Oesophageal & Duodenal Atresia

Question 1

Outline the primary care of oesophageal atresia with TOF

Answer 1

Suction proximal oesophageal ouch with 8F nasal tube every 15min or continuous using double lumen replogle tube
Keep nil per os
Prevent aspiration by positioning in lateral head up position at 30 degrees
Peroxide oxygen to prevent hypoxia
Broad spectrum antibiotics
Avoid ETT due to risk of air going down and causing distension of abdo.
10% dextrose to prevent hypoglycemia
Maintain warmth in an incubator
Refer urgently to tertiary

Question 2

Standard tx of TOA

Answer 2

Repaired through a right lateral thoracotomy
• Division and closure of the TOF and end to end anastomosis of the
oesophageal ends.

Question 3

Complications of surgical anastomosis of TOF

Answer 3

GERD
Anastomotic structures
Tracheomalacia which presents with barking cough and frequent chest infections

Question 4

Clinical presentation of oesophageal atresia and TOF

Answer 4

Drooling
Coughing or Resp distress after feeds, tachypnoea (aspiration protection)
Milk vomits
Stridor

Question 5

Duodenal stenosis vs duodenal atresia

Answer 5

Stenosis is incomplete obstruction and atresia is complete obstruction/obliteration (so it’s on its own)

Question 6

Clinical presentation of duodenal atresia

Answer 6

Antenatal
-Polyhydramnions
Growth retardation

Postnatal
-vomiting -bile stained
-abdo distension (epigastric distension)
-failure to pass normal meconium (white stool)
-dehydration and biochemical deraingments (hypochloremic, Hyponatremiatremic metabolic alkalosis + jaundiced)

Question 7

Special investigations in duodenal atresia

Answer 7

AXR
Contrast meal follow through

Question 8

Which congenital abnormality is associated

Answer 8

Trisomy 21

Question 9

Management of duodenal atresia preoperatively

Answer 9

ETT on free drainage
Aspiration prevention: nil by mouth
Replacements: IV fluid (resusc, mainainance and replacement of fluid lossses)
Broad spectrum
Dextrose , maintain and monitor serum glucose levels
Resp support
Keep warm
Monitor cardio, Resp and metabolic status.

Question 10

Differentials for biliary atresia

Answer 10

Midgut vulvulus
GERD
Jejune-ioeal atresia

Question 11

What comorbidities are associated with jejune-ileum atresia

Answer 11

Prematurity
Cystic fibrosis
Gastroschisis

Question 12

Contraindications to anastomosis in colon obstruction / atresia

Answer 12

Hirschprung disease
Longer distance between proximal dilated colon and distal unused narrow bowel

Question 13

When does intessusception occur

Answer 13

3 months (peak) to 3 years

Question 14

Complications of Hirschsprung’s disease

Answer 14

Infection- (enterocolitis)
Small bowel

Question 15

Risk factors for Hirschsprung’s disease

Answer 15

Family hx
Male
Trisomy 21, CHD

Question 16

Clinical presentation of intesusception

Answer 16

• Sudden onset of colicky abdominal pain associated with vomiting.
• Pain is severe enough to wake the child. The classic feature is one of pulling the
legs up to the abdomen during the pain. The pain is colicky and intermittent and
may then go away only to return every half hour or so, lasting 20 to 30 seconds.
The child lies very still in between attacks.
• Vomiting may initially be milk feeds but becomes bilious, and later faeculent
• Passage of blood and mucus per rectum (“RED CURRANT JELLY” stools)
• Progressive abdominal distension.

Question 17

Contraindications of air reduction of intessusception

Answer 17

Pure small bowel intessusception
Shock or incomplete Descuss
Signs of peritonitis or dead bowel

Question 18

Where do most neoplasms in children occur

Answer 18

More than 90% neoplasms in children occur in the parotid glands

Question 19

Features of a non benign lesion (non-benign radula)

Answer 19

Firm, fixed lesions that are often non tender

Question 20

Special investigations for a mass in sublingual suggestive of a ranula

Answer 20

Ultrasonography
CT
MRI
Tissue specimen to conform dx by needle aspiration, truculent biopsy or excision biopsy

Question 21

What is sialadenitis

Answer 21

Inflammation of salivary glands

Question 22

Discuss management of ranula

Answer 22

Tx or ranula varies from simple marsupialisation (small incision to make continuos surface-imbobo) to complete excision of the gland.
Non benign are treated according to oncological principles and pleomorphic. Are treated with small excision.
Sialadenitis (inflammation) and in case an abscess has formed, careful incision and drainage of ductal orifice. Rarely entire gland needs to be excised.

