplant
describe type V choledochal cyst. what is the treatment?
caroli’s disease: intrahepatic cysts: get hepatic fibrosis; may be a/w congenital hepatic fibrosis and medullary sponge kidney. rx: resection; may need liver lobectomy; possible liver transplant
what pediatric disease causes lymphadenopathy most often?
usu acute suppurative adenitis associated with URI or pharyngitis
what do you do if LAD in child is fluctuant?
FNA, culture and sensitivity, abx. may need I&D if it fails to resolve
what are the causes of chronic LAD?
cat scratch fever, atypical mycoplasma
what are the causes of asymptomatic LAD? what is treatment?
lymphoma until proven otherwise. abx for 10d, excisional bx if no improvement
what is a cystic hygroma? where is it found? what is rx?
lymphangioma in children, found usually in lateral cervical regions of neck, lateral to the SCM. can get infected. rx: resect
what is the overall survival of diaphragmatic hernia in children?
50%
are diaphragmatic hernias on the left or right usually in children?
left
what is a complication of diaphragmatic hernia in children?
pulm htn
what pediatric anomalies are a/w diaphragmatic hernias? how often?
cardiac and neural tube defects mostly; malrotation. 80% have associated anomalies
how do you diagnose a diaphragmatic hernia in children?
prenatal ultrasound
what are sx of diaphragmatic hernia in children?
resp distress
what is treatment for diaphragmatic hernia in children?
high freq ventilation, inhaled NO, may need ECMO. stabilize these pts before operating, need to reduce bowel and repair defect with or without mesh (abd approach), look for visceral anomalies (run the bowel)
what is bochdalek’s hernia?
most common diaphragmatic hernia, located posteriorly. http://cl.ly/SwAL
what is morgagni’s hernia? common?
rare. located anteriorly. http://cl.ly/SwAL
what is pectus excavatum? what is rx and when do you do it?
chest that sinks in. sternal osteotomy, need strut; performed if causing resp sx or emotional stress
what is pectus carinatum? what is rx and when do you do it?
pigeon chest. strut not necessary, repair for emotional stress
what complications can arise out of untreated branchial cleft cysts?
leads to cysts, sinuses, and fistulas
what is it called when cyst is located at angle of mandiblel? what is it associated with?
1st branchial cleft cyst. a/w facial nerve, can connect with auditory canal.
what is it called when a cyst is located on anterior border of mid-SCM muscle? what structures does it go through?
2nd branchial cleft cyst. through carotid bifurcation into tonisllar pillar
what is it called when a cyst is located in the lower neck, medial to or through the lower SCM?
3rd branchial cleft cyst.
what is rx for all branchial cysts?
resection
what is the most common branchial cleft cyst?
2nd.
where are each of the branchial cleft cysts located?
http://cl.ly/SvyJ
in pts with branchial cleft remnants, who gets sinuses, fistulas, and cysts?
sinuses and fistulas seen in infants and young children, cysts appear at a later age.
how does a thyroglossal duct cyst arise in children?
from the descent of thyroid gland from the foramen cecum
what is so bad about a thyroglossal duct cyst?
it may be teh only thyroid tissue the pt has
how does a thyroglossal duct cyst present?
midline cervical mass, goes through hyoid bone
what is rx of thyroglossal duct cyst?
excision of cyst, tract, and hyoid bone (at least the central portion)
when does hemangioma appear in peds?
at birth or shortly after
what is the course of a hemangioma in ped pts?
rapid growth in first 6-12mo of life, then begins to involute
what is rx for hemangioma in children?
observation, most resolve by age 7-8
when do you treat peds hemangioma? how do you treat?
uncontrollable growth, impairs function (eyelid or ear canal, or is persistent after age 8. treat w oral steroids. laser or resection if steroids not successful
what is the most common solid abd malignancy in children?
neuroblastoma
how does neuroblastoma usu present?
asymptomatic mass
what are sx of neuroblastoma in children?
secretory diarrhea, raccoon eyes (orbital mets), HTN, opsomyoclonus syndrome (unsteady gait)
if a pt with neuroblastoma has raccoon eyes, what are you concerned for?
orbital mets
where are neuroblastomas most commonly located?
on adrenals, but can occur anywhere on sympathetic chain
when does neuroblastoma commonly present?
