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
