Pediatric Flashcards
Operative steps in pyloromyotomy
- Begin incision 2mm proximal to pyloric vein 2. incise to see bulging of mucosa 3. Muscle on either side should move independently. 4. If perforation of duodenal mucosa, close in layers, including serosa, flip pylorus over and do myotomy on other side. 5. Insufflate the NG at end of case to check for leak.
Feeding after pyloromyotomy
- STart 4-6 hours post op with Pedialyte 2. If tolerates, advance 10-15 cc per feed until at 90cc 3. Transition to breast milk or forumla. 4. If emesis, hold for 3 hours and try again.
Differential diatnosis of bilious emesis
- malrotation
- duodenal stenosis/web/atresia
- jejunal atresia
- NEC
- GERD
- Meconium ileus
- annular pancreas
Timing of diagnosis of malrotation (% diagnosed at 3 days, 1 week, 1st month)
30%, 50%, 80%
Studies available to help diagnose malrotation if UGI negative
CT abdomen and pelvis
U/S looking for SMV to the left or anterior to SMA
Ladd’s procedure in newborn or infant
- Horizontal supraumbilical incision
- Counterclockwise rotation of bowel between 1 and 3 full roations.
- Take down Ladd’s bands - right colon to right abdominal wall
- Appendectomy
- May incise peritoneum over mesentery to move colon further left.
- Place duo and small bowel on right and colon on left.
Neuroblastoma stats
most common cancer of infants
Most common solid tumor of children (10% of childhood malignancies)
50% diagnosed by 2 years old
50% in adrenal gland
Imaging work up for neuroblastoma, biopsy?
- U/S
- CT scan
- MIBG scan
- Biopsy needed of mass and bone marrow for staging.
Treatment for neuroblastoma
Complex decision making - surgery for early or low stage disease, induction chemo (Carboplatin/etopiside) + / - surgery for mid stage disease.
Imaging work up for abdominal mass in children
- U/S
- CT with IV/PO contrast
- May need doppler U/S to analyze IVC involvement (Wilms)
Principles of surgical management of Wilms’ tumor
- Diagnosis
- Resection without tumor spillage
- Avoid resection of adjacent organs
If can’t obtain all these initially (or if have IVC tumor thrombi) need pre-operative Chemotherapy (Vincristin, dactinomycin)
If abdomina spillage, patient will also need abdominal radiation.
of note, chemotherapy is started in hospital before discharge.
In addiiton to U/S and CT, what imaing and labs necessary if concern for hepatoblastoma
- MRI
- CBC, lytes, liver profile, AFP, B HCG, urinalysis
If hepatoblastoma is metastatic or unresectalbe?
need biopsy, then neoadjuvant therapy
Diagnostic work up for RLQ pain in child (intussuception)
Ultrasound, target sign
Treatment: air contrast enema
Instructions for air contrast enema
- Rectal tube
- Insufflation up to 120 mm Hg under fluoroscopy.
- Air in small bowel is diagnostic of success.
- Need to keep for observation for several hours prior to discharge
NEC with portal venous gas
Minimum length of viable and functioning bowel
40 cm
Length of bowel to have nutritional autonomy
Historically 100 cm of small bowel without IC valve and 70 with IC valve and some colon
Differential for lower GI bleed in child
- Meckel’s
- Anal fissures
- IBD
- Intestinal polyps or duplications
Work up for Lower GI bleed and concern for Meckel’s
Meckel’s scan (Technetium 99 pertechnetate) (gastric mucosa)
Rule of 2s for Meckel’s
- 2% of population
- 2 feet of IC valve
- 2 in in length
- symptomatic by 2
- 2 times more common in boys
- 2 types of mucosa (gastric, pancreatic)
- 2 presentations (obstruction - more common, bleeding)
If Meckel’s scan is negative, further work up?
Diagnostic laparoscopy looking for Meckel’s with false negative
How to resect Meckel’s
If not bleeding, with narry neck - may staple diverticulum off
If bleeding - wedge resection to inspect mucosa of ileum and then Transverse closure
If wide neck or complicaitons - segmental bowel resection.
Omphalocele classificaiton
small - < 5 cm - only bowel
Giant > 5 cm - liver, bowel, spleen
IN midline covered by peritoneum
Gastroschisis
Defect to right of umbilicus, with protruding bowel, not covered by peritoneum
Basic work up with omphalocele
Chromosomal analysis
Cardiac work up
Temperature management
Frequent glucoses
IV, gastric, bladder access
Antibiotics and vitamin K
Treatment for giant (> 5 cm) omphalocele that can’t be primarily closed
Paint and wait
Most common types of TEF
A. esophageal atresia and distal TEF (~80%)
B. Esophageal atresia alone
E. H type with no atresia, but fistula to trachea
VACTERL
- vertebral
- Anorectal
- cardiac
- TEF
- renal
- LImb
all diagnosed with physical exam and X ray for Vertebral and ECHO