1st 2 yrs of life
which population has best prognosis after diagnosis of neuroblastoma?
chlidren <1 yo
what chemicals are increased with neuroblastoma?
inc catecholamines, VMA, HVA, metanephrines (HTN)
what cells do neuroblastoma arise from?
neural crest cells
does neuroblastoma invade or encase vasculature?
encase
where can neuroblastoma rarely met?
lung and bone
what can neuroblastoma look like on abd xr?
stippled calcifications in the tumor
what factors indicate a worse prognosis of neuroblastoma?
NSE, LDH, HVA< diploid tumors, and N-myc amplification (>3 copies)
what lab finding is increased in pts with mets from neuroblastoma?
NSE
what is treatment for neuroblastoma? what is cure rate?
resection (adrenal gland and kidney are taken; 40% cured)
what can you do to make unresectable neuroblastoma tumors resectable?
doxorubicin-based chemo
how do you stage neuroblastoma?
I, II, III, IV, IV-S. http://cl.ly/SvtD
What is another name for wilms tumor?
nephroblastoma
how does wilms tumor present?
asymptomatic mass; can have hematuria or HTN
how often is wilms tumor b/l?
10%
what is the mean age at diagnosis of wilms tumor?
3yo
what is prognosis of wilms tumor based on? what types of tumors have worse prognosis?
tumor grade (anaplastic and sarcomatous variations have worse prognosis)
what is treatment for wilms tumor? what is percent cure?
nephrectomy. chemo with actinomycin and vincristine in all pts except if they have stage I and 500g tumor. 90% cure
what do you do for wilms tumor if it extends in the renal vein?
tumor can be extracted from vein. need to examine contralateral kidney and look for peritoneal implants.
what do you ahve to be careful of when resecting wilms tumor?
avoid rupture of tumor, which will increase stage.
what are the stages of wilms tumor?
http://cl.ly/SwRE
what is the most common malignant liver tumor in children?
hepatoblastoma.
what is a good marker for hepatoblastoma?
inc AFP in 90% of pts
what are si/sx of hepatoblastoma?
fractures, precocious puberty (from beta-hcg release)
how does hepatoblastoma compare to HCC in terms of prognosis?
hepatoblastoma better prognosis
is vascular invasion of hepatoblastoma common?
yes
what is the treatment for hepatoblastoma?
resection optimal; otherwise doxorubicin and cisplatin based chemo. may downstage tumors and make them resectable
what does survival of hepatoblastoma related to (in children)?
resectability
what type of histology of hepatoblastoma has the best prognosis in children?
fetal histology
what is the most common children’s malignancy overall?
leukemia (ALL)
what is the most common solid tumor class in children?
CNS tumors
what is the most common general surgery tumor? in child 2 yrs?
neuroblastoma. 2yrs is wilms tumor
what is the mcc of duodenal obstruction in newborns (<1week)?
duodenal atresia
what is the mcc of colon obstruction in children?
hirschsprung’s disease
what is the most common liver tumor in children? what percentage of liver tumors in children are malignant?
hepatoblastoma. 2/3 of liver tumors in children are malignant?
what is the most common lung tumor in children?
carcinoid
what is the mcc of painful lower GI bleeding in children?
benign anorectal lesions (fissures, etc)
what is the mcc of painless lower GI bleed in children?
Meckel’s diverticulum
what is the mcc of upper GI bleed in 0 to 1 yo? 1 yo to adult?
0 to 1 yo: gastritis, esophagitis. 1 yo to adult: esophageal varices, esophagitis
where is meckel’s diverticulum found in chidlren?
antimesenteric border of small bowel
where does meckel’s diverticulum derive?
persistent vitelline duct
where is meckel’s diverticulum located?
2 feet from ileocecal valve (rule of 2s)
what perecent of population has meckel’s diverticulum?
2% of population (rule of 2s)
what percent of people with meckels are symptomatic?
2% symptomatic (rule of 2s)
what are the tissue types of mecekls?
2 tissue types (pancreatic - most common, gastric - most likely to be symptomatic) (rule of 2s)
what are the presentations of meckels?
