, , Alicja Rymaszewska Clinical Ward of General and Oncological Surgery for Children and Adolescents

gastroesophageal reflux – normal especially in newborns antireflux mechanisms are immature)

gastroesophageal reflux disease

Antireflux mechanisms Anatomical 1 ) lower sphincter (1-3 cm), spontaneous relaxation 2 ) section intra-abdominal esophagus section- an increase of intra-abdominal pressure 3 ) Gubroff’s valve ( folds of the mucosa border esophagus and the stomach) 4 ) Angle of His sharp/ obtuse 5) esophageal hiatus - the right arm of the sphincter of the diaphragm – sphincter pressure 6 ) ligament diaphragmatic - esophageal hiatus ; Functional:

- Coordinated esophageal peristalsis

- Differential pressure chest- abdomen

- saliva

- Emptying of the stomach

Symptoms

In the digestive system : - Regurgitation , vomiting - Delayed physical development - Inflammation of the esophagus ( bleeding - anemia , anxiety when feeding , dysphagia ) In the respiratory system : - Chronic cough - airway inflammation; - Shortness of breath - Apnea - SIDS ( Sudden Infant Death Syndrome ) = sudden infant death syndrome - reflex n . X.- tightening of the airways neurobehavioural : - ( tilt of the head and neck forward) - Tearfulness , irritability - Sleep disorders Diagnosis

pH-metria 24 h X ray with contrast

Congenital defects coexisting with GERD Esophagus atresia Duodenum atresia Congenital diaphragm hernia Abdominal wall defects Maltrotations Treatment Conservative - mostly infants : - Positional - 45-60st - Frequent feeding with smaller volumes - Thickening of food - Pharmacological (drugs neutralizing , prokinetics, drugs that reduce the secretion of HCl - H2 blockers,PPIs)

Infants - wait for 1 years of age ! Operational - indications : urgent : - Complications of gastroesophageal reflux disease ( erosions , ulcers , scars, metaplasia - Barrett's esophagus ) - Recurrent pulmonary inflammation , apnea

Scheduled : - Failure of conservative treatment - The coexistence of hernia ( paraesophageal and tackles ) Operacje:

Objective: To restore as much as possible antireflux barrier Fundoplication : redouble fundus to form a cuff around the esophagus Fundoplication rear : - Nissen ( 360 *) - Toupet (270*) Fundoplication front deepening Hisa angle : - Thal in modification Boix Ocho Gastropexia - not in children: - Front : PSV - Rear : Hill The aim of surgery • Lengthening the abdominal esophagus • Recreate the angle of His • Strengthening the barriers gastro- oesophageal / by fundoplication of the stomach around the inlet • Narrowing of the diaphragm hiatus

Types Primary : - otherwise healthy children systemic -most often duodenum ulcer -often family history Secondary ulcers : - In children treated for other reasons - Often life-threatening conditions / shock , trauma , / = stress ulcer

Cushing ulcer - traumatic(cranio- cerebral injuries ) Curling's ulcer - burning Primary ulcer Secondary ulcer Etiologic agent of Helicobacter pylori Etiological factor : Location: the most common ulcer XII - with after extensive trauma , burns , surgery concomitant inflammation in the Location: the most common ulcer without membrane mucositis Symptoms: stomach bleeding , perforation Symptoms: - newborn and infant rapid treatment: - Prevention by progress with gastrointestinal prophylactic H2 blockers bleeding gastrointestinal perforation - The administration in children treated for child of preschool age and older other reasons abdominal pain , loss of apetite, anemia due - Treatment : endoscopic or operational in to bleeding the event of perforation or massive bleeding that persists despite conservative Conservative treatment : - Alkalizing agents treatment ( cold compresses on the , H2 blockers - Tetracycline or amoxicillin abdomen , ingots with cold saline into the and metronidazole effective in 80 % of stomach ) children resolution of symptoms after approx. 8 weeks of treatment

Rarely, surgical treatment . Conservative treatment

Endoscopy : - rubber band ligation - Injections ( adrenaline )

operations : - closing of perforation Closing of bleeding vessels within sores - In exceptional circumstances, partial resection of the stomach

Narrowing of the antrum of the stomach, caused by overgrowth of the muscle layer in neonates and infants, which hinders the passage of gastric contents from the stomach to duodenum the twelfth months One of the most comon surgical issue in newborns and infantf 1-4 / 1000 4-8 times more often boys 3-6 week Family history Hipothesis No clear etiopathogenesis ! Hypothesis formation : - Development disorders or decreased amounts of ganglion cells - Ganglion cell immaturity - Irritant effect truncated milk in the stomach ---- Hypergastrynemia hyperacidity - The role of growth factors in the local - Disturbances in the local synthesis of NO - reduced muscle relaxation - Erythromycin - folic acid deficiency during pregnancy Symptoms Progressive : Regurgitation after feeding , vomiting initially , then increased , projectile , ingesta , without the admixture of Persistent good appetite Weak growth b.w. Stools in the form of pellets - alleged - dehydration

