General Paeds Surgery Flashcards
Paediatric renal transplant
In children obstructive uropathy is the leading cause
followed by structural abnormalities and
focal segmental glomerulosclerosis.
Glomerulonephritis is more common in adult patients.
The first choice of donor for a pediatric transplant is a living donor graft, followed by an adult size cadaver source. If a pediatric donor must be used, the age should be at least 6 years old and preferably over age 10
What are the energy requirement of term PN fed? And enteraly fed?
85-90 kcal/kg/day if PN +10% if enteral fed
What are the pathogens in Neutropenic necrotizing fasciitis?
gastrointestinal flora, gram negative rods and vancomycin resistant enterococcus are more commonly isolated
In which pathology(s) 11:22 translocation is found?
Ewing’s sarcoma
PNET; primitive neuro-ectodermal tumour
Is bi directional flow on echo an indication for PDA ligation?
Bi-directional shunting in the PDA suggests that pulmonary hypertension has not resolved. Ligation of the PDA in this setting may cause serious right heart failure and demise of the infant
What is Fontan procedure?
is a palliative surgical procedure used in children with univentricular hearts. It involves diverting the venous blood from the inferior vena cava (IVC) and superior vena cava (SVC) to the pulmonary arteries without passing through the morphologic right ventricle
What are the indications for endocarditis prophylaxis?
The current recommendations in CHD are:
a. Respiratory related procedures may require prophylaxis if the mucosa is incised such as in a lobectomy.
b. Congenital heart repairs that have prosthetic materials that may incompletely epithelialized(6 month) and may be exposed to soilage within are also considered appropriate for prophylaxis.
c. Certain dental procedures may require prophylaxis.
What is the type of abdominal injury in NAI?
Solid organ
Small intestine perforation (not usually colonic)
What is Ludwig’s angina?
is a rapidly spreading, firmly indurated cellulitis that originates intraorally and involves supramylohyoid and inframylohyoid compartments bilaterally, but without abscess or lymphadenopathy
It presents with acute left neck pain, difficulty swallowing, drooling, and displacement of the tongue superiorly
What are the signs and cause of cat scratch disease?
Papule on extremity Long Hx of lymphadenopathy Low grade temperature Bartonella is the causative organism Management is reassurance, adequate follow-up and analgesics
In PNLAD, what are the proposed mechanism to explain the beneficial effect of ω3FAs (omega3, omegavin).
First, the addition of ω3FAs results in an improvement in bile flow. Second, ω3FAs result in decreased steatosis.
Third, the addition of ω3FAs shifts the eicosanoid profile towards a reduced inflammatory state
What are the carbs in breast milk?
Carbohydrates in breast milk include lactose & oligosaccharides.
The oligosaccharides act as probiotics stimulating growth of Lactobacillus and Bifidobacterium
What’s Reye syndrome and Reye-like syndrome?
Reye syndrome is an acute metabolic encephalopathy, largely affecting children and adolescents.
In Reye-like syndrome, because of inborn errors of metabolism, hypoglycemia, hypoketonemia, elevated ammonia, and organic aciduria are often evident.
What’s the genetic insult in DiGeorge syndrome?
DiGeorge syndrome (DGS) is one of a group of phenotypically similar disorders including velocardiofacial syndrome (VCFS, or Shprintzen syndrome) and conotruncal anomaly face (CTAF) syndrome that share a microdeletion of chromosome 22q11.2, a region known as the DGS critical region
Loss of heterozygosity (LOH) of chromosome arm 11p markers occurs commonly in hepatoblastoma identified in association with?
Beckwith-Wiedemann syndrome (BWS) and hemihypertrophy
What is the management of Pediatric adrenocortical tumors (ACT) ?
Surgical resection, no role for neo-adjuvant chemotherapy
Mitotane is an adrenolytic agent which blocks adrenal steroid hydroxylation; it may help alleviate symptoms in patients who cannot undergo complete resection.
