Ophelm: Peds GI Surgery Flashcards Preview

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Flashcards in Ophelm: Peds GI Surgery Deck (65):
1

How do you take a hx for a GI complain in a pediatric pt?

Varies depending on age of the patient

Birth history: GESTATIONAL AGE, twin, prolonged hospital stay, medical issues– respiratory failure, jaundice, cardiac issues

Feeding pattern: bottle vs. breastfed, special diet

2

What does a physical exam look like in for a pediatric pt w/ a GI complaint?

Face flushed, diaphoretic, lots of blankets?
Interaction with you/others
Active, wiggling around vs. laying still
Curled up or laying flat
Arms above head or protecting belly
Does ancillary exam “bother” them?

Can the patient:
Sit up so you can check their back/ listen to their lungs
Deep breath, forceful cough
Reach above their head
Twist their torso
Lift each leg against resistance
Stand at the bedside and jump up and down

Make it a game for the little kids


3

What labs should be done on a pediatric pt w/ GI complaints?

Complete blood count with differential
WBC, hemoglobin, platelet
Neutrophil %
Basic metabolic profile
CRP
Sed rate
Urinalysis

4

What special studies should be done for a pediatric pt w/ GI complaints?

Plain films
CXR, abdominal x-rays
Ultrasound
Advantage: no radiation
CT scan
Disadvantage: radiation
Barium enema
Can be diagnostic AND therapeutic

5

What is an acute abdomen?

“Signs and symptoms of abdominal pain and tenderness, a clinical presentation that often requires emergency surgical therapy.”

6

What is peritonitis?

Peritoneal inflammation
Severe abdominal tenderness
Guarding: voluntary and/or involunatry
Rebound

7

What causes an acute abdomen?

Infection
Obstruction
Ischemia
Perforation

8

Does an acute abdomen often require surgery?

Often but not always

MASKERS:
Endocrine, metabolic, hematologic, toxins/drugs
DKA, porphyria, lead poisoning, hypercalcemia, Addison’s disease, constipation

9

What is the normal embryology of our gut rotation?

Midgut herniates at 4th week and returns approx. 10th week.

Rotates around the axis of SMA 270 degrees in counterclockwise direction>
Final Position (ligament of Treitz LUQ/cecum RLQ)

10

What type of malrotation occurs most frequently?

Complete nonrotation:

Forming no C-Loop, the ligament of treitz on the right side of the abdomen and does not cross midline.

11

How does malrotation usually present?

First month of life
Bilious emesis
Lethargic
Toxic (if late)

12

How do you dx malrotation?

Plain abdominal x-ray
Upper GI contrast study
Duodenum the right side of abdomen with birds beak

13

How do you manage malrotation?

IV fluid resuscitation
Placement of nasogastric tube
Foley catheter placement
Ladd’s procedure

14

What is Ladd's procedure?

Evisceration and detorsion
Division of ladd’s bands (ascending colon to duodenum)
Broadening of the mesentery
appendectomy

15

What is pyloric stenosis? What age range does it usually affect?

Hypertrophy of the pylorus muscle (d/t improper innervation of pyloric sm muscle)

Most common in first-born males (4:1 male to female)

Age range typically 2 weeks - 2 months of age

*Incidence 1/3000-4000

16

What are RFs for pyloric stenosis?

Higher risk in male infant if mother had HPS as baby
bottle fed infants

17

2 mo old presents w/ projectile, non-bilious (curdled milk/formula) vomiting w/ recent hx of formula intolerances. The baby is acting hungry.

Dx?

Pyloric stenosis

18

How does a baby act if they have dehydration secondary to pyloric stenosis?

No tears when baby cries
Infrequent wet diapers
Lethargy

19

An infant w/ a palpable "olive" in the RUQ on PE indicates...

pyloric stenosis

20

What imaging should be done for pyloric stenosis?

