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