Chapter 5: Pediatric Surgery Flashcards
What are some physical symptoms associated with Esophageal Atresia?
- Excessive salivation noted shortly after birth
2. Choking spells when first feeding is attempted
Where with the NG tube placement be seen on an XRAY with a baby with esophageal atresia?
NGT will be seen coiled in the upper chest when XRAYs are done.
What is the most common type of esophageal atresia?
A blind pouch in the upper esophagus and a fistula between the lower esophagus and the tracheobronchial tree. Normal gas pattern in the bowel.
What is the VACTER constellation that needs to be ruled out before therapy is under taken for esophageal atresia?
- Vertebral
- Anal: Imperforation **
- Cardiac
- Tracheal
- Esophageal
- Renal
- Radial
If surgery has to be delayed in esophageal atresia what has to be done?
A gastrostomy has to be done to protect the lungs from acid reflux.
What VACTER constellation should you be wary of on physical exam, that if its there you should look for the others?
Imperforate Anus.
What should you look for if you have an imperforate anus?
Look for a fistula nearby to vagina or perineum
If a fistula is present with an imperforate anus what should you do surgically
Repair can be delayed until further growth (but before toilet training time)
If there is no fistula present with an imperforate anus what should you do surgically?
A colostomy needs to be done for high rectal pouches (and later the repair) or a primary repair can be done right away if the blind pouch is almost at the anus
How is the level of the pouch for an imperforate anus determined?
With X-rays taken upside down so that the gas in the pouch goes up , with a metal marker taped to the anus
In a congenital diaphragmatic hernia what side do they happen on?
Always on the left and the bowel will be up in the chest.
What is the problem with a congenital diaphragmatic hernia?
the hypo plastic lung that still has fetal type circulation
How long do you have to wait to repair a congenital diaphragmatic hernia?
3-4 days to allow maturation.
What do babies need if they have a congenital diaphragmatic hernia?
- respiratory distress and need endotrachaeal intubation
- low pressure ventilation (careful not to blow up the other lung)
- sedation
- NG suction
In a difficult case of congenital diaphragmatic hernia what might the baby need?
Extracoporeal membrane oxygenation (ECMO)
How are patients diagnosed with a congenital diaphragmatic hernia?
before birth by sonogram
What are the two abdominal wall defects in the middle of the belly?
- Gastroschisis
2. Omphalocele
In gastroschisis where is the defect in relation to the cord? is the defect protected?
The cord is normal (it reaches the baby) and the defect is to the right of the cord.
The cord has no protective membrane and the bowel looks angry and matted.
In an omphalocele where does the cord go?
The cord goes to the defect, which has a thin membrane under which one can see normal-looking bowel and a little slice of liver
How are large defects in an omphalocele reduced?
By the construction of a Silastic “silo” to house and protect the bowel. The contents are then squeezed into the belly, a little bit every day until complete closure can be done in about a week
What other important thing do babies with gastroschisis need because of the angry looking bowel?
Vascular access for parental nutrition. the bowel will not work for about 1 month.
Describe the appearance of exstrophy of the urinary bladder.
Another abdominal wall defect but over the pubis (which is not fused), with a medallion of red bladder mucosa, wet and shining with urine.
How quickly do you need to fix exstrophy of the urinary bladder?
Repair must be done within the first 1 or 2 days of life. delayed repairs do not work.
What is a double bubble sign on x ray?
A large air-fluid level in the stomach, and a smaller one to its right in the first portion of the duodenum.
In what illnesses do you find green vomiting and a double bubble?
- Duodenal atresia
- Annular pancreas
- malroation
Which one of the vomiting plus double bubble signs is the most dangerous?
Malrotation because the bowel can twist on itself , cut off its blood supply and die
If there is a normal gas pattern beyond the double bubble sign which is more likely?
Malrotation, can happen within the first few weeks of life
How is malrotation diagnosed?
- contrast enema (safe but not always diagnostic)
2. upper GI study (more reliable, but more risky)
How does intestinal atresia present on X-ray?
Green vomiting but with multiple air-fluid levels throughout the abdomen
How does intestinal atresia happen?
