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Common problems In Pediatric Surgery
• •1J'Yll1iiu~'YnJlhw'l 'Il1~'llmffllVftll'f~{ !l1Ull1hiA'~lv'l ~~ii
I. Respiratory Distress Syndrome
2. Acute Abdomen
3. GI bleeding
4. Mass (tumor)
5. Miscelleneous
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RespIratory distress in new born,d... d 'i.!
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Classification of neonatal respiratory distress
I. Medical condition - Pulmonary edema
CHF
Pnewnonia etc.
2. Surgical condition
2.1 Developmental anormalies of the oropharynx. b' dro . ~«\' .L~ '''\ I-- ~~- j\IIn\1.l t.~,:l v~(j~~h).- PIerre Ro 10Syn me Vl""";S,, 11""" ,.,Im ~"
- Retrognathia with, without cleft palate
- Malformation of cheek, tongue
- Hematoma of tongue("CtHtH'1M vf\.ll.../
- Haemangioma of tongue '\
• Nasopharyngeal tumor - i~"'\""''l"'I>~- Chaochal atresia' ~- {.;I"',<A1~lilu',
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2.2 Laryngeal and tracheal malformations
• congenital microlarynx
• congenital of the larynx
- Laryngeal web
- Haemangioma of the larynx
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- Tracheal stenosis
- Traeheolaryngeal malasia
2.3 Massive swelling of neck and floor of the mouth'.
2.4 Pleural conditions
- Empyema flllJl1lr~ infection ••• >yoJu;, for nl<l
- Haemothorax lltl~trauma ••
~Pneumothorax "Hr~resuscitation, on respira
2.5 The pulmonary condition
- congenital lung cyst •
- congenital lobar emphysema
- congenital cystic disease oflung - CCAM
2.6 Mediastinal condition
- Pneumothorax ••
- Mediastinal teratoma
- Duplication cysts - Esophageal duplication
2.7 Diaphragmatic hernia ••••
2.8 Tracheoesophageal malformation •••
2.9 Abdominal condition ••••
- Intestinal obstruction
- Abdominal distension due to
Ascitis, Bile, Chylous
Peritonitis
Intraabdominal mass
Principle of management
~ "...1 v Q; Yb1 ..J.""J'llJVYiUrespirat.ory failure lflfl'IJU~:::9mnUlLfll'IJfll ~111m9,J'l1lfl~'lJU
i~""""....Q; $I 1 ~11fl1'1U~IIIJ'l1lJflflV~ ~VVlrrV clinical sign Lm:::fl , investication
• 4 l . .•'" ~, i-Im1~11l Degree of respITatory 1L~:::l1H)metabolic ac doSlS lYimUlJILU1'l1Nfl1"fl~1~V 1J
1Mfl1' l'fl~ll'1 NflMfln lJ~ llJ11111191,Clinical groups of degree of respiratory distress
2.2
3
I. Severe respiratory failure in present
1.1 Endotracheal indubation & assisted ventilation
1 ';1' " ~.. 1" 1 ",.1 ,1.2 Tracheostomy U'llVl1 11'tube 111l11lJ'lf1VMM1V~~'lJU l'lfU tracheal stenosis
2. Mild to moderate respiratory distress in present (not treatening of life) 11ll:;lrl!JiJ~ll.jl1'll1.J
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2.1 Investication MllY1LM'l1'lfUx-raylid ,,!'t1 ~1ll1Ylf1!J1m'l11l1~:;'l!J~llf1I'IJ'lllJ'IJ!J I
2.3 Resuscitation 'lllJfl11lJ~11tlulm:: 1 M'f1m.h.;~i'f11l1mlJr\'ULM'l
3. Resiration distress is not present, work for Diagnosis 111l:;i'mn911lJ.rULM'l~!Jill, "e:l •.•
Acute abdomen !J1m'l'l11~'lf!J~l1!J~UW1.J'YlllU
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h\'lu.r!J~m 1~ll1'lJ!Jill• CBC, Urine, stool exam
• Chest film PA,
• KUB
• (Ba. Enema)
• Upper GI series
• UlS of abdomen
• CT & etc.,'" ,!!10l'ln'Yl1J1J!!V1'IJM Acute Abdomen
I. Abdomen pain
2. Diarrhea
3. Vomiting nausea
4. Fever
5. Contipation,obtipation
Common causes of Acute Abdomen
I. Traumatic
Blunt trauma
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Stab wound /I'\~'"nl' '1'''01Blast injury
2. Non traumatic caused
With bowel obstruction
With out bowel obstruction
Adhesion
Infection
Congenital
Perforation
Vulumlus
Etc.
Intestinal obstruction" " ..!I d S1 ••• ~ '"I "I I I ••• ~
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I. Non biliary vomiting
Atresia & stenosis *.
