Pre-Test: Pediatric Surgery/DVS Flashcards
A neonate is examined in the nursery and found to have no anal orifice; only a small perineal fistulous opening is visualized. A complete workup is negative for any cardiac, esophageal, GU, or MSK anomalies. Which of the following is the best next step in the mgmt of this pt?
a. Diverting colostomy only
b. Posterior sagittal anorectoplasty only
c. Posterior sagittal anorectoplasty with diverting colostomy
d. Perineal operation only
e. Perineal operation with diverting colostomy
d. Perineal operation only
Pt has low imperforate anus (type of anorectal malformation that affeects M and F w/ approx same frequency)… due to failure of descent of urorectal septum
Mgmt depends on whether lesion is high or low, which is defined by location of end of rectum relative to level of levator ani complex
A 2 mo old boy is examined b/c he has been straining while passing stool and has a distended abdomen. He is very low on the growth chart for age. The PCP suspects that the boy has Hirschsprung disease. What is the diagnostic finding on workup?
Absence of ganglion cells on full-thickness rectal biopsy 2 cm above dentate line
** Unlike imperforate anus, which is associated with high incidence of GU tract anomalies and risk of longer-term fecal incontinence, in Hirschsprung disease repair leads to satisfactory bowel fxn in most affected pts. **
A newborn has a midline defect in the anterior abdominal wall. The parents ask what, if anything, should be done. Spontaneous closure of which of the following congenital abnormalities of the abdominal wall generally occurs by the age of 4?
a. Umbilical hernia
b. Patent urachus
c. Patent omphalomesenteric duct
d. Omphalocele
e. Gastroschisis
a. Umbilical hernia
In most children, umbilical hernias close spontaneously by age of 4 and need not be repaired unless incarcerated or symptomatic.
Omphalocele + gastroschisis –> evisceration of bowel and require emergency surgical tx
Patent urachal or omphalomesenteric ducts result from incomplete closure of embryonic connections from bladder and ileum, respectively, to abdominal wall. They are appropriately treated by excision of tracts and closure of bladder or ileum
A neonate is found to have an imperforate anus. As the pediatric surgeon, you recommend studies to search for other anomalies. Which of the following is an associated abnormality?
a. Congenital pulmonary airway malformation
b. Hydrocephalus
c. Duodenal atresia
d. Congenital heart disease
e. Corneal opacities
d. Congenital heart disease
VACTERL
A 1 y/o child has repeated episodes of vomiting and abdominal distension. An x-ray shows obstruction at the second portion of the duodenum. Laparotomy is performed and annular pancreas is discovered. For symptomatic partial duodenal obstruction 2/2 annular pancreas, which of the following is the operative tx of choice?
a. Whipple procedure
b. Gastrojejunostomy
c. Vagotomy and gastrojejunostomy
d. Partial resection of annular pancreas
e. Duodenoduodenostomy
e. Duodenoduodenostomy
Bypass procedure = operation of choice for obstruction 2/2 annular pancreas.
Whipple = too radical… partial resection of annular pancreas = complicated by fistula and does not treat underlying duodenal obstruction
Approximately 2 weeks after viral respiratory illness, 18 m/o child complains of abdominal pain and passes some bloody mucus per rectum. A long, thin mass is palpable in the RUQ of the abdomen. No peritoneal signs present. Intussusception is suspected. Which of the following is the most appropriate next step?
a. Diagnostic air enema w subsequent observation and serial abdominal exams
b. Hydrostatic reduction with air enema
c. Diagnostic laparoscopy with laparoscopic reduction
d. Exploratory laparotomy with bowel resection
b. Hydrostatic reduction with air enema
An infant is born with a defect in the anterior abdominal cavity. Upon examination, there are abdominal contents (small bowel and liver) protruding directly through the umbilical ring. Which of the following should be considered in the mgmt of this condition?
a. No further workup is indicated prior to closure of the defect.
b. Silastic silo should be placed with immediate reduction of the viscera into the abdominal cavity.
c. Broad-spectrum IV abx should be administered prophylactically.
d. Enteral feeds for nutritional support should be initiated prior to operative mgmt.
c. Broad-spectrum IV abx should be administered prophylactically.
A 29 y/o previously healthy male infant presents with fevers, abdominal distention, feeding intolerance, and bloody stools at 3 weeks of age. The patient undergoes x-ray and U/S exam for possible NEC. Which of the following finds on imaging is an indication for surgical mgmt?
a. Pneumoperitoneum
b. Ascites
c. Portal venous gas
d. Ileus
e. Pneumatosis intestinalis
a. Pneumoperitoneum
NEC is the most common GI emergency in the neonatal period. Prematurity is the single most important risk factor.
A newborn presents with signs and sx of distal intestinal obstruction. Abdominal x-rays reveal dilated loops of small bowel, absence of air-fluid levels, and a mass of meconium within the R side of the abdomen mixed with gas to give a ground-glass appearance. Which of the following should be performed as the initial mgmt of the pt?
a. Administration of oral polyethylene glycol
b. Bowel rest with NG decompression and broad-spectrum IV abx
c. Contrast enema
d. Surgical evac of luminal meconium
c. Contrast enema
Pt has simple meconium ileus; initial mgmt is a contrast enema
In meconium ileus, the terminal ileum is dilated and filled with thick, tarlike, inspissated meconium –> meconium ileus in the newborn represents the earliest clinical manifestation of cystic fibrosis
initial tx is water-soluble contrast enema to relieve obstruction
A 1-mo female infant presents with persistent jaundice. A serum direct bilirubin is 4.0 mg/dL and a u/s of abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. Which of the following is the most appropriate initial mgmt of this pt?
a. NPO and TPN
b. Oral choleretic bile salts
c. Methylprednisolone
d. IV abx
e. Ex lap
e. Ex lap
This infant has findings consistent with biliary atresia and the tx is laparotomy with Kasai hepatoportoenterostomy
An infant with persistent jaundice after the first few weeks of life needs to be evaluated with lab studies and an abdominal u/s
Bilary atresia is characterized by progressive oblieration of the extrahepatic and intrahepatic bile ducts… delay in dx of this leads to irreversible hepatic fibrosis
A 4 week old boy presents with a 3 day hx of forceful vomiting. The mother states that the vomitus only contains partially digested milk. She notes that the infant seems very hungry between feedings and drinks vigorously. PMH significant for a skin infection for which the infant received oral erythromycin. On exam, infant appears to be healthy appearing and in no acute distress. The physician feels there may be a small palpable mass in the RUQ, but it is not certain. Electrolytes are normal. What is the best way to establish the most likely dx?
a. Plain abdominal x-rays
b. Laparoscopy
c. CT abdomen
d. U/S
a. Plain abdominal x-rays
Worsening repiratory status with feeding is suggestive of an anatomic or physiologic defect of the upper aerodigestive tract. The next step is to attempt to place an OGT and perform AP and lateral CXR.
Failure to pass OCT with CXR confirmation is that the tube –> esophageal atresia
Which of the following is the next best step in the mgmt of a 1-week-old infant born at full term with bilious emesis?
a. Abdominal U/S
b. Broad-spectrum abx and blood cultures
c. immediate operative repair
d. Contrast enema
e. IV fluids and NGT placement
e. IV fluids and NGT placement
The first steps in treating a pt with bilious emesis are fluid resuscitation and GI decompression (via NGT). Once IV fluid resuscitation has begun, the pt may undergo upper GI study to evaluate for evidence of midgut volvulus.
