Pediatric-chest, GI, GU Flashcards
croup-what, who, syx’s, orgm
- acute laryngotracheobronchitis
- 6 mo-3 yrs (avg 1 yr)
- barky cough
- parainfluenza
steeple sign
loss of normal shouldering/lateral convexities of subglottic trachea
epiglottis-who, orgm cause of death
- 3.5 yrs (Recent spike in teenagers)
- H influenza
- death by asphyxiation from aryepiglottic folds (not epiglottis)
mcc acute upper airway obstruction in children
Croup
normal appearance of subglottic trachea
- “shouldering”
- lateral/outward convexities
croup appearance on chest xray
- narrowing subglottic trachea or overdistanded pharynx
- epiglottis & aryepiglottic folds normal
epiglottitis xray appearance
-thickening epiglottis (“thumb sign”) or aryepiglottic folds
omega epiglottis-fake out, how to distinguish
- epiglottitis fake out caused by oblique imaging
- look at aryepiglottic folds
exudative tracheitis (bacterial tracheitis)-what, orgm, who, img
- rare, deadly exudative infection of trachea
- staph aureus
- 6-10 yo
- “linear soft tissue filling defect in airway”, irregular tracheal plaques
retropharyngeal cellulitis, abscess-what, causes, syx’s, who, app
- pyogenic infection of retropharyngeal space usually following recent pharyngitis or URI
- sudden onset fever, stiff neck, dysphagia, stridor
- 6 mo-12 mo
- massive retropharyngeal soft tissue thickening
normal soft tissue thickness btw pst pharynx and ant vertebral body
- should not exceed AP diameter of cervical VBs
- ~ 6mm at C2, 22m at C6
pseudothickening RPS-who, when, how to distinguish
- infants, short necks
- neck not well extended
- distinguish: true thickening=apex anterior convexity of ST, repeat with neck in full extension, gas in ST
subglottic hemangioma-what, where, ass
- MC ST mass in trachea, MC subglottic
- asymmetric narrowing trachea (left MC)
- ass:
- cutaneous hemangiomas 50%
- PHACES syndromen 7%
PHACES
- Posterior fossa (Dandy walker)
- Hemangiomas
- Arterial anomolies
- Coarctation of aorta, cardiac defects
- Eye abN
- Subglottic hemangiomas/Sternal Cleft/Supraumbilical raphe
laryngeal cleft-aka, what, ass, img, dx
-aka laryngoesophgeal cleft
-communicating defect in pst wall of larynx and esophagus or anterior hypopharynx
- different cleft classifications
- ass malformations (usually GI, VACTER)
- fluoro: thin tract of contrast extending to larynx or trachea)
- dx=direct visualization/scope
aw papilloma-what, cause, app
- lobulated mass(es) in airways & ass pulm nodules (solid & cavitated)
- HPV (perinatal transmission)
- usually mult: “papillomatosis” –> mult areas of atelectasis & air trapping (vs solitary carcinoid or FB)
adenoids
- seen at 3-6 mo
- full at 1-2 yrs
- too big when encroach on airway
How often does meconium staining of amniotic fluid occ? What does it look like? Aspiration syndrome?
15%, 5%
-green stained amniotic fluid
group B Strep vs non GBS neonatal PNA
- GBS= mc pna, low lung vol, 67% pl eff
- non GBS-hyperinflated, patchy & asymm perihilar densities, pl eff 75%
how often is meconium aspiration asss w/ PTX?
20-40%
when does TTN start, peak and resolve?
6 hrs, 24 hrs, 3 d
true or false: a normal plain film at 6 hrs excludes SDD
True
Increased risks of surfactant therapy
- pulmonary hemorrhage
- PDA
GBS neonatal PNA-how, who, app
- mc neonatal pna
- from birth canal
- (+) risk if premature
- low lung vol, granular opacities, pl effusion 25%
“granular opacities”
GBS neonatal PNA (pl eff) & SDD (no pl eff)
persistent pulmonary HTN/persistent fetal circulation-what, 2˚ causes
- persistence of high pressure in lungs
- 1 or 2˚ (hypoxia-from pna, meconium aspiration etc.)
