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Core > Pediatrics: Gastrointestinal, Luminal > Flashcards

Pediatrics: Gastrointestinal, Luminal Flashcards

1
Q

Frontal chest radiograph with an NG tube stopped in the upper neck…

A

Think tracheoesophageal fistula/esophageal atresia

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2
Q

What is the most common subtype of esophageal atresia/tracheoesophageal fistula?

A

N-type fistula (85%)

Note: This is a blind ending upper esophagus with the lower esophagus communicating with the trachea.

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3
Q

H-type esophageal atresia

A

When the entire esophagus is present, but there is also a tracheoesophageal fistula

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4
Q

How do you diagnose esophageal atresia/tracheoesophageal fistula?

A

Fluoroscopic swallow study

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5
Q

Esophageal atresia/tracheoesophageal fistula is associated with…

A

VACTERL:

  • Vertebral anomalies
  • Anus, imperforate
  • Cardiac anomalies
  • Tracheoesophageal fistula/Esophageal atresia
  • Renal anomalies
  • Limb anomalies
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6
Q

Excessive air in the stomach in a newborn…

A

Think tracheoesophageal fistula (classically H-type, but also seen with N-type)

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7
Q

What are the major subtypes of tracheoesophageal fistula?

A
  • N-type (blind ending upper esophagus; lower esophagus connects to the trachea)
  • Esophageal atresia (blind-ending upper esophagus without any connection to the trachea)
  • H-type (full esophagus with additional tracheoesophageal fistula)
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8
Q

No air in the stomach of a newborn…

A

Think esophageal atresia

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9
Q

What imaging finding should be mentioned (if present) prior to repair of a tracheoesophageal fistula?

A

Right aortic arch (changes surgical approach)

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10
Q

VACTERL

A

A collection of congenital anomalies that are highly associated:

  • Vertebral anomalies (37%)
  • Anus, imperforate (63%)
  • Cardiac anomalies (77%)
  • Tracheoesophageal fistula/Esophageal atresia (40%)
  • Renal anomalies (72%)
  • Limb anomalies (58%)
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11
Q

Diagnosis of VACTERL

A

When 3 or more of the VACTERL anomalies are found in a pt

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12
Q

Which of the VACTERL anomalies are the most common to find?

A
  • Cardiac (77%)
  • Renal (72%)
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13
Q

Major complication of esophageal atresia repair

A

Focal anastomotic stricture (occurs in 30% of cases)

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14
Q

A coin is present at the level of the thoracic inlet and appears linear (not round) on a frontal chest radiograph. Where is it?

A

Trachea, the flexible posterior membrane causes coins to orient in the sagittal plane

Note: If it appears round on frontal radiograph, it is more likely in the esophagus.

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15
Q

Why are pennies minted after 1982 a more problematic foreign body than other coins?

A

Pennies minted after 1982 are mostly made of zinc, which can cause gastric ulcerations when exposed to stomach acid

Note: Pennies minted before 1982 were made of copper, which is relatively safe.

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16
Q

Management of ingested AA or AAA batteries

A

Serial plain films and extraction if they stay in the stomach for more than 2 days

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17
Q

Management of ingested disc battery

A

Emergency removal if in esophagus (within 2 hours)

Urgent/emergent removal from stomach (within 12 hours)

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18
Q

Name the vascular impression

A

Pulmonary sling (the only variant that goes between the esophagus and the trachea)

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19
Q

Name the vascular impression

A

Double aortic arch

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20
Q

Name the vascular impression

A

Innominate artery compression

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21
Q

Name the vascular impression

A

Left arch with aberrant right subclavian

OR

Right arch with aberrant left subclavian

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22
Q

Pulmonary sling has a high risk of…

A

Tracheal stenosis

Note: The pulmonary sling is when the left pulmonary artery arises from the right pulmonary artery and then runs between the trachea and esophagus.

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23
Q

Treatment of pulmonary sling

A

Surgical repositioning of the malpositioned left pulmonary artery (to avoid tracheal stenosis)

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24
Q

What is the most common symptomatic vascular ring?

