Post on 03-Dec-2014
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1-Cervical rib in a child2-Diaphragmatic hernias3-Congenital pyloric stenosis4-Pyloric obstruction5-Coin test
• Plain x ray neck and upper chest ( thoracic inlet ) showing rib attached to transverse process of c7 in left side
• Diagnosis : Left cervical rib.
Q.1 : c\p ?? 1- neurological :- pain + parathesia
in lt should 2- muscle atrophy 3-Horner syndrome 4- Raynaud’s phenomenon
Q.2 : Other investigations ?? * M.R.I * U\S * Arteriography * nerve conduction study
Q.3 : D.D ?? *Cervical disc prolapse *carpal tunnel syndrome * other causes of Raynaud’s
phenomenon
Q.4 : TTT ?? surgical excision + 1st rib excision
+ myotomy of scalenus ant. muscle
• Cervical rib * Female patient حلق 30 يوجد years complaining pain & numbness in left hand
1- Diagnosis Left cervical rib
2- X ray of female (√)
3- X ray show scalene muscle hypertrophy (X) (As soft tissue not appear in x ray)
4- Thoracic outlet syndrome manifested at adult life (until hypertrophy of muscle)
5- Has relation to posture changes & occupation example: *persistent elevation of shoulder (hyper abduction) aggravate thoracic outlet
syndrome eg hairdresser, painter, lorry drivers *depression of shoulder by lifting heavy objects examples porters
6- In this case, vascular deficit > neurological one (X) (N>A>V)
7- Distribution of nerve is radial side (X) ulnar side (with wasting in hypothenar muscle)
8- Condition may be asymptomatic (√)
9- Condition dated since birth or early in life (X)
10- Commoner in painter & drivers not student (√)
11- Increase by abduction & face turing to same side (X) to opposite side
11- Anatomical variations & postural changes predispose to manifestations (√)
12- Bruit heard above midclavicular area (√) over subclavian artery at mid not medial 13- Surgery is mandatory (X) it may be asymptomatic *Resection of rib or first rib (supraclavicular or axillary approach preferred) *Division of scalene anterior
14- Addson's test (tilting the head to opposite side leads to increase pain & decrease pulse)15- post-stenotic dilatation can be manifested (√) to subclavian artery may thrombosis gangrene in
fingers
• Plain x ray chest + upper abdomen showing intestinal gas shadow in the chest
• Diagnosis : Congenital diaphragmatic
hernia.
Q. c\p ?? 1-abdominal pain 2- vomiting 3- distension +
constipation 4-c/p of complication
*respiratory distress *bleeding *intest. obstruction *vomiting *dehydration
• Gastrografin meal Showing stomach in the chest
• Diagnosis :
(cong diaph. hernia)
• Q. c\p as before
Congenital Diaphragmatic Hernia:
Young baby, his mother said that he is crying é dyspnea, tachycardia & cyanosis, tachypnea, ABG → show ↓ O2 saturation
1- Trauma is predisposing factor (× ) baby mainly congenital
2- This is congenital diaphragmatic H. (√ )
3- Thoracotomy is the best approach of ttt ( ( × Laparotomy is tried 1st to pull hernia content.
4- thoracotomy done in adults due to presence of adhesions with chest wall (√ )
5- needs C.T for sure diagnosis (√ )
• Gastrograffin meal• Ryle tube in chest ,
stomach in the chest on the lt side
• Left traumatic diaphragmatic hernia.
Q.1 : Investigation ??? 1-plain x-ray 2-gastrog.meal 3-oesophagoscopy
Q.2 : TTT ??? 1- conservative :
antishock measure + Ryle + i.v fluid
2-surgical reduction of the stomach e closure of the defect in the diaphragm
• Plain x ray chest.
• Left traumatic
diaphragmatic hernia.
• Barium enema with chest x ray.
• Traumatic diaphragmatic hernia.
• (splenic flexure in the chest).
• Q. ( see pediatric X-ray )
Traumatic diaphragmatic hernia
A- Early laparotomy
B- Late thoracotomy
*thoracotomy is tried in adult due to
adhesions é chest wall ( √ )
* Needs C.T for sure diagnosis (√ )
• Gastrograffin meal in Trenlenberg’s position showing reflux of the barium throw esophagogastric junction
• Diagnosis :
Hiatus hernia in a child.
Important Q. on Hiatus hernia Q.1 : C\P ???a) Asymptomaticb) Symptoms of reflux esophagitis : *heart burn *vomiting *water brash *Dysphagiac) complications : -esophageal stricture - Dysphagia >>> anorexia -malignant transformation -shortening of esophagus
Q.2 : Other investigations ?? *esophagescopy * esophageal manometry
Q.2 : TTT ??? *Conservative : (elevate head of bed , regulation of diet , Drugs >>> antacids , H2 receptor blocker , omeprazole ) * surgical : (antireflux operations) eg. : 1- Belsy mark 4 repair 2- Nissen’s fundoplication
• Gastrografin swallow lateral view
• Describe :
shows arrest of dye which fail to reach stomach (blind pouch full of gastrografin )
• Diagnosis :
Esophageal Artesia.
