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📚 PEDIATRIC SURGERY — COMPREHENSIVE EXAM NOTES

Avicenna Tajik State Medical University | 5th Year Medical Faculty

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TOPIC 1 — Malformations and Diseases of the Esophagus

A. Esophageal Atresia (EA) + Tracheoesophageal Fistula (TEF)

• 3 Cs: Coughing, Choking, Cyanosis on first feed
• Excessive drooling / pooling of saliva
• Unable to pass nasogastric tube (NG coils in upper pouch, shown on X-ray)
• Polyhydramnios on prenatal US
• VACTERL association: Vertebral, Anorectal, Cardiac, TEF/EA, Renal, Limb defects

• Failure to pass NG tube (stops at 10–12 cm)
• CXR: coiled tube in upper mediastinum; air in stomach confirms distal fistula
• Echocardiogram mandatory (cardiac anomalies in 30%)

• Keep baby propped 30–45°, head up
• Continuous suction of upper pouch (Replogle tube)
• IV fluids + antibiotics; avoid mask ventilation

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B. Achalasia of the Esophagus

• Barium swallow: "Bird-beak" narrowing at GEJ + dilated body
• Manometry (gold standard): absent peristalsis + failed LES relaxation
• Endoscopy: exclude malignancy

• Surgical (first-line in children): Laparoscopic Heller myotomy + anterior partial fundoplication (Dor)
• Endoscopic balloon dilation (temporizing)
• POEM (per-oral endoscopic myotomy) — emerging option

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C. Chalasia (Gastroesophageal Reflux) / Congenital Short Esophagus

• Clinic: Regurgitation, failure to thrive, Sandifer syndrome (arching), aspiration
• Diagnosis: pH-metry (gold standard), upper GI series, endoscopy for esophagitis
• Treatment: Positioning, thickened feeds, proton-pump inhibitors (omeprazole); surgical (Nissen fundoplication) if medical therapy fails or complications (Barrett's, severe apnea)

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TOPIC 2 — Lung Malformations + Diaphragmatic Hernia

A. Congenital Lobar Emphysema (Overinflation)

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B. Congenital Pulmonary Airway Malformation (CPAM / formerly CCAM)

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C. Lung Cysts

• Bronchogenic cyst: Most common; mediastinal or intrapulmonary. Lined by respiratory epithelium. Causes compression → infection. Treatment: resection.
• Simple pulmonary cyst: Air-filled, may rupture → pneumothorax.

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D. Spontaneous Pneumothorax

• Small (<20%): Observation, high-flow O₂
• Moderate–large: Needle decompression (2nd ICS, midclavicular) → chest tube (5th ICS, mid-axillary)
• Recurrence: VATS with pleurodesis or bullectomy

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E. Pulmonary Sequestration

• Intralobar (75%): Shares pleura with normal lung; drains via pulmonary veins; left lower lobe; tends to get infected
• Extralobar (25%): Own pleura; systemic venous drainage; multiple associated anomalies (65%)

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F. Congenital Diaphragmatic Hernia (CDH)

• Bochdalek hernia (>90%): Posterolateral defect; predominantly left (85%); herniation of bowel/stomach/spleen/liver into chest
• Morgagni hernia (<10%): Anterior retrosternal defect; often right-sided; less severe

• Prenatal: US (cystic/solid thoracic mass containing bowel at ~20 weeks); MRI for lung volume measurement
• Postnatal CXR: bowel loops in chest, mediastinal deviation, absent/small gastric bubble

1. Stabilize first — intubate, NG suction, AVOID mask ventilation
2. Treat PPHN: sedation, inhaled NO, HFOV, ECMO if refractory
3. Surgery once stable: Reduction of herniated organs + primary diaphragm repair or patch (Gore-Tex)

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TOPIC 3 — Malformations of Stomach and Small Intestine

A. Hypertrophic Pyloric Stenosis (HPS)

• Progressively worsening non-bilious projectile vomiting (after every feed)
• Hungry infant (wants to feed immediately after vomiting)
• Dehydration: sunken fontanelle, dry mucous membranes
• "Olive-shaped" palpable epigastric mass (after NG decompression)
• Visible peristaltic wave left → right across upper abdomen

• Ultrasound (gold standard): Pyloric muscle thickness ≥4 mm, channel length ≥16 mm
• Upper GI series (if US equivocal): "string sign," "double-track sign," "shoulder sign"

• NS bolus(es) 20 mL/kg
• D5/0.45NS + KCl at 1.5× maintenance
• Target: Cl⁻ ≥90 mEq/L, HCO₃⁻ ≤30 mEq/L (otherwise risk post-op apnea)

