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Flashcards in Pediatric Surgery Deck (101):
1

3 most common solid pelvic/abdominal malignancies in children

1. Neuroblastoma (forms in nervous tissue -- usually adrenal glands)
2. Wilm's Tumour (Nephroblastoma)
3. Lymphoma

2

Good first lineimaging technique for children

Ultrasound

3

Common cancer staging system

T (tumour size and possible local invasion)
N (nodes -- local vs more extensive spread)
M (metastases - # and location)

4

Biopsies in children

Needle biopsy is not common b/c this technique is best for carcinomas which are not common in children
Incisional (removing a part of the tumour) and excision (removing the entire tumour) are common

5

Blastoma

Malignancy in precursor cells (blasts)

6

In children. green vomit is ___ until proven otherwise

Bowel obstruction

7

First step for possible bowel obstruction

Decompress bowel (NG tube) and support baby (IV)

8

Best imaging technique for bowel obstruction

X-rays (supine and upright to see air-fluid levels)
U/S is not favourable b/c it is confounded by gas, and there is a lot of gas with bowel obstruction

9

Atresia

Luminal structure in body that doesn't form correctly and is obstructed

10

Duodenum formation

Duodenal tissue forms vacuoles that coalesce

11

Duodenal atresia associated with

Trisomy 21 and congenital heart disease
Polyhydramnios

12

Duodenal atresia common finding on AXR

Double bubble -- 2 air filled bubbles that suggest 2 discontinuous loops of proximal small bowel

13

Duodenal atresia tx

Find obstruction at laparotomy
Duodeno-duodenostomy repair (bypass obstruction by sewing proximal duodenum to distal)

14

Most common cause of newborn bowel obstructions

Imperforate anus

15

Adhesive bowel obstruction

Secondary to previous surgery/inflammation

16

Abdominal obstructions in the newborn

Atresias (small bowel and colonic)
Malrotation with Ladd's bands (adhesions)
Malrotation with volvulus (twisting of bowel leading to obstruction and vascular compromise)
Meconium ileus (GI obstruction secondary to thick meconium; common in CF)
Hirschprung's (aganglionosis of distal bowel)
Imperforate anus
Biliary atresia
Urinary obstruction

17

Abdominal obstructions in infant

Pyloric stenosis
Intussception
Malrotation
Hirschprung's

18

Abdominal obstructions in children

Intussception
Appendicits
Adhesions
Malrotation

19

Clinical presentation of infantile hypertrophic pyloric stenosis

PPP = persistent, projectile, progressive emesis
3-8wks of age
1st born male
Metabolic alkalosis

20

Tx for pyloric stenosis

Resuscitate first
Pyloromyotomy - incision into longitudinal and circular muscles of pyloric muscle

21

Clinical presentation of infantile intussusception

3mo-3yrs
Crampy, intermittent knees up abdominal pain
Red currant jelly stool
Sausage shaped abdominal mass

22

Tx for intussception

Enema reduction
Surgery if necessary

23

Typical presentation of extra cranial solid malignant tumours

Visible/palpable lump that does not cause any pain or other manifestations

24

Most common malignancy in children

CNS/brain tumours

25

Common therapies in childhood solid tumours

Chemotherapy
Surgery
Radiation

26

Wilm's tumour (nephroblastoma)

~85% survival rate

27

Why might bloodwork in a neonate not be very useful?

Neonate was receiving blood from mom right up until birth so bloodwork may appear misleadingly normal

28

Bowel adhesion tx

No cure
May resolve with just 'drip and suck'
Laparotmy and lysis can help but they can reform

