Abdominal Trauma, Hirschsprung Disease, Malrotation, and Tracheoesophageal Fistula

Question 1

Blunt truama, gun penetrating and knife penetrating

Answer 1

Blunt typically affects more solid - spleen and liver

Penetrating is more viscus - bowel, liver

Question 2

Blunt abdominal trauma in general and

Splenic
Liver

Answer 2

MVA

Children more susceptible bc larger liver and spleen

Splenic injuries result in subcapsular hematomas and or laceration of hilar vessels leading to splenic rupture or devasc…any injury resulting in extravasaiton of blood outside spenen can rapidly lead ot life-threating intra-abdominal hemorrhage

Liver - subcapsular hematomas or laceration of vesicles leading to avulsion or disruption…life-threatening hemorrhage

Question 3

Blunt trauam

Stomach/bowel/colon
Pancreatic
Genitourinary

Answer 3

Crushing bowel between spine and device of impact

Rapid deceleration injuries…most time referable to abdominal wall…may develop acute panc

Kidney is most common…decelerating avuldion of renal pedical or artery dissection…weakest bladder area is periotneal surface of the dome so low ab injuries can result in contusion or rupture

Question 4

Penetrating ab trauma

Answer 4

Diaphragmatic can result in lacerations…may present as a herniation or paralysis

Anterior ab injuries tend to lead to bowel injuries…pay att to RUQ injuries which can affect colon and liver

Flank and back could lead to kidney, ureter, or aortic in addition to bowel

Question 5

Eval of injuries

Answer 5

Diaphragm/ab wall - breathing

Spleen/liver/vasc - hemorrhage

Seat belt sign - hollow viscous
Rib fracture - hepatic contusion or splenic injury
CUllen’s sign or Grey Turner’s sign - intraperiotoneal or retroperitoneal

Question 6

FAST

Answer 6

ID free intraperiotenal fluid indicavtive of intrab bleeding

Limitation is that it cannot ID the source of fluid

Get a CT

Question 7

Lab tests in trauam

Answer 7

Hb/Hct - hemorrhage
Urinalysis - renal/uretral/bladder
AST/ALT - hepatic
Lipase - pancreatic

Question 8

Hirsch patho

Answer 8

4th week of gestation…neroblasts begin migrating in craniocaudal direction of GI tube…integrate into wall to form ganglia to control peristalsis and motitliy

By 7th weke, arrive at distal colon

Hursch means failure to migrate…RET proto-oncogene?

Gnaglion cells are responsbiel for smooth muscle relaxation so will see a contracted distal segment…this means intraluminal contents cannot pass so area proximal is dilated

Question 9

Epidem of Hirsch and CM

Answer 9

10% have downs

Most will fail to pass meconium within first 48 hours of life

If extensive, could get intestinal obstruction

Less extensive may not be dx til later…present iwht lifelong hx of constripation

May have squirt sign

Question 10

Dx and tx of Hirsch

Answer 10

Rectal biopsy is gold standard..will see absence of ganglion cells

On radiograph see dec of absent air in rectum and dilated coonic loops prox to obstruction

Surgical resection of aganglionic segemtn

Question 11

Malrotation path

Answer 11

During early embryonic development, around 6th week, primary intestinal loop hernaites into umbilicus rotating 90 deg counterclockwise

Small intestines formm jejunla ileal loops while cecum and appendix grow

At 10th week, primary intestinal loop retracts into ab cavity and rotats another 180deg counter

During 11th week, completes rotation

Midgut malroaton occurs bc of failred counterclockwide roation of mesenteric root at end of 10th week…cecum becomes logated in mid-upper abdomen and fixed to wall by peritoneal bands

Ladd bands cross over duodenum leading to extrinsic compression and maybe obstruction

ALSO, mesentery on right is shorted which means excessive mobility and potential for bowel sichemia

Question 12

Epi and CM of malroatation

Answer 12

Most becomes sx before age 5…associated with other dzx

Duodenal obstruction or volvulus (twisting of mesenteric base)

Infants mostly present within 1st mo of life

Duodenal obstruction presents with recurrent episodes of bilious emesis and ab pain…some with failure to thirve

Volvulus over first few mos and prresent with acute onset of vomiting…progress rapdily to shock

Question 13

Dx and mg of malrotation

Answer 13

Acutely ill should get surgical consult

If stable, can get upper GI series

Surgicial repair

Question 14

Path of TE fistula

Answer 14

4th week of gestation…2 primordial lung buds arise from ventral foregut endoderm

Lateral septation through formation of tracheoesophageal ridge should sepatate trachea from digestive tube…this lateral septation is incomplete

Most common is proximal esophageal atrea with a distal TEF

Question 15

Associations of TEF

Answer 15

VACTERL
Vertebral (most common)
Anal atresia
Cardiac def
TE fistula 
Renal anomoly
Limb 

CHARGE
Coloboma
Heart
Choanal atresia
Retardation
Genital ab
Ear ab (most common)

Question 16

CM of TEF

Answer 16

Depends

Pt with esoph atresia will typically have polyhydramnios noted during mothers pregnancy…preventsd swalling oral secretions so may drool or choke

Question 17

Dx, mg, prognosis of TEF

Answer 17

Dx - commonly made when can’t pass catheter from mouth to stomach…flueorscopy with water soluble will confirm

Mg - surgical repair

Prog - isolated has a good prognosis…chromosoomal abnormality is more complicated