Summary of Essentials - Ch. 30-35 (Pediatrics)

Question 1

True or false - the most common causes of newborn respiratory distress are not surgical.

Answer 1

True

Question 2

In stable newborns with signs of respiratory distress, what should be done first in most cases?

Answer 2

Place OG/NGT followed by CXR to confirm/rule out common surgical diagnoses

Question 3

Presentation - newborn with severe respiratory distress, absent breath sounds, scaphoid abdomen

Answer 3

Congenital diaphragmatic hernia

Question 4

The majority of CDH occur on the ___ side. The most common defect is located ___.

Answer 4

Left; posterolateral

Question 5

Herniation of abdominal contents results in ___ on ipsilateral and contralateral sides.

Answer 5

Pulmonary hypoplasi

Question 6

Compare the effects of pulmonary HTN vs. hypoplasia.

Answer 6

HTN - decreased pulmonary blood flow and hypoxia

Hypoplasia - decreased exchange, CO2 retention

Question 7

Common anomalies associated with CDH?

Answer 7

Chromosomal defects
Rotational defects
Cardiac (VSD/ASD) defects
CNS defects
Limb defects
GU defects

Question 8

Management of CDH?

Answer 8

Immediate intubation with ventilator support if signs of respiratory distress
Delay surgery to allow lungs to mature and pulmonary HTN to improve or reverse
Evaluate for other anomalies prior to surgery

Question 9

Why should you avoid blow-by oxygen or excessive bag-mask ventilation in CDH?

Answer 9

This may worsen lung compression and mediastinal shift

Question 10

True or false - bilious emesis in a newborn (0-1 months) is a surgical problem until proven otherwise

Answer 10

True

Question 11

True or false - passage of meconium rules out obstruction.

Answer 11

False

Question 12

In a stable newborn with bilious emesis, what should be done first and why?

Answer 12

Plain abdominal radiograph to r/o gross perforation, proximal vs. distal obstruction, presence/absence of distal case

Question 13

Presentation - “double-bubble” + no distal gas = ?

Answer 13

Complete duodenal obstruction (usually duodenal atresia)

Question 14

If distal gas is seen, what should be suspected?

Answer 14

Malrotation with midgut volvulus (before duodenal web or partial duodenal obstruction)

Question 15

Cause of duodenal atresia?

Answer 15

Failure to recanalize early in development

Question 16

Common anomalies associated with duodenal atresia?

Answer 16

Trisomy 21
Annular pancreas
Cardiac

Question 17

Management of duodenal atresia?

Answer 17

Correct fluid and electrolyte imablances and place NGT first
R/o other anomalies prior to surgery
Unstable patient -> suspect malrotation with midgut volvulus and go to OR emergently
Duodenoduodenstomy is procedure of choice

Question 18

True or false - bilious emesis during infancy (1-24 months) is a surgical problem until proven otherwise.

Answer 18

True

Question 19

Work-up for a stable infant with bilious emesis?

Answer 19

Plain abdominal radiographs first to exclude gross perforation
If negative -> UGI contrast study to evaluate the duodenum and proximal small intestine
Always suspect mal with midgut voluvulus

Question 20

What is the midgut and what supplies it (artery)?

Answer 20

Second portion of duodenum through 2/3 transverse colon; SMA

Question 21

Cause of malrotation?

Answer 21

Developmental failure of normal 270-degree counterclockwise midgut rotation

Question 22

Classic appearance of malrotation on imaging?

Answer 22

Narrow mesenteric base
Ligament of Treitz located right of midline
Cecum in epigastrium
Ladd’s bands from cecum to RUQ crossing duodenum

Question 23

What happens in volvulus?

Answer 23

Midgut rotates around SMA axis leading to duodenal obstruction and vascular compromise of bowel`

Question 24

Classic UGI appearance of malrotation?

Answer 24

Corkscrew appearance of contrast in bowel lumen

Question 25

Management of malrotation with volvulus?

Answer 25

Place NG tube to decompress stomach
Give ABX and IVF while preparing for laparotomy
If hemodynamically unstable with acute GI obstruction -> rapid fluid resuscitation, immediate surgical intervention without additional studies
Ladd’s procedure - relieve obstruction by untwisting bowel, prevent future episodes by broadening mesenteric base
Exclude duodenal stenosis or atresia during surgery

Question 26

True or false - malrotation with midgut volvulus may present with non-bilious vomiting

Answer 26

True, depending on location of obstruction

Question 27

Most common surgical cause of nonbilious vomiting in an infant?

Answer 27

Hypertrophic pyloric stenosis

Question 28

Classic presentation of pyloric stenosis?

Answer 28

Projectile, non-bilious vomiting in healthy 4-8 week-old male with palpable RUQ olive mass, visisble peristalsis over the epigastrium. Hypochloremic, hypokalemic metabolic alkalosis and paradoxical aciduria

Question 29

Dx pyloric stenosis?

Answer 29

If unclear, U/S. Criteria: pyloric length >15 mm, thickness >3 mm.
If U/S equivocal or concerned for malrotation with midgut volvulus or GERD, contrast UGI

Question 30

Management of pyloric stenosis?

Answer 30

Fluid resuscitation, correct electrolyte imbalances
Ramstedt pyloromyotomy (gold standard) - incise/split muscular layers, leaving the mucosa and submucosa intact
Delay surgery until infant is resuscitated and lytes are normal

Question 31

If there is persistent vomiting post-op from a pyloromyotomy, what should be evaluated?

Answer 31

Possible incomplete pyloromyotomy

Question 32

Gastroschisis v. Omphalocele?

Answer 32

Gastroschisis - paraumbilical (typically to the R of the umbilicus), exposed bowel

Omphalocele - umbilicus inserts into the sac, associated with more congenital defects

Question 33

Conditions associated with omphalocele?

Answer 33

Beckwith-Wiedemann Syndrome
Trisomy 13, 18
Pentalogy o Cantrell

Question 34

Cause of gastroschisis vs. omphalocele?

Answer 34

Gastroschisis - in utero vascular insult, abdominal wall defect

Omphalocele - arrest of cell migration, incomplete return of midgut to the peritoneal cavity

Question 35

Neonatal management of gastroschisis or omphalocele?

Answer 35

Secure the airway (difficulty ventilating suggests a problem with the lungs)
Normothermia and fluid management (radiant heater, orogastric suction, protect exposed viscera with plastic wrap, IV fluids and ABX)

Gastroschesis - surgical evaluation for atresia, ischemia, or volvulus. TPN when intestine appears inflamed
Protective silo and serial reduction
Surgical repari

Post-op: vent requirement may persist, TPN if necessary, monitor for abdominal compartment syndrome

Question 36

Presentation - newborn with excessive drooling/feeding difficulties - desaturations only while feeding?

Answer 36

Anatomic or functional problem with proximal aerodigestive tract

Question 37

Best initial diagnostic test for feeding difficulties with excessive drooling?

Answer 37

AP and lateral CXR after NG or OG tube placement

Question 38

Most common TE fistula?

Answer 38

EA with a distal TEF (Type C)

Question 39

Common associated abnormalities with TEF?

Answer 39

CV most common

VACTERL

Question 40

Management of esophageal atresia/TEF in infant?

Answer 40

If respiratory compromise - intubate/MV
Pre-op goal: minimize risk of aspiration (suction upper esophageal pouch, head elevation, ABX)
Evaluation for anomalies (echo, renal U/S, radiographs)
Surgery - division of fistula tract, repair trachea, primary anastomosis of the esophagus
Post-op complications are very common (leak, stricutre, GERD)