pediatric surgery Flashcards
a neonate is examined in the nursery and found to hae no anal orificce; only a small perineal fistulous opening is visualized. a complete workup is negative for any cardiac, esophgeal, GU or MSK anomalies. which of the following is the best next step in the management of this pt?
a. diverting colostomy only
b. posterior sagittal anorectoplasty only
c. posterior sagittal anorectoplasty with diverting colostomy
d. perineal operation only
e. perineal operation with diverting colostomy
D. low imperforate anus –> d/t failure of descent of urorectal septum
associated with:
- esophgeal atresia
- tethered spinal cord
- GU abnormalities
complications
- rectal/ prostatic urethra or vagina
- incontinence
tx: make a hole, but need a sphincter
- HIGH imperforate anus (proximal to levator ani complex) ==> diverting colostomy + pull-through postieror sagittal anoplasty. likely incontinent
- LOW imperforate anus (distal to levator ani complex) ==> perineal operation. children will be continent
a 2mo boy is examined b/c he has been straining while passing stool and has a distended abdomen. he is very low on the growth chart for age. the PCP suspects that the boy has Hirschspruing disease. which of the following findings on workup is diagnostic?
a. absence of ganglion cells on full thickness rectal biopsy 2cm above the dentate line
b. absence of ganglion cells on full thickness rectal biopsy 1cm above the dentate line
c. absence of ganglion cells on suction rectal biopsy 1cm above the dentate line
d. identification of a transition zone b/w the sigmoid colon and the distal rectum on barium enema
e. inhibition of the resting anal inhibitory reflex on anorectal manometry
a. at least 2cm above the dentate line (lack of ganglion cells at level fo internal sphincter may be normal)
dx
- neonates = suction rectal biopsy
- children = full-thickness rectal biopsy
sxs
- barium enema –> with distal narrow segment of bowel with markedly distended colon proximally; lack of elmination of contrast after 24h
- malnourished; enterocolitis
tx
- colostomy decompression
- delayed definitive repair with adequate nutrition
a newborn has a midline defect in the anterior abdominal wall. the parents ask what, if anything, should be done. spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4? a. umbilical hernia b. patent urachus c. patent omphalomesenteric duct d. omphalocele e gastroschisis
A. umbilical hernias close by age 4.
tx
- expectant management
- if incarcerates symptomatic –> repair
omphalocele and gastroschisis have to be closed surgically
–> immediate / staged reduction and abdominal wall closure
urachal / omphalomesenteric ducts –> due to incomplete closure of embryonic connections from bladder / ileum to abdominal wall
tx = excision of tracts and closure of bladder / ileum
a neonate is found to have an iimperforate anus. as the pediatric surgeon you recommend studies to search for other abnormalities. which of the folllowing is an associated abnormality?
a. congenital pulmonary airway malformation
b. hydrocephalus
c. duodenal atresia
d. congenital heart disease
e. corneal opacities
D
associated with VACTERL
- V ertebral anomalies: tethered spinal cord
- A nal atresia
- C ardiac defect
- T racheo
- E sophageal fistula / atresia
- R enal abnomalies
- L imb defects (radial dysplasia)
- gU abnormalities (double urinary collecting systems, hydronephrosis; communication between rectum & urinary tract, vagina, perineum)
a 36yo infant presents with bilious vomiting and an increasingly distended abdomen. At exploration, SB segment (dilated proximal, decompressed distal) as the point of obstruction. what is the best next step in management?
a. gentle, persistent traction on the specimen
b. enteroenterostomy
c. SB resection with exteriorization of the ends
d. SB resection with anastomosis
e. lysis of Ladd band
D
ileal/jejunal atresia ==> due to mesenteric vascular accident during intrauteirne growth
tx = small bowel resection & primary anastomosis
if duodenal atresia ==> enteroenterostomy
if malrotation/vovulus ==> lysis of Ladd bands to release
a 1yo child has repeated episodes of vomiting and abdominal distention. an xrary shows obstruction at the 2nd portion of the duodenum. laparotomy is performed and an annular pancreas is discovered. for a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice?
