Flashcards in Ophelm: Peds GI Surgery Deck (65):
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
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
What labs should be done on a pediatric pt w/ GI complaints?
Complete blood count with differential
WBC, hemoglobin, platelet
Basic metabolic profile
What special studies should be done for a pediatric pt w/ GI complaints?
CXR, abdominal x-rays
Advantage: no radiation
Can be diagnostic AND therapeutic
What is an acute abdomen?
“Signs and symptoms of abdominal pain and tenderness, a clinical presentation that often requires emergency surgical therapy.”
What is peritonitis?
Severe abdominal tenderness
Guarding: voluntary and/or involunatry
What causes an acute abdomen?
Does an acute abdomen often require surgery?
Often but not always
Endocrine, metabolic, hematologic, toxins/drugs
DKA, porphyria, lead poisoning, hypercalcemia, Addison’s disease, constipation
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)
What type of malrotation occurs most frequently?
Forming no C-Loop, the ligament of treitz on the right side of the abdomen and does not cross midline.
How does malrotation usually present?
First month of life
Toxic (if late)
How do you dx malrotation?
Plain abdominal x-ray
Upper GI contrast study
Duodenum the right side of abdomen with birds beak
How do you manage malrotation?
IV fluid resuscitation
Placement of nasogastric tube
Foley catheter placement
What is Ladd's procedure?
Evisceration and detorsion
Division of ladd’s bands (ascending colon to duodenum)
Broadening of the mesentery
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
What are RFs for pyloric stenosis?
Higher risk in male infant if mother had HPS as baby
bottle fed infants
2 mo old presents w/ projectile, non-bilious (curdled milk/formula) vomiting w/ recent hx of formula intolerances. The baby is acting hungry.
How does a baby act if they have dehydration secondary to pyloric stenosis?
No tears when baby cries
Infrequent wet diapers
An infant w/ a palpable "olive" in the RUQ on PE indicates...
What imaging should be done for pyloric stenosis?
Upper GI series with contrast
What is seen on an abdominal xray in a pt w/ pyloric stenosis?
Air- or fluid-filled stomach= gastric outlet obstruction
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
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
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)
What are the surgical approaches to pyloric stenosis?
Right upper quadrant incision
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
What is intussusception?
Inversion of one portion of the intestine w/in another
Intussusception usually occurs to...
Age range 3 months – 3 years
-Most common in 5-10 month age range
What are lead points in up to 12% of children?
Increases with age
Polyp or tumor
Hypertrophied lymphoid tissue
What causes intussusception?
Most cases are idiopathic, no pathologic lead point
A 6 mo M presents w/ colicky abdominal pain, bilious emesis and CURRANT JELLY stools.
How does intussusception ultimately lead to ischemia and necrosis?
impaired arterial blood flow>
ischemia nad necrosis
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
What do ultrasound findings show in a pt w/ intussusception?
“target sign” when bowel is viewed in transverse orientation
How do you medially manage intussusception?
80% success rate
11% recur, typically within 24 hours
Can do BE twice, 3rd time recurrence is indication for OR
What is a coiled spring sign?
indication of intussusception
How do you surgically manage intussuception?
Push or “milk back,” DO NOT PULL
May need resection if unable to reduce
Also perform appendectomy
What is the MC cause of acute surgical abdomen in children?
(coincides w/ greatest number of lymphoid follicles)
What is the etiology of appendicitis?
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
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.
What are exam findings in a pt w/ appendicitis?
Pain at McBurney’s point
Psoas sign– retrocecal appendix
Obturator sign– pelvic location of appendix
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
“sterile pyuria”– WBC in urine without bacteria
What is a way to diagnose appendicitis in children w/ out the risk of radiation?
6 mm diameter lumen, non-compressible, sonographic McBurney’s
What would a CT scan of the abdomen/pelvis show in a pt w/ appendicitis?
Distended appendix, inflammatory stranding, +/- abscess
Can evaluate for abscess or alternative diagnosis
How do you manage appendictis?
Appendectomy: laparoscopic or open
Timing– significant delay can result in rupture
How long does it take before a pt w/ uncomplicated appendicits goes home?
w/in 24 hrs
How long will a pt spend in the hospital if they have a perforated appendicitis?
What is Meckel's Diverticulum?
a TRUE diverticulum that involves all layers of the bowel wall and is cuased by a persistent vitelline duct
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
What can cause a painless lower GI bleed and obstruction?
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
How do you tx Meckel's Diverticulum?
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
What is meckel's diverticulitis?
Presentation like acute appendicitis, but appendix looks normal during surgery
Need to rule out Meckel’s diverticulitis
What causes Hirschsprung's Disease? Where is it located?
Absence of Ganglion cells in the myenteric and submucosal plexus
Aganglionosis always involves DISTAL RECTUM
What pts have a higher risk for Hirschsprung's Disease?
Higher risk in patient’s with family hx and in Down syndrome patients.
A pt presents w/ abdominal distension, bilious emesis and a failure to pass meconium in the first 24 hrs.
How do you dx Hirschsprung's Disease?
-Manometry (absent rectoanal inhibitory reflex)
-Full thickness rectal biopsy
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
How do you tx Hirschsprung's disease if hte pt has a megacolon?
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)
How do you manage an omphalocele?
Dx associated anomalies(PE/cxr/echo/renal U/S)
Surgical correction dependent on size of defect
What is Gastroschisis?
No sac covering abdominal contents
Intestinal atresia (15%)