Describe the initial management of a patient w/ hx of swallowing a battery and dysphagia
- AP and lateral CXRs
- Urgent endoscopy
- Risk of thermal or caustic injury
Three most common locations for airway lodgement of a foreign body.
R bronchial tree (~50%)
L bronchial tree (~40%)
What is the suggested diagnosis in a CXR showing post-obstructive lung collapse OR hyperinflation in a pediatric patient w/ hx of dyspnea and wheezing
foreign body aspiration
Age associated with the highest incidence of foreign body ingestion
6 mo - 3 yrs
Age range associated with the highest incidence of foreign body aspiration?
under 4 yrs
Most common object reportedly ingested in foreign body cases
Most common reported type of foreign body aspirated
How often is a foreign body ingestion passed spontaneously? How often is it endoscopically retrieved?
What are the typical presenting signs and symptoms of an ingested foreign body?
dysphagia, drooling, postprandial regurgitation of undigested food
How do you counsel parents in avoiding ingested foreign bodies?
small objects and toys with small components are removed from environments with at-risk children, with particular attention paid to marbles, rubber balls, and balloons
when introducing table food, parents should avoid providing potentially obstructive foods that are difficult to chew (such as whole grapes, hot dogs, peanuts, and raw carrots)
An 18-month-old female presents with feeding intolerance characterized by regurgitation and emesis of solid and semi-solid food. Describe your initial approach.
- likely ingested foreign body lodged in esophagus
- PA and lateral XR
- urgency dependent on exam and XR findings - more urgency for ingested battery vs a coin
- EGD retrieval if in esophagus
An 18-month-old female presents with feeding intolerance characterized by regurgitation and emesis of solid and semi-solid food. PA and lateral films of the chest are obtained. They demonstrate a disc-shaped, radio-opaque foreign body located 1 cm superior to the clavicles and posterior to the airway. How should you proceed?
- likely FB ingestion of coin in the esophagus
- extract under general w/ endoscope (rigid or flexible)
- if it is in the stomach on XR, expectant management is appropriate
A 7-year-old male presents to the Emergency Department after a fall from standing that occurred in the school cafeteria. The patient arrives in respiratory distress, and cyanosis and stridor are noted. As preparations are made for orotracheal intubation, a rapid secondary survey reveals no penetrating injury. What are the next steps in management?
- first is airway management
- FB within the larynx/trachea/or esophagus can obstruct
- attempt orotracheal/nasotracheal intubation - consider surgical airway if unable to intubate
- direct laryngoscopy/bronchoscopy under general anesthesia can remove the object
If an object is within the stomach should retrieval be attempted?
normally no, but expectant management should not be the primary option if the object is sharp
A 5-year-old male presents with complaints of emesis, dysphagia, and odynophagia for the past 36 hours. Past surgical history is notable for repair of tracheo-esophageal fistula (unknown type) as an infant. What is your initial approach?
- postoperative stricture is a risk factor for retained FB
- initial workup is unchanged - PA and lateral XR
- esophagoscopy is the preferred exam
Pulmonology requests a consult for a 4-year-old male with recurrent right lower pneumonia and concern for evolving bronchiectasis. Symptoms began abruptly about 15 months ago and the patient has been treated with antibiotics on five occasions.
- some objects cannot be identified on XR
- bronchoscopic eval of the affected lobe is necessary
- if this is a chronically lodged object, it may be difficult to retrieve
Describe the histological findings of hypertrophy and hyperplasia of the muscular layer primarily involved in hypertrophic pyloric stenosis.
gross shows pale muscle mass
histology shows hypertrophy & hyperplasia of inner circular layer with associated mucosal hypertrophy
Describe the role of neuronal nitric oxide synthase in the development of hypertrophic pyloric stenosis.
Isolated inactivity of nitric oxide synthase is seen in the circular fibers, possibly explaining the phenomenon of pylorospasm.
Describe the gender ratio, familial pattern, and overall incidence of hypertrophic pyloric stenosis.
- 1–4 per 1000 live births in Caucasian infants. Less prevalent in other races
- 2–5:1, male: female
- Not a congenital abnormality
- Increased risk in first-born infants with a + family history
- A child is more likely to have IHPS if their mother had IHPS.
Describe the typical presentation of hypertrophic pyloric stenosis and identify the time course for development of symptoms.
- Nonbilious vomiting starting at 2–8 weeks of life. Can become blood tinged with frequent episodes.
- Emesis can start low frequency and force, but this increases over time, becoming very forceful.
- Dehydration leads to lethargy.
- Occasionally: hyperbilirubinemia, diarrhea (starvation stools)
Given a 4-week-old male who is vomiting the full volume of each feed, describe the finding on physical exam that is pathognomonic for hypertrophic pyloric stenosis.
