Chapter 43 - Pediatrics II Flashcards
Where is Meckel’s diverticulum found?
What is the rule of 2s?
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)
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: Pancreatic
Symptomatic: Gastric
Treatment for Meckel’s diverticulum?
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
What is the presentation of pyloric stenosis? Exam findings? Lab abnormality?
3-12wks, firstborn males with projectile vomiting
Olive mass in stomach
Hypochloremic, 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? Diagnostic evaluation?
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)
Lead points for intussusception in children?
1 Peyer’s patches, lymphoma, Meckel’s
What % of intussusception in children recur after reduction? How do you proceed if abdominal pain recurs?
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.
Treatment for intussusception in children?
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.
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 multiple
Barium enema to r/o Hirschsprung’s, resection
What other anomalies is duodenal atresia associated with?
Polyhydramnios in mother
Cardiac, 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?
Resuscitation
Duodenoduodenostomy or duodenojejunostomy
What is the most common type of Tracheoesophageal (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 fistula
Similar to type C
What is type E TE fistula?
H configuration of esophagus and trachea
Most 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 TE 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 1y
75% in 1st month
Diagnosis of malrotation? Treatment?
UGI duodenum does not cross midline
Ladd’s procedure: Resect 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 bowel
Can 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 defect
Occurs 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 enema
Surgery: 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 vagina
Colostomy, 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 constipation
Need anal dilation to avoid stricture
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
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
What is omphalocele?
Failure of embryonal development, midline defect
Increased 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, NPO
Repair 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 24h
Can also present in older age groups as chronic constipation, distention, colitis
Explosive release of watery stool with rectal exam
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
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 sepsis
Rectal 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 vaginalis
60% right, 30% left, 10% bilateral
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
Where is cystic duplication most commonly found? Treatment?
In ileum, often on mesenteric border
Resect 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, cirrhosis
Kasai 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?
Lung
Resection of primary and pulmonary mets if isolated
Lab findings with teratoma? Type found in neonates? Treatment?
Elevated AFP and beta-HCG
Sacrococcygeal
Excision
What % of sacrococcygeal teratomas are benign at birth?
90%; >2mo usually malignant
Great potential for malignancy
Treatment for teratoma?
Coccygectomy and long-term followup
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
Cancer risk with undescended testicles?
Seminoma risk
Risk 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 suckling
Surgical 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 canal
Frequently involutes after puberty, can treat with endoscopic removal or laser; frequently recurs
