- •Guide to Pediatric Urology and Surgery in Clinical Practice
- •Preface
- •Contributors
- •Key Points
- •1.1 Introduction
- •1.2 Risk Factors
- •1.3 Presentation
- •1.4 Diagnosis
- •1.5 Common Pathogens
- •1.6 Treatment
- •1.7 Imaging
- •1.8 Indications for Referral
- •Suggested Reading
- •Key Points
- •2.1 Introduction
- •2.2 Pathogenesis
- •2.3 Establishing the Diagnosis
- •2.4 Acute Management
- •2.5 Once the Diagnosis Is Established
- •2.6 Long Term Management
- •References
- •Key Points
- •3.1 Introduction
- •3.2 Aetiology
- •3.3 Pathogenesis and Risk Factors
- •3.4 Classification
- •3.5 Signs and Symptoms
- •3.6 Diagnosis
- •3.7 Imaging Studies
- •3.8 Ultrasound Scan (USG)
- •3.9 Voiding Cystourethrography (VCUG)
- •3.10 Dimercapto-Succinic Acid Scan (DMSA)
- •3.11 Treatment
- •3.12 Prophylaxis and Prevention
- •References
- •Key Points
- •4.1 Epidemiology
- •4.2 Presentation
- •4.3 Diagnosis and Workup
- •4.4 Management
- •4.5 Investigations after First UTI in a Child
- •4.6 Prevention of UTIs
- •4.7 Managing VUR and UTIs
- •References
- •Key Points
- •5.1 Introduction
- •5.2 Common Abnormalities of the Scrotum
- •5.4 Indications for Referral
- •Suggested Readings
- •Key Points
- •6.1 Introduction
- •6.2 Common Foreskin Conditions
- •6.3 Treatment of Conditions of the Foreskin
- •6.4 Indications for Referral
- •References
- •Key Points
- •7.1 Hypospadias
- •7.1.1 Introduction
- •7.1.2 Management Issues
- •7.1.3 Indications and Timing of Referral
- •7.1.4 Complications of Surgery
- •7.2 Epispadias
- •Key Points
- •7.2.1 Introduction
- •7.2.2 Management Issues
- •7.2.3 Surgery, Common complications, and Postoperative Issues
- •7.3 Concealed Penis
- •7.3.1 Introduction
- •7.3.2 Referral and Treatment
- •7.3.3 Complications
- •7.3.4 Benign Urethral Lesions in Boys
- •7.3.5 Treatment
- •7.3.6 Follow-Up After Treatment
- •Key Points
- •References
- •Key Points
- •8.1 Introduction
- •8.2 Common Conditions
- •8.3 Treatment of Undescended Testis
- •8.4 Indications for Referral
- •References
- •Key Points
- •9.1 Natural History of the Prepuce
- •9.2 Benefits of Circumcision
- •9.3 Absolute Indications for Circumcision
- •9.4 Relative Indications for Circumcision
- •9.5 Surgical Options
- •9.6 Contraindications to Circumcision
- •9.7 Complications of Circumcision
- •9.8 Conclusion
- •References
- •Key Points
- •10.1 Introduction
- •10.2 Labial Adhesions
- •10.3 Interlabial Masses
- •10.4 Paraurethral (Skene’s Duct) Cyst
- •10.5 Imperforate Hymen with Hydrocolpos
- •10.6 Prolapsed Ectopic Ureterocele
- •10.7 Urethral Prolapse
- •10.8 Urethral Polyp
- •10.10 Vaginal Discharge and Vaginal Bleeding
- •References
- •Key Points
- •11.1 Introduction
- •11.2 Functional LUTS
- •11.2.1 Overactive Bladder
- •11.2.2 Dysfunctional Voiding
- •11.2.3 Underactive Bladder
- •11.2.4 Uroflowmetry
- •11.2.5 Treatment
- •11.2.5.1 Standard Outpatient Urotherapy
- •11.2.5.2 The Failed Training
- •11.2.6 Giggle Incontinence, Incontinentia Risoria
- •References
- •Key Points
- •12.1 Introduction
- •12.1.1 Definition
- •12.1.2 Prevalence
- •12.1.3 Causes
- •12.1.4 Monosymptomatic Enuresis
- •12.1.4.1 Genetics
- •12.1.4.2 Sleep
- •12.1.4.3 Sleep-Disordered Breathing
- •12.1.4.4 Small Functional Bladder Capacity
- •12.1.4.5 Psychological/Behavioral
- •12.1.5 Nonmonosymptomatic (Organic) Enuresis
- •12.1.5.2 Polyuria
- •12.1.5.3 ADH Secretion
- •12.1.5.4 Food Sensitivity
- •12.2 Investigations
- •12.2.1 History
- •12.2.2 Physical Examination
- •12.2.3 Laboratory Tests
- •12.2.4 Imaging Studies
- •12.2.5 Evaluation of Functional Capacity
- •12.3 Conventional Treatment
- •12.3.1 Behavioral Therapy
- •12.3.2 Alarm Therapy
- •12.3.3 Pharmacologic Therapy
- •12.4 Alternative Treatment
