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GI- Week 6 > Ophelm: Peds GI Surgery > Flashcards

Ophelm: Peds GI Surgery Flashcards

1
Q

How do you take a hx for a GI complain in a pediatric pt?

A

Varies depending on age of the patient

Birth history: GESTATIONAL AGE, twin, prolonged hospital stay, medical issues– respiratory failure, jaundice, cardiac issues

Feeding pattern: bottle vs. breastfed, special diet

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2
Q

What does a physical exam look like in for a pediatric pt w/ a GI complaint?

A 
Face flushed, diaphoretic, lots of blankets?
Interaction with you/others
Active, wiggling around vs. laying still
Curled up or laying flat
Arms above head or protecting belly
Does ancillary exam “bother” them?

Can the patient:
Sit up so you can check their back/ listen to their lungs
Deep breath, forceful cough
Reach above their head
Twist their torso
Lift each leg against resistance
Stand at the bedside and jump up and down

Make it a game for the little kids

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3
Q

What labs should be done on a pediatric pt w/ GI complaints?

A 
Complete blood count with differential
WBC, hemoglobin, platelet
Neutrophil %
Basic metabolic profile
CRP
Sed rate
Urinalysis
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4
Q

What special studies should be done for a pediatric pt w/ GI complaints?

A 
Plain films
CXR, abdominal x-rays
Ultrasound
Advantage:  no radiation 
CT scan
Disadvantage:  radiation
Barium enema
Can be diagnostic AND therapeutic
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5
Q

What is an acute abdomen?

A

“Signs and symptoms of abdominal pain and tenderness, a clinical presentation that often requires emergency surgical therapy.”

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6
Q

What is peritonitis?

A

Peritoneal inflammation
Severe abdominal tenderness
Guarding: voluntary and/or involunatry
Rebound

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7
Q

What causes an acute abdomen?

A

Infection
Obstruction
Ischemia
Perforation

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8
Q

Does an acute abdomen often require surgery?

A

Often but not always

MASKERS:
Endocrine, metabolic, hematologic, toxins/drugs
DKA, porphyria, lead poisoning, hypercalcemia, Addison’s disease, constipation

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9
Q

What is the normal embryology of our gut rotation?

A

Midgut herniates at 4th week and returns approx. 10th week.

Rotates around the axis of SMA 270 degrees in counterclockwise direction>
Final Position (ligament of Treitz LUQ/cecum RLQ)
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10
Q

What type of malrotation occurs most frequently?

A

Complete nonrotation:

Forming no C-Loop, the ligament of treitz on the right side of the abdomen and does not cross midline.

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11
Q

How does malrotation usually present?

A

First month of life
Bilious emesis
Lethargic
Toxic (if late)

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12
Q

How do you dx malrotation?

A

Plain abdominal x-ray
Upper GI contrast study
Duodenum the right side of abdomen with birds beak

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13
Q

How do you manage malrotation?

A

IV fluid resuscitation
Placement of nasogastric tube
Foley catheter placement
Ladd’s procedure

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14
Q

What is Ladd’s procedure?

A

Evisceration and detorsion
Division of ladd’s bands (ascending colon to duodenum)
Broadening of the mesentery
appendectomy

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15
Q

What is pyloric stenosis? What age range does it usually affect?

A

Hypertrophy of the pylorus muscle (d/t improper innervation of pyloric sm muscle)

Most common in first-born males (4:1 male to female)

Age range typically 2 weeks - 2 months of age

*Incidence 1/3000-4000

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16
Q

What are RFs for pyloric stenosis?

A

Higher risk in male infant if mother had HPS as baby

bottle fed infants

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17
Q

2 mo old presents w/ projectile, non-bilious (curdled milk/formula) vomiting w/ recent hx of formula intolerances. The baby is acting hungry.

Dx?

A

Pyloric stenosis

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18
Q

How does a baby act if they have dehydration secondary to pyloric stenosis?

