Surgical d/o Flashcards
Red flags of neonatal surgical d/o’s?
Maternal polyhydramnios Delayed meconium passage Abd distention (Obstruction) Perinatal vomiting (bilious or non-bilious)
Maternal polyhydramnios is?
Inability of fetus to swallow/digest amniotic fluid = fluid backs up
MC TE fistula variation?
Esophageal atresia - w/ distal TEF
Esophageal atresia is?
Esophagus is incomplete and not continuous
Pathophys of Esophageal atresia?
Baby cannot swallow amniotic fluid >
Fluid cannot pass into intestine/transfer to placenta >
Mom cannot dispose >
=== Polyhydramnios (fluid backs up)
TE fistula presents as?
(MC) Cough, choking, respiratory distress, cyanosis Excess saliva (drooling) Symptoms worse w/ feeding Single umbilical artery (common) VACTRL
TE fistulas ass/w VACTRL are?
Anomalies V - Vertebrae (70%) A - Anal atresia (imperforate anus) C - Cardiac T - TEF (itself) (70%) R - Renal L - Limb (polydactyly etc.) (70%)
TE fistulas are Dx how?
OG tube placement fails (CXR - catheter tube curled)
If difficult
- Water soluble gastrografin swallow study
- Methylene blue challenge
TE fistula TXT?
Ligate fistula, re-approximate esophagus
- anastomosis (may need to postpone due to gap)
Gastrostomy tube for feedings until surgery
Number one cause of Intestinal obstruction <3mo old?
Pyloric stenosis
MC pop of Pyloric stenosis
<3mo (2-6wk old MC)
M>F 5:1
1st born more common
Pyloric stenosis is?
Pyloric muscle hypertrophy and spasms = obstruction
Classic Pyloric stenosis presentation?
Post-prandial - nonbilious PROJECTILE vomit
Ravenously hungry > FTT and Lethargic
Labs of pyloric stenosis
Vomiting d/o = hypo Cl- and K+ (metabolic alkalosis) Elevated BUN (dehydration)
Pyloric stenosis Abdominal exam signs?
Palpable - hypertrophied pylorus (An Olive)
LUQ Peristaltic Waves
Pyloric stenosis RADs? Findings?
U/S - elongated thickened pylorus
Barium Upper GI series - “String sign”
- barium passes elongated, constricted pyloric channel
Pyloric stenosis mgmt?
IV fluids/lytes resus (NS bolus > D5 w/ K+)
OG tube - slow feeds until surgery
Surgery = Pyloromyotomy
Congenital Diaphragmatic Hernia is?
Large posterolateral opening in diaphragm (usually unilateral) that allows bowel to herniate
Congenital Diaphragmatic Hernia occurs MC on what side?
L-side
Bochdalek formation is ass/w?
Congenital Diaphragmatic Hernia
Pathophys of Congenital Diaphragmatic Herniation?
Bowels develop BEFORE lungs >
Bowels impede NL lung development >
Left (Posteriorly)
Congenital Diaphragmatic Hernia presents as?
Progressive severe respiratory distress after delivery Scaphoid Abd (hollowed anterior abd wall) Bowel sounds in L-chest
Congenital Diaphragmatic Hernia Dx via?
XR
Congenital Diaphragmatic Hernia TXT?
Intubate/ventilate
Oro-gastric decompression
Surgery
Umbilical hernia is?
Imperfect closure/weakness of umbilical ring 1-5cm
May contain portions of Omentum/Sml intestines
What size Umbilical hernia will most likely NOT close on their own?
> 2cm
RFs of Umbilical hernia?
Low birth weight
AA
MC age Umbilical hernia is seen?
Most 6mo of age and disappear by 1yr
When is surgery recommended for Umbilical hernia?
Hernia persists to 4-5yo
Symptomatic or strangulated
Larger after 1-2yrs
Malrotation w/ midgut volvulus is?