- •12.5 Conclusion
- •12.5.1 Areas of Uncertainty
- •12.5.2 Guidelines
- •References
- •Key Points
- •13.1 Introduction
- •13.2 Definition of Constipation
- •13.3 Evaluation
- •13.4 Treatment of Constipation
- •13.5 Indications for Referral
- •Suggested Readings
- •Key Points
- •14.1 Hematuria
- •14.1.1 Important Points in the History
- •14.1.2 Causes of Hematuria
- •14.1.3 Investigations
- •14.1.4 Management
- •14.2 Proteinuria
- •14.2.1 Quantification of Proteinuria
- •14.2.2 Causes of Proteinuria
- •14.2.2.1 Non-Pathological Proteinuria
- •14.2.2.2 Orthostatic Proteinuria (Postural Proteinuria)
- •14.2.2.3 Pathological Proteinuria
- •14.2.3 Investigations
- •References
- •Key Points
- •15.1 Introduction
- •15.2 Indications for Referral
- •References
- •Key Points
- •16.1 Introduction
- •16.2 Treatment of Angular Dermoid
- •16.3 Indications for Referral
- •16.4.1 Introduction
- •Suggested Reading
- •Key Points
- •17.1 Introduction
- •17.2.1 Thryoglossal Duct Cyst
- •17.2.2 Midline Dermoid Cyst
- •17.2.3 Lymph Nodes
- •17.2.4 Thyroid Nodule
- •17.2.5 “Plunging” Ranula
- •17.2.6 Investigations
- •17.3 Treatment
- •17.3.1 Thryoglossal Duct Cyst
- •17.3.2 Midline Dermoid Cyst
- •17.3.3 Lymph Nodes
- •17.3.4 Plunging Ranula
- •Key Points
- •18.1 Introduction
- •18.2.1 Lymph Nodes
- •18.2.1.1 Infective
- •18.2.1.2 Inflammatory
- •18.2.1.3 Neoplastic
- •18.2.2.1 Investigations
- •Key Points
- •19.1 Introduction
- •19.2 Etiology and Types of Torticollis
- •19.3 Treatment of Torticollis
- •19.4 Indications for Referral
- •Suggested Readings
- •Key Points
- •20.1 Introduction
- •20.2 Common Umbilical Conditions
- •20.4 Indications for Referral
- •20.5 Epigastric Hernia
- •20.5.1 Introduction
- •References
- •Key Points
- •21.1 Introduction
- •21.2 Common Sources of Abdominal Pain
- •21.2.1 Children
- •21.2.2 Infants
- •21.3 Treatment of Conditions
- •21.4 Indications for Surgical Referral in Children with Abdominal Pain
- •References
- •Key Points
- •22.1 Introduction
- •22.2 History
- •22.3 Physical Examination
- •22.4 Laboratory Tests
- •22.5 Diagnostic Imaging
- •Suggested Readings
- •Key Points
- •23.1 Introduction
- •23.2 Investigations
- •23.3 Treatment
- •References
- •Key Points
- •24.1 General Principles
- •24.2 Neonates and Newborn
- •24.3 Infants and Young Toddlers
- •24.4 Older Children
- •24.5 Conclusion
- •References
- •Key Points
- •25.1 Introduction
- •25.3 Neonatal Intestinal Obstruction (Distal)
- •25.4 Childhood Intestinal Obstruction
- •References
- •26.1 Introduction
- •26.3 Initial Management
- •26.4 Causes of Neonatal Bilious Vomiting
- •Key Points
- •26.6 Necrotizing Enterocolitis
- •26.7 Duodenal Atresia
- •26.8 Small Bowel Atresia
- •26.9 Meconium Ileus
- •26.10 Hirschsprung’s Disease
- •26.11 Anorectal Malformations
- •26.12 Conclusion
- •References
- •Key Points
- •27.1 Introduction
- •27.2 Presentation
- •27.3 Investigations
- •27.4 Management
- •References
- •Key Points
- •28.1 Introduction
- •28.2 Presentation
- •28.3 Investigations
- •28.4 Management
- •28.5 Surgical Management
- •References
- •Key Points
- •29.1 Introduction
- •29.2 Types of Vascular Anomalies
- •29.3 Investigation of Vascular Anomalies
- •29.4 Treatment of Vascular Anomalies
- •29.5 Indications for Referral
- •Suggested Readings
- •Index
Chapter 21. Surgical Aspects of Abdominal Pain 203
3.Malrotation with midgut volvulus: A life-threatening surgical emergency in which the intestine becomes twisted as a result of malrotation of the intestine during fetal development. Because the consequences of malrotation associated with midgut volvulus may be catastrophic, prompt diagnosis and treatment are required to prevent mortality and short-gut syndrome.
