Stomach, duodenum, small intestine Department of General and Oncological Surgery for Children and Adolescents ⚫ gastroesophageal reflux – physiological especially in newborns - antireflux mechanisms are immature ⚫ gastroesophageal reflux disease ⚫ Anatomical ⚫ 1 ) lower esophageal sphincter (1-3 cm), spontaneous relaxation ⚫ 2 ) intra-abdominal esophagus section- an increase of intra-abdominal pressure ⚫ 3 ) Gubroff’s valve ( folds of the mucosa at the border of esophagus and the stomach) ⚫ 4 ) sharp angle of His ⚫ 5) esophageal hiatus – part of the diaphragm – sphincter pressure ⚫ 6 ) diaphragmatic ligament – in case of incompetency = esophageal hiatus hernia ; hiatal hernia ⚫ Functional: - coordinated esophageal peristalsis - differential pressure chest- abdomen - saliva - emptying of the stomach ⚫ 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 ⚫ - shortness of breath ⚫ - apnea ⚫ - SIDS ( Sudden Infant Death Syndrome ) = sudden infant death syndrome - reflex n . X.- tightening of the airways ⚫ neurobehavioural : ⚫ - Sandifer syndrome ( tilt of the head and neck forward) ⚫ - tearfulness , irritability ⚫ - sleeping disorders ⚫ 24 hours pH-metry ⚫ Upper GI - X ray contrast study ⚫ Endoscopy ⚫ esophageal atresia ⚫ duodenal atresia ⚫ congenital diaphragmatic hernia ⚫ abdominal wall defects ⚫ maltrotations ⚫ Conservative - mostly in infants : ⚫ positional - 45-60st ⚫ frequent feeding with smaller volumes ⚫ thickening of food ⚫ pharmacological (neutralizing drugs, prokinetics, drugs reducing the secretion of HCl - H2 blockers, PPIs) Infants – depending on severity of symptoms ⚫ Surgical - 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 To restore antireflux barrier Fundoplication : redouble fundus to form a cuff around the esophagus Fundoplication rear : - Nissen ( 360 *) - Toupet (270*) Fundoplication front deepening His angle : Thal in modification Boix • lengthening the abdominal part of esophagus • recreate the angle of His • strengthening gastro- oesophageal barriers/ by fundoplication of the stomach around the inlet • narrowing of the diaphragm hiatus ⚫ Primary peptic ulcer disease : ⚫ otherwise healthy children ⚫ most often ulcer of duodenum ⚫ often family history ⚫ Secondary ulcers : ⚫ in children treated for other reasons ⚫ often life-threatening conditions / shock, trauma, sepsis /= stress ulcer ⚫ Cushing ulcer – traumatic (cranio- cerebral injuries) ⚫ Curling's ulcer - burning Primary ulcer Secondary ulcer ⚫ Etiology - Helicobacter pylori ⚫ Etiological factor : ⚫ after extensive trauma, burns , surgery ⚫ Location: most common duodenal ulcer - with concomitant inflammation in ⚫ Location: the most common ulcer without the gastric mucosa mucositis ⚫ Symptoms: - newborn and infant rapid ⚫ Symptoms: stomach bleeding , perforation progress with gastrointestinal bleeding and gastrointestinal perforation - The child ⚫ Prevention by prophylactic H2 blockers of preschool age and older: abdominal pain , administration in children treated for loss of apetite, anemia due to bleeding other reasons ⚫ ⚫ Conservative treatment : Alkalizing agents, ⚫ Treatment : endoscopic or surgical in the H2 blockers - Tetracycline or amoxicillin and event of perforation or massive bleeding metronidazole effective in 80 % of children resolutionthat persists despite conservative of symptoms after approx. 