Pediatric Conditions

Question 1

Differentials for non-bilious vomiting

Answer 1

• Gastroenteritis
• Acute viral illness
• Food allergy
• Pyloric stenosis
• GERD
• Meconium ileus

Question 2

Differentials for bilious vomiting

Answer 2

• Volvulus with rotation
• Intussusception
• Ileus (meconium, septic, etc)
• Meconium plug syndrome
• Bowel perforation
• Hirschsprung
• Intestinal atresia
• Necrotising enterocolitis

Question 3

Clinical features of Meckel’s diverticulum

Answer 3

• Typically asymptomatic, incidental finding - most frequently symptomatic <2y
• Commonly presenting with painless GI bleeding (hematochezia or melena)
• Abdominal pain (usually RLQ)
• Intestinal obstructive symptoms (if herniated or twisted)

Question 4

Diagnosis and management of Meckel’s diverticulum

Answer 4

• Diagnostic:
  
  • Meckel’s scan (Technetium-99 scan)
  • X-ray: limited but can be used for detecting obstruction or perforation
• Management:
  
  • Asymptomatic:
    
    • Resection indicated for all children or young adults
  • Symptomatic: diverticulectomy or segmental resection

Question 5

Clinical features of intussusception

Answer 5

• Most commonly in children between 3m - 5y old
• Initially non-bilious vomiting, bilious if becomes obstructive
• Abdominal pain: acute, cyclical, colicky
• Palpable abdominal mass - usually RUQ
• Bloody stools: “currant jelly”
• Lethargy, pallor, other sympoms of shock

Question 6

Diagnostic and management of intussusception

Answer 6

• Abdominal ultrasound: target sign
• Air or barium enema
• Management:
  
  • Initial steps: NG decompression and fluid resuscitation
  • Non-surgical: air enema
  • Surgical reduction

Question 7

Clinical features of pyloric stenosis

Answer 7

• Forceful projectile vomiting after feeds
• Difficulty feeds and irritable
• Palpable, non-tender, epigastric mass
• Visible peristaltic waves
• Dehydration symptoms:
• Presenting around 2-7 weeks of life

Question 8

Diagnostic and management of pyloric stenosis

Answer 8

• Definitive imaging: abdominal ultrasound or barium studies
• FBE: late signs include electrolyte derangements (hypochloremic metabolic alkalosis)
• Management:
  
  • Correct any electrolyte derangment and fluid replacement
  • NPO
  • Surgical procedure: pyloromyotomy

Question 9

Clinical features of Hirschsprung

Answer 9

• Initial presentation
  
  • Meconium not passing in the first 48h of life
  • Abdominal bloating and tenderness
  • Bilious vomiting
• Late presentation
  
  • Chronic presentation (in milder cases)
  • Failure to thrive/poor feeds

DRE exam findings: tight anal spinchter, squirt sign (explosive stool release after finger removal)

Question 10

Diagnosis and management of Hirschsprung

Answer 10

• Initial imaging: X-ray and barium enema
• Diagnostic imaging: rectal biopsy
• Management:
  
  • Initial:
    
    • correct fluid and electrolyte disturbance
    • NG decompression and colonic irrigation
    • screen for signs of enterocolitis
  • Surgical resection of aganglionic region

Question 11

Differential diagnosis of delayed passage of meconium

Answer 11

• Hirschsprung
• Meconium ileus
• IND
• Congenital hypothyroidism

Question 12

Types of acyanotic congenital heart disease

Answer 12

VSD, ASD, PDA, coarctation of aorta

Question 13

Types of cyanotic congenital heart diseases

Answer 13

• Tetralogy of Fallot
• Transposition of the great vessels

Question 13

Difference between acyanotic and cyanotic lesions

Answer 13

• Acyanotic conditions (“pink babies”): Have left-to-right shunts in which oxygenated blood from the lungs is shunted back into the pulmonary circulation.
• Cyanotic conditions (“blue babies”): Have right-to-left shunts in which deoxygenated blood is shunted into the systemic circulation

Question 14

Describe Eisenmenger syndrome

Answer 14

Reversal of left-right shunt to right-left shunting due to increased pulmonary pressures (pulmonary hypertension), leading to cyanosis.

Question 15

Clinical features and auscultation findings of VSD

Answer 15

• Holosystolic murmur - best heard in the LLSE
  
  • Louder in small defects
  • Louder with maneuvers increasing afterload (e.g. handgrip)
• Presenting with recurrent chest infections, dyspnea, CHF, failure to thrive

Question 16

Clinical features and auscultation findings of ASD

Answer 16

• Systolic ejection murmur over ULSE - widely fixed split S2
• Recurrent respiratory infection, easily fatigued, failure to thrive

Question 17

Management of ASD/VSD

Answer 17

• Most septal defects close spontaneously
• Follow-up echo based on size
• If CHF developmnes: initial treatment includes diuretics + inotropes + ACEi

Question 18

Clinical features and auscultation findings of PDA

Answer 18

• Typically asymptomatic; patients with large defects may present with FTT, recurrent lower respiratory tract infections, clubbing, and CHF.
• Continuous “machinery murmur” at the second left intercostal space at the sternal border

Question 19

What do you give to close a PDA? When is this contraindicated?

Answer 19

• Indomethacin (NSAID)
• Contraindicated in cyanotic lesions that require PDA for survival (transposition of great vessels, tetralogy of Fallot, coarctation of aorta)

Question 20

Clinical features of coractation of aorta

Answer 20

Narrowing of aorta at the aortic isthmus - in the descending or abdominal aorta
* Features:
* Differential cyanosis - affecting lower extremities
* Asymptomatic hypertension, lower extrimity claudication,
* Continous murmur may be heard diffusely over the torso

Question 21

Management of coarctation of aorta

Answer 21

• Prostaglandin - reopen PDA
• Surgical repair or balloon dilatation