pediatric surgery

Question 1

how do most pediatric extracranial solid malignant tumours usually present

Answer 1

as a palpable lump without pain or other manifestations

Question 2

what investigations should you do when a mass is detected in a child

Answer 2

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

Question 3

why is a CT helpful in assessing a mass in a child

Answer 3

CT helps with tumour staging based on TMN

Question 4

list the common pediatric solid tumours

Answer 4

1. neuroblastoma
2. wilm’s tumour/nephroblastoma (left flank solid mass)
3. lymphoma
4. rhabdomyosarcoma
5. ewing’s sarcoma
6. hepatoblastoma and hepatocellular carcinoma
7. other

Question 5

how should you manage a child presenting with green, bilious vomiting

Answer 5

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)

Question 6

what is the “double bubble sign”

Answer 6

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

Question 7

list the causes of newborn bowel obstructions

Answer 7

1. atresia
2. imperforate anus (most common)
3. hirschprung’s disease
4. meconium ileus
5. malrotation
6. extrinsic obstructions

Question 8

what types of atresia can cause bowel obstruction in the newbown

Answer 8

duodenal

small bowel

colonic

Question 9

what is the most common cause of newborn bowel obstruction

Answer 9

imperforate anus

Question 10

what is hirschprung’s disease

Answer 10

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

Question 11

how do you investigate hirschprungs

Answer 11

barium enema/colon contrast study then biopsy of the inner wall for definitive diagnosis

Question 12

how do you treat hirschprungs

Answer 12

resection of the aganglionic portion of the colon then pull through and reattachement

Question 13

what are adhesive bowel obstructions

Answer 13

secondary to previous surgery/inflammation usually

Question 14

how do you manage adhesive bowel obstructions

Answer 14

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

Question 15

what conditions are associated with intestinal obstruction in kids (what is the pneumonic?)

Answer 15

VACTERL

Vertebral anomalies
Anal atresia
Cardiac defects
Tracheoesophageal fistula
Esophageal atresia 
Renal (and radial) anomalies 
Limb defects

Question 16

what are the main symptoms of infantile hypertrophic pyloric stenosis

Answer 16

PPP–>

persistent
projectile
progressive emesis

palpation reveals something like an “olive”
metabolic alkalosis

Question 17

when does infantile hypertrophic pyloric stenosis occur

Answer 17

3-8 weeks of age

Question 18

how do you manage infantile hypertrophic pyloric stenosis

Answer 18

resuscitate first, then treat with pyloromyotomy–surgical incision in the longitudinal and circular muscles to loosen the pyloric sphincter

Question 19

how does intussusception usually present in kids

Answer 19

crampy, intermittent “knees up” abdo pain

sausage shaped abdominal mass with red-current jelly stool

Question 20

what age is usually affected by intussusception

Answer 20

3 mo to 3 years

Question 21

how do you manage intussusception

Answer 21

resuscitate first then treat with enema reduction

(pressure in the intestine to reverse the telescoping… air is better than liquid)

surgery if necessary

Question 22

ddx for newborn rectal bleeding

Answer 22

1. swallowed blood from birth process or breastfeeding–> test with Apt test with differentiates fetal blood (positive) from maternal blood in newborn stool or vomit
2. coagulopathy–> check IM vitamin K status, platelet count, fibrinogen, PT/INR for extrinsic/common clotting pathways and PTT for intrinsic/common clotting pathways
3. intussusception–> 3 months to 3 years
4. necrotizing enterocolitis–> usually in a premature baby, more than 2 days old, have been fed–> investigate with abdo xray
5. vascular malformation of GI tract–> rare
6. peptic ulcer–> rare in babies because acid causes ulcers and babies are achlorhydric for first few days
7. 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

Question 23

how do you manage newborn rectal bleeding

Answer 23

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)

Question 24

what number is associated with meckel’s diverticulum

Answer 24

“the answer is always 2”

Question 25

why do we care about meckel’s diverticulum

Answer 25

ectopic mucosa secretes acid excessively causing ulceration and bleeding of the adjacent small bowel mucosa

