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Lithiasis due to interruption of the enterohepatic circulation of bile salts
232
ABSTRACTS
junction. Both polyps, removed endoscopically, were identified as inflammatory polyps. Of 15 previously reported cases 12 were in men aged 20-68 yr and common clinical findings included pyrosis or abdominal pain (12), hiatal hernia (11), and dysphagia (4). These two cases represent the first such reported in children. The boy improved on medical management but the girl's symptoms continued but an anti-reflux procedure was refused.--Randall W. Powell
ance 22 showed patchy abnormality, The authors advocate the use of a double port biopsy capsule, which obtains a larger area of mucosa for study. Twelve pieces of mucosa obtained by the double port biopsy capsule would have been graded normal if the other piece in each instance had not been obtained and which was found to be abnormal.--Peter Gornall
Pyloric Diaphragm, Antral Web, Congenital Antral Membrane--A Surgical Rarity? K. G. Mitchell, A. McGowan, D.
Regionalis Enteritis (Crohn's Disease) in Two Twelve-YearOld Sisters. L. Magnus and H. -U. Sauerbrei. P~id und P~idol
C. Smith, et al. Br J Surg 66:572 574, (August), 1979.
14/1: 97-102, 1979.
Three cases of pyloric diaphragm presenting for the first time in late adult life are presented. The diagnosis was made at endoscopic examination in all three cases. Management of this condition is surgical and may consist of either incision or excision of the diaphragm or antrectomy as performed by the authors in this series. Histologic examination showed a central core of submucosa covered on both proximal and distal aspects by normal gastric mucosa, suggesting that the lesion is of congenital rather than acquired origin.--L. Spitz
Familial occurence of Crohn's disease is 10 times as frequent as statistically suspected. In 17% of the cases there is a family history. Constitutional and hereditary factors seem to be important as shown by the authors. They present the history of 2 sisters, who were affected by the disease at the age of 12 yr at an interval of 8 yr.--G. Brandesky
Duplication Cyst of the Ileum in a Newborn Infant. A.
Shibata, et al. J Jpn Soc Pediat Surg 15:761-767, (August), 1979.
The Treatment of Congenital Pyloric Atresia. G. Belloli, G.
Locatelli, L. Bedogni, et al. Ped Med Chir 1:53-56, (January-February), 1979. Three newborn babies weighing 2540 kg, 2180 kg, and 2850 kg were operated upon with the preoperative diagnosis of pyloric atresia. Excision of the diaphragm and dilatation was unsuccessful in the first baby, secondary pylorop)asty was also unsuccessful. A gastrojejunostomy was performed 3~/2 mo later followed by cure. Excision of the pyloric diaphragm associated with pyloroplasty was also unsatisfactory in the second baby and secondary gastrojejunostomy was performed. On the third baby excision of the pyloric diaphragm associated with gastrojejunostomy was successful. An additional 75 cases were reviewed from the literature. The high mortality rate may be mainly attributed to associated congenital anomalies. Gastroduodenostomy and gastrojejunostomy are the methods of choice.--C. A. Montagnani Neonatal Gasless Adbomen: Another Cause. R. L. Siegle.
A m J Roentgenol 133:522-523, (September), 1979. Two premature newborn infants required administration of pancuronium bromide (a curariform blocking agent) to prevent ventilator resistance. Both developed a gasless abdomen which persisted until the neuromuscular blockade was discontinued. The paralysis of muscles involved in swallowing is felt to be the cause. It must be recognized as a benign condition but it m a y mask radiographic changes in the bowel that depend on the presence of intraluminal air.--Randall IV. Powell Patchy Enteropathy in Childhood. P. D. Manuel, J. A.
Walker-Smith, (March), 1979.
and N.
E. France. G u t
20:211-215,
O f 278 duodenal biopsies studied by dissecting microscope and histology, 106 were abnormal and 49 of these showed patchy abnormality. Of 33 patients with cow's milk intoler-
A case of duplication cyst of the terminal ileum seen in a 3-day-old male baby was reported and 199 cases of duplication of the alimentary tracts were collected from the Japanese literature. A m o n g 199 cases of duplication of the alirnentrary tract reported in the Japanese literature, 39 cases were newborn infants. Sites of duplication were: duoden u m in 2, jejunum in 7, ileum in 10, terminal ileum or ileo-cecum in 17, transverse colon in 1, total colon in 1, and abdominal cavity in 1 case. Type of duplication was cystic in 37 cases and tubular in 2 cases. Multiple occurrence was seen in two cases. Associated malformations were seen in 13 cases; atresia or stenosis in 9, malrotation in 3, and Meckel's diverticulum in 1 case. Complications were seen in 20 cases; volvulus in 8, intussusception in one, peritonitis in 10, and bleeding in one case. Presenting signs were; vomiting and/or distension in 38, constipation in 4, melena in 4, tumor in 14 cases. Correct diagnosis was made preoperatively in only 2 of these 39 cases. O f these 39 cases, 25 survived. H. S u z u k i Lithiasis Due to Interruption of the Enterohepatic Circulation of Bile Salts. D. R. Kirks. A m J Roentgenol 133:383
388, (September), 1979. A 3-yr-old girl who developed cholesterol cholelithiasis following major small bowel resection for midgut volvulus as a neonate and an I 1-yr-old girl with regional enteritis who developed an obstructing oxalate ureteral calculus are presented. The mechanism for developing cholelithiasis with ileal dysfunction involves inadequate bile salt absorption and the resultant lower bile salt content in the excreted bile. This results in bile which is supersaturated with cholesterol. The development of oxalate urolithiasis probably involves three mechanisms: (1) increased production by bacteria of oxalate from glycine-conjugated bile salts which is converted to oxalate by the liver, (2) binding of calcium by malabsorbed fatty acids that increases unbound dietary oxalate which is then absorbed, and (3) increased permeability of the colon to oxalate due to unabsorbed bile salts. An extensive differen-
ABSTRACTS
tial diagnosis of pediatric cholelithiasis and urolithiasis is also presented.--Randall W. Powell Appendicitis in Acute Leukemia. K. Ver Steeg, A. LaSalle, and L Ratner. Arch Surg 114:632-633, (May), 1979.
