group 2 pediatric sur

acute abdomen

acute abdomen

sudden onset of severe abd pain, urgent dx

acute surgical abd

1. localised pain

2. diffuse abd pain

3. rebound tenderness

4. guarding (invol cont of abd m)

acute appendicitis

most common acute abd in children and adults

mesenteric tonsilitis

abdo lymp nodes enlarge, after throat or ear infection

inguinal region PE

hernia, testicular torsion

a. appendicitis beginning 6-12h

visceral pain around umbilicus, nausea and vomiting

a. appendicitis 12-24h

pain becomes local, right lower quadrant (somatic pain), direct and indirect tenderness, guarding

a. appendicitis 24-48h

gangrene and perforation (39C), abcess or generalised peritonitis

a. appendicitis adults

obst due to fecaloid

a. appendicitis children

submucosal lymhoid proliferation

perforated appendicitis

bilious vomiting, disseminated abd pain, 39C

diyafram altında sebest hava

perforasyon

volvulus

kahve çekirdeği

ileus ve invaginasyon

hava sıvı seviyesi

basal pneumonia

diyafram üzerinde odak

kabızlık

fecalom beyaz küp çakıl taşı (tx: lavman)

a appendicitis in children

USG (komplike ise CT)

rasyasyon yok smaller abd cavity to see all

meckel’s diverticulum

omphalımesenteric duct 6-8w’de kaybolmazsa

meckel’s diverticulum

true divert, antimesenteric site,

uracus

median umbilical lig

2 arter umbilical cordda

medial umbilical lig

1 ven umbilical cordda

falciform lig

Meckel rule of 2s

2% of pop

m/f 2/1

2 feet prox to ileocecal valve

½ symptom before age of 2

2 heterotopic mucosas: gastric and panreatic

Meckel presentation

bleeding

intestinal obs: intussusception, band obstruction, volvulus

diverticulitis (dd: acute appendicitis)

foregut

epigast, pain receptors

midgut

umbilical, treitz-transverse 1/3, kasılmaya bağlı kolik

hindgut

lower abd

meckel bleeding

painless, vişne çürüğü, ectopic gastric mucosa in the lumen of diverticulum

meckel dx

tc-99m sodium pertechnetate scan, isotope uptake

meckel obstruction

segmental intes volvulus or fibrous cord compression

check hava sıvı seviyesi

if 5-7 proximal

if more distal

intussusception

invagination of prox into distal, mostly ileocecal

peak in 5-10m

idiopathic: peyer plaques active until 2 yo, lypmhoid tissue islands thickening

intussusception symp

colicky crampy abd pain

vomiting

abd mass

currant jelly stools, çilek jölesi (içinde mukus)

abd distention

mechanic intestinal obs

vomiting, nausea (late billous önce mide content)

colic pain

distantion (gas)

gaz, gaitada kesilme

intussusception

çilek jölesi kan

USG: target sign

intussusception etio

polyp, meckel, tumor, duplication

all these need surgery as tx

older than 2

intussusception tx

1. oral kes, NGT! (aspirasyon riskini azaltıyor, laryngospazm)

2. damar yolu

   correct electrolyte disorder, monitor urine output

melena

dark colored digested blood, upper gir, treitz prox

hematochezia

red blood stool, lower gi, meckels or intuss, treitz distal

occult blood

colon ca

anal fissure

parlak kan, most of lower gi bleeding

adult: hemorrhoid

anal inspection: crack in anocutenous junction

necrotizing enterocolitis

premature

most imp vital in kids

pulsed

daily fluid main 1-10kg

100ml/kg/day

daily fluid main 10-20kg

1000ml+50ml/kg/d

daily fluid main 20-30kg

1500ml+20ml/kg/day

daily sodium

3-4 mEq/kg/d

daily potasium

1-2mEq/kg/d

daily calcium

1mEq/kg/d

daily magnesium

0.5-1

upper limit of potasium

40 mEq in 1L

urine output

1-2ml/kg/hr

if none, do not add K, kidneys are not filtering

hyponatremia (na below 135)

(aimed na level - serum na level) x body weight x 0.6

half is given in first 8h, remaining in 16h cause of brain edema risk

hypovolemic shock

20ml/kg isotonic saline or ringers lactate rapidly in 20-30min

if no improvement, 10-20 is repeated in 20-30min

if still no improv despite 3 times, ongoing fluid loss or cardiac or renal pathoh

hipovolemik şok

soluk, konfuze or loss of conc

filiform pulse: çok hızlı ama zayıf, sıvı V yok

capillary return 2snden uzun

DEKSTROZLU SIVI KONTRAENDİKE zaten hiperglis

şok 20ler kuralı

yüzde 20 kayıp—>istonic nacl or ringer laktat

kilo başı 20ml

20dkda ver, 1 saatte 3 kez

şokta monitor et

body weight esp in neonates

urine v, density, osmolarity

blood gasi pulse, blood pressure

total parenteral nutrition

indication:

gis cannot be used, cannot be fed for more than 4-5d, prolonged starvation, meet conditions of a diet

TPN fluids

carbohy (%50), 5 10 20 30 D, 15-30 gr/kg/day, 3.4cal/gr

protein (20): trophamine, hepatamine, neframin; 2-4; 3.4

lipid (35): 10 20, 1-3, 9

TPN complications

gis devreye girdiği an kesilmeli

septicemia

metabolic compl: liver failure, allergy, electrolyte, volume overload, resp failure

levator muscle complex

wraps rectum

hammock from symphysis pubis

fecal continance

anorectal malformation female

perineal fistula Low

vestibular fistula Low

persistent cloaca short common channel High

persistent cloaca long common channel High

anorectal malformation male

perineal Low

prostatic urethral fistula High

vesical fistula High

no fistula Low or High

ARM radiology

cross table lateral xray, invertogram

gas in the most distal, around 20-24h after birth

ARM ass anomalies

V: vertebral defects (incontinance both urinary and defacation if more than 3 spine is missing)

A: anal atresia

C: cardiac defects (EKO cardogram)

T: tracheo-esophageal fistula (NGT gets stuck 10 cm in)

R: renal anomalies

E: esophageal atresia

L: limb abnormalities

low ARM tx

24-48h surgeryh

high ARM tx

colostomy in newborn (diverting colostomy: 2 ayrı uç, kaka ilkinde torbaya distalde sadece mukus var)

definitive surgery 4-6m

colostomy closure

1 yaşına kadar yapılmalı, temiz aralıklı kontinans, levator kontinansı kesin değil

hirschsprung’s disease

no ganglion cells in myenteric and submucosal plexus, agonglionosis of the bowel due to failure of migration

no jumps, proximal is normal

parasym neural cell fibers and setilcholineterase activity increased

mostly rectosigmoid colon

distal bowel cannot relax→ mechanical obs

gangion cells

source: vagal neural crest

5th week esophagus

7th week midgut

12th week rectum

transmural migration: 1st myenteric (auerbach)→12-16th week→ submucosal (meissner) plexus

relaxation of the bowel

hirschsprung’s

newborn: no meconium in first 2 days, intest obs signs

child: long term constipation, abd distention, DRE: explosive air stool outut

hirschsprung’s dx

rectal biopsy

hirschsprung’s tx

transanal endorectal pull through

transanal pull through for sigmoid

hirschsprung’s enterocolitis

abdominal disten, vomiting, fever, diarhea (foul smell)

yaş ilerledikçe geriliyor

antibiotic yıkama, staz (bakteri), perforasyon riski