Master the board step 3

Surgery
Hypertrophic Pyloric Stenosis
This shows up as nonbilious projectile vomiting after each feeding at approximately
3 weeks of age. Look for gastric peristaltic waves and a palpable
“olive-size” mass in the right upper quadrant.
Diagnose with a sonogram.
Treat as follows:
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First correct dehydration and associated hypochloremic, hypokalemic
metabolic alkalosis.
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Follow this with pyloromyotomy.
Biliary Atresia
This appears in 6- to 8-week-old babies who have persistent, progressively
increasing jaundice (conjugated bilirubin).
Diagnose in the following ways:
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Conduct serologies and sweat test to rule out other problems.
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Order HIDA scan after 1 week of phenobarbital (a powerful choleretic).
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If no bile reaches the duodenum even with phenobarbital stimulation, surgical
exploration is needed.
Hirschsprung Disease (Aganglionic Megacolon)
The most important clue to diagnosis is chronic constipation. A rectal exam
may lead to explosive expulsion of stool and flatus with relief of abdominal
distention.
Diagnose by getting a full-thickness biopsy of rectal mucosa.
Surgical Conditions Later in Infancy
Intussusception
This presents in 6- to 12-month-old chubby, healthy-looking kids with brief
episodes of colicky abdominal pain that makes them “double up and squat.”
There is also the following:
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A vague mass on the right side of the abdomen
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An “empty” right lower quadrant
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“Currant jelly” stools
A barium or air enema is both diagnostic and therapeutic. Perform surgery if
enema fails to achieve reduction.
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