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Flashcards in Pestana Pediatric Surgery Deck (39)
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1

Congenital anomalies that require surgical intervention between birth - 24 hours

  • esophageal atresia
  • imperforate anus
  • congenital diaphragmatic hernia
  • gastroschisis/omphalocele
  • exstrophy of urinary bladder
  • green vomit +/- double bubble (duodenal atresia, annular pancreas, malrotation)
  • intestinal atresia

2

Congenital anomalies that require surgical intervention between first few days - 2 months of life

  • necrotizing enterocolitis
  • meconium ileus
  • hypertrophic pyloric stenosis
  • biliary atresia
  • hirschsprung disease (aganglionic megacolon)

3

Congenital anomalies that require surgical intervention between later during infancy

  • intussusception
  • child abuse
  • meckels diverticulum

4

a newborn infant begins to choke after his mom tries to breast feed him for the first time after birth; excessive drooling is noted.

esophageal atresia

5

what is the next best step in management for a newborn with suspected esophageal atresia?

  • pass an NG tube and image - it will be seen coiled in the upper chest.
  • If there is normal gas pattern in the bowel, then the infant likely has the most common type of esophageal atresia (blind pouch in upper esophagus with fistula between lower esophagus and tracheobronchial tree)

6

most common type of esophageal atresia?

blind pouch in upper esophagus with fistula between lower esophagus and tracheobronchial tree

7

once you establish that a newborn infant has esophageal atresia, what is the next best step in management?

rule out other associated anomalies (VACTERL: vertebral defects, anal atresia, cardiac defects, tracheal-esophageal fistula, renal defects, limb defects) BEFORE doing surgical repair

  • *note these structures are of mesodermal origin*

8

if there is a delay in surgical repair of a esophageal atresia, what is the next best step in management?

gastrostomy (creation of an external opening into the stomach for nutritional support/GI compression) has to be done in order to protect the lungs from acid reflux

9

how is an imperforate anus with a fistula at the vagina or perineum managed?

repair is delayed until further growth of the infant

10

how is an imperforate anus without evidence of a fistula at the vagina or perineum managed?

  • colostomy (for high rectal pouches with subsequent repair when the infant is older)
  • primary repair (for rectal pouches that are close to the anus)

11

when is a congenital diaphragmatic hernia repaired? rationale? what should you do in the interim?

3-4 days after birth to allow for maturation of the hypoplastic lung must give endotracheal intubation, low pressure ventilation, sedation, and NG suction since the infants are usually in respiratory distress

12

where is a congenital diaphragmatic hernia usually located?

always on the L

13

when are most congenital diaphragmatic hernia diagnosed?

in utero via sonogram

14

∆ btwn gastroschisis and omphalocele? What are they caused by?

  • gastroschisis - not covered by peritoneum with angry looking bowel
  • omphalo"cele" - "sealed" by peritoneum; normal looking bowel

both caused by abdominal wall defect in the middle of the belly

15

management of newborn infant with gastroschisis? 2

construction of a silastic "silo" to house and protect the bowel. Contents of the silo are then squeezed into the belly a little bit everday until complete closure can be done (~1 week)

vascular access for parenteral nutrition because the bowel function usually takes ~1 month to return

16

management of newborn infant with omphalocele?

construction of a silastic "silo" to house and protect the bowel. Contents of the silo are then squeezed into the belly a little bit everday until complete closure can be done (~1 week)

17

What is exstrophy of the urinary bladder and what is it caused by?

caused by abdominal wall defect over the pubis

results in a medallion of red bladder mucosa, wet and shining with urine

18

management of an infant with this

exstrophy of the urinary bladder

surgical repair within the first 1-2 days of life, otherwise delayed repairs do not work

19

green vomit + double bubble on xray in a newborn should make you immediately  these 2 differentials

duodenal atresia

annular pancreas

malrotation

20

How does duodenal atresia, annular pancreas, and malrotation all present?

green vomiting + double bubble on x-ray

21

of these, which one is the most dangerous?

duodenal atresia, annular pancreas, or malrotation 

How is it diagnosed?

 

malrotation - bowels can twist on itself and cut off its blood supply, and die

diagnosis: 

  • if there is little gas beyond the double bubble seen on x-ray
  • contrast enema or upper GI study

note: malrotation can show up at any time within the first few days of life

22

What is this pathology?

intestinal atresia

23

How does intestinal atresia occur? how does it present?

aka  "apple peel atresia" - result of a vascular accident in utero

green vomit + multiple air fluid levels throughout the abdomen seen on x-ray (ø double bubble)

24

premature infant is fed for the first time develops abdominal distension, thrombocytopenia, and feeding intolerance

feeding intolerance - inability to digest enteral feedings; gastric residual volume >50%, abdominal distention, emesis, and disruption of the patient's feeding plan.

necrotizing enterocolitis

25

management of infant with suspected necrotizing enterocolitis

  • stop all feeds
  • administer
    • broad spectrum abx
    • IVF
    • IV nutrition

26

when is surgical intervention required in an infant with necrotizing enterocolitis?

when the infant develops

  • abdominal wall erythema
  • air in the portal vein
  • intestinal pneumoatosis (air in bowel wall) or
  • pneumoperitoneum (indication of necrosis+perforation)

27

meconium ileus occurs in which patient population?

how do these patients present?

cystic fibrosis 

feeding intolerance + bilious vomiting

Xray shows multiple dilated loops of small bowel and ground-glass apperance in the lower abdomen

28

treatment of infants with meconium ileus?

gastrografin enema - draws fluid into the fluid and dissolves the pellets of meconium

29

how do babies with hypertrophic pyloric stenosis present?

first born boys, about 3 weeks old

non-bilious projectile vomiting after each feed, baby is hungry and eager to eat again after the vomits

usually present with dehydration with palpable olive mass in RUQ, labs show hypochloremic, hypoklaemic metabolic alkalosis

30

how are infants with hypertrophic pyloric stenosis managed? 3

  1. rehydration with IVF
  2. correction of hypochloremic, hypokalemic metabolic alkalosis
  3. ramstedt pyloromyotomy or balloon dilation