• Incise muscle from stomach to duodenal side; mucosa must bulge
• Air leak test (30–60 mL) to confirm intact mucosa

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B. Congenital High Intestinal Obstruction

• Incidence 1 in 5,000–10,000; 50% associated with Down syndrome (Trisomy 21)
• Type I (membrane), Type II (fibrous cord), Type III (complete gap)
• "Double bubble" sign on AXR and prenatal US (stomach + dilated duodenum)
• Bilious vomiting immediately after birth (obstruction distal to ampulla of Vater in 80%)
• Treatment: Duodenoduodenostomy (diamond anastomosis)

• "Apple peel" (Type IIIb) most severe — blood supply from single marginal artery
• AXR: multiple air-fluid levels; microcolon on contrast enema (from disuse)
• Treatment: Resection + primary anastomosis; proximal tapering for markedly dilated segment

• Failure of midgut rotation → duodenum crosses superior mesenteric artery (SMA) + Ladd bands compress duodenum
• Midgut volvulus = surgical emergency: Bilious vomiting in neonate, acute abdomen
• UGI series: "corkscrew" duodenum; duodenal-jejunal junction (Treitz) not in left upper quadrant
• Ladd procedure: Counter-clockwise de-volvulation, divide Ladd bands, broaden mesenteric base, appendectomy

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TOPIC 4 — Anorectal Malformations + Hirschsprung Disease

A. Anorectal Malformations (ARM) / Imperforate Anus

• Absence of normal anal opening on newborn exam
• Invertogram (cross-table lateral X-ray with baby prone): air bubble location relative to ischial line
• MRI/spinal US: sacral/spinal anomalies
• Echocardiogram, renal US mandatory

• Low (perineal fistula): Primary anoplasty in neonatal period (no colostomy needed)
• High/complex: Three-stage: (1) Colostomy → (2) Posterior sagittal anorectoplasty (PSARP, Peña) at 1–3 months → (3) Colostomy closure
• Persistent cloaca (single perineal orifice): Requires cloacal reconstruction

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B. Hirschsprung Disease (HD)

• Rectosigmoid (short segment): 75% — most common
• Long segment: 10–15%
• Total colonic aganglionosis (TCA): ~5%

• Neonatal: Delayed passage of meconium (>48h), abdominal distension, bilious vomiting — relieved by PR finger/rectal tube
• Older child: Chronic constipation, abdominal distension, failure to thrive
• Hirschsprung enterocolitis (HAEC): Explosive bloody diarrhea, fever, septic shock — can occur pre- or post-op — life-threatening

1. Suction rectal biopsy (definitive): Absence of ganglion cells + increased acetylcholinesterase-positive nerve fibers
2. Contrast enema: "Transition zone" (narrow distal + dilated proximal colon); delayed evacuation
3. Anorectal manometry: Absent rectoanal inhibitory reflex (RAIR)

• Definitive: Pull-through procedure (Swenson, Duhamel, or Soave technique) — resect aganglionic segment, anastomose ganglionated bowel to anus
• Staging: Colostomy in sick neonates or TCA before pull-through
• Complications: Anastomotic leak, HAEC (pre/post-op), soiling, constipation

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TOPIC 5 — Malformations of the Urinary System in Children

Classification:

• Ureteropelvic junction (UPJ) obstruction — most common; hydronephrosis; treatment: pyeloplasty (Anderson-Hynes)
• Posterior Urethral Valves (PUV) — males only; bilateral hydronephrosis, thickened bladder wall, dilated posterior urethra; treatment: endoscopic valve ablation
• Megaureter — dilated ureter >7mm; may be obstructive, refluxing, or both

• Grade I–V (I = ureter only; V = massive reflux with intrarenal reflux)
• Causes recurrent pyelonephritis → renal scarring
• Diagnosis: VCUG (voiding cystourethrogram)
• Treatment: Grade I–III: prophylactic antibiotics; Grade IV–V: surgical ureteral reimplantation

• Horseshoe kidney, ectopic kidney, duplex collecting system, multicystic dysplastic kidney
• Polycystic kidney disease (autosomal recessive — infantile presentation)

• Hypospadias: Incomplete fusion of urethral folds; meatus opens on ventral surface; chordee (ventral curvature)
• Treatment: Surgery at 6–12 months (Snodgrass TIPU or other tubularization)

