0071643192.pdf

PEDIATRICS

SYMPTOMS

■ Respiratory distress

■ Drooling, with difficulty handling oral secretions

■ Nonbilious vomiting immediately after/during feeding

EXAM

Physical exam may be normal, or there may be associated abnormalities,

including the VATER complex.

DIFFERENTIAL

Extensive differential diagnosis, including sepsis, gastroesophageal reflux,

choanal atresia

DIAGNOSIS

Inability to pass an NGT into the stomach. The blind proximal esophageal

pouch can often be demonstrated on plain radiographs by injecting a small

amount of air into the catheter when the chest radiograph is taken. Surgical

exploration confirms the diagnosis.

TREATMENT

■ Fluid resuscitation

■ Antibiotics to cover possible sepsis

■ Surgical correction

COMPLICATIONS

Chemical pneumonitis can occur if gastric contents reflux into the distal

esophagus, enter the TEF, and go into the lungs. Dehydration may also occur.

MALROTATION WITHVOLVULUS

During the first 3 months of gestation, there is normally a 270 degree coun-

terclockwise rotation of the midgut, with subsequent fixation of the small

bowel in the left upper quadrant (ligament of Treitz) and right lower quad-

rant. When malrotation occurs, the small bowel is not anchored in the LUQ

or RLQ. Bands of tissue (Ladd’s bands)form between the cecum and duo-

denum, potentially causing duodenal obstruction. Worse, the narrow vascu-

lar pedicle of the SMA is prone to clockwise volvulus of the midgut. Of

patients with malrotation, 33% present with symptoms within the first week

of life, 50% present within the first month, and 85% present within the first

year. A number of congenital anomalies may be associated with malrotation,

including:

■ Diaphragmatic hernia

■ Abdominal wall defects

■ Duodenal atresia

■ Hirschsprung disease

■ Intussusception

SYMPTOMS/EXAM

Symptoms depend upon the degree of bowel obstruction. Most common

presentation is that of intermittent duodenal obstruction at the site of the Ladd

bands. Patients with intermittent duodenal obstruction typically will have:

The VATER complex:

Vertebral anomalies

Anus (imperforate)

TEF

Renal defects