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Chapter 39: Pediatric Surgery

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Operative management of a newborn with the chest X-ray shown in Fig. 39-1 should occur

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A. Immediately after birth

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B. Within 24 hours

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C. Within 72 hours

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D. None of the above

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Answer: D

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The diagnosis of congenital diaphragmatic hernia (CDH) is made by chest X-ray, with the vast majority of infants developing immediate respiratory distress and pulmonary hypertension. CDH care has improved considerably through effective use of improved methods of ventilation and timely cannulation for extracorporeal membrane oxygenation. In the past, correction of the hernia was believed to be a surgical emergency, and patients underwent surgery shortly after birth. It is now accepted that the presence of persistent pulmonary hypertension that results in right-to-left shunting across the patent foramen ovale or the ductus arteriosus and the degree of pulmonary hypoplasia are the leading causes of cardiorespiratory insufficiency. Current management therefore is directed toward managing the pulmonary hypertension, which is usually seen within 7 to 10 days, but in some infants, may take up to several weeks. (See Schwartz 10th ed., Figure 39-3, pp. 1604–1605.)

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Fig. 39-1. Chest X-ray showing a left congenital diaphragmatic hernia.

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Which of the following is most consistent with pyloric stenosis?

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A. Na 140 Cl 110 K 4.2 HCO3 26

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B. Na 142 Cl 90 K 5.2 HCO3 39

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C. Na 140 Cl 95 K 4.0 HCO3 18

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D. Na 139 Cl 85 K 3.2 HCO3 36

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Answer: D

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Infants with hypertrophic pyloric stenosis (HPS) develop a hypochloremic, hypokalemic metabolic alkalosis. The urine pH level is high initially, but eventually drops because hydrogen ions are preferentially exchanged for sodium ions in the distal tubule of the kidney as the hypochloremia becomes severe (paradoxical aciduria). The diagnosis of pyloric stenosis usually can be made on physical examination by palpation of the typical “olive” in the right upper quadrant and the presence of visible gastric waves on the abdomen. When the olive cannot be palpated, ultrasound (US) can diagnose the condition accurately in 95% of patients. Criteria for US diagnosis include a channel length of over 16 mm and pyloric thickness over 4 mm. (See Schwartz 10th ed., pp. 1613–1614.)

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An infant presents to the emergency room with bilious emesis and irritability. Physical examination is notable for abdominal tenderness and erythema of the abdominal wall. Abdominal X-ray demonstrates dilated proximal bowel with air-fluid ...

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