“reduced thoracic circumference” on OB US
pulmonary hypoplasia
“fetal lung:head ratio <1” on OB US
pulmonary hypoplasia
CDH associations
- cong heart dx
- malrotation (ess 100%)
- right sided -GBS
mortality rate in CDH related to…
degree of pulmonary hypoplasia
NG tube in CDH
curves into chest
true or false: bronchogenic cysts comm w/ aw
false
“recurrent PNA in same area”
intralobar sequestration
bronchopulmonary sequestration
extra lung that is NOT conn to aw or pulmonary arteries.
intralobar bronchopulmonary sequestration-how common, who, cong ass, img, where
- MC (75%)
- adolescence
- pulmonary venous drainage
- no pleural cover–> recurrent inf (bacteria migrates in from pores of Kohn)
- no ass cong anomolies
- LLL pst segm (60%), RLL 40%
extra lobar bronchopulmonary sequestration-how common, present, ass
- 25%, infancy
- respiratory distress/cyanosis (rel to associated congenital anomalies)
- ass w/ cong anomalies (extra for extra things)
- pleural covering–> rarely infected
- systemic venous drainage
Extralobar BPS associated congenital anomalies
extra for extra things:
- CCAM
- CDH
- pulm hypoplasia (Can’t breath)
- cong heart disease
- vertebral anomalies (Cervical, not actually but fits the mnemonic.)
congenital lobar emphysema-mx
lobectomy
ccam-acronym
congenital cystic/pulmonary adenomatoid malformation
CCAM types
1) 1+ large cysts (2-10cm)-50%
2) numerous small, uniform size cysts-50%
3) solid appearing but microscopic cysts-10%
4) unlined cyst typically affecting single lobe, indist from type 1
0) acinar dysgenesis or dysplasia, represents global arrest of lung development, v rare
CCAM mx
- 90% spon’t decrease during 3rd TM
- resect-risk of peluropulmonary blastoma, rhabdomyosarcoma
mass on 2nd TM US
pulmonary congenital malformation
normal 2nd TM US –> mass
1˚pulmonary tumor
pleuropulmonary blastoma (PPB)-what, where, img, types, ass
- Rare malignant embryonal mesenchymal neoplasm of lung & pleura that arises during organ development
- mc 2˚lung malignancy in children. Big fucking mass in chest of 1-2 yo
- R-sided, pleural based, no chest wall invasion or Ca
- types: cystic, mixed, solid
- solid –> brain, bones
- cystic < 1yo, benign
- 10% multilocular cystic nephromas
PPB vs askin tumor or Ewing sarcoma of chest wall
PPB no chest wall/rib invasion
ideal termination of UA catheter
T8-10 or L3-L5
avoid renal arteries
what abdominal cong abN is a CI to UA catheter placement
omphalocele
UV catheter complications
- clot in portal v–> lobar atrophy
- cystic liver mass ==> hematoma; sugg erosion into liver
classic img viral pna. what is special about RSV?
- peribronchial edema
- mucus/debris in aw –> hyperinfl & subsegm atel
- RSV: segmental or lobar atel, esp RUL
round PNA-who, orgm, path, where, next step
-<8 yo
-S pneumonia
-path: don’t have goo collateral ventilation pathways
solitary
-pst lobes
-next step: follow up xray (no CT to exclude cancer)
lipoid pneumonia-classic hx, app, dx test of choice?
- parents giving olive oil daily –> chronic fat aspiration
- low attenuation in consolidated areas
- dx=bronchoalveolar lavage?
Swyer James-which lung is abnormal?
- post viral obliterative bronchiolitis –> affected lung smaller than normal/hyperexpanded lung.
- cause of unilateral Lucent lung
pulmonary hypoplasia
lung tiny or incompletely developed-1˚ or 2˚
pulmonary papillomatosis-app, risk/compl, sim to what disease?
- ST masses in aw & lungs/”multiple lung nodules w/ cavitation
- 2˚ risk SCC
- cysts & nodules = LCH + tracheal involvement
sickle cell/acute chest
- kids > adults (2-4)
- leading cause of death
- rib infarct –> pain causes decreased inspiration –> atelectasis/ infection
- pulmonary microvascular occlusion, infarct
- img: opacities
findings of sickle cell in cheset
- big heart
- humeral head infarcts
- h shaped vertebra
- cholecystectomy clips
CF in the chest
- apical predominant
- mucous plugging –> bronchiectasis, hyperinflation, finger in glove
- PAH
primary ciliary dyskinesia
- ciliopathy-motile part doesn’t work
- lower lobe predominant bronchiectasis
- kartageners 50%
- infertility (M); sub fertility (F)
why are men infertile in CF vs 1˚ ciliary dyskinesia
- CF: vas deferences absent
- PCD: sperm don’t swim
mc mediastinal mass
thymus
sail sign vs spinnaker sail sign of thymus
sail sign=normal triangular shape of thymus in kids (esp large in <5 yo)
-spinnaker sail sgx-lifting of thymus in PMX
things that make you think thymus cancer
- abN size for age (~15 yo)
- heterog
- Ca
- compression aw/vasc
thymic rebound
thymus shrinks in acute stress (PNA, radiation, cry, burns)
- recovery phase= return to size (sometimes larger); pet+!
