Chapter 43: Pediatric Surgery Flashcards
What makes up the foregut?
Lungs, esophagus –> duodenum to ampulla + pancreas, liver, gallbladder
What makes up the midgut?
Duodenum from ampulla –> distal 1/3 of transverse colon
What makes up the hindgut?
Distal 2/3 transverse colon –> anal canal
Which way/how far does the midgut rotate?
270 degrees counterclockwise
What defines low birth weight? Premature?
<2,500g, <37wks
What makes up infant’s immunity at birth?
IgA from milk, IgM synthesized in child
What is the #1 cause of childhood death?
Trauma
What makes up a trauma bolus for kids?
20cc/kg x2; then give blood 10cc/kg
What is the best indicator of shock in peds?
TachycardiaNeonate: 150+< 1 yo: 120+ > 1yo: 100+
What is the normal UOP for ped?
2-4cc/kg/hr
What % GFR capacity do kids have compared to adults?
25%; poor concentrating ability
What makes up the umbilical vessels?
2 arteries and 1 vein
What are maintenance IV fluids
4cc/kg/hr for the 1st 10 kg2cc/kg/hr for the 2nd 10 kg1cc/kg/hr for everything after that
What is pulmonary sequestration?
nonfunctioning mass of normal lung tissue that lacks normal communication with the tracheobronchial tree, and that receives its arterial blood supply from the systemic circulation. * Arterial supply MC from thoracic aorta or abdominal aorta through inferior pulmonary ligament. * Extra lobar: systemic venuous drainage via azygous system * Intra Lobar: pulmonary vein drainage
What is the most common presentation of pulmonary sequestration? Treatment?
Infection, respiratory compromise, abnormal CXRTx: Ligate arterial supply first (risk of severe hemorrhage) then lobectomy
What is congenital lobar overinflation (emphysema)?
Cartilage fails to develop in bronchus leading to air trapping with expiration * normal vascular suply * normal lobes * LUL most commonly affected
Presentation of congenial lobar overinflation? Treatment?
Can get vascular compromise (same mechanism as tension pneumo) or respiratory insufficiencyTx: Lobectomy
What is congenital cystic adenoid malformation? (CCAM)
Alveolar structure not well developed although lung tissue is present, connects with airway
Presentation of congenital cystic adenoid malformation? Treatment?
Resp compromise and recurrent infectionTx: Lobectomy
What is a bronchiogenic cyst?
Extrapulmonary cysts formed from bronchial tissue and cartilage wall * MC cyst of the mediastinum, usually posterior to the carina.
Presentation of bronchiogenic cyst? Treatment?
Presents as mediastinal mass filled with milky fluid, can compress adjacent structures or become infectedTx: Cyst resection
What is the most common mediastinal mass in children?
Neurogenic tumors (neurofibroma, neuroganglionoma, neuroblastoma) * Usually located posterior
What symptoms are common to all mediastina masses regardless of location?
Respiratory symptoms, dysphagia
What are anterior mediastinal masses?
T cell lymphoma, teratoma (and other germ cell tumors), thymoma, thyroid ca
What are middle mediastinal masses?
T cel lymphoma, teratoma, cyst (cardiogenic, bronchiogenic)
What are posterior mediastinal masses?
T cell lymphoma, neuroblastoma, neurogenic tumors
What is the treatment for choledochal cysts?Etiology?
All need resection do to risk of cholangiocarcinoma, pancreatitis, cholangitis, obstructive jaundiceEtiology: Reflux of pancreatic enzymes into biliary system in utero
What is a type I choledochal cyst?%?
Fusiform dilation of entire common bile duct, mildly dilated CHD, normal intrahepatic ducts85%
What is a type II choledochal cyst?%?
True diverticulum that hangs off the common bile duct3%
What is a type III choledochal cyst?%?
Dilation of distal intramural common bile duct, involves sphincter of Oddi1%
What is a type IV choledochal cyst? %?
Multiple cysts, both intra and extrahepatic10%
What is type V choledochal cyst? Other name?%?
Caroli’s disease Intrahepatic cysts, get hepatic fibrosis, may be associated with congenital hepatic fibrosis and medullary sponge kidney
What is lymphadenopathy most likely caused by?
Acute suppurative adenitis associated with URI or pharyngitis
Workup for fluctuant lymphadenophathy? Asymptomatic?
Fluctuant: FNA, culture and sensitivity, abx; may need I&DAsymptomatic: abx for 10d –>excisional biopsy if no improvement (lymphoma until proven otherwise)
What causes chronic fluctuant lymphadenopathy?
Cat scratch fever, atypical mycoplasma
What is cystic hygroma? Treatment?
Lymphangioma Found in lateral cervical and submandibular regions in neck, gets infectedTx: Resection
Overall survival of diaphragmatic hernias?
50%
What % of diaphragmatic hernias have associated anomalies? What are they?
