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Pediatrics- Noelle > General surgery > Flashcards

General surgery Flashcards

1
Q

what is the most common surgical emergency?

A

appendicitis

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2
Q

what is the peak age for appendicitis

A

11-12 years

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3
Q

Ddx of appendicitis

A

GI: gastroenteritis, lymphadenitis, colitis/IBD, Meckel’s, cholecystitis
GU: UTI, pyelonephritis, renal calculi
Ob-Gyn: ectopic pregnancy, ovarian torsion, ovarian cyst, tuba-ovarian abscess/PID
Other: DKA, HSP, RLL pneumonia

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4
Q

what is the management for simple appendicitis

A 
laproscopic technique
no antibiotics (just at induction of surgery)
discharge home within 24 hours
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5
Q

what is the management for perforated appendicitis

A

managed more and more non operatively with IV antibiotics until afebrile
typically abc for 7-10d
may require drainage procedure for large abscess

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6
Q

what is the non-operative management of acute appendicitis in children?

A

IV abs for 24-72 hours then oral for 1 week

high rate of failure or recurrence in 1st year (40%)

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7
Q

what is the age for presentation of hypertrophic pyloric stenosis

A

2 week to 2 months

- premature babies diagnosed later

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8
Q

pyloric stenosis
classic presentation
risk factors
olive

A

classic presentation: non bilious projectile emesis

  • emesis is progressive over a short period of time until it occurs with every feed
  • coffee grounds in emesis are not uncommon

M>F
risk factors: family history, first born, maternal feeding patterns
olive= pylorus

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9
Q

what is the gold standard for diagnosis of pyloric stenosis

A

ultrasound
length >14 mm
width >4 mm

UGIS another option- see string sign

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10
Q

what are the metabolic derangements seen with pyloric stenosis

A

hypochloremic hypokalemic metabolic alkalosis

lose electrolytes in non bilious vomiting- especially H+ and Cl-

kidney tries to correct pH and Cl- by excreting Na and HCO3 making alkalosis worse
when more volume depleted aldosterone kicks in and reabsorbs Na and volume at expense of H+ and K+
therefore you get a PARADOXICAL ACIDURIA
- K+ loss is really mediated and occurs with prolonged emesis

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11
Q

What is the initial management for a patient with pyloric stenosis? what do the electrolytes have to be to be safe for anesthesia?

A

IV fluid bolus with 0.9%NS- 10mL/kg until urine output resumes
then switch to D51/2NS + 20-40meq/L KCL
reassess fluid and electrolyte status to ensure normalization of metabolic status prior to OR
Cl>95
HCO3<28
K+>3.5

Correction of the alkalosis is essential to prevent postoperative apnea, which may be associated with anesthesia.

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12
Q

what is the surgical treatment for pyloric stenosis?

A

pyloromyotomy

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13
Q

what are some complications of pyloromoyomy (2)

A

mucosal perforation- become septic
incomplete pyloromyomy

if you think there is a leak then do UGI

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14
Q

what is the most common pathological lead point seen with intussusception?

A

meckel’s diverticulum

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15
Q

what is intussusception

A

teloscoping or prolapse of one portion of the bowel into an immediately distal adjoining part

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16
Q

what age do we see intussusception? gender preference?

A

3 months to 3 years
peak at 9months-12 months
M>F 3:1

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17
Q

what time frame is highest risk for recurrence of intussusception?

A

first 24 hours

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18
Q

what is the most common type of intussusception

A

ileocolic

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19
Q

what type of intussusception is seen with HSP

A

Ileo-ileal

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20
Q

what are the 4 types of intussusception?

A

ileocolic
ileo-ileal
coli-colic
jejuno-jejunal

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21
Q

what is the common presentation of intussusception

A

intermittent cramps colicky pain with sudden onset
inconsolable during “crisis”
quiet between episodes

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22
Q

what is the most common cause of intussuception

A

idiopathic- lymphoid hyperplasia
predisposing factors- recent upper respiratory illness (Adenovirus)
recent diarrheal illness (enterovirus)

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23
Q

what are some pathological lead points for intussusception? Whats the most common?

A

Meckels (MOST COMMON)
HSP
appendix, hemangioma, foreign body, ectopic mucosa, hamartoma
malignancy (lymphoma, small bowel tumors, melanoma)

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24
Q

what is the gold standard investigation for intussusception?

