Category Archives: PAEDIATRIC SURGERY

Jejunoileal atresia

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Type I:
intraluminal diaphragm or web may present with windsock anomaly.
NO MESENTERIC DEFECT
NORMAL LENGTH

Type II
Connected by fibrous atretic cord.
NO MESENTERIC DEFECT
NORMAL LENGTH

Type IIIA
NO FIBROUS CORD
VSHAPED MESENTERIC DEFECT
SHORTENED LENGTH

Type IIIB
bowel wraps around a single perfusing vessel( christmas tree app)
LARGE MESENTERIC DEFECT
SIGNIFICANTLY SHORTENED

Type IV
MULTIPLE DEFECTS

Whereas associated anomalies are found in 30-40% of neonates with duodenal atresias, associated anomalies are found in only 10% of neonates with jejunoileal atresias

There is maternal polyhydramnios

RX
RESECTION AND ANASTOMOSIS
TAPERING ENTEROPLASTy(for shortenede bowel)

From emedicine:

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Intestinal atresia type IIIa. A clamp is applied on the distal bowel, and sodium chloride solution is instilled through a purse-string suture to dilate the intestine and diminish the size discrepancy between the two loops to facilitate the anastomosis. The dotted line marks the area of the resection.

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The proximal dilated pouch is transected in a 90° angle to maximize its vascularity, while the distal intestine is transected obliquely to diminish the size discrepancy between the segments.

Malrotation and volvulus neonatorum

Volvulus always associated with malrotation

Two presentations
Acute:bilious vomiting(metabolic acidosis) The volvulus may compromise blood flow leading to ischemia hence tender rigid abdomen

We fear from massive loss of small intestine if neglected…he may not survive…or the lesser catastrophe is the SHORT GUT SYNDROME

Chr: chr intmt abd pain, constipation.

DOUBLE BUBBLE SIGN

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Normally SMV IS ON THE RIGHT. IF THE REVERSE HAPPENS, SUSPECT MALROTATION.(BY U/S!!!!!)
DILATED STOMACh AND DUODENUM WITH TWISTING OF THE MIDGUT LOOP: applepeel, twisted ribbon, corkscrew

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Do ladds procedure:
Untwist
Divide( ladds band)
appendectomy

Neonatal duodenal obstruction

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SEARCH FOR ASSOCIATED ANOMALIES!

Normal or scaphoid abdomen is obs is proximal!

FIRST OF ALL, RESUSCITATE AND DECOMPRESSION

ITS DANGEROUS!!! WHY??
close proximity to the ampulla of vater & pancreatic blood supply.

Rx: DUODENODUODENOSTOMY AND DUODENOJEJUNOSTOMY. IF THERE IS MALROT- LADDS PROCEDURE
we can also do DIAMON SHAPED ANASTOMOSIS BECAUSE THE DIAMETER OF THE PROXIMAL AND DISTAL PART TO THE OBSTRUCTION IS NOT PROPORTIANATE.

In duodenal web, do DUODENOTOMY. BE CAREFUL OF OTHER DEFECTS AND AMPULLA OF VATER.

?

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About ladds band(excerpt from emedicine)

abnormal cecal peritoneal bands that cross over the duodenum in the right upper quadrant may be found in cases of malrotation. These abnormal cecal attachments are called Ladd bands. In both nonrotation and incomplete rotation, cecal bands may cause obstruction and ischemia before birth, leading to congenital duodenal atresia or stenosis

In many cases, the abnormal Ladd bands cause only partial and intermittent obstruction, which can manifest as intermittent episodes of bilious vomiting and/or feeding intolerance.

I5

Previously healthy baby

Red currant jelly stool is a late sign..dont sit and wait for that to happen

Not so hi mortality rate but we fear of transmural gangrene

Commonest age…age of weaning 4m-10m

If more than 2 y, suspect a secondary cause..the most common 2ry cause is ileocecal lymphoma and meckels

Important signs:
Dance s
Target s
Cobra head s
Air fluid level
Pseudokidney s

25% of abdominal surgical emergencies less than 5, EXCEEDING APPENDICITIS

ANY CHILD W BILIOUS VOMITING, CONSIDER IT A SURGICAL DISEASEUNTIL PROVED OTHERWISE

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IHPS

More common in males

First male

Hypochloraemia, hyponatremia, hypokalemia metabolic alkalosis

U/s! Thickness >4mm, length >16 mm

Dehydration, failure to thrive, HUNGER AFTER FEEDING,OLIVE MASS, PROJECTILE, NON BILIOUS VOMITING, persistent and progresses with time.

IT IS NOT CONGENITAL HENCE IT NEVER PRESENTS before 2weeks of life. It takes time for the circular muscle to undergo HYPERTROPHY AND HYPERPLASIA ( >2wks- 8wks)

DDX OF NON BILIOUS VOMITING: physiological GERD/ proximal to ampulla of vater duodenal obstruction/ errors in feeding/ NON SPECIFIC MARKER OF ILLNESS

TREATMENT: RESUSCITATE FIRST, THIS IS NOT AN EMERGENCY.
DEFINITIVE TREATMENT= RAMSTEDT PYLOROMYOTOMY

Important! Look for target sign.
String sign.

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Double bubble sign

Due to the exams tomorrow, i bet more than half will diagnose duodenal atresia when he/ she sees the double bubble sign, when in fact, there are numerous cause that can produce the same effect.Its not an exclusive sign, you know?

In general, this sign denotes an obstruction present, whether the cause is external or internal at the duodenum….probably the 2nd or 3rd part.

Causes:
Duodenal atresia/web/stenosis
Annular pancreas
Malrotation with volvulus
Preduodenal portal vein

It is accompanied by relative paucity of the lower GI tract.

