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Surgery Clerkship > Peds > Flashcards

Peds Flashcards

1
Q

What are the most common causes of respiratory distress in newborns?

A
  • Transient tachypnea of newborn: residual pulmonary fluid in lung
  • Hyaline membrane disease / respiratory distress syndrome
  • Meconium aspiration syndrome
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2
Q

In a newborn with respiratory distress, what should we do to confirm/rule out common surgical diagnoses?

A

Place OGT/NGT

Get CXR

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3
Q

What signs in a newborn suggest congenital diaphragmatic hernia (CDH)?

A

Severe resp distress
Absent breath sounds
Scaphoid abdomen

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4
Q

How is CDH usually diagnosed?

A

In utero: prenatal US

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5
Q

Where do CDH most commonly occur?

A

L side: posterolateral/Bochdalek hernia

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6
Q

What does herniation of abdominal contents in CDH cause?

A

Pulmonary hypoplasia: ipsi and contra

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7
Q

What is the pathophysiology of respiratory distress in CDH?

A

Pulm HTN –> Decreased pulm blood flow / hypoxia

Pulm hypoplasia –> decreased gas exchange and CO2 retention

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8
Q

What common associated anomalies occur with CDH?

A 
Chromosomal defects
Rotational
Cardiac (VSD/ASD)
CNS
Limb
GU
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9
Q

What is mortality related to in CDH?

A

Degree of pulmonary hypoplasia / Pulmonary HTN

Presence of congenital anomalies

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10
Q

What is the first step in management of newborn respiratory distress?

A

Immediate intubation

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11
Q

What is the first step in management of newborn respiratory distress?

A

Immediate intubation

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12
Q

What is survival related to in CDH?

A

Degree of pulmonary hypoplasia and HTN

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13
Q

What is the goal of treatment for CDH?

A

provide pulmonary support w/o further damaging the lungs

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14
Q

When is the optimal timing for surgery for CDH: immediate or wait?

A

Delay: allow lungs to mature and pulmonary HTN to improve

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15
Q

Before surgery for CDH, what must be done?

A

Evaluate for other congenital anomalies

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16
Q

Why must blow-by oxygen or excessive bag mask ventilation be avoided in CDH?

A

Worsens lung compression and mediastinal shift

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17
Q

What happens with CDH?

A

Failure of septum transversum to completely divide the pleural and coleomic cavities during fetal development

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18
Q

What’s the most important step in clinical management for CDH?

A

Immediate intubation

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19
Q

What’s the best initial diagnostic test for newborn respiratory distress?

A

OGT + CXR

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20
Q

What do we think: bilious vomiting in a newborn 0-1 month?

A

Surgical problem until proven otherwise

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21
Q

Does passage of meconium rule out obstruction?

A

No: mucuous and epithelium is shed along entire length of intestine - distal to the obstruction, it may still pass!

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22
Q

In a stable newborn with bilious vomiting, what is the first step?

A

Plain abdominal XR to rule out perforation, prox vs. distal obstruction, presence or absence of distal gas

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23
Q

What are the key features on XR of duodenal obstruction/atresia?

A

Double bubble sign + no distal gas

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24
Q

If a newborn with bilious vomiting has distal gas, what’s the most likely diagnosis?

A

Malrotation + midgut volvulus before duodenal web or partial duodenal obstruction

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25
Q

What causes duodenal atresia?

A

failure of recanalization early in development

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26
Q

> 50% of patients with duodenal atresia have what associated anomalies?

A

Trisomy 21
Annular pancreas
Cardiac (most common)

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27
Q

What is the management for a newborn with bilious vomiting?

A
  1. Get IV access: Correct fluid/electrolyte abnormalities
  2. Place NGT
  3. Rule out other anomalies prior to surgery
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28
Q

If a newborn with bilious vomiting is unstable, what do we suspect? Next steps?

A

Suspect malrotation with midgut volvulus

Go to OR emergently

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29
Q

What is the procedure of choice for duodenal atresia?

A

Duodenoduodenostomy

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30
Q

How can duodenal atresia present with non bilious vomiting?

A

Obstruction proximal to the ampulla: present with nonbilious emesis

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31
Q

What key comorbidity must be identified before surgery for duodenal atresia? Why?

A

Annular pancreas: Injury to the ring of pancreatic tissue can lead to pancreatic enzyme leak and pancreatitis

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32
Q

What is bilious emesis?

