Peads surgery Flashcards
At what age would duodenal atresia present?
Few hours after birth
Association of duodenal Atresia
Trisomy 21 (30%) Cardiac/renal/other GI defects, Annular pancreas VACTERL
Presentation of duodenal Atresia antenatally?
Dilated stomach and first part of duodenum showing double bubble sign on USS
Presentation of duodenal atresia postnatally?
Early bilious vomiting in post-natal period (unless “pre-ampullary” atresia = non-bilious vomiting) Dilated stomach and first part of duodenum ‘Double-bubble sign’ on AXR
Management of Duodenal Atresia
NG tube
IV resusitation
Look for associated anomalies
Surgical duodeno-duodenostomy
What is this showing?
Double Bubble in Duodenal Atresia
Difference between presentation of malrotation vs malrotation with volvulus?
Malrotation - bilious vomiting, well baby (ladd’s bands obstruct duodenum)
Volvulus - bilious vomiting, unwell baby, peritonitis, metabolic acidosis *SURGICAL EMERGENCY*
At what age would malrotation with volulus present?
3-7 days after birth
Investigation of malrotation?
AXR can show paucity of distal gas; usually diagnosed by UGI contrast (if baby stable enough to perform)
Mnagement of malrotation?
Fluid resuscitation
Broad spectrum antibiotics
Immediate “Ladd’s procedure” – counter-clockwise detorsion of bowel and widening of mesentery
When would meconium ileus present and what does it mean?
- Meconium with abnormal mucous and enzyme content becomes solid and obstructs the gut antenally, presents in first few days of life
- Pathognomic of cystic fibrosis - represents more severe phenotype
Mnagement of meconium ileus?
Appropriate resuscitation
NG tube
Contrast enema may disimpact, as can N-acetylcysteine (PR and NG)
Laparotomy and evacuation of meconium may be required
what is the presentation of necrotising entoerocolitis?
Ischaemia and infection of the bowel in newborn. Leads to perforation, peritonitis, overwhelming sepsis
Predisposing factors: prematurity, formula feeds, respiratory distress syndrome, asphyxia, sepsis
Babies present with feed intolerance, bilious vomiting, abdominal wall discolouration, blood in stools, sepsis
What would an AXR show for necrotising entoerocolitis?
AXR shows pneumatosis intestinalis, portal venous gas, “fixed loop”, football sign (indicates perforation)
Management of enterocoliits?
Uncomplicated NEC: treat with antibiotics, gut rest, supportive care (7-10 days)
Surgical: can be difficult decision, perforation is absolute indication, mortality 25-40%
What is the diagnosis?
Hirchsprung disease:
Distal obstruction- Enema shows collapsed distal bowel with dilated proximal segment
Presentation fo hirchsprung?
- Failure to pass meconium in <48 hrs
- Bilious vomiting
- Abdominal distension
How would Hirchsprung associated enterocollitis (HAEC) present?
It typically presents within 2-4 weeks of birth with fever, abdominal distention, diarrhoea (often with blood) and features of sepsis.
It is life threatening and can lead to toxic megacolon and perforation of the bowel.
It requires urgent antibiotics, fluid resuscitation and decompression of the obstructed bowel.
Diagnosis and Management of hirchsprung?
Gold standard diagnosis is suction rectal biopsy
Managements:
- Appropriate resuscitation
- NG tube
- Antibiotics
- Decompression of the bowel with rectal washouts
- Surgical “pull through” procedure when 3-6 months of age
Age of presentation of intussusception?
boys 4-7 months
Describe the pathology of intussusception?
Intussusception is a condition where a segment of bowel (the intussusceptum) invaginates into the adjacent segment of bowel (the intussuscipiens)
classic triad presentation of intussuseption?
- Colicky abdominal pain
- Vomiting
- Redcurrent jelly stool (only present in 1/3 cases)
Describe the pain in intussusception?
- Child becomes pale and unsettled whilst drawing their knees up to their chest
- Episodes last between 2-3 minutes and occur at 10-15 minute intervals
- In between episodes, the child appears increasingly lethargic, clammy, pale and exhausted
- As time progresses, the pain may become constant
what to expect on examination of a child with intussusception?
Pale, lethargic, dehydrated and unwell child
Abdominal examination:
- May reveal a sausage shaped mass classically located in the right hypochondrium
- Signs of bowel obstruction (distension and tinkling bowel sounds)
- localised or generalised peritonism (if there is bowel ischaemia)
Always look in the nappy- PR exam may reveal blood on the tip of the glove or the apex of the intussusception
Investigation findings of intussusception?
Abdominal USS Scan shows a ‘target sign’ present on a cross sectional view of the intussusception
Management of intussusception?
Intravenous fluid resuscitation (up to 40-60 ml/kg)- The most important action
NG Tube
IV antibiotics- risk of translocation of bacteria from sick bowel and perforation
Analgesia- beware of respiratory depression with opioid analgesia in inadequately resuscitated child
Air reduction enema (pressure regulated pneumatic reduction)- Once haemodynamically stable
When would surgery be indicated in intussusception?
If air enema unsuccesful:
- Bowel perforation
- Generalised peritonitis (rigid abdomen) due to bowel ischaemia
- Poor prognostic signs on abdominal ultrasound scan
- Fluid between layers of intussusception
Describe the intussusception surgical procedure?
- Laparotomy and manual reduction of the intussusception.*
- if the bowel is non-viable, or there is an obvious pathological lead point, then resection with a primary end to end anastomosis*
age of onset of pyloric stenosis?
4-8 weeks
Investigation fo pyloric stenosis
- Abdominal USS- to assess pyloric stenosis
- Test feed; Visible peristaltic wave when feeding- stomach is trying to push the food through the thickened pylorus.
- Palpable olive mass in the right upper abdomen.
what electrolyte abnormality of seen in pyloric stenosis
Hypochloraemic hypokalaemic Metabolic alkalosis due to vomiting up all stomach acid
Treatment of pylroic stenosis
- Paediatric A-E approach
- Fluid resuscitation may be needed to correct dehydration
- Careful and slow correction of any underlying metabolic abnormalities
- Stop Oral intake, pass NG tube, leave on free drainage and replace losses appropriately
- Maintenance fluids
What are paeds maintenance fluids?
- 150ml/kg/24hrs of 0.45%Nacl/5%Dextrose*
- 10-20mmolKCl in 500ml*
colour of vomit in pyloric stenosis?
milky