- grows but maintains N triangular morphology
mc abnormal mediastinal mass in children
lymphoma (~>10 yrs vs normal thymus)
lymphoma vs ALL/leukemia
indistinguishable on img (st mediastinal mass)
47 XXY
klinefelter’s syndrome
3 flavors of mediastinal GCT
- teratoma-cystic, fat, Ca
- seminoma-midline; bulky, lobulated
- NSGCT- big & ugly; hemorrhage, necrosis; lung invasion
who’s at increased risk chest GCTs?
Klinefelter’s syndrome (300x risk)
middle mediastinal LAD causes
- granulomatous (Tb or fungal) MC; lymphoma
- mono (EBV 90%, CMV 10%)
- 1˚ tb
- histoplastmosis
- coccidioidomycosis
- lymphoma
- sarcoid
what do pt’s with mono get after amoxicillin
rash
histoplasmosis-US region, chest imaging
- MW, SE
- CXR: N (MC), hilar LAD
coccidioidomycosis-US region, chest img
-SW
-consolidation, nodules
hilar LAD
mediastinal lymphoma-which type
Hodgkins (4x MC than NHL)
-HL involves thymus 90%
pediatric chest sarcoid
- rare, onset usually ~20s
- few case reports
mediastinal duplications cysts-
- bronchogenic
- enteric
- neuroenteric
enteric mediastinal duplication cyst
- abut esophagus, same attenuation, may comm (fluid/air)
- distal R esophagus=2nd MC loc (ileum #1)
- middle or pst mediastinum
bronchogenic mediastinal duplication cyst
- abut trachea or bronchus, NO comm
- fluid/mucous filled
- subcarinal
- middle mediastinum (70%), hila (30%)
pst mediastinal masses-peds
- NB. GN, GB
- Ewing Sarcoma
- Askin Tumor (primitive neuroectodermal tumor of cw)
- neuroenteric cyst
- extramedullary hematopoiesis
- round PNA
- extralobar sequestration
neuroblastoma vs ganglioneuromas
- GN: less aggressive, more cirdcumscribed, no Ca, older children
- can’t differentiate based on imaging alone)
askin tumor (primitive neuroectodermal tumor of chest wall)-aka, features/img
part of Ewing sarcoma spectrum!
- aka “Ewing sarcoma of cw”
- displace rather than invade (exc when large)
- heterogenous, enhancing solid parts, no Ca
neuroenteric cyst-where, features, ass
Cyst along neuraxis (usually intraspinal)
- Most are intradural, extramedullary simple unilocular cysts ventral to spinal cord
- lower cervical/thoracic region
- well-demarcated, fluid att. no comm w/ csf
- ± vertebral anomalies, other closed spinal dysraphisms
extra medullary hematopoiesis-who, app, ass
myeloproliferative disorders, bone marrow infiltration (including SCD)
- BL, smooth sharply delineated ST paraspinal masses
- HMG, SMG
mc posterior mediastinal mass in child <2 yo
neuroblastoma
what does better: thoracic or abdominal neuroblastoma
Thoracic
imaging pst mediastinal NB
- pst mediastinal st mass, heterog + enh, Ca
- +/0 invasion ribs, VBs
spectrum ganglioneuromas
- ganglioneuroma (most mature)
- ganglioneuroblastoma (intermediate)
- neuroblastoma (undifferentiated)
normal thymus vs lymphoma?
age: <10 yo n thymus, >10 yo lymphoma
anterior mediastinal masses-peds
-normal thymus
-lymphoma
thymic hyperplasia
GCT
lymphangioma
mediastinal lymphoma-img
- usually >10 yo
- ant or middle mediastinal mass
- thymus, homogenous ST density, pericardial effusion, vascular/airway involvement
- Ca uncommon if untreated
pst mediastinal masses-approach
<10 yo: malignant; NB
>10 you: benign:
-round mass: ganglioneuroma, NF
-cystic + spinal anomaly: neuroenteric cyst
-course bone trabecularion, hx anemia-EMH
big chest masses
Askin (PNET/Ewings)
Pleuopulmonary blastoma
*age
MC TE fistula
N type (85%)
esophageal atresias/fistulas-types to know
- N type (85%)=blind ending esophagus w/ distal TE fistula
- Esophageal atresia, no fistula (10%)
- H type (1%)=no atresia, TE fistula; delayed diagnosis
TE fistulas w/ excessive air in stomach
N and H types
fake out for TE fistula
simple aspiration (look for laryngeal penetration)
what must be described prior to surgery in setting of EA/TE
right arch (4%)-changes approach
VACTERL
3+ anomalies. Heart & kidney MC Vertebral (37%) Anal (63%) Cardiac (77%) TE (40%) Renal (72%) Limb (radial ray) (58%)
relationship btw limbs and kidneys in VACTERL
- Both limbs involved –> both kidneys
- One limb involved –> one kidney
FB in trachea vs esophagus
- esophagus flexible, accommodates FB-coin turned in any dir
- trachea rigid, forces coin to rotate into pst mem (skinny in AP dir)
FB, what to do: AA or AAA batteries
- serial xray
- remove if in stomach >2d
FB, what to do: disc batteries
- es-2 hrs
- stom-4 hrs
disc battery vs coin
disc=2 rings
FB, what to do: coin
remove if:
- es 24 hrs
- stom 28 d
FB, what to do: penny minted after 1982
remove from stomach
what makes pennies minted after 1982 special? what’s the problem?
