Pediatric Surgery Flashcards
Foregut
lungs, esophagus, stomach, pancreas, liver, gallbladder bile duct, and duodenum proximal to ampulla
midgut
- duodenum distal to ampulla, small bowel, and large bowel to distal 1/3 transverse colon
- rotates 270 degrees counterclockwise
hindgut
distal 1/3 of transverse colon to anal canal
low birth weight
< 2,500 g
premature
< 37 weeks
trauma bolus peds
20 cc/kg X 2, then give 10 cc/kg blood
tachycardia (peds)
best indicator of shock (neonate > 150, < 1 year > 120, rest > 100
urine out put
2-4 cc/kg/hr
children have poor concentrating ability
< 6 months 25 % capacity of adults
maintenance fluids
4 cc/kg/hr for 1st 10 kg
2 cc/kg/hr 2nd 10 kg
1 cc/kg/hr every kg after that
caloric need (kcal /day)
90-120 till age 1
70-90 1-12yrs
30-60 12-18 yrs
pulmonary sequestration
lung tissue has systemic arterial supply (aorta) and either systemic venous or pulmonary vein drainage BUT DOESNT COMMUNICATE with tracheobronchial tree
- can be intralobar or extra lobar
- PRESENTS WITH INFECTION
TX lobectomy
congenital lobar overnflation
- cartilage fails to develop in bronchus, leading to air trapping with expiration
- can develop hemodynamic instabiity (same mechanism as tension PTX) or respiratory compromise
- LUL, RML most commonly affected
- TX: lobectomy
congenital cystic adenoid malforamation
- communicates with airway
- alveolar structure not well developed although lung tissue is present
- Sxs: respiratory infection or resp compromise
- TX: lobectomy
Bronchogenic cyst
- extrapulmoary cyts formed from bronchial tissue and cartilage wall
- usually present with a mediastinal mass filled with milky fluid
- can become infected or compress adjacent structures
- TX: resect cyst
Neuorgenic tumors
exs. neurofirbroma, neuroganglioma, neuroblastoma
MOST common mediatinal tumor in children - usually posterior located
Mediastinal masses in children
present with respiratory symptoms and dysphagia
T cell lymphoma - can presnt anterior, middle or posterior
teratomas - ant and middle
thymomas, and thyroid cancer - middle
choledochal cyst
TX resect
- risk of cholangiocarcinoma, pancreatitis, cholangitis, obstructive jaundice
- thought to be caused by refux of pancreatic enzymes in to the biliary system
Types of choledochal cysts - TYPE I
MOST COMMON
fusiform dilation of entire common bile duct, midly dilated common hepatic duct
TX: hepaticojejunostomy
Types of choledochal cysts- TYPE V
Carolis disease - intrahepatic cysts
hepatic fibrosis
cystic hygroma
lymphangioma - found in lateral cervical and submandibular regions in neck
TX: resection
asymptomatic lymphadenopathy
ABX for 10 days
excisional bxif no improvement β> lymphoma until proven otherwise
fluctuant lymphadenopathy
FNA, CX, ABX may beed I&D
chronic causes: cat scratch fever, atypical mycoplasma
lymphadenopathy
usually caused by acute suppurative adenitis associated with URI, or phyaryngitis
diaphragmatic hernias
80% left sided
80% associated anomalies ( cardiac and neural tube defects, malrotation)
MOST COMMON - Bochdalkβs
TX: abdominal approach, reduce bowel, high frequency ventilation, prostacyclin (pulmonary vasodilator)
Bochdalekβs hernia
located posterior laterally
Morgagniβs hernia
diaphragmatic hernia - located anteriorly
eventration
failure of the diaphragm to fuse
pectus excavatum
(sinks in) sternal osteotomy, need strut
pectus carinatum
(pigeon chest) repair for emootinal stress
1st branchial cleft cyst
angle of mandible, may connect with external auditory canal, often associated with facial nerve
2nd branchial cyst
MOST COMMON