المرىء نهاية
Important Q. on esophageal ArtesiaQ.1 : C\P ??? * vomiting *constipation *distention *failure to thrive *complications : - inability to swallow - chocking & cyanosis - abd. Distention & flatulence - failure to catheter
Q.2 : Other investigations ?? *plain x-ray erect position
Q.3 : Other types of this anomalies ?? *Artesia e out fistula *fistula e out Artesia *Artesia e fistula to upper pouch *stenosis e out fistula Q.3 : TTT ??? * Conservative : (antishock measure + Ryle + i.v fluid ) *Gastric up if long Artesia or end to end anastmosis if atretic part is short
• Gastrografin meal erect position (lateral view) shows dilated stomach e narrow pyloric canal e cone shaped termination & failure of dye to reach intestine
• Diagnosis : Congenital pyloric stenosis.
• Gastrograffin meal erect position (lateral view) shows dilated stomach e narrow pyloric canal e cone shaped termination & failure of dye to reach intestine
• Diagnosis :
Congenital pyloric stenosis.
• Gastrograffin meal erect position (lateral view) shows dilated stomach e narrow pyloric canal e cone shaped termination & failure of dye to reach intestine
• Diagnosis : Congenital pyloric stenosis.
•CHPS
• CHPS
• CHPS
Important notes on (CHPS)Q.1 : Type of patient ??*common in 1st male baby with +ve family history
Q.1 : C\P ??? * vomiting (projectile , bile free , soon after meal ) *distension * constipation *olive shaped tumour *visible peristalsis * Complications : 1 - hypochloraimic alkalosis 2-Electrolyte disorder 3-dehydration 4- malnutrition 5-loss of baby wt.
Q.2 : D.D ??? *Pylorospasm *gastroenteritis * duodenal Artesia * intussception *volvulus neonatorum
Q.3 : Other investigations ?? *U\S (measure thickness of pyloric sphincter) * Gastric aspiration
Q.3 : TTT ??? ** Conservative : (antishock measure + Ryle + i.v fluid ) ** surgical : Ramsted operation ( pyloromyotomy )
Gastrographin meal CHPS Highly dilated stomach é convex very narrow pyloric canala) Abd. U/S is investing of choice (√) to detect /
– thickness >4 mm is diagnostic,– pylorus length > 14 mm is diagnostic .
Thickness is more pathognomonic than length
c) Diagnosis is clinically no need for investing (√)
d) presentation at 3rd – 4th week (√) ( from 1st day to 9th month )
e) ↑ gastrin one theory of explanation of cause (√)
f) Effortless vomiting (×) projectile < vigorous wave of anti-peristalysis
g) Bile free vomiting (√) ( bilious vomiting in duodenal obstruction )
h) Acute surgical emergency (×) Acute medical dehydration.
e) fluid of choice is hypotonic saline ( 0,5 % )
i) Hypochloremic hypokalaemic metabolic alkalosis (√)
j) palpable mass at Rt is indication of No further investing .
k) surgical approach paramediam incision (×) ( Transverse )
l) medical trial except in presence of olive mass
m) operation is Ramested operation ( longitudinal incision in muscle of pylorus till mucosa bulge . incision stop at pyloro-duodenal junction at pre-pyloric vein of Mayo
n) patient 3 weeks old presented with repeated vomiting & palpable epigastric mass /– abd. U/S is highly recommended for diagnosis (x) – it is medical emergency (√ )
• Gastrograffin meal.• Huge dilatation of
stomach and duodenum.
• Diagnosis : Duodenal obstruction.
• Q. ( see stomach )
• Q. Cause of intestinal obstruction in this case ??
failure of absorption of mesentery of caecum &asc. Colon leads to mainly to Volvulus neonatorum
( المريضطفل ان هنا الحظ
)
duodenum
stomach
• Barium enema shows barium arrest &claw sign
• Diagnosis :
Intussusception
intussusception & cancer caecum الفرق
ان بالك خلى السن هوصغير طفل هنا
• Barium enema. shows barium arrest &claw sign
• Diagnosis :
Intussusception.
• Barium enema. shows barium arrest & claw sign
• Diagnosis :
Intussusception.
