Pestana- 5. Pediatric Surgery

Question 1

What do you expect if a baby shows up with excessive salivation noted shortly after birth or choking spells when first feeding is attempted?

Answer 1

esophageal atresia

Question 2

What can be done to make the diagnosis of esophageal atresia?

Answer 2

pass an NG tube and see it coiled up in the chest on CXR

Question 3

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)?

Answer 3

normal gas pattern in the bowel

Question 4

What must you also look for in a patient with esophageal atresia?

Answer 4

VACTERL

imperforate anus, cardiac anomalies, renal anomalies, vertebral anomalies

Question 5

What must you do in a patient with esophageal atresia if surgery has to be delayed?

Answer 5

gastrostomy (protects lungs from acid reflux)

Question 6

What should you look for if your patient has an imperforate anus?

Answer 6

nearby fistula (to vagina or perineum)

Question 7

If a fistula is nearby, what does this mean for surgery?

Answer 7

it can be delayed (but needs to be done before toilet training)

Question 8

How do you determine the level of the rectal pouch?

Answer 8

x-ray taken upside down with metal marker taped to the anus

Question 9

Congenital diaphragmatic hernia is always on what side?

Answer 9

left (bowel up in chest)

Question 10

What is the major problem in CDH?

Answer 10

hypoplastic lung that still has fetal-type circulation

Question 11

How long must you wait before you repair CDH?

Answer 11

3 or 4 days

Question 12

What is the treatment for pre-op CDH?

Answer 12

• Endotracheal intubaiton
• Low pressure ventilation
• Sedation
• NG suction

Question 13

What may you have to do for difficult cases of CDH?

Answer 13

Extracorporeal Membrane Oxygenation

Question 14

When is CDH usually diagnosed?

Answer 14

before birth (sonogram)

Question 15

What side is gastrochisis on?

Answer 15

right

Question 16

Is there a cord in omphalocele?

Answer 16

not really, the cord goes to the defect

Question 17

What all is in the omphalocele membrane?

Answer 17

normal-looking bowel and a little slice of liver

Question 18

How long does silo closure usually take?

Answer 18

about a week

Question 19

How long does it take gastrochisis bowel to start working?

Answer 19

around a month (baby needs vascular access for TPN)

Question 20

How quickly must you repair exstrophy of the bladder?

Answer 20

within 1-2 days of life

Question 21

In what 3 conditions may you see “double-bubble” and bilious vomiting?

Answer 21

• Duodenal atresia
• Annular pancreas
• Malrotation

Question 22

WHy is malrotation very dangerous?

Answer 22

volvulus can occur and the bowel can become ischemic and die

Question 23

If you see double bubble with little normal gas pattern beyond, what should you think of?

Answer 23

malrotation

Question 24

How do you diagnose malrotation?

Answer 24

• Contrast enema (safe but not always diagnostic)

- Upper GI study (risky but more reliable)

Question 25

When will malrotation typically present?

Answer 25

within the first few weeks of life

Question 26

What do you expect with bilious vomiting and multiple air-fluid levels?

Answer 26

intestinal atresia

Question 27

What leads to intestinal atresia?

Answer 27

vascular accident in utero

Question 28

What do you suspect in a premature infant who develops feeding intolerance, abdominal distention, and a rapidly dropping platelet count after their first feed?

Answer 28

necrotizing enterocolitis

Question 29

How do you treat necrotizing enterocolitis?

Answer 29

- Stop feedings - Broad spectrum Abx - IVF - IV nutrition

Question 30

When is surgical intervention required for necrotizing enterocolitis?

Answer 30

- Abdominal wall erythema - Air in portal vein - Intestinal pneumatosis - Pneumoperitoneum (necrosis + perf)

Question 31

What should you suspect in a baby with CF who develops feeding intolerance and bilious vomiting?

Answer 31

meconium ileus

Question 32

What does an x-ray of meconium ileus look like?

Answer 32

multiple dilated loops of small bowel and ground-glass appearance in lower abdomen

Question 33

What is the diagnosis/treatment for meconium ileus?

Answer 33

Gastrografin enema

Question 34

What condition typically presents around 3 weeks in firstborn boys?

Answer 34

hypertrophic pyloric stenosis

Question 35

How does hypertrophic pyloric stenosis present?

Answer 35

nonbilious projectile vomiting

Question 36

What is the physical exam for pyloric stenosis?

Answer 36

- Dehydration - Gastric peristaltic waves - Palpable olive-like mass in right upper quadrant

Question 37

If you cannot feel the olive, how do you diagnose pyloric stenosis?

Answer 37

ultrasound

Question 38

What electrolyte abnormality is seen with pyloric stenosis?

Answer 38

Hypochloremic, hypokalemic metabolic alkalosis

Question 39

What are the two most common operations performed for pyloric stenosis?

Answer 39

Ramstedt pyloromyotomy | Balloon dilatation

Question 40

What do you expect in a 6 to 8 week old baby with progressively increasing jaundice (mostly conjugated)?

Answer 40

biliary atresia

Question 41

What is the diagnostic test for biliary atresia?

Answer 41

HIDA scan after 1 week of phenobarbital showing no bile reaching the duodenum

Question 42

What are the three paths for infants with biliary atresia?

Answer 42

- 1/3 get long-lasting surgical derivation - 1/3 need liver transplant after surgical derivation - 1/3 need transplant right away

Question 43

What is the cardinal symptom of Hirschsprung disease?

Answer 43

chronic constipation

Question 44

What happens during the rectal exam in a patient with Hirschsprung disease?

Answer 44

explosive expulsion of stool and flatus

Question 45

What does an x-ray show with Hirschsprung disease?

Answer 45

distended proximal colon with "normal looking" distal colon

Question 46

Which part of the colon on x-ray is aganglionic?

Answer 46

the distal colon that is skinny

Question 47

How do you diagnose Hirschsprung disease?

Answer 47

full-thickness biopsy of the rectal mucosa

Question 48

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?

Answer 48

intussusception

Question 49

What is the classic physical exam finding with intussusception?

Answer 49

currant jelly stools

Question 50

What is the diagnosis and treatment of intussusception?

Answer 50

barium or air enema

Question 51

What do you think of in a child with SDH and retinal hemorrhages?

Answer 51

shaken baby syndrome

Question 52

What do you always expect in lower GI bleeding in the pediatric age group?

Answer 52

Meckel diverticulum

Question 53

What do you do to diagnose Meckel diverticulum?

Answer 53

radioisotope scan (look for gastric mucosa in the lower abdomen)

Question 54

By what age does an orchiopexy need to be done for an undescended testicle?

Answer 54

by one

Question 55

What do you call a testicle that is in the canal at birth but can be pulled down where it belongs?

Answer 55

overactive cremasteric muscle

Question 56

What do you expect if a baby has an abdominal mass that moves up and down with respiration?

Answer 56

malignant liver tumor (hepatoblastoma or hepatocellular carcinoma)

Question 57

What hormone is elevated in liver tumors?

Answer 57

AFP

Question 58

True or false: neuroblastomas can involute and revert to benign forms

Answer 58

true!