80%Cardiac and neural tube defects, malrotation
Diaphragmatic hernias are increased on which side?
Left
Treatment for diaphragmatic hernias?
High-frequency ventilation, ECMO, prostacyclin (pulmonary vasodilator); stabilize before operating, reduce bowel, repair +/- mesh, look for visceral anomalies (run the bowel)
What is Bochdalek’s hernia?
Most common diaphragmatic herniaPosterior
What is Morgagni’s hernia?
Rare diaphragmatic herniaAnterior
What is eventration?
Failure of diaphragm to fuse
Treatment for pectus excavatum?
(Sinks in)Sternal osteotomy, need strutPerformed if causing respiratory symptoms or emotional distress
Treatment for pectus craniatum?
(Pigeon chest)Strut not necessaryRepair for emotional distress
Branchial cleft cyst causes what?
Cysts, sinuses, fistulas
Where is a 1st branchial cleft cyst? Associated with which nerve?
Angle of mandible, may connect with external auditory canalFacial nerve
Where is a 2nd branchial cleft cyst?
On anterior border of SCM muscle, goes through carotid bifurcation into tonsillar pillar
Where is a 3rd branchial cleft cyst?
Lateral neck
What is the treatment for branchial cleft cysts? Which is most common?
Resection2nd branchial cleft cyst most common
Where is a thyroglossal duct cyst? Presentation?
From descent of thyroid gland from foramen cecum, goes through hyoidPresents as midline cervical mass
Treatment for thyroglossal duct cyst?
Resection of cyst, tract, and hyoid bone
Characteristics of hemangioma?
Appears at birth or shortly afterRapid growth between 6-12mo, then begins to involute
Treatment of hemangioma?
ObservationSteroids, laser/surgery if uncontrollable growth, impairs function (eyelid/ear canal), persistent after age 8
What is the #1 solid abdominal malignancy in children?
Nueroblastoma
How do neuroblastomas usually present?
Asymptomatic massCan have secretory diarrhea, raccoon eyes (orbital mets), HTN, opsomy oclonus syndrome (unsteady gait)
What is the most common location of neuroblastomas?
Adrenals; can occur anywhere on sympathetic chain
Most common lab findings with neuroblastoma?
Elevated catecholamines, VMA, HVA, metanephrines
Abd xray findings of neuroblastoma?
Stippled calcifications in tumor
What is elevated in all patients with neuroblastoma mets?
Elevated NSE
Treatment for neuroblastoma?
Resection (30-40% cured), chemo if initially unresectable
Presentation of Wilms tumor?
Usually as asymptomatic massHematuria, HTN, 10% bilateral
What is prognosis of Wilms tumor based on?
Tumor gradeAnaplastic and sarcomatous variations with worst prognosis
Where do mets from Wilms tumor go?
Bone and lung; can resect lung mets
What syndromes are Wilms tumors associated with?
Beckwith-Widermann (hemihypertrophy, cryptorchidism, Drash syndrome, aniridia)
What are CT findings with Wilms tumors?
Replacement of renal parenchymaNOT displacement as seen with neuroblastoma
Treatment for Wilms tumor?
Nephrectomy (80-90% cured)Examine contralateral side for implantsAvoid rupture of tumorActinomycin and vincristine (except for stage I <500g)
What is the most common malignant tumor in children?
Hepatoblastoma
What lab value is elevated in hepatoblastoma? Presentation?
Elevated AFP in 90%Fractures, precocious puberty (from beta-HCG release)
Hepatoblastomas are associated with what syndrome?
Beckwith-Wiedemann syndrome
Treatment for hepatoblastoma?
Resection; otherwise doxorubicin-cisplatin based chemo
What is the #1 children’s malignancy overall?
ALL
What is the #1 solid tumor class?
CNS tumors
What is the #1 general surgery tumor in child 2?
2y: Wilms tumor
What is the #1 cause of duodenal obstruction in newborns?
Duodenal atresia
What is the #1 cause of duodenal obstruction after newborn period and overall?
Malrotation
Wat is the #1 cause of colon obstruction?
Hirschsprung’s disease
What is the #1 liver tumor in children?
Hepatoblastoma
What is the #1 lung tumor in children?
Carcinoid
What is the #1 cause of painful lower GI bleeding?
Benign anorectal lesion (fissure, etc.)
What is the #1 cause of painless lower GI bleeding?
Meckel’s diverticulum
What are the causes of upper GI bleeding in children 0-1? 1-adults?
0-1y: gastritis, esophagitis1-adult: esophageal varices, esophagitis
Where is Meckel’s diverticulum found? What is the rule of 2s?
Antimesenteric border of the small bowel2 ft from ileocecal valve2% of the population2% symptomatic2 tissue types (pancreatic, gastric)2 presentations (diverticulitis, bleeding)
What is the embryology of Meckel’s diverticulum?