ant border of SCM, goes through carotid bifurcation into tonsillar pillar
3rd branchial cyst
lateral neck
thyroglossal duct cyst
from the descent of the thyroid gland from the foramen cecum
may be only thyroid tissue pt has
presents as a midline cervical mass
TX excision of cyst, tract, and hyoid bone
hemangioma
rapid growth during first 6- 12 months of life, then involutes
TX: observation, UNLESS uncontrollable growth, impair function, persists after age 8, tx with steroids, laser, resection
neuroblastoma
1 solid abdominal malignancy in children
most common location - adrenals
most common 1st 2 yrs of life
SXS: diarrhea, raccoon eyes (orbital metastases), HTN, unsteady gate (opsomyoclonus)
derived from neural crest cells
TX: chemotherapy, resect
diagnosing neuroblastoma
- abdominal xray - may show stippled calcifications in the tumor
- Increased cateholamines, VMA, HVA, metanephrines
neuron specific enolase
increased in neuroblastomas with mets
rare mets to lung and bone
high risk neuroblastoma
> 1 yr, N- myc, diploid, LDH, shimada classification
Wilms tumor
nephroblastoma
mean age at diagnosis - 3 years
frequent mets to bone and lung
PROGNOSIS BASED ON TUMOR GRADE
Wilms tumor associations
Beckwith - Wiedmann syndrome (hemihypertrophy, cryptorchidism, Drash syndrome, aniridia)
Treartment of Wilms tumor
NEPHRECTOMY
ALL stage < 500 g actinomycin and vincristine (except stage I)
Stage II or greater > 500g add doxorubicin
Stage III or greater add XRT
Stage V Wilms tumor
Bilateral renal involvement
10%
Hepatoblastoma
MOST COMMON MALIGNANT liver tumor in children
AFP - increased in 90%
prefetal histology has best prognosis
TX of hepatoblastoma
RESECTION
doxorubicin cisplatin based chemotherapy to downstage tumors and allow resection
Leukemia (ALL)
1 childrens malignancy overall
CNS tumors
1 solid tumor class
Neuroblastoma
1 general surgery tumor
duodenal atresia
1 cause of duodenal obstruction in newborns
malrotation
1 cause of duodenal obstruction after newborn period (> 1 week)
Hirschsprungs disease
1 cause of colon obstruction
painless lower GI bleeding in peds
meckels diverticulum
upper GI bleeding <1 yr
gastritis
Meckels diverticulum
persistent vitelline duct found on antimesenteric border rule of 2s 2 feet from ileocecal valve, 2%population, 2 % symptomatic, 2 tissue types (pancreatic, gastric), 2 presentations - diverticulitis and bleeding TX: resect
pyloric stenosis
projectile vomiting
firstborn males @3-12 weeks
olive mass in stomach
hypochloremic, hypokalemic metabolic alkalosis
Diagnosing pyloric stenosis
US- pylorus > 4mm thick, > 14 mm long
Pyloric stenosis TX
pyloromyotomy (RUQ incison), circular muscles of the stomach
intussesception
invagination of one loop of intestine into another
3 months to 3 years
lead points: enlarged Peyers patches (MOST COMMON), lymphoma, Meckels
15 % recurrence after reduction
Intussesception symtoms
currant jelly stools ( from vascular congestions, not an indication for resection), sausage mass, abdominal distension, RUQ pain, and vomiting
Intussesception treatment
AIR CONTRAST ENEMA max pressure:120 mm HG max column if barium: 3 feet 80% successful, peritonitis, free air, unable to reduce --> OR reduce via distal limb
intestinal atresia
result from intrauterine vascular accidents
sxs: bilious emesis, distension, most do not pass meconium
get barium enema to r/o hirschprungs before surgery β > resection
Duodenal atresia
usually distal to ampulla of vater, causes bilious vomiting, feeding intolerance
associated with cardiac, renal, and other GI anomalies
20% have down syndrome
AXR: double bubble
TX: duodenostomy
