Some Pediatric surgical problems - PowerPoint Presentation

1. Some Pediatric surgical problems Three days old NN brought to the hospital by caregiver C/O not passing meconium , but passing urine normally .The condition is associated with abdominal distension, lethargy , decreased feeding & appearance of jaundice ,the pregnancy is uneventful, apart from some polyhydramnios .on Exam. there is abdominal distension and decreased primitive reflexes , no dysmorphic features but jaundiced.

2. Some GIT surgical problems Duodenal atresiaThe incidence of duodenal atresia is 1 in 10,000, and accounts for 60% of intestinal atresias.•Detected at antenatal sonography in ~ 50% of cases— ‘double bubble’ &polyhydramnios..Postnatally, vomiting occurs in the first 48 hrs & is bilious if the obstruction is distal to the ampulla of Vater (two- thirds of cases), or non- bilious if the obstruction is proximal.NG decompression & IV fluid resuscitation. Surgery is usually not an emergency.SurgeryDuodeno- duodenostomy (laparoscopic or open). The proximal &distal duodenal pouches are opened and joined— bypassing the atretic segment. Placement of a trans- anastomotic (nasojejunal) tube allows early enteral feeding, and avoids the need for long line/ parenteral nutrition.Long- term outcome : duodenoplasty is required if severe proximal dilatation occur

3. Anatomy of the anal canal. (Adapted from Brunicardi FC, Anderson DK,Billar TR, et al: Schwartz's principles of surgery , ed 8, New York, 2004, McGraw-Hill.)Imperforate anus in females. A, Vestibular fistula. B, Cloaca. (From Peña A: Atlas of surgical management of anorectal malformations , New York, 1989, Springer- Verlag, pp 50, 60.)

4. Imperforate anus in males. A, Low lesions. B, High lesions. (From Peña A: Atlas of surgical management of anorectal malformations , New York, 1989, Springer-Verlag, pp 7, 26.)

5. Intussusception occurs when a portion of the alimentary tract is telescoped into an adjacent segment.5 mo & 3 yr of age~ 90% of cases of intussusception in children are idiopathic.2–8% of pts, recognizable lead points for the intussusception are found, such as a Meckel diverticulum, intestinal polyp, neurofibroma, intestinal duplication cysts, inverted appendix stump,leiomyomas, hamartomas, ectopic pancreatic tissue, anastomotic suture line, enterostomy tube, posttransplant lymphoproliferative disease, hemangioma, or malignant conditions such as lymphomasudden onset, in a previously well child, of severe paroxysmal colicky pain that recurs at frequent intervals and is accompanied by straining efforts with legs and knees flexed and loud criesclinical history and physical findings suggest intussusception, an ultrasound is typically performedIntussusception in an infant. The obstruction is evident in the proximal transverse colon. Contrast material between the intussusceptum and the intussuscipiens (arrows) is responsible for the coiled-spring appearance.

6. Hirschsprung diseaseHD is congenital aganglionosis of the distal colon, extending proximally from the rectum. HD usually affects the recto- sigmoid only (short- segment). In 25% of cases, aganglionosis extends more proximally, total colonic aganglionosis occurs in 10%.Classic triad is of neonatal bilious vomiting, abdominal distension, & delayed passage of meconium (>48 hours).Diagnosis Suction rectal biopsy can be performed in the neonate without general an-aesthesia (GA); open biopsy under GA is required in older infants/ children. Dx is confirmed by histological confirmation of absent ganglion cells (H&E stain) and hypertrophic nerve trunks on acetylcholinesterase staining. Calretinin staining (absent in HD) may be supportive.Contrast enema may demonstrate a transition zone,Surgical treatment is excision of the aganglionic segment and colo- anal anastomosis (pull- through) of proximal normally innervated colon. Initial management is directed at nasogastric decompression, rectal washouts (up to three times per day, retained volume should be <20mL/ kg saline)

7. Non-bilious vomiting is the initial symptom of pyloric stenosisstarts after 3 wk of age, but symptoms can develop as early as the first wk of life and as late as the 5th moHypochloremic metabolic alkalosis .Unconjugated hyperbilirubinemia is more common than conjugated and usually resolves with surgical correctionDx by palpating the pyloric mass. firm, movable, approximately 2 cm in length, olive shaped, hard,best palpated from the left side, and located above and to the right of the umbilicus in the mid epigastrium beneath the liver's edge.Ultrasound examination confirms the DxGastric peristaltic wave in an infant with PSTreatment 1-Supportive2-Surgery

8. Esophageal atresiausually associated with a tracheoesophageal fistula

9. *Select patients with abdominal pain who require emergency Tx.*Show clinical findings which are key to instituting the most likely source of the pain.*Distinguish acute from chronic pain & organic from functional*Understand the abdominal x-rays*Perform an effective plan of Mx for a pt with AP *Define which pts have significant liver dysfunction & its cause*Distinguish between the causes of jaundice .*immunization status, past & FHx. *Discuss abnormal LFT in the setting of the clinical presentation, & choice pts needing medical Mx.*Outline the epidemiology & natural Hx of viral hepatitis*Select & interpret an appropriate investigations for pts with jaundice (e.g., liver enzymes.*List the indications for an abdominal U\S, spiral CT, MRI, ERCP& PTC. *Outline a Mx plan for pts with acute hepatic failure.Learning objectives:

10. References:1.Nelson textbook of Pediatrics last edition2.Illustrated textbook of Paediatrics Last edition 3.Internet educational websitesTHANKS