Persistent vitelline duct
What type of tissue is most commonly found in Meckel’s diverticulum? What type is most likely to be symptomatic?
Most common: PancreaticSymptomatic: Gastric
Treatment for Meckel’s diverticulum?
Resection with symptoms, suspicion of gastric mucosa, narrow neckSegmental resection if diverticulitis involving the base or if base is >1/3 the size of the bowel
What is the presentation of pyloric stenosis? Exam findings? Lab abnormality?
3-12wks, firstborn males with projectile vomitingOlive mass in stomachHypochloremic, hypokalemic metabilic alkalosis
US findings with pyloric stenosis?
Pylorus >4mm thick, >14mm long
Treatment for pyloric stenosis?
IVF resuscitation (initially with NS, then switch to D5NS)Pyloromyotomy (RUQ incision, proximal extent should be the circular muscles of stomach)
Presentation of intussusception? Exam findings?
3mo - 3y; currant jelly stools (from vascular congestion, not an indication for resection)Sausage mass, abdominal distention, RUQ pain, vomiting
Lead points for intussusception in children?
1 Peyer’s patches, lymphoma, Meckel’s
What % of intussusception in children recur after reduction?
15%
Treatment for intussusception in children?
Reduce with air-contrase enema (80% successful), proceed to OR if exceed ed max pressure (120mmHg) or max column height (1m)
Why do intestinal atresias develop?
As a result of intrauterine vascular accidents
Symptoms of intestinal atresias?
Bilious emesis, distention, most do not pass meconium
Most common location of intestinal atresias? Treatment?
Jejunum, can be multipleBarium enema to r/o Hirschsprung’s, resection
What other anomalies is duodenal associated with?
Polyhydramnios in motherCardiac, renal, other GI anomalies
Duodenal atresia is associated with what syndrome? %?
Down’s syndrome 20% of patients
Abd xray findings with duodenal atresia?
Double bubble
Treatment for duodenal atresia?
ResuscitationDuodenoduodenostomy or duodenoj
What is the most common type of TE fistula?
Type C (80-90%)Proximal esophagus atresia and distal TE fistula
Symptoms of type C TE fistula?
Newborn spits up feeds, has excessive drooling and resp symptoms with feeding, cannot place NGT in stomach
What is type A TE fistula? Symptoms?
Esophageal atresia without fistulaSimilar to type C
What is type E TE fistula?
H configuration of esophagus and tracheaMost likely to present as adult, not associated with atresia
What does VACTERL stand for?
Vertebral, anorectal (imperforate anus), cardiac, TE fistula, radius/renal and limb anomalies
Treatment for TE fistula?
Right extrapleural thoracotomy, primary repair, place G tube
Complications of repair?
GERD, leak, emphysema, stricture, fistula
What is the presentation of malrotation?
Sudden onset bilious vomiting due to Ladd’s bands causing duodenal obstruction
When do most present with malrotation?
90% by 1y75% in 1st month
Diagnosis of malrotation? Treatment?
UGI duodenum does not cross midlineResect Ladd’s bands, counterclockwise rotation, cecum in LLQ with cecopexy, duodenum in RUQ, appendectomy
What is the presentation of meconium ileus?
Distal ileal obstruction, abdominal distention, bilious vomiting and distended loops of bowelCan cause perforation causing meconium pseudocyst or free perf
What other tests are necessary after diagnosis of meconium ileus?
Sweat chloride or PCR for Cl channel defectOccurs in 10% of CF pts
What are the abd xray findings with meconium ileus?
Dilated loops of small bowel without air-fluid levels (meconium is too thick to separate from bowel wall), can have ground-glass or soap suds appearance
Treatment for meconium ileus?
Gastrograffin enema (80% effective)Could also use N-acetylcysteine enemaSurgery: manual decompression and create vent for N-acetylcysteine enema antegrade enema
Classic presentation of NEC?
Bloody stools after 1st feeding in preemies
Risk factors for NEC?
Prematurity, hypoxia, hypotension, anemia, polycythemia, sepsis
Symptoms of NEC?
Lethargy, resp decompensation, abdominal distention, vomiting, blood pre rectum
Abd xray findings with NEC?
Pneumatosis intestinalis,free air, portal vein air
Treatment for NEC?
Resuscitation, NPO, abx, TPN, orogastric tube
Indications for operation for NEC?
Free air, peritonitis, clinical deterioration
Mortality with NEC?
10%
Indication for surgery for congenital vascular malformation?
Hemorrhage, ischemia, CHF, nonbleeding ulcers, functional impairment, limb-length discrepancy
Treatment for congenital vascular malformation?
Embolization and resection
Characteristics of high imperforate anus? Treatment?
Meconium in urine or vaginaColostomy, later anal reconstruction with posterior sagittal anoplasty
Treatment for low imperforate anus?
