Pestana- 5. Pediatric Surgery Flashcards
What do you expect if a baby shows up with excessive salivation noted shortly after birth or choking spells when first feeding is attempted?
esophageal atresia
What can be done to make the diagnosis of esophageal atresia?
pass an NG tube and see it coiled up in the chest on CXR
What is the sign that a baby has the most common form of esophageal atresia (blind pouch in upper esophagus and fistula between lower esophagus and tracheobronchial tree)?
normal gas pattern in the bowel
What must you also look for in a patient with esophageal atresia?
VACTERL
imperforate anus, cardiac anomalies, renal anomalies, vertebral anomalies
What must you do in a patient with esophageal atresia if surgery has to be delayed?
gastrostomy (protects lungs from acid reflux)
What should you look for if your patient has an imperforate anus?
nearby fistula (to vagina or perineum)
If a fistula is nearby, what does this mean for surgery?
it can be delayed (but needs to be done before toilet training)
How do you determine the level of the rectal pouch?
x-ray taken upside down with metal marker taped to the anus
Congenital diaphragmatic hernia is always on what side?
left (bowel up in chest)
What is the major problem in CDH?
hypoplastic lung that still has fetal-type circulation
How long must you wait before you repair CDH?
3 or 4 days
What is the treatment for pre-op CDH?
- Endotracheal intubaiton
- Low pressure ventilation
- Sedation
- NG suction
What may you have to do for difficult cases of CDH?
Extracorporeal Membrane Oxygenation
When is CDH usually diagnosed?
before birth (sonogram)
What side is gastrochisis on?
right
Is there a cord in omphalocele?
not really, the cord goes to the defect
What all is in the omphalocele membrane?
normal-looking bowel and a little slice of liver
How long does silo closure usually take?
about a week
How long does it take gastrochisis bowel to start working?
around a month (baby needs vascular access for TPN)
How quickly must you repair exstrophy of the bladder?
within 1-2 days of life
In what 3 conditions may you see “double-bubble” and bilious vomiting?
- Duodenal atresia
- Annular pancreas
- Malrotation
WHy is malrotation very dangerous?
volvulus can occur and the bowel can become ischemic and die
If you see double bubble with little normal gas pattern beyond, what should you think of?
malrotation
How do you diagnose malrotation?
- Contrast enema (safe but not always diagnostic)
- Upper GI study (risky but more reliable)
When will malrotation typically present?
within the first few weeks of life
What do you expect with bilious vomiting and multiple air-fluid levels?
intestinal atresia
What leads to intestinal atresia?
vascular accident in utero
What do you suspect in a premature infant who develops feeding intolerance, abdominal distention, and a rapidly dropping platelet count after their first feed?
necrotizing enterocolitis
How do you treat necrotizing enterocolitis?
- Stop feedings
- Broad spectrum Abx
- IVF
- IV nutrition
When is surgical intervention required for necrotizing enterocolitis?
- Abdominal wall erythema
- Air in portal vein
- Intestinal pneumatosis
- Pneumoperitoneum (necrosis + perf)
What should you suspect in a baby with CF who develops feeding intolerance and bilious vomiting?
meconium ileus
What does an x-ray of meconium ileus look like?
multiple dilated loops of small bowel and ground-glass appearance in lower abdomen
What is the diagnosis/treatment for meconium ileus?
Gastrografin enema
What condition typically presents around 3 weeks in firstborn boys?
hypertrophic pyloric stenosis
How does hypertrophic pyloric stenosis present?
nonbilious projectile vomiting
What is the physical exam for pyloric stenosis?
- Dehydration
- Gastric peristaltic waves
- Palpable olive-like mass in right upper quadrant
If you cannot feel the olive, how do you diagnose pyloric stenosis?
ultrasound
What electrolyte abnormality is seen with pyloric stenosis?
Hypochloremic, hypokalemic metabolic alkalosis
What are the two most common operations performed for pyloric stenosis?
Ramstedt pyloromyotomy
Balloon dilatation
What do you expect in a 6 to 8 week old baby with progressively increasing jaundice (mostly conjugated)?
biliary atresia
What is the diagnostic test for biliary atresia?
HIDA scan after 1 week of phenobarbital showing no bile reaching the duodenum
What are the three paths for infants with biliary atresia?
- 1/3 get long-lasting surgical derivation
- 1/3 need liver transplant after surgical derivation
- 1/3 need transplant right away
What is the cardinal symptom of Hirschsprung disease?
chronic constipation
What happens during the rectal exam in a patient with Hirschsprung disease?
explosive expulsion of stool and flatus
What does an x-ray show with Hirschsprung disease?
distended proximal colon with “normal looking” distal colon
Which part of the colon on x-ray is aganglionic?
the distal colon that is skinny
How do you diagnose Hirschsprung disease?
full-thickness biopsy of the rectal mucosa
What do you expect in a 6-12 month old child with episodes of ~1 minute colicky abdominal pain that makes them double-up and squat?
intussusception
What is the classic physical exam finding with intussusception?
currant jelly stools
What is the diagnosis and treatment of intussusception?
barium or air enema
What do you think of in a child with SDH and retinal hemorrhages?
shaken baby syndrome
What do you always expect in lower GI bleeding in the pediatric age group?
Meckel diverticulum
What do you do to diagnose Meckel diverticulum?
radioisotope scan (look for gastric mucosa in the lower abdomen)
By what age does an orchiopexy need to be done for an undescended testicle?
by one
What do you call a testicle that is in the canal at birth but can be pulled down where it belongs?
overactive cremasteric muscle
What do you expect if a baby has an abdominal mass that moves up and down with respiration?
malignant liver tumor (hepatoblastoma or hepatocellular carcinoma)
What hormone is elevated in liver tumors?
AFP
True or false: neuroblastomas can involute and revert to benign forms
true!