• Most common renal tumor in children (peak 3–4 years)
• Smooth, painless abdominal mass; rarely crosses midline
• Dx: US + CT abdomen
• Treatment: Nephrectomy + chemo (actinomycin D + vincristine ± doxorubicin) ± radiotherapy
• Favorable histology (blastema-predominant): excellent prognosis (>90% survival)

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TOPIC 6 — Malformations of the Umbilical Duct

A. Omphalocele (Exomphalos)

• Small (<5 cm): contains bowel only
• Giant (>5 cm/liver-containing): difficult abdominal closure

• Intact sac: Cover with warm saline-soaked gauze, IV fluids, NG, antibiotics
• Primary closure if small; staged closure (silo) if giant; "paint and wait" (escharotic agents) for giant if unstable
• Surgical repair once abdomen can accommodate viscera without compromise

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B. Gastroschisis

• Wrap bowel in plastic bag/wrap immediately at birth, keep warm
• Surgical reduction: Primary if tolerated by IVC/lung pressure; Staged silo reduction if not
• Prolonged TPN while gut recovers motility (weeks)
• Complications: Short bowel syndrome (especially if atresia associated), sepsis, prolonged ileus

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C. Fistula of the Navel (Urachus / Vitelline Duct Remnants)

• Complete: Enteric contents drain from umbilicus
• Meckel's diverticulum (most common): rule of 2s — 2% prevalence, 2 feet from ileocecal valve, 2 cm long, 2× more common in males, 2 types of ectopic tissue (gastric most common → bleeding)
• Treatment: Diverticulectomy or segmental resection if complicated

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TOPIC 7 — Acute Appendicitis in Children

Clinical Features by Age:

• RLQ tenderness on percussion/cough/hopping: 2 points each
• Anorexia, nausea/vomiting, fever, leukocytosis: 1 point each

• CBC: Leukocytosis (WBC >10,000/µL); bands > 75%
• CRP elevated
• Urinalysis (exclude UTI)
• US (first-line in children): Non-compressible appendix >6 mm
• CT with contrast (if US equivocal; "gold standard"): Periappendiceal fat stranding, appendicolith

• Uncomplicated: Laparoscopic appendectomy (better outcomes than open in children)
• Perforated with abscess: IV antibiotics first, interval appendectomy vs. early laparoscopic appendectomy (both acceptable per APSA guidelines)
• Post-perforation antibiotics: ≥3–5 days IV (piperacillin-tazobactam or cefoxitin + metronidazole)
• Non-operative management (select cases): WBC <18,000; early presentation <48h; no perforation on imaging; antibiotics IV → oral; 22% recurrence at 1 year

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TOPIC 8 — Peritonitis in Children

Primary (Spontaneous) Peritonitis

• Bacterial peritonitis without hollow viscus perforation
• Organisms: Streptococcus pneumoniae, E. coli
• Common in nephrotic syndrome, liver cirrhosis
• Diagnosis: Paracentesis — PMN >250/µL, positive culture

Secondary Peritonitis (most common in children)

1. Reactive (0–12h): Localized pain, early peritoneal signs, minimal systemic signs
2. Toxic (12–24h): Diffuse board-like rigidity, high fever, tachycardia, paralytic ileus
3. Paralytic/terminal (>24h): Abdominal distension, absent bowel sounds, septic shock, multi-organ failure

• Abdominal pain (diffuse), guarding, rigidity, rebound tenderness
• Fever, tachycardia, hypotension (septic shock)
• Paralytic ileus → abdominal distension, absent bowel sounds, vomiting
• AXR: Free air under diaphragm (perforation); ground-glass opacity; air-fluid levels

1. IV fluids + resuscitation (aggressive)
2. Broad-spectrum IV antibiotics: piperacillin-tazobactam; or cefotaxime + metronidazole + aminoglycoside (neonates)
3. Emergency surgery: Laparotomy/laparoscopy — identify and close source, peritoneal lavage + drainage
4. NPO, NG decompression, urinary catheter, ICU monitoring

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TOPIC 9 — Hematogenous Osteomyelitis in Children

• Hematogenous (most common in children)
• Contiguous focus (trauma, surgery)
• Chronic osteomyelitis

• Fever + localized bone pain, tenderness, erythema, swelling
• Refusal to weight-bear (child)
• Neonates: Pseudoparalysis, fever, irritability

• Blood culture (positive in 50–60%) — BEFORE antibiotics
• WBC, CRP, ESR elevated
• MRI (most sensitive early): Bone edema, periosteal elevation within 24–48h
• X-ray: Normal at 2–3 days; periosteal elevation + bone destruction after 7–10 days
• Bone scan (Tc-99m): Sensitive before X-ray changes