A

Double aortic arch

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25
Q

Diverticulum of Kommerell

A

A pouch like aneurysmal dilatation of the origin of an aberrant right subclavian artery

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26
Q

Dysphagia lusoria

A

Dysphagia secondary to an aberrant right subclavian artery

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27
Q

Differential for high bowel obstruction in the neonate

A
  • Midgut volvulus/malrotation
  • Duodenal atresia
  • Duodenal web
  • Annular pancreas
  • Jejunal atresia
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28
Q

Differential for low bowel obstruction in the neonate

A
  • Hirschprung disease
  • Meconium plug syndrome
  • Ileal atresia
  • Meconium ileus
  • Anal atresia/colonic atresia
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29
Q

Neonatal radiograph demonstrates absent bowel gas except for a single bubble in the left upper quadrant…

A

Think gastric (astral or pyloric) atresia

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30
Q

Neonatal radiograph demonstrates absent bowel gas except for a double bubble in the left upper quadrant…

A

Duodenal atresia

Note: The “double bubble” sign without any distal gas is highly specific for duodenal atresia. Any distal gas excludes duodenal atresia.

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31
Q

Jejunal atresias are associated with…

A

Other atresias (e.g. colonic atresia)

Note: Jejunal atresia is usually due to a vascular insult during development that causes multiple atresias.

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32
Q

Neonatal radiograph demonstrates prominent gastric bubble with some distal air in a newborn with bilious vomiting…

A

Suspicious for midgut volvulus, recommend emergent upper GI study

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33
Q

Neonatal radiograph demonstrates a “double bubble” in the left upper quadrant with scant gas distally…

A

Think duodenal web, duodenal stenosis, or midgut volvulus and recommend an upper GI series

Note: Any distal gas, even small volumes, excludes duodenal atresia.

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34
Q

Neonatal radiograph demonstrates diffusely dilated loops of bowel…

A

Think low obstruction (e.g. ileum or large bowel) and recommend a contrast enema (if normal, then get upper GI to exclude atypical midgut volvulus)

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35
Q

Third trimester ultrasound demonstrates “double bubble” appearance in fetal left upper quadrant…

A

Duodenal atresia

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36
Q

Neonatal upper GI

A

Corkscrew duodenum, diagnostic of midgut volvulus (surgical emergency)

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37
Q

What should you look for on a neonatal upper GI series?

A
  • Does contrast opacify the entire duodenum (if not, think duodenal obstruction)
  • Does the duodenum pass the midline to the left hemiabdomen (if not, think malrotation/volvulus)
  • Is there a corkscrew appearance of the duodenum (midgut volvulus)
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38
Q

Malrotation is associated with a high risk of what complications?

A

Midgut volvulus and internal hernias

Note: They can also get intermittent duodenal obstruction due to compression from Ladd’s bands.

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39
Q

Malrotation is associated with…

A
  • Heterodoxy syndrome
  • Omphaloceles
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40
Q

On US or CT, the SMA is to the right of the SMV…

A

Malrotation

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41
Q

1 month old with non bilious vomiting…

A

Think hypertrophic pyloric stenosis and recommend an ultrasound

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42
Q

Infant with bilious vomiting…

A

Think midgut volvulus and recommend emergent upper GI series

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43
Q

Ladd’s bands

A

Fibrous bands attaching the cecum to the abdominal wall that can cause intermittent obstruction in the setting of malrotation

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44
Q

Ladd’s procedure

A

Treatment for malrotation (surgical disruption of the Ladd’s bands that predispose to duodenal obstruction and midgut volvulus)

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45
Q

Preduodenal portal vein

A

An anatomic variant where the portal vein sits anterior to the 2nd part of the duodenum

Note: This is associated with duodenal obstruction 50% of the time secondary to Ladd’s bands, annular pancreas, or other causes of duodenal obstruction.

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46
Q

Causes of partial duodenal obstruction in a neonate

A

Extrinsic compression (Ladd’s bands in malrotation, annular pancreas)

Intrinsic narrowing (duodenal web, duodenal stenosis)

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47
Q

When does hypertrophic pyloric stenosis occur?

A

2-12 weeks of age (peak 3-6 weeks)

Note: NOT before 2 weeks and not after 3 months.

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48
Q

Ultrasound criteria for hypertrophic pyloric stenosis

A

4 mm single wall thickness and length of at least 14 mm

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49
Q

What is the main differential diagnosis for hypertrophic pyloric stenosis on ultrasound?

