Chapter 43 - Pediatrics II Flashcards

1
Q

Where is Meckel’s diverticulum found?

What is the rule of 2s?

A

Antimesenteric border of the small bowel

2 ft from ileocecal valve
2% of the population
2% symptomatic
2 tissue types (pancreatic, gastric)
2 presentations (diverticulitis, bleeding)
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2
Q

What is the embryology of Meckel’s diverticulum?

A

Persistent vitelline duct

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3
Q

What type of tissue is most commonly found in Meckel’s diverticulum? What type is most likely to be symptomatic?

A

Most common: Pancreatic

Symptomatic: Gastric

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4
Q

Treatment for Meckel’s diverticulum?

A

Resection if symptoms, suspicion of gastric mucosa, narrow neck.
Segmental resection if diverticulitis involving the base or if base is >1/3 the size of the bowel

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5
Q

What is the presentation of pyloric stenosis? Exam findings? Lab abnormality?

A

3-12wks, firstborn males with projectile vomiting
Olive mass in stomach
Hypochloremic, hypokalemic metabilic alkalosis

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6
Q

US findings with pyloric stenosis?

A

Pylorus >4mm thick, >14mm long

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7
Q

Treatment for pyloric stenosis?

A
IVF resuscitation (initially with NS, then switch to D5NS)
Pyloromyotomy (RUQ incision, proximal extent should be the circular muscles of stomach)
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8
Q

Presentation of intussusception? Exam findings? Diagnostic evaluation?

A

Psx: 3mo - 3y w/ abd pain (diffx from Meckel bleed), N/V, currant jelly stool
PE: sausage mass, distention
Dx: made clinically if psx is classic
Unclear: XR can r/o perf (may just see dilation), US can confirm (target sign)

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9
Q

Lead points for intussusception in children?

A

1 Peyer’s patches, lymphoma, Meckel’s

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10
Q

What % of intussusception in children recur after reduction? How do you proceed if abdominal pain recurs?

A

10-15%
Suspect recurrent intussusception, but perforation is on ddx - get XR to find free air, then US can confirm, and reduction can be re-attempted w/ air-enema.

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11
Q

Treatment for intussusception in children?

A

Reduce with air-contrast enema (80% successful), proceed to OR if exceeded max pressure (120mmHg) or max column height (1m).
This is an emergency and can cause bowel ischemia with perforation.

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12
Q

Why do intestinal atresias develop?

A

As a result of intrauterine vascular accidents

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13
Q

Symptoms of intestinal atresias?

A

Bilious emesis, distention, most do not pass meconium

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14
Q

Most common location of intestinal atresias? Treatment?

A

Jejunum, can be multiple

Barium enema to r/o Hirschsprung’s, resection

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15
Q

What other anomalies is duodenal associated with?

A

Polyhydramnios in mother

Cardiac, renal, other GI anomalies

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16
Q

Duodenal atresia is associated with what syndrome? %?

A

Down’s syndrome 20% of patients

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17
Q

Abd xray findings with duodenal atresia?

A

Double bubble

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18
Q

Treatment for duodenal atresia?

A

Resuscitation

Duodenoduodenostomy or duodenoj

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19
Q

What is the most common type of TE fistula?

A
Type C (80-90%)
Proximal esophagus atresia and distal TE fistula
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20
Q

Symptoms of type C TE fistula?

A

Newborn spits up feeds, has excessive drooling and resp symptoms with feeding, cannot place NGT in stomach

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21
Q

What is type A TE fistula? Symptoms?

A

Esophageal atresia without fistula

Similar to type C

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22
Q

What is type E TE fistula?

A

H configuration of esophagus and trachea

Most likely to present as adult, not associated with atresia

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23
Q

What does VACTERL stand for?

A

Vertebral, anorectal (imperforate anus), cardiac, TE fistula, radius/renal and limb anomalies

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24
Q

Treatment for TE fistula?

