Gastrointestinal and Hepatobiliary Surgery
The jaundiced infant
Any infant jaundiced beyond 14 days needs a fractionated bilirubin. Biliary atresia is an obliterative cholangiopathy presenting with conjugated hyperbilirubinaemia, pale stools and dark urine; Kasai portoenterostomy works best before 60 days and results fall sharply with age. Work-up is sequential: conjugated bilirubin, ultrasound (triangular cord sign, absent or small gallbladder), HIDA scan after phenobarbital and liver biopsy, with intraoperative cholangiogram as confirmation. After Kasai, cholangitis and portal hypertension dominate, and many children eventually need transplantation.
Choledochal cyst presents with pain, jaundice and a mass; MRCP defines the type; treatment is complete cyst excision with Roux-en-Y hepaticojejunostomy because of malignant risk.
Intussusception
Typical age is 6-36 months with colicky pain, redcurrant stool and a sausage mass; ultrasound shows a target sign. First-line treatment is pneumatic or hydrostatic reduction when there is no peritonitis, shock or perforation. In a child over three years, or with recurrence, suspect a pathological lead point such as Meckel diverticulum, polyp, lymphoma or Peutz-Jeghers syndrome.
Traps
Do not attempt enema reduction with peritonitis or perforation. Meckel is asked as a "most likely" question using the rule of twos: 2% of the population, 2 feet from the ileocaecal valve, 2 inches long, two ectopic mucosal types and presentation before age two. Biliary atresia is not neonatal hepatitis - pale stools and a shrunken gallbladder point away from hepatitis.
Worked example
A 10-week-old has conjugated jaundice and pale stools. Rule of thumb: pale stool plus conjugated jaundice at six weeks means urgent Kasai work-up; each week of delay reduces native-liver survival.