- contain zinc
- problems:
- stomach acid–> gastric ulceration
- Zn toxicosis (if absorbed in great enough quality)–> pancreatic dysfunction, pancreatitis
FB, what to do: lead
- remove immediately from stomach (gastric acid leads to immediate absorption)
- distal passage must be confirmed
FB, what to do: sharp objects
- esophagus-remove immediately
- stomach-removed immediately
- post pylorus=follow vs sx (if it does not perforated small bowel, it will be at IC valve)
classic ddx obstruction in older child-AIM
- appendicitis; adhesions
- inguinal hernia; intussuscpetion
- midgut volvulus; meckels
vascular rings & slings
- Pulmonary sling
- double aortic arch
- Innominate artery compression
- aberrhant left subclavian + right arch
- aberrhant right subclavian + L arch
only vascular ring/sling to go btw es & trachea?
pulmonary sling
what tracheal abnormality is pulmonary sling ass with?
tracheal stenosis
pulmonary sling is ass with many other cardiopulmonary & systemic anomalies. which ones?
hypoplastic right lung, horseshoe lung, TEF, imperforate anus, complete tracheal rings
pulmonary sling rx
surgical repositioning of artery (controversial)
dysphagia lusoria
trouble swallowing in setting of left arch with aberrant right subclavian
diverticulum of kommerell
pouch like aneurysmal dilation of proximal portion right subclavian artery
finding highly specific for duodenal atresia? when would you see it?
- double bubble
- 3rd TM OB US, plain film or MRI
what is malrotation ass with?
- heterodoxy syndromes
- omphalocele
- of note: SMA to right of SMV
FP malrotation on upper GI
distal bowel obstruction displacing duodenum (bc of ligamentous laxity)
corkscrew duodenum
midgut volvulus
Next step: non-bilious vs bilious vomiting
- US (pyloric stenosis)
- upper GI (midgut volvulus until proven otherwise)
Ladd’s bands
fibrous stalk of peritoneal tissues that fixes cecum to abdominal wall –> obstruction duodenum (intermittent episodes)
partial vs complete duodenal obstruction
- complete= midgut volvulus, duodenal atresia
- partial=ladd band, annular pancreas, duodenal web, stenosis
pre-duodenal portal vein-what, ass
anatomic variant, PV sit ant to D2
-duo obstr 50%, but ISN’T the cause (ass w/ other things…ladds bands, annular pancreas, etc)
Borchardt Triad
Gastric volvulus
1) inability to pass NGT
2) severe epigastric pain
3) retching w/o vomiting
When does hypertrophic pyloric stenosis occur?
specifically 2-12 wks (ie: not at birth and not >3mo)
-peak-3-6wks
primary differential pyloric stenosis
pyorospasm (will relax during exam)
MC patient pitfall during exam for pyloric stenosis that creates FN?
gastric overdistention –> displacement antrum & pylorus –> FN
pylori stenosis FP
off axis measurement
“paradoxical aciduria”
pyloric stenosis
Organoaxial vs mesenteroaxial age diff
Organo=Old
duodenal atresia association
- DS (30%)
- other intestinal atresia
- biliary abN
- cong heart dx
- VACTER
How do we know that double bubble is not an acute obstruction caused by a midgut volvulus, which is, a surgical emergency?
Dilatation of the duodenal bulb is seen only with chronic causes of obstruction. Not enough time for the bulb to become dilated in acute obstruction, such as with midgut volvulus
duodenal atresia vs stenosis
- atresia=occlusion, stenosis=fixed narrowing
- With duodenal stenosis, the double bubble is seen in association with the presence of distal bowel gas
duodenal web-what, where, ass, img
- partial canalization (not total like atresia)
- distal to ampulla
- ass: DS, malrot
- pin sized hole;
- wind sock deformity-older kids where web-like diaph stretched
small left colon- aka, what, mx
- meconium plug
- Functional colonic obstr,
- self limited, relieved by contrast enema
What is small left colon ass and NOT ass with
- NOT ass w/ CF
- mothers with DM or Mg sulfate for eclampsia
Hirschsprung dx-who
boys (4:1)
DS