DEPT OF PAEDIATRIC SURGERY Dr. E VAMSHI KRISHNA CASE PRESENTATION - PowerPoint PPT Presentation

12-10-2017 DEPT OF PAEDIATRIC SURGERY • Dr. E VAMSHI KRISHNA CASE PRESENTATION • PG- General surgery BILIARY TRACT • Dr. GANGADHAR ANATOMY • PG- Dept of anatomy • Dr. M SRAVAN KUMAR CASE DISCUSSUION • PG- General surgery

CASE REPORT (PAEDIATRIC SURGERY) DR E VAMSHI KRISHNA 2 ND YR POST GRADUATE GENERAL SURGERY

2yrs old female baby brought to the paediatric surgery OPD by her Mother With c/o abdominal pain since 1 month

• Pt was apparently assymptomatic 1 month back then she developed mild pain in upper abdomen since 1 month - intermittent - colicky type - not associated with vomitings - episodes of lite yellowish colored stools since 10 days • No fever, constipation / diarrhoea / malena

• No h/o cough/ hemoptysis • No respiratory symptoms • No urinary symptoms - urine colour normal

Past history • h/o 3 similar attacks of abdominal pain which was subsided with medication - No h/o jaundice in the past • Not a k/c/o DM/ HTN/ TB/ Asthma/ Epilepsy • No previous surgical history

Birth history • Product of Non consanguineous marriage • Mother Age 26 yrs, G2 P1 L1 • Order of birth : 2 nd baby • Full term , LSCS ( Indication – previous LSCS) • Birth weight = 3.1 kgs • No h/o birth asphyxia Neonatal period • No prolonged period of physiological jaundice

Developmental history • Attained milestones as per age • No regression Vaccination : • Vaccinated regularly as per schedule

Personal history • Diet – mixed • Appetite – normal • Bowel , bladder - regular Family history • No h/o similar complaints in other family members Socio economic status • Lower middle class

GENERAL EXAMINATION • Baby is active, cooperative • Mild - icterus present • No- pallor ,no- clubbing, no- cyanosis, no- lymphadenopathy, no- edema Vitals: • Temp = 98.6 F • PR-96 bpm, regular, rhythmic normal volume. • BP-100/60 mmHg measured on Rt arm in supine position.

Anthropometry • Weight : 10 kgs (50 th percentile) • Height : 84cm ( 50 th percentile) • Head circumference : 47cm ( 50 th percentile) • Abdominal girth : 46cm • Mid arm circumference : 15cm

Examination of abdomen Inspection • Abdomen is flat, no localised fullness • Umbilicus central in position, inverted. • All quadrants are equally moving with respiration, abdomino-thoracic type • No scars, no discharging sinuses, engorged veins, visible pulses, visible peristalisis • No visible mass

Palpation • Mild tenderness present in right hypo chondrium • Vague irregular mass approximately 4 x3 cm palpated in right hypo chondrium, borders are ill defined, • Moving with respiration cranio caudally • Firm in consistency • No hepato spleno megaly • Renal angles not full

Percussion • Liver dull note- 5 th ICS in MCL continued with the mass inferiorly No free fluid in abdomen Auscultation: • Normal bowel sounds heard • Hernial sites- normal Per rectal examination • Normal • Stool colour - normal

• Cardiovascular system : NAD • Respiratory system : NAD • No neurological deficit

PROVISIONAL DIAGNOSIS With history and clinical examination findings • Distended gall bladder • Choledochal cyst • Liver abscess • Retroperineal swelling

INVESTIGATIONS Blood group- A +ve Hb- 11.2 gm% TLC- 6,000 /cu.mm Platelet count: 2.5 lakhs/cumm CUE = WNL BT-2mins 30 sec CT-4mins PT = 14 seconds, APTT = 29 second INR = 1.11

RFT Blood urea- 28mg/dl Creatinine- 0.4mg/dl Uric acid 1.6 mg/dl Calcium 8.5mg/dl Sodium 144meq/litre Potassium 3.5meq/litre Chloride 99meq/litre RBS = 115mg/dl

LFT TSB 2.32 mg/dl DB 1.30 m/dl SGOT 444 IU/L SGPT 56 IU ALP 403 IU Total protiens 4.6 gm/dl Albumin 2.6 gm/dl A/g ratio 1.03 • Sr amylase = • Sr lipase =