Tracheoesophageal (TE) fistulas
Type C - most common; promximal esophageal atresia (blind pouch) and distal TE fistula
Sxs: newbors spit up feeds, excessive drooling, respiratory sxs.`
VACTERL
vertebral, anorectal, cardiac, TE fistula, radius/renal, limb anomalies
TX: right extrapleural thoracotomy
complications: GERD, LEAK, empyema, stricture, fistula
Malrotation
sudden onset of bilious vomiting (Ladds bands from right retroperitoneum attached to cecum cause duodenal obstruction)
compromise of SMA
failure of the normal 270 counterclockwise rotation
Malrotation treatment
UGI diagnosis
resect LAdds bands, counterclockwise rotation, cecopexy LLQ, appendectomy`
meconium ileus
distal ileal obstruction, abdominal distension, bilious vomiting
sweat chloride test or PCR for cl channel defect
(cystic fibrosis 10%)
AXR: soap suds appearance
TX. gastrograffin enema
alt: N-acetlycysteine enema
Necrotizing entercolitis
bloody stools after 1st feeding in premature infant
risk factors: hypoxia, hypotension, anemia, polycythemia, sepsis
Sxs: lethargy, resp decompression, abdominal distension, vomiting blood PR
Diagnosing NEC
AXR: pneumatosis intestinalis, free air, portal vein air
NEC - TX
resuscitation, NPO, ABX, TPN, orogastric tube
ORβ> free air, peritonitis, clinical deterioration, needs barium enema first r/o distal obs, then ostomies
congenital vascular malformation
surgery for hemorrhage, ischemia, chf, nonbleeding ulcers, fuctional impairment and limb discrepancy
embolization
imperforate anus
high (above levators) - meconium in urine of vagina(fistula to bladder/vagina/prostatic urethra)
TX: colostomy, later anal reconstruction with posterior sagittal anoplasty
low (below levators) - perform sagittal anoplasty
gastroschisis
intrauterine rupture of umbilical vein; does not have a peritoneal sac
herniates to the right of umbilicus
TX: saline soaked guaze, TPN NPO, repair when stable, silo
omphalocele
failure of embryonal developement, midline defect,
increased congenital anomalies (50%) , peritoneal sac with cord attached
TX: silo, later closure
cantrell pentology
cardiac defects pericardium defects sternal cleft diaphragmatic septum transversum absence omphalocele
hirschprungs
infants fail to pass meconium in 1st 24 hrs
dx rectal bx (absence of ganglion cells in myenteric plexus)
failure of neural crest cells to progress in craniocaudal direction
hydrocele
transluminates
TX: surgery at 1 if not resolved or if thought to communicate
umbilical hernia
failure of closure of linea alba; most close by age 3
TX: surgery if not closed by age 5 or incarceration
inguinal hernia
persistent processus vaginalis M>F, R>L
cystic duplication
most common in ileum, often on mesenteric border
resect
biliary atresia
most common cause of neonatal jaundice requiring surgery
jaundice persisting > 2 weeks after birth
biliary atresia
liver bx showing periportal fibrosis, bile plugging
biliary atresia
TX of biliary atresia
hepaticoportojejumostomy
preform before age 3 months
teratoma
AFP, beta HCG
neonates - sarcococcygeal
sarcococcygeal teratomas
90% benign at birth
if presents > 2 months β> malignant
associated with bilateral cryptochidism
prune belly syndrome
laryngomalacia
most common cause of airway obstruction in infants
outgrow by 12 months
caused by immature epiglottis cartilage with intermittent collapse
choanal atresia
obstruction of choanal opening by either bone of mucus membrane, usually unilateral
intermittent resp distress, poor suckling
laryngeal papillomatosis
most common tumor of the peds larynx
involutes after puperty
possible HPV form mom