Palpable epigastric mass – “olive”
Given a patient with presumed pyloric stenosis, describe the electrolyte abnormalities associated with prolonged gastric outlet obstruction and demonstrate knowledge of the appropriate fluids and laboratory testing necessary for adequate resuscitation.
- Elevated bicarbonate, hypokalemia, hypochloremia
- Resuscitate with 5% Dextrose, 0.45% NaCl, 20 mEq/L K
- Rate of resuscitation should depend on level of dehydration—start with 1.25 to 2 times normal maintenance rate
- Monitor urine output and serum electrolytes
- HCO3 should rise, Cl should fall, and K should correct before OR
Given a patient with an equivocal clinical diagnosis of hypertrophic pyloric stenosis, describe the options for diagnostic studies and the findings that would be characteristic of hypertrophic pyloric stenosis.
- Ultrasound is the gold standard—pyloric muscle thickness of 4 mm (3.5 mm if premature), length 16 mm or greater
- Upper GI series—elongated pyloric channel and indentation on antral outline. Barium must leave the stomach to make the diagnosis.
Given a patient with advanced symptoms of hypertrophic pyloric stenosis, describe the goals of preoperative preparation.
Preoperative preparation: correction of electrolyte abnormalities, Bicarb > 30 mEq/dL, normovolemia
Describe the key steps in performing a pyloromyotomy for hypertrophic pyloric stenosis.
- abdominal access, retract liver superiorly
- deliver pylorus into wound without trauma
- open serosa sharply
- bluntly divide muscle fibers to expose the submucosa from just proximal to hypertrophied muscle to just proximal to the pyloric vein
- return to abdominal cavity, check for leak
- patients DC when they tolerate PO, usually same day
Describe the natural history of hypertrophic pyloric stenosis and explain the risk/benefits of nonoperative and operative approaches to treatment.
Non-operative management: not practiced in North America. Management with frequent small feedings. Requires a prolonged hospital stay. Can take months for the muscle hypertrophy to resolve. Higher risk of mortality.
Risk: comparable outcomes in open versus laparoscopic approaches. Risks include wound infection, duodenal perforation, incomplete myotomy.
Describe the expected outcome, potential complications, and mortality rate of surgical treatment of hypertrophic pyloric stenosis.
- Most infants can start feeding between and 4 and 12 hours post procedure.
- Duodenal or pyloric leak: 2.3%
- Wound-related complication: 1%
- Abdominal hernia: up to 7%
- Mortality rate should be exceedingly rare.
In a patient who has recently undergone a pyloromyotomy, recognize the implication of persistent vomiting and list differential diagnoses for the etiology of the postoperative vomiting.
DDx: GERD, discoordination of gastric peristalsis, gastric atony, incomplete myotomy, leak
Describe the typical clinical, laboratory, and physical findings for an infant with concerns for hypertrophic pyloric stenosis.
- Nonbilious projectile postprandial vomiting in infants 2-12 weeks of age. Possible decreased UOP.
- Palpable olive-shaped mass on abdominal exam.
- Hypochloremic, hypokalemic metabolic alkalosis.
List the preoperative and operative steps in treatment of a patient with hypertrophic pyloric stenosis.
- Resusc: NS boluses 20ml/kg, document UOP, MIVF D51/2NS + 20 mEq of KCl
- Correction of lytes: Cl >90-95, Bicrab <30
- Aspirate stomach before intubation
- Single longitudinal incision in pyloric muscle
- Avoid pyloric vein
- Adequate pyloromyotomy when submucosae bulges into myotomy site
Explain the treatment of an inadvertent duodenotomy or gastrotomy during the performance of a pyloromyotomy.
Must immediately recognize and repair: 2 options
- Approximate submucosae with interrupted absorbable suture, place omentum over repair
- Re-approximate myotomy site, rotate pylorus 180 degrees, perform second myotomy on posterior wall of pylorus.
How do you differentiate between a communicating and a noncommunicating hydrocele in a child? Why is this important?
- Hydrocele psx: isolated fluid-filled mass, transilluminates
- If present at birth, decreasing in size, or does not change in size w/ straining, it is more likely noncommunicating
- If it fluctuates in size with Valsalva (crying, straining) or throughout the day, it is more likely communicating
- noncommunicating hydroceles do not require repair
- communicating - open process vaginalus
A 10-month-old infant presents with intermittent, foul-smelling, green discharge from the umbilicus. What will the next step be in diagnosis or treatment?
- Omphalomesenteric remnants (cyst, sinus, polyp, band, Mekel) may persist and present as fistulas from the intestine to the umbilicus.
- Contrast study via umbilicus doesn't change approach.
- US is reasonable.