Abdominal x-rays
Ultrasound
Upper GI series with contrast

21

What is seen on an abdominal xray in a pt w/ pyloric stenosis?

Air- or fluid-filled stomach= gastric outlet obstruction

22

What is the diagnostic test of choice for a pt w/ pyloric stenosis?

Ultrasound: 3mm thick, 1.7 cm length
Near 100% sensitivity and specificity
No radiation exposure

23

If an upper GI series w/ contrast shows a "string sign"...

Helps to lower the suscpicion of HPS and may indicate:

Malrotation, reflux, anatomic abnormalities

24

How do you tx pyloric stenosis?

Optimize infant's medical status

1. Hypokalemic, hypochloremic metabolic alkalosis
-Emesis– loss of HCL
-Kidneys retain H+ instead of K+

2. Correct electrolytes

3. IV hydration (based on degree of dehydration)

4. NPO

25

What are the surgical approaches to pyloric stenosis?

Ramstedt Pyloromyotomy

Right upper quadrant incision
Periumbilical incision
Laparoscopic

26

What are complications of pyloric stenosis?

1. Incomplete pyloromyotomy
Prolonged time until baby tolerates ad lib feedings

2. Mucosal injury– the most severe complication
-Recognized: repair intra-op
-Unrecognized: leakage of gastric contents into intra-abdominal space
acute abdomen, fever, leukocytosis

3. Incisional hernia

4. Wound infection

27

What is intussusception?

Inversion of one portion of the intestine w/in another

28

Intussusception usually occurs to...

Males

Age range 3 months – 3 years
-Most common in 5-10 month age range



29

What are lead points in up to 12% of children?

Increases with age
Polyp or tumor
Hypertrophied lymphoid tissue

30

What causes intussusception?

Most cases are idiopathic, no pathologic lead point
-Ileocolic

31

A 6 mo M presents w/ colicky abdominal pain, bilious emesis and CURRANT JELLY stools.

Dx?

Intussusception

32

How does intussusception ultimately lead to ischemia and necrosis?

Lymphatic obstruction>
venous congestion>
impaired arterial blood flow>
ischemia nad necrosis

33

What do xray findings show in a pt w/ intussusception?

Can show findings consistent with distal small bowel obstruction
Lack of air in colon
Presence of mass in right abdomen

34

What do ultrasound findings show in a pt w/ intussusception?

“target sign” when bowel is viewed in transverse orientation

35

How do you medially manage intussusception?

Barium Enema
80% success rate
11% recur, typically within 24 hours

Can do BE twice, 3rd time recurrence is indication for OR

36

What is a coiled spring sign?

indication of intussusception

37

How do you surgically manage intussuception?

Manual reduction
Push or “milk back,” DO NOT PULL
May need resection if unable to reduce
Also perform appendectomy

38

What is the MC cause of acute surgical abdomen in children?

appendicitis

12-18 y/o
(coincides w/ greatest number of lymphoid follicles)

39

What is the etiology of appendicitis?

Lymphoid hyperplasia
Fecolith
Foreign body

40

What is the pathophysiology of appendicitis?

Obstruction of appendix traps bacteria within>
Bacteria multiply> appendix distends>
Distention impairs venous outflow>
Arterial inflow then becomes impaired>
Ischemia, gangrene, necrosis, perforation

41

A 14 y/o F presents w/ periumbilical pain that moves to RLQ, as well as anorexia THEN pain THEN nausea/emesis. She also has diarrhea but it is not her primary concern.

Appendicitis

42

What are exam findings in a pt w/ appendicitis?

Pain at McBurney’s point
Psoas sign– retrocecal appendix
Obturator sign– pelvic location of appendix

Rovsing sign

43

What labs do you do for appendicitis?

WBC count is typically normal for the first 24 hours (Neutrophil count will often rise first)

Mild elevation in WBC is common

High WBC (~15k) suggests perforation

Urinalysis
“sterile pyuria”– WBC in urine without bacteria

44

What is a way to diagnose appendicitis in children w/ out the risk of radiation?

