Surgery Flashcards
What are some potential causes of intussusception?
- idiopathic (viral, related to Peyer’s patches)
- pathological lead point (Meckel’s diverticulum, polyps, HSP, appendix)
- foreign body
- malignancy
What is the diagnostic approach to someone with suspected intussusception?
- 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
What are 3 absolute contraindications to attempted decompression?
- perforation
- peritonitis
- persistently low BP
Where in the body are the majority of intussusceptions?
Ileo-colic
What symptoms are associated with increased risk if present prior to surgery?
- fever, cough, rhinorrhea, mucopurulent discharge or wheeze
If a child is wheezing with cough, how long should their elective procedure be delayed?
4-6 weeks
What is the rate of spontaneous reduction of intussusception?
4-10%
What is the success rate of air enema in intussuscepetion?
80-95%
What is the definitive treatment for biliary cysts? What benefit does this provide the child long term?
Surgical resection (though this depends on the type of cyst)
Prevention of biliary adenocarcinoma later in life (will need regular imaging and surveillance)
What are the “rules of 2” as related to Meckel’s Diverticulum?
- 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
Why do Meckel’s diverticulum bleed?
- 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)
What is the most sensitive test for confirmation of Meckel’s diverticulum?
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
What are the indications for surgical intervention in the case of umbilical hernias?
○ Persistence to age 4-5 ○ Symptomatic ○ Strangulation ○ Progressing after age 1-2 ○ Defects >2 cm are unlikely to close spontaneously - epithelized omphalocele
What is the major limiting factor with regards to congenital diaphragmatic hernia?
Pulmonary hypoplasia (reduction in pulmonary mass and number of bronchial divisions, respiratory bronchioles, and alveoli)
What are 2 risk factors for umbilical hernia?
- black race
- low birth weight
What are the different types of CDH?
• 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)
What is a poor prognostic sign in the case of CDH?
Respiratory distress within the first 6 hours of life
What initial steps should be taken in the case of known CDH?
- 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
What long term complications must be considered in the case of CDH?
- 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
What are the 5 different types of TEF?
- 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
What are the most common associations related to TEF?
- Cardiac
* Skeletal/vertebral
What complications are seen post surgical management of TEF?
- Refistulization
- Anastomotic leak
- Stricture
- Laryngeal cleft
- Vocal cord paralysis
- Tracheomalacia
What are the differences between gastroschisis and omphaloceles?
- 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
What are the most common causes of acute pancreatitis?
• 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
What is the criteria for diagnosing pancreatitis in a child?
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
When can a child with pancreatitis eat?
NPO while vomiting, but once vomiting ceases, guidelines state may resume eating by NG or PO
What causes SMA syndrome?
- 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
What are the management steps for SMA syndrome?
- Obstructive relief
- Lateral or prone positioning
- Prokinetic agents
- Surgery (for definitive treatment)
- Nutritional rehabilitation
- NJ or TPN
- Correction of associated fluid and electrolyte abnormalities
What other conditions are associated with malrotation?
Think abdominal wall defects:
- omphalocele
- gastroschisis
- congenital diaphragmatic hernia
What is the difference between malrotation and volvulus?
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
What test is the gold standard for diagnosis of volvulus?
Upper GI series with contrast
What risk factors are linked to pyloric stenosis?
- First born male
- Paternal family history
- Maternal/infant use of macrolides
- Some conditions i.e. smith-lemli-opitz
What is the classic clinical presentation for pyloric stenosis?
- 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
What is the threshold for diagnosis on U/S of pyloric stenosis?
“Pi”-loric stenosis - 3 mm thick
14 mm long
What treatment options are available for children with pyloric stenosis?
- Pyloromyotomy
- IV/PO atropine
- betablockers
- NG feeds
What are potential complications following operative management of inguinal hernia?
- injury to vas deferens
- recurrence
- iatrogenic undescended testis
- edema/swelling
What must be present for inguinal hernia to occur?
Patent processus vaginalis
On which side do most inguinal hernias occur?
60% on R
If an inguinal hernia is noted on the R, what circumstances would dictate surgical exploration of the L side?
• Prematurity
What are potential causes for appendicitis?
- 50% secondary to intestinal obstruction i.e. fecalith, tumour, pinworms
- secondary to infection (i.e. adenovirus)
- thickened mucous in cystic fibrosis
What signs are concerning on U/S for appendicitis?
- swollen appendix >6 mm
- appendicolith
- lumen distension
- appendix that is non-compressible
- complex mass in RLQ