a. a Whipple
b. gastrojejunostomy
c. vagotomy and gastrojejunostomy
d. partial resection of the annular pancreas
e. duodenoduodenostomy
E. Obstruction due to annular pancreas (benign)
tx ==> bypass procedure –> does not require a vagotomy to prevent marginal ulceration
approx 2w after a viral respiratory illness, an 18mo child complains of abdominal pain and passes some bloody mucus per rectum. a long, thin mass is palpable in the RUQ of the abdomen. no peritoneal signs are present. intussusception is suspected. which of the following is the most appropriate next step?
a. diagnostic air enema with subsequent observation and serial abdominal examinations
b. hydrostatic reduction with air enema
c. diagnostic laparoscopy with laparoscopic reduction
d. exploratory laparotomy with bowel resection
e. decompressive colonoscopy with placement of a rectal tube
B intussusception (currant jelly stool), w/out evidence of peritonitis. ==> dx & tx = barium / air contrast enema
if signs of peritonitis / bowel ischemia
==> surgical exploration (open / lap) +/- bowel resection for ischemia / necrosis
no need for serial abdominal examinations b/c unlikely to recur.
an 18yo woman presents with abdominal pain, fever, and leukocytosis. with the presumptive diagnosis of appendicitis, a RLQ (McBurney) incision is made and a lesion 60cm proximal to the ileocecal valve is identified, that is large and dark and lobulated. which of the following is the most likey diagnosis.
a. intestinal duplication
b. mesenteric cyst
c. meckel diverticulum
d. ileoileal intussusception
e. “christmas tree” type of ileal atresia
C. Inflamed Meckel diverticulum.
should be in the ileum
Meckel & appendicitis ==> clinically similar
dx = Tc99m pertechnetate
tx (asymptomatic) = expectant management
tx (diverticula with narrow neck, palpable ) = surgical excision d/t concerns of obstruction
tx (symptomatic abd pain) = diverticulectomy
complications of Meckel ==> hemorrhage, obstruction
a newborn infant born from a mother with polyhydramnios presents with excessive salivation along with coughing and choking with the first oral feeding. an xray of the abdomen shows gas in the stomach and a NGT coiled in the esophagus. which of the following is the most likely diagnosis?
a. esophgeal atresia
b. tracheoesophgeal fistula
c. esophageal atresia and tracheoesophgeal fistula
d. omphalocele
e. gastroschisis
C. esophageal atresia (NGT curled up) and TE fistula (air in stomach)
there is air in the stomach somehow
RFs
- maternal hx of polyhydramnios during pregnancy
sxs = infant who presetns with excessive drooling, coughing, shocking during first oral feeding
complications = reflux of gastric contents –> tachypnea, apnea, cyanosis
tx = evaluation for VACTERLU; surgical repair
an infant born with a defect in the anterior abdominal cavity. upon exam, there are abdominal contents (SB & liver) protruding directly through the umbilical ring. which of the following should be considered in the management of this condition?
a. no further workup is indicated prior to closure of the abdominal wall defect
b. a silastic silo should be placed with immediate reduction of the viscera into the abdominal cavity
c. broad-spectrum IV antibiotics should be administered prophylactically.
d. topical antimicrobial solutions should be administered prophylactically
e. enteral feeds for nutritional support should be initiated early prior to operative management
C. need IV Abx b/c bowel exposed to teh world.
omphalocele (thru inguinal ring)==> spillage of bowels
gastroschisis (bowel exposed to amniotic fluid) ==> covered by membrane.
management
1) broad spectrum prophylactic IV abx
2) prevention of hypothermia
3) cardiopulmonary resuscitation
4) gastric decompression
5) OMPHALOCELE-associated congenital defects
GASTROSCHISES - skip --> not associated with congenital defects like omphalocele is
---------
6) closure of abdominal wall defect
a 2w old infant presents with sudden onset of bilious emesis. plain films of the abdomen show evidence of an intestinal obstruction. a UGI contrast series reveals a midgut volvulus with the site of obstruction at the 3rd portion of the duodenum. which of the following is the most likely diagnosis?
a. necrotizing enterocolitis (NEC)
b. intussusception
c. Hirshspruing disease
d. anomalies of intestinal rotation and fixation
e. hypertrophic pyloric stenosis.