29

Ddx for rectal bleeding

1. Swallowed blood from mom during labour or from breastfeeding; baby is well and does not have tender abdomen
2. Coagulopathy -- all newborns should get a newborn shot of IM Vitamin K
3. Intussusception -- generally in 3mo-3yo
4. Necrotizing enterocolitis -- >3d old and have been fed, usually premature, perinatal asphyxiation event or are on drugs; pneumatosis intestinalis (bubbles of air in bowel wall)**
5. Vascular malformation of GIT (RARE)
6. Peptic ulcer -- RARE b/c newborns are achlorhydric for the first few days (no acid, no ulcer)
7. Intestinal malrotation with acute volvulus -- Volvulus can cause vascular compromise of mesentery which leads to intestinal ischemic necrosis and congestive bleeding/sloughing off of intestinal mucosa; hemodynamically compromised and tender abdomen, abdo distension and bilious emesis due to duodenal obstruction by Ladd's bands**

** = ones you do not want to miss b/c they are the most life-threatening

30

Ladd's bands

Often present in intestinal malrotation that sweep from right lateral abdominal wall across duodenum to right colon

31

Best imaging to denote malrotation

Upper GI contrast x-ray

32

First steps for bleeding patient

IV started
Cross-match
CBC and coag profile

33

Meckel scan

Injection of Technetium-99m which gathers in gastric mucosa --> evidence of contrast build up in area outside of stomach = MD
MD typically has ectopic gastric and pancreatic cells

34

Meckel's diverticulum

Occurs when vitelline duct (duct btwn fetal midgut and yolk sac) doesn’t close properly causing a blind-ending diverticulum that contains all layers found in ileum
Located in distal ileum

35

How does meckel's diverticulum cause bleeding?

Meckel's ectopic gastric mucosa secretes acid --> causes adjacent small bowel mucosa to ulcerate and bleed profusely
Blood is usually melena or at least dark purple b/c of acid enviro

36

Gestational week that vitelline duct should regress and disappear

5th-8th gestational week

37

Tx for meckel's diverticulum

Laporoscopic resection

38

Most common age at presentation of MD

2 yrs

39

% of population have MD?

2%

40

How far from the terminal ileum is a MD?

2 feet

41

How many different types of ectopic mucosa can a MD have?

2 - gastric and pancreatic

42

How many inches long is a MD?

2 inches

43

MD typical presentation

1. Bleeding
2. Diverticulitis mimicking appendicits
3. Intussception causing obstruction
4. Meckel's band causing obstruction
5. Malignancy
6. Littres hernia -- inguinal hernia with MD in it

44

Fistula

Abnormal connection between 2 epithelialized or endothelialized surfaces

45

Sinus tract

Abnormal connection between two surfaces only one of which is epithelialized

46

Pneumothorax

Air fills in pleural space, causing partial collapse of lung and potential profound collapse of lung

47

Pneumothorax tx

Chest tube placed in right pleural cavity
Leak should seal itself over in a few days
If not, video-assisted thorascopic surgery (VATS) may be done to surgically seal the leak. The parietal pleura is either scraped and irritated, or actually stripped away so that re-expanded lung will stick to chest wall and not collapse again

48

Normal time to pass meconium

Within first 24h of life

49

Most common cause of not passing meconium

1. Imperforate anus
2. If baby has anus, they may have Hirschsprung's disease

50

Best imaging for Hirschsprung investigation and usual results

1. AXR (supine and upright) -- air fluid levels and NO air in rectum
2. Colon contrast enema (barium enema) -- narrowed rectum and colon dilation at transition zone from ganglionic to ganglionated bowel

51

Hirschsprung disease

Lack of ganglia cells in rectal wall --> chronic rectal spasm and functional obstruction of lower GIT
ALWAYS no ganglia in rectum; absence of ganglia extends proximal up the colon and can even go into small intestine
DRE can sometimes break rectal spasm and may see a rush of fecal matter

52

Diagnostic method for Hirschsprung

RECTAL BIOPSY -- take 3 or 4 samples of inner wall of rectum at various levels
- above the transition zone: ganglia
- below the transition zone: no ganglia and hypertrophied nerve trunks

53

Tx for hirschsprung

Pull through = Resection of aganglionic portion of colon and ganglionate colon is "pulled through" and sewn to the anal canal

54

Classic presentation of appendicitis

Previous healthy child with sudden onset of abdo pain starting in mid-ado and then localizing in RLQ
P/E localized tenderness and guarding at McBurney's point