• If diagnosed early (<2–3 days), no dead bone, no septic arthritis: IV antibiotics alone
  • Empirical: Anti-Gram-positive (flucloxacillin or cephalosporins); add gentamicin in infants <1 year
  • IV → oral switch when clinically improving + CRP falling (usually 3–5 days IV)
  • Total duration: 3–6 weeks
• Surgical indications: No response to antibiotics in 24–48h, subperiosteal abscess, septic arthritis, devitalized bone (sequestrum)
  • Drilling/cortical window → drainage of pus + removal of sequestrum

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TOPIC 10 — Suppurative Lung Diseases: Destructive Pneumonia + Bronchiectasis

A. Destructive (Staphylococcal) Pneumonia

• Acute high fever, toxemia, respiratory distress
• Rapid progression over hours–days
• Infants: septic shock, "toxic" appearance

• Aggressive IV antibiotics: anti-staphylococcal (cloxacillin/vancomycin for MRSA)
• Chest tube for empyema/pyopneumothorax
• Surgical drainage (VATS decortication) if fibropurulent stage
• Pneumatoceles: mostly resolve spontaneously; surgery if tension or infected

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B. Empyema Thoracis

1. Exudative (thin fluid, responsive to antibiotics + chest drain)
2. Fibrinopurulent (loculated, thick; needs VATS or intrapleural fibrinolytics)
3. Organizing (pleural peel; needs open decortication)

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C. Bronchiectasis in Children

• Medical: Chest physiotherapy, mucolytics (hypertonic saline, DNase in CF), antibiotics for exacerbations, treatment of underlying cause
• Surgical: Segmentectomy/lobectomy for localized, unresponsive disease or recurrent hemoptysis

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TOPIC 11 — Echinococcosis (Hydatid Disease) in Children

• Pericyst: Host-derived fibrous outer layer
• Ectocyst (laminated membrane): White, avascular
• Endocyst (germinal layer): Inner; produces protoscolices + brood capsules + daughter cysts + hydatid sand

• Slow-growing RUQ mass (often asymptomatic for years)
• Compressive symptoms, jaundice (biliary), portal hypertension
• Rupture → anaphylaxis, peritoneal seeding (secondary hydatid disease)
• Superinfection → liver abscess

• Serology: ELISA, indirect hemagglutination (IHA), Casoni skin test (less specific)
• US (first-line): Cystic lesion with "water lily sign" (collapsed endocyst), daughter cysts, calcification
• CT/MRI: Stage I–V (Gharbi/WHO classification)

• Surgery (mainstay): Cystectomy — aspirate cyst, inject scolicide (hypertonic saline 20%, cetrimide), aspirate, inject, re-aspirate (PAIR technique). Remove pericyst. Manage biliary communication. Omentoplasty.
• PAIR (Percutaneous Aspiration-Injection-Re-aspiration): US-guided; indicated for accessible unilocular cysts; always cover with albendazole
• Medical: Albendazole 400 mg BD in 28-day cycles (pre-/post-op adjuvant; primary in inoperable cases)
• Avoid: Incomplete decompression without scolicide → severe anaphylaxis, seeding

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TOPIC 12 — Purulent Inflammatory Diseases of Newborns + NEC

A. Furuncle, Carbuncle, Phlegmon, Mastitis

• 1–5 weeks of age; S. aureus
• Unilateral breast swelling, erythema, fluctuance
• Risk: Inappropriate squeezing of physiologic breast hypertrophy
• Treatment: IV cloxacillin/flucloxacillin; incision + drainage if abscess (preserve areola and breast bud)

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B. Necrotizing Enterocolitis (NEC)

• Pneumatosis intestinalis (intramural gas) — pathognomonic
• Portal venous gas — ominous
• Fixed dilated bowel loops
• Free air under diaphragm = perforation

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TOPIC 13 — Cardiopulmonary Anesthesia Features in Children + Poisoning

A. Features of Pediatric Anesthesia

• Higher oxygen consumption; smaller FRC → rapid desaturation
• Obligate nasal breathers (infants <3–4 months)
• Large occiput → neutral position = sniffing position
• Loose deciduous teeth; large tongue; narrow subglottic airway (narrowest point = cricoid in children <8 years → use uncuffed ETT or cuffed with low inflation)
• Bradycardia common response to hypoxia in infants (vs. tachycardia in adults) → treat hypoxia first

