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Indications for operation in acute necrotizing enterocolitis of the neonate
100
Volvulus of the Stomach. N. Iwai, Y. Goto, K. Hashimoto,
et al. J Jpn Soc Pediatr Surg 16:673-676, (June), 1980.
Eight cases of volvulus of the stomach were reported. Onset of presenting symptoms (vomiting in 5, vomiting and distension of the upper abdomen in 3 cases) was immediately after birth in 3, within one week after birth in 3, and 5 to 6 months after birth in 2 cases. Six cases were treated conservatively, but 2 cases underwent surgical correction. Type of volvulus was organoaxial in 3, and mesentericoaxial in 5 cases.--H. Suzuki Pyloric Stenosis and Direct Hyperbilirubinemia With Alpha-I-Antitrypsin Deficiency. F. K. Ghishan, D. R.
LaBreeque, F~ A. Mitros, et al. Clin Pediatr 19:293-295, (April), 1980.
A 2-wk-old male infant presented with projectile vomiting and jaundice with a total bilirubin of 14 mg/dl and a direct fraction of 10 mg/dl. After pyloromyotomy a work-up for the direct byperbilirubinemia revealed an alpha-l-antitrypsin deficiency of Pi Z Z phenotype. Statistically the two would be expected to occur in 1 in 2.5 million of the population. The authors point out the need tO fractionate the bilirubin in patients with pyloric stenosis and jaundice so that the infrequent cases of direct hyperbilirubinemia can be properly evaluated.--Randall W. Powell Atypical Muscle Hypertrophy in Pyloric Stenosis. L. E. Swischuk, C. K. Hayden, Jr., K. R. Tyson. Am J Roentgenol 134:481~,84, (March), 1980.
Seventeen patients with atypical pyloric muscle hypertrophy revealed four atypical pyloric configurations during contrast studies. Six patients had a persistent lesser curve mass due to hypertrophy of the torus region (concentration of fibers on the lesser curve). This represents the most difficult to recognize and a pyloric mass is not usually palpable. Three patients demonstrated a funnel shape antrum which represents muscle hypertrophy to a degree just less than that necessary to produce a string sign. Four patients had a spiculated antrum felt to represent irregular hypertrophy of the muscle fiber groups resulting in an irregular rather than smooth pyloric canal. Four patients demonstrated a pyloric niche or diamond sign felt to represent mucosa bulging between two separately hypertrophied muscle fiber groups. This latter form must be differentiated from a channel ulcer by its change in size. The latter three groups usually have a palpable mass but the mass may not be constant from exam to exam.--Randall W. Powell Delayed Diagnosis of Duodenal Obstruction in Down's Syndrome. G. V. Smith and R. L. Teele. Am J Roentgenol
134:937 940, (May), 1980. Four patients with Down's syndrome ranging in age from 6 to 12 yr presented with problems with recurrent episodes of vomiting. One patient also demonstrated an esophageal stricture due to gastroesophageal reflux. All four patients had foreign bodies proximal to their duodenal stenosis. All underwent successful surgical correction. The foreign bodies probably exacerbated the symptoms in these patients. The diagnosis of duodenal stenosis must be considered in patients with
ABSTRACTS
Down's syndrome who present with feeding problems, intermittent abdominal pain, poor growth, or esophagitis with gastroesophageal reflux.--Randall W. Powell Angiography in Mid-Gut Malrotat o n With Volvulus. L. B,
Griska and G. L. Popky. Am J Roentgenol 134:1055-1056, (May), 1980:
A 10-yr-old male presented with episodic vomiting and abdominal pain without significant clinical findings. UGI series and barium enema revealed a malrotation. Selective superior mesenteric angiography revealed a classic "barber pole sign" (rotation of small intestine around the root of the mesentery with a corkscrew appearance of the superior mesenteric artery) and a tortuous and dilated superior mesenteric vein. A malrotation and volvulus were t~und and the volvulus reduced. In chronic volvulus with nonspecific findings angiography allows the demonstration of vascular compromise and earlier surgical correction. Randall W. Powell Incomplete Rotation of the Intestine With a Normal Cecal Position. T. L. Slovis, M. D. Klein, F. B. Watts, Jr. Surgery
87:325 330, (March), 1980. The unreliability of a normal cecal position in excluding malrotation of the intestine is documented in a series of 19 infants and children with documented incomplete intestinal rotation. In six patients (32%) normal cecal position was found but an abnormal duodenojejunal junction was determined by x-ray or at operation. Three of the 6 had a midgut volvulus, and 1 had LADD's bands obstructing the duodenum. The 2 remaining patients were premature, have not been operated upon and may have achieved postnatal rotation and fixation. This study documents the superiority of the upper gastrointestinal series in reliably diagnosing intestinal malrotation.--Eugene S. Wiener Indications for Operation in Acute Necrotizing Enterocolitis of the Neonate. A. M. Kosloske, L.-A. Papile, J. Burstein.