A

Green or yellow emesis

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33
Q

What type a problem is bilious emesis in an infant?

A

Surgical until proven otherwise!

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34
Q

In a stable infant with bilious emesis, what is the first step?

A

Plain abdominal radiograph first to exclude gross perforation

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35
Q

If initial XR is negative in an infant with bilious emesis, what is the next step?

A

UGI contrast study: evaluate duodenum and proximal SI

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36
Q

In infants with bilious vomiting, what MUST we suspect first due to danger?

A

Malrotation with midgut volvulus

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37
Q

What is the midgut embryologically?

A

SMA: Second portion of duodenum to 2/3 of transverse colon

38
Q

What is malrotation in the gut due to?

A

Developmental failure of normal 270 degree counterclockwise midgut rotation

39
Q

What is the classic pattern of congenital malrotation?

A

narrow mesenteric base

Ligament of Treitz located R of midline, cecum in epigastrium, Ladd’s bands from cecum to RUQ crossing duodenum

40
Q

What is a volvulus in setting of malrotation?

A

Midgut rotates around SMA axis causing duodenal obstruction and vascular compromise of bowel

41
Q

What is the classic UGI radiograph of volvulus in setting of malrotation?

A

“corkscrew” appearance of contrast in bowel lumen

42
Q

What is the management of treating midgut volvulus?

A
  1. Place NGT to decompress stomach
  2. Give ABx / IVF while prepping for laparotomy
  3. Laparotomy
43
Q

What is the first management step of treating hemodynamically unstable acute GI obstruction in an infant?

A
  1. Rapid fluid resuscitation

2. Immediate surgical intervention w/o additional studies!

44
Q

What is Ladd’s procedure?

A

Relieving obstruction by untwisting the bowel and brooding the mesenteric base to prevent future episodes

45
Q

How can malrotation with midgut volvulus present (2 ways)?

A

Bilious or non bilious vomiting depending on location

46
Q

What is the most common bowel gas pattern in malrotation with midgut volvulus?

A

Normal

47
Q

During surgery in an infant with bilious emesis, what must be ruled out?

A

Duodenal stenosis / atresia

48
Q

In newborn with bilious emesis whose XR shows proximal obstruction: distal bowel gas + “double bubble”, what is the next step?

A

UGI contrast study: should show malrotation +- midgut volvulus

49
Q

In a newborn with bilious emesis whose XR shows “double bubble” w/o distal gas, what is the diagnosis?

A

Duodenal atresia

50
Q

In an newborn with bilious emesis whose XR shows distal obstruction with multiple loops of dilated small bowel, what is the next step and likely diagnoses?

A

Contrast enema:

  • Intestinal atresia
  • Meconium ileus
  • Hirschsprung’s disease
51
Q

Of patients with non bilious emesis in infancy, which disease are managed medically?

A

Acute gastroenteritis
GERD
Metabolic d/o
Pylorospasm

52
Q

Of patients with non bilious emesis in infancy, which disease are managed surgically?

A

Antral web
Enteric duplication cyst
GERD
Pyloric atresia / stenosis

53
Q

What is the most common surgical cause of non bilious vomiting in an infant?

A

Hypertrophic pyloric stenosis (HPS)

54
Q

What is classic PE sign of HPS?

A

Palpable RUQ “olive” mass with visible peristalsis over the epigastrium

55
Q

If diagnosis of HPS is unclear, what should be done?

A

US

56
Q

What is the diagnostic criteria for HPS?

A
  • Pyloric length > 15mm

- Thickness > 3mm

57
Q

What electrolyte abnormalities are common in HPS?

A
  • Hypochloremic, hypokalemic, metabolic acidosis

- Paradoxical aciduria

58
Q

What is pathophysiology of HPS?

A

Hyperplasia and hypertrophy of pylorus –> GOO

59
Q

What is the first treatment for HPS?

A
  1. Fluid resuscitation

2. Correct electrolyte imbalances

60
Q

What is the gold standard surgery for HPS?

A

Ramstedt pyloromyotomy: incise and split the muscular layers, leaving the mucosa and submucosa intact

61
Q

When is the optimal timing of surgery for HPS?

A

Delay until infant resuscitated and electrolyte levels are normal

62
Q

When does feeding start after HPS repair? What is common?