Posterior sagittal anoplasty (pull anus down into sphincter mechanism); no colostomy needed
Post-op complications after surgery for imperforate anus?
Pts prone to constipationNeed anal dilation to avoid stricture
What is gastroschisis?
Intrauterine rupture of umbilical vein; does not have peritoneal sacTo the right of midline, stiff bowel from exposure to amniotic fluid, low rate of congenital anomalies except malrotation
Treatment for gastroschisis?
Initially place saline-soaked gauzes and resuscitation; TPN, NPORepair when stable, place bowel back in abdomen, may need Vicryl mesh silo and primary closure at later date
What is omphalocele?
Failure of embryonal development, midline defectIncreased risk of congenital anomalies (50%), has peritoneal sac with cord attached
What is Cantrell pentalogy?
Cardiac defects, pericardium defects (usually at diaphragm), sternal cleft or absence of lower sternum, diaphragmatic septum transversum abscence, omphalocele
Treatment for omphalocele?
Saline-soaked gauze and resuscitation, TPN, NPORepair when stable, try to place bowel in abdomen, may need vicryl mesh and delayed primary closure
What is the most common sign of Hirschsprung’s? Other presentations?
Infants fail to pass meconium in 1st 24hCan also present in older age groups as chronic constipation, distention, colitisExplosive release of watery stool with rectal exam
Diagnosis of Hirschsprung’s?
Barium enema: may be normal, often with spastic distal segment and dilated proximal segmentRectal biopsy with absence of ganglion cells in myenteric plexus
Treatment for Hirschsprung’s?
Resect colon until proximal to where ganglion cells appear; may need to bring up colostomy initially, eventually connect the colon to the anus (Soave or Duhamel procedure)
What is Hirschsprung’s colitis?Treatment?
Rapidly progressive, manifested by abdominal distention, foul smelling diarrhea; lethargy and signs of sepsisRectal irrigation, may need emergency colectomy
Treatment for hydrocele?
Surgery at 1y if not resolved or if though to be communicating (waxing/waning size), resect and ligate processus vaginalis
Treatment for umbilical hernia?
Repair if not closed by age 5 or incarceration or if pt has VP shunt
Inguinal hernias are in what % of infants? % R. vs. L.? % bilateral?
3% due to failure of closure of processus vaginalis60% right, 30% left, 10% bilateral
Treatment of inguinal hernias?
Emergent operation if not able to reduce, otherwise elective repaire with high ligationExplore contralateral side if left sided, female, or child <1y
Where is cystic duplication most commonly found? Treatment?
In ileum, often on mesenteric borderResect cyst
What is the most common cause of neonatal jaundice requiring surgery?
Biliary atresia
Presentation of biliary atresia? Diagnosis?
Progressive jaundice (suggestive of atresia if persists >2wks after birth), cholngitis, continued cirrhosis, eventual hepatic failure
Diagnosis of biliary atresia? Treatment?
US and cholangiography; liver biopsy showing periportal fibrosis, bile plugging, cirrhosisKasai procedure before age 3 mo. (hepaticoportojejunostomy): 1/3 get better, 1/3 go on to liver transplant, 1/3 die
Where do mets from osteosarcoma go? Treatment?
LungResection of primary and pulmonary mets if isolated
Lab findings with teratoma? Type found in neonates? Treatment?
Elevated AFP and beta-HCGSacrococcygealExcision
What % of sacrococcygeal teratomas are benign at birth?
90%; >2mo usually malignantGreat potential for malignancy
Treatment for teratoma?
Coccygectomy and long-term followup
Treatment for undescended testicles?
Wait until 2yoOrchiopexy through inguinal incision, if not able to get testicles down, close and wait 6mo and try again, if will not come down, perform division of spermatic vessels
Cancer risk with undescended testicles?
Seminoma riskRisk stays the same even if testicle brought down into scrotum
What is prune belly syndrome?
Rare; hypoplasia of the abdominal wall, urinary tract abnormalities with dilated urinary system and bilateral cryptorchidism
What is the most common cause of airway obstruction in infants?
Laryngomalacia; caused by immature epiglottis cartilage with intermittent collapse of the epiglottis airway
Symptoms of laryngomalacia?
Intermittent respiratory distress and stridor exacerbation in the supine position
Treatment for laryngomalacia?
Most children outgrow by 12mo Surgical trach if necessary
What is choanal atresia? Symptoms? Treatment?
Obstruction of choanal opening by either bone or mucus membrane (usually unilateral)Intermittent respiratory distress, poor sucklingSurgical correction
What is the most common tumor of the pediatric larynx?
Laryngeal papillomatosis
Cause of laryngeal papillomatosis? Treatment?
From HPV in mother during passage through birth canalFrequently involutes after puberty, can treat with endoscopic removal or laser; frequently recurs