Surgery 87:502-508, (May), 1980. Ten clinical, radiologic, and laboratory criteria were evaluated to determine their value in predicting the need for operation in neonates with proven acute necrotizing enterocolitis (NEC). All 42 infants were initially treated by standard medical means. Each of the 10 criteria was correlated with the presence of full thickness intestinal necrosis as documented at operation or autopsy in 24 infants. Those 18 infants who recovered without operation were considered not to have had intestinal gangrene. The following criteria were verified as being valid indications for immediate surgery: (1) pneumoperitoneum, (2) positive paracentesis (as previously described by these authors), (3) erythema of the abdominal wall, (4) persistently dilated intestinal loop on serial x-rays. Invalid operative criteria, according to this study were: (1) clinical deterioration, (2) persistent abdominal tenderness, (3) profuse lower GI bleeding, (4) x-ray evidence of gasless abdomen with ascites and (5) severe thrombocytopenia. The authors validate the 10th criteria of a fixed abdominal mass although their results would signify otherwise. Perhaps as more data is accumulated, clearer criteria will be established
ABSTRACTS
to aid the neonatologist and surgeon in predicting which of these neonates will benefit from earlier operative intervention. This study suggests that this may be p o s s i b l e . ~ u g e n e S. Wiener
Nacrotizing Enterocolitis and Neuraminidase = Producing
Bacteria. R. Seger, P. Joliet, G. W. G. Bird, et al. Heir Paediatr Aeta 35:121-128, 1980.
The authors study the usefulness of a rapid and reproducible serologic test for anaerobic bacterial involvement in necrotizing enterocolitis (NEC). The test is based on the ability of extra cellular neuraminidase, produced by many anaerobes, to split off N-acetylneuraminic acid from the red cell membrane so that T-antigen (Thomsen) is exposed and demonstrable by anti-T-agglutinins (Arachis titre). In 9 out of 26 newborns with NEC, this T-antigen was demonstrated. The serologic titre appeared to correlate with the course of the disease. Further, in patients with high Arachis titre, an increase agglutinin reactivity and therefore, hazard from ordinary blood transfusions was shown. The authors suggest routine testing for T-antigen before transfusing these patients and then using only washed cells.--J. Deevey
Meckel Diverticulum: Radiologic Demonstration By Entero-
clysis. D. D. T. Maglinte, M. F. E/more, M. Isenberg, et al. Am J Roentgenol 134:925-932, (May), 1980.
A surgically confirmed Meckel's diverticulum was found in 13 patients undergoing enteroclysis with 11 of these patients being symptomatic. Two patients were discovered to have diverticula in association with Crohn's disease. Two other patients with diverticula noted during enteroclysis were not confirmed surgically. A false negative diagnosis occurred in two patients and a false positive in one. Of five patients with symptomatic bleeding undergoing technetium scans only two were positive. The authors feel that enteroclysis, a selective antegrade small bowel enema, will prove to be the most reliable preoperative study for the diagnosis of a Meckel's diverticulum.--Randall I4( Powell
Intestinal Obstruction Associated With Cholestyramine
Therapy. D. F. Merten and H. Grossman. Am J Roentgenol 134:827-828, (April), 1980.
