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Pediatrics > Surgery > Flashcards

Surgery Flashcards

1
Q

What are some potential causes of intussusception?

A
  • idiopathic (viral, related to Peyer’s patches)
  • pathological lead point (Meckel’s diverticulum, polyps, HSP, appendix)
  • foreign body
  • malignancy
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2
Q

What is the diagnostic approach to someone with suspected intussusception?

A
  • AXR: to rule out perforation
  • US looking for target sign
  • if US positive, confirm with air/contrast enema
  • NPO and bowel rest
  • CBC and electrolytes
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3
Q

What are 3 absolute contraindications to attempted decompression?

A
  • perforation
  • peritonitis
  • persistently low BP
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4
Q

Where in the body are the majority of intussusceptions?

A

Ileo-colic

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5
Q

What symptoms are associated with increased risk if present prior to surgery?

A
  • fever, cough, rhinorrhea, mucopurulent discharge or wheeze
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6
Q

If a child is wheezing with cough, how long should their elective procedure be delayed?

A

4-6 weeks

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7
Q

What is the rate of spontaneous reduction of intussusception?

A

4-10%

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8
Q

What is the success rate of air enema in intussuscepetion?

A

80-95%

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9
Q

What is the definitive treatment for biliary cysts? What benefit does this provide the child long term?

A

Surgical resection (though this depends on the type of cyst)

Prevention of biliary adenocarcinoma later in life (will need regular imaging and surveillance)

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10
Q

What are the “rules of 2” as related to Meckel’s Diverticulum?

A
  • 2 inches in length
  • present in 2% of population
  • located about 2 feet from ileocecal valve
  • presents before age 2
  • 2 types of cells (pancreatic or gastric)
  • 2x more common in F than M
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11
Q

Why do Meckel’s diverticulum bleed?

A
  • Acid secreting gastric mucosa causes intermittent painless rectal bleeding by ulceration of adjacent normal ileal mucosa
  • May also be associated with partial or complete bowel obstruction (intraperitoneal bands connecting residual omphalomesenteric duct remnants to the ileum and umbilicus)
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12
Q

What is the most sensitive test for confirmation of Meckel’s diverticulum?

A

Diagnosis: Meckel radionuclide scan: (Technetium-99 pertechnetate)

○ Gastric cells take up the pertechnetate, making them visible
○ False negative is seen with anemic patients
○ False positives reported with intussusception, appendicitis, duplication cysts, AVM, and tumours
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13
Q

What are the indications for surgical intervention in the case of umbilical hernias?

A 
○ Persistence to age 4-5
○ Symptomatic
○ Strangulation
○ Progressing after age 1-2
○ Defects >2 cm are unlikely to close spontaneously - epithelized omphalocele
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14
Q

What is the major limiting factor with regards to congenital diaphragmatic hernia?

A

Pulmonary hypoplasia (reduction in pulmonary mass and number of bronchial divisions, respiratory bronchioles, and alveoli)

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15
Q

What are 2 risk factors for umbilical hernia?

A
  • black race

- low birth weight

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16
Q

What are the different types of CDH?

A

• Bochdalek → posterolateral portion of diaphragm; most commonly left sided
○ accounts for 90% of hernias seen in newborn period; 80-90% are left sided

• Morgagni → retrosternal; accounts for 2-6% of CDH

  • esophageal hiatus (hiatal)
  • paraesophageal (adjacent to hiatus)
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17
Q

What is a poor prognostic sign in the case of CDH?

A

Respiratory distress within the first 6 hours of life

18
Q

What initial steps should be taken in the case of known CDH?

A
  • Rapid endotracheal intubation, sedation, possibly paralysis (avoid BMV in delivery room)
  • Arterial (pre and post-ductal) and central venous (umbilical) lines are mandated
  • Catheter
  • NG tube
  • Gentle ventilation with permissive hypercapnia → reduces lung injury, need for ECMO and mortality
19
Q

What long term complications must be considered in the case of CDH?

A
  • Pulmonary problems → both obstructive and restrictive patterns can occur, BPD
  • GERD
  • Intestinal obstruction, may result from mid-gut volvulus, adhesions, recurrent hernia that became incarcerated
  • Recurrent diaphragmatic hernia is reported in 5-20%
  • Delayed growth for first 2 years of life
  • Neurocognitive defects are common and may result from disease or interventions; higher incidence in infants who required ECMO
  • Pectus excavatum
  • Scoliosis
20
Q

What are the 5 different types of TEF?

A
  • H - fistula
  • Upper esophageal atresia with fistula (most common)
  • Lower esophageal atresia with fistula
  • Double pouched esophageal atresia, no fistula
  • Double fistula, non-communicating esophagus
21
Q

What are the most common associations related to TEF?

