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Flashcards in PEDS Deck (41):
1

Meckel's workup

Put in NG tube first to rule out upper gastrointestinal bleed.


Technetium 99 – Meckel's scan

Increased sensitivity with H2 blocker, glucogon, tinted Gaston stimulation

angeo and tagged red blood cell not as good.

If failed to diagnose:
diagnostic laparoscopy

Consider non-umbilical sight of trocar because of risk of vitelline duct attachement.



2

Meckel's diverticulectomy

right peri Median incision(or laparoscopy)

Incidental appendectomy.

Ligate a large mesenteric vessel at tip of diverticulum.

If a acute hemorrhage:
Wedge resection of diverticulum and adjacent ilio alteration

Control sites of bleeding of ileal mucosa

Closed transversely handsewn

(may close with stapler if narrow base)

If an intestinal ischemia, extensive inflammation, irreducible intussusception, very wide diverticulum, or palpable ectopic mucosal tissue near the diverticulum:

Segmental RESECTION of involved illium

If significant alteration and bleeding opposite to the diverticulum on the mesenteric side:

Segmental RESECTION.


3

Omphalocele define

midline anterior abdominal wall

fascial defect > 4 cm.

The rectus muscles are present and normal but insert widely on the costal margins and do not meet in the middle at the xiphoid.

allows for herniation of the midgut and other abdominal viscera.

The herniated organs are contained within a membranous sac that consists of peritoneum, Wharton’s jelly, and amnion.

The umbilical cord inserts on the apex of this membrane.

Small omphalocele contains small bowel with or without stomach and has a fascial defect 5 cm.

Ruptured omphalocele is the third presentation of omphalocele where the sac has ruptured in utero or during birth.

4

Gastroschisis defined

is a full-thickness abdominal wall defect that occurs just to the RIGHT
of a normally inserted umbilical cord.

The herniated bowel and abdominal viscera are not covered by a membrane.

The viscera are subjected to exposure to amniotic fluid during gestation.

5

An umbilical hernia defined

abdominal wall defect caused by a persistent umbilical ring and is covered by skin.

6

Pentalogy of Cantrell defined

is a rare congenital

omphalocele,

anterior diaphragmatic hernia,

malformation or absence of the pericardium,

sternal cleft,

and cardiac malformations.

7

Ectopia cordis thoracis defined

partial or complete failure of midline fusion of the sternum resulting in the heart protruding from the chest through a split sternum.

In contrast to the Pentalogy of Cantrell, the heart is not covered by a membrane in ectopia cordis thoracis.

8

prune belly syndrome

constellation of anomalies including deficient or absent abdominal wall muscles,

bilateral cryptorchidism,

dilated dysmorphic urinary tract.

9

work up of omphalocele

Chest x-ray, echocardiogram, renal ultrasound, and skeletal radiography are performed and note no abnormalities.

10

omphalocele associations

(Beckwith-Wiedemann, OEIS [omphalocele, exstrophy, imperforate anus, and spinal
anomalies],

Gershoni-Baruch, Donnai-Barrow)

or

with an associated chromosomal abnormality (trisomy 13,14, 15, 18, or 21 DOWNS).

Fifty percent to seventy percent of patients with an omphalocele will have at least one associated anomaly.

Cardiac defects represent the most frequent anomaly occurring in 30% to 50% followed by
musculoskeletal,
gastrointestinal,
genitourinary

Chromosomal abnormalities occur in 30%.

Omphalocele has also been seen with Turner’s syndrome and triploidy.

11

Beckwith-Wiedemann syndrome is


umbilical defect,

macroglossia,
hyperinsulinemia,
organomegaly,

increased risk of
Wilms’ tumor,
hepatoblastoma,
neuroblastoma.

Omphalocele is also part of the OEIS complex, which involves
bladder exstrophy,
imperforate anus,
spinal defects.

Lower midline syndrome includes
exstrophy of the
bladder or cloaca,
vesicointestinal fissure,
colon atresia,
imperforate anus,
sacral vertebral defects,
lipomeningocele or meningomyelocele.

12

Management of sick kids with omphalocele

Immediate D 10/0.25 normal saline IV

150 mL per kilogram per day

Then reduce to a maintenance of 100 mL per kilogram per day

If sac ruptured needs immediate surgical intervention.