8 weeks of treatment (cold compresses on the treatment abdomen, ingots with cold saline into the stomach) ⚫ Rarely, surgical treatment ⚫ Endoscopy : - rubber band ligation - Injections ( adrenaline ) ⚫ operations : ⚫ 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 ⚫ One of the most common surgical issue in newborns and infants ⚫ 1-4 / 1000 ⚫ 4-8 times more often boys ⚫ 3-6 week ⚫ Family history No clear etiopathogenesis ! Hypothesis about pyloric stenosis development : - disorders or decreased amounts of ganglion cells -ganglion cell immaturity -irritant effect of milk in the stomach - the role of growth factors - disturbances in the local synthesis of NO - reduced muscle relaxation - erythromycin - folic acid deficiency during pregnancy Progressive : - regurgitation after feeding initially - non-bilious vomiting - projectile vomiting - persistent good appetite - poor weight gain - stools in the form of pellets - constipation - dehydration ⚫ epigastric fullness - visible through the thin abdominal walls peristaltic waves in the upper abdomen ⚫ symptom of olive - palpable rounded, moving structure ⚫ Ultrasound!!! ⚫ Blood tests hypochloremic hypokalemic metabolic alkalosis H - alkalosis – kidneys are saving H+ and hypocalcemia occurs Cl - hypochloremia ⚫ Abdominal X-ray (nowadays not so often)– bloated stomach, slight gas in intestines - Contrast examination of the upper GI: passage of the gastrointestinal tract – „string sign”= difficulties in passing to duodenum ⚫ First – nasogastric tube - no feeding - water and electrolyte abnormalities correction ⚫ Surgery: ⚫ pyloromyotomy longitudinalis m. Ramstedt-Weber - - ⚫ dividing the muscle of the pylorus to open up the gastric outlet ⚫ can be done through a single incision (usually 3–4 cm long) or laparoscopically (through several tiny incisions) ⚫ Start to feed a baby with gradually increasing volume even 6 hours after the surgery ⚫ malformation involving the existence of an additional segment of the gastrointestinal tract ⚫ 2 forms: ⚫ cystic ⚫ tubular (cylindrical) - most are attached along the dorsal or mesenteric border of the bowel ⚫ 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 ⚫ closely linking the digestive tract ⚫ vascularization of arteries from 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 epithelium) ⚫ always on the mesenteric edge ⚫ rare - 1 : 35.000 ⚫ chest - 24% ⚫ abdomen - 70 % : ⚫ the most small intestine - ileum, jejunum ⚫ both cavities , neck - 6% ⚫ typically, the shape of cysts ⚫ tumor (compression) ⚫ difficulties, disorders in breathin ⚫ difficulty in swallowing ⚫ vomiting ⚫ abdominal pain ⚫ obstruction of the gastrointestinal tract ⚫ bleeding - ulceration ⚫ constipation ⚫ perforation ⚫ in the stomach – carcinoid ⚫ asymptomatic ⚫ Usg ⚫ X ray ⚫ CT ⚫ Scyntygraphy STOMACH DUPLICATION - cystic or cylindrical - most common prepyloric area - cylindrical form along the greater curvature of the stomach - symptoms: obstruction, ulceration, carcinoid DUPLICATION of DUODENUM – depending on the location - The upper part of duodenum - a considerable distance before common bile duct - remove entirely, anastomosis of duodenum and stomach by Billroth I method - Just above the common bile duct - resection, gastric stump and duodenum closure with anastomosis of the prepyloric stomach with the loop of jejunum modo Billroth II Duplication of the jejunum and ileum - the most common - cylindrical - jejunum - cystic - ileum - cylindrical: usually connection with the lumen at the inlet - often, chronic or acute bleeding anemia - cylindrical duplication requires resection with adjacent normal intestine due to a common wall and vascularity - cystic duplication – without connection with the intestinal lumen; sometimes cause torsion, intussusception COLON DUPLICATION - most frequently ascending colon and sigmoid - cystic and cylindrical - cylindrical form resection / connection intestinal lumen - duplication of cecum is resected with cecum assembling the ileum of the ascending colon RECTUM DUPLICATION - accompanied by other defects of this area - rarely additional separate anus – in caudal duplication syndrome - surgical access by a combined abdomino-perineal and sacral approach - common wall - connection SURGERY - complete excision - excision of mucosa + marsupialisation - partial resection and anastomosis Tubular Cystic duplication duppliction.