What is Paget von Schrötter syndrome?
axillary-subclavian effort-induced venous thrombosis, commonly after pole vaulting sport. secondary to compression of the subclavian vein at the thoracic outlet between the clavicle and first rib.
Neurological symptoms are rare
Venous gangrene is rare
Treatment is catheter directed thrombolysis and resection of first rib
How do you correct coagulopathy in a patient with inherent coagulopathy or on warfarin sustained head trauma?
Recombinant factor VIIa (rFVIIa, 7)
What is the success rate of re-do fundoplication?
70% regardless of the technique of the first procedure
What are the complications of fundoplication?
herniation of the wrap through the hiatus, “slipped wrap” onto the stomach, disruption of the wrap and gas bloat. Wrap herniation through the hiatus appears to be the most common complication associated with recurrence of symptoms.
What are the complications/ presentations of Meckel’s diverticulum?
Bleeding 50%
Obstruction (intuss-volvulus) 15-20%
Diverticulitis 15-20%
Umbilical symptoms
Which type of button batteries cause more injury?
Lithium is more dangerous than alkaline cells with necrosis beginning in fifteen minutes
What are the manifestation and treatment of local anaesthetic toxicity?
Toxicity manifests with neurologic (agitation, seizures) and cardiac (dysrythmias) side effects.
timely infusion of 1 to 2 mg/kg of 20% intralipid emulsion can reverse the toxic effects of bupivicaine
In Preoperative preparation for general anesthesia in sickle cell, transfusion aim is?
Transfusion to a hemoglobin of 10g/dL was found to be just as effective at decreasing the incidence of postoperative sickle exacerbations as a more aggressive transfusion strategy (decreasing the Hg S fraction to less than 30%).
What are the factors associated with increased risk of anaesthesia in mediastinal masses?
- orthopnea (although the absence of symptoms does not imply safety)
- greater than a 50% decrease in tracheal cross-sectional area on CT
- greater than a 50% decrease in supine peak expiratory flow rate
- severe narrowing or occlusion of one or both mainstem bronchi
What are the causes of Congenital hydrocolpos?
Cloaca, congenital imperforate hymen, complete transverse vaginal septum, or partial vaginal agenesis, as well as several genetic syndromes including the McKusick-Kaufman syndrome and Bardet-Biedl syndrome
What are the potential risks after splenectomy?
overwhelming postsplenectomy sepsis (OPSI).
Splenectomy increases the risk of vascular thrombosis.
increased intravascular hemolysis.
What is the best test to differentiate focal hyperinsulinism from focal HI?
PET scans with 18-fluoro-L-3,4-dihydroxyphenylalanine (18F-DOPA) have been shown to discriminate focal HI from diffuse
What does the medical management of HI involve?
First-line therapy for HI is medical, using diazoxide, a KATP channel agonist. Some patients do not respond to diazoxide because of mutations in KATP channel. Second-line therapy is with octreotide, a somatostatin analog
Glucagon to maintain euglycaemia
What is the most common malignant for of SCT?
Endodermal sinus tumour
If the tumor is malignant, chemotherapy with vincristine, actinomycin C, and cytoxan (VAC), and cisplatin, etoposide, and bleomycin (PEB) results in improved survival.
What is the rate of anatomical abnormalities in patients with reflux?
5%
UGI contrast have 50% false positive rate in GORD
What is the risk of GU anomalies in ARM?
50%
Cloaca or rectovesical fistula have a nearly 90% incidence of GU abnormalities, while perineal fistulas have a less than 10% incidence
Müllerian abnormalities are found in about 30- 45% of females with ARMs
Tethered cord 25%
Trisomy 21 is the most common chromosomal anomaly associated with ARMs
What are viral B, C & HIV transfusion risk?
HIV & C 1 in 2 million
B 1 in 200,000
What Skin changes can be seen in ulcerative colitis?
erythema nodusum (painful red nodules on the legs and arms)
pyoderma gangrenosum (small painful purulent ulcers, usually on the legs)
What is Lamber-Eaton syndrome?
