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Intestinal obstruction in children in India
INTERNATIONAL ABSTRACTS Controlled Trial of Bowel Rest and Nutritional Support in the M a n a g e m e n t of Crohn's Disease. G.R. Greenberg, C.R. Fleming,
K.N. Jeejeebhoy, et al. Gut 29:1309-1315, (October), 1988. This report outlines the treatment of 51 patients aged 17 to 60 years, with Crohn's disease unresponsive to other medical management. Nutritional support for 21 days included: (1) total parenteral nutrition with nil by mouth, (2) defined elemental diet through nasogastric tube, and (3) partial parenteral nutrition with oral feeding. Clinical readmission in the three groups occurred in 71%, 58%, and 60%, respectively. At 1 year after successful therapy it was 42%, 55%, and 56%. These differences were not significant. Bowel rest was not considered a major factor in achieving remission during nutritional support and did not influence outcome at 1 year. Another article in the same issue (Total Parenteral Nutrition as Primary Treatment in Crohn's Disease--RIP? J.J. Payne-James and D.B.A. Silk, Gut 29:1304-1308, (October), 1988) suggests that TPN in Crohn's disease should be restricted to the treatment of complications. The greatest benefit is the improvement of the nutritional state. Its use as primary therapy is doubtful. The importance of glutamine and intraluminal fermentable fibre for gut healing is stressed.--Caroline M. Doig Decreased Height Velocity in Children and Adolescents Before the Diagnosis of Crohn's Disease. M.E. Kanof, A.M. Lake, and T.M.
Bayless. Gastroenterology 95:1523-1527, (December), 1988. The height velocities of 50 children with Crohn's disease were reviewed. Decreased height velocity antedated the diagnosis in 44 patients. Additionally, 17 of 32 patients with attenuated linear growth had a reduction in height velocity before any weight loss was evident. Thus linear growth impairment in Crohn's disease is common, may precede the weight loss, and can be the earliest indicator of disease. There is some potential for catch-up growth if the inflammatory process is suppressed, daily corticosteroid usage is minimized, and energy intake is adequate. Correction of the attenuated linear growth velocity can be a useful marker of the adequacy of treatment in children with Crohn's disease.--Richard R. Ricketts Intestinal Obstruction in Children in India. A.N. Gangopadhyay and H. Wardhan. Pediatr Surg Internat, 4:84-87, (February), 1989 A total of 243 cases of intestinal obstruction were seen in the Paediatric Surgery Unit of S.S. Hospital, Varanasi, during a period of 2.5 years. Surgical exploration was required in 85%; 15% responded to conservative treatment. Intussusception (15%), Ascaris bolus obstruction (13.5%), enteric perforation (12.3%), and abdominal tuberculosis (11%) formed the majority of the cases. Morbidity and mortality due to intestinal obstruction and its complications is high in India due to delayed medical attention, poor primary health services, health ignorance, and poor socioeconomic status--Prem Purl Ascaris Lumbrieoides Causing Intestinal Obstruction in C h i l d r e n - A Review of 33 Cases. H. Wardhan, A.N. Gangopadhyay, S.C.
Gopal, et al. Pediatr Surg Internat 4:88-89, (February), 1989. Intestinal obstruction in children due to Ascaris lumbricoides is not an uncommon occurrence in developing countries of Asia and Africa and more so in children of low socioeconomic status. It may produce either subacute or acute obstruction. Thirty-three children with intestinal obstruction due to Ascaris lumbriceides were seen in a period of 2.5 years (January 1984 to July 1986) in the Children's Hospital Division of Pediatric Surgery, Varanasi, India. Nonoperative treatment was given in 24 cases; 18 (75%) responded with return of bowel activity within 24 to 36 hours and an average hospital stay
945
of four days. Surgical exploration was required in 15 cases, including six cases where nonoperative treatment failed. There was no mortality.--Prem Purl Extensive Short Bowel Syndrome in Neonates: Outcome in the 1980s. D.A. Caniano, J. Starr, and M.E. Ginn-Pease. Surgery
105:119-124, (February), 1989. The clinical course of 14 infants with short bowel syndrome (SBS) is reviewed. The mean residual jejunoileal length was 16% of normal length and resulted from gastrochisis (five), jejunal atresia (five), necrotizing enterocolitis (two), midgut voivulus (one), and congenital SBS (one). Predictable complications were T P N related, either catheter sepsis or cholestasis. Twelve of 14 patients survived with eight patients off TPN. For the seven patients with an intact ileocecal valve, six adapted to complete enteral feeding over an average 18 months. This remarkable achievement occurred with as low as 9% residual small bowel. No patients underwent operative small or large bowel augmentation. Both the duration and cost of hospitalization were monumental. The ethical concerns surrounding these babies have been presented in a separate report published by the New England Journal of Medicine (318:703-706, March, 17, 1988).--Tom Tracy, Jr Intraperitoneal AIIogenic Transplantation of Fetal Small Intestine
in the Rat. St. Kellnar, C. Rock, U. Schuhmacher, et al. Z Kinderchir 43:331-333, (October), 1985. The possibility of successful transplatation of fetal rat small intestine into the peritoneal cavity of adult rats is demonstrated. Several combinations of rat strains with defined genetic differences were used. In more than 66% of the transplantations performed, successful adequate growth of the transplants was noted. Oral immunosuppression with cyclosporine A (20 m g / k g / d ) to prevent allograft rejection was given only in major genetic differences. Preoperative insertion of a nonabsorbable 7-0 tie into the lumen of the transplant supported the development of a tubular segment of small intestine which can then be anastomosed with the host small intestine in a second operation. Further experiments on intestinal function, passage, motility, and resorption will clarify whether the rat model provides clinical application in small-bowel s y n d r o m e . Thomas A. Angerpointner Segmental Intestinal Transplantation in Rats W i t h Resected Entire Small Bowel, Ileocecal Valve, and Cecum. K. Kimura, C_A.