A

ultrasound

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25
Q

once ultrasound has suggested a diagnosis of intussusception what is done to confirm

A 
air enema (PNEUMATIC REDUCTION)
or contrast enema
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26
Q

what are 3 absolute contraindications for pneumatic reduction of intussusception

A

peritonitis
persistent hypotension
free air (pneumoperitoneum)

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27
Q

what presents with painless rectal bleeding

A

Meckel’s diverticulum
- typically see a drop in hemoglobin

Meckel diverticulum accounts for 50% of all lower GI bleeds in children younger than 2 yr of age.

acid-secreting mucosa that causes intermittent painless rectal bleeding by ulceration of the adjacent normal ileal mucosa.

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28
Q

what is the most common congenital anomaly of the GI tract?

A

Meckel’s diverticulum

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29
Q

what are the rules of 2 for Meckels diverticulum

A

2% of the population
2:1 M: F
2-6% symptomatic, complicated
2 years (50-75% symptomatic by age 2 years)
2 feet from ileocecal valve
2 inches long
2 types of heterotypic mucosa: gastric, pancreatic

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30
Q

what investigation do you do for Meckel’s diverticulum?

A

Meckel’s scan
99Tc scan
- detects gastric mucosa
-pretreat with H2-blocker (enhances uptake)

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31
Q

what is the most common presentation of Meckel’s? what’s another presentation?

A

painless rectal bleeding is the most common presentation

20-25% present with diverticulitis (resect with laparoscopy)

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32
Q

what is the management of a baby born with known congenital diaphragmatic hernia (2)

A

Intubate on first breath

NG tube to decompress the stomach

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33
Q

what investigation should be done for a baby with CDH?

A

cardiac echo

should also look for chromosomal anomalies

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34
Q

what is the most important predictor of outcome for babies with CDH

A

size of the defect

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35
Q

what is the most important maneuver to confirm a diagnosis of EA-TEF?

A

attempt insertion of NG tube

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36
Q

what major anomaly occurs MOST frequently with EA-TEF?

A

cardiovascular

remember that TEF is a part of VACTERL therefore need to work up for VACTERL

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37
Q

what is a red flag on feeding history for TEF?

A

coughing, gagging, cyanosis with feeding

profuse oral secretions

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38
Q

what size NG should you use to check for TEF

A

8-10F

usually blocks at 10cm

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39
Q

how can you confirm the presence of a fistula with esophageal atresia on x ray

A

air in stomach/abdomen confirms presence of fistula

40
Q

what is the management of TEF

A

urgent surgical consult
closure of fistula is essential even if atresia cannot be repaired at same time (aspiration)

minimal investigations prior to OR: echo, NGT, rectal exam
if infant urinates then no need for abdominal US until after OR

41
Q

why do we follow babies with TEF long term

A

they need long term surveillance for feeding, growth, GERD and other anomalies as needed

42
Q

what is considered normal rotation

A

complete C loop
duodenojejunal junction at the level of the pylorus
proximal jejunum to the left of the left vertebral pedicle
first loops that fill should be the LUQ

43
Q

what is the management of a patient with midgut volvulus

A

NG to low suction
IV fluid resuscitation
IV antibiotics
transfer to surgical centre

44
Q

what is the gold standard test for volvulus?

A

UGIS

45
Q

what is the treatment of volvulus

A

Ladd’s procedure

  • retort
  • lyse Ladd’s bands
  • widen messentary
  • remove appendix
46
Q

Ddx Bilious vomiting

A 
midgut volvulus
malrotation
duodenal or other atresia
hirschprung's disease
ileus
47
Q

what is the triad for intussusception

A

pain
palpable sausage-shaped abdominal mass (most often in the right upper abdomen)
red currant jelly stool

48
Q

what does intussusception look like on ultrasound

A

doughnut or target on transverse views

49
Q

what is the recurrence rate after reduction of intussusceptions?

A

The recurrence rate after reduction of intussusceptions is approximately 10%, and after surgical reduction it is 2–5%

50
Q

what is the treatment for symptomatic Meckel’s?

A

The treatment of a symptomatic Meckel diverticulum is surgical excision, diverticulectomy

51
Q

what is Meckel’s Diverticulum?