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B. Poisoning in Children

1. Supportive care: ABC; O₂; IV access; fluids
2. Decontamination:
   • Activated charcoal (within 1–2 hours; most effective): 1 g/kg; contraindicated if airway unprotected, hydrocarbon, caustic
   • Gastric lavage: Only if large toxic dose, within 1 hour, airway protected
   • Skin: Remove clothing, wash with water
3. Antidotes (specific):
   • Paracetamol (acetaminophen): N-acetylcysteine (NAC)
   • Opioids: Naloxone
   • Benzodiazepines: Flumazenil
   • Organophosphates: Atropine + pralidoxime
   • Iron: Deferoxamine
   • CO: 100% O₂; consider hyperbaric O₂
4. Enhanced elimination: Urinary alkalinization (salicylates); dialysis (severe)

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TOPIC 14 — Urolithiasis in Children

• Metabolic (most common in developed world): Hypercalciuria (idiopathic), hyperoxaluria, hyperuricosuria, cystinuria, low urinary citrate
• Anatomic: UPJ obstruction, horseshoe kidney (urinary stasis)
• Infection: Struvite stones (Proteus, Klebsiella → urea-splitting → alkaline urine)
• Prematurity/NICU: Furosemide-induced hypercalciuria

• Flank/colicky abdominal pain (older children)
• Gross hematuria (85%)
• Recurrent UTI (especially struvite)
• Infants: Non-specific (irritability, UTI, hematuria)

• Urinalysis: Hematuria, pH (alkaline = struvite/RTA, acidic = uric acid)
• Urine culture
• Serum: BMP, Ca, phosphate, uric acid, PTH if hypercalcemia
• 24-hour urine: Ca, oxalate, uric acid, citrate, creatinine
• Imaging: Non-contrast CT KUB (most sensitive); Renal US (first-line in children, avoids radiation); KUB X-ray (radiopaque Ca-oxalate/struvite; radiolucent uric acid)

• Conservative (stones <5 mm): Hydration, analgesia (NSAIDs/opioids), alpha-blockers (tamsulosin — promote spontaneous passage)
• ESWL (Extracorporeal shock wave lithotripsy): Stones ≤2 cm, upper urinary tract; first-line in children
• Ureteroscopy (URS): Ureteral stones resistant to ESWL
• Percutaneous Nephrolithotomy (PCNL): Large stones (>2 cm), staghorn calculi
• Metabolic management: Thiazides (hypercalciuria), allopurinol (hyperuricosuria), potassium citrate, dietary modification

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TOPIC 15 — Trauma to Abdominal and Thoracic Organs + Internal Bleeding

Pediatric Trauma Differences

• Abdominal wall thin + pliable → organs less protected
• Proportionally larger liver and spleen (less protected by ribs)
• Elastic chest wall → rib fractures less common but significant force transmitted to lung/heart (pulmonary contusion without rib fractures)
• Children compensate hemodynamic ally until severe blood loss → blood pressure is a late indicator

Abdominal Trauma

1. Spleen (#1) → subcapsular hematoma, splenic laceration/rupture
2. Liver (#2) → right lobe laceration most common
3. Kidney, pancreas, hollow viscus (rare — mesenteric root avulsion, duodenal hematoma)

• Grade I–II: Minor lacerations/hematomas → non-operative management (NOM)
• Grade III: Moderate → NOM if hemodynamically stable
• Grade IV–V: Major → NOM attempted in stable patients; surgery/angioembolization if unstable

• Hemodynamic stability required
• Serial exams + monitoring in ICU
• Blood transfusion threshold: Hb <7 g/dL or active bleeding
• Activity restriction 3–6 weeks (grade-dependent)

• Duodenal hematoma: Child abuse; bicycle handlebars; bilious vomiting; "coiled spring" on UGI series; mostly managed conservatively (NG, TPN) — resolves in 1–3 weeks.
• Pancreatic trauma: Transection at spine; elevated amylase/lipase; MRCP/ERCP for ductal injury; distal pancreatectomy if main duct disrupted.

Thoracic Trauma

Internal Bleeding — Recognition and Management

• IV/IO access × 2; 20 mL/kg NS bolus × 1–2; if no response → activate massive transfusion protocol
• Massive transfusion: pRBC : FFP : Platelets = 1:1:1
• Tranexamic acid (TXA): 15 mg/kg IV within 3 hours of injury (anti-fibrinolytic)
• Permissive hypotension: systolic 80–90 mmHg until surgical hemorrhage control
• Damage control surgery: Temporary hemorrhage control (packing) + abdominal closure; definitive repair when physiology corrected (hypothermia, acidosis, coagulopathy reversed)

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QUICK REFERENCE — KEY EXAM FACTS

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