4.Necrotizing enterocolitis (NEC): The most common disease process of the gastrointestinal (GI) tract of premature neonates that results in segmental or total bowel necrosis.
21.3 Treatment of Conditions
1.Nonsurgical conditions: Gastroenteritis, constipation, colic, and other extra-abdominal conditions require treatment directed at the underlying cause.
2.Surgical conditions: In general, prompt surgical intervention is required for pathologies associated with:
a.Vascular compromise (malrotation with volvulus, irreducible incarcerated hernias, nonreduced intussusception, adhesive bowel obstruction, solid organ torsion, and trauma)
b.Perforated viscus (acute appendicitis, NEC, Meckel’s diverticulum, trauma, and foreign bodies)
c.Acute hemorrhage (Trauma, Meckel’s diverticulum, and ectopic pregnancy)
21.4 Indications for Surgical Referral in Children with Abdominal Pain
1.Increasing abdominal pain with progressive clinical deterioration
2.Bilious vomiting
3.Involuntary abdominal guarding or rigidity
4.Rebound abdominal tenderness
5.Marked abdominal distension with tympany
6.Acute fluid or blood loss into the abdomen
204 J.A. Sandoval
7.Abdominal trauma
8.Abdominal pain without clear etiology
References
1.Acute abdomen. Semin Pediatr Surg 1997;6:57-111.
2.Ashcraft KW. Consultation with the specialist: acute abdominal pain. Pediatr Rev. 2000;21:363-367.
3.Leung AK, Sigalet DL. Acute abdominal pain in children. Am Fam Physician. 2003;67:2321-2326.
4.Mason JD. The evaluation of acute abdominal pain in children.
Emerg Med Clin North Am. 1996;14:629-643.
5.Buchert GS. Abdominal pain in children: An emergency practitioner’s guide. Emerg Med Clin North Am. 1989;7(3):497-517.
Chapter 22
Approach to Abdominal Masses
Kenneth W. Gow and Martin A. Koyle
Key Points
››Most abdominal masses originate from the retroperitoneum with the kidney accounting for more than half of the lesions.
››Most lesions in infants are benign and malignant in older children.
››Diagnostic imaging commonly begins with an ultrasound followed by a CT scan to characterize the lesion and determine the anatomical relationships.
22.1 Introduction
Pediatricians commonly see abdominal masses in their patient population. While most abdominal masses will not require surgery, it is estimated that 40% will.The key task for the clinicians is to determine which need further work-up. Most disorders originate from the retroperitoneum with the kidney accounting for more than half of the lesions. Only 10% will arise from intraperitoneal organs. While most lesions in infants are benign in nature (Fig. 22.1), there is a higher risk of malignancy in older children (Fig. 22.2). The method of determining which abdominal masses need surgical attention involves a thorough history and physical, followed by selected laboratory tests, and focused diagnostic imaging (Fig. 22.3).
P.P. Godbole et al. (eds.), Guide to Pediatric Urology and |
205 |
Surgery in Clinical Practice, DOI: 10.1007/978-1-84996-366-4_22,
© Springer-Verlag London Limited 2011
206 |
K.W. Gow and M.A. Koyle |
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Intraperitoneal − 20% |
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Flank − 65% |
• GI Masses − 15% |
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• Renal − 55% |
• Duplication |
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• Hydronephrosis |
• Meconium ileus |
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• Polycystic kidney |
• Mesenteric-omental cyst |
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• Mesoblastic nephroma |
• Hepatobiliary − 5% |
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• Renal ectopic |
• Hemangioendotheloma |
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• Renal vein thrombosis |
• Hepatoblastoma |
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• Nephroblastomatosis |
• Hepatic cyst |
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• Wilms tumor |
• Choledochal cyst |
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• Nonrenal − 10% |
• Hydrops of gallbladder |
•Adrenal hemorrhage
•Neuroblastoma
•Teratoma
elvic − 15%
Hydrometrocolpos Ovarian cyst
• Sacrococcygeal teratoma
FIGURE 22.1. The common causes of abdominal masses in infants.