Given antibiotics and VITAMIN K

Close on Felicio with plastic wrap to maintain body heat

Glucose monitor
(asso with Beckwith- Wiedemann)

13

Fluid resuscitation for pyloric stenosis

D5 half normal saline
or
1/2 NS
20 mL per kilogram

AND
Maintenance:
4:2:1 with D5

14

What a electrolyte marker is used for adequate fluid resuscitation

Bicarbonate

15

What is normal bicarbonate level

22 – 26

16

What is normal sodium

135 – 145

17

What is normal chloride

105

100 – 112

18

What is normal potassium

Three – 4.5

19

What is normal B UN

10 – 12

20

What is normal creatinine

0.5 – 1.4

21

What is the inferior limit marking the pyloromyotomy

Main of Mayo

22

What is postoperative feeding recommendations after pyloromyotomy

Pedialyte
Start feeds four – six hours
May have some emesis

23

what do you do with the sleeve resection of the Meckles

appy!

24

signs of baby obstruction

Polyhydramnios. The fetus swallows 50% of the amniotic fluid daily, which is largely absorbed in the upper intestinal tract. A high obstruction allows this fluid to back up and accumulate in excessive quantities. 2 Bilious vomiting. Nonbilious vomiting is common in infants; bilious vomiting is much more often pathologic. 3 Abdominal distention. Distention develops within 24 hours of birth in distal obstructions, as swallowed air accumulates above the blockage. 4 Failure to pass meconium. Within 24 hours of birth, 95% of term babies pass meconium. A delay may signify obstruction.

25

Meconium ileus

cystic fibrosis = thick secretions

"Ileus = ileum"

15% of infants with cystic fibrosis, from the abnormally viscid enzymes secreted by the pancreatic and intestinal glands.

nonoperatively with diatrizoate (gastrografin) enemas.

Gastrografin is a radiopaque fluid with a very high osmolarity that causes fluid to be drawn into the bowel lumen.

The sticky meconium is hydrated and may be spontaneously evacuated.

Intravenous fluids must be infused during the procedure, to avoid systemic hypovolemia.

If the obstruction persists or if there is evidence of perforation, surgery is mandatory.

26

Colon Obstruction Congenital colorectal obstruction may be due to:

(a) Hirschsprung’s disease,

(b) meconium plug

(NOT ileus that is in the ileum)

(c) neonatal micro left colon syndrome,

(d) atresia
(rare)

27

Hirschsprung

ganglion cells of the parasympathetic nervous system are absent from the wall of the distal intestinal tract.

The transition zone between the narrow aganglionic distal bowel and the dilated normal proximal bowel is usually in the rectosigmoid colon

but can occur anywhere,

The aganglionic bowel is not capable of normal peristalsis, producing a functional obstruction at the transition zone.

first present in the newborn as a lower bowel obstruction or later in childhood as severe chronic constipation

A contrast enema usually demonstrates the transition zone

anorectal manometry will show absence of the internal sphincter relaxation reflex.

A rectal biopsy will confirm the absence of ganglion cells.

28

The treatment for Hirschsprung’s disease

classically staged:
temporary colostomy brought out proximal to the transition zone.

several months later by a “pull-through” procedure, in which the ganglionic bowel is brought down and anastomosed to the anal canal.

this traditional approach is being replaced by:
transanal pull-through procedure
during the first few days of life, with optional laparoscopic assistance.

Occasionally, patients with Hirschsprung’s disease may develop a severe enterocolitis, with dehydration, peritonitis, and sepsis.

This may be the first manifestation of the disease or may even occur after surgery.

Treatment of Hirschsprung’s enterocolitis must be prompt with intravenous fluids, antibiotics, and colonic irrigations.

29

Meconium plug

etiology

treatment

frequently occur in premature

probably caused by transient motility disturbances of the immature colon.


A contrast enema is generally both diagnostic and therapeutic.

30

micro left colon syndrome most common in


etiology

treatment

infants of diabetic

probably caused by transient motility disturbances of the immature colon.

A contrast enema is generally both diagnostic and therapeutic.

A contrast enema is generally both diagnostic and therapeutic.

Babies are usually normal after treatment, but subsequent testing for Hirschsprung’s disease or cystic fibrosis may be indicated.

31

(imperforate anus)

Imperforate anus is part of the VACTER association (see earlier section on Esophageal Atresia and Tracheoesophageal Fistula) and associated abnormalities, particularly genitourinary, frequently occur.

rectum fails to reach its normal perineal termination.

above the levator muscles = high,

anterior fistulous tract.