Lambert-Eaton myasthenic syndrome (LEMS) is a rare presynaptic disorder of neuromuscular transmission. It’s a para-neoplastic syndrome; This is usually a small cell lung cancer (SCLC), lymphosarcoma, malignant thymoma, or carcinoma of the breast, stomach, colon, prostate, bladder, kidney, or gallbladder.
What are the indications of bariatric surgery in adolescents?
adolescent with a :
-BMI of 35 kg/m2 or greater in the presence of severe obesity related co-morbidities
- in the absence of co-morbidity if the BMI is 40 kg/m2
Comorbidities: joint replacement, type 2 diabetes mellitus, pseudotumor cerebri, sleep apnea (apnea-hypopnea index > 15) and severe steohepatitis
What are the types of blunt cardiac injury and how to diagnose?
BCI, 95% are cardiac contusions followed by valvular dysfunction and ventricular septal defect
Troponin I is a sensitive and more specific measure than CK-MB, levels become elevated within hours of injury and remain elevated for 4-7 days
Ina newborn infant when does the kidney reach GFR and concentration ability?
GFR 90% by 3 months
Renal tubular maturation (concentration) takes two to three years to reach adult levels.
Creatinine clearance reaches adult levels by two years of age.
What’s shunt fraction, and what affects it?
The shunt fraction is the percentage of blood pumped from the heart that is not completely oxygenated.
“physiological shunt,” and is rarely over 4%
Atelectasis, pulmonary contusion and aspiration increase shunt fraction
Placing a patient prone will often redistribute blood from the dependent areas full of inflammatory fluid to those areas with better ventilation, decrease shunt fraction
Stress ulcer prophylaxis in intensive care unit (ICU) patients is associated with decreased?
Blood in gastric aspirated
There is no evidence to suggest reduced significant GI bleed, mortality or ventilator associated pneumonia
How much bile acid is secreted daily?
3 grams per day in 4-12 cycles, 95% reabsorbed and only 2-5% is excreted in faeces
What is the indicative ratio of The CPAM volume to head circumference ratio (CVR)?
Those with a CVR >1.6 have a large mass lesion that will result in fetal morbidity or mortality in about 80% of cases without fetal intervention.
The CPAM lung lesions with a CVR < 1.6 will often not continue to grow past the 28th week of gestation.
What is the management of cholestasis in premature infants?
Conservative main; continue enteral feeding
Gallstones in neonates, even from TPN, may be expected to resolve spontaneously.
Biliary tree irrigation has also been reported to be beneficial in instances where there is not biliary tree dilation, but where cholestasis is not resolving.
no benefits from cholecystokinin-octapeptide or ursodeoxycholic acid in this condition
What’s delayed gastric emptying?
more than 50% retained labeled liquid or solid meal within the stomach after 120 minutes in children younger than two years and after 60 minutes in children older than two years
What percentage of GORD patient have delayed gastric emptying?
It is estimated that forty to fifty percent of children with symptomatic gastroesophageal reflux have delayed gastric emptying.
Studies have demonstrated that fundoplication alone decreases gastric emptying time
What is the percentage of malformation in Prune belly?
Thirty percent of patients will have intestinal malrotation. Although jejunoileal atresia remains rare, imperforate anus and anorectal agenesis have been reported. The latter has been noted in a significant number of patients, 5/13 in one series.
What is the Na concentration of normal saline and ringer lactate?
lactated ringers (LR) (134 mEq/l Na) Normal saline (154 meq Na/l)
What percentage of rectal prolapse have CF?
Cystic fibrosis accounted for 11% of patients with rectal prolapse in one historical series and current recommendations include cystic fibrosis screening in patients with rectal prolapse. The recommendations are based on 30 year old literature. In a recent 15 year review there were no patients diagnosed with CF on evaluation for rectal prolapse.
In PN patient, which trace element deficiency can cause DM like symptoms?
Chromium deficiency
What are the common mutations in HD?