D. Normal developmental rotation 270deg CC around SMA ==> places ligament of Treitz in LUQ and cecum in RLQ of the abdomen
vovulus = twisting around transition point.
sxs of malrotation
- volvulus
- duodenal obstruction
- intermittent / chronic abdominal pain.
MOST COMMON ==> complete nonrotation fo the midgut –> where proximal jejunum & ascending colon are fused together as one pedicle –> with midgut volvulus on the pedicle –> ischemic necrosis of entire midgut
29 week old previously healthy male infant presents with fevers, abdominal distention, feeding intolerance, and bloody stools at 3w of age. the pt undergoes xray and US for possible necrotizing enterocolitis. which of the following on imaging is an indication for surgical management?
a. pneumoperitoneum
b. ascites
c. portal venous gas
d. ileus
e. pneumatosis intestinalis
A. necrotizing enterocolitis = most common GI emergency in the neonatal period (80% in first month of life)
pneumoperitoneum = gas in area of peritoneum (perforation)
pneumatosis intestinalis = gas in bowel wall
RFs of NEC
- prematurity
- ischemia, infection, cytokines
- enteral feeding
sxs of NEC
- pneumatosis intestinalis
- involvement of distal ileum, ascending colon OR entire colon
complications
= clinical deterioration, abdominal wall cellulitis, leukopenia, thrombocytopenia, palpable abdominal mass, persistent fixed loop on AXR
- intestinal strictures
- intestinal perforation
tx
- bowel rest, NGT, fluids, broad-spectrum Abx
- Surgery
a newborn presents with signs and sxs of distal intestinal obstruction. AXR reveal dilated loops of small bowel, absence of air fluid levels, and a mass of meconium within the R side of the abdomen mixed with gas to give a ground-glass appearance. which of the following should be performed as the initial management of the pt?
a. administration of oral polyethylene glycol
b. bowel rest with NGT decompression and broad-spectrum IV Abx
c. contrast enema
d. surgical evacuation of the luminal meconium
e. resection of the dilated terminal ileum
C. meconium ileus ==> dilated terminal ileum; filled with thick, tarlike inspissated meconium
Dx & TX
1) water-soluble contrast enema
2) surgery –> enterotomy through dilated distal ileum –> irrigate proximal & distal bowel with NS or 4% N-acetylcysteine –> then milk meconium through distal colon / enterotomy –> then close enterotomy through 2 layers
Associated conditions
- cystic fibrosis (meconium ileus = earliest clinical manifestation of CF)
4wo male infant presents with projectile, nonbilious emesis. US of the abdomen reveals a pyloric muscle thickness of 8mm (nml = 3-4mm). which of the following is the best initial management of this pt?
a. urgent pyloromyotomy
b. urgent pyloroplasty
c. urgent gastroduodenostomy
d. fluid hydration and correction of electrolyte abnormalities prior to operative management
e. administration of sodium bicarbonate to correct aciduria prior to operative management.
D
Sxs: vomiting ==> hypokalemic, hypochloremic metabolic alkalosis
tx
1) optimization of fluids & electrolytes (to prevent postoperative apnea from compensatory mechanism of hypoventilation / respiratory acidosis for metabolic alkalosis)
2) pyloromyotomy
1mo female infant presents with persistent jaundice. a serum dbili is 4.0, and an US of the abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. which of the following is the most appropriate initial management of this pt?
a. NPO and TPN
b. oral choleretic bile salts
c. methyprednisolone
d. IV Abx
e. exploratory laparotomy
E
weird anatomy ==> biliary atresia = progrressive obliteration of the extra hepatic and intrahepatic bile ducts
sxs = persistent jaundice after first few weeks of life
complications = irreversible hepatic fibrosis
dx = labs, abd US, liver needle biopsy
==> fibrotic biliary remnants and absent proximal & distal bile duct patency.
tx = laparotomy with Kasai hepatoportoenterostomy (best success <60d of life)
