TEST 3 Flashcards
Wilms tumor/nephroblastoma
-asymptomatic abdominal mass
-2-5yo
-hematuria
-HTN
-Mets to bone and lung
-if pulm mets pt will require whole lung radiation
-does NOT cross midline
-DX:
-US
-CT scan will differentiate it from a neuroblastoma
-Tx-
-nephrectomy with exploration of the other kidney and peritoneum.
-Tumor MUST NOT rupture when being taken out -> worsens prognosis.
-Chemo in all pts -> Actinomycin and Vincristine -> unless Stage 1 or < 500 g in wt
pyloric stenosis
-Males
-first 1-12 wks of life
-Projectile nonbilious vomiting
-olive shaped mass, non-tender
-palpable
-peristaltic waves visible
-DX:
-US
-pyloric thickness > 4mm
-length > 14 mm
-barium- string sign, beak sign
-Labs- Hypochloremic hypokalemic metabolic alkalosis
-Resuscitate with:
-NS boluses until urine production.
-Then D5 NS with 10 meq of KCL.
-Must have saline as infants develop hyponatremia.
-ALWAYS include glucose due to low reserves.
-TX-
-Pyloromotomy
meckels diverticulum
-MC congenital GI anomaly- 2%
-M>F 2:1
-<2yo
-2ft proximal to ileocecal valve
-<2inches
-can be 2 types of mucosa lining
-can be asymptomatic
-MC- lower GI bleeding -> currant jelly, hematochezia, tar
-RLQ pain
-DX-
-Lower GI bleed workup
-Tx-
-surgical resection
-complications- obstruction (intussusception, volvulus), perforation, hemorrhage
umbilical hernia
-opening from umbilical cord
-linea alba doesnt close
-usually no complications and close by 3yo
-can be reduced (unless incarcerated)
-if not closed by 5 -> surgery
-if incarceration or strangulation -> emergent repair
neuroblastoma
-MC solid malignancy in children
-palpable abdominal mass
-younger = better prognosis
-secrete catecholamines
-MAY cross midline
-Secretory diarrhea, racoon eyes (mets), HTN, gait abnormalities.
-Involves adrenals but can occur anywhere along sympathetic chain.
-Tumor wraps around vessels instead of invading them.
-mets is rare -> bone and lung
-DX-
-urine/blood catecholamines
-CT/MRI
-scintigraphy / MIBG
-TX-
-Surgery- resection of kidney and adrenal gland.
-Doxorubicin - unresectable tumors.
reducible vs irreducible hernia
REDUCIBLE
-may ache but NOT tender to touch
-bulge increases with standing or increased intra-abdominal pressure
-can be treated surgically but doesnt need to
IRREDUCIBLE
-AKA incarcerated
-vascular supply is NOT compromised
-painful enlargement of previously reducible hernia
-can be painless
-can lead to strangulation
-try to reduce -> emergent surgery
strangulated hernia
-vascular supply compromised
-pain -> tenderness
-sometimes bowel obstruction -> N/V
-may appear ill -> fever
-surgical emergency
-pain out of proportion to exam
-pain that persists after reduction of hernia
inguinal hernia
-75% of abdominal hernia
-M>F 25x
-surgical repair
-INDIRECT
-congenital or acquired
-due to incomplete closure of deep inguinal ring
-can protrude into scrotum
-MC in males and older men -> more common as you age
-through external and internal ring -> outside hesselbach
-lateral
-DIRECT
-acquired
-where the abdominal wall is thinner
-middle aged and elderly
-through external ring -> within hesselbach
-medial
-FEMORAL
-less common
-MC in women
-acquired
-through femoral ring into femoral canal
-below inguinal ligament/crease and middle thigh
-easy to be incarcerated and strangulated
obturator foramen hernia
-extremely rare
-F>M
-protrudes through pelvic cavity through obturator foramen
-no bulge!
