pediatric surgery Flashcards
how do most pediatric extracranial solid malignant tumours usually present
as a palpable lump without pain or other manifestations
what investigations should you do when a mass is detected in a child
hx/px
urinalysis
ultrasound
CT–> important specialized imaging but generally not first line of imaging
biopsy for tissue diagnosis after suspicion for malignancy… generally not needle biopsy in kids
why is a CT helpful in assessing a mass in a child
CT helps with tumour staging based on TMN
list the common pediatric solid tumours
- neuroblastoma
- wilm’s tumour/nephroblastoma (left flank solid mass)
- lymphoma
- rhabdomyosarcoma
- ewing’s sarcoma
- hepatoblastoma and hepatocellular carcinoma
- other
how should you manage a child presenting with green, bilious vomiting
bowel obstruction until proven otherwise
manage acutely–> NG tube to suction stomach, IV fluid maintenance
investigate with abdo xray upright and supine (U/S confounded by gas)
what is the “double bubble sign”
evidence that a bowel obstruction in a child is high (no distal gas) and is classic for duodenal atresia
1/3 of duodenal atresia cases have trisomy 21–> there are often other congenital anomalies (i.e congenital heart disease)
failure of vacuolization of the duodenal lumen and polyhydramnios can occur
primary repair is by duodeno-duodenostomy bypass
list the causes of newborn bowel obstructions
- atresia
- imperforate anus (most common)
- hirschprung’s disease
- meconium ileus
- malrotation
- extrinsic obstructions
what types of atresia can cause bowel obstruction in the newbown
duodenal
small bowel
colonic
what is the most common cause of newborn bowel obstruction
imperforate anus
what is hirschprung’s disease
congenital megacolon due to lack of ganglion cells in the colon myenteric/submucosal plexuses of the wall such that the affected part of the colon cannot relax/spasm and pass stool so obstruction results (most often distal colon)
if a baby has a patent anus and hasnt passed meconium in the first 24 hours, thing hirschprung’s (often DRE can break the rectal spasm and allow passage of meconium)
usually there is no air in the rectum
how do you investigate hirschprungs
barium enema/colon contrast study then biopsy of the inner wall for definitive diagnosis
how do you treat hirschprungs
resection of the aganglionic portion of the colon then pull through and reattachement
what are adhesive bowel obstructions
secondary to previous surgery/inflammation usually
how do you manage adhesive bowel obstructions
resuscitation of volume and electrolytes is critical–> IV and NG suction
monitor and repeat physical and exams–> persistent pain, fever, high WBC are BAD
CT is rarely required
laparotomy and lysis of adhesions can be done if no resolution
adhesions are hard to cure–> appropriate approaches include meticulous surgical technique, minimal bowel handling and laparoscopic surgery
what conditions are associated with intestinal obstruction in kids (what is the pneumonic?)
VACTERL
Vertebral anomalies Anal atresia Cardiac defects Tracheoesophageal fistula Esophageal atresia Renal (and radial) anomalies Limb defects
what are the main symptoms of infantile hypertrophic pyloric stenosis
PPP–>
persistent
projectile
progressive emesis
palpation reveals something like an “olive”
metabolic alkalosis
when does infantile hypertrophic pyloric stenosis occur
3-8 weeks of age
how do you manage infantile hypertrophic pyloric stenosis
resuscitate first, then treat with pyloromyotomy–surgical incision in the longitudinal and circular muscles to loosen the pyloric sphincter
how does intussusception usually present in kids
crampy, intermittent “knees up” abdo pain
sausage shaped abdominal mass with red-current jelly stool
what age is usually affected by intussusception
3 mo to 3 years
how do you manage intussusception
resuscitate first then treat with enema reduction
(pressure in the intestine to reverse the telescoping… air is better than liquid)
surgery if necessary
ddx for newborn rectal bleeding
- swallowed blood from birth process or breastfeeding–> test with Apt test with differentiates fetal blood (positive) from maternal blood in newborn stool or vomit
- coagulopathy–> check IM vitamin K status, platelet count, fibrinogen, PT/INR for extrinsic/common clotting pathways and PTT for intrinsic/common clotting pathways
- intussusception–> 3 months to 3 years
- necrotizing enterocolitis–> usually in a premature baby, more than 2 days old, have been fed–> investigate with abdo xray
- vascular malformation of GI tract–> rare
- peptic ulcer–> rare in babies because acid causes ulcers and babies are achlorhydric for first few days
- intestinal malrotation with acute volvulus–> causes acute mesentery vascular compromise leading to intestinal ischemic necrosis and bleeding/sloughing of intestinal mucosa; may cause abdo distension, green vomiting from duodenal obstruction etc
how do you manage newborn rectal bleeding
IV fluids and NG tube for suction
abdo xray
upper GI contrast xray to diagnose malrotation if child well enough to tolerate it
CBC, coag studies, cross match and type
transfusion?
start IV
meckel scan for abnormal uptake in gastric mucosa where ectopic acid secretion is occurring –> small bowel mucosal ulceration and profuse bleeding (melena)
what number is associated with meckel’s diverticulum
“the answer is always 2”