Important Q. on Intussusception.Q.1 : etiology ?? ** P.Fs : -bulky ilieocaecal valve -wide ilieocaecal angle
-mobile caecum & ascending colon ** ppt. Fs : swelling of Payer’s patches due to: -gastroenteritis at time of teething or weaning
- respiratory infection by adenovirus
Q.2 : C\P ??? @symptoms : *Abd. Pain ( sudden , infant draws his leg up & screams )
*vomiting * Intussusception rarely protrude from anus
@signs : *mass ( sausage shaped , below costal margin , concave toward
umbilicus ) *Dance’s sign : sense of emptiness of Rt. Iliac fossa ( ascended
caecum ) *P-R : red current jelly stool
Q.3 : Complications ??? *intestinal obstruction e its Complications ( mention ) *gangren , perforation , peritonitis Q.4 :D.D ??? * Gastroenteritis & enterocolitis * rectal prolapse
*Hench Scheonlein’s purpura
Q.5 : TTT ??? ** Conservative : (antishock measure + Ryle + i.v fluid ) ** surgical : -Exploration & try to reduce Intussusception in situ by milking apex prox. -failed >>>> try again after hot fomentation -failed >>>> Cope’s method -failed >>>> open the ensheathing layer & reduce Intussusception
• Barium enema.
• Atresia of transverse colon.
• C\P , Complications , Invest. , TTT ??
(as intest. Obstruction )
• Barium enema.
• Total colonic Atresia
• C\P , Complications , Invest. , TTT ??
(as intest. Obstruction )
• Barium enema. • Hugely dilated
colon and rectum e funnel shaped termination
• Diagnosis : Congenital
megacolon.
• Barium enema. • Hugely dilated colon
and rectum e funnel shaped termination
• Diagnosis :
Congenital megacolon.
Important Q. on Congenital megacolon.
Q.1 : Type of patient ??*common in 1st male baby with +ve family history
Q.2 : Etiology ??*congenital absence of parasympathetic ganglion cells in segment in distal bowel
Q.3 : C\P ??Start soon after birth * constipation ( failure to pass meconium in 1st 2 days , then pass tooth past like motion
after finger insertion into rectum ) *abd. Distention * indentible fecal mass in iliac fossa
Q.4 : Complications ??? *toxic absorption >>> anemia , delayed growth *recurrent enterocolitis *acute on top of ch. Intestinal obstruction
Q.5 : Other investigations ??? *anorectal manometry *rectal biobsy
Q.6 : How to make definite diagnosis of this condition ?? * by rectal Biobsy >>> absence of ganglion cells in submucosa
Q.7 : D.D ?? a) other causes of huge abd. Distention in infant ( Wilm’s tumour ,
neuroblastoma ) b) from Acquired megacolon ( * barium enema >>> dilatation of both colon &
rectum down to anal canal , * P.R >>> dilated rectum filled with faeces)
Q.8 : TTT ??? ** Preoperative : -improve general condition -colonic lavage e saline enema -preliminary colostomy ** surgery : -when baby reach 10 Kg Wt. - operation : (Soave’s operation >>>> most popular or Swenson’s
operation or Duhamel’s operation or Lynn’s operation
• Plain x-ray lateral view in upside down e coin strapped to site of anus
(invertogram.)
(Coin test.)
• Air shadow above the pubococcygeal line.
• Low variety
( imperforate anus )
Coin test = Invertogram 1- possible diagnosis→ low imperforate anus . (why ?? )
2- pubococcygeal line ( pelvic diaphragm ) is the landmark above it , low anomaly
3- patient comes é delayed passage of meconium ( × ) Failure to pass meconium
4- In Hirschsprung disease, there is delayed passage of meconium ( √ )
5- Urgent correction from abdomen mandatory ( × ) خالص o النه low تحتperineal approach ( perineal pull through )
7- Done immediately after birth ( × ) after 24 h
8- Baby held & do it immediately ( × ) after 4-5min.
9- Colostomy is mandatory here ( × ) only in high anomaly
10- Best ttt is 1st stage operation (√) as it is low
• Plain x-ray lateral view in upside down e coin strapped to site of anus
(invertogram.)
(Coin test.)
• Air shadow below the pubococcygeal line.
• high variety.
( imperforate anus )
Important notes on Invertogram Q.1 : Indications ?? *D.D between high & low anorectal anomalies ( see before )
Q.2 : Timing ?? ** after 24 hour of birth
Q.3 : Fallacies ??? *baby < 24 h ……..false high *viscid meconium (meconium plug >>> false high ) *crying or straining during radiography *displaced or unfitted coin *position of baby not correct * baby not kept in upright for proper time ( at least 5min )
• Plain X-ray AP view of the abdomen
• Necrotizing enterocolitis
Necrotizing enterocolitis
1-Dilated loops of bowel
2- Edema of wall
3- Bilat. Gas under diaphragm é distended infantile
4- Diagnosis: distended abdomen & multiple air-fluid levels
5- Gas inside gut é thick gut wall
6- Typical picture of NEC
( Neomatosis intest ) = gas within the bowel