Pediatrics Flashcards
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.
Esophageal atresia
Most common of the four types of esophageal atresia
Type C: Blind pouch in the upper esophagus and a fistula between the lower esophagus and the tracheobronchial tree. (85% of cases)
VACTERL constellation
Anomalies assc w/ TEF and often associated with each other: Vertebral, Anorectal, Cardiovascular, Tracheal, Esophageal, Renal, and Limb
What may be the only physically obvious presentation of the VACTERL constellation?
Imperforate anus
On which side will a congenital diaphragmatic hernia always be on?
the left side
What is the most pressing problem in a baby with a congenital diaphragmatic hernia?
The hypoplastic lung, which still has fetal-type circulation
An abdominal wall defect to the right of the umbilical cord of a baby, with no protective membrane; bowel looks angry and matted
Gastroschisis
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.
Omphalocele
An abdominal wall defect over the pubis, with a medallion of red bladder mucosa, wet and shining with urine.
Exstrophy of the urinary bladder. REPAIR IMMEDIATELY.
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)
Duodenal atresia, annular pancreas,
or malrotation.
Suspect this in a baby with green vomit and multiple air-fluid levels throughout the abdomen.
Intestinal atresia
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)
Necrotizing enterocolitis
Treatment for pediatric necrotizing enterocolitis
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).
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.
Meconium Ileus
Diagnostic and therapeutic test for meconium ileus
Gastrografin enema (draws fluid in, dissolves the obstructing pellets)
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.
Hypertrophic pyloric stenosis. (p.s. Tx w/ Ramstedt pylorotomy or balloon dilatation)
Suspect this in 6- to 8-week-old babies who have persistent, progressively increasing jaundice (which includes a substantial conjugated fraction).
Biliary atresia
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.
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.
Diagnostic test for Hirschsprung’s disease (aganglionic megacolon)
Full thickness biopsy
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.
Intussusception. Do a barium or air enema.
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).
Meckel’s diverticulum
Tx for omphalocele and gastroschesis
Create a silo for the bowel. Must be water-proof to prevent insensible water loss. Then serial reduction.
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.
Congenital diaphragmatic hernia
What imaging modality should be used when you suspect congenital diaphragmatic hernia?
X-ray. Will show abdominal contents in the chest.
Most common variant of congenital diaphragmatic hernia.
Posterolateral, “Bochdalek hernia”. The other is Anteromedial, “Morgagni hernia”.
Most important step in managing congenital diaphragmatic hernia?
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.
Why should you delay surgery for congenital diaphragmatic hernia?
To allow the lung to mature and pulmonary hypertension to improve or reverse. Studies showed no survival advantage to doing the surgery immediately.
What imaging should you order for a baby with bilious emesis
2-view plain abdominal radiograph after placement of a naso/orogastric tube
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?
No distal air bubbles: complete duodenal atresia.
Normal distal air: malrotation with midgut volvulus
Management of duodenal atresia.
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.
Surgical tx for duodenal atresia
Duodenoduodenostomy to bypass atretic segment. If not possible, duodenojejunostomy.
List the 3 most common problems associated with duodenal atresia
Down syndrome, annular pancreas, congenital heart disease are most common. Assess for heart disease and correct it before surgery for other stuff.
What defines the midgut
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.
What supplies the foregut
The celiac axis
What supplies the hindgut
IMA
Suspect this in a baby with bilious vomiting, and a “corkscrew” appearance of contrast in the bowel on plain abdominal radiograph
Malrotation with midgut volvulus
Tx for malrotation with midgut volvulus
Surgical emergency! Urgent Laparotomy. It’s called the Ladd procedure.
Suspect this when you see projectile, nonbilious emesis in a healthy infant. Vomiting gets progressively more forceful.
Infantile Hypertrophic Pyloric Stenosis (HPS)
Clinical diagnosis of hypertrophic pyloric stenosis. If not possible, what imaging should you order?
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.
What electrolyte abnormalities would you expect to see in a baby who is vomiting, especially due to pyloric stenosis
Hypochloremic, hypokalemic, metabolic alkalosis. Possible paradoxical aciduria. Treat these first, as it’s a medical emergency.
surgical tx for pyloric stenosis
Ramstedt pylorotomy
Omphalocele associated conditions:
Beckwith-Weidemann syndrome, trisomy 18, trisomy 13, Pentalogy of Cantrell
What Is the Significance of Oxygen Desaturation that Only Occurs While Feeding?
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).
Meconium plug - baby most likely has what
Cystic fibrosis
How do you treat a baby with meconium plug?
Water-soluble contrast enema - diagnostic and therapeutic, dissolves the plug