Sialadenitis can be classified into viral (CMV,EBV,HIV,Mumps),
bacterial(Staph,Strep)or chronic (obstructive from stones or non-obstructive
associated with systemic conditions such as sarcoidosis, tuberculosis or Sjorgen’s
syndrome)

Question 23

What’s the normal size of lymph nosed in children

Answer 23

Less than 1cm

1-2cm, firm and fixed nodes warrant investigation, also, persistent lymphadenopathy (more than 4-6 weeks)

Question 24

What conditions can cause lymphadenopathy and hence can be our differentials

Answer 24

1. TB (firm, fixed, non tende)
2. EBV
3. CMV
4. Bacterial lymphadenitis (inflamed)
5. Malignancy (firm, fixed, non tender)
   neoplasticism conditions include lymphoma, leukaemia or distal metastasis

Question 25

Special investigations in lymphadenitis

Answer 25

Bloods: FBC,smear and LDH, Infectious markers TB investigation Tissue sample by needle aspirate or incision/excision

Question 26

Tx of lymphadenitis

Answer 26

Depends on condition diagnosed Malignancy: chemo and radiotherapy often Incision and drainage in case of an abscess

Question 27

Presentation of thyroglsal cysts

Answer 27

Midline mass neck that moves upwards when protruding tongue If cysts is infected, drainage sinus is seen Cysts mat communicate with oral cavity, foul taste reported by patient in their mouth

Question 28

Differentials for thyroglobulin cyst

Answer 28

Thyroid nodule Goitre Thyroditis Dermoid cysts (if small, firm and mobile central neck mass been present at birth)

Question 29

Tx of duodenal atresia

Answer 29

Resp and stabilise NG tube Fluid bolus normal saline Maintenance fluid and electrolytes -KCL and 5% dextrose Keep warm (Risk of pontine demyelination if sodium is raised quickly) When ph<7.5, sodium<100, normal potassium and chloride Ramstedt pyeloromyopathy -laparoscopic and open

Question 30

What condition gives you ‘double bubble’ on radiological investigations

Answer 30

Duodenal atresia

Question 31

In which part of the duodenum do you get bile stained vomiting And in which part do you get milky vomits

Answer 31

Bile stained: distal to ampulla of Vater (most common) Milky: proximal to ampulla of vater

Question 32

What metabolic deraingments do you get with duodenal atresia

Answer 32

Hypochloremic Hyponatremic hypokalemic aklalosis

Question 33

What is the average time to full feed in an uncomplicated oesophageal atresia post op

Answer 33

10days

Question 34

What is the pathophysiology of jejuno-ileal atresia

Answer 34

-Mesenteric vascular insult in intrauterine life disrupts focal development of section of intestinal wall -Causes of vascular insult: Micro-emboli or antenatal volvulus, gastroschisis as well. Vascukar insipult results in proximal and distal blind ending bowel lumen on either side of the necrotic portion of bowel (bowel ihlukana phakathi)

Question 35

Main complication of jejune-ileal atresia

Answer 35

Short bowel syndrome

Question 36

Classify the different types of Jejunal-ileal atresia

Answer 36

Stenosis Type 1 atresia Type 2 atresia Type 3A Type 3B Type 4 Stenosis, Type 1&2 don’t result in loss of bowel length. Type 3 and 4 is associated with short bowel syndrome

Question 37

When do intestines return to pleuroperitoneal folds

Answer 37

Week 10-14

Question 38

When does diaphragm develop

Answer 38

Week 7-10

Question 39

2 most common sites of diaphragm hernia

Answer 39

Parasternal (Morgagni) hernia Posterolateral (Bochdalek) hernia

Question 40

Complications of diaphragmatic hernia

Answer 40

• Lung hypoplasia – there are fewer alveoli than normal • Mediastinal shift- heart is shifted to contralateral side • Thickened pulmonary arteries – there is more muscle in the arterioles and less surfactant in the lungs • Pulmonary arterial hypertension – resulting in a left to right shunt, persistent foetal circulation, hypoxia and hypercarbia GORD post op, Chronic lung disease and failure to thrive too

Question 41

Symptoms of diaphragmatic hernia

Answer 41

• Respiratory distress, cyanosis – both to a variable degree • Asymmetric chest development and movements • Absent breath sounds on the affected side • Heart sounds on the right • Bowel sounds in the chest • Scaphoid abdomen