Pediatrics

Question 1

Suspect this in a newborn who presents with excessive salivation noted shortly after birth, or choking spells when first feeding is attempted. A small NG tube is passed, and is seen coiled in the upper chest on x-ray.

Answer 1

Esophageal atresia

Question 2

Most common of the four types of esophageal atresia

Answer 2

Type C: Blind pouch in the upper esophagus and a fistula between the lower esophagus and the tracheobronchial tree. (85% of cases)

Question 3

VACTERL constellation

Answer 3

Anomalies assc w/ TEF and often associated with each other: Vertebral, Anorectal, Cardiovascular, Tracheal, Esophageal, Renal, and Limb

Question 4

What may be the only physically obvious presentation of the VACTERL constellation?

Answer 4

Imperforate anus

Question 5

On which side will a congenital diaphragmatic hernia always be on?

Answer 5

the left side

Question 6

What is the most pressing problem in a baby with a congenital diaphragmatic hernia?

Answer 6

The hypoplastic lung, which still has fetal-type circulation

Question 7

An abdominal wall defect to the right of the umbilical cord of a baby, with no protective membrane; bowel looks angry and matted

Answer 7

Gastroschisis

Question 8

An abdominal wall defect right at the umbilical cord, with a translucent membrane under which you can see normal-looking bowels and a sliver of liver.

Answer 8

Omphalocele

Question 9

An abdominal wall defect over the pubis, with a medallion of red bladder mucosa, wet and shining with urine.

Answer 9

Exstrophy of the urinary bladder. REPAIR IMMEDIATELY.

Question 10

Suspect these three possibilities in a baby with green vomit and a “double bubble” picture in X-rays (a large air-fluid level in the stomach, and a smaller one to its right in the first portion of the duodenum)

Answer 10

Duodenal atresia, annular pancreas,

or malrotation.

Question 11

Suspect this in a baby with green vomit and multiple air-fluid levels throughout the abdomen.

Answer 11

Intestinal atresia

Question 12

Suspect this in a baby who gets sick after first being fed. There is feeding intolerance, abdominal distention, and a rapidly dropping platelet count (in babies, a sign of sepsis)

Answer 12

Necrotizing enterocolitis

Question 13

Treatment for pediatric necrotizing enterocolitis

Answer 13

Stop all feedings and administer broad-spectrum antibiotics, IV fluids, and IV nutrition. Surgical intervention is required if the infant develops abdominal wall erythema, air in the portal vein, intestinal pneumatosis (presence of gas in the bowel wall), or pneumoperitoneum (signs of intestinal necrosis and perforation).

Question 14

Diagnosis in babies with cystic fibrosis, who develop feeding intolerance and bilious vomiting. X-rays show multiple dilated loops of small bowel and a ground-glass appearance in the lower abdomen.

Answer 14

Meconium Ileus

Question 15

Diagnostic and therapeutic test for meconium ileus

Answer 15

Gastrografin enema (draws fluid in, dissolves the obstructing pellets)

Question 16

Suspect this in a ~3 week old boy who projectile vomits (non-bilious) after feeding, but who is still super hungry afterwards. On PE, they’re dehydrated, have visible peristaltic waves in the abdomen, and a palpable “olive-sized” mass in the RUQ.

Answer 16

Hypertrophic pyloric stenosis. (p.s. Tx w/ Ramstedt pylorotomy or balloon dilatation)

Question 17

Suspect this in 6- to 8-week-old babies who have persistent, progressively increasing jaundice (which includes a substantial conjugated fraction).

Answer 17

Biliary atresia

Question 18

The cardinal symptom of this pediatric condition is chronic constipation. With short segments, rectal exam may lead to explosive expulsion of stool and flatus, with relief of abdominal distention. X-rays show distended proximal colon and normal-looking distal colon.

Answer 18

Hirschsprung’s disease (aganglionic megacolon). The “normal looking” distal colon is the aganglionic part, and the proximal colon gets distended when stool can’t pass through the aperistaltic aganglionic distal colon.

Question 19

Diagnostic test for Hirschsprung’s disease (aganglionic megacolon)

Answer 19

Full thickness biopsy

Question 20

Suspect this in 6- to 12-month-old chubby, healthy-looking kids who have episodes of colicky abdominal pain that makes them double up and squat. The pain lasts for about 1 minute, and the kid looks perfectly happy and normal until he gets another colic. Physical exam shows a vague mass on the right side of the abdomen, an “empty” right lower quadrant, and “currant
jelly” stools.

Answer 20

Intussusception. Do a barium or air enema.

Question 21

Always suspect this in lower GI bleeding of the pediatric age group. Definition: slight bulge in the small intestine present at birth, a vestigial remnant of the omphalomesenteric duct (also called the vitelline duct or yolk stalk).

