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The website contains the most important ABSITE information.

Each "Question" is designed to address the knowledge found on the actual ABSITE test.

Please reply to any post with suggestions to add information or questions.

Pediatric ABSITE Questions

Pediatrics

Neuroblastoma
Third Most common Pediatric malignancy
tumor of neural crest cells - found in adrenal medulla
Mets to skin = blueberry muffin lesions
Dx - vanillymandelic acid and homovanillic acid urine levels
Treatment - resection with chemotherapy however some can spontaneously regress!
 
Nephroblastoma (Wilms Tumor)
Second most common pediatric tumor
Associated with Beckwith-Wiedemann (macrogloassia, hypoglycemia, gigantism, visceromegaly) and WAGR (wilms, aniridia, genitourinary abnormalities)
Treatment = nephrectomy
Thyroglossal Duct Cyst
midline anterior neck mass that moves up and down with tongue movement
remnant of base of tongue to pyramidal lobe of thyroid
Treatment = Sistrunk procedure (with removal of central portion of hyoid bone)

Branchial cleft cyst
1st - connect with external auditory canal, associated with facial nerve
2nd - MOST COMMON - through carotid bifucation into tonsillar pillar
3rd - lateral neck
 
Cystic Hygroma
obstructed lymph vessels lead to mass usually in neck and can cause obstruction
Can often get infected
treatment - urgent aspiration if airway compromise then serial resections

Esophageal Atresia (EA)/ Tracheoesophageal Fistula (TE)

Type A: EA without TE
Type B: EA with TE fistula b/w proximal esophogeal stump and trachea
Type C: EA with TE fistula b/w distal esophageal stump and trachea (MOST COMMON)
Type D: EA with both proximal and distal TE
Type E: TE without EA (aka “H” type)
Diagnosis: prenatal polyhydraminous EA: inability to pass NG tube. TE: air in distal GI tract
Most (30 – 50 percent) have associated abnormalities, 20% cardiac malforation
MUST get echo to see if aortic arch is on the right and not left to plan which thoractomy to do
Tx: right thoracotomy and end to end anastomosis and closure of trachea
Complications: REFLUX - sometimes requires an anti-reflux procedure 

Pulmonary Sequestration
intralobar (pulmonary venous drainage, older child), extralobar (systemic drainage, infants)

Congential lobar emphysema
failure of cartialge developement leads to hyperinflation
Bronchoscopy will worsen condition
Urgent resection (lobectomy) may be needed to avoid pulmonary or cardiac compression
Congential Cystic adenoid malformation
cyst in airway leading to recurrent infection or respiratory compromise

Bronchiogenic cyst
extrapulmonary cysts that compress structures - resect cyst

Pyloric Stenosis
Nonbilious projectile vomiting, generally in children ages 4 to 8 weeks
HYPOKALEMIC, HYPOCHLOREMIC, METABOLIC ALKALOSIS with PARADOXICAL ACIDURIA
    Renal Tubules resorbes sodium for volume loss in exchange for potassium
    As potassium levels decrease secondary to gastric content, potassium is resorbed in exchange for hydrogen and thus urine becomes acidic
Diagnosis: >4mm thick or >14mm long
Treatment: Resuscitate; pyloromyotomy
 
Prune-Belly Syndrome
Abdominal wall defect associated with dilated urinary tract and bilateral undescended testes that will require bilateral orchipexy
Treatment - abdominal wall reconstruction

Duodenal Atresia

Failure of recanalization
Diagnosis: Double bubble sign on x-ray; GI series shows duodenum past midline
Treatment: Duodenoduodenostomy versus duodenotomy (for webs / windsock deformity - Do not resect for risk of injury of ampulla and pancreatic duct
Associated with Down’s Syndrome
 
Intestinal Atresia (Jejunal / Ileal)Intrauterine vascular accident; not failure of recanalization
Type I: intraluminal diaphragm or web
Type II: Fibrous cord connecting two ends; mesentery intact
Type IIIa: Discontinuous bowel; V-shaped mesenteric defect
Type IIIb: apple core deformity
Type IV: multiple atretic segments
Treatment: Excision; multiple lesions in approximately 10 percent

Biliary Atresia
Diagnosis: HIDA scan doesn't show filling into the intestine
Treatment: Roux-en-Y hepaticojejunostomy (Kasai procedure); often requires OLT

Choledochal Cysts
Classification:
Type I: solitary extrahepatic fusiform cyst (most common)
Type II: diverticulum of common bile duct
Type III: choledochocele
Type IV: Multiple intra- and extrahepatic cysts
Type V: Caroli’s Disease (diffuse intrahepatic cysts)
Diagnosis: U/S, ERCP, PTC
Treatment: Hepaticojejunostomy (type I); diverticulectomy (type II); excision / sphincteroplasty (type III); OLT (types IV & V)
 