Question 26

what is the most common age of presentation of meckel’s diverticulum

Answer 26

2 years old

Question 27

what % of the population gets meckel’s diverticulum

Answer 27

2%

Question 28

where is meckel’s diverticulum found

Answer 28

2 feet from the terminal ileum

Question 29

what types of ectopic mucosa are possible in meckel’s diverticulum

Answer 29

2

gastric and pancreatic

Question 30

how long is meckel’s diverticulum

Answer 30

2 inches

Question 31

how many ways can meckel’s diverticulum present

Answer 31

6 ways

bleeding

diverticulitis mimicking appendicitis

intussuscepting causing obstruction

meckel’s band causing obstruction

malignancy

etc

Question 32

what is a fistula

Answer 32

an abnormal connection between two epithelialized of endothelialized surfaces

i.e gastro-colic fistula, tracheo-esophageal fistula etc…

Question 33

what is a sinus tract

Answer 33

abnormal connection between two surfaces only one of which is epithelialized

ie abscess training to the small intestine

Question 34

how can we recognize a pneumothorax clinically and radiologically

Answer 34

clinical–> SOB, decreased breath sounds in a certain area

radiological–> visible lung/lobe border

Question 35

management of a pediatric pneumothorax

Answer 35

CXR

insert chest tube with a one way valve and collection chamber

leaking lung bullae (especially in teenagers) can seal themselves over a few days but video assisted thoracoscopic surgery may be used to seal the leak

Question 36

what are dr blair’s three rules of testing

Answer 36

1. dont order a test unless the results will change your management
2. dont order a test if you do not know the tests inherent accuracies in the context of your patient
3. consider the risk of a test and whether the testing risk is appropriate in the context of your patient’s present and future health

Question 37

what is the classic presentation of appendicitis in a child

Answer 37

abdo pain from central to RLQ and tenderness to palpation localized at mcburney’s point

Question 38

how would you manage appendicitis in a child

Answer 38

possible U/S though likely wont change management plan since acute surgery is needed

urinalysis, CBC, IV bolus if volume depleted

urgent laparoscopic appendectomy with prophylactic broad-spectrum abx

Question 39

5 basic clinical manifestations of inflammation

Answer 39

rubor (red)
calor (warmth
dolor (pain)
tumor (swelling)
functio laesi (disabled function)

Question 40

if a kid presents with acute scrotal pain, what is your first working dx

Answer 40

testicular torsion–have 6 hours to save a twisted testicle so go to OR immediately

Question 41

what are the basic types of abdominal wall hernias and defects that present in kids

Answer 41

1. gastroschisis
2. omphalocele
3. umbilical hernia
4. indirect inguinal hernia
5. hydrocele

Question 42

how do you manage a gastroschisis

Answer 42

characteristically the stomach, small bowel and colon are totally outside the body through a defect that is to the right of the navel

usually an isolated anomaly

treatment is to place the organs back into the body slowly over time (may require a silo that is squeezed daily to gradually place intestines back into the abdo)

TPN for a while until bowel healed

Question 43

how do you manage a omphalocele

Answer 43

abdominal organs (primarily bowel and liver) protrude through a variably sized central abdo defect that is at the umbilicus and is contained within a thin membrane

can often be reliably detected prenatally by U/S

50% will have other major congenital defects

palce organs back into body with gentle compression of the omohalocele and eventual closure of the fascia surgically and then investigate for other congenital abnormalities

TPN until bowel healed

Question 44

how do you manage a pediatric umbilical hernia

Answer 44

often benign fascial opening in the umbilical fascia–with crying or straining the umbilical skin can bulge

most close on their own by a year whereas some persist beyond 5 years and can then be repaired for cosmetic reasons

Question 45

how do you manage a indirect inguinal hernias

Answer 45

congenital patent processus vaginalis (supposed to close prior to birth) leads to protrusion at the internal inguinal ring

usually bulges in and out over time and is painful

common in 1-2% of boys and 0.5% of girls

often appear in early infancy especially in premature children

if they incarcerate they can present with an irreducible bulge, pain, tenderness and eventual signs of bowel obstruction–> bowel and/or testicle ischemia

diagnosis is purely clinical–> surgical repair should soon follow

Question 46

how do you manage a hydrocele

Answer 46

can be communicating or non communicating—generally painless in babies and children, often vary in size throughout the day if communicating

treat with monitoring and elective repair

Question 47

why do we need to be careful with regard to occult traumatic injury in kids

Answer 47

(still treat trauma with ABCDEs)

children do not have the muscle bulk and rib stiffness that protects the spleen and liver in adults, so relatively low kinetic energy hits can result in solid organ damage without rib fractures

significant internal organ damage can also occur with little outward evidence of significant injury

crushed chest can cause the glottis to close and a resultant sudden rise in thoracic pressure and CVP causes capillary bursting in the head and neck region

FAST scan can be used to detect blood around the heart or abdo organs after trauma