A

No tears when baby cries
Infrequent wet diapers
Lethargy

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19
Q

An infant w/ a palpable “olive” in the RUQ on PE indicates…

A

pyloric stenosis

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20
Q

What imaging should be done for pyloric stenosis?

A

Abdominal x-rays
Ultrasound
Upper GI series with contrast

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21
Q

What is seen on an abdominal xray in a pt w/ pyloric stenosis?

A

Air- or fluid-filled stomach= gastric outlet obstruction

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22
Q

What is the diagnostic test of choice for a pt w/ pyloric stenosis?

A

Ultrasound: 3mm thick, 1.7 cm length
Near 100% sensitivity and specificity
No radiation exposure

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23
Q

If an upper GI series w/ contrast shows a “string sign”…

A

Helps to lower the suscpicion of HPS and may indicate:

Malrotation, reflux, anatomic abnormalities

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24
Q

How do you tx pyloric stenosis?

A

Optimize infant’s medical status

  1. Hypokalemic, hypochloremic metabolic alkalosis
    - Emesis– loss of HCL
    - Kidneys retain H+ instead of K+
  2. Correct electrolytes
  3. IV hydration (based on degree of dehydration)
  4. NPO
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25
What are the surgical approaches to pyloric stenosis?
Ramstedt Pyloromyotomy Right upper quadrant incision Periumbilical incision Laparoscopic
26
What are complications of pyloric stenosis?
1. Incomplete pyloromyotomy Prolonged time until baby tolerates ad lib feedings 2. Mucosal injury– the most severe complication -Recognized: repair intra-op -Unrecognized: leakage of gastric contents into intra-abdominal space acute abdomen, fever, leukocytosis 3. Incisional hernia 4. Wound infection
27
What is intussusception?
Inversion of one portion of the intestine w/in another
28
Intussusception usually occurs to...
Males Age range 3 months – 3 years -Most common in 5-10 month age range
29
What are lead points in up to 12% of children?
Increases with age Polyp or tumor Hypertrophied lymphoid tissue
30
What causes intussusception?
Most cases are idiopathic, no pathologic lead point | -Ileocolic
31
A 6 mo M presents w/ colicky abdominal pain, bilious emesis and CURRANT JELLY stools. Dx?
Intussusception
32
How does intussusception ultimately lead to ischemia and necrosis?
Lymphatic obstruction> venous congestion> impaired arterial blood flow> ischemia nad necrosis
33
What do xray findings show in a pt w/ intussusception?
Can show findings consistent with distal small bowel obstruction Lack of air in colon Presence of mass in right abdomen
34
What do ultrasound findings show in a pt w/ intussusception?
“target sign” when bowel is viewed in transverse orientation
35
How do you medially manage intussusception?
Barium Enema 80% success rate 11% recur, typically within 24 hours Can do BE twice, 3rd time recurrence is indication for OR
36
What is a coiled spring sign?
indication of intussusception
37
How do you surgically manage intussuception?
Manual reduction Push or “milk back,” DO NOT PULL May need resection if unable to reduce Also perform appendectomy
38
What is the MC cause of acute surgical abdomen in children?
appendicitis | 12-18 y/o coincides w/ greatest number of lymphoid follicles
39
What is the etiology of appendicitis?
Lymphoid hyperplasia Fecolith Foreign body
40
What is the pathophysiology of appendicitis?
Obstruction of appendix traps bacteria within> Bacteria multiply> appendix distends> Distention impairs venous outflow> Arterial inflow then becomes impaired> Ischemia, gangrene, necrosis, perforation
41
A 14 y/o F presents w/ periumbilical pain that moves to RLQ, as well as anorexia THEN pain THEN nausea/emesis. She also has diarrhea but it is not her primary concern.
Appendicitis
42
What are exam findings in a pt w/ appendicitis?
Pain at McBurney’s point Psoas sign– retrocecal appendix Obturator sign– pelvic location of appendix Rovsing sign
