Pediatric Surgery Flashcards
3 most common solid pelvic/abdominal malignancies in children
- Neuroblastoma (forms in nervous tissue – usually adrenal glands)
- Wilm’s Tumour (Nephroblastoma)
- Lymphoma
Good first lineimaging technique for children
Ultrasound
Common cancer staging system
T (tumour size and possible local invasion)
N (nodes – local vs more extensive spread)
M (metastases - # and location)
Biopsies in children
Needle biopsy is not common b/c this technique is best for carcinomas which are not common in children
Incisional (removing a part of the tumour) and excision (removing the entire tumour) are common
Blastoma
Malignancy in precursor cells (blasts)
In children. green vomit is ___ until proven otherwise
Bowel obstruction
First step for possible bowel obstruction
Decompress bowel (NG tube) and support baby (IV)
Best imaging technique for bowel obstruction
X-rays (supine and upright to see air-fluid levels)
U/S is not favourable b/c it is confounded by gas, and there is a lot of gas with bowel obstruction
Atresia
Luminal structure in body that doesn’t form correctly and is obstructed
Duodenum formation
Duodenal tissue forms vacuoles that coalesce
Duodenal atresia associated with
Trisomy 21 and congenital heart disease
Polyhydramnios
Duodenal atresia common finding on AXR
Double bubble – 2 air filled bubbles that suggest 2 discontinuous loops of proximal small bowel
Duodenal atresia tx
Find obstruction at laparotomy
Duodeno-duodenostomy repair (bypass obstruction by sewing proximal duodenum to distal)
Most common cause of newborn bowel obstructions
Imperforate anus
Adhesive bowel obstruction
Secondary to previous surgery/inflammation
Abdominal obstructions in the newborn
Atresias (small bowel and colonic)
Malrotation with Ladd’s bands (adhesions)
Malrotation with volvulus (twisting of bowel leading to obstruction and vascular compromise)
Meconium ileus (GI obstruction secondary to thick meconium; common in CF)
Hirschprung’s (aganglionosis of distal bowel)
Imperforate anus
Biliary atresia
Urinary obstruction
Abdominal obstructions in infant
Pyloric stenosis
Intussception
Malrotation
Hirschprung’s
Abdominal obstructions in children
Intussception
Appendicits
Adhesions
Malrotation
Clinical presentation of infantile hypertrophic pyloric stenosis
PPP = persistent, projectile, progressive emesis
3-8wks of age
1st born male
Metabolic alkalosis
Tx for pyloric stenosis
Resuscitate first
Pyloromyotomy - incision into longitudinal and circular muscles of pyloric muscle
Clinical presentation of infantile intussusception
3mo-3yrs
Crampy, intermittent knees up abdominal pain
Red currant jelly stool
Sausage shaped abdominal mass
Tx for intussception
Enema reduction
Surgery if necessary
Typical presentation of extra cranial solid malignant tumours
Visible/palpable lump that does not cause any pain or other manifestations
Most common malignancy in children
CNS/brain tumours
Common therapies in childhood solid tumours
Chemotherapy
Surgery
Radiation
Wilm’s tumour (nephroblastoma)
~85% survival rate
Why might bloodwork in a neonate not be very useful?
Neonate was receiving blood from mom right up until birth so bloodwork may appear misleadingly normal
Bowel adhesion tx
No cure
May resolve with just ‘drip and suck’
Laparotmy and lysis can help but they can reform
Ddx for rectal bleeding
- Swallowed blood from mom during labour or from breastfeeding; baby is well and does not have tender abdomen
- Coagulopathy – all newborns should get a newborn shot of IM Vitamin K
- Intussusception – generally in 3mo-3yo
- Necrotizing enterocolitis – >3d old and have been fed, usually premature, perinatal asphyxiation event or are on drugs; pneumatosis intestinalis (bubbles of air in bowel wall)**
- Vascular malformation of GIT (RARE)
- Peptic ulcer – RARE b/c newborns are achlorhydric for the first few days (no acid, no ulcer)
- Intestinal malrotation with acute volvulus – Volvulus can cause vascular compromise of mesentery which leads to intestinal ischemic necrosis and congestive bleeding/sloughing off of intestinal mucosa; hemodynamically compromised and tender abdomen, abdo distension and bilious emesis due to duodenal obstruction by Ladd’s bands**
** = ones you do not want to miss b/c they are the most life-threatening
Ladd’s bands
Often present in intestinal malrotation that sweep from right lateral abdominal wall across duodenum to right colon
Best imaging to denote malrotation
Upper GI contrast x-ray
First steps for bleeding patient
IV started
Cross-match
CBC and coag profile
Meckel scan
Injection of Technetium-99m which gathers in gastric mucosa –> evidence of contrast build up in area outside of stomach = MD
MD typically has ectopic gastric and pancreatic cells
Meckel’s diverticulum
Occurs when vitelline duct (duct btwn fetal midgut and yolk sac) doesn’t close properly causing a blind-ending diverticulum that contains all layers found in ileum
Located in distal ileum
How does meckel’s diverticulum cause bleeding?