A

Right extrapleural thoracotomy, primary repair, place G tube

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25
Complications of repair?
GERD, leak, emphysema, stricture, fistula
26
What is the presentation of malrotation?
Sudden onset bilious vomiting due to Ladd's bands causing duodenal obstruction
27
When do most present with malrotation?
90% by 1y | 75% in 1st month
28
Diagnosis of malrotation? Treatment?
UGI duodenum does not cross midline | Resect Ladd's bands, counterclockwise rotation, cecum in LLQ with cecopexy, duodenum in RUQ, appendectomy
29
What is the presentation of meconium ileus?
Distal ileal obstruction, abdominal distention, bilious vomiting and distended loops of bowel Can cause perforation causing meconium pseudocyst or free perf
30
What other tests are necessary after diagnosis of meconium ileus?
Sweat chloride or PCR for Cl channel defect | Occurs in 10% of CF pts
31
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
32
Treatment for meconium ileus?
Gastrograffin enema (80% effective) Could also use N-acetylcysteine enema Surgery: manual decompression and create vent for N-acetylcysteine enema antegrade enema
33
Classic presentation of NEC?
Bloody stools after 1st feeding in preemies
34
Risk factors for NEC?
Prematurity, hypoxia, hypotension, anemia, polycythemia, sepsis
35
Symptoms of NEC?
Lethargy, resp decompensation, abdominal distention, vomiting, blood pre rectum
36
Abd xray findings with NEC?
Pneumatosis intestinalis,free air, portal vein air
37
Treatment for NEC?
Resuscitation, NPO, abx, TPN, orogastric tube
38
Indications for operation for NEC?
Free air, peritonitis, clinical deterioration
39
Mortality with NEC?
10%
40
Indication for surgery for congenital vascular malformation?
Hemorrhage, ischemia, CHF, nonbleeding ulcers, functional impairment, limb-length discrepancy
41
Treatment for congenital vascular malformation?
Embolization and resection
42
Characteristics of high imperforate anus? Treatment?
Meconium in urine or vagina | Colostomy, later anal reconstruction with posterior sagittal anoplasty
43
Treatment for low imperforate anus?
Posterior sagittal anoplasty (pull anus down into sphincter mechanism); no colostomy needed
44
Post-op complications after surgery for imperforate anus?
Pts prone to constipation | Need anal dilation to avoid stricture
45
What is gastroschisis?
Intrauterine rupture of umbilical vein; does not have peritoneal sac To the right of midline, stiff bowel from exposure to amniotic fluid, low rate of congenital anomalies except malrotation
46
Treatment for gastroschisis?
Initially place saline-soaked gauzes and resuscitation; TPN, NPO Repair when stable, place bowel back in abdomen, may need Vicryl mesh silo and primary closure at later date
47
What is omphalocele?
Failure of embryonal development, midline defect | Increased risk of congenital anomalies (50%), has peritoneal sac with cord attached
48
What is Cantrell pentalogy?
Cardiac defects, pericardium defects (usually at diaphragm), sternal cleft or absence of lower sternum, diaphragmatic septum transversum abscence, omphalocele
49
Treatment for omphalocele?
Saline-soaked gauze and resuscitation, TPN, NPO | Repair when stable, try to place bowel in abdomen, may need vicryl mesh and delayed primary closure
50
What is the most common sign of Hirschsprung's? Other presentations?
Infants fail to pass meconium in 1st 24h Can also present in older age groups as chronic constipation, distention, colitis Explosive release of watery stool with rectal exam
51
Diagnosis of Hirschsprung's?
Barium enema: may be normal, often with spastic distal segment and dilated proximal segment Rectal biopsy with absence of ganglion cells in myenteric plexus
52
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)
53
What is Hirschsprung's colitis? | Treatment?
Rapidly progressive, manifested by abdominal distention, foul smelling diarrhea; lethargy and signs of sepsis Rectal irrigation, may need emergency colectomy
54
Treatment for hydrocele?
Surgery at 1y if not resolved or if though to be communicating (waxing/waning size), resect and ligate processus vaginalis
55
Treatment for umbilical hernia?
Repair if not closed by age 5 or incarceration or if pt has VP shunt
56
Inguinal hernias are in what % of infants? % R. vs. L.? % bilateral?
3% due to failure of closure of processus vaginalis | 60% right, 30% left, 10% bilateral
57
Treatment of inguinal hernias?
Emergent operation if not able to reduce, otherwise elective repaire with high ligation Explore contralateral side if left sided, female, or child <1y
58
Where is cystic duplication most commonly found? Treatment?
In ileum, often on mesenteric border | Resect cyst
59
What is the most common cause of neonatal jaundice requiring surgery?
Biliary atresia
60
Presentation of biliary atresia? Diagnosis?
Progressive jaundice (suggestive of atresia if persists >2wks after birth), cholngitis, continued cirrhosis, eventual hepatic failure
61
Diagnosis of biliary atresia? Treatment?
US and cholangiography; liver biopsy showing periportal fibrosis, bile plugging, cirrhosis Kasai procedure before age 3 mo. (hepaticoportojejunostomy): 1/3 get better, 1/3 go on to liver transplant, 1/3 die
62
Where do mets from osteosarcoma go? Treatment?
Lung | Resection of primary and pulmonary mets if isolated
63
Lab findings with teratoma? Type found in neonates? Treatment?
Elevated AFP and beta-HCG Sacrococcygeal Excision
64
What % of sacrococcygeal teratomas are benign at birth?
90%; >2mo usually malignant | Great potential for malignancy
65
Treatment for teratoma?
Coccygectomy and long-term followup
66
Treatment for undescended testicles?
Wait until 2yo Orchiopexy 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
67
Cancer risk with undescended testicles?
Seminoma risk | Risk stays the same even if testicle brought down into scrotum
68
What is prune belly syndrome?
Rare; hypoplasia of the abdominal wall, urinary tract abnormalities with dilated urinary system and bilateral cryptorchidism
69
What is the most common cause of airway obstruction in infants?
Laryngomalacia; caused by immature epiglottis cartilage with intermittent collapse of the epiglottis airway
70
Symptoms of laryngomalacia?
Intermittent respiratory distress and stridor exacerbation in the supine position
71
Treatment for laryngomalacia?
Most children outgrow by 12mo | Surgical trach if necessary
72
What is choanal atresia? Symptoms? Treatment?
Obstruction of choanal opening by either bone or mucus membrane (usually unilateral) Intermittent respiratory distress, poor suckling Surgical correction
73
What is the most common tumor of the pediatric larynx?
Laryngeal papillomatosis
74
Cause of laryngeal papillomatosis? Treatment?
From HPV in mother during passage through birth canal | Frequently involutes after puberty, can treat with endoscopic removal or laser; frequently recurs