A premature infant being treated with cholestyramine for control of hyperbilirubinemia, developed evidence of a bowel obstruction. At exploration a fecal impaction with inspissated, gritty, yellow-green fecal material was found and a portion of the terminal ileum was necrotic, requiring resection. In spite of aggressive support the infant died at 70 days of age. Constipation represents a well-known complication of cholestyramine therapy and one case of an intestinal obstruction in a ten-month-old infant has been reported. The combination of hypoperistalsis in this debilitated premature infant and the inspissating effects of cholestyramine led to the intestinal obstruction. Early recognition may allow resolution of the obstruction by water soluble contrast e n e m a s . Randall IV. Powell
101 Intussusception of the Appendiceal Stump. A. J. LaSalle, R. ,I. Andrassy, C. P. Page, et al. Clin Pediatr 19:432-435, (June), 1980.
A 14-yr-old girl developed abdominal pain, anorexia and diarrhea following appendectomy with stump inversion and three weeks following surgery a barium enema revealed a cecocolic intussusception which reduced but a filling defect in the cecum persisted. After appropriate bowel preparation a partial right colectomy removed a 5-cm cecal mass in the area of the invaginated appendiceal stump. A review of the nineteen reported cases of intussusception of the appendiceal stump revealed an age range of 11 months to 29 yr with a mean of 15 years. Inversion of the appendiceal stump was performed in 16 patients, not specified in two and not done in one patient. Sixteen of the nineteen patients (84%) developed symptoms within two weeks following appendectomy. Symptoms included abdominal pain in 18 patients (95%), vomiting in nine (47%), and bloody stools in five (26%). A palpable abdominal mass occurred in thirteen (68%). The interval from onset of symptoms to operation varied from several hours to up to 5 yr (median of 8 days). Operative management included right colectomy in 11 patients, cecetomy in 2, cecopexy in 2, and reduction only in 4. Etiologic factors include an appendiceal stump abscess after invagination, cecal wall thickening due to inflammation and abnormal cecal mobility. Surgical management requires reduction and prevention of recurrence. Right colectomy often is necessary to remove the cecal mass and prevent ileocecal valve compromise.--Randall W. Powell
ABDOMEN Real Time Ultrasonography. P. L. Cooperberg, H. J. Burhenne. N Engl M Med 302:1277-1279, 1980
Real time Ultrasonography is advocated as the primary screening study in the patient with suspected gallstones. In 313 patients who subsequently had stones confirmed by cholecystectomy or autopsy, ultrasound correctly demonstrated the presence of calculi in 256 and the absence in 43, an accuracy rate of 96%. In 5 patients (1.6%) calculi were missed by ultrasound: in 3 patients, (1%) stones noted on ultrasound were not found at operation. In 124 patients who underwent both ultrasound and oral cholecystography, five were found to have calculi missed on adequate oral cholecytograms. The ease, speed and absence of radiation exposure offered by Real Time Ultrasonography would seem to make this the preferred method of diagnosing calculus gallbladder disease and would supplant oral cholecystography as the primary screening study.--Eugene S. Wiener Gastric Polyp of the Umbilicus in an 8-yr-old boy. E. A.
Bambirra and D. Miranda. Clin Pediatr 19:430-432, (June), 1980.
An 8-yr-old male presented with a nodule of the umbilicus which was sessile, elastic, and nontender with a bright red surface. Pathologic examination following surgical excision revealed gastric mucosa with adjacent smooth muscle. The authors briefly discuss the differential diagnosis and the possibility of internal anomalies.--Randall W. Powell
Volvulus of the Stomach. N. Iwai, Y. Goto, K. Hashimoto,
et al. J Jpn Soc Pediatr Surg 16:673-676, (June), 1980.
