Pediatric Surgery

Question 1

Excessive salivation after birth or choking spells during first feed. What other potential abnormalities should be investigated before therapy is undertaken?

Answer 1

ESOPHAGEAL ATRESIA
VACTER: vertebral (xray), anal (imperforation), cardiac (echocardiogram), tracheal, esophageal, renal (sonogram), and radial anomalies

Question 2

If primary surgical repair of esophageal repair must be delayed, what should be done to protect the lungs from acid reflux?

Answer 2

gastrostomy

Question 3

What is the most common type of tracheoesophageal abnormality?

Answer 3

Esophageal atresia with distal TEF (between lower esophagus and tracheobronchial tree)

Question 4

What is the approach to treating imperforate anus?

Answer 4

1) look for associated VACTER anomalies
2) look for fistula; if one is present, can delay repair until before toilet training
3) find where the pouch is:
- if high rectal pouch, colostomy (with later repair)
- if blind pouch almost at level of anus, can do primary repair right away

Question 5

Congenital diaphragmatic hernia is always on the (right/left).

Answer 5

Left

Question 6

Why must repair of congenital diaphragmatic hernia be delayed 3 or 4 days?

Answer 6

To allow maturation of hypoplastic lung that still has fetal-type circulation

Question 7

How do you treat respiratory distress in infant with congenital diaphragmatic hernia?

Answer 7

intubation, low pressure ventilation, sedation, NG suction

ECMO for difficult cases

Question 8

In (omphalocele/gastrochisis), the defect is to the right of the cord and the bowel looks angry and matted, requiring TPN for about a month before it can work well.

Answer 8

gastrochisis!
In omphalocele, cord goes to the defect (can see normal-looking bowel and a little slice of liver through the thin membrane covering the defect)

Question 9

While small gastrochisis or omphalocele defects can be closed primarily, large ones require construction of a ___________ to house and protect the bowel. Contents are squeezed into the belly a little each day–takes about a week to replace.

Answer 9

silastic silo

Question 10

Baby with an abdominal wall defect over the pubis (which is not fused), with a medallion of red bladder mucosa, wet and shining. Next steps?

Answer 10

Exstrophy of the urinary bladder! Must transfer immediately to specialized center to perform repair within 1-2 days (delayed repairs do not work)

Question 11

What are 3 causes of green vomiting and double-bubble abdominal X ray in infants?

Answer 11

1) duodenal atresia
2) annular pancreas
3) malrotation

Question 12

If in addition to a double bubble on AXR, there is a little normal gas pattern beyond, the chances of which diagnosis are higher?

Answer 12

malrotation

Question 13

Green vomiting in new born with AXR showing multiple air fluid levels (and not a double bubble). What causes this condition?

Answer 13

Intestinal atresia, resulting from a vascular accident in utero

Question 14

Premature infant with feeding intolerance, abdominal distention, and a rapidly dropping platelet count:
Treatment?

Answer 14

necrotizing enterocolitis

Treatment: stop all feedings, administer broad spectrum abx, IV fluids, IV nutrition

Question 15

When is surgical intervention required in necrotizing enterocolitis?

Answer 15

1) abdominal wall erythema
2) air in the portal vein
3) intestinal pneumatosis (presence of gas in the bowel wall)
4) pneumoperitoneum (intestinal necrosis and perforation)

Question 16

Feeding intolderance, bilious vomiting, X ray showing multiple dilated loops of small bowel and a ground-glass appearance in lower abdomen:
Next step?

Answer 16

meconium ileus (usually in CF infants)
Perform gastrografin enema to diagnose (microcolon and inspissated pellets of meconium in the terminal ileum) AND for therapy (Gastrografin draws fluid in, dissolves the pellets)

**Note: “soap bubble” or “ground glass” appearance in lower abdomen is due to small air bubbles mixed with the meconium is diagnostic of meconium ileus

Question 17

More commonly seen in firstborn boys, nonbilious projectile vomiting after each feeding, starting around age 3 weeks, palpable olive-size mass in RUQ (and sometimes visible gastric peristaltic waves!):
Diagnosis/therapy?

Answer 17

Diagnose with sonogram if mass can’t be felt
Therapy with rehydration, correction of hypochloremic, hypokalemic metabolic alkalosis, followed by Ramstedt pyloromyotomy or balloon dilatation

Question 18

___________ should be suspected in a 6- to 8-week-old baby who has persistent progressively increasing jaundice (including a substantial conjugated fraction).

Answer 18

Biliary atresia

Question 19

A HIDA scan should be performed after 1 week of __________ (a powerful choleretic) in babies for whom biliary atresia is suspected (after serologies and sweat test rule out other problems).

Answer 19

phenobarbital

Question 20

What is the treatment of biliary atresia?

Answer 20

Surgical derivation. 1/3 of patients need liver transplant right away.

Question 21

Constipation with X ray showing distended proximal distention and “normal-looking” distal colon:
How is the diagnosis made?

Answer 21

Hirchsprung disease

Diagnosis made with full-thickness biopsy of rectal mucosa. Surgery.

Question 22

6–12-month old infant with colicky abdominal pain, currant jelly stools, “empty’ RLQ and potential palpable mass on the right side of the abdomen.
Next step for diagnosis/therapy?

Answer 22

barium or air enema is diagnostic and therapeutic

Question 23

Subdural hematoma and retinal hemorrhages:

Answer 23

shaken baby syndrome, child abuse

Question 24

What is an X ray finding that suggests child abuse?

Answer 24

multiple fractures in different stages of healing

Question 25

Lower GI bleeding in children. Next step?

Answer 25

Potential Meckel diverticulum. Do technetium scan looking for ectopic gastric mucosa in lower abdomen