how do most pediatric extracranial solid malignant tumours usually present
as a palpable lump without pain or other manifestations
what investigations should you do when a mass is detected in a child
hx/px
urinalysis
ultrasound
CT–> important specialized imaging but generally not first line of imaging
biopsy for tissue diagnosis after suspicion for malignancy… generally not needle biopsy in kids
why is a CT helpful in assessing a mass in a child
CT helps with tumour staging based on TMN
list the common pediatric solid tumours
- neuroblastoma
- wilm’s tumour/nephroblastoma (left flank solid mass)
- lymphoma
- rhabdomyosarcoma
- ewing’s sarcoma
- hepatoblastoma and hepatocellular carcinoma
- other
how should you manage a child presenting with green, bilious vomiting
bowel obstruction until proven otherwise
manage acutely–> NG tube to suction stomach, IV fluid maintenance
investigate with abdo xray upright and supine (U/S confounded by gas)
what is the “double bubble sign”
evidence that a bowel obstruction in a child is high (no distal gas) and is classic for duodenal atresia
1/3 of duodenal atresia cases have trisomy 21–> there are often other congenital anomalies (i.e congenital heart disease)
failure of vacuolization of the duodenal lumen and polyhydramnios can occur
primary repair is by duodeno-duodenostomy bypass
list the causes of newborn bowel obstructions
- atresia
- imperforate anus (most common)
- hirschprung’s disease
- meconium ileus
- malrotation
- extrinsic obstructions
what types of atresia can cause bowel obstruction in the newbown
duodenal
small bowel
colonic
what is the most common cause of newborn bowel obstruction
imperforate anus
what is hirschprung’s disease
congenital megacolon due to lack of ganglion cells in the colon myenteric/submucosal plexuses of the wall such that the affected part of the colon cannot relax/spasm and pass stool so obstruction results (most often distal colon)
if a baby has a patent anus and hasnt passed meconium in the first 24 hours, thing hirschprung’s (often DRE can break the rectal spasm and allow passage of meconium)
usually there is no air in the rectum
how do you investigate hirschprungs
barium enema/colon contrast study then biopsy of the inner wall for definitive diagnosis
how do you treat hirschprungs
resection of the aganglionic portion of the colon then pull through and reattachement
what are adhesive bowel obstructions
secondary to previous surgery/inflammation usually
how do you manage adhesive bowel obstructions
resuscitation of volume and electrolytes is critical–> IV and NG suction
monitor and repeat physical and exams–> persistent pain, fever, high WBC are BAD
CT is rarely required
laparotomy and lysis of adhesions can be done if no resolution
adhesions are hard to cure–> appropriate approaches include meticulous surgical technique, minimal bowel handling and laparoscopic surgery
what conditions are associated with intestinal obstruction in kids (what is the pneumonic?)
VACTERL
Vertebral anomalies Anal atresia Cardiac defects Tracheoesophageal fistula Esophageal atresia Renal (and radial) anomalies Limb defects
what are the main symptoms of infantile hypertrophic pyloric stenosis
PPP–>
persistent
projectile
progressive emesis
palpation reveals something like an “olive”
metabolic alkalosis
when does infantile hypertrophic pyloric stenosis occur
3-8 weeks of age
how do you manage infantile hypertrophic pyloric stenosis
resuscitate first, then treat with pyloromyotomy–surgical incision in the longitudinal and circular muscles to loosen the pyloric sphincter
how does intussusception usually present in kids
crampy, intermittent “knees up” abdo pain
sausage shaped abdominal mass with red-current jelly stool
what age is usually affected by intussusception
3 mo to 3 years
how do you manage intussusception
resuscitate first then treat with enema reduction
(pressure in the intestine to reverse the telescoping… air is better than liquid)
surgery if necessary
ddx for newborn rectal bleeding
- swallowed blood from birth process or breastfeeding–> test with Apt test with differentiates fetal blood (positive) from maternal blood in newborn stool or vomit
- coagulopathy–> check IM vitamin K status, platelet count, fibrinogen, PT/INR for extrinsic/common clotting pathways and PTT for intrinsic/common clotting pathways
- intussusception–> 3 months to 3 years
- necrotizing enterocolitis–> usually in a premature baby, more than 2 days old, have been fed–> investigate with abdo xray
- vascular malformation of GI tract–> rare
- peptic ulcer–> rare in babies because acid causes ulcers and babies are achlorhydric for first few days
- intestinal malrotation with acute volvulus–> causes acute mesentery vascular compromise leading to intestinal ischemic necrosis and bleeding/sloughing of intestinal mucosa; may cause abdo distension, green vomiting from duodenal obstruction etc
how do you manage newborn rectal bleeding
IV fluids and NG tube for suction
abdo xray
upper GI contrast xray to diagnose malrotation if child well enough to tolerate it
CBC, coag studies, cross match and type
transfusion?