A

outpouching of the ileum along the antimesenteric border approximately 2 feet from the ileocecal valve

52
Q

Is TEF associated with oligo or polyhydramnios?

A

polyhydramnios

53
Q

what is the treatment for esophageal atresia and TEF

A

Surgical ligation of the TEF

primary end-to-end anastomosis of the esophagus via right-sided thoracotomy

54
Q

what are 2 future complications of esophageal atresia and TEF

A

Gastroesophageal reflux disease contributes significantly to the respiratory disease (reactive airway disease)

55
Q

what is the most common form of esophageal atresia and TEF

A

the upper esophagus ends in a blind pouch and the TEF is connected to the distal esophagus (type C).

56
Q

how might H type fistula present

A

TEF in the absence of EA (“H-type” fistula) might come to medical attention later in life with chronic respiratory problems
(refractory bronchospasm, recurrent pneumonias)

57
Q

Name 3 syndromes associated with Hirschprung’s disease

A

Trisomy 21
NF
MEN2
congenital hypoventilation

58
Q

if hirschprung disease is not diagnosed what complication can they have

A

enterocolitis
fever, distension, lethargy, hemodynamic instability

treat with antibiotics

59
Q

what is the gold standard for diagnosing Hirschsprung disease

A

Rectal suction biopsy is the “gold standard”

60
Q

how does a baby with Hirschsprung disease present?

A
  • Failure to pass meconium within 24 hours of birth
  • Abdominal distension
  • Vomiting (bilious)

Infants with a missed diagnosis may present with severe
constipation

61
Q

where is the aganglionic segment for Hirschsprung disease located in 80% of patients?

A

The aganglionic segment is limited to the rectosigmoid in 80% of patients.

62
Q

what is seen on rectal biopsy for Hirschsprung disease?

A
  • No ganglion cells (G)
  • Hypertrophic nerves
  • Increased acetylcholinesterase staining
63
Q

what is seen with contrast enema for Hirschsprung disease

A

Contrast enema reveals a “transition zone” in 80%

64
Q

what is the treatment for Hirschsprung disease?

A

primary pull-through procedure
• Soave
• Swenson
• Duhamel

65
Q

what is the management of Hirschsprung disease

A

rectal decompression with saline irrigations

66
Q

omphaocele is associated with what syndrome

A

Beckwith-Wiedemann syndrome

67
Q

Omphalocele

A 
• Defect THRU UMBILICUS
• Defect can be “giant”
• Contains liver or >5cm
• Peritoneal sac
• Normal bowel
• 50% associated with other anomalies,
especially cardiac
• Prompt recovery of bowel function
68
Q

Gastroschisis

A 
• Defect RIGHT of umbilicus
• Defect usually small
• No peritoneal sac
• “Angry” bowel
• 10% associated with atresia &amp;
volvulus
• No other system anomalies
• Prolonged ileus/gastro-intestinal
dysfunction
69
Q

what is the most common age for inguinal hernia

A

Most common in children under 1 year
• 30% less than 6 months
M>F
60% right sided

70
Q

who’s at highest risk of incarceration for inguinal hernia

A

newborns
Highest in children < 1 year (12-17%)
• Attempt reduction with sedation with repair in 24-48 hours (allows edema to resorb)

71
Q

what is the technique for reducing an inguinal hernia

A 
Push down towards pubis w/ left fingers
—push up towards canal w/ right fingers
— maintain pressure
— use sedation if child cries
—difficult reduction: observe overnight
72
Q

when should pediatric hernias be repaired?

A

All pediatric hernias should be repaired soon after diagnosis (median 2 weeks)
Doubled risk of incarceration if wait >30 days

73
Q

when is CONTRALATERAL exploration for inguinal hernia indicated?

A

The only current indication for contralateral exploration is for the infant with a history of prematurity

Only 5-8% of children develop contralateral hernias

74
Q

what is the treatment for inguinal hernias

A

high ligation of the hernia sac

75
Q

what patients are at higher risk of recurrence of inguinal hernias? (3)

A

VP shunts
Peritoneal dialysis
premature infants
incarcerated

76
Q

what are some complications of inguinal hernia repair?