Ultrasound

6 mm diameter lumen, non-compressible, sonographic McBurney’s

45

What would a CT scan of the abdomen/pelvis show in a pt w/ appendicitis?

Distended appendix, inflammatory stranding, +/- abscess

97% accuracy

Radiation exposure

Can evaluate for abscess or alternative diagnosis

46

How do you manage appendictis?

Perioperative antibiotic

Appendectomy: laparoscopic or open
Timing– significant delay can result in rupture

47

How long does it take before a pt w/ uncomplicated appendicits goes home?

w/in 24 hrs

48

How long will a pt spend in the hospital if they have a perforated appendicitis?

several deays

-ileus
-intra-abdominal abscess

49

What is Meckel's Diverticulum?

a TRUE diverticulum that involves all layers of the bowel wall and is cuased by a persistent vitelline duct

50

What is the rule of 2s in diagnosing Meckel's diverticulum?

2% of population
Within 2 feet of ileocecal valve
2 types of heterotopic tissue: gastric (50%) and pancreatic
2 inches in length
2 year old

51

What can cause a painless lower GI bleed and obstruction?

meckel's

52

What causes the painless lower GI bleed in Meckel's? Dx?

Due to the gastric tissue contained in the diverticulum

Bleeding occurs on wall opposite of the Meckel’s


Technetium-99m pertechnetate scintigraphy

53

How do you tx Meckel's Diverticulum?

surgical resection

54

How does meckel's cause obstruction? How do you dx it and tx it?

Band adhesion, intussusception, Littre’s hernia

Diagnosis: various imaging modalities

Treatment: dependent on cause, resect the Meckel’s

55

What is meckel's diverticulitis?

Presentation like acute appendicitis, but appendix looks normal during surgery

Need to rule out Meckel’s diverticulitis
Remove appendix

56

What causes Hirschsprung's Disease? Where is it located?

Absence of Ganglion cells in the myenteric and submucosal plexus

Aganglionosis always involves DISTAL RECTUM

57

What pts have a higher risk for Hirschsprung's Disease?

Higher risk in patient’s with family hx and in Down syndrome patients.

58

A pt presents w/ abdominal distension, bilious emesis and a failure to pass meconium in the first 24 hrs.

HIrschsprung's disease

59

How do you dx Hirschsprung's Disease?

-Barium enema
-Manometry (absent rectoanal inhibitory reflex)
-Full thickness rectal biopsy

60

What is the gold standard test for hirschprung's disease?

Full thickness rectal biopsy

Bx 2cm from dentate line
Acetylcholinesterase staining reveals hypertrophied nerve trunks throughout the lamina propria and muscularis propria layers of the bowel wall.
Recent studies suggest that immunohistochemical (IHC) staining for calretinin might be more accurate than acetylcholinesterase staining in diagnosing congenital aganglionosis among suction biopsy specimens

61

How do you tx Hirschsprung's disease if hte pt has a megacolon?

diversion

62

What is an omphalocele? What populations does it commonly occur in? What syndromes is it associated with?

Covered by peritoneum

Karyotype abnormalities are present in 30% (trisomies 13/18/21)

More the 50% have other malformations (cardiac>MS,GI,GU)
Associated with Beckwith-Wiedemann syndrome(omphalocele, hyperinsulinemia, macroglossia)

63

How do you manage an omphalocele?

IV fluids
IV antibiotics
NG decompression
Sterile dressings
Dx associated anomalies(PE/cxr/echo/renal U/S)
Surgical correction dependent on size of defect

64

What is Gastroschisis?

No sac covering abdominal contents
Intestinal atresia (15%)
SGA

65

How do you manage gasroschisis?

IV fluids
IV antibiotics
Dressings
Surgical management of abdominal wall defect similar to omphalocele, but differs if intestinal atresia present