43
What labs do you do for appendicitis?
WBC count is typically normal for the first 24 hours (Neutrophil count will often rise first) Mild elevation in WBC is common High WBC (~15k) suggests perforation Urinalysis “sterile pyuria”– WBC in urine without bacteria
44
What is a way to diagnose appendicitis in children w/ out the risk of radiation?
Ultrasound 6 mm diameter lumen, non-compressible, sonographic McBurney’s
45
What would a CT scan of the abdomen/pelvis show in a pt w/ appendicitis?
Distended appendix, inflammatory stranding, +/- abscess 97% accuracy Radiation exposure Can evaluate for abscess or alternative diagnosis
46
How do you manage appendictis?
Perioperative antibiotic Appendectomy: laparoscopic or open Timing– significant delay can result in rupture
47
How long does it take before a pt w/ uncomplicated appendicits goes home?
w/in 24 hrs
48
How long will a pt spend in the hospital if they have a perforated appendicitis?
several deays - ileus - intra-abdominal abscess
49
What is Meckel's Diverticulum?
a TRUE diverticulum that involves all layers of the bowel wall and is cuased by a persistent vitelline duct
50
What is the rule of 2s in diagnosing Meckel's diverticulum?
``` 2% of population Within 2 feet of ileocecal valve 2 types of heterotopic tissue: gastric (50%) and pancreatic 2 inches in length 2 year old ```
51
What can cause a painless lower GI bleed and obstruction?
meckel's
52
What causes the painless lower GI bleed in Meckel's? Dx?
Due to the gastric tissue contained in the diverticulum Bleeding occurs on wall opposite of the Meckel’s Technetium-99m pertechnetate scintigraphy
53
How do you tx Meckel's Diverticulum?
surgical resection
54
How does meckel's cause obstruction? How do you dx it and tx it?
Band adhesion, intussusception, Littre’s hernia Diagnosis: various imaging modalities Treatment: dependent on cause, resect the Meckel’s
55
What is meckel's diverticulitis?
Presentation like acute appendicitis, but appendix looks normal during surgery Need to rule out Meckel’s diverticulitis Remove appendix
56
What causes Hirschsprung's Disease? Where is it located?
Absence of Ganglion cells in the myenteric and submucosal plexus Aganglionosis always involves DISTAL RECTUM
57
What pts have a higher risk for Hirschsprung's Disease?
Higher risk in patient’s with family hx and in Down syndrome patients.
58
A pt presents w/ abdominal distension, bilious emesis and a failure to pass meconium in the first 24 hrs.
HIrschsprung's disease
59
How do you dx Hirschsprung's Disease?
- Barium enema - Manometry (absent rectoanal inhibitory reflex) - Full thickness rectal biopsy
60
What is the gold standard test for hirschprung's disease?
Full thickness rectal biopsy Bx 2cm from dentate line Acetylcholinesterase staining reveals hypertrophied nerve trunks throughout the lamina propria and muscularis propria layers of the bowel wall. Recent studies suggest that immunohistochemical (IHC) staining for calretinin might be more accurate than acetylcholinesterase staining in diagnosing congenital aganglionosis among suction biopsy specimens
61
How do you tx Hirschsprung's disease if hte pt has a megacolon?
diversion
62
What is an omphalocele? What populations does it commonly occur in? What syndromes is it associated with?
Covered by peritoneum Karyotype abnormalities are present in 30% (trisomies 13/18/21) More the 50% have other malformations (cardiac>MS,GI,GU) Associated with Beckwith-Wiedemann syndrome(omphalocele, hyperinsulinemia, macroglossia)
63
How do you manage an omphalocele?
IV fluids IV antibiotics NG decompression Sterile dressings Dx associated anomalies(PE/cxr/echo/renal U/S) Surgical correction dependent on size of defect
64
What is Gastroschisis?
``` No sac covering abdominal contents Intestinal atresia (15%) SGA ```
65
How do you manage gasroschisis?
IV fluids IV antibiotics Dressings Surgical management of abdominal wall defect similar to omphalocele, but differs if intestinal atresia present

GI- Week 6 (14 decks)

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