HIV-Non reactive HbsAg-Negative HCV-Negative

USG ABDOMEN • 36mm hypoechoeic lesion anterior to portal vein • Dilated IHBDR • S/O Choledochal cyst

CECT ABDOMEN

HEPATO BILIARY SCINTIGRAPHY • Large choledochal cyst involving entire CBD with obstructive pattern of drainage with preserved hepatic function

ECG

FINAL DIAGNOSIS • Choledochal cyst type 1-A

• Planned for surgery: Cyst excision and Roux-en-Y – Hepaticojejunostomy Preoperative preperation: • IV antibiotics : 3 days inj CEFOTAXIM 500mg/IV/BD inj METROGYL 15ml /IV/TID • Inj Vitamin K 2mg/ im given 3 doses • IVF 5% DEXTROSE- 500ml

• Surgery planned : cyst excision and Roux-en-Y – Hepaticojejunostomy • Position: supine • Under general anesthesia • NG tube, foley’s catheter inserted • Incision: right subcostal

INCISION

DISTENDED GALL BLADDER

Tube introduced for inta op cholangiogram

Intra operative cholangiogram

Mobilization of gall bladder from its bed

Cystic duct leading to choledochal cyst

Choledochal cyst opened

Lily’s procedure

Gall bladder is attached to upper ½ of cyst

Distal end of CBD is cannulated

POD - 0 • NBM • IVF – ISOLATE P 1000ml • Inj.CEFOTAXIM 500mg/iv /BD • Inj.AMIKACIN 100mg / iv/ BD • Inj.METROGYL 15ml/iv/TID • Inj.PARACETAMOL 150mg/iv/TID • O2 inhallation- 3lit/min • Ryles tube aspiration

POD - 1 • No fever/ vomittings • PR: 106/min • BP: 100/60 mmHg • NG tube – minimal • Drain site – minimal soakage, bile stained • P/A- soft, no distension no guarding/ rigidity bowel sounds- not present • Input/ output – 1100/ 800ml • Same treatment continued • Chest physiotherapy

POD - 2 • No fever/ vomittings • PR: 108/min • BP: 100/60 mmHg • NG tube – minimal • Drain site – minimal soakage, bile stained • P/A- soft, no distension no guarding/ rigidity bowel sounds- sluggish • Same treatment continued • Chest physiotherapy • ASD – done, wound healthy healing

POD - 3 • No fever/ vomittings • NG tube – scanty • Drain site – minimal soakage • P/A- soft, no distension no guarding/ rigidity bowel sounds- present • Passed flatus • IVFluids- isolate-p 500ml, DNS- 500ml, with Inj.MVI 1amp • Same treatment continued • Chest physiotherapy • ASD – done, wound healthy healing

POD - 4 • No fever/ vomittings • NG tube – nil • Drain site – minimal soakage • P/A- soft, no distension no guarding/ rigidity bowel sounds- present • Passed stools • NG tube, foley’s catheter removed • Sips of oral fluids • Inj. PCM 15mg/IV /SOS • Same treatment continued • Chest physiotherapy • ASD – done, wound healthy healing

POD - 5 • Tolerating sips of oral fluids • No fever/ vomittings • Drain site – minimal soakage • P/A- soft, no distension bowel sounds- present • Passed stools • Liquid diet • Same treatment continued • Chest physiotherapy • ASD – done, wound healthy healing

POD - 6 • Tolerating liquid diet • No fever/ vomittings • Drain site – minimal soakage • P/A- soft, no distension bowel sounds- present • Passed stools • soft diet • Same treatment continued • Chest physiotherapy • CRD shortened • ASD – done, wound healthy healing

POD - 7 • Tolerating liquid diet • No fever/ vomittings • Drain site – minimal soakage • P/A- soft, no distension bowel sounds- present • Passed stools • soft diet • Same treatment continued • Chest physiotherapy • CRD shortened • ASD – done, wound healthy healing

• POD 8 – CRD removed • POD 9 – Alternate sutures removed • POD 10 – All sutures removed wound healthy healing, no gaping, no discharge

Post operative CT ABDOMEN with Oral contrast

• Discharged on POD- 11 • Advised syrup SEPTRAN- 2.5ml /BD (TRIMETHAPRIME 40mg + SUXAMETHAZONE 200mg in 5ml) • Reviewed after 1 week • Next follow up after 3 months

THANK YOU