Intestines fail to rotate during development causing a volvulus (obstruction/necrosis)
Pathophys of Malrotation w/ midgut volvulus?
Intestines fail to rotate during development > Intestines twist on itself > Intestinal obstruction > Mesenteric artery occlusion > Ischemia /infarcation/necrosis
Presentation of Malrotation w/ midgut volvulus?
Bilious vomiting in 1st mo of life or later in infancy
TTP Abd
Ladd’s bands are?
Duodenal constrictions that may cause vomiting despite malrotation of midgut
Malrotation w/ midgut volvulus Rad?
XR - obstruction
Barium enema - Cecum in RUQ (twist pulls cecum up)
Corkscrew effect of upper GI - barium swallow
TXT of Malrotation w/ midgut volvulus
Fluids
OG decompression
Immediate - laparotomy
Ddx Difference between bilious and non-bilious vomiting
Bilious
- Malrotation w/ midgut volvulus
- Intestinal atresia
- Hirschsprung disease
Non-bilious vomiting - Pyloric stenosis
Intestinal atresia ass/w?
Meconium ileus w/ cystic fibrosis (Check CF)
Trisomy 21
Intestinal atresia presents as?
Bilious vomiting Jaundice Polyhydramnios Failed attempts to feed Abd distention
Intestinal atresia Studies?
XR, Contrast study, Labs (CBC, CMP, amylase/lipase)
Intestinal atresia XR may show?
Double bubble sign - if Duodenal atresia
Long dilated segments of air filled bowel - Distal atresia
Intestinal atresia mgmt?
IV fluids
OG/NG decompression
Broad apectrum Abx
Surgery
Gastrochisis is?
Split or open stomach - (Linear abdominal wall split/defect) exposes intestines to amniotic fluid w/ thick exudative peel over intestines (irritant)
Gastroschisis occurs on what side MC?
Right side
Does Gastroschisis involve umbilicus?
NO
Gastroschisis is ass/w?
Segments of atresia
Omphalocele pathophys is?
Impaired abdominal wall growth >
Intestines to remain in umbilical cord >
Herniation of bowel through umbilical ring
Which is ass/w umbilicus Gastroschisis or Omphalocele?
Omphalocele is ass/w the umbilicus
Gastroschisis/Omphalocele mgmt?
OG/NG decompress
IVF and Parenteral nutrition
Sterile dressing coverings
Surgery
Gastroschisis/Omphalocele surgery considerations?
Small defects <2cm repaired immediately
Large defects req staged procedure
Meckel’s diverticulum is?
A congenital malformation outpouching if ileum (remnant of vitelline duct) that may have ectopic mucosae similar to gastric/pancreatic
MC intestinal malformation is?
Meckel’s diverticulum (true diverticulum)
Meckel’s diverticulum rule of 2’s?
2% of population Presents w/in 2yrs of life W/in 2 ft of cecum on ileum 2 inches long 2 ectopic mucosae (gastric/pancreatic)
Meckel’s diverticulum presents as?
Asymptomatic OR
- Massive painless GI bleed
- Ulceration of ileum
- Intestinal obstruction
Complications of Meckel’s diverticulum?
Intussusception or Volvulus = Obstruction
Diverticulitis
Bleeding > Perforation
Meckel’s diverticulum Dx is performed?
Meckel Scan - (Technetium-99m scan) tests for gastric acid
U/S, video capsule endoscopy, surgical investigation
Anorectal malformations are?
Absence of normal anal opening
Fistulas connecting structues present (meconium leak)
Anorectal malformations mgmt?
Lateral XR = gas in bladder > distention > cath
MRI - check tethered spinal cord
Other complications of Anorectal malformations?
Urologic dysfx
Anorectal malformations TXT?
Surgery - colostomy after anogenital reconstruction
Hirschsprung disease is?
Absent Motility defect causing congenital megacolon(dilation) proximal to aganglionic segment causing functional obstruction.