Eight cases of volvulus of the stomach were reported. Onset of presenting symptoms (vomiting in 5, vomiting and distension of the upper abdomen in 3 cases) was immediately after birth in 3, within one week after birth in 3, and 5 to 6 months after birth in 2 cases. Six cases were treated conservatively, but 2 cases underwent surgical correction. Type of volvulus was organoaxial in 3, and mesentericoaxial in 5 cases.--H. Suzuki Pyloric Stenosis and Direct Hyperbilirubinemia With Alpha-I-Antitrypsin Deficiency. F. K. Ghishan, D. R.
LaBreeque, F~ A. Mitros, et al. Clin Pediatr 19:293-295, (April), 1980.
A 2-wk-old male infant presented with projectile vomiting and jaundice with a total bilirubin of 14 mg/dl and a direct fraction of 10 mg/dl. After pyloromyotomy a work-up for the direct byperbilirubinemia revealed an alpha-l-antitrypsin deficiency of Pi Z Z phenotype. Statistically the two would be expected to occur in 1 in 2.5 million of the population. The authors point out the need tO fractionate the bilirubin in patients with pyloric stenosis and jaundice so that the infrequent cases of direct hyperbilirubinemia can be properly evaluated.--Randall W. Powell Atypical Muscle Hypertrophy in Pyloric Stenosis. L. E. Swischuk, C. K. Hayden, Jr., K. R. Tyson. Am J Roentgenol 134:481~,84, (March), 1980.
Seventeen patients with atypical pyloric muscle hypertrophy revealed four atypical pyloric configurations during contrast studies. Six patients had a persistent lesser curve mass due to hypertrophy of the torus region (concentration of fibers on the lesser curve). This represents the most difficult to recognize and a pyloric mass is not usually palpable. Three patients demonstrated a funnel shape antrum which represents muscle hypertrophy to a degree just less than that necessary to produce a string sign. Four patients had a spiculated antrum felt to represent irregular hypertrophy of the muscle fiber groups resulting in an irregular rather than smooth pyloric canal. Four patients demonstrated a pyloric niche or diamond sign felt to represent mucosa bulging between two separately hypertrophied muscle fiber groups. This latter form must be differentiated from a channel ulcer by its change in size. The latter three groups usually have a palpable mass but the mass may not be constant from exam to exam.--Randall W. Powell Delayed Diagnosis of Duodenal Obstruction in Down's Syndrome. G. V. Smith and R. L. Teele. Am J Roentgenol
134:937 940, (May), 1980. Four patients with Down's syndrome ranging in age from 6 to 12 yr presented with problems with recurrent episodes of vomiting. One patient also demonstrated an esophageal stricture due to gastroesophageal reflux. All four patients had foreign bodies proximal to their duodenal stenosis. All underwent successful surgical correction. The foreign bodies probably exacerbated the symptoms in these patients. The diagnosis of duodenal stenosis must be considered in patients with
ABSTRACTS
Down's syndrome who present with feeding problems, intermittent abdominal pain, poor growth, or esophagitis with gastroesophageal reflux.--Randall W. Powell Angiography in Mid-Gut Malrotat o n With Volvulus. L. B,
Griska and G. L. Popky. Am J Roentgenol 134:1055-1056, (May), 1980:
A 10-yr-old male presented with episodic vomiting and abdominal pain without significant clinical findings. UGI series and barium enema revealed a malrotation. Selective superior mesenteric angiography revealed a classic "barber pole sign" (rotation of small intestine around the root of the mesentery with a corkscrew appearance of the superior mesenteric artery) and a tortuous and dilated superior mesenteric vein. A malrotation and volvulus were t~und and the volvulus reduced. In chronic volvulus with nonspecific findings angiography allows the demonstration of vascular compromise and earlier surgical correction. Randall W. Powell Incomplete Rotation of the Intestine With a Normal Cecal Position. T. L. Slovis, M. D. Klein, F. B. Watts, Jr. Surgery
87:325 330, (March), 1980. The unreliability of a normal cecal position in excluding malrotation of the intestine is documented in a series of 19 infants and children with documented incomplete intestinal rotation. In six patients (32%) normal cecal position was found but an abnormal duodenojejunal junction was determined by x-ray or at operation. Three of the 6 had a midgut volvulus, and 1 had LADD's bands obstructing the duodenum. The 2 remaining patients were premature, have not been operated upon and may have achieved postnatal rotation and fixation. This study documents the superiority of the upper gastrointestinal series in reliably diagnosing intestinal malrotation.--Eugene S. Wiener Indications for Operation in Acute Necrotizing Enterocolitis of the Neonate. A. M. Kosloske, L.-A. Papile, J. Burstein.