-can act like bowel obstruction -> N/V
-Howship-Romberg sign: pain and paresthesia over the inner aspect of the thigh down to knee -> from obturator nerve injury
-inner thigh pain on internal rotation of hip
-paralysis of hip adductors
epigastric, spigelian, incisional, umbilical hernias
-EPIGASTRIC
-fatty tissue not intestine
-painless
-unable to be reduced
-SPIGELIAN
-edge of rectus abdominus
-INSICIONAL
-high reoccurrance
-risk- wound infection, smoking, ischemia, tension, obesity
-UMBILICAL
-pregnancy
wound
-seroma- formation of fluid collection under skin -> no systemic signs (flap surgery)
-wound infections -> purulent
-wound dehiscence -> opening of incision under skin -> fluid under skin -> systemic sx
-evisceration -> can see bowel
hiatal hernia
-10% of pts
-heartburn
-sudden regurgitation
-burping
-pain on swallowing hot fluids
-feeling of food stuck in esophagus
-MC- overwt middle aged women and elderly
-pregnancy
-type 2 GEJ stays below diaphragm
-dx-
-barium swallow
-endoscope
-radiograph
-Tx-
-no tx if no symptoms
-wt loss
-eat small meals frequently
-stop smoking
-antacids
-avoid hot, spicy, gassy drinks
-if GERD, failure of tx, large, complications (stricture, ulceration, bleeds) -> surgery for type 1
-all types except type 1 -> nissen fundoplication or hiatoplasty
nissen fundoplication
-for hiatal hernia or GERD
-gastric fundus is wrapped around the back of lower esophagus
-360 degrees
-can cause vagus nerve damage -> decrease emptying of stomach -> pyloroplasty (widen pyloric sphincter)
hiatal hernia
GERD
-loss of LES function
-can cause barrets, schatzki, adenocarcinoma
-hoarse
-dx-
-if red flags do an EGD
-if chronic GERD and >=3 risks for barrets -> EGD
-tx-
-H2, PPI
-Nissen fundoplication (complete
fundoplication)- make new sphincter from stomach
achalasia
-mobility disorder -> cant relax lower esophageal sphincter
-nonperistaltic contraction of lower 2/3rds
-dysphagia to solid AND liquid
-regurgitation
-wt loss
-retrosternal pain
-pneumonia from aspiration
-dx-
-EGD and barium swallow
-bird beak
-esophageal manometry
-tx-
-pneumatic dilation of LES
-LES myotomy (heller myotomy)- LES incised longitudinally to re-enable passage of food/liquids
-peroral endoscopic myotomy (PEOM)- myotomy of inner circular muscular layer of LES (not the longitudinal)
-high risk- botox, nitrates, CCB
preseptal/periorbital cellulitis
-soft tissues anterior to orbital septum -> eyelid
-MCC from scratch, bite
-red eye, swelling, systemic signs (fever, preauricular and submandibular adenopathy)
-EOM nontender, normal IOP, normal visual acuity, normal sensation
-clinical dx
-swab for gram stain and culture
-empiric oral antibiotics
-consider IV for young pts with red flags
orbital cellulitis
-soft tissues posterior to orbital septum -> orbital fat, extraocular muscles, neurovascular tissues
-medical emergency
-MCC- bacterial sinusitis through ethmoid
-infants -> dacryocystitis
-systemic signs of infections
-swelling, fever, tender EOM, elevated IOP, impaired vision
-proptosis, chemosis, decrease visual acuity, ophthalmoplegia, optic neuropathy
-relative afferent pupillary defect (RAPD) aka marcus gunn ->
-clinical dx -> confirmed on CT orbits and sinuses
-blood cultures
-tx-
-empiric IV antibx -> vanco + ??
-surgery and urgent opth consult
-complications- visual loss (optic nerve), orbital compartment syndrome, systemic or CNS infection (meningitis), cavernous sinus thrombosis (bilateral), subperiosteal abscess
eye exam
-visual acuity:
-myopia- nearsighted (long globe)- can only see close
-hyperopia- farsighted (short globe)- can only see far
-external exam:
-penlight or during slit lamp
-Orbit Inflammation (cellulitis)
-Trauma (ecchymosis)
-Dermatological abnormalities (herpes zoster ophthalmicus)
-lacrimal Inflammation (dacryocystitis, dacryoadenitis)
-Eyelash Inflammation (blepharitis)
-Swelling of the eyelid margins (blepharitis, chalazion, mass)
-EOM:
-CN palsies
-nystagmus or lid lag: sympathetic overactivity, sclera can be seen above iris as he looks down
-strabismus