A
  • Cardiac

* Skeletal/vertebral

22
Q

What complications are seen post surgical management of TEF?

A
  • Refistulization
  • Anastomotic leak
  • Stricture
  • Laryngeal cleft
  • Vocal cord paralysis
  • Tracheomalacia
23
Q

What are the differences between gastroschisis and omphaloceles?

A
  • Location: paraumbilical vs. base of umbilical cord
  • Involved organs: usually just small bowel vs many intra-abdominal organs
  • Etiology: spontaneous vs. chromosomal i.e. Beckwidth-Wiedemann
  • Associated anomalies: Cardiac/GI vs. GI
  • Oligohydramnios vs polyhydramnios
24
Q

What are the most common causes of acute pancreatitis?

A

• Blunt abdominal injuries
• Hemolytic uremic syndrome
• Inflammatory bowel disease
• Biliary stones or microlithiasis (sludging)
• Drug toxicity
- Valproic acid, L-asparaginase, 6-mercaptopurine, and azathioprine are the most common causes of drug-induced pancreatitis

25
Q

What is the criteria for diagnosing pancreatitis in a child?

A

Must meet 2/3 criteria:
○ Abdominal pain
○ Serum amylase and/or *lipase activity at least 3 times greater than the upper limit of normal
○ Imaging findings characteristic of, or compatible with, acute pancreatitis

  • Serum lipase is now considered the test of choice for acute pancreatitis as it is more specific than amylase for acute inflammatory pancreatic disease
26
Q

When can a child with pancreatitis eat?

A

NPO while vomiting, but once vomiting ceases, guidelines state may resume eating by NG or PO

27
Q

What causes SMA syndrome?

A
  • Results from compression of the 3rd duodenal segment by the superior messenteric artery against the aorta
  • Malnutrition or catabolic states (i.e. Major surgery) cause mesenteric fat depletion, which collapses the duodenum within a narrowed aortomessenteric angle
  • Other causes:
    • Extrabdominal compression (body cast)
    • Mesenteric tension i.e. Ileoanal pouch anastomosis
28
Q

What are the management steps for SMA syndrome?

A
  • Obstructive relief
    • Lateral or prone positioning
    • Prokinetic agents
    • Surgery (for definitive treatment)
  • Nutritional rehabilitation
    • NJ or TPN
  • Correction of associated fluid and electrolyte abnormalities
29
Q

What other conditions are associated with malrotation?

A

Think abdominal wall defects:

  • omphalocele
  • gastroschisis
  • congenital diaphragmatic hernia
30
Q

What is the difference between malrotation and volvulus?

A

Malrotation is incomplete rotation of the gut around the SMA during prenatal development

Vovulus is a life-threatening obstruction caused by malrotation around the SMA resulting in vascular compromise of the bowel wall

31
Q

What test is the gold standard for diagnosis of volvulus?

A

Upper GI series with contrast

32
Q

What risk factors are linked to pyloric stenosis?

A
  • First born male
  • Paternal family history
  • Maternal/infant use of macrolides
  • Some conditions i.e. smith-lemli-opitz
33
Q

What is the classic clinical presentation for pyloric stenosis?

A
  • non-bilious emesis directly after feeding that is projectile in nature
  • child may be hungry and want to eat immediately afterwards
  • hypochloremic metabolic alkylosis
  • unconjugated hyperbilirubinemia
34
Q

What is the threshold for diagnosis on U/S of pyloric stenosis?

A

“Pi”-loric stenosis - 3 mm thick

14 mm long

35
Q

What treatment options are available for children with pyloric stenosis?

A
  • Pyloromyotomy
  • IV/PO atropine
  • betablockers
  • NG feeds
36
Q

What are potential complications following operative management of inguinal hernia?

A
  • injury to vas deferens
  • recurrence
  • iatrogenic undescended testis
  • edema/swelling
37
Q

What must be present for inguinal hernia to occur?

A

Patent processus vaginalis

38
Q

On which side do most inguinal hernias occur?

A

60% on R

39
Q

If an inguinal hernia is noted on the R, what circumstances would dictate surgical exploration of the L side?

A

• Prematurity

40
Q

What are potential causes for appendicitis?

A
  • 50% secondary to intestinal obstruction i.e. fecalith, tumour, pinworms
  • secondary to infection (i.e. adenovirus)
  • thickened mucous in cystic fibrosis
41
Q

What signs are concerning on U/S for appendicitis?

A
  • swollen appendix >6 mm
  • appendicolith
  • lumen distension
  • appendix that is non-compressible
  • complex mass in RLQ

Pediatrics (27 decks)

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