55

Common first steps for emergency patient

Urinalysis
CBC
IV if patient is volume depleted
O2 if patient has trouble breathing

56

Appendicitis treatment

IF STRONG CLINICAL SUSPICION, THAT IS ENOUGH TO GO THROUGH WITH SURGERY WITHOUT IMAGING

1. Prophylactic broad-spectrum abx IV
2. Laporascopic appendectomy under GA
3. Intermittent IV morphine for post-op pain
4. Acetaminophen for pain PRN

57

If you were to order imaging for appendicitis, what imaging technique would you use?

U/S, but still ~5% possibility appendicitis will be missed

58

If appendicitis left untreated...

possible perforation and sepsis which may lead to death

59

5 basic attributes of inflammation

1. Redness
2. Warmth
3. Pain
4. Swelling
5. Disabled function (ie. neck mobility)

60

Abscess

Collection of pus

61

Abscess treatment

Incision and drainage

62

Common abscess in toddlers

Cervical abscesses
Usually caused by staph or strep infections of cervical lymph nodes

63

Acute scrotal pain in healthy boy, swollen and extremely tender

Acute scrotum

64

Acute scrotum working dx

Testicular torsion

65

Ddx for acute scrotum

Epididymo-orchitis (inflammation of epididymis and testes)
Acute hydrocele (accumulation of fluid around testicle)
Hernia
Torsion of appendix testes (small appendage on top of epididymis)

66

Amount of time that you have to save a twisted testicle

6 hours

67

Testicular torsion

Results from lack of fixation of testicle within tunica vaginalis = bell clapper deformity
Allows testicle to twist on its vascular pedicle
Twisted spermatic cord

68

Testicle layers (outside in)

Tunica vaginalis
Tunica albuginea
Seminiferous tubules separated by septum

69

Treatment of testicular torsion

Orchidopexy

70

Orchidopexy

Pulling undescended testicle (cryptorchid) down and fixing it into the scrotum

71

Abdominal wall hernias

Gastroschisis
Omphalocele
Indirect inguinal hernia

72

Gastroschisis

Stomach, small bowel and colon are completely outside body through defect that is to the right of the naval
Can be detected prenatally by fetal ultrasound
Usually isolated anomaly

73

Omphalocele

Abdominal organs (usually bowel and liver) protrude through central abdominal defect at umbilicus
Protrusion is covered by thin membrane
Detected prenatally by ultrasound
50% have other major congenital defects

74

Gastroschisis tx

Place bowels in a "silastic silo" --> squeeze daily for up to 1 week --> gradually place intestines back in abdomen
TPN until bowel is ready

75

Omphalocele tx

Attend to any other congenital anomalies
Paint dress membrane protectively and gently compress omphalocele
Over MONTHS organs fit into abdomen and eventually fascia is surgically closed anteriorly
TPN until bowel is ready

76

Umbilical hernia

Benign fascial opening
Can cause bulging when baby cries or strains
Non-pathological and no risk of incarceration (bowel gets trapped and ischemic)

77

Umbilical hernia tx

Should close at age 1 yr
May be surgically repaired in school-age children primarily for cosmetic reasons
Do NOT recommend parents tape our bind them

78

Indirect inguinal hernia

More common in boys and premature babies
Congenital patent processus vaginalis (should close prior to birth)
Protrusion at internal inguinal ring -- hernia 'sac' follows down inguinal canal towards scrotum
20% present bilaterally
Contain bowel and may incarcerate (irreducible bulge, pain, tenderness and eventually signs of bowel obstruction)
Bowel and testicle may become ischemic
May not present until child is a bit older and patent processes vaginalis is larger
Dx is purely clinical (U/S is useless)
Reducible

79

Indirect inguinal hernia repair

Surgical -- tie off the patent process vaginalis
No mesh is needed because posterior inguinal wall is generally intact and strong (unlike in adult direct inguinal hernia repair)

80

Indirect inguinal hernia in girls

Less common
Added danger of not only having bowel incarcerate in them but also ovaries

