Surgical Problems of the Neonate

Question 1

List the 3 ways a tube can become obstructed.

Answer 1

1. External pressure.
2. Something in the lumen, intra-luminal obstruction
3. Something in the wall.

Question 2

At what day, should you be concerned if a baby has no passed faeces?

Answer 2

By day 3

Question 3

Describe a babies first poo.

Answer 3

Black, like tar (this is called meconium) – if it doesn’t come through then you start to worry

Question 4

What is meconium ileus the initial presentation of?

Answer 4

CF

Question 5

How many babies with CF will present with meconium ileus?

Answer 5

1/3

Question 6

What is meconium ileus?

Answer 6

Lumen is full of meconium – thick and black

Question 7

Where is the obstruction in meconium ileus?

Answer 7

LUMEN OF THE BOWEL !!!

Question 8

What is the characteristic sign of meconium ileus?

Answer 8

Soap sign/foaming sign

Question 9

What is the Ix for meconium ileus?

Answer 9

Water soluble contrast, given rectally - x ray

Question 10

What would be seen on x-ray of a child with meconium ileus?

Answer 10

Distended loops of bowel upstream

Tangled bit of bowel – filled with ‘stuff’ which we can’t move, doughy

Distended small bowel

Question 11

Describe the presentation of a baby with meconium ileus.

Answer 11

Baby has not passed faeces yet (48 hrs should be upper limit)

Tummy big, and baby is vomiting. Initially keen to eat.

Question 12

What is the treatment for meconium ileus?

Answer 12

Make an incision in the bowel and squeeze the meconium out, but this meconium is not normal

Question 13

What is jejunal atresia a problem of?

Answer 13

An obstruction in the wall of the bowel

Question 14

What may there be evidence of in jejunal atresia?

Answer 14

There may be evidence on scanning of the bowel being a wee bit more dilated than normal, or a bit more echoic

Question 15

Describe the presentation of a baby with jejunal atresia.

Answer 15

Baby not pooing, but there might be a wee bit of something

Abdomen might be a bit distended. Likely to want to feed, but feeds don’t stay down ie. they’re vomiting.

Question 16

What would be seen on x-ray of a baby with jejunal atresia?

Answer 16

Obstructed

Very big loops, in little ladders (making straight lines)

No gas in the rectum – nothing getting through.

Question 17

Jejunal atresia can be described as what type of obstruction?

Answer 17

Quite a high obstruction – not much area for distension of abdomen

Question 18

Outline the treatment of jejunal atresia.

Answer 18

Remove the very distended bowel and re-attach

Question 19

What Ix can be done for jejunal atresia? Describe this.

Answer 19

Water soluble lower GI contrast (inserted rectally)

Stuff in the lumen – goes across, but then there’s a big loop.

Question 20

What would there be an absence of at the site of a hernia?

Answer 20

Groin crease

Question 21

What is a hernia a problem of?

Answer 21

Obstruction outside the wall

Question 22

Why might there be an obvious mass in the scrotum of a baby with a hernia?

Answer 22

A loop of bowel has come down through the inguinal canal

Question 23

Failure of what to close can result in hernias?

Answer 23

Peritoneal lining

Question 24

Failure of what to close can result in hernias?

Answer 24

Peritoneal lining

That leaves room for a loop of bowel or omentum to come down.

Question 25

What would be seen on an x-ray of a baby with a hernia?

Answer 25

Big loops, ladder effect (don’t like to see straight lines). X-ray shouldn’t really have been taken – waste of time, should’ve just called the surgical team.

Question 26

‘Laddering’ ….

Answer 26

An x-ray sign seen in hernias

Question 27

‘Laddering’ ….

Answer 27

An x-ray sign seen in hernias

The more lines there are, the lower down the obstruction

Question 28

GREEN VOMITING IN BABIES IS BAD

Answer 28

Think malrotation

Question 29

What is bile?

Answer 29

A breakdown product of bilirubin, secreted into jejunum

Question 30

Describe the colour of bile?

Answer 30

Moss green

Fairy liquid green

Question 31

If a child is vomiting a moss green colour, what is it until proven otherwise?

Answer 31

MALROTATION !!

Question 32

What Ix is used for a child vomiting bile?

Answer 32

Upper GI contrast with follow-through, a water solube contrast is used + FOLLOW THROUGH – this is very important as you need pictures of the contrast moving further down

Question 33

Describe a normal upper GI tract contrast and follow through.

Answer 33

C shape of duodenum and normal bowel crossing vertical column

Question 34

Describe an abnormal upper GI tract contrast and follow through.

Answer 34

Fixed points being low and to the right

Question 35

What is the longest diameter in the bowel?

Answer 35

DJ flexure to caecum !!!!

2 points joined by line – from top left to bottoms right – is the longest point in belly.

Along that line, all the blood supply to the midgut comes off. From superior mesenteric artery. These points should be fixed and stable

Question 36

Describe malrotation.

Answer 36

DJ flexure is lying low and caecum is lying high.

All blood supply is going to midgut through a narrow base. Get twist around point, and bowel is at risk of ischaemia. Needs an operation as unstable and bowel is at risk of ischaemia.

Question 37

‘Air in the wrong place’ …. what is this?

Answer 37

Pneumoperitoneum

Hole in the bowel, air has gone from gassy bowel to the outside

Question 38

Who gets ‘air in the wrong place’?

Answer 38

Premature neonates

Question 39

What is necrotising enterocolitis?

Answer 39

An acquired pathology because baby’s gut hasn’t formed properly