A

Pylorospasm (which should relax during the exam; true hypertrophy will not relax)

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50
Q

What is a major cause of false negatives on US for hypertrophic pyloric stenosis?

A

Gastric over distention (which can displace the gastric antrum/pylorus)

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51
Q

Organoaxial gastric volvulus

A

The greater curvature flips over the lesser curvature (rotation around the long axis)

Note: This type is mainly seen in older pts with paraesophageal hernias.

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52
Q

Mesenteroaxial gastric volvulus

A

Twisting of the mesentery so that the gastric antrum flips up over the GE junction (rotation around the short axis)

Note: This type is more common in kids and requires surgical correction.

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53
Q

What are the types of gastric volvulus?

A
  • Organoaxial (usually older pts)
  • Mesenteroaxial (usually kids)
54
Q

Which type of gastric volvulus requires surgical correction?

A

Mesenteroaxial (twisting of the mesentery can lead to ischemia)

55
Q

Inability to pass an NG tube, severe epigastric pain, and retching without vomiting…

A

Borchardt triad, suggestive of gastric volvulus

56
Q

Do you get bilious or non-bilious vomiting with a duodenal web?

A

Bilious

Note: The web is distal to the ampulla of Vater.

57
Q

Duodenal webs are associated with…

A
  • Malrotation
  • Downs syndrome
58
Q

Duodenal obstruction with pancreatic tissue surrounding the duodenum on CT…

A

Annular pancreas

59
Q

What are the four major categories of findings on a neonatal barium enema?

A
  • Normal
  • Short microcolon
  • Long microcolon
  • Caliber change
60
Q

Short microcolon on barium enema…

A

Think colonic atresia

61
Q

Long microcolon on barium enema…

A
  • Meconium ileus (contrast reaches ileal loops)
  • Distal ileal atresia (no contrast reaches ileal loops)
  • Total colonic aganglionosis (rare variant of Hirschsprung disease that affects the entire colon)

Note: Long microcolon is when the entire colon opacifies, but is narrow caliber.

62
Q

Meconium ileus indicates that the pt has…

A

Cystic fibrosis (thickened meconium causes the microcolon)

Note: Do not confuse meconium ileus (affects entire colon) with meconium plug syndrome (only affects a distal portion of the colon and is not associated with CF).

63
Q

Treatment for meconium ileus

A

Enema (diagnostic and therapeutic)

64
Q

Treatment for distal ileal atresia

A

Surgery

65
Q

Small left colon syndrome

A

AKA meconium plug syndrome is a transient functional colonic obstruction due to a stuck piece of meconium

Note: Diagnosis and treatment is with an enema.

66
Q

Risk factors for meconium plug syndrom

A
  • Maternal diabetes
  • Mom received magnesium sulfate for eclampsia

Note: Meconium plug syndrome is NOT associated with cystic fibrosis (meconium ileus is).

67
Q

Epidemiology of Hirschsprung disease

A

4:1 more common in boys

68
Q

Hirschprung disease is associated with…

A

Downs syndrome (10% of cases)

69
Q

Diagnosis of Hirschsprung disease

A

Rectal biopsy (showing lack of ganglion cells)

70
Q

Barium enema demonstrates a recto-sigmoid ratio < 1

A

Hirschsprung disease

Note: Is the rectum is smaller than the sigmoid, its Hirschsprung.

71
Q

Barium enema demonstrates a “sawtooth” pattern of the rectum…

A

Hirschsprung disease

Note: The sawtooth pattern is due to bowel spasm.

72
Q

Newborn fails to pass stool for > 48 hours after birth and has forceful passage of stool after rectal exam…

A

Hirschsprung disease

73
Q

Barium enema demonstrates a long microcolon and also narrowing of the terminal ileum…

A

Think total colonic aganglionosis (a rare variant of Hirschsprung disease that involves the entire colon and can also involve the distal ileum)

74
Q

Infant radiograph demonstrates a large eggshell calcified mass in the mid abdomen…

A

Think meconium peritonitis (sterile peritoneal reaction to an in-utero bowel perforation)

Note: Usually the perforation seals itself off before birth.

75
Q

Meconium peritonitis

A

A sterile peritoneal reaction to an in-utero bowel perforation that results in a large mass-like calcification on radiographs

Note: This is often a complication of bowel atresia or meconium ileus.