Putting the stomach - visible through the thin abdominal walls peristaltic waves in the upper abdomen Symptom olives - palpable rounded , moving creature knobby epigastric Diagosis Ultrasound!!!!!!!! Blood tests hypochloremic hypocaliemic metabolic alkalosis zasadowica H - alkalosis – kindeys are saving H and giving hypocaliemia Cl - hypochloremia RTG: of abdomen – bloated stomach, slight gas in intestines - passage of the – string sign”= tit sign, shoulder sign - difficulties in passing to duodenum Treatment Firstly – stomach probe - no feeding - water and electrolyte balance

Surgery: pyloromyotomy longitudinalis m. Ramstedta-Webera (dividing the muscle of thepylorus to open up the gastric outlet). This surgery can be done through a single incision (usually 3–4 cm long) or laparoscopically(through several tiny incisions), depending on the surgeon's experience and preference Start to feed a baby with gradually bigger amounts even 6 hours after the surgery

Duplication of gastrointestinal tract Malformation involving the existence of an additional segment of the gastrointestinal tract 2 forms: cystic Cylindrical - proper bowel next to and peripherally in the mesentery It occurs from the mouth to the anus The three main features: closely linked to the digestive tract - common wall The source of vasculature are the arteries of the gastrointestinal tract The three-layer wall construction J. cienkie Żołądek Characteristic features Closely linking the digestive tract Vascularization of arterias od digestive tract The three-layer construction of the wall ( Mucosa , muscle and serum ) The mucosa is not always the mucosa of the section at which there is ( in the chest can be respiratory ephitelium) Always on the edge of mesenteric !

Occurence Rare - 1 : 35.000 Chest - 24% Belly - 70 % : the most small intestine - , , and esophagus, ileocecal region rarely , and stomach (usually greater curvature and pyloric region ) least likely to duodenum Both cavity , neck - 6% Typically, the shape of cysts Other drawbacks are often comorbid

symptoms Tumor ( compression ) disordered breathing , difficulty swallowing , vomiting abdominal pain, flatulence Obstruction of the gastrointestinal tract – vomiting bleeding . - ulceration Difficulty in passing stool perforation In the stomach - carcinoid – symptoms of carcinoid syndrome(serotonin ) asymptomatic Diagnosis Usg Rtg TK Scyntygraph STOMACH DUPLICATION cystic or cylindrical Mostly no connection thick wall The most common prepyloric area Cylindrical form along the greater curvature of the stomach Symptoms: obstruction , ulceration , carcinoid

DUPLIcATION of DUODENUM - The upper part of duodenum , a considerable distance before common -removed entirely , weaving together the duodenum and stomach by Billroth I method - Just above the - resection , gastric stump and duodenum closure and anastomosis of the prepyloric stomach part of the first loop of jejunum by Billroth II - Integral cystic dupplications on the left side of the concave portion of the descending adjacent to the pancreatic head resection aren’t subject to total resection - Integral to the right of the convex parts- cylindrical cystic and cystic – like above, Cylindrical , broad anastomosis with duodenum with the removal of the wall - Strong stimulation of the celiac plexus pectoris Duplication of the jejunum and ileum - the most common - Frequently cylindrical - jejunum - Cystic frequently in the ileum - Cylindrical Integral usually have a connection with inlet- not cause distension - Often, chronic or acute bleeding anemia trobieli- ---- Statement during the operation redouble its cylindrical requires resection with adjacent normal intestine due to a common wall and vascularity - Cystic dupplication - centrally in mesentery , they have no connection with the mouth of intestine sometimes cause twist , intussusception - Ileo angle

COLON duplication - Most frequently and sigmoid - Form of cystic and cylindrical - cylindrical form resection / connection intestinal lumen - Duplication of cecum is resected with cecum assembling the ileum of the ascending colon rectum rarely Rectum Duplication - Often accompanied by other defects of this area -- Duplication is to the right rear of the rectum , is connected to the inlet - Rarely separate anus- celostomy lower - Loosely access by a combined perineal resection - Common wall - connection Treatment Operations (! ) : Excision of the whole membrane excision mucosa + marsupializati on partial resection and anastomosis

Tubular Cystic dupplicati duppliction on