- Resuscitate the patient.
- Operative exploration through the umbilicus, ID umbilical structures down to their origin, divide the ductal remnant, and close of the ileum.
- Small bowel resection is often unnecessary.
During an operative repair of an inguinal hernia, no sac is identified after dissection of the cord. How do you proceed?
- assess the roof and floor - roof is the internal oblique and transversus abdominis; floor is the inguinal ligament
- may have direct hernia through posterior wall (transversalis)
- lift the cord and dissect it carefully
- look for a femoral hernia under the inguinal ligament
When evaluating an infant with radiographically confirmed hypertrophic pyloric stenosis, you receive pre-operative labs revealing hypokalemic, hypochloremia, and metabolic alkalosis. How would you proceed?
- Resuscitate the infant before proceeding to the OR.
- After UOP is documented, follow with maintenance fluids of D5 ½ NS with 20MeqKCl/L.
- No surgery until resolution of the alkalosis.
- Serum bicarbonate must be <30.
- Serum chloride must be >95.
- Serum bicarbonate must be <30.
- Serum chloride must be >95.
A 3-month-old male infant presents to the emergency room with a groin mass. What are the pertinent questions to ask the adult(s) accompanying the child?
- H&P including birth history
- Is the patient dehydrated, unstable, or obstructed?
- How long has the mass been present?
- Previous episodes of a mass in this area?
- Does the mass fluctuate in size?
- Ddx: inguinal hernia, hydrocele, undescended testes
How does one assess and treat a gonad encountered during a hernia repair?
- Reduce the ovary even if ischemic-appearing.
- Be prepared to perform orchiopexy if the scrotal attachment is lost or not present.
- Treat the vessel or vas injury.
What are the concerns surrounding an incarcerated inguinal hernia that presents as a small bowel obstruction?
- ischemic bowel requiring resection/anastomosis
- higher risk to the vas and testis w/ emergent surgery
You are evaluating a 1-month-old infant in the emergency department with progressive, nonbilious vomiting. There is a history of hypertrophic pyloric stenosis in the family. What radiographic studies would you consider?
- Ultrasound is the most sensitive study - elongated pyloric channel and thickened muscular rim.
- Upper GI contrast series if the dx remains in question.
- Never CT unless the ddx has shifted drastically.
You are obtaining consent from an infant’s family for a laparoscopic pyloromyotomy. The mother asks if there are any other non-operative treatments. How would you answer her?
- Hypertrophic pyloric stenosis is a progressive situation that can subsequently resolve over several weeks to months.
- Non-operative treatment during this period requires prolonged TPN and lengthy hospital stay.
- Relate that, despite being occasionally used in European countries, this approach is not practical or warranted in the United States health care system.
During a pyloromyotomy, what are some steps to assure that the myotomy is sufficient to relieve the obstruction? How does one treat a leak?
- Regardless of approach (open RUQ, open peri-umbilical, laparoscopic), extend myotomy from the gastric end of the pyloric channel to the vein of Mayo at duodenal end.
- The adequacy of the myotomy should be checked before leaving the OR. Independent movement of the cut halves of the myotomy, air, or fluid injected via an orogastric tube through the channel, and/or bulging mucosa through the site of myotomy are all acceptable answers.
- Recognize that leaks are divided into two categories: recognized at the initial surgery or postoperatively.
- If recognized during the initial operation, small leaks can be oversewn with absorbable stitches with the possible addition of an omental patch. Large injuries should be treated with closure of the mucosal defect and the myotomy and performance of the myotomy on the opposite side of the pylorus.
- Treatment of late leaks needs to be tailored to the overall status of the infant. Stable infants can be treated much the same as a leak discovered at time of myotomy.
- Septic infants with soilage are probably best treated with closure of the myotomy alone with a plan for reoperation after stabilization.
What is the surgical differential diagnosis for a 1-month-old infant with vomiting?
- Bilious vomiting: assess immediately, resuscitate before dx, radiology (US or UGI) STAT. Pts may be unstable or lethargic.
- Bilious vomiting < 2 mo of age ddx: malrotation +/- midgut volvulus, duodenal web, foregut duplication, choledochal cyst (w/ compression), or ileus 2/2 sepsis.
- Non-bilious vomiting: broader, less emergent ddx: pyloric stenosis and duodenal web are surgical; and GERD, overfeeding, milk allergy are non-surgical causes.
A 10-month-old African-American girl who was a 28-week gestational age infant presents with an umbilical hernia with a 2 cm fascial defect. The hernia is soft and easily reducible. Should this child undergo an umbilical hernia repair?
- >75% of preterm infants will have an umbilical hernia.
- The majority will close spontaneously by 2 years of age.
- A period of observation is warranted.