----------

high anomalies:
urethra or bladder in males

with the vagina in females

low malformations

externally in both genders,

anterior to the normal anal site



32

WORK UP OF INPERF ANUS

ultrasound,
computed tomography (CT),
agnetic resonance imaging (MRI)
to identify the level of the rectum more precisely.

The invertogram is being replaced by US
“invertogram” is traditionally performed. The baby is held prone and head-down, and if on lateral x-ray air in the rectum rises to within 1 cm of the perineal skin, the lesion is low; if not, it is probably high.

33

TX OF imperf anus


A fistula only slightly anterior to the normal anal location (anterior anus) can often function normally and may therefore be left alone!

perineal anoplasty
done in the newborn period
(or later, if the external fistula can be dilated sufficiently to permit the passage of stool)

establish an adequate communication between the rectum and the perineum, at the center of the external sphincter.

---------------------

intermediate and high malformations:

initial colostom traditionally

Over the next several months a pull-through procedure is performed:
rectum brought through the center of the levator sling, and anastomosed to the perineum.

the Peña operation, in which all the muscles are divided posteriorly in the midline standard because of the excellent visualization that is obtained.

More recently a laparoscopic approach has been advocated, with or without the utilization of a protective colostomy.

34

antibiotics for NEC

Empiric broad-spectrum antibiotics combinations used to treat NEC include, but are not limited to, the following choices [9]:

●Ampicillin, gentamicin (or amikacin), and metronidazole

●Ampicillin, gentamicin (or amikacin), and clindamycin

●Ampicillin, cefotaxime, and metronidazole

●Piperacillin-tazobactam and gentamicin (or amikacin)

●Vancomycin, piperacillin-tazobactam, and gentamicin

●Meropenem

35

biliary atresia

Scleral icterus and/or generalized jaundice typically develop by eight weeks

Infants may also have acholic
stools
dark urine,
and/or a firm liver
and splenomegaly (or asplenic!)

conjugated bilirubin (>2 mg/dL)

mild or moderate elevations in serum aminotransferases

with a disproportionately increased GGTP

36

The diagnosis of BA is

made with a series of imaging and laboratory tests and liver biopsy to exclude other causes of cholestasis.

The definitive diagnosis of BA is made by a cholangiogram. This is typically performed intraoperatively; if the diagnosis of BA is confirmed, the surgeon performs a hepatoportoenterostomy (HPE, Kasai procedure) (figure 1). (See 'Cholangiogram' above.)

37

treatement of BA

We suggest that infants and children be treated with ursodeoxycholic acid (UDCA) after Kasai HPE (Grade 2C). To avoid potential toxicity, UDCA therapy should be discontinued if the total bilirubin level rises above 15 mg/dL. We do not recommend treatment with glucocorticoids (Grade 1A). (See 'Choleretics' above and 'Glucocorticoids' above.)

prophylactic antibiotics in the first year of life (Grade 2B). (See 'Ascending cholangitis' above.)

DEAK vits

After Kasai HPE, if there is persistent jaundice three months later then the patient should be referred for liver transplant evaluation. Other indications for early liver transplantation include failure to thrive despite vigorous nutritional rehabilitation. (See 'Liver transplantation' above.)

n the current era, at least 60 to 80 percent of patients with BA will eventually require liver transplantation. Indications for liver transplantation include complications of portal hypertension (recurrent variceal bleeding or intractable ascites), growth failure, and progressive liver dysfunction. (See 'Liver transplantation' above.)

A minority of patients with BA treated with Kasai HPE survive to 20 years or more without liver transplantation. However, many of these patients have chronic liver disease with cirrhosis and portal hypertension. (See 'Survival without transplantation' above.)

38

Peds blood pressure

systolic
70 + age x 2

infant 70-80 normal
preschool 90
Adol 100

pulse
infant 160 !
preschool 120!
Adol 100!

RR
infant 40!
Preschool 30!
Adol 20

39

Treatment for thyroglossal duct cyst

Sistrunk procedure
Hi transverse incision
Platysma flaps
Reflect strap muscles
Resect cyst to hyoid bone
Resect middle third of hyoid bone

40

Management of a nine month old with toxic picture Central cystic lesion of the neck with a temperature of 104

Put Protect the airway
Just I and D and packet open

Need ultrasound and make sure that the thyroglossal duct system does not represent the only thyroid tissue in the patient!!

41

20-year-old of pharyngitis for one week
Tender mass in an neck
No constitutional symptoms
4 cm mass submandibular midline
No palpable nodes

branchial cleft cyst

Ultra sound

CT scan

+/- FNA (acellular colloid)