start IV
meckel scan for abnormal uptake in gastric mucosa where ectopic acid secretion is occurring –> small bowel mucosal ulceration and profuse bleeding (melena)
what number is associated with meckel’s diverticulum
“the answer is always 2”
why do we care about meckel’s diverticulum
ectopic mucosa secretes acid excessively causing ulceration and bleeding of the adjacent small bowel mucosa
what is the most common age of presentation of meckel’s diverticulum
2 years old
what % of the population gets meckel’s diverticulum
2%
where is meckel’s diverticulum found
2 feet from the terminal ileum
what types of ectopic mucosa are possible in meckel’s diverticulum
2
gastric and pancreatic
how long is meckel’s diverticulum
2 inches
how many ways can meckel’s diverticulum present
6 ways
bleeding
diverticulitis mimicking appendicitis
intussuscepting causing obstruction
meckel’s band causing obstruction
malignancy
etc
what is a fistula
an abnormal connection between two epithelialized of endothelialized surfaces
i.e gastro-colic fistula, tracheo-esophageal fistula etc…
what is a sinus tract
abnormal connection between two surfaces only one of which is epithelialized
ie abscess training to the small intestine
how can we recognize a pneumothorax clinically and radiologically
clinical–> SOB, decreased breath sounds in a certain area
radiological–> visible lung/lobe border
management of a pediatric pneumothorax
CXR
insert chest tube with a one way valve and collection chamber
leaking lung bullae (especially in teenagers) can seal themselves over a few days but video assisted thoracoscopic surgery may be used to seal the leak
what are dr blair’s three rules of testing
- dont order a test unless the results will change your management
- dont order a test if you do not know the tests inherent accuracies in the context of your patient
- consider the risk of a test and whether the testing risk is appropriate in the context of your patient’s present and future health
what is the classic presentation of appendicitis in a child
abdo pain from central to RLQ and tenderness to palpation localized at mcburney’s point
how would you manage appendicitis in a child
possible U/S though likely wont change management plan since acute surgery is needed
urinalysis, CBC, IV bolus if volume depleted
urgent laparoscopic appendectomy with prophylactic broad-spectrum abx
5 basic clinical manifestations of inflammation
rubor (red) calor (warmth dolor (pain) tumor (swelling) functio laesi (disabled function)
if a kid presents with acute scrotal pain, what is your first working dx
testicular torsion–have 6 hours to save a twisted testicle so go to OR immediately
what are the basic types of abdominal wall hernias and defects that present in kids
- gastroschisis
- omphalocele
- umbilical hernia
- indirect inguinal hernia
- hydrocele
how do you manage a gastroschisis
characteristically the stomach, small bowel and colon are totally outside the body through a defect that is to the right of the navel
usually an isolated anomaly
treatment is to place the organs back into the body slowly over time (may require a silo that is squeezed daily to gradually place intestines back into the abdo)
TPN for a while until bowel healed
how do you manage a omphalocele
abdominal organs (primarily bowel and liver) protrude through a variably sized central abdo defect that is at the umbilicus and is contained within a thin membrane
can often be reliably detected prenatally by U/S
50% will have other major congenital defects
palce organs back into body with gentle compression of the omohalocele and eventual closure of the fascia surgically and then investigate for other congenital abnormalities
TPN until bowel healed
how do you manage a pediatric umbilical hernia
often benign fascial opening in the umbilical fascia–with crying or straining the umbilical skin can bulge
most close on their own by a year whereas some persist beyond 5 years and can then be repaired for cosmetic reasons
how do you manage a indirect inguinal hernias
congenital patent processus vaginalis (supposed to close prior to birth) leads to protrusion at the internal inguinal ring
usually bulges in and out over time and is painful
common in 1-2% of boys and 0.5% of girls
often appear in early infancy especially in premature children
if they incarcerate they can present with an irreducible bulge, pain, tenderness and eventual signs of bowel obstruction–> bowel and/or testicle ischemia
diagnosis is purely clinical–> surgical repair should soon follow
how do you manage a hydrocele
can be communicating or non communicating—generally painless in babies and children, often vary in size throughout the day if communicating
treat with monitoring and elective repair
why do we need to be careful with regard to occult traumatic injury in kids
(still treat trauma with ABCDEs)
children do not have the muscle bulk and rib stiffness that protects the spleen and liver in adults, so relatively low kinetic energy hits can result in solid organ damage without rib fractures
significant internal organ damage can also occur with little outward evidence of significant injury
crushed chest can cause the glottis to close and a resultant sudden rise in thoracic pressure and CVP causes capillary bursting in the head and neck region
FAST scan can be used to detect blood around the heart or abdo organs after trauma