A

After surgery - vomiting may occur but should resolve

63
Q

If a patient has equivocal US suspicious for HPS or concern for malrotation with midgut volvulus, what else should be done? What is the risk

A

Contrast UGI

- Risk of aspiration

64
Q

Is HPS a medical or surgical emergency?

A

Medical!

65
Q

If an infant has persistent fever after surgery for HPS, what should be considered?

A

incomplete pyloromyotomy

66
Q

If an infant has HPS surgery and has post-op fever and tachycardia, what must it be until proven otherwise?

A

perforation

67
Q

How do we diagnose abdominal wall defects in newborns?

A

Prenatal ultrasound usually

68
Q

What are key identifying features of gastroschisis?

A

Paraumbilical (R) and exposed bowel

69
Q

What are key identifying features of omphalocele?

A

Sac from the umbilicus, associated with more congenital defects

70
Q

What are the associated syndromes with omphalocele?

A

Beckwith-Wiedemann Syndrome
Trisomies 13, 18
Pentalogy of Cantrell

71
Q

What is the etiology of gastroschisis?

A

In utero vascular insult causing abdominal wall defect

72
Q

What is the etiology of omphalocele?

A

Arrest of cell migration causing incomplete return of midgut to the peritoneal cavity

73
Q

What is the most important first 2 steps in management of abdominal wall defect in newborn?

A
  1. Ventilation: secure airway
  2. Normothermia and fluid management:
    - Radiant heater
    - Orogastric suction
    - Protect exposed viscera with plastic wrap
    - IV fluids + broad spectrum Abx
74
Q

What is the definitive treatment for gastroscisis or omphalocele?

A
  • Protective silo and serial reduction OR

- Surgical repair

75
Q

What must a gastroschisis patient be evaluated for?

A

Atresia, ischia or volvulus

76
Q

What must be given to a gastroschisis patient while they are awaiting reduction of the bowel or surgery? Why?

A

TPN - intestine likely inflamed

77
Q

What are key considerations after post-op repair of gastroschisis or omphalocele?

A
  1. Ventilator if needed
  2. TPN if needed
  3. Monitor for abdominal compartment syndrome!
78
Q

What’s in the differential for feeding intolerance in a newborn?

A
  • Anatomic malformation of naso- and oropharynx, tracheobronchial tree and esophagus
  • GERD
  • Extrinsic esophageal compression
  • Food sensitivity
  • Neurologic d/o
79
Q

What do desaturations only while feeding imply in a newborn?

A

Anatomic or functional problem w/ proximal aerodigestive tract

80
Q

What is the best initial diagnostic test in a newborn with feeding intolerance?

A

AP and lateral chest XR after NG/OGT placement

81
Q

What is the pathophysiology of EA +/- TEF?

A

Defect in development of longitudinal tracheoesophageal fold separating foregut into trachea and esophagus

82
Q

What is the most common type of TEF?

A

Distal: Type C: Trachea with esophagus going off of it

83
Q

Most patients with TEF +/- EA have what type of anomalies?

A 
VACTERL:
Vertebral
Anorectal
CV
Tracheoesophageal
Renal
Limb
84
Q

In patients with TEF +/- EA, what is prognosis for those with comorbidites or requiring surgery?

A

Excellent w/o comorbidiites

* Significant sequelae from surgery!

85
Q

What is management in newborns with respiratory compromise?

A

Intubation/mechanical ventilation

86
Q

What is the preoperative management goal in patient with TEF +/- EA?

A

Minimize risk of aspiration: NGT of upper esophageal pouch, head elevation, AB

87
Q

In patients with TEF +/- EA, what must be done before surgery?

A

Eval for associated anomalies: echo, renal US, XRays

88
Q

What is the surgical repair for TEF +/- EA?

A

Division of fistula tract, repair of trachea, primary anastomosis of esophagus

89
Q

What are the post-operative complications from surgery for TEF +/- EA and how common are they?

A

Common!

  • Anastomotic leak
  • Stricture
  • GERD
90
Q

Why do we avoid contrast esophagram in newborns with suspected TEF +/- EA?

A

Risk of aspiration pneumonitis

91
Q

Why do we avoid distending GI tract in patients with TEF +/- EA?

A

Avoid further aspiration and lung injury, esp in patients on ventilator support

92
Q

What must be done before surgery for TEF +/- EA?

A

Assess vascular anatomy:

  • IVC can drain into RA via azygous system
  • 5% patients have R sided aortic arch

Surgery Clerkship (16 decks)

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