Surgery Flashcards
Management of peds umbilical hernia
> 90% spontaneous resolute, rarely symptomatic
Surgery if persists @ 3-5 yrs
What acid-base abnormality would be likely to result from pyloric stenosis?
Hypochloremia, hypokalemic metabolic alkalosis
Age of pyloric stenosis typically?
3 weeks - 3 months
Fluids for pyloric stenosis
NS with potassium at 2x maintenance
Most common cause of bowel obstruction in early childhood (<2yo)
Intussusception
Intussusception most often occurs near…
The ileocecal junction (ileo-colic)
What is a meckel diverticulum
Congenital sacculation of the antimesenteric border of the distal ileum
TRUE diverticulum (contains all layers of the intestinal wall)
May contain heterotopic tissue (usually gastric, sometimes pancreatic or other)
Symptoms of Meckel diverticulum
Obstruction –> pain, N/V
Meckel Diverticulitis –> similar pain to appendicitis. vomiting
Repeat episodes of BRBPR
Currant jelly stool is a sign of what? Other symptoms?
Inruccusception
Episodes of inconsolable crying
Vomit once obstruction progresses
Meckel’s rule of 2s (6 things)
2% of population
Present @ 2 yrs
2 inches in length
Within 2 ft of ileocecal valve
Males:females 2:1
2% develop complication
Complications of Meckel’s
OHIP:
Obstruction (most common complication in adults)
Hemorrhage (most common complication in children)
Inflammation
Perforation
Ultrasound sign of intussuception
Target sign
Treatment for intussusception
Air/CO2 enema (diagnostic & therapeutic)
85% success rate, 5-10% recurrence
Drooling baby should raise concern for…
Esophageal atresia & tracheoesophageal fistula
Meconium should be passed within…
24 hours
“Double bubble” sign on ultrasound typically indicates…
Duodenal atresia (bubbles = stomach + duodenum)
How to tell SBO & LBO apart on X-ray
LBO: peripheral, haustration (don’t go fully across), diameter up to 8cm
SBO: plicae cicrulares (AKA valvulae conniventes), central, diameter up to 5cm
Congenital absence of ganglion cells in rectum/distal colon =
Hirschsprung’s disease
Normal transition zone between normal & abnormal bowel in Hirschsprung’s disease is…
Rectosigmoid junction
Diagnosis & treatment of hirschsprung’s disease
Rectal biopsy
Pullthrough procedure (bringing normally innervated bowel to the anus with preservation of the anal sphincters)
When should an asymptomatic meckel’s be reseted?
Narrow opening
Palpable gastric mucosa
Most common GI emergency in neonates
Necrotizing enterocolitis
Cystic hygroma = a common peds subtype of…
Lymphangioma
Lump in sternomadoid of 3-6 week old baby with their head turned away from it is typically…
Treatment?
Congenital muscular torticollis
Typically treated with passive stretching exercises, rarely surgery
Ddx for painless abdominal mass in child <5 yrs
Neuroblastoma (usually suprarenal, sick pt, mets, poor prognosis)
Wilms’ tumor = nephroblastoma (renal, no mets, good prognosis)
Atresia of jejunum or ileum is thought to occur due to what?
Duodenal?
Vascular accident in utero–> necrosis + reabsorption of fetal intestine (e.g. with cocaine use/tobacco)
vs duodenal is associated with chromosomal abnormalities
Hallmark x-ray finding of necrotizing enterocolitis
Air in the bowel wall = Pneumatosis intestinalis
Portal venous air also common due to transmigration of gas from bowel wall to mesenteric & portal veins
Pneumoperitoneum can be see if there’s a perf
Neuroendocrine tumors usually in distal SI, proximal colon, and lung, with strong propensity for mets to liver. What can result from mets to liver
Carcinoids
Carcinoid syndrome
Pts on warfarin needing emergency surgery should receive what for reversal?
Prothrombin complex concentrate
IV Vitamin K
How long should ASA be held before/after surgery
72 hours before
Restart 8-10 days after major surgery
Maintenance fluid rule. Target urine output?
4:2:1 rule (per Kg per HOUR)
To maintain 0.5mg/kg/hr for adults, 1mL/kg/hr for kids
Contents of normal saline
154 mEq/L Na
154 mEq/L Cl
Electrolyte contents of Ringers
130 mEg/L Na
109 mEq/L Cl
4 mEq/L K
28 mEqL HCO3-
Admission orders mnemonia
Admit to
Diagnosis
Diet
Activity
Vitals
Ins/Outs
IVs/fluids
Investigations
Drugs, Drains, Dressings
How to estimate maintenance fluid requirements based on operative losses
hrs NPO x maintenance req
+ # hrs case x maintenance
+ operative blood loss
+ insensible losses (varies based on extend of procedure)
Cause of post-op fever in the first 48 hours?
Atelectasis
Necrotizing infections
Med reactions/blood products
Malignant hyperthermia
Causes of post-op fever days 3-5
Pneumonia
UTI
IV site infection
Early wound infections? (usually ~day 5+)
Causes of post-op fever day 5+?
Anastomotic leak
Abscess formation
Wound infx
Infx related to catheters/foreign bodies
When does function typically resume for each part of the GI tract post op after paralytic ileus?
Small bowel - 24h
Colon - 24-48h
Gastric - 48-72h
Practice guidelines recommend biopsy for all BI-RADS _____ lesions
4 & 5 (for 3 do short-interval followup with mammogram q6-12 month and biopsy if it grows)
What is Prehn’s sign? Name 2 diagnoses where it would be positiev and 1 where it would be negative
Relief of pain with lifting of testicle, e.g. in epididymitis & orchitis
NEGATIVE in testicular torsion
Rule out testicular torsion with…
U/S doppler
Crohn’s tends to have ___ on microscopy, whereas UC will have ____
Crohns –> granulomas
UC –> crypt abscesses
Most common CRC mets
Liver (usually first), peritoneum, lung
*from rectum can “skip” liver and go to lungs bc it drains into IVC not portal veins
___ lymph nodes are required for staging CRC
12+
What autosomal dominant disease (APC gene mutation) has 100% colon cancer rate by 40s
Familial adenomatous polyposis
Normal thickness of GB wall & CBD
Wall <3mm
CBD <7mm
Normal appendix thickness
1cm
Recurrence of appy with non-surg management
30% in 1 year
40% in 5 yrs
___% of hernias managed by “watchful waiting” are converted to surgical repair annually (i.e. become symptomatic)
10%
Lichtenstein repair for inguinal hernia AKA
Open or “tension-free”
Diagnostics for pancreatitis
2/3 of: biochemical (lipase), radiological, clinical (Sx)
In infants, delay elective procedures until when?
60 wks postconceptual age
Breast cancer usually originates in the…
Ducts
Breast cancer screening guideline Ontario for regular-risk pts
Mammogram q2 years from age 50-74
Core needle biopsy vs FNA?
FNA has high false-neg rate so can’t rule out
Core needle is more accurate
Is surgical management indicated in acute pancreatitis?
NOT USUALLY, VERY HIGH M&M
Only if pt has infected pancreatic necrosis and hasn’t responded to perc drain using step-up approach
Is urine acidic or alkaline in pyloric stenosis
Paradoxic aciduria due to rental retention of Na, exchanged for K+ & H+
Positive pyloric stenosis ultrasound
Pylorus with length of 14mm+ and wall thickness of 4mm+