Meckel’s ectopic gastric mucosa secretes acid –> causes adjacent small bowel mucosa to ulcerate and bleed profusely
Blood is usually melena or at least dark purple b/c of acid enviro
Gestational week that vitelline duct should regress and disappear
5th-8th gestational week
Tx for meckel’s diverticulum
Laporoscopic resection
Most common age at presentation of MD
2 yrs
% of population have MD?
2%
How far from the terminal ileum is a MD?
2 feet
How many different types of ectopic mucosa can a MD have?
2 - gastric and pancreatic
How many inches long is a MD?
2 inches
MD typical presentation
- Bleeding
- Diverticulitis mimicking appendicits
- Intussception causing obstruction
- Meckel’s band causing obstruction
- Malignancy
- Littres hernia – inguinal hernia with MD in it
Fistula
Abnormal connection between 2 epithelialized or endothelialized surfaces
Sinus tract
Abnormal connection between two surfaces only one of which is epithelialized
Pneumothorax
Air fills in pleural space, causing partial collapse of lung and potential profound collapse of lung
Pneumothorax tx
Chest tube placed in right pleural cavity
Leak should seal itself over in a few days
If not, video-assisted thorascopic surgery (VATS) may be done to surgically seal the leak. The parietal pleura is either scraped and irritated, or actually stripped away so that re-expanded lung will stick to chest wall and not collapse again
Normal time to pass meconium
Within first 24h of life
Most common cause of not passing meconium
- Imperforate anus
2. If baby has anus, they may have Hirschsprung’s disease
Best imaging for Hirschsprung investigation and usual results
- AXR (supine and upright) – air fluid levels and NO air in rectum
- Colon contrast enema (barium enema) – narrowed rectum and colon dilation at transition zone from ganglionic to ganglionated bowel
Hirschsprung disease
Lack of ganglia cells in rectal wall –> chronic rectal spasm and functional obstruction of lower GIT
ALWAYS no ganglia in rectum; absence of ganglia extends proximal up the colon and can even go into small intestine
DRE can sometimes break rectal spasm and may see a rush of fecal matter
Diagnostic method for Hirschsprung
RECTAL BIOPSY – take 3 or 4 samples of inner wall of rectum at various levels
- above the transition zone: ganglia
- below the transition zone: no ganglia and hypertrophied nerve trunks
Tx for hirschsprung
Pull through = Resection of aganglionic portion of colon and ganglionate colon is “pulled through” and sewn to the anal canal
Classic presentation of appendicitis
Previous healthy child with sudden onset of abdo pain starting in mid-ado and then localizing in RLQ
P/E localized tenderness and guarding at McBurney’s point
Common first steps for emergency patient
Urinalysis
CBC
IV if patient is volume depleted
O2 if patient has trouble breathing
Appendicitis treatment
IF STRONG CLINICAL SUSPICION, THAT IS ENOUGH TO GO THROUGH WITH SURGERY WITHOUT IMAGING
- Prophylactic broad-spectrum abx IV
- Laporascopic appendectomy under GA
- Intermittent IV morphine for post-op pain
- Acetaminophen for pain PRN
If you were to order imaging for appendicitis, what imaging technique would you use?
U/S, but still ~5% possibility appendicitis will be missed
If appendicitis left untreated…
possible perforation and sepsis which may lead to death
5 basic attributes of inflammation
- Redness
- Warmth
- Pain
- Swelling
- Disabled function (ie. neck mobility)
Abscess
Collection of pus
Abscess treatment
Incision and drainage
Common abscess in toddlers
Cervical abscesses
Usually caused by staph or strep infections of cervical lymph nodes
Acute scrotal pain in healthy boy, swollen and extremely tender
Acute scrotum
Acute scrotum working dx
Testicular torsion
Ddx for acute scrotum
Epididymo-orchitis (inflammation of epididymis and testes)
Acute hydrocele (accumulation of fluid around testicle)
Hernia
Torsion of appendix testes (small appendage on top of epididymis)
Amount of time that you have to save a twisted testicle
6 hours
Testicular torsion
Results from lack of fixation of testicle within tunica vaginalis = bell clapper deformity
Allows testicle to twist on its vascular pedicle
Twisted spermatic cord
Testicle layers (outside in)
Tunica vaginalis
Tunica albuginea
Seminiferous tubules separated by septum
Treatment of testicular torsion
Orchidopexy
Orchidopexy
Pulling undescended testicle (cryptorchid) down and fixing it into the scrotum
Abdominal wall hernias
Gastroschisis
Omphalocele
Indirect inguinal hernia
Gastroschisis
Stomach, small bowel and colon are completely outside body through defect that is to the right of the naval
Can be detected prenatally by fetal ultrasound
Usually isolated anomaly
Omphalocele
Abdominal organs (usually bowel and liver) protrude through central abdominal defect at umbilicus
Protrusion is covered by thin membrane
Detected prenatally by ultrasound
50% have other major congenital defects
Gastroschisis tx
Place bowels in a “silastic silo” –> squeeze daily for up to 1 week –> gradually place intestines back in abdomen
