Pediatrics 1 Flashcards
What is VACTERL?
syndrome combining Vertebral anomalies Anal anomalies Cardiac anomalies Trachea anomalies Esophagus anomalies Renal anomalies Limb anomalies
What should be done incase of trauma in children?
- avoid overextension of the neck (obstructs airway)
- fluid replacement = 20ml/kg -> could be repeated twice then blood
- use long saphenous vein at ankle for IV access, or scalp veins in babies
- intraosseous infusion is useful in children
- elastic ribs that deform can cause lung contusions
What are the causes of hernia?
CONGENITAL
- preformed sac
- congenital defect (UNOBLITERATED PROCESSUS VAGINALIS)
ACQUIRED
- predisposing factors (weak abdominal wall)
- precipitating factors (increase intra-abdominal pressure)
How is a congenital inguinal hernia diagnosed?
- complete from the start
- testis is felt as a part of hernial content
diagnosed clinically
How should a congenital inguinal hernia be treated?
- perform herniotomy once diagnosed
hernioplasty is contra-indicated
What are the types of hydrocele?
- congenital: inguinoscrotal
- infantile: inguinoscrotal
- encysted: scrotal or inguinoscrotal, separated from testis
- vaginal: purely scrotal & not separated from testis
What investigations & treatment should be done for hydrocele?
SCROTAL US
- congenital -> only surgical: excision of processus vaginalis with closure of peritoneal connection
- infantile -> conservatuve
- encysted -> excision
- vaginal -> excision, eversion, or plication
What is the pathway of the descent of the testis?
- START -> renal angle opposite L2
- 5th week -> starts descent
- 7th month -> internal ring
- 9th month -> in scrotum
What are the factors that affect the testicular descend?
MECHANICAL
- gabernaculum
- high intra-abdominal pressure
HORMONAL
- testosterone
- maternal HCG
- fetal Mullerian inhibiting factor
what are the types of imperfectly descended testis?
- Undescended testis: arrested at any point of the normal descend pathway
- ectopic testis: present at any site away from normal pathway
- retractile testis: descend normally then retract into inguinal region
What are the causes for undescended testis?
UNILATERAL (mechanical)
- dysgenetic testicle
- large testicle
- short spermatic cord
- short testicular artery
- band of adhesion
- associated congenital inguinal hernia
BILATERAL (hormonal)
- bilateral mechanical cause
- defect in maternal HCG
- defect in pituitary gonadotropin or testicular sensitivity to it
What side is more likely to be affected by undescended testis?
right side & in pre matures
What are the sites where the descend of the testes will stop?
- intra abdominal
- inguinal canal
- at the neck of the scrotum
What is the clinical picture of an undescended testis?
- empty scrotum
- poorly developed scrotum
- deviated median raphe towards affected side
Why are undescended testis difficult to palpate?
- could be dysgenetic
- external oblique aponeurosis infront of it
- lax fascia transversalis behind it
What are the complications of undescended testis?
- reduced fertility
- torsion
- testicular tumor
- epididymo-orchitis
What investigations should be done for undescended testis?
INITIALLY -> US (difficult to see gonads)
BEST -> MRI
MOST VALUABLE -> exploratory laparoscopy (diagnostic & therapeutic)
How should undescended testis be treated?
NO interference before 6 months
androgens contraindicated
BILATERAL -> bHCG for 4 weeks (2months max)
-> bilateral orcheopexy in 2 sets with 6 months in between
UNILATERAL -> orcheopexy at 6-24months (divide any adhesions & excise any hernial sac & fix testis in dartos pouch)
How should undescended testis be treated if discovered late?
adults -> ORCHEOPEXY (works as endocrine)
intra-abdominal -> if orcheopexy is difficult -> subcutaneous
What are the sites an ectopic testis is found in?
- superficial inguinal pouch
- femoral triangle
- root of the penis
- perineum
LOOKWOOD THEORY
How does an ectopic testis differ from an undescended one?
- well developed
- easily palpable
- more palpable with contraction of anterior abdominal wall muscles
- long cord & well developed scrotum
- orcheopexy is less challenging
What is a retractile testis?
exaggerated cremasteric reflex leading to retraction into the inguinal region in exposure to cold & scratching of medial aspect of the thigh
How is retractile testis diagnosed & treated?
- examine patient in warm room in squatting position
- try to milk the testis down
reassurance or divide cremasteric muscle if severe
What are the types of congenital umbilical hernia?
EXOMPHALOS MAJOR
- large >5cm
- covered by amniotic membrane
- contains any a of abdominal viscera up to liver
- treated by complex & staged repair
EXOMPHALOS MINOR
- small <5cm
- covered by amniotic membrane & Warton’s jelly
- contains small loop of intestine
- simple, reduction, herniotomy & herniorraphy
What is an infantile umbilical hernia?
Imperfect closure of umbilical scar
- present few days or weeks after birth
- covered by skin
- contents are not apparent
- closes spontaneously
- if it doesn’t close for > 2 years or if admits 2 finger surgery is indicated
What is gastroschisis?
Defect of anterior abdominal wall with intact peritoneum
- contents are covered with peritoneum or totally exposed
A lack of abdominal musculature & wrinkled skin associated with undescended testis & mega-ureter with vesico-ureteric reflux?
Prune Belly Syndrome
Absent lower anterior abdominal wall, & anterior bladder wall, & wide separation of symphysis pubis is know as? What are its complications & treatment?
Ectopic Vesica
Complications -> severe UTI, metaplasia
Treatment -> initially: temporary closure of defect
-> definitive reconstruction of bladder & pelvic wall