The more common mutations associated with Hirschsprung’s disease are the RET gene, the EDNRB and the END3 gene
What percentage of OA/TOF develops trachiomalacia?
Up to 75% of infants with esophageal atresia and a TEF will have structural abnormalities in the trachea with weakened cartilaginous rings, though only 25% may become symptomatic.
In ITP how does steroids and IVIG work?
Corticosteroids work by inhibition of reticuloendothelial binding of platelet/antibody complexes
IVIG inhibits Fc receptor binding of platelets by macrophages
What is The most significant factor affecting post-operative recurrence of Crohn‘s?
Smoking
at least double the risk of recurrence
What is the most common site of rebleeding after sclerotherapy for oesophageal varices in extra hepatic portal venous obstruction?
Gastric varices (30%) As opposed to (4.6%) oesophageal varices in one study
What is the definition of portal hypertension?
Pressure more than 5-10 mmHg
What is The most common presentation of extrahepatic portal venous obstruction (EHPVO) in children?
is variceal bleed and splenomegaly
Non cirrhotic, not jaundice
Post splenectomy sepsis is higher post traum or haematology?
Splenectomy from trauma is associated with significantly lower PSS risk than for other indications, specifically hematologic abnormalities
What percentage of spleen is required to prevent PSS?
It is felt that preservation of more than 40% of the native splenic volume is necessary for prevention of PSS, although the evidence behind this recommendation is relatively weak
What percentage of Extralobar sequestration is associated with other anomalies?
30% including cardiac, hindgut and gastrointestinal abnormalities.
Does intralobar sequestration associate with GI anomalies?
Communication between the lesion and the GI tract occurs in about 10%.
What percentage of the <2 years develop FIA following perineal abscess I&D?
anal fistula in up to 30% of patients following Incision and drainage of a perianal abscess in the < two-year-old age group
Is neonatal torsion associated with difficult delivery?
There is retrospective evidence to suggest that neonatal torsions occur in mothers with difficult deliveries
What are calcinurin inhibitors?
Calcineurin inhibitors (eg, cyclosporin A [CSA], tacrolimus [TAC]) are steroid-sparing agents that can also be used in children who fail to respond to, or who subsequently relapse after, treatment with cyclophosphamide (from nephrotic syndrome)
In coach what are the rates for GU anomalies?
50% will develop renal insufficiency
50-67% will have gyne abnormality
30-40% menstrual obstruction
What’s the accepted pre- post- ductal saturations in CDH?
preductal oxygen saturation levels from 85-95%,
post ductal oxygen saturation >70% and
paCO2 of 45 – 60 mm Hg
What is undrained traumatic hemothorax (UTH) and how you manage it?
Residual collection in the chest following tube thoracostomy alone in trauma case, it occurs in 8% of cases of haemothorax treated by tube thoracotomy.
Administration of intrapleural thrombolytic agents has been found to be cost effective and successful in treating UTH in over 90% of patients and should be the preferred initial therapy.
In inhumanly hernias what is the rate of:
Incarceration as first presentation?
Contralateral PPV?
Need for groin exploration in adulthood?
<20% will present with incarceration
contralateral PPV 63% < 2months and 41% >2years, highest rate of metachronous hernia development approaching 31%
repeat groin exploration was 8% (with a median time to re-exploration being 38 years)
In circumcision what’s the rates of UTI prevention?
Given the normal risk of male urinary tract infection (UTI) of one percent, the number-needed-to-treat (NNT) to prevent a single UTI is 111. For patients with high grade vesicoureteral reflux who have a 30% rate of UTI the NNT is 4.
In Meckel’s diverticulum what is the rate of pancreatic mucosa?
15%
radionuclide technetium 99m pertechnetate excreted by the acid -secreting parietal cells of gastric mucosa and does not detect pancreatic mucosa
What is the histopathology findings of neuronal intestinal dysplasia (NID)?
Type B: 15-20% giant ganglia in the submucosal layer, increased Ach staining in the lamina propria or around submucosal vessels
What is the incidence of recurrent symptoms after Heller’s and how to manage?
