Chapter 5 - Pediatric Surgery Flashcards
Management of most congenital anomalies?
Most require surgical correction, but in many of them, other anomalies have to be looked for first
Presentation of esophageal atresia?
Excessive salivation noted shortly after birth, or choking spells with first feeding is attempted
First step in working-up possible esophageal atresia?
Small NG tube passed, will be seen coiled in the upper chest when x-rays are done
If normal gas pattern in bowel, the baby has the most common form of the 4 types (blind pouch in upper esophagus + fistula between lower esophagus and tracheabronchial tree)
Before treating esophageal atresia, what must be done?
Rule out associated anomalies -> VACTER constellation (vertebral, anal, cardiac, tracheal, esophageal, renal, and radial)
- Examine anus for imperforation
- XR for vertebral and radial anomalies
- Echo for cardiac
- Sonogram for renal
Rx of esophageal atresia?
Primary surgical repair (preferred)
If it must be delayed, gastrostomy has to be done to protect the lungs from acid reflux
Management of imperforate anus found on physical exam?
Rule out VACTER anomalies as above
Look for nearby fistula to vagina or perineum -> if present, repair can be delayed until further growth *before toilet training)
If not -> colostomy for high rectal pouches (with later repair) or primary repair if blind pouch is almost at the anus
How is the level of the imperforate anal pouc determined?
XR taken upside down (so that the gas in the pouch goes up, with a metal marker taped to the anus)
Congenital diaphragmatic hernia is always on the ___ (side).
Left
What is the main problem with congenital diaphragmatic hernia?
The real problem is not the mechanical one, but the hypoplastic lung that still has fetal-type circulation.
Rx congenital diaphragmatic hernia?
Repair must be delayed 3-4 days to allow maturation. Babies are in respiratory distress, need ET intubation, low-pressure ventilation, sedation, and NG suction
Very severe cases that do not respond to conventional therapy are treated with ECMO
Dx congenital diaphragmatic hernia?
Prenatal sonogram
Presentation of gastroschiis?
Abdominal wall defect in the middle of the belly with a normal cord (defect is to the right of the cord). NO protective membrane, bowel looks angry and matted.
Presentation of omphalocele?
Abdominal wall defect in the middle of the belly. Cord goes to the defect, which has a thin membrane under which one can see normal-looking bowel and a little slice of liver
Rx gastroschisis and omphalocele?
Small defects can be closed primarily. Large defects require construction of a Silastic “silo” to house and protect the bowel. The contents of the silo are then squeezed into the belly, a little bit every day, until complete closure can be done in about a week.
Gastroschisis -> need vascular access for parenteral nutrition, because the bowel will not work for ~1 month
Presentation of exstrophy of the urinary bladder?
Abdominal wall defect over the pubis which is not fused, with a medallion of red bladder mucosa, wet and shining with urine
Management of exstrophy of the urinary bladder?
Transfer immediately to a specialized center where a repair can be done within the first 1-2 days of life. Delayed repairs do not work.
DDx - green vomiting and a “double-bubble” picture on XR (large air-fluid level in the stomach, smaller one to the right in the first portion of the duodenum)? Which is the most dangerous?
Duodenal atresia
Annular pancreas
Malrotation - most dangerous because the bowel can twist on itself, cut off its blood supply, and die
Note - all require surgical correction
Dx malrotation?
Contrast enema (safe, but not always diagnostic) or upper GI study (more reliable, but more risky)
Suggested with a normal
Presentation of intestinal atresia?
Green vomiting + multiple air-fluid levels throughout the abdomen
What other congenital anomalies should be suspected in the setting of intestinal atresia?
None - this condition results from a vascular accident in utero
List the 7 conditions to be worried about in newborns through the first 24 hours.
- Esophageal atresia
- Imperforate anus
- Congenital diaphragmatic hernia
- Gastroschisis and omphalocele
- Exstrophy of the urinary bladder
- Green vomiting -> duodenal atresia, annular pancreas, malrotation
- Intestinal atresia
Presentation of necrotizing enterocolitis?
Seen in premature infants when they are first fed
Feeding intolerance, abdominal distention, rapidly dropping platelet count (sign of sepsis in babies)
Rx necrotizing enterocolitis?
Stop all feedings
Administer broad-spectrum ABX
IV fluids
IV nutrition
When is surgical intervention indicated in the setting of necrotizing enterocolitis?
