Peds Part 1

​Pediatrics

part 1

Multiple Choice

A 4-week-old neonate presents with elevated liver enzymes and mixed hyperbilirubinemia. You obtain a right upper quadrant ultrasound that demonstrates a normal gallbladder and unclear delineation of the bile ducts. You are worried about biliary atresia and order hepatobiliary scintigraphy. What medication should be given as pretreatment for 5 days prior to the study?

• Phenobarbital

• Cholecystokinin

• Morphine

• Sincalide

• Atropine

• ​Phenobarbital is known to enhance biliary excretion of conjugated bilirubin in patients with patent extrahepatic ducts.

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• Use prior to hepatobiliary scintigraphy improves the diagnostic accuracy of imaging and the ability to distinguish biliary atresia from neonatal hepatitis.

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• It is usually given as pretreatment for 5 days prior to the study at a dose of 5 mg/kg per day.

Multiple Choice

A 16-month-old toddler is brought in by his mother with an abrupt onset of irritability that began 12 hours ago associated with projectile emesis. On examination, he is lethargic but not distended and with minimal focal tenderness over the right mid abdomen. A mass is palpated in the right upper quadrant. Abdominal ultrasonography is obtained and is shown. What is the most appropriate next step in the management of this patient?

• Atropine

• CT abdomen

• Pneumatic reduction

• Pyloromyotomy

• Bowel resection

​The abdominal ultrasonography image shows the classic target sign, which is diagnostic of intussusception. The treatment is a fluoroscopic pneumatic or hydrostatic enema reduction and is successful in 85-90% of cases. Close observation is required due to the heightened possibility of recurrence within the first 24 hours

Multiple Choice

An 18-month-old child presents to your office with left neck cellulitis, and a small pit is noted anterior to the border of the left sternocleidomastoid. What is the next step in management of this suspected branchial anomaly?

• Urgent fistula excision

• Antibiotics to cover skin flora

• Broad spectrum IV antibiotics

• Incision and Drainage

• Observation only

• ​Approximately 20% of branchial anomalies become infected prior to excision. For an infected lesion, the preferred initial management is with antibiotic treatment, because lesions that are infected at the time of excision have an increased risk of incomplete excision requiring further procedures and damage to surrounding structures. In most cases, coverage for skin flora is sufficient, unless a connection with the oropharynx is suspected.

• Elective excision should be planned after the infection has been treated.

• If an abscess develops, aspiration is preferred to incision and drainage to minimize disruption of tissue planes, which make subsequent excision more difficult.

Multiple Choice

A 15-year-old boy is seen in your clinic with a severe symptomatic pectus excavatum. He has a history of metal allergy, and on patch allergy testing he reacts severely to both nickel and chromium. What treatment should you recommend for this patient?

• Observation

• Ravitch Procedure

• Nuss procedure with a titanium bar

• Preoperative and post operative steroids

• Preoperative steroids alone

• ​Patch allergy testing may be recommended preoperatively for patients suspected of having a metal allergy.

• If a metal allergy is confirmed (particularly to nickel and chromium, which are significant components of stainless steel), a pre-bent titanium bar should be ordered. A Nuss procedure should be performed.

• A Ravitch procedure is a much more invasive and morbid way to correct a pectus excavatum in that it requires resection of the costochondral junctions at multiple levels and a sternal osteotomy. Usually, a stainless steel bar is placed behind the sternum so patients could still potentially react to it.

• Although steroids can be used postoperatively to successfully treat an undiagnosed metal allergy, they are not standard of care in the preoperative period.

Multiple Choice

A 5-year-old girl presents with fever, abdominal pain and jaundice. On laboratory evaluation, she has a white count of 13,000, AST 45, ALT 60, total bilirubin 1.3, and alkaline phosphatase 160. An abdominal ultrasound is obtained demonstrating a 1.2-cm bile duct. An MRCP is subsequently obtained demonstrating intra- and extrahepatic bile duct dilation with a hilar stricture. What is the most appropriate management?

• Observation

• Piperacillin-tazobactam

• Liver transplant

• ERCP with sphincterotomy and marsupialization

• Cyst excision plus Roux-en-Y hepaticojejunostomy

​The most important management strategy is to address complications and stabilize the patient prior to definitive treatment of the cyst. In the scenario presented, the patient has ascending cholangitis, and the first step in management is empiric antibiotics to cover enteric pathogens. Definitive management of this type IV cyst is cyst excision with Roux-en-Y reconstruction; however, addressing the infection is priority. .

Multiple Choice

A newborn who was diagnosed with a congenital diaphragmatic hernia at birth has been physiologically stabilized and is ready to undergo repair of the defect. The defect is left sided. Intraoperatively, you note a sizeable defect that has a significant amount of tension when attempting to reapproximate. What are the options in this patient?