This condition results from a vascular accident in utero
Necrotizing enterocolitis presents in what manner?
Premature infants when they are first fed.
- Feeding intolerance
- Abdominal distention
- A rapidly dropping platelet count
What is a rapidly dropping platelet count in babies indicative of?
A sign of sepsis.
What is the treatment for necrotizing enterocolitis?
- stop all feedings
- administer broad spectrum antibiotics
- IVF
- IV nutrition
When is surgery indicated in a baby with necrotizing enterocolitis?
- infant develops abdominal wall erythema
- air in the portal vein
- intestinal pneumatosis (presence of gas in the bowel wall)
- Pneumoperitoneum ( signs of intestinal necrosis and perforation)
Who normally has meconium ileus?
Babies who have cystic fibrosis
How do babies with meconium ileus present?
Develop feeding intolerance
Bilious vomiting
What do X-rays show for a baby with meconium ileus?
X-rays show multiple dilated loops of small bowel and a ground glass appearance in the lower abdomen
What is diagnostic and therapeutic of meconium ileus?
Gastrographin enema (diagnostic =microcolon and inspissated pellets of meconium in the terminal ileum) (therapeutic= draws fluid in, dissolves the pellets)
How does hypertrophic pyloric stenosis present?
3 weeks of age, more commonly in first born boys, with non bilious projectile vomiting after each feeding. the baby is hungry and gear to eat again after he vomits. They are dehydrated. visible gastric peristaltic waves and a palpable olive size mass in the RUQ.
What is diagnostic of hypertrophic pyloric stenosis?
Palpable olive size mass in the RUQ or sonogram.
What is the treatment for hypertrophic pyloric stenosis?
Therapy begins with rehydration and correction of the hypochloremic, hypokalemic metabolic alkalosis, followed by Ramstedt pyloromyotomy or balloon dilation.
When should someone suspect biliary atresia?
6-8 week old babies who have persistent, progressively increasing jaundice
What test should you do if you suspect biliary atresia?
HIDA scan after 1 week of phenobarbital. If no bile reaches the duodenum even with phenobarbital stimulation, surgical exploration is needed.
With surgical derivation how often is it possible to need a liver transplant with someone with biliary atresia?
one third need a liver transplant right away
What is another name for Hirschsprung disease?
Aganglionic megacolon
What is the cardinal symptom of Hirschsprung disease?
Chronic constipation
What may happen with rectal exam with Hirschsprung disease?
may lead to explosive expulsion of stool and flatus, with relief of abdominal distention.
What do X-rays show with Hirschsprung disease?
distended proximal colon (the normal part) and normal looking distal colon, which is the aganglionic part.
How is diagnosis made of Hirschsprung disease?
Full thickness biopsy
How does intussuception present?
6 to 12 month old
chubby
healthy looking kids
who have episodes of colicky abdominal pain that makes them double up and squat.
What does the physical exam show with intussuception?
vague mass on the right side of the abdomen, an “empty” RLQ and currant jelly stools
What is both diagnostic and therapeutic in intussuception?
Barium or air enemas
When do you suspect meckel diverticulum?
Suspected in lower GI bleeding in the pediatric age group
What test do you do and what are you looking for with meckel diverticulum?
Do radioisotope scan looking for gastric mucosa in the lower abdomen.
If a baby has an abdominal mass that moves up and down with respiration what is it? What is elevated in these patients?
Most likely a malignant liver tumor (hepatoblastoma or hepatocellular carcinoma) usually alpha fetoprotein is elevated.
If a baby has an abdominal mass that is deeper and non mobile what is it?
Wilms tumor arising from the kidney or a neuroblastoma growing in the adrenal gland
In a patient with neuroblastoma what is the prognosis?
Depends on the age of discovery. The earlier it is discovered the better the cure rate.
What is a curious added feature of the neuroblastoma?
IT may involute and spontaneously revert to a benign neuroma
What if a baby has an undescended testicle by the age of one?
Needs to be surgically brought down to the scrotum and fixed into place. (orchiopexy)
What is an overactive cremasteric muscle?
A testicle that is in the canal at birth, but can be easily pulled down where it belongs is NOT an undescended testicle.