- Unless complications occur, re-evaluate at 2 to 3 yrs.
A 1-year-old boy presents with an easily reducible umbilical hernia. Externally, the umbilicus skin is proboscis-like and is 3 cm in diameter but the fascial defect is only 1 cm. Should this child undergo an umbilical hernia repair?
- Most umbilical hernias close spontaneously by 2 yrs.
- The fascial defect is often smaller than the external hernia.
- Although externally this umbilical hernia may be impressive to parents and practitioners, it should be observed.
A 2-year-old boy presents with pain on urination and intermittent drainage of clear fluid from the umbilicus. What will the next step be in diagnosis or treatment?
- Urachal remnants may present w/ umbilical drainage.
- Surgical exploration is indicated. Imaging (CT, MRI, or ultrasonography) may be helpful but is not necessary.
- Resection of the urachal remnant should include a complete resection of the remnant, including a cuff of the bladder.
Key steps of an umbilical hernia repair:
- make a semicircular or "smiley face" incision on the inferior border of the umbilical hernia
- circumferentially dissect the neck of the hernia sac off the overlying umbilical skin and away from the underlying fascia circumferentially (1 cm) without violating the sac
- close the fascia with buried interrupted sutures in a transverse fashion
Given a 1-year-old child with a persistently draining "wet" umbilicus with a small 1-cm umbilical hernia and a small "opening" at the inferior base, what is at the top of the differential? What is the workup and management?
- possible persistence of a urachal remnant - fistula or sinus
- although not mandatory, fistulography can be performed to confirm its connection to the bladder
- umbilical exploration, excision of the urachal remnant, partial cystectomy, and repair of the umbilical hernia
A patient on 2 week follow-up visit after umbilical hernia repair has a persistent, asymptomatic, reducible umbilical protrusion in which no fascial defect seems to be present. What has happened?
despite the appearance of a recurrent umbilical hernia, that the fascia is closed, the hernia is repaired, and no further surgical intervention is necessary unless there is a cosmetic indication
A 4-year-old girl undergoing elective repair of a 2 cm umbilical hernia is found to have a thick fibrinous stalk is encountered during opening of the hernia sac. What is this? How do you proceed?
a remnant of the omphalomesenteric duct persists as a Meckel's sinus and should be resected down to the small intestine without performing a small bowel resection
What is the major technical difference between hernia repair in a child and an adult?
- floor repair is usually unnecessary
- when floor repair is necessary, mesh is usually avoided
- laparoscopy is possible - sac division and ligation at the internal ring w/o mesh
A 5-year-old boy has an easily reducible umbilical hernia. Externally, the umbilicus is approximately 3 cm in diameter but the fascial defect is only 1 cm. Should this child undergo an umbilical hernia repair?
- most umbilical hernias close spontaneously by 2 yrs
- eval for incarceration or obstruction
- the fascial opening is often smaller than the external hernia
- repair this hernia d/t age
A 3-year-old toddler presents with pain on urination and intermittent drainage of clear fluid from the umbilicus. What will the next step be in diagnosis or treatment?
- Urachal remnants - psx w/ drainage from the umbilicus
- With late presentation, may have distal obstruction
- Imaging (US, CT, MRI) may be helpful, but not necessary
- Surgical exploration is indicated
- Resection of the urachal remnant should include a complete resection with a cuff of bladder for risk of malignancy.
A 9-month-old African-American boy, who was a 32-week gestational age infant, presents with an umbilical hernia with a 2 cm fascial defect. The hernia is soft and easily reducible. Should this child undergo an umbilical hernia repair?
- >75% of preterm infants will have an umbilical hernia.
- Most umbilical hernias will close spontaneously by 2 yrs.
- No repair now. The infant should be observed and re-evaluated when he is 2 years of age.
The resident is asked to evaluate a "large umbilical hernia" on a 2-day-old infant. On physical examination, the "hernia" has a pink exterior and is draining mucus. How should this lesion be evaluated and treated?
- Umbilical lesions may exist as remnants of the omphalomesenteric and urachal systems.
- This is likely an umbilical polyp - bothersome, risks infection
- Surgical excision requires exploration, ID of the umbilical structures, including a fistulous connection to the small intestine.
- May be a granuloma - tx w/ silver nitrate
When should you perform a floor repair in addition to a high ligation in a pediatric patient with a hernia?
- direct hernia
- peritoneal dialysis
- peritoneal shunts
A 2-year-old male has an acutely incarcerated inguinal hernia. How will you reduce the hernia prior to taking the child to the operating room for repair?
- pain control, Trendelenburg position
- may require more sedation
- pressure on the ring and the scrotum
Is it necessary to explore the opposite side in a child with a unilateral inguinal hernia?