• Continue with the primary repair because tension of the repair rarely causes complications

• Perform tissue closure of the subcutaneous layers and repair at a later date

• Repair the defect with a cone-shaped diaphragmatic patch or muscle flap

• Perform temporary closure and reevaluate in 24 hours

• Leave the patient open and place the patient on advanced resuscitative measures ( ECMO)

• ​A tension-free closure is imperative in congenital diaphragmatic hernia. If this is unable to be accomplished with a primary repair, it is acceptable to use a diaphragmatic patch or a muscle flap (latissimus dorsi flap).

• Recurrence rates are variable with diaphragmatic patch repair. The rates are slightly lower with a muscle flap.

• Temporary closure would not be ideal in this situation.

• A stable patient does not require extracorporeal membrane oxygenation (ECMO) just because of the size of the defect.

Multiple Choice

A neonatologist consults you regarding a full-term male infant born today with prenatally confirmed trisomy 21 and an abdominal radiograph demonstrating a double bubble. You counsel the family that this is likely duodenal atresia and the infant will require a diamond duodenoduodenostomy. What other information should you obtain before taking the patient to the operating room for surgery?

• Upper GI series

• Renal U/S

• ECHO

• CXR

• EKG

​Echocardiography (ECHO) should be performed preoperatively to rule out congenital heart disease (CHD) because 22% of infants with duodenal atresia have associated CHD. Exposure to general anesthesia without the knowledge of CHD being present could be an unnecessary cause of morbidity and mortality.

Multiple Choice

A 2-week-old baby boy in the neonatal ICU, who was born at 33 weeks gestation, is being evaluated for bilious emesis. The results of an upper GI contrast study are shown. The patient is taken to the OR emergently. Which of the following is a necessary step for the procedure performed to treat this patient's underlying condition?

• Removal of aganglionic segment of bowel

• Placement of the cecum and large intestine in the left hemi-abdomen

• The muscle fibers overlying the GE junction are incised

• The small bowel mesentary is rotated in a clockwise manner

• Multiple partial transverse staple lines are created along a length of dilated small bowel

Multiple Choice

A neonatologist consults you on a 1 day old, 36-week female infant, who has a large cyst with air-fluid level and eggshell calcifications seen on abdominal radiograph. The infant's abdominal examination reveals a distended, erythematous abdomen that is tender to palpation with guarding. What is the best treatment for this child at this time?

• Water soluble contrast enema to clear meconium from the terminal ileum

• Bowel rest, decompression with NG tube, and broad-spectrum antibiotics

• Ex lap with possible peritoneal drain and possible ostomy creation

• Ex lap with simple resection of the cyst

• Sweat test for cystic fibrosis

• ​Meconium pseudocyst occurs after perforation of the intestine in utero results in accumulation of meconium in the peritoneal cavity during gestation.

• This pseudocyst presents postnatally as calcified walls surrounding meconium, with the remaining unaffected bowel peripheral to the walls of the pseudocyst.

• Treatment almost always requires exploratory laparotomy at birth, especially in the presence of peritonitis.

  • The main goal intraoperatively is to assess and preserve intestinal length. If the intestine can be identified, an ostomy is often created.

  • If the surrounding intestine cannot be identified, peritoneal drains are left in the cavity with the plan to return for a second look in 4 to 8 weeks to reassess.

Multiple Choice

A 1-month-old child presents with chronic mucus drainage from the umbilicus. An ultrasound demonstrates a tubular structure at the base of the umbilicus. What is the next appropriate step in this child's management?

• Emergency abdominal exploration

• Cystoscopy

• Umbilical hernia repair

• Elective resection of the diverticulum

• Application of silver nitrate

​This scenario is consistent with a patent omphalomesenteric duct and warrants elective resection. It is not an urgent problem, but it should be referred for elective resection by a pediatric surgeon.

Multiple Choice

A 7-year-old is diagnosed with small-bowel to small-bowel intussusception on CT imaging obtained to rule out appendicitis. It appears to be causing a small bowel obstruction. The patient has leukocytosis and peritoneal signs on physical examination, and he appears lethargic. In addition to fluids and nasogastric decompression, how would you proceed?

• Attempted air contrast enema in radiology

• Observation

• ultrasound to confirm intussusception prior to intervention

• immediate surgical exploration

Multiple Choice

A 3-year-old boy presents to the emergency department (ED) with 24 hours of bloody bowel movements. In the ED, his heart rate is 110 beats/min, his blood pressure is 105/70 mm Hg, and his temperature is 36.8°C. On examination, he has mild tenderness to palpation in the right lower quadrant without rebound or guarding. Abdominal ultrasound is concerning for a noncompressible tubular structure emanating from the ileum. You take him to the operating room and perform which of the following procedures?

• Laparoscopic appendectomy

• Meckel diverticulectomy

• Small bowel resection incorporating a Meckel diverticulum

• Appendectomy and Meckel diverticulectomy

• Small bowel resection incorporating a Meckel diverticulum and an appendectomy

​The boy has a Meckel diverticulum, presenting with painless lower GI bleeding. The majority (75%) of Meckel diverticula contain heterotopic gastric mucosa, which can cause adjacent small bowel ulceration and lower GI bleeding. In this boy, the differential diagnosis includes appendicitis and intussusception, but the lack of significant abdominal pain rules these out.

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