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Intraperitoneal − 18% |
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• GI Masses − 12% |
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• Appendiceal abscess |
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Flank − 78% |
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• Congenital abnorm. |
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• Renal − 55% |
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• Other neoplasms |
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• Wilms tumor |
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• Hepatobiliary − 6% |
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• Hydronephrosis |
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• Hepatoblastoma |
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• Cystic disease |
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• Hepatocellular ca |
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• Nonrenal − 23% |
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• Choledochal cyst |
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• Neuroblastoma |
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•Teratoma
•Other neoplasms
Pelvic − 4%
Ovarian cyst
Hydrometrocolpos
FIGURE 22.2. The common causes of abdominal masses in children and adolescents.
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History, Physical, Lab Tests |
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ABDOMINAL MASS |
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Abdominal Radiograph |
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Bowel Obstruction |
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Calcifications |
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REFER |
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Bowel gas displacement |
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Consider: BE or UGI |
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Abdominal Ultrasound |
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FLANK |
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INTRAPERITONEAL |
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PELVIC |
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Renal |
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Adrenal |
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Other |
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Cystic |
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Solid |
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Complex |
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Solid |
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Cystic |
Pregnancy |
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Cystic |
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Solid |
Cystic |
Solid |
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Cystic |
Solid |
Omental,Choledochal Urachal, P.Sten., |
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Mesenteric |
Cyst |
Duplication IBD, |
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Intussusception |
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Distended |
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|||||||
NUCLEAR SCAN, VCUG |
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CT SCAN OF ABDOMEN |
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CT SCAN OF ABD. |
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Bladder |
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Nonfunctional |
|
Functional |
Mesoblastic |
Adrenal |
NB, |
Cystic |
Teratoma, |
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Hemangioma, |
HB, |
Pancreatic |
|
Appy Meconium Sacro- |
Ovarain Cyst, |
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Nephroma,hemorrhage Pheo. |
Hygroma, |
Sarcoma, |
|
HIDA |
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Organomegaly, |
HCC, |
Pseudocyst Abscess |
Cyst |
Coccygeal Hydrometro- |
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||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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Wilms Tumor, |
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Abscess |
Pancreas, |
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Lymphoma, |
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Teratoma, |
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Colpos, |
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|||||||||||||||||||||||||||
MCDK, |
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CCSK, MRTK |
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Lymphoma, |
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Mets |
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Sarcoma |
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Ant. |
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|||||||||||||||||||||
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RCC |
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Neuroblastoma |
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||||||||||||||||||||||||||
UPJO, |
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Meningo- |
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||||||||||||||||||||
No |
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||||||||||
Duplication |
|
+/- Reflex |
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Myelocele, |
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||||||||||||||
Ureterocele reflux |
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Rectal |
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||||||||
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||||||||||
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duplication |
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||||
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PUV, |
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|||||||
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UPJO, |
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|||||
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Stricture |
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||||||
|
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|
UVJO, |
|
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|
Duplication |
|
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|
PEDIATRIC GENERAL SURGERY REFERRAL |
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|
|||||||||||||||||||||||||
|
Duplication, |
|
|
1°/2 |
°? |
|
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|||||
|
ureterocele, |
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|||||||
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||||||
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PCDK |
|
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Follow, |
Follow, |
|
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Follow, |
|
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Fo low, |
A/B, |
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|||||||||||||||||||
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|
OR |
Follow |
|
OR |
OR |
OR |
|
OR |
|
OR |
|
OR |
|
OR |
|
OR |
OR |
Cath. Mx |
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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OR |
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OR |
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PED. UROLOGY REFERRAL
Abbreviations: BE – Barium enema; UGI – Upper gastrointestinal contrast study; IBD – Inflammatory bowel disease; MCDK – Mu ticystic dysplastic kidney; UPJO– Ureteropelvic junction obstruction;
UVJO – Ureterovesical junction obstruction; PCDK – Polycystic disease of the kidneys; PUV – Posterior urethral valves; CCSK – Clear cell sarcoma of the kidney; MRTK – Malignant rhabdoid tumor the kidney; RCC – Renal cell carcinoma; NB – Neuroblastoma; Pheo. – Pheochromocytoma; HIDA – Hepatobiliary iminodiacetic acid scan; HB – Hepatoblatoma; HCC – Hepatocellular carcinoma; Appy – Appendiceal; OR – Operative management; A/B – Antibiotics; Cath – Catheterize; Mx – Management
FIGURE 22.3. A flowchart for work-up of abdominal mass in pediatric patients.
207 Masses Abdominal to Approach .22 Chapter