Answer 21

Meckel’s diverticulum

Question 22

Tx for omphalocele and gastroschesis

Answer 22

Create a silo for the bowel. Must be water-proof to prevent insensible water loss. Then serial reduction.

Question 23

Suspect this in a newborn with bad O2 sat, tachypneic, tachycardic, decreased breath sounds on the left, barrel chest and scaphoid abdomen, and a heartbeat displaced to the right.

Answer 23

Congenital diaphragmatic hernia

Question 24

What imaging modality should be used when you suspect congenital diaphragmatic hernia?

Answer 24

X-ray. Will show abdominal contents in the chest.

Question 25

Most common variant of congenital diaphragmatic hernia.

Answer 25

Posterolateral, “Bochdalek hernia”. The other is Anteromedial, “Morgagni hernia”.

Question 26

Most important step in managing congenital diaphragmatic hernia?

Answer 26

If the baby is in respiratory distress, intubate. Use 100% O2 and low pressure settings, so as not to damage the normal lung tissue. Place an orogastric tube to decompress abdominal contents and give the lung space to grow. Do ECMO if still hypoxemic after that.

Question 27

Why should you delay surgery for congenital diaphragmatic hernia?

Answer 27

To allow the lung to mature and pulmonary hypertension to improve or reverse. Studies showed no survival advantage to doing the surgery immediately.

Question 28

What imaging should you order for a baby with bilious emesis

Answer 28

2-view plain abdominal radiograph after placement of a naso/orogastric tube

Question 29

In a baby with a “double bubble” on radiograph: what does it mean when no distal air bubbles are seen? what about many normal distal air bubbles?

Answer 29

No distal air bubbles: complete duodenal atresia.

Normal distal air: malrotation with midgut volvulus

Question 30

Management of duodenal atresia.

Answer 30

Pts are rarely unstable (if they are unstable, rule out malrotation with midgut volvulus), so optimize pt w/ intravenous access, NG tube, and IVF. Consider central line for nutrition, for the first few days after surgery. When pt is in good shape for surgery, do surgery.

Question 31

Surgical tx for duodenal atresia

Answer 31

Duodenoduodenostomy to bypass atretic segment. If not possible, duodenojejunostomy.

Question 32

List the 3 most common problems associated with duodenal atresia

Answer 32

Down syndrome, annular pancreas, congenital heart disease are most common. Assess for heart disease and correct it before surgery for other stuff.

Question 33

What defines the midgut

Answer 33

The portion of the bowel that is supplied by the SMA: 2nd part of duodenum to 2/3rds of the way across the transverse colon.

Question 34

What supplies the foregut

Answer 34

The celiac axis

Question 35

What supplies the hindgut

Answer 35

IMA

Question 36

Suspect this in a baby with bilious vomiting, and a “corkscrew” appearance of contrast in the bowel on plain abdominal radiograph

Answer 36

Malrotation with midgut volvulus

Question 37

Tx for malrotation with midgut volvulus

Answer 37

Surgical emergency! Urgent Laparotomy. It’s called the Ladd procedure.

Question 38

Suspect this when you see projectile, nonbilious emesis in a healthy infant. Vomiting gets progressively more forceful.

Answer 38

Infantile Hypertrophic Pyloric Stenosis (HPS)

Question 39

Clinical diagnosis of hypertrophic pyloric stenosis. If not possible, what imaging should you order?

Answer 39

History and a palpable “olive”-sized mass in the RUQ. If no mass is palpable, do an ultrasound to look at the stomach pylorus: >3-4 mm thickness and >15-16 mm length is diagnostic. If that is equivocal, do an upper gastrointestinal (UGI) contrast study.

Question 40

What electrolyte abnormalities would you expect to see in a baby who is vomiting, especially due to pyloric stenosis

Answer 40

Hypochloremic, hypokalemic, metabolic alkalosis. Possible paradoxical aciduria. Treat these first, as it’s a medical emergency.

Question 41

surgical tx for pyloric stenosis

Answer 41

Ramstedt pylorotomy

Question 42

Omphalocele associated conditions:

Answer 42

Beckwith-Weidemann syndrome, trisomy 18, trisomy 13, Pentalogy of Cantrell

Question 43

What Is the Significance of Oxygen Desaturation that Only Occurs While Feeding?

Answer 43

When a newborn has desaturations while feeding, it implies that there is a significant anatomic or functional problem with the proximal alimentary tract ( nasopharynx, oropharynx, esophagus, or stomach).

Question 44

Meconium plug - baby most likely has what

Answer 44

Cystic fibrosis

Question 45

How do you treat a baby with meconium plug?

Answer 45

Water-soluble contrast enema - diagnostic and therapeutic, dissolves the plug