30-50%. When symptoms recur, an attempt at balloon dilation with or without Botox injection is a reasonable option; however, revision Heller myotomy provides the best long term results
What is Petersen’s window?
In Roux en Y gastric bypass, left to right bowel herniation through Petersen’s window between the Roux en Y limb and the transverse mesentery can occur and can give The “mushroom sign” CT, suggests a herniation of the small bowel with streaming edematous mesentery through a mesenteric defect.
What is the incidence of typhlitis?
2-30% of patients
more prevalent during induction chemotherapy and in AML vs ALL
The presence of clostridium septicum should also alert one to the potential for ileocecal disease
How do you manage leg ischemia from femoral artery ECMO cannula?
placement of a femoral artery catheter in a distal direction at the common femoral access site, to allow distal perfusion via the ECMO circuit
Which factor is associated with the highest risk of developing recurrent gastroesophageal reflux disease (GERD) following fundoplication in children?
postoperative retching and postoperative esophageal dilation highest risk (Ngerncham et al, 2007)
Age less than six years, preoperative hiatal hernia were significant factors
neurologic impairment was not associated with increased risk for recurrent disease when controlled for the other factors
What is the presentation of MEN 2A?
All patients 100% develop MTC on the basis of C-cell hyperplasia. About 50% of patients with MTC manifest pheochromocytomas (usually late in life), and
20% of patients have hyperparathyroidism.
Which Abx is most effective in pouchitis?
Cochrane Reviews suggest that ciprofloxacin is a more effective treatment for acute pouchitis than other antibiotics like metronidazole
In long term NB, what is the rate of secondary malignancy?
second malignancies in 3.5% of patients at 25 years and 7% at 30 years.
The most common second malignancy is thyroid cancer, followed by renal cell cancer
What is the risk of malignancy in UDT compared to general population?
Historically 40-60 times, recent reports 2-8 times
What is the risk of malignancy in intra abdominal compared to other types of UDT?
The risk of cancer of an intra-abdominal testicle is about x4-5 four to five times that of other undescended testicles.
What are the types of malignancies that develops in UDT?
Seminoma is the predominant cancer that develops in uncorrected undescended testicles while
embyronal tumors or teratocarcinoma make up the majority of cancers found in testicles that have undergone orchipexy.
which mechanism an oscillatory ventilator provides its protection against lung injury as compared to conventional ventilators ?
minimizing tidal volume
A high frequency ventilator uses small tidal volumes delivered at a fast rate while maintaining an appropriate end expiratory pressure to keep an optimal amount of alveoli open
What factors increase long term lung morbidity in CDH?
The need for patch repair is associated with a x3 three-fold higher risk and
a right-sided hernia a x2 two-fold higher risk of bronchopulmonary dysplasia in patients who survive past thirty day
What percentage of ovarian torsion are due to malignancy ?
Twenty percent of patients presenting with ovarian torsion will have an underlying ovarian neoplasm
Five percent of ovarian teratomast will present with torsion.
What percentage of incidental adrenal masses in children are malignant?
One third
adrenalectomy is warranted
What is the risk of oesophageal CA in OA patient compared to general population?
X50
The risk of a patient with esophageal atresia developing carcinoma of the esophagus may be up to fifty times greater than that of the general population
What is the incidence of right aortic arch and OA?
between 4 and 16%.
Patients with a right-sided arch are more likely to have:
a long gap atresia,
more likely to have a cardiac anomaly,
twice as likely to have perioperative complications and
ten times as likely to have a vascular ring (38 vs. 3.8%).
In cases associated with a vascular ring, left thoracotomy allows for division of the patent ductus which facilitates esophageal mobilization.
In sickle cell disease what are the indications of splenectomy?
1- acute splenic sequestration crisis; Splenectomy is indicated after one major sequestration crisis (Hg decrease more than 3 g/dl) or multiple minor crises (Hg drop less than 3 g/dl).
2- hypersplenism
3- splenic abscess
4- massive splenic infarction