2 presentations (diverticulitis and bleeding)
if you have trouble locating meckel’s diverticulum but you are suspicious, what test can you get?
meckel’s diverticulum scan with pertechnetate.
what is treatment of meckel’s?
resection if they have symptoms.
when do you consider segmental resection?
if symptoms, and diverticulitis involves the base or if the base is >1/3 the size of bowel.
what is the epidemiology of pyloric stenosis?
3-12 week old firstborn males
what are the si/sx of pyloric stenosis?
projectile vomiting, olive mass in stomach
what lab abnormalities are a/w pyloric stenosis?
hypochloremic, hypokalemic, metabolic alkalosis
what imaging do you use for pyloric stenosis? what are your findings?
ultrasound - pylorus >= 4mm thick, >= 14mm long
how do you treat pyloric stenosis?
normal saline boluses until making urine. then switch to D5NS with 10K mIVF
what should you avoid when resuscitating kids?
k containing fluids (hyperkalemia) and non-salt-containing solutions (hyponatremia). should give glucose mivf to infants b/c of limited reserves for gluconeogenesis and volunerability for hypoglycemia.
what is treatment for pyloric stenosis?
pyloromyotomy (RUQ incision; proximal extent should be the circular muscles of stomach)
when do children get intussusception?
3 mo to 3 yrs
what are si/sx of intussusception?
currant jelly stools (from vascular congestion). sausage mass, abdominal distension, RUQ pain, vomiting
is currant jelly stool an indication for resection?
no.
what is the recurrence of intussusception after resection?
15%
what are the causes of lead point in intussusception?
enlarged peyer’s patches (#1), lymphoma, meckel’s diverticulum.
what is the treatment of intussusception? how successful is this method? do you need surgery if this works?
reduce with air-contrast enema. 80% successful. will not need surgery after
what is the max pressure with air contrast enema for treatment of intussusception? what is max column height with barium enema? what happens if you go beyond these values? what do you do then?
120mmhg. 1meter (3 feet). risk of perforation if above these. need to go to OR with peritonitis or free air, or if unable to reduce
where should you place traction when reducing intussusception in the OR?
apply pressure to the distal limb, not the proximal limb of bowel
if a child has intusussception without lead point, do you need to resect?
no resection if not a/w lead point.
if an adult has intussusception, do they have lead point? what do you do then?
yes. they likely have a malignant lead point. (colon ca in cecum. need to go to OR for resection
what causes intestinal atresia?
intrauterine vascular accident
what are sx of intestinal atresia?
bilious emeesis, distention, most do not pass meconium
where is the most common site of intestinal atresia?
jejunum. can be multiple areas of atresia
what is workup of intestinal atresia?
rectal biopsy to rule out hirschprung’s before surgery
what is treatment of intestinal atresia?
resection
where does duodenal atresia occur most commonly?
usually distal to ampulla of vater
what are the si/sx of duodenal atresia?
bilious vomiting, feeding intolerance
what is duodenal atresia associated with in the mother?
polyhydramnios
what abnormalities are a/w duodenal atresia?
cardiac, renal, other GI abnormalities, down’s syndrome
what percentage of pts with duodenal atresia have downs?
20%. check chromosomal studies.
what is an imaging sign of duodenal atresia?
double bubble
what is treatment for duodenal atresia?
resuscitation, duodenoduodenostomy or duodenojejunostomy
what is the most common type of tracheoesophageal fistula?
type C. 85%
what is type C tracheoesophageal fistula?
proximal esophageal atresia (blind pouch) and distal TE fistula
what are sx of type C tracheoesophageal fistula?
newborn spits up feeds, has excessive drooling, respiratory sx w feeding, cannot place NG in stomach
what does abd xr show on type C tracheoesophageal fistula?
distended, gas fille dstomach
what is type A tracheoesophageal fistula? how common?
2nd most common (5%). esophageal atresia and no fistula
what are sx of type A tracheoesophageal fistula?
newborn spits up feeds, has excessive drooling, respiratory sx w feeding, cannot place NG in stomach
what does abd xr show you in type A tracheoesophageal fistula?
gasless abdomen
what is vacterl syndrome?
vertebral, anorectal (imperforate anus), cardiac, TE fistula, radius/renal, and limb anomalies
what is treatment for tracheoesophageal fistula?
right extrapleural thoracotomy for most; perform primary repair and place G tube. azygous vein needs to be divided
what do you do for premature infants who have tracheoesophageal fistula?
