1. CDH: pulmonary HTN from thickening of pulmonary vessels due to increased intrathoracic pressures; additionally, ipsi and contralateral lung hypoplasia from pressure on the mediastinum on the opposite side.
-Bochdalek: failure of pleuropericardial folds to fold. this occurs on L more than R, posterior more than anterior.
-Morgani: failure of septum transversum to form properly.
2. Treatment for CDH: Breathless intubation. Get the tube in before the baby even cries, because crying could lead to increased gas in the GI tract which will worsen the compression on the lungs. Do not try to bag, for the same reason. Put in an NG tube to decompress, go on ECMO if you need to.
3. If you seen any midline anomaly (like TEF), work up/examine for signs of VACTERL anomalies--
-vertebral (CXR, u/s to look at spine-- kids have windows between vertebrae so you can look with u/s)
-anorectal (exam)
-cardiac (echo)
-TEF (NG + xray)
-renal (check that they are making urine, renal u/s to look at upper GU, VCUG to look at lower GU)
-limb (exam).
4. Bilious vomiting requires an upper GI series STAT. This is a surgical emergency, because it indicates malro/volvulus until proven otherwise.
5. Omphalocele is associated with many other defects. There is a peritoneal covering over bowels, its usually midline, there are occasionally other organs that herniate, the defect is usually >4cm. Other defects tend to be above the omphalocele (cardiac, lung hypoplasia) or below (GU, kidneys). They are rarer than gastroischesis 1:5000. These cannot be pushed in like gastroischisis, you have to wait for skin to grow around it, and then push it in around a year of age, sometimes you can't.
6. Gastroischesis: R>L, <4cm, not associated with other defects, you push it in after they're born. Put the whole thing into a silo, slowly twist the top of the silo so it pushes the guts back in.
7. Metabolic defects assoc with pyloric stenosis: chronic vomiting, you get loss of K and H, so hypokalemia, metabolic alkalosis with paradoxical aciduria. You lose volume from vomiting, so you secrete aldo which increases resorption of Na, lose K and H. Treatment is with boluses of NS until they pee (which tells you the volume is adequate). Then you give maintenance D5 0.45NS +20mEq K @1.5x maintenance rate until the electrolyte abnormalities are corrected.
8. Malro: the cecum doesn't do its counter-clockwise rotation, and stays up by the duodenum. Additionally, the mesentery of the small bowel is tight and bunched up, making volvulus much more likely. Ladd's bands form between cecum and R abdominal wall, crushing the duodenum and causing bilious vomiting. Treat by cutting the ladd's bands, stuff the small bowel on the R side of the abdomen, the large bowel on the L side, remove appendix because if you don't, if they get appendicitis they will get LLQ pain and it will go undiagnosed. Diagnosis of malro: do an upper GI series, watch for the contrast to go into stomach and then make the C-curve to the R, down, left back across the midline indicating a continuous duodenum. If the dye fails to re-cross the midline, suspect malro.
9. Intussuception: ileo-ileo is common, happens frequently, nothing to worry about. Ileo-colic is the bad one.
10. Hydroceles usually go away by 1 year, no need to fix it surgically, unless it is a communicating hydrocele, or there is a hernia. Transillumination will not tell you the difference between a hydrocele and a hernia. The way to tell is that a hydrocele can only be palpated in the base of the scrotum near the testicle, while the hernia can be palpated up the spermatic cord. Inguinal hernias are at a higher risk for incarceration in kids vs adults, so you should repair them; preemies get hernias more than full term babies, so fix their hernias before they leave the hospital.