If the 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)
Presentation of meconium ileus?
Seen in babies who have CF
Feeding intolerance and bilious vomiting
XR - multiple dilated loops of bowel and a ground-glass appearance in the lower abdomen
Dx and Rx meconium ileus?
Gastrografin enema is both diagnostic (microcolon and inspissated pellets of meconium in the terminal ileum) and therapeutic (draws fluid in, dissolves the pellets)
Presentation of hypertrophic pyloric stenosis?
Presents ~3 weeks
More common in first-born boys
Non-bilious projectile vomiting after each feeding
Baby is hungry and eager to eat again after vomiting
Visible gastric peristaltic waves
Palpable olive-sized mass in the RUQ
Dx hypertrophic pyloric stenosis?
If mass cannot be felt -> sonogram
Rx hypertrophic pyloric stenosis?
Rehydration and correction of the hypochloremic, hypokalemic metabolic alkalosis
Ramstedt pyloromyotomy or ballon dilatation
Presentation of biliary atresia?
6- to 8-week old babies
Persistent, progressively increasing jaundice (substantial conjugated fraction)
Work-up suspected biliary atresia?
Serologies and sweat test to r/o other problems
HIDA scan after 1 week of phenobarbital (powerful choleretic)
If no bile reaches the duodenum even with phenobarb stimulation -> surgical exploration
Prognosis of babies with biliary atresia?
1/3 get a long-lasting surgical derivation
1/3 need a liver transplant after surviving for a while with a surgical derivation
1/3 need transplant right away
Presentation of Hirschsprung disease (aganglionic megacolon)?
Can be recognized early or go undiagnosed for many years
Cardinal symptom is chronic constipation
With short segments, rectal exam may lead to explosive expulsion of stool and flatus, with relief of abdominal distention
Older kids - presence of fecal soiling
XR - proximal colon distended, normal-looking distal colon (aganglionic part)
Dx and Rx Hirschsprung?
Dx - full-thickness biopsy of rectal mucosa
Rx - operations that preserve the unique sensory input of the motor-impaired rectum, while adding the normal propulsive capability of the innervated colon
List the 5 conditions to be worried about in newborns from a few days old through the first 2 months.
- Necrotizing enterocolitis
- Meconium ileus
- Hypertrophic pyloric stenosis
- Biliary atresia
- Hirschsprung disease
Presentation of intussusception?
6 to 12-month-old chubby, healthy-looking kids
Episodes of colicky abdominal pain that make them double up and squat. Lasts for ~1 minute, kid goes back to normal
Exam - vague mass on the right side of the abdomen, “empty” RLQ, “currant jelly” stools
Dx and Rx intussusception?
Barium or air enema (dx and rx). Surgery if reduction is not achieved radiologically, or if there are recurrences
Classic presentations of child abuse?
Subdural hematoma + retinal hemorrhages (shaken baby syndrome)
Multiple fractures in different bones at different stages of healing
All scalding burns, particularly burns of both buttocks (child held by arms and legs and dipped into boiling water)
___ should be suspected in lower GI bleeding in the pediatric age group. Dx?
Meckel diverticulum; radioisotope scan (technetium) to look for gastric mucosa in the lower abdomen
Management of undescended testicle?
Orchiopexy (surgically brought down and fixed in place) if still undescended by 1 y/o
What is a testicle that is in the canal at birth and can be easily pulled down where it belongs?
NOT an undescended testicle -> overactive cremasteric muscle. Reassure parents o the benign nature.
Abdominal mass in children that moves up and down with respiration?
Most likely a malignant liver tumor (hepatoblastoma or HCC)
-Expect, alpha fetoprotein to be elevated
Deeper, non-mobile mass?
Wilms tumor arising from kidney or a neuroblastoma gorwing in adrenals
Dx abdominal mas?
CT or MRI
Why do babies have greater fluid requirements?
More body surface area per unit of weight
Calculate pediatric fluid requirements (daily).
Peds patient should get :
100 cc/kg/day up to 10 kg of body weight
+
50 cc/kg/day for the next 10 kg of body weight
+
20 cc/kg/day for anything above 20 kg
Calculate pediatric fluid requirements (hourly).
5 cc/kg/hr for the first 10 kg
2 cc/kg/hr for the next 10 kg
1 cc/g/hr for anything past this