Surgery 87:502-508, (May), 1980. Ten clinical, radiologic, and laboratory criteria were evaluated to determine their value in predicting the need for operation in neonates with proven acute necrotizing enterocolitis (NEC). All 42 infants were initially treated by standard medical means. Each of the 10 criteria was correlated with the presence of full thickness intestinal necrosis as documented at operation or autopsy in 24 infants. Those 18 infants who recovered without operation were considered not to have had intestinal gangrene. The following criteria were verified as being valid indications for immediate surgery: (1) pneumoperitoneum, (2) positive paracentesis (as previously described by these authors), (3) erythema of the abdominal wall, (4) persistently dilated intestinal loop on serial x-rays. Invalid operative criteria, according to this study were: (1) clinical deterioration, (2) persistent abdominal tenderness, (3) profuse lower GI bleeding, (4) x-ray evidence of gasless abdomen with ascites and (5) severe thrombocytopenia. The authors validate the 10th criteria of a fixed abdominal mass although their results would signify otherwise. Perhaps as more data is accumulated, clearer criteria will be established
ABSTRACTS
to aid the neonatologist and surgeon in predicting which of these neonates will benefit from earlier operative intervention. This study suggests that this may be p o s s i b l e . ~ u g e n e S. Wiener
Nacrotizing Enterocolitis and Neuraminidase = Producing
Bacteria. R. Seger, P. Joliet, G. W. G. Bird, et al. Heir Paediatr Aeta 35:121-128, 1980.
The authors study the usefulness of a rapid and reproducible serologic test for anaerobic bacterial involvement in necrotizing enterocolitis (NEC). The test is based on the ability of extra cellular neuraminidase, produced by many anaerobes, to split off N-acetylneuraminic acid from the red cell membrane so that T-antigen (Thomsen) is exposed and demonstrable by anti-T-agglutinins (Arachis titre). In 9 out of 26 newborns with NEC, this T-antigen was demonstrated. The serologic titre appeared to correlate with the course of the disease. Further, in patients with high Arachis titre, an increase agglutinin reactivity and therefore, hazard from ordinary blood transfusions was shown. The authors suggest routine testing for T-antigen before transfusing these patients and then using only washed cells.--J. Deevey
Meckel Diverticulum: Radiologic Demonstration By Entero-
clysis. D. D. T. Maglinte, M. F. E/more, M. Isenberg, et al. Am J Roentgenol 134:925-932, (May), 1980.
A surgically confirmed Meckel's diverticulum was found in 13 patients undergoing enteroclysis with 11 of these patients being symptomatic. Two patients were discovered to have diverticula in association with Crohn's disease. Two other patients with diverticula noted during enteroclysis were not confirmed surgically. A false negative diagnosis occurred in two patients and a false positive in one. Of five patients with symptomatic bleeding undergoing technetium scans only two were positive. The authors feel that enteroclysis, a selective antegrade small bowel enema, will prove to be the most reliable preoperative study for the diagnosis of a Meckel's diverticulum.--Randall I4( Powell
Intestinal Obstruction Associated With Cholestyramine
Therapy. D. F. Merten and H. Grossman. Am J Roentgenol 134:827-828, (April), 1980.