Malrotation
any child under 2 with bilious vomitng = UPPER GI EMERGENTLY
Treatment: Ladds Procedure (counterclockwise detorsion, lysis bands from cecum to abdominal wall and bands between duodenum and terminal ileum, broadening the mesentery, appendectomy, placement of cecum to left lower quadrant and duodenum to right lower quadrant)

Hirschsprungs disease
failure of neural crest nerve cells to migrate with abscense of Auerbach's plexus
75% rectosigmoid, 15% past splenic flexure, 5% total colon
Dx = suction rectal biopsy 2 cm above dentate line
Tx = swenson (pull through with complete removal or afunctional colon)

Meckel’s Diverticulum
Remnant of omphalomesenteric duct on antimesenteric side of bowel
most common lead point for intussusception and most common pediatric lower GI bleeding cause
Rule of two’s: 2 percent, two feet of ileocecal valve, two types of tissue (gastric, pancreatic), 2 percent symptomatic
if incidentially found at abdominal operation - only resect if narrow base

Intussusception
colicky abdominal pain, bilious emesis, currant jelly stools, abdominal mass on physical exam
Treatment: Hydrostatic or pneumatic reduction (80% successful); surgery for failure / recurrence
Max Pressure for air contrast enema = 120mmHg, Max column height for barium enema = 1 meter
Surgery (gentle pressure rather than pulling the bowel), recurrence is 5-10% after surgery, usually within 24 hours
 
Meconium Ileus
obstruction due to thick meconium
“soap-bubble” sign = meconium mixed with air
Treatment = water-soluble contrast enema

Hirschsprung DiseasePresentation: Bilious emesis, abdominal distension, constipation, failure to pass meconium
suction rectal biopsy (presence of ganglion cells rules out diagnosis) - shows absence of Auerbach plexus
Treatment: 1. colostomy; 2. ileorectal anastomosis (various types); 3. colostomy takedown

Necrotizing Enterocolitis (NEC)
Indications for Surgery - Free air, portal venous gas, abdominal wall changes, peritonitis, worsening acidosis/thrombocytopenia, but NOT Pneumatosis    Bell Stage I - suspicious (NPO, TPN, ABX)
    Bell Stage II - definite NEC - close observation
    Bell Stage III - advanced NEC (absolute indications for surgery) = Surgery

Imperforate Anus
high (stump above puborectalis) - diverting colostomy and delayed anastomosis -  low: posterior saggital anorectoplasty (PSARP) (Pena Procedure)
    High lesions usually form fistulas either to prostatic urethra or vagina
low (stump below puborectalis)
    Low lesions usually with a fistula to perineum (scrotal raphe or vaginal fourchette)
 
Sacrococcygeal Teratoma
most common teratoma in the neonate and can grow so large that they lead to high output failure, hydrops, and fetal demise
treatment - resection
 
Gastroschisis
(bad bowel, good baby”) without peritoneal sac. Rarely associated with other abnormalities.
Treatment: primary abdominal wall closure, TPN; Silastic silo if unreducible

Omphalocele
(“good bowel, bad baby”) bowel hernia with peritoneal covering. Commonly associated with other abnormalities
Treatment: reduction and abdominal wall closure Silastic silo to facilitate reduction, primary abdominal wall closure once reducible
 
Umbilical Hernia
most close spontaneously; repair for defect greater than 2 cm, age > 5 years
Pentalogy of Cantrell
Omphalocele, Anterior diaphragmatic hernia, Sternal cleft, Ectopia cordis, VSD or left ventricle diverticulum

Congenital Diaphragmatic Hernia

Bochdalek (back and to the left) - most common, usually symptomatic so usually wait 1-3 days for stabilization possibly on ECHO then repair
Morgagni - anterior - usually not symptomatic so usually noted in adulthood

Inguinal Pathology
Hernia: patent process vaginalis; repair open versus laparoscopically
more common on right, increased risk with prematurity
Hydrocele: fluid collection within scrotum; either communicating or non-communicating, depending on patency of process vaginalis. Non-communicating hydroceles tend to resolve spontaneously. Treatment via surgical evagination with repair of patent process vaginalis

Testicular Torsion 
acute scrotal pain and high riding testicle 
 Bilateral exploration through scrotal incision, Pexy both testicles, resect if necrotic

Undesceded Testicle
Repair at 2 years old
orchiopexy doesn't decrease malignancy risk but increases chance of fertility and allows for earlier identification for cancer if in scrotum 

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