An excerpt from here

The double-bubble is often accompanied by a relative paucity of lower GI gas. This is highly suggestive of volvulus or duodenal stenosis and atresia. A double-bubble sign with paucity of lower GI gas combined with clinical signs and symptoms of distress, such as fever, lower abdominal distention, melena, or hemodynamic instability, suggests volvulus and possibly gangrene and should lead directly to laparotomy. In this situation, pneumatosis coli may be observed on plain radiographs and is an ominous sign.

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Train your pretty eyes bayybeh!!!

Robert downey jr

I am so elated today because robert downey jr taught us lecture today.hahaha…. Not literally …

Doctors and professors are like celebrities to me! In fact, in my eyes, their position is unquestionably higher than hollywood stars who serves nothing to the community…except some…maybe.

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P/s: dont ask me why i call him robert downey jr. Hahaha.

Hirschsprung’s disease(HSD)

When i was in my preclinical years…. I thought the diseased part is the dilated part.it turns out that i am actually wrong all these years!!

That usually happens if you plan to study and NOT UNDERSTAND.boohoo.

It is the narrown part that is the diseased….why? The parasympathetic ganglions are missing so…the sympathetic takes the upper hand… Leading to spasm.

Basically….. The complaint will be delayed passage of MECONIUM….normally it would take one to two days… If it goes beyond that…. List a handful of DDs.one of them being HSD.the abdomen is so freakin distended that you can literally see the colon through the abdomen!!!

The problem with hsd is actually enterocolitis…. In babies…this is fatal! Due to the stagnation of stools…..this invites EC so easily….. And what we fear from is SEPSIS…..

The Dr said…PLEASE DONT DELAY SURGERY FOR HSD!!!

There is no rule for conservative treatment of course….

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So…what to search for??? I dont think just by plain xray would 100% conclude that its hsd. Anyway, you will find a distended colon…filled with gases…. And in one of the pics… The rectum is devoid of any gases….

By barium enema…on the lateral view, clearly shows…. The proximal dilated segment….and the distal narrower segment denoting the defective part….

Some important notes to remember…
An excerpt form emedicine:

Barium enema
Avoid washing out the distal colon with enemas before obtaining the contrast enema because this may distort a low transition zone.
The catheter is placed just inside the anus, without inflation of the balloon, to avoid distortion of a low transition zone and the risk of perforation.
Radiographs are taken immediately after hand injection of contrast and again 24 hours later.
A narrowed distal colon with proximal dilation is the classic finding of Hirschsprung disease after a barium enema. However, findings in neonates (ie, babies aged < 1 mo) are difficult to interpret and will fail to demonstrate this transition zone approximately 25% of the time.[21]
Another radiographic finding suggestive of Hirschsprung disease is the retention of contrast for longer than 24 hours after the barium enema has been performed.

If you suspect perforation or enterocolitis..so dont perform barium enema as it may pass to the peritoneum if this happens and leading to chemical peritonitis.

From what i have studied…. Sometimes… There is no delayed passage of meconium….so when this happens… You need to DD it with other diseases..

If the results is negative for hsd after rctal biopsy, do the SWEAT TEST to detect whether it is CYSTIC FIBROSIS.

this is a nice read. 🙂

Renew your intention

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Meconium

Today…there was a presentation…. And i kinda wondered…….whats a meconium plug syndrome!!! I didnt know…. Thats okay.there is nothing to be ashamed of. Feeling insufficient when you are seeking knowledge is a good sign.dont feel stupid…. Because you are not.

Excerpt from emedicine

Meconium plug syndrome, also termed functional immaturity of the colon, is a transient disorder of the newborn colon characterized by delayed passage (>24-48 h) of meconium and intestinal dilatation

Oooooooooooo……gtew rupanya…

And meconium ileus???? Its due to impaction of inspissated meconium…and it happens in babies with cystic fibrosis.

Tracheooesophageal fistula

This is what i asked the doctor just now
IN ONE OF THE BABIES WITH TRACHEO OESOPHAGEAL FISTULA, THE FIRST PRESENTATION RIGHT AFTER BIRTH WAS… RESPIRATORY DISTRESS…. WHY????

Normally…. In Tof, dpending on which type…. If there is oesophageal atresia…. So there maybe accumulation of saliva…which will enter the respiratory tract by the larynx i suppose… Leading to aspiration….or…if we do feeding to the baby,…( not in the same case though) the milk may get aspirated to…or…. After feeding,… Depending on the type of tof…gastric reflux may enter the respiratory tract by the fistula..
The doctor drew this

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Btw…if the upper oes pouch is too much away from the lower pouch… Gastrotomy and oesophagotomy is done…and temporary?

Some xrays on TOF

search for the kinked nasogastric tube.
The stomach may or may not be distended…this dpends on the type of TOF.if the fistula is connected to the oesophagus then to the stomach..so some air will enter causing this distension.

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How to manage?
Prior to operation…give him medical care…. The primary repair….should be delayed if his lungs condition doesnt permit him ….
Medical care includes:
Continuous suctioning to prevent aspiration
ETI distal to the part of fistula to prevent GASTRIc REFLUX
Be aware that this condition may deteriorate the lung due to the aspiration…if he has infection…administer antibiotics….

Extracted from emedicine…read further here.

If the patient develops acute respiratory failure, endotracheal intubation and mechanical ventilation are performed. Administer broad-spectrum antibiotics for patients who may have developed lower respiratory tract infection. For patients known to have pneumonia or other pulmonary problems, a gastrostomy for gastric decompression may be required to prevent further reflux of gastric contents into the trachea. The use of proton pump inhibitors may be helpful.

Btw….this is the most common type

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