76
Q
A

Peripherally calcifies mass in an infant, suggestive of calcified meconium peritonitis

77
Q

What should you recommend if you identify an imperforate anus?

A

Screening ultrasound for tethered spinal cord (these are highly associated)

78
Q

Imperforate anus is associated with…

A
  • VACTERL anomalies
  • Tethered spinal cord
79
Q

What is a common complication of an imperforate anus?

A

Enteric fistula formation to the genitourinary tract

80
Q

What are the major causes of bowel obstruction in over children?

A

AAIIMM

  • Appendicitis
  • Adhesions
  • Inguinal hernia
  • Intussusception
  • Midgut volvulus
  • Meckels
81
Q

What is the most common cause of bowel obstruction in children over age 4?

A

Appendicitis

82
Q

Which type of inguinal hernia is most common in children?

A

Indirect inguinal hernias (lateral to the inferior epigastric artery)

83
Q

What is the most common cause of bowel obstruction in a male 1 month to 1 year old?

A

Inguinal hernia

84
Q

What is the normal age range for obstructive intussusception?

A

Between 3 months and 3 years (90%)

Note: Before 3 months or after 3 years, you should be suspicious about a pathological lead point.

85
Q

Intussusceptum vs intussuscipiens

A

The intussusceptum is the proximal bowel that herniates into the lumen of the distal bowel (the intussuscipiens)

Note: In the target sign, the intussuscipiens would be on the outside.

86
Q

How can you tell between a problematic intussusception and a transient one?

A

Problematic intussusceptions tend to be larger than 2.5 cm from outer wall to outer wall, usually enterocolic (small bowel-large bowel)

Transient intussusceptions tend to involve only the small bowel (small bowel-small bowel) and are often less than 2.0 cm in diameter

87
Q

What are common causes of lead points that can cause intussusception?

A
  • Vasculitis (e.g. IgA vasculitis/Henoch-Schonlein purpura)
  • Meckle diverticulum
  • Enteric duplication cysts
88
Q

Contraindications to nonoperative reduction of intussusception

A
  • Pneumoperitoneum (check plain film for free air)
  • Peritonitis (based on exam)
89
Q

Is recurrence common following nonoperative reduction of intussusception?

A

Yes (10% of cases), usually within 72 hours

90
Q

What is the success rate of pneumatic nonoperative reduction of intussusception?

A

80-90%

Note: Success rate is lower for pts with IgA vasculitis/Henoch Schonlein purpura.

91
Q

What is the major risk of nonoperative reduction of intussusception?

A

Bowel perforation (0.5% of cases)

92
Q

Why is air used more often than barium for nonoperative reduction of intussusception?

A

Air causes less peritonitis than barium

93
Q

Pressure should not exceed ______ during nonoperative reduction of intussusception

A

120 mmHg

94
Q

Nest step: nonoperative reduction of intussusception complicated by bowel perforation with development of tension pneumoperitoneum…

A

Emergent needle decompression

95
Q

A Meckels diverticulum is a persistent piece of the…

A

Omphalomesenteric duct

96
Q

Where are Meckels diverticula located?

A

Distal ileum (2 feet from the ileocecal valve)

Note: Rule of 2’s.

97
Q

Rule of 2’s for Meckels diverticula

A
  • 2% of the population
  • 2 feet from the IC valve
  • 2 inches long
  • 2 types of heterotypic mucosa (gastric and pancreatic)
  • Usually symptomatic by age 2
98
Q

Meckel’s scan

A

A Tc-Pertechnetate nuclear imaging study that visualizes heterotypic gastric mucosa within a Meckels diverticulum

99
Q

Which Meckel’s diverticula tend to bleed?

A

Those with heterotypic gastric mucosa

100
Q

Clinical presentation of Meckel’s diverticulum

A

Kid with GI bleeding (usually due to heterotypic gastric mucosa in the diverticulum)

101
Q

Complications of Meckel’s diverticula

A
  • GI bleed
  • Meckel’s diverticulitis
  • Intussusception (usually the diverticulum will be inverted within the bowel lumen)
  • Bowel obstruction
102
Q

Gastroscisis

A

Extra-abdominal evisceration of neonatal bowel through a paraumbilical wall defect without a surrounding membrane

103
Q

Omphalocele

A

Herniation of neonatal bowel through a midline abdominal wall defect at the base of the umbilical cord with a surrounding membrane (peritoneum)

104
Q

Gastroschisis always occurs on the…

A

Right side

105
Q

Gastroschisis is associated with…

A

Not much (unlike omphaloceles)

Note: Some association with intestinal atresias.

