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GI Week 6 > Pediatric GI Surgery > Flashcards

Pediatric GI Surgery Flashcards

1
Q

What is an acute abdomen

A

signs and symptoms of abdominal pain and tenderness - a clinical presentation that often requires emerency surgical therapy

basically peritonitis

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2
Q

What are the signs of peritonitis?

A

it’s severe peritoneal inflammation with abdominal tenderness, guarding and rebound

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3
Q

What are the four general causes of acute abdomen?

A

infection, obstruction, ischemia, perforation

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4
Q

Does acute abdomen always require surgery?

A

no - there are some endocrine, metabolic, hematologic, toxins/drugs that can cause it and don’t require surgery

(like DKA, pophyria, lead poisoning, hypercalcemia, Addison’s disease and constipation)

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5
Q

Describe malrotation

A

It’s when the bowels don’t return in the right position (ligamen tof trietx LUQ and cecum RLQ)

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6
Q

WHat’s the most frequent type of malrotation?

A

complete nonrotation

you dn’t get formation of the colon loop. the ligament of treitz comes back on the right instead of the left and the duodenum won’t cross the midline

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7
Q

What will malrotation present wtih?

A

usually in the first mnoth of life you’ll get bilious emesis, lethargy and toxicity late

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8
Q

What’s the gold standard for diagnosing malrotation?

A

plain abdominal x ray with upper GI contrast study to look for the duodenum on the right side of the abdomen with a birds beak at the twist

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9
Q

What is the management for malrotation?

A
  1. IV fluid resuscitation
  2. place NG tube
  3. Foley catheter
  4. Ladd procedure
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10
Q

Describe what goes into a ladd’s procedure?

A
  1. evisceration
  2. detorsion of the twist
  3. divide Ladd’s bands between the ascending colon to the duodenum
  4. broaden the mesentery so the bowel can’t twist on itself again
  5. appendectomy
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11
Q

In what babies is pyloric stnosis most common?

A

first born males (especially if mom had it)

higher in bottle-fed babies
uncommon in preemies

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12
Q

pyloric stenosis is hypetropy of th ecircular layer of muscle in the pyloric sphincter, but what’s the baseline cause of that?

A

improper innervation of the pyloric smooth muscle

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13
Q

How will a baby present with pyloiric steosis?

A

projectile, non-bilious vomiting with recent history of formula intolerances

baby acts hungry

eventually becomes dehydrated - no tears, infrequent wet diapers, lethargy late

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14
Q

What’s the most important question to ask about the emesis?

A

what color is it - non-bilious or bilious

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15
Q

What exam sight is pathonomomic for pyloric stenosis?

A

feeling the olive in the abdomen - this can be tricky though, so just becaus eyou don’t feel it doesn’t mean pyloric stenosis isn’t the answer

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16
Q

What is the imaging test of choice for pyloric stenosis?

A

ultrasound - looking for a pyloric sphincter at least 3 mm thick and 1.7 cm in length

this has near 100% sensitivity and specificity with no radiation exposure

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17
Q

What sign would you likely see on an upper GI series with ocntrast in pyloric stenosis?

A

the string sign

this is helpful if you have lower suscpiciou for pyloric stenosis and need to rule out other likes as wlel like malrotation, reflux or other anatomic abnormalities

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18
Q

What is the first step in management for pyloric stenosis (this was a hand riase)

A

first - medical management with IV resuscitation using normal saline. after they start urinating again, then you have to replace potassium (because they’ll be in hypokalemic, hypochloremic metabolic alkalosisdue to emesis loss of HCl leading to kidneys retaining H instead of K)

NPO

then surgery

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19
Q

What is the surgical approach for pyloric stenosis?

A

Ranstedt pyloromyotomy

You expose the pyloris, made an incision along the outer muscle layer. then spread the layers gently until the mucosa starts to bulge out

don’t puncture the mucosa! That would allow GI contents to spill into the peritoneum (bad)

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20
Q

What are the complications of pyloric stenosis surgery?

A
  1. incomplete pyloromyotomy with prolonged time until baby tolerates ad lib feedings
  2. mucosal injury THE BIG ONE - if you recognize you did it, you need to fix it. if you don’t recognize it you’ll have leakage of GI contents into the peritoneum with acute abodmen, peritonitis, fever and leukcytosis
  3. incisional hernia
  4. wound infections
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21
Q

When does intussusception usually present?

A

3 months to 3 years (with 66% of patients less than 1 year of age - usually in 5-10 month range)

22
Q

True or false: most cases of intussusception have an identifiable lead point?

A

false - most are idiopathic with no pathologic lead point (usually in the ileocolic area)

lead point i sonly found in 12% of children

23
Q

What are the clinical triad of symptoms you see in intussusception?