TPN until bowel is ready
Omphalocele tx
Attend to any other congenital anomalies
Paint dress membrane protectively and gently compress omphalocele
Over MONTHS organs fit into abdomen and eventually fascia is surgically closed anteriorly
TPN until bowel is ready
Umbilical hernia
Benign fascial opening
Can cause bulging when baby cries or strains
Non-pathological and no risk of incarceration (bowel gets trapped and ischemic)
Umbilical hernia tx
Should close at age 1 yr
May be surgically repaired in school-age children primarily for cosmetic reasons
Do NOT recommend parents tape our bind them
Indirect inguinal hernia
More common in boys and premature babies
Congenital patent processus vaginalis (should close prior to birth)
Protrusion at internal inguinal ring – hernia ‘sac’ follows down inguinal canal towards scrotum
20% present bilaterally
Contain bowel and may incarcerate (irreducible bulge, pain, tenderness and eventually signs of bowel obstruction)
Bowel and testicle may become ischemic
May not present until child is a bit older and patent processes vaginalis is larger
Dx is purely clinical (U/S is useless)
Reducible
Indirect inguinal hernia repair
Surgical – tie off the patent process vaginalis
No mesh is needed because posterior inguinal wall is generally intact and strong (unlike in adult direct inguinal hernia repair)
Indirect inguinal hernia in girls
Less common
Added danger of not only having bowel incarcerate in them but also ovaries
Hydrocele
Communicating vs non-communicating
Very small patent processes vaginalis
Both are usually painless
Communicating hydrocele will vary in size over the day vs non-communicating is static in size
Not manually reducible
Usually you can palpate normal cord structures above
Transilluminate
Hydrocele treatment
Benign
Usually watch and wait both communicating and non-communicating
Elective repair in older children may be recommended
Cryptorchidism
Hidden testicle due to…
- Undescended testicle*
- Testicle descended but atrophied because of newborn torsion or inadequate vasculature
- Agenesis of testicle
- Ectopic testicle
- Retractile testicle*
- = most common
Undescended testicle
Testicles descend in early fetal life from formation in abdomen
Usually found in inguinal canal but may be higher in abdomen
If they haven’t descended by 6mo they aren’t going to
Orchidopexy should be done by 1y.o.
Ectopic testicle
Testicle descended but then veered off to lodge in upper thigh or lower abdomen
Retractile testicle
In the scrotum when he’s calm and warm, but when he’s upset or cold, the cremasteric muscle pulls it up to the inguinal canal
Can be manually brought down into scrotum and should stay there for ~10s when released
No tx needed, F/U in 6-12 months
Cremaster muscle
Thin layer of skeletal muscle found in the inguinal canal and scrotum surrounding the spermatic cord and testes
Supplied by: cremasteric artery (branch of inferior epigastric artery)
Innervated by: Genital branch of genitofemoral nerve
Kehr’s sign
Blood irritating underside of diaphragm is interpreted as C3,4,5 dermatome pain
Traumatic asphyxia
Occurs when chest is crushed under a weight and glottis is closed causing a sudden rise in thoracic pressure and CVP which in turn causes capillary bursting in head and neck region
Why are children more susceptible to traumatic injury?
They do not have the muscle bulk and rib stiffness to protect vital organs
Intussception
Segment of intestine invaginate into adjoining intestinal lumen causing bowel obstruction
Typically in 5-10months
Intussception tx
Hydrostatic or pneumatic enema
Surgical - manual reduction or segmental resection
Layers of spermatic cord
External spermatic fascia
Cremaster muscle
Internal spermatic fascia
Contents of spermatic cord
Arteries (testicular, cremasteric) Nerves (genital branch of genitofemoral, testicular) Vas deferens Lymphatic vessels Tunica vaginalis
VACTERL
Vertebral anomalies, anal atresia, cardiac malformations, tracheoesophageal fistula, esophageal atresia, renal anomalies, limb anomalies
Appendicitis alvarado score
Alvarado Score = MANTRELS
* Symptoms
* Abdominal pain that Migrates to RLQ (1)
* Anorexia (loss of appetite) or ketones in urine (1)
* Nausea or vomiting (1)
* Tenderness in RLQ (2)
* Signs
* Rebound tenderness (Blumberg) (1)
* Elevated fever >/= 37.3C (1)
* Laboratory
* Leukocytosis >10 000 (2)
* Neutrophilia >70% / Left Shift (1)
Alvarado scoring
Scoring system:
* <5 = Low risk
* PO challenge then possible d/c home
* 5-8 = Moderate risk
* IV fluids
* NPO
* Analgesia
* U/S
* > 8 = Increased risk
* IV fluids
* NPO
* Analgesia
* GSx consult
* IV abx
* No imaging until GSx consult
Typical abx for appendicitis
IV Cefoxitin 30mg/kg/dose q6h (max 2g dose)
Most common type of tracheoesophageal fistula
Atresia with distal fistula
Types of esophageal atresia /tracheoesophageal fistula that cause gas in stomach
Atresia with distal fistula
Atresia with double fistula
H-type isolated tracheoesphageal fistula
Types of hernias
- Inguinal - most common
- Femoral
- Umbilical
- Incisional
- Epigastric
- Hiatal