A premature infant being treated with cholestyramine for control of hyperbilirubinemia, developed evidence of a bowel obstruction. At exploration a fecal impaction with inspissated, gritty, yellow-green fecal material was found and a portion of the terminal ileum was necrotic, requiring resection. In spite of aggressive support the infant died at 70 days of age. Constipation represents a well-known complication of cholestyramine therapy and one case of an intestinal obstruction in a ten-month-old infant has been reported. The combination of hypoperistalsis in this debilitated premature infant and the inspissating effects of cholestyramine led to the intestinal obstruction. Early recognition may allow resolution of the obstruction by water soluble contrast e n e m a s . Randall IV. Powell
101 Intussusception of the Appendiceal Stump. A. J. LaSalle, R. ,I. Andrassy, C. P. Page, et al. Clin Pediatr 19:432-435, (June), 1980.
A 14-yr-old girl developed abdominal pain, anorexia and diarrhea following appendectomy with stump inversion and three weeks following surgery a barium enema revealed a cecocolic intussusception which reduced but a filling defect in the cecum persisted. After appropriate bowel preparation a partial right colectomy removed a 5-cm cecal mass in the area of the invaginated appendiceal stump. A review of the nineteen reported cases of intussusception of the appendiceal stump revealed an age range of 11 months to 29 yr with a mean of 15 years. Inversion of the appendiceal stump was performed in 16 patients, not specified in two and not done in one patient. Sixteen of the nineteen patients (84%) developed symptoms within two weeks following appendectomy. Symptoms included abdominal pain in 18 patients (95%), vomiting in nine (47%), and bloody stools in five (26%). A palpable abdominal mass occurred in thirteen (68%). The interval from onset of symptoms to operation varied from several hours to up to 5 yr (median of 8 days). Operative management included right colectomy in 11 patients, cecetomy in 2, cecopexy in 2, and reduction only in 4. Etiologic factors include an appendiceal stump abscess after invagination, cecal wall thickening due to inflammation and abnormal cecal mobility. Surgical management requires reduction and prevention of recurrence. Right colectomy often is necessary to remove the cecal mass and prevent ileocecal valve compromise.--Randall W. Powell
ABDOMEN Real Time Ultrasonography. P. L. Cooperberg, H. J. Burhenne. N Engl M Med 302:1277-1279, 1980
Real time Ultrasonography is advocated as the primary screening study in the patient with suspected gallstones. In 313 patients who subsequently had stones confirmed by cholecystectomy or autopsy, ultrasound correctly demonstrated the presence of calculi in 256 and the absence in 43, an accuracy rate of 96%. In 5 patients (1.6%) calculi were missed by ultrasound: in 3 patients, (1%) stones noted on ultrasound were not found at operation. In 124 patients who underwent both ultrasound and oral cholecystography, five were found to have calculi missed on adequate oral cholecytograms. The ease, speed and absence of radiation exposure offered by Real Time Ultrasonography would seem to make this the preferred method of diagnosing calculus gallbladder disease and would supplant oral cholecystography as the primary screening study.--Eugene S. Wiener Gastric Polyp of the Umbilicus in an 8-yr-old boy. E. A.
Bambirra and D. Miranda. Clin Pediatr 19:430-432, (June), 1980.
An 8-yr-old male presented with a nodule of the umbilicus which was sessile, elastic, and nontender with a bright red surface. Pathologic examination following surgical excision revealed gastric mucosa with adjacent smooth muscle. The authors briefly discuss the differential diagnosis and the possibility of internal anomalies.--Randall W. Powell