1.1 Intrinsic caused
Esophageal atresia TB malformation 00
Chalasia
Hiatus hernia
Esophageal stenosis
Hypertrophic pyloric stenosis
1.2 Extrensic causes
vascular ring
Duplication
2. Biliary vomiting
2.1 Duodenal obstruction
,lJd1l.,kAnular of pancreas 000 dooU. 'ian.Duodenal Web an diaphragm 00 'l\o\h bw'o\. )
2.2 Malrotation 0
2.3 Jujunal, ileal atresia 000
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2.4 Meconium ileus ~\1~>t\o('n
2.5 Meconium plug syndrome J2.6 Duplication
2.7 Hirschsprung's disease (Megacolon) ••••
2.8 Imperforate Anus (with or without fistula) ••••
2.9 Volvulus - mid gut
Non intestinal obstruction
I. PU Perforation, Gastric perforation •
2. Intestinal perforation - Typhoid perforation ••
3. Enderocolitis: Acute segmented ischemic jejunitis '1nm'D~u'1,],l
NEe (Neonatal necrotizing enterocolitis)"
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8. Liver abscess rupture •
9. Mesenteric lyphadinitis •
7. Intraperitonial hemorrhage
6. Bile peritonitis
5. Mechel's diverticulitis •• disease on S- 'ccl> U ""~ l.c,- nUlL,
Hirschsprung's disease ••••
4. Acute appendicitis •••• '\....(\~ I "."n, ~O, /0.0 ~nl,,;\l<Nv I r-h~'e",\\;)ryC n1Q 0nm
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10. Abdominal tumor, Wilm tumor. Neuroblastoma, Hepatoma ••., -"'"0fh.~hM~,rrd>l <: p-rfolak
11. G.U. tract, GU mfeclIon ',~. '-.l\ ',,'VfH ~v.- ? 00, \...., rp"ndi\
TorSion testis' - (Retractile testis)
PID
Epididymo~is ~,,,rrr.~~Ectopic pregnancy
12. Hernia
Management
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1. NPO, GI Decompression
2. Fluid electrolyte correction
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3. Fluid I/O
4. GIM & blood transfusion mlJmllJ~ll1'Jw
5. Preoperative care
6. Antibiotic cover gram negative gram positive L111::Anaerotie \llllJt111lJ~111'JW
7. Temperature controlod..... .d jJ
Surgical treatment \lll1JfflLl1ijVl'VlU'I1l1~Resuscitation f1Utl1
Early diagnosis, and proper operation
1. Pre-operative care - Resuscitation hl'~~l1\ll
2. Operative care F.h.r\lli"n1Jl~WLl1ij'll!H1Hl
3. Postop care - wound care
Intake and output
Antibiotic
Prevent complication etc.
Prognosis.1 ~ 9. ~~ ~ 1 ,.. "" "o 'IIWnU011 ~'I10111w~n/J 1t1 mJn~HH11\ll111L1lJW/Jlll\ll'I1W
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Gastrointestinal bleeding
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Gastrointestinal Bleeding,• ••Etiology Vl\llltJ~lfll'11~VVf1mlJVlqll'l"ltJ
1. New born
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o Swallowed matamal blood (most common) •••
o Primary coagulation defect (Common) ••
o NEC ••• lurol'\
o PU (stress ulcer, Drug induced) 'io As ~ I \I\Jcnvi\1~ '11'L
o Gastric erosion
o Anal fissure (common) •••
7
o Yovlus (Rare)
••2. Infancy (J-241'lfJU)
Most cOmmon
- Anal fissure
• Meckel's diverticulum
- Intussusception
• Polyps
- Duplication
3. Children (over 2 years)
• Polyps
- Meckel's diverticulum fl'qrri vtJ.
- Duplication
- Amebic colitis
• F.B.
oJ &!:I Q,oO I uClinical picture fJ1mn1l'l1JfJ1UlJllnlJru::911~'1 f1U9IllJl1'lll1~
Epistoxis Nasopharyngial bleeding
Bleeding Hematemisis upper GI
- upper GI
- Melena upper G.!. bleeding
- Hematochezia (Reddish brown) mid gut
- Fresh blood, Lower GI, Anus
Less COmmon
PU & Stress ulcer
Peptic esophagitis
Esophageal varices
Enterocolitis
FB trauma
Less cOmmon
Esophageal varices
Ulcerative colitis
Peptic esophagitis
Intussusception
Hemach-Schonlein purpora
Hemorrhage gastitis
- Bloodymucous or Gelationus, GI irritation
Volume of bleeding
1. Massive bleeding
• Meckel's diverticulum
- Esophageal varices
- Acute hemorrhagic gastritis
-PU
- Colonic polyp
- Leech in rectum
8
- Acute gangrenous jejunitis
2. Scanty
. Rectal polyp
. Amebiasis
. Intussusception
. Prolapse rectum
• Anal fissure .