<2500g or sick infants: treat respiratory symtpoms, place G-tube; delay repair.
what are complications of repair of TEFistula?
GERD, leak, empyema, stricture, fistula
what is survival of TE fistula related to?
birth weight and associated anomalies.
what are si/sx of malrotation?
sudden onset of bilious vomiting.
what causes duodenal obstruction in pts with malrotation?
ladd’s bands cause duodenal obstruction, coming out from the right retroperitoneum.
what are the complications of volvulus?
volvulus a/w compromise of SMA, leading to infarction fo the intestine.
what causes malrotation?
failure of normal counterclockwise rotation (270 deg)
when does malrotation occur in peds?
75% in 1st month; 90% present by 1st year of age
what do you do for a child with bilious vomiting?
needs UGI to rule out malrotation.
how do you diagnose malrotation?
UGI: duodenum doesn’t cross midline; duodenal-jejunal junction displaced to the right.
what is treatment for malrotation?
resect ladd’s bands, counterclockwise rotation (may require multiple turns), place cecum in LLQ (cecopexy), place duodenum in RUQ, and appendectomy
http://cl.ly/Swgt
what are the si/sx of meconium ileus?
distal ileal obstruction, abdominal distention, bilious vomiting, and distended loops of bowel
what test do oyu do for meconium ileus?
need sweat chloride test or PCR for chloride channel defect
why do you need sweat chloride or PCR for chloride channel defect?
a/w cystic fibrosis
what percentage of children with meconium ileus have cystic fibrosis?
10%
what are the findings of meconium ileus on abd xr?
dilated loops of bowel without air fluid levels (meconium is too thick to separate from the bowel wall); can have groudn glass or soapsuds appearance
what is a complication of meconium ileus? what do you do for it?
perforation, leading to meconium pseudocyst or free perforation. need to go to OR for laparotomy
what is the treatment for meconium ileus? how effective is it?
gastrografin enema, effective in 80%. can also make the diagnosis and potentially treat the patient. can also use N-acetylcysteine enema.
what do you do for meconium ileus if surgery is required?
manual decompression and create a vent for n-acetylcysteine antegrade enemas
how does necrotizing enterocolitis present? in whom?
classically, bloody stools after first feeding in premature neonate
what are the risk factors for necrotizing enterocolitis?
prematurity, hypoxia, sepsis.
what are the symptoms of necrotizing enterocolitis?
lethargy, respiratory decompensation, abd distention, vomiting, blood per rectum
what are abd xr findings in necrotizing enterocolitis?
pneumatosis intestinalis, free air, or portal vein air
how do you make sure children with necrotizing enterocolitis dont have perforation?
need serial lateral decub films
what is the initial treatment for necrotizing enterocolitis?
resuscitation, NPO, antibiotics, TPN, OG tube
what are the indications for operation for necrotizing enterocolitis? what do you do in the operation?
free air, peritonitis, clinical deterioration. resect dead bowel and bring up ostomies
in pts with necrotizing enterocolitis, what do you need to do prior to taking down ostomies that had been placed for dead bowel?
need to have a barium contrast enema to rule out distal obstruction from stenosis.
what is the mortality of necrotizing enterocolitis?
10%
when do you do surgery for congenital vascular malformation?
surgery for hemorrhage, ischemia, CHF, nonbleeding ulcers, functional impairment, or limb-length discrepancy
what is the treatment for congenital vascular malformation?
embolization (may be sufficient on its own) and or resection.
is imperforate anus more common males or females?
males
what do you need to check for in pts with imperforate anus?
VACTERL anomalies (renal, cardiac, vertebral). have to do a VCUG
what defines a high or low imperforate anus?
high: above levators, low: below levators
what are si/sx of high imperforate anus? and what do the symptoms represent anatomically?
meconium in urine or vagina. (fistula to bladder/vagina/prostatic urethra)
what is the treatment for high imperforate anus?
colostomy, later anal reconstruction with posterior or sagittal anoplasty
what are si/sx of low imperforate anus?
meconium to perineal skin
how do oyu treat low imperforate anus? do you need a colostomy?
posterior sagittal anoplasty (pull anus down into sphincter mechanism); no colostomy needed
what do you need to do postop for imperforate anus? why?
postop anal dilation to avoid stricture; these patients are prone to constipation