106
Q

What specific lab finding is seen in gastroschisis?

A

Elevated maternal serum AFP (more elevated than in omphalocele)

107
Q

Is prognosis better with gastroscisis or omphalocele?

A

Prognosis is better with gastroscisis (due to the syndromes associated with omphalocele)

108
Q

Major complication of gastroschisis repair

A

Bad gastroesophageal reflux

109
Q

Omphalocele is associated with…

A
  • Trisomy 18 (most common associated chromosomal anomaly)
  • Cardiac anomalies (50%)
  • GI anomalies
  • CNS anomalies
  • GU anomalies
  • Turners syndrome
  • Klinefelters
  • Beckwith-Wiedemann
  • Pentalogy of Cantrell
  • Umbilical cord cysts (allantoic cysts)
110
Q

Pentalogy of Cantrell

A
  • Omphalocele
  • Ectopia Cordis (abnormal location of heart)
  • Diaphragmatic defect
  • Pericardial defect or sternal cleft)
  • Cardiovascular malformations
111
Q

Neonate with bowel herniated through a ventral wall defect that pushes the umbilicus to the left…

A

Gastroschisis

Note: Omphaloceles have bowel herniating through the umbilicus (you wouldn’t identify a normal umbilicus for omphaloceles).

112
Q

Which has a midline defect: gastroschisis or omphalocele?

A

Omphalocele (the defect in gastroschisis is always to the right of midline)

113
Q

Kid had a bicycle accident and banged against his handlebars…

A

Think duodenal hematoma

114
Q

Common causes of duodenal hematoma

A
  • Bicycle handlebar accident
  • Child abuse
  • Endoscopy
115
Q

What is the most common location for a duodenal hematoma?

A

D3

116
Q

Duodenal hematoma and retroperitoneal gas…

A

Bowel perforation

117
Q

Prenatal ultrasound demonstrates a cyst in the fetal abdomen…

A
  • enteric duplication cyst (if it has gut signature)
  • Mental cyst (if it does not have gut signature)
118
Q

In 30% of cases, enteric duplications cysts are associated with…

A

Vertebral anomalies

119
Q

What is the most common location for an enteric duplication cyst?

A

Ileum (40%)

120
Q

Enteric duplication cyst

A

A developmental anomaly (failure to canalize) of the GI tract that may or may not communicate with a bowel lumen

121
Q

Complications of enteric duplication cysts

A

In utero bowel obstruction/perforation

122
Q

Gut signature

A

The alternating hyperechoic and hypo echoic layers that identify a viscus as bowel

123
Q

Distal intestinal obstruction syndrome

A

Bowel obstruction in an older child (around 20s) with cystic fibrosis due to poor adherence with pancreatic enzymes resulting in thickened stool in the ileum/ascending colon

124
Q

Pts with cystic fibrosis who don’t take their pancreatic enzymes may end up with…

A

Distal intestinal obstruction syndrome (bowel obstruction due to thickened stool in cystic fibrosis)

125
Q

Cluster of large lymph nodes in the right lower quadrant without any other abnormalities…

A

Think mesenteric adenitis (diagnosis of exclusion)

126
Q

Necrotizing enterocolitis

A

Life-threatening bowel inflammation due to immature bowel allowing fecal pathogens to translocate to the peritoneal cavity

127
Q

What is the age range for necrotizing enterocolitis?

A

90% occur within the first 10 days of life (mostly in premature infants)

128
Q

Risk factors for necrotizing enterocolitis

A
  • Prematurity
  • Low birth weight
  • Cardiac problems (NEC can even happen in full term infants with heart problems)
  • History of perinatal asphyxia
  • Hirschsprung kids (usually occurs later, around 1 month of age)
129
Q

Classic imaging findings of necrotizing enterocolitis

A
  • Pneumatosis/portal venous gas
  • Focally dilated bowel (especially in the right lower quadrant)
  • Edematous small bowel loops (separated by a lot of space and no valvular conniventes)
  • Unchanging bowel gas pattern
130
Q
A

Core (98 decks)

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