Investicatlon
• NG intubation and lavage
. PR 'lltnllJ ••
. Stool exam for occult blood
- Proctoscope and sigmoidoscope
• Colonoscope
. Gastro and esophagoscopy
. Baenema
- Upper GI series
T 99M •. x scannmg
• Serial Hb & Hct
. PT & PTI Coagulation study
Treatment
~ v'1. Medical treatment 1110fllJ'l'J0'1111J
- Emergency therapy - treat shock - IV fluid
. Blood transfusion
• Vit K I
• GI lavage & Decompression
. Specific treatment - Antacid, Histamine Iireceptor antagonist etc.. Depend upon etiology
• Follow up - observation
• • ••• InveslIcatlon l'l'lfll1ll'1'1lMfJ
9
2. Surgical treatment
.1 '~v 1 '" i d" v , " v- "U1Wfl1J~Um~"ll~ 1f1111ll Ufl1Oll'lconservative 11"1 lJ f1H"• •- Preop & postop care.; , i d .d""Incidence 'YI'111J1JlllJUlflfll'llJbleeding perrectum
Rectal polyp 36.31% .
Intussusception 17.58%
Amebiasis I 1.55%
Anal fissure 9.22%
Negative study 15.58%
Mass LtJUUfll'l'lm"ll1rl~~'I11J1hw1fIlJlJ1~i'1/Jl~ll~ihl'llUtJiI1w1iwl nu llWl'ltJ1" lJu~LiiI]j1l1lljjmfl11~'A'I. Swelling of the neck
- Nonspecific hyhperplesia, of corveral LN ••
- Acute lymphadenitis •
- Chronic specific lymphadenitis ••
- Lymphoma'
- Thyroglossal cyst ••
- Bronchial sinus or cyst'
- Cystic hygroma ••
- Epidermoid cyst
- Thyroid swallowing
- Neonatal coiter
- Colloid goiter'
- Thyrotoxicosis
- Adenoma
- Carcinoma
- Torticolis ••
~.1,~ ~,;<, ''''V ~ 1fl1nmn"Ull~fltJfl11m1~flmlluUll~ 1~~ l1fl1nflfllmlJl'I'lm>]"IH 1f1v i)l d _I 'j} <!t)1 ..; I
2. Abdominal mass flllU Ul'lll~m~lJmfll1u1f1'11ll~ 111llfl1IJlllfl11llU'l nlJ
55-60 % Medical problem
40-45 % Surgical problem, 50% GU tract
10
Age incidence
Neonate - congenital kidney inorigin
hypertrophicpyloric stenosis
Intussusception
Malignancy - Wilum's tumor
5iJ - Neuroblastoma
- Rhabdosarcoma
- Malignant lymphoma
\
Congenital Benign lesion - Hydronephrosis
8'"1] - Cyst
------Inflarnmatory - Appendicial abscess
Incidence Llti~mlJrrll11'l~""1J'jh'1'Ill1. Malignancy 20%
2. Congenital abnormality 20%
3. Inflammatory mass 20%
4. Spemomagaly 20%
5. Other mass 20%
Etiology ~""lJ~1'1ill1. Congenital
2. Inflammatory
3. Trauma
4. Tumor
5. Miscellunoma
Hydronephrisis
TB abscess
Hematoma
Malignancy, Benign
Intussusception
II
Sign & Symptom Imlillltll5111lJ hili 1l1~YlU"wu~lihy i.WlllJ 'I11lJll1Jll~'111~lJlJdilti'lJ1Jlld~u~nlll
1 'I Y ''1 Q Y ~ Y Q Q' Q d.. Y dIU' ,'I '\Jill:: 9llJlnUllUlll'l l1U 1111::lJ"'I1f111UIl1U1::'\JNll'lU~lYlU~'I 1l1~lJllltll5l51mll'lflf11~Il'lflJA. Acute on set- Intussusception
- Appendicial abscess
- Twisted cyst
B. Slow progressive
Malignancy - Wilm's tumor
- Neuroblastoma
- Rhabdosarcoma
Benign
- Malignant
- Congenital hydronephrosis
- Mesenteric & omental cyst.1 I ••••••• I ~ •••• • ..d. ~
lnvestlcation '\JlJlJ~f1Uflfl1111::151l1~Yl~nIll111lmlJl1~1IUlJ
- Routone lab
- KUB, chest film PA
- VIS 'lhU'lJtll51iJ~l1unllUlJ/h~lJlf1
- IVP, RP
- Angiogram, venogram
- CT
-Homonal study
- Bone, Liver scan
• Bone marrow study
Treatment
- Surgical treatment
- Merlocal treatment
- Total excision
- Radical surgery
- Internal drainage
. External drainage
• Partial excision
- Palliative or bypass procedure etc.
- Antibiotic
. Anti. T.B.
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- Surgery & Medical
- Chemotherapy
• Etc.
- Hydrocele •••
_Undescended testis" ~'''''''uS~tlV1
- Trauma *
- Gastroschesis ••
- Bum'
- Surgery & Radiation
• Surgery & Medical & radiation
- Omphaloce1 ••
- Hernia IIH ••••
- Medical & Radiation
.x '~Q 1';'" ' ~Prognosis 'lJ1J{)~n'lJ'lf1J~'lJtH~tlYll1J1JLLCl::m~response ~tlm~~n'lJl
Miscellenous htl~61~'Yl'lJumJ'1
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- Torsion testis
- Obstruction jaundice - Biliary atresia ••
- Choleductal duct cyst •
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