Hirschsprung disease is MC located where in GI?
Rectosigmoid region 75%
Hirschsprung disease presents as?
95% don’t pass stool by 24hrs of age
Abd distention due distal bowel obstruction
Bilious vomiting
Hirschsprung disease Dx via?
XR - Dilated SML/LRG bowel proximal
Barium enema - Megacolon/Colonic impaction
Rectal Bx of aganglionic mucosa
Anorectal manometry
DRE - finger withdrawn = stool expulsion or empty.
Hirschsprung disease TXT?
Surgery Colostomy above affected segment
- Remove aganglionic section
- Decompress distended/inflamed bowel
Necrotizing enterocolitis is?
Ischemia 2nd to immature GI system and is ass/w prematurity and enteral feedings.
Necrotizing enterocolitis mgmt?
Stop enteral feeds > Total parenteral nutrition (TPN)
GI decompression w/ NG
Fluid/Lyte replacement
Broad spectrum Abx
Surgery - laparotomy w/ excision of affected bowel.
Necrotizing enterocolitis EARLY presentation?
Abd distention
feeding intolerance
Rectal bleed/occ. diarrhea
Emesis
Necrotizing enterocolitis LATE presentation?
Bluish abdomen = Intestinal perforation Bilious vomiting Ascites Lethargy DIC/Shock
Necrotizing enterocolitis Dx?
Clinical S/S
XR
Necrotizing enterocolitis XR shows?
Ileus w/ bowel loop thickening and air-fluid levels
Bacterial Gas between bowel wall (pneumatosis int)
Dilated bowel
Pneumoperitoneum = perf
Intrahepatic venous gas
Intussusception is?
Telescoping of proximal bowel into distal bowel
Intussusception ass/w?
Meckels diverticulum (Ileocecal valve)
Peyer’s patched (lymphoid hyperplasia)
Rotavirus infection
Intussusception presents as?
Paroxysmal, crampy abd pain/distention Bilious vomiting Currant jelly stools RUQ/epigastric sausage shaped mass Lethargy, Crying and drawing legs up Refuses feeds
Currant jelly stools appears?
Mixture of mucus, sloughed mucosa, and blood.
Intussusception Dx?
Pneumatic or Barium enema w/ fluoroscopy
- Dx and TXT
Intussusception Mgmt?
Fluid resuscitation
NG tube decompression
Pneumatic/Barium enema (Dx and TXT)
Surgical consult - reduction or resection
MC surgical emergency in children?
Appendicitis
Peak age for pediatric appendicitis?
10-12yo
Appendicitis is?
Obstruction of appendix lumen (MC-fecalith or LN hyperplasia after viral infection.
Appendicitis pathophys?
Obstruction >
Trapped bacteria proliferation >
Invade appendix wall >
Inflammation/rupture
Timeframe for Appendicitis rupture after onset of S/S?
W/in 48hrs of s/s
Appendicitis presents as?
Periumbilical visceral pain RLQ pain - McBurney's point Appendiceal distention Voluntary guarding > rigidity > rebound TTP N/V
Alvarado/Mantrels rule applies to? Is?
Appendicitis (<4pt = unlikely OR > 7pt = likely) (1pt each) - Pain migration to RLQ - Anorexia - N/V - Rebound pain - Fever - WBC L-shift >75% Segs (2pt each) - RLQ TTP - Leukocytosis >10k
Appendicitis Dx?
CT w/ IV contrast - MOST accurate
U/S
XR - Abd series/KUB
Lab - CBC, CMP, UA/Cx
Appendicitis mgmt?
Appendectomy
IV Antibitoics
Appendicitis PE signs for surgery?
Guarding/rigidity
Sev TTP
+ rebound TTP or referred pain
Appendicitis tests to perform in PE?
Heel strike Obturator sign (Int rotation of flexed thigh) Psoas sign (Extension of hip on side)