LaRosa, S.R. Money, et al. J Surg Res 45:349-356, (October), 1988. In this study, the effectiveness of segmental jejunal allografts in a model of severe short gut syndrome in rats in whom the entire small bowel, ileocecal valve, and cecum were resected was evaluated. All control animals died. All animals receiving transplantation but no cyclosporine died of rejection by ten days. None of the transplanted animals receiving cyclosporine died. The animals receiving a jejunal segment equivalent to half the length of the small intestine showed good growth. By decreasing the length of the intestinal grafts or by taking jejunum rather than ileum, the mortality from graft-versushost disease was significantly reduced. The only disadvantage of jejunal grafts v those containing ileum as well is the lack of ability to absorb vitamin B 12 and bile acids.--Richard R. Ricketts Appendicitis Complicating Meconium Ileus Equivalent. J.A.P. Rim-
mer, J.M. Gilbert, and T.G. Allen-Mersh. Br J Surg 76:168, (February), 1989. In discussing this case report the authors indicate that with increasing life expectancy appendicitis can be expected to occur
K.N. Jeejeebhoy, et al. Gut 29:1309-1315, (October), 1988. This report outlines the treatment of 51 patients aged 17 to 60 years, with Crohn's disease unresponsive to other medical management. Nutritional support for 21 days included: (1) total parenteral nutrition with nil by mouth, (2) defined elemental diet through nasogastric tube, and (3) partial parenteral nutrition with oral feeding. Clinical readmission in the three groups occurred in 71%, 58%, and 60%, respectively. At 1 year after successful therapy it was 42%, 55%, and 56%. These differences were not significant. Bowel rest was not considered a major factor in achieving remission during nutritional support and did not influence outcome at 1 year. Another article in the same issue (Total Parenteral Nutrition as Primary Treatment in Crohn's Disease--RIP? J.J. Payne-James and D.B.A. Silk, Gut 29:1304-1308, (October), 1988) suggests that TPN in Crohn's disease should be restricted to the treatment of complications. The greatest benefit is the improvement of the nutritional state. Its use as primary therapy is doubtful. The importance of glutamine and intraluminal fermentable fibre for gut healing is stressed.--Caroline M. Doig Decreased Height Velocity in Children and Adolescents Before the Diagnosis of Crohn's Disease. M.E. Kanof, A.M. Lake, and T.M.
Bayless. Gastroenterology 95:1523-1527, (December), 1988. The height velocities of 50 children with Crohn's disease were reviewed. Decreased height velocity antedated the diagnosis in 44 patients. Additionally, 17 of 32 patients with attenuated linear growth had a reduction in height velocity before any weight loss was evident. Thus linear growth impairment in Crohn's disease is common, may precede the weight loss, and can be the earliest indicator of disease. There is some potential for catch-up growth if the inflammatory process is suppressed, daily corticosteroid usage is minimized, and energy intake is adequate. Correction of the attenuated linear growth velocity can be a useful marker of the adequacy of treatment in children with Crohn's disease.--Richard R. Ricketts Intestinal Obstruction in Children in India. A.N. Gangopadhyay and H. Wardhan. Pediatr Surg Internat, 4:84-87, (February), 1989 A total of 243 cases of intestinal obstruction were seen in the Paediatric Surgery Unit of S.S. Hospital, Varanasi, during a period of 2.5 years. Surgical exploration was required in 85%; 15% responded to conservative treatment. Intussusception (15%), Ascaris bolus obstruction (13.5%), enteric perforation (12.3%), and abdominal tuberculosis (11%) formed the majority of the cases. Morbidity and mortality due to intestinal obstruction and its complications is high in India due to delayed medical attention, poor primary health services, health ignorance, and poor socioeconomic status--Prem Purl Ascaris Lumbrieoides Causing Intestinal Obstruction in C h i l d r e n - A Review of 33 Cases. H. Wardhan, A.N. Gangopadhyay, S.C.
