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Few topics in pediatric surgery spark more disagreement and foster more misunderstandings about pathophysiology and management than gastroesophageal reflux disease. The picture is confounded by the differences between small children and adults, the vastly higher energy (and volume) requirements of babies, the preponderance of non-acid reflux, the poorly defined accuracy of the diagnostic tests for...
Hypertrophic pyloric stenosis (HPS) is an acquired disorder that presents in infants between 3 and 8 weeks of age. The radial smooth muscle of the pylorus undergoes concentric hypertrophy, which causes narrowing of the pyloric channel and produces a gastric outlet obstruction. The obstruction results in progressive, projectile, nonbilious emesis, which can lead to dehydration, metabolic alkalosis,...
The creation of surgical access to the gastrointestinal tract for the direct administration of food and medications or for decompression is a common procedure and familiar to most surgeons. While the technical aspects are straightforward, some degree of critical thinking in the selection of patients as well as close attention to surgical details will reward the patient, the family, and the surgeon...
Duodenal atresia is a congenital bowel obstruction, usually located between the first and second portions of the duodenum. The overall incidence is approximately 1 in 6,000 births. Approximately one-third of patients with neonatal duodenal obstruction also have trisomy 21. Other frequently associated anomalies include congenital heart disease, annular pancreas, and malrotation. The widely accepted...
Intestinal atresia is a congenital obstruction of the intestine, sometimes associated with a loss of tissue, resulting in a disruption of intestinal continuity. An atresia can occur anywhere throughout the gut, including the esophagus, pylorus, pancreatic duct, bile duct and rectum. The incidence of intestinal atresia is approximately 1 in 4000 live births. The two principal hypotheses regarding the...
Many intra-abdominal cystic masses are being detected by prenatal imaging. They are often asymptomatic but those that cause symptoms usually do so in the first year or two of life. Symptoms are usually the result of compression or obstruction due to enlargement of the cyst as it gradually fills with fluid, or bleeding and ulceration due to gastric or pancreatic lining of the cyst. Cysts can arise...
Rotational anomalies of the intestinal tract refer to the failure of the primitive midgut to establish its normal anatomical relationships and attachments as it develops into duodenum, small bowel, and proximal colon. The incidence of isolated malrotation in the general population is estimated at 1 in 500 live births, but it is much more common in a number of genetic, chromosomal, and congenital disorders...
Necrotizing enterocolitis (NEC) is the most common diagnosis that requires emergent operation in the neonate. Since first described by Touloukian in 1966, the pathophysiology of this disease remains an enigma. The disease involves the culmination of three factors: a premature infant, an immature immune system, and a gastrointestinal tract colonized with pathologic bacteria (Fig. 49.1). When these...
To appreciate the complexities of short bowel syndrome, the disease should be thought of as a functional disorder rather than a simple anatomical abnormality. For this reason, many experts in the field now prefer the term intestinal failure (IF) as a more appropriate description of this syndrome. The true definition of IF is a reduction of the functional gut mass below the level needed to allow adequate...
Meconium ileus is a small bowel obstruction in newborns caused by inspissated meconium. It is associated with cystic fibrosis in nearly all cases, and up to 20% of newborns with cystic fibrosis present with meconium ileus. Pancreatic enzyme insufficiency leads to extremely viscous meconium that cannot pass through the ileum, although why some infants with cystic fibrosis develop meconium ileus and...
Intussusception is a telescoping of the intestine into itself. It is one of the most common causes of abdominal pain in children under 5 years of age. The disease occurs most commonly in children between 6 and 18 months of age, but has been described in all age groups including babies in utero and in adults. Approximately half of all cases occur in the second 6 months of life, and 90% of all cases...
In 1809, the German anatomist Johann Meckel the Younger described the structure that now bears his name and postulated its embryologic origin. The embryonic midgut is connected ventrally to the yolk sac via the vitelline duct, also known as the omphalomesenteric or omphaloenteric duct. Normally regressing between the fifth and seventh weeks of gestation, persistence of a portion of the vitelline duct...
Adolescent obesity is reaching near-epidemic proportions in the United States, lagging behind but following the trend of adult obesity. In some regions, nearly 40% of adolescents are obese, and many are developing severe obesity-related comorbid conditions that result in a reduced quality of life and can be progressive and life-threatening. Although nutritional counseling and behavioral modification...
Chronic abdominal pain, loosely defined as recurrent episodes of pain occurring at least weekly for 1–2 months, is a common complaint, estimated to affect approximately 20% of school-age children. It results in school absenteeism, family disruption and sometimes depression and anxiety. In the majority of children, chronic abdominal pain is thought to be “functional,” which means there is no objective...
Crohn’s disease is one of the two commonly seen inflammatory bowel diseases. As opposed to ulcerative colitis, which only directly affects the colon and rectum, Crohn’s disease can affect any part of the intestinal tract. It can also involve the full thickness of the bowel wall, which accounts for many of the complications seen with the disease. Surgery is not curative but is reserved for the treatment...
In any age group, creation of an intestinal stoma is a significant event with major physiologic, body image, lifestyle, and psychosocial implications. Management and indications for ostomies in infants and young children are often different than in adolescents and adults. This is a consequence of the differing diagnoses, physiology, size, growth and development issues, complications, and unique patient...
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