Pediatric Surgery Flashcards
What do you suspect in a newborn who presents with excessive salivation or choking spells during first feeding attempt?
Esophageal atresia- likely due to TE fistula
MC type of TE fistula
Proximal blind esophagus
Distal esophagus joins trachea
You insert a NGT in a baby and on XR it appears it has coiled back on itself in the upper chest…
Suspect TE fistula
You diagnose a baby with TE fistula, what are the first steps that need to be taken?
Rule out VACTERL abnormalities
- vertebral, anal, cardiac, TE and renal/radial
- once this has been R/O then you should proceed with surgery
A newborn baby is found to have an imperforate anus on PE- what is the next step?
Part of VACTERL group of abnormalities
Next step - XR while holding baby upside down and metal marker on anal dimple to assess level of blind pouch
Tx of imperforate anus
If fistula to vagina or perineum present, repair can be done later
If low blind pouch, repaired with simple operation
If high blind pouch, colostomy with reconstruction later
surgery for a baby with TE fistula must be delayed, what should be done in the meantime?
Gastrostomy to protect lungs from acid reflux
Newborn baby is tachypneic, cyanotic and grunting; bowel sounds are heard over the left chest - dx test? Dx?
Should do a chest XR: will show bowel in chest
- congenital diaphragmatic hernia
Tx of hypoplastic lung due to congenital diaphragmatic hernia
Surgery - but wait 36-48 hrs to allow transition from fetal circulation
In the meantime, intubation, low pressure hyperventilation, sedation and NGT suction
Bilious vomiting, ground glass appearance on abdominal XR and family history of CF
Meconium Ileus
3 week old baby with projectile vomiting following each feeding and on physical exam you see visible gastric persistaltic waves and a palpable olive mass
Hypertrophic pyloric stenosis
9 month old baby with intermittent colicky pain and currant jelly stool
Intussusception
Newborn with large abdominal wall defect to the right of the umbilicus - normal cord but protruding from the cord are edematous bowel loops
Gastroschisis
Newborn with shiny, thin membranous sac at the base of the umbilical cord; inside the sac you see part of the liver and loops of normal bowel
Omphalocele
Newborn with moist medallion of mucosa occupying the lower abdominal wall (above public and below umbilicus) that is constantly bathed in urine
Exstrophy of the urinary bladder
Tx of exstrophy of bladder
Emergent transfer to specialized institution
- requires rapid within 48 hrs
A baby with Down syndrome vomits green fluid. What study do you order?
X-ray
What can the double bubble sign on XR mean?
Annular pancreas
Duodenal atresia
What does a double bubble sign with no gas in the rest of the bowel mean?
Likely that complete obstruction is present and surgery is needed
- dx is most likely duodenal atresia in a new born with Downs
What does a double bubble sign with air in the distal bowel mean? What test should you do next?
Incomplete obstruction (duodenal stenosis, annular pancreas, malrotation) - order barium enema
A newborn baby has repeated episodes of green vomiting, it also didn’t pass meconium; XR shows multiple air fluid levels and distended loops of bowel
Intestinal atresia
- vascular accident in utero with loss of blood supply tons segment of bowel
You had suspected intestinal atresia based on XR and clinical findings, but when you operate you find all the bowel is there…
Consider aganglionic megacolon with involvement of entire bowel
- do frozen sections on appendix
What are the signs of sepsis in a newborn?
Rapidly dropping platelet count
Premature baby develops feeding intolerance, abdominal distention and rapidly dropping platelet count; baby is 4 days old and was treated with indomethacin for PDA - what do you suspect?
Necrotising enterocolitis
Tx for necrotizing enterocolitis
NPO, broad spec antibiotics, IVF/ nutrition
What are indications for surgical intervention in a baby with necrotizing enterocolitis?
Abdominal wall erythema
Air in portal vein
Pneumo-peritoneum
Intestinal pneumatosis (gas in bowel wall)
What is the next step when you have a baby with meconium Ileus? What can you see?
Gastrografin swallow - both diagnostic and therapeutic
Dx. See microcolon and inspissated pellets of meconium in terminal ileum
Tx. Gastrografic is hypertonic so it draws in fluid and dissolves the pellets
A baby has had trouble feeding; he now has bilious vomiting. XR show double bubble sign with normal looking gas pattern in the rest of the bowel - dx?
Malrotation - emergency!
You see signs of malrotation on XR (double bubble with air after), what is the next test you order?
Barium enema
Once you suspect hypertrophic pyloric stenosis in a baby, what should you check next?
Electrolytes - hypokalemic, hypochloremic metabolic alkalosis
- correct and rehydrate
Tx for hypertrophic pyloric stenosis
Ramstedt pyloromyotomy or balloon dilatation
8 week old baby is brought in due to progressively increasing jaundice; bilirubin is sig.elevated, ESP CB - dx?
Biliary atresia
- baby is not born this way rather something destroys the biliary tree
Best diagnostic test for biliary atresia
HIDA scan - after one week of phenobarbital treatment (stimulates liver to produce bile, then you do the scan and all the bile is within the liver )
Tx. Biliary atresia
Surgical derivation but 2/3 of children will require liver transplant
2 month old baby boy is brought in bc of chronic constipation and abdominal distention; XR show dilated loops of bowel throughout; DRE is followed by explosive expulsion of stool and flatus which relieves the distention
Hirschsprung disease
What studies are diagnostic for Hirschsprungs dz?
Barium enema
Full thickness biopsy of rectal mucosa
Tx. Hirschsprung’s disease
Ileostomy followed by reconstruction later
9 month old boy has episode of colicky abdominal pain that make him double up and squat; the episodes last 1 min and then go away. On exam, there is a vague mass on right side of abdomen, empty lower right quadrant and currant jelly stools
Intussusception
What test is both diagnostic and therapeutic for intussusception
Barium enema
- if does not help,proceed to surgery
What are some signs of child abuse!
Subdural hematoma, retinal hemorrhage - shaken baby
Fractured humerus or fractures are various stages of healing
Second degree burns on both buttocks
7 yo boy passes large bloody stool
Meckel’s diverticulum
Diagnostic test for Meckel’s diverticulum
Radioisotope scan looking for gastric mucosa in the lower abdomen