Gopal, et al. Pediatr Surg Internat 4:88-89, (February), 1989. Intestinal obstruction in children due to Ascaris lumbricoides is not an uncommon occurrence in developing countries of Asia and Africa and more so in children of low socioeconomic status. It may produce either subacute or acute obstruction. Thirty-three children with intestinal obstruction due to Ascaris lumbriceides were seen in a period of 2.5 years (January 1984 to July 1986) in the Children's Hospital Division of Pediatric Surgery, Varanasi, India. Nonoperative treatment was given in 24 cases; 18 (75%) responded with return of bowel activity within 24 to 36 hours and an average hospital stay
945
of four days. Surgical exploration was required in 15 cases, including six cases where nonoperative treatment failed. There was no mortality.--Prem Purl Extensive Short Bowel Syndrome in Neonates: Outcome in the 1980s. D.A. Caniano, J. Starr, and M.E. Ginn-Pease. Surgery
105:119-124, (February), 1989. The clinical course of 14 infants with short bowel syndrome (SBS) is reviewed. The mean residual jejunoileal length was 16% of normal length and resulted from gastrochisis (five), jejunal atresia (five), necrotizing enterocolitis (two), midgut voivulus (one), and congenital SBS (one). Predictable complications were T P N related, either catheter sepsis or cholestasis. Twelve of 14 patients survived with eight patients off TPN. For the seven patients with an intact ileocecal valve, six adapted to complete enteral feeding over an average 18 months. This remarkable achievement occurred with as low as 9% residual small bowel. No patients underwent operative small or large bowel augmentation. Both the duration and cost of hospitalization were monumental. The ethical concerns surrounding these babies have been presented in a separate report published by the New England Journal of Medicine (318:703-706, March, 17, 1988).--Tom Tracy, Jr Intraperitoneal AIIogenic Transplantation of Fetal Small Intestine
in the Rat. St. Kellnar, C. Rock, U. Schuhmacher, et al. Z Kinderchir 43:331-333, (October), 1985. The possibility of successful transplatation of fetal rat small intestine into the peritoneal cavity of adult rats is demonstrated. Several combinations of rat strains with defined genetic differences were used. In more than 66% of the transplantations performed, successful adequate growth of the transplants was noted. Oral immunosuppression with cyclosporine A (20 m g / k g / d ) to prevent allograft rejection was given only in major genetic differences. Preoperative insertion of a nonabsorbable 7-0 tie into the lumen of the transplant supported the development of a tubular segment of small intestine which can then be anastomosed with the host small intestine in a second operation. Further experiments on intestinal function, passage, motility, and resorption will clarify whether the rat model provides clinical application in small-bowel s y n d r o m e . Thomas A. Angerpointner Segmental Intestinal Transplantation in Rats W i t h Resected Entire Small Bowel, Ileocecal Valve, and Cecum. K. Kimura, C_A.
LaRosa, S.R. Money, et al. J Surg Res 45:349-356, (October), 1988. In this study, the effectiveness of segmental jejunal allografts in a model of severe short gut syndrome in rats in whom the entire small bowel, ileocecal valve, and cecum were resected was evaluated. All control animals died. All animals receiving transplantation but no cyclosporine died of rejection by ten days. None of the transplanted animals receiving cyclosporine died. The animals receiving a jejunal segment equivalent to half the length of the small intestine showed good growth. By decreasing the length of the intestinal grafts or by taking jejunum rather than ileum, the mortality from graft-versushost disease was significantly reduced. The only disadvantage of jejunal grafts v those containing ileum as well is the lack of ability to absorb vitamin B 12 and bile acids.--Richard R. Ricketts Appendicitis Complicating Meconium Ileus Equivalent. J.A.P. Rim-
mer, J.M. Gilbert, and T.G. Allen-Mersh. Br J Surg 76:168, (February), 1989. In discussing this case report the authors indicate that with increasing life expectancy appendicitis can be expected to occur