81

Hydrocele

Communicating vs non-communicating
Very small patent processes vaginalis
Both are usually painless
Communicating hydrocele will vary in size over the day vs non-communicating is static in size
Not manually reducible
Usually you can palpate normal cord structures above
Transilluminate

82

Hydrocele treatment

Benign
Usually watch and wait both communicating and non-communicating
Elective repair in older children may be recommended

83

Cryptorchidism

Hidden testicle due to...
1. Undescended testicle*
2. Testicle descended but atrophied because of newborn torsion or inadequate vasculature
3. Agenesis of testicle
4. Ectopic testicle
5. Retractile testicle*

* = most common

84

Undescended testicle

Testicles descend in early fetal life from formation in abdomen
Usually found in inguinal canal but may be higher in abdomen
If they haven't descended by 6mo they aren't going to
Orchidopexy should be done by 1y.o.

85

Ectopic testicle

Testicle descended but then veered off to lodge in upper thigh or lower abdomen

86

Retractile testicle

In the scrotum when he's calm and warm, but when he's upset or cold, the cremasteric muscle pulls it up to the inguinal canal
Can be manually brought down into scrotum and should stay there for ~10s when released
No tx needed, F/U in 6-12 months

87

Cremaster muscle

Thin layer of skeletal muscle found in the inguinal canal and scrotum surrounding the spermatic cord and testes
Supplied by: cremasteric artery (branch of inferior epigastric artery)
Innervated by: Genital branch of genitofemoral nerve

88

Kehr's sign

Blood irritating underside of diaphragm is interpreted as C3,4,5 dermatome pain

89

Traumatic asphyxia

Occurs when chest is crushed under a weight and glottis is closed causing a sudden rise in thoracic pressure and CVP which in turn causes capillary bursting in head and neck region

90

Why are children more susceptible to traumatic injury?

They do not have the muscle bulk and rib stiffness to protect vital organs

91

Intussception

Segment of intestine invaginate into adjoining intestinal lumen causing bowel obstruction
Typically in 5-10months

92

Intussception tx

Hydrostatic or pneumatic enema
Surgical - manual reduction or segmental resection

93

Layers of spermatic cord

External spermatic fascia
Cremaster muscle
Internal spermatic fascia

94

Contents of spermatic cord

Arteries (testicular, cremasteric)
Nerves (genital branch of genitofemoral, testicular)
Vas deferens
Lymphatic vessels
Tunica vaginalis

95

VACTERL

Vertebral anomalies, anal atresia, cardiac malformations, tracheoesophageal fistula, esophageal atresia, renal anomalies, limb anomalies

96

Appendicitis alvarado score

Alvarado Score = MANTRELS
* Symptoms
* Abdominal pain that Migrates to RLQ (1)
* Anorexia (loss of appetite) or ketones in urine (1)
* Nausea or vomiting (1)
* Tenderness in RLQ (2)
* Signs
* Rebound tenderness (Blumberg) (1)
* Elevated fever >/= 37.3C (1)
* Laboratory
* Leukocytosis >10 000 (2)
* Neutrophilia >70% / Left Shift (1)

97

Alvarado scoring

Scoring system:
* <5 = Low risk
* PO challenge then possible d/c home
* 5-8 = Moderate risk
* IV fluids
* NPO
* Analgesia
* U/S
* > 8 = Increased risk
* IV fluids
* NPO
* Analgesia
* GSx consult
* IV abx
* No imaging until GSx consult

98

Typical abx for appendicitis

IV Cefoxitin 30mg/kg/dose q6h (max 2g dose)

99

Most common type of tracheoesophageal fistula

Atresia with distal fistula

100

Types of esophageal atresia /tracheoesophageal fistula that cause gas in stomach

Atresia with distal fistula
Atresia with double fistula
H-type isolated tracheoesphageal fistula

101

Types of hernias

* Inguinal - most common
* Femoral
* Umbilical
* Incisional
* Epigastric
* Hiatal