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Chapter 43. Pediatric Surgery

What is the most appropriate diagnostic test for an otherwise healthy 2 month old with new-onset bilious emesis?

A. Ultrasound

B. Upper GI series

C. CT scan abdomen/pelvis

D. Contrast enema

E. Esophagram

B. Bilious emesis is indicative of a proximal bowel obstruction. In a 2 month old who has been thriving, the abnormality that must be ruled out is a midgut volvulus. This typically occurs in the setting of malrotation with a narrow-based mesentery that is susceptible to clockwise rotation and strangulation of the mesenteric vessels. While Ultrasound has been used in the diagnosis of malrotation based on the relationship of the superior mesenteric vessels, it is not currently the test of choice with acute obstruction. CT scan can make the diagnosis, but it is unnecessarily costly and time consuming. Contrast enema can be indicative of malrotation, but will not confirm midgut volvulus. Esophagram will show neither malrotation nor midgut volvulus. Upper GI series is the current test of choice. The study classically shows a “corkscrew” sign with twisting of the small intestine near the ligament of Treitz, which may be displaced medially in the setting of malrotation.

Which of the following statements is not true concerning thyroglossal duct remnants?

A. Thyroglossal duct containing thyroid tissue has a higher risk of developing papillary carcinoma

B. Resection of the hyoid bone surrounding the duct is necessary to prevent recurrence

C. Thyroglossal ducts always occur in the midline of the neck

D. Resection when infected carries no higher risk of recurrence

E. Thyroglossal duct cysts can often be differentiated from other neck lesions on exam as they tend to move with swallowing

D. Thyroglossal duct remnants are the most common midline cervical congenital anomaly. Complete excision is indicated because of the risk of infection and the possibility of the development of papillary carcinoma later in life. Acute infection in thyroglossal tracts should be treated with antibiotics. Abscesses should be incised and drained. After complete subsidence of the inflammatory reaction (approximately 6 weeks), a thyroglossal cyst and its epithelial tract should be excised. The mid portion of the hyoid bone should be removed en bloc with the thyroglossal tract to the base of the tongue (Sistrunk procedure). Recurrences occur when the hyoid is not removed and when the cyst was previously infected or drained. Lymph nodes, dermoid cysts, and enlarged Delphian nodes containing tumor metastases may be confused with thyroglossal ...

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