A

Scrotal swelling/hematoma – resolves within 10-14 days
iatrogenic undescended testicle – 0.2%
Recurrence – up to 0.8% all comers (15% in premature infants, 20% if incarcerated)
Injury to vas deferens – 0.2%
Testicular atrophy – 2.3%

77
Q

What is the MAIN indication for orchidopexy for undescended testes?

A

risk of infertility
changes start @ 9-12 months
• decreased spermatogonia
• increasing interstitial fibrosis

78
Q 
Definitions:
Undescended
Ectopic 
Absent or atrophic 
Retractile
Ascending testicle
A

Undescended – arrest of descent along normal path
Ectopic –arrest of descent outside normal path
Absent or atrophic – perinatal testicular torsion
Retractile – “high” resting position but able to be brought
down to scrotum
Ascending testicle – ascends with time

79
Q

what is the treatment for an undescended testis

A

Surgical: inguinal orchidopexy

80
Q

when should you refer a patient with an undescended testis?

A

Current recommendations indicate surgical
referral by 6-9 months of age
spontaneous descent of the testis will not occur after 4 mo of age.
• Rationale: gonocytes change to “adult dark” spermatogonia at 2-3 months age
transform primary spermatocytes at 4-5 years of age

81
Q

what is the most common tumor that develops in an undescended testis

A

The most common tumor developing in an undescended testis in an adolescent or adult is a seminoma

82
Q

In a newborn phenotypic male with bilateral nonpalpable testes what should you consider?

A

a newborn phenotypic male with bilateral nonpalpable testes, as the child could be a virilized female with congenital adrenal hyperplasia

83
Q

what is the most common inguinal hernia in children?

A

congenital indirect hernias (99%) because of a patent processus vaginalis (PV)

84
Q

what is a strangulated hernia?

A

A strangulated hernia is one that is tightly constricted in its passage through the inguinal canal, and as a result, the hernia contents have become ischemic or gangrenous

85
Q

How long should you observe patients after inguinal hernia repair if <3mo or preterm <60 weeks

A

Full-term infants <3 mo of age and preterm infants <60 wk postconceptual age should be observed following repair for a minimum of 12 hr postoperatively and potentially overnight following general anesthesia for the development of apnea and bradycardia.

86
Q

what are the hallmark signs of an inguinal hernia on physical exam?

A

The hallmark signs of an inguinal hernia on physical examination are a smooth, firm mass that emerges through the external inguinal ring lateral to the pubic tubercle and enlarges with increased intraabdominal pressure

87
Q

what does incarcerated hernia mean?

A

hernia sac cannot be reduced

2/3 occur in 1st year of life

88
Q

when should you consider surgery for umbilical hernia

A

if it persists beyond 4-5y

defects >2cm are less likely to close spontaneously

89
Q

TIME BEFORE SURGERY (hr) ORAL INTAKE

A

2- Clear, sweet liquids
4- Breast milk
6- Infant formula, fruit juices, gelatin
8- Solid food

90
Q

Name 2 indications for surgery for a hydrocele (3)

A
  1. persists >18 months
  2. unable to clearly examine the testis
  3. unable to distinguish from an inguinal hernia
91
Q

Picture of gastroschisis (still same poor picture). Most common associated anomaly?

a. Intestinal atresia
b. cardiac defect
c. renal defects

A

intestinal atresia

92
Q

A 15 year old girl presents with right lower quadrant pain and vomiting. On examination, she has right lower quadrant tenderness and rebound tenderness. Name three serious conditions you need to consider.

A
  1. Appendicitis
  2. Ovarian torsion
  3. Ectopic pregnancy
93
Q

DDX vomiting with abdominal distension

A 
ž + Abdo Distension
ž Hirschsprung’s
ž Volvulus
ž Jejunal/ileal atresia
ž Meconium ileus
ž Imperforate anus
ž Meconium plug
ž Colonic atresia
ž NEC stricture
94
Q

DDX vomiting without abdominal distension

A 
Duodenal
atresia/stenosis/web
Malrotation/Volvulus
žAnnular pancreas
žHPS
žAntral stenosis
žPreduodenal portal vein
95
Q

The MOST COMMON cardiac malformation

associated with omphalocele is:

A

Tetralogy of Fallot

Pediatrics- Noelle (28 decks)

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