A

colicky abdominal pain
bilious emesis
currant jelly stools

24
Q

What would you see on x-ray in intussusception?

A

lack of air in the colon

presence of a mass in the right abdomen

25
Q

What sign would you see on US or CT when the bowel is viewed in transferse orientation for intussusception?

A

a target sign

26
Q

Describe medical management for intussusception,

A

barium enema - has an 80% success rate and only 11% recur (typically within 24 hours)

27
Q

How many times is barium enema a viable option?

A

you can try it a second time, but if there is a third recurrence you need to do surgery

28
Q

What are the two signs you could see on a barium enema study in intussuscepton?

A

a meniscus sign where the barium is blocked by the telescoped bowel

a coiled spring sign - where the die sort of squeezes aroudn the teloscoped bowel and make sit look like a slinky

29
Q

Describe the surgical procedure for intussusception?

A

you open up and do manual reduction

do not pull it out! it will tear! you need to milk it out.

may need to resect if unable to reduce

also perform an appendectomy

30
Q

What is the most common cause of acute surgical abdomen inchildren?

A

appendicitis

31
Q

What is the most common presenting age for appendicitis?

A

12-18 yo

coincides with the greatest number of lymphoid follicles

32
Q

Describe the pathophysiology of appendicitis

A
  1. obstruction of appendix traps bacteria within
  2. bacteria multiply and release, causing appendix to distend
  3. distention imparis venous outflow
  4. arterial inflow becomes impaired
  5. get ischemia, gangrene, necrosis and perforation
33
Q

Describe the clinical presentaiton for appendicitis?

A

periumbilical pain that moves to the RLQ
anorexia, then pain, then nausea/emesis
can have diarrhea

34
Q

What are the typical exam findings for appendicits?

A

typically pain as mcburney’s point

rosving sign - tap on the left abdomen and they’ll feel pain on the right side because of referred pain with peritonitis

35
Q

What does a positive psoas sign tell you?

A

you put the patient on their left side and extend their right leg back, then push it in

is they get pain in their belly, this means their appendix is retrocecal

36
Q

What does a positive obturator sign tell you?

A

flex right knee and hip, then internall rotate it.

pain means the appendix is located down in the pelvis

37
Q

What will you see on labs with appendicitis?

A

WBC will typically be normal for the fist 24 hours and then neutrphil count will rise first

high WBC suggests perforation

urinalysis will have sterile pyuria - WBC in urine without bacteria

38
Q

What imaging study do you start with for appendicitis?

A

US - it’s 90% accurate wihtout risk of radiation

just know that you have to order a CT scan if you can’t find the appendix with US

39
Q

What will you see in appendicitis with a CT?

A

distended appendix, inflammatory fat stranding, plus or minus abscess formation

40
Q

Do you always need imaging for appendicitis?

A

no - it cna be just a clinical diagnosis, but let the parents know that a surgery might end up being unnecessary

41
Q

What are the major complications if the appendix perforated?

A

ileus, intra-abdominal abscess

42
Q

What are the potential complications of a meckel’s diverticulum?

A

painless lower GI bleed
obstruction
meckel’s diverticulitis

43
Q

Why can you get painless lower GI bleeding with a meckel’s diverticulum?

A

because there can be ectopic gastric tissue in the diverticulum that secretes acid which then breaks down the wall opposite of the meckels

44
Q

What’s the imaging study for meckel’s diverticulum?

A

a meckel’s scan

uses technetium 99m pertechnetate scintigraphy to see if there is uptake in gastric mucos outside of the stomach

45
Q

What can the presentation of a meckel’s diverticulitis look like?

A

appendicitis - so rule it out if the appendix ends up looking normal during surgery

46
Q

What area of the bowel will ALWAYS have aganglionosis in hirschsprung’s disease?

A

distal rectum - helps with diagnostics

47
Q

What is the presentaiton of Hirschrpung’s disease?

A

abdominal distension, bilious emesis, failure to pass meconium in the first 24 hours!!!!

48
Q

How can you diagnose hirschprung’s disease?

A
  1. barium enema
  2. manometry to look for absent rectoanal inhibitory reflex
  3. full thickenss rectal biopsy is gold standard test
49
Q

Where should you take the full thickness rectal biopsy?

A

2 cm above the dentate line

50
Q

What can you stain the biopsy with to see if there is an issue?

A

acetylcholinesterase staining will reveal hypertrophied nerve turnks trhoughout the lamina propria and muscularis propria layers of the bowel wall

might use IHC stain for calretinin in the future

51
Q

What is the management of an omphalocele?

A
  1. IV fluids
  2. IV antibiotids
  3. NG decompression
  4. Sterille dressing over it so the covering doesn’t dry out
  5. surgical correction if defect is huge, otherwise you can use the silo technique

GI Week 6 (14 decks)

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