Five cases of appendicitis in leukemic children were reviewed. Four children were receiving prednisone. All had appendectomy and survived the immediate postoperative period. One child had a spontaneous remission following appendectomy while two of three children in remission had serious postoperative complications (abscesses). Appendicitis in leukemia should be managed s u r g i c a l l y . ~ d w a r d J. Berman
A Double-Blind Trial of a Single Intravenous Dose of Metronidazole as Prophylaxis Against Wound Infection Following Appendicectomy. M. J. Greenall. A. Bakran, I. R.
Pickford, et al. Br J Surg 66:428-429, (June), 1979. One hundred patients (mostly adults) undergoing appendicectomy through a right iliac fossa incision were randomized to receive either normal saline or 500 nag metronidazole as an intravenous infusion during operation. There were 13 wound infections, 12 (out of 51) in the saline group and 1 (out of 49) in the metronidazole group. This work supports the value of metronidazole and suggests that a single-dose regimen is adequate for prophylaxis.--L. Spitz
Intrarectal Metronidazole in the Prevention of Anaerobic Infections A f t e r Emergency Appendicectomy: A Controlled Clinical Trial. J. Rodgers, D. Ross, HI. McNaught, et al. Br J
Surg 66:425-427, (June), 1979. A series of 102 patients with presumptive acute appendicitis were entered into a prospective, randomized, clinical trial of intrarectal metronidazole given over a 48-hr period commencing before surgery. Adequate levels of circulating metronidazole were achieved. A significant reduction in the incidence of anaerobic wound infections was observed in the treated group (p < 0.02).--L. Spitx
Ultrasound Diagnosis of Portal Vein Thrombosis as a Complication of Appendicitis. D. S. Babcock, A m J Roent-
genol 133:317-319, (August), 1979. A 6-yr-old boy presented with a 2-wk history of epigastric and RLQ pain, fever, and increasing hepatosplenomegaly and had been treated at another hospital for 10 days with antibiotics. Physical examination revealed fever, tachycardia, jaundice, and hepatosplenomegaly with moderate liver tenderness. Blood cultures grew E. coli and a liver biopsy revealed acute cholangitis and also grew E. coil He did not respond to intravenous antibiotics and an ultrasonic examination could not demonstrate the portal vein but echogenic material was present in the region of the portal vein. Laparotomy revealed dilated mesenteric and retroperitoneal vessels. The appendix, retrocecal in position, was adherent to the peritoneum but was not acutely inflamed. Pathologic examination revealed resolving acute appendicitis. The
233
patient's postoperative course was complicated by continued fever and positive blood cultures and a repeat ultrasound examination 10 days later revealed an abscess in the right lobe of the liver which was drained. A third examination prior to discharge revealed the portal vein to be filled with echogenic thrombus.--Randall IV. Powell Postoperative Intussusception in Infancy and Childhood: Analysis of 119 Cases. D. L. Mollitt, T. 1I. N. Ballantine,
and J. L. Grosfeld. Surgery 86:402 408, (September), 1979. The authors review 119 cases (including 14 of their own) of postoperative intussusception. Twenty-four (20%) patients had undergone retroperitoneal procedures, 17 (14%) followed pull through procedures, 16 (13%) followed appendectomy, while the remaining instances followed a variety of operations including operative reduction of ileocolic intussusception and other major abdominal procedures as well as some non-abdominal operations. The age range was 1 wk to 15 yr and the sex was evenly distributed. Sixty-four percent were symptomatic within 1 wk with 90% within 2 wk. The prominent symptoms were abdominal distension, prolonged or increasing nasogastric output or vomiting and abdominal pain. Rectal bleeding and abdominal masses were uncommon. The majority of sites of intussusception were in the small bowel with 73 (62%) ileoileal. Manual reduction was successful in 110 patients (95%). This reemphasizes the importance of considering this diagnosis in the postoperative infant or child who has signs of intestinal obstruction in the early postoperative period.--Eugene S. Wiener
Closure of Colostomy in Infants and Children. A. M . K.
Rickwood, V. Hemalatha, and P. Brooman. Br J Surg 66:273-274, (April), 1979. A retrospective study of 100 conservative colostomy closures over a 10-yr period is presented. The majority involved infants with either anorectal anomalies or Hirschsprung's disease. Preoperative bowel preparation varied from nil (6 patients) to mechanical preparation and oral nonabsorbable sulphonamide (69 patients) to radical preparation including mechanical evacuation, low residue diet, sulphonamide, gentamicin and metronidazole (25 patients). Operative closure of the colostomy consisted of an intraperitoneal resection and end-to-end anastomosis. Fecal fistula developed in 5 cases and there were 8 other major complications. Wound infection occurred in 43 infants (45%). The authors claim a greatly reduced incidence of wound infection (16%) following the introduction in 1975 of a more radical bowel preparation prior to closure of the eolostomy. The paper lacks any formal control and merely outlines the experience of the authors with a relatively small number of patients over a long period.--L. Spitz
X-Ray Diagnosis of Hirschsprung's Disease W i t h Total Colonic and Ileal Involvement. H Ohkawa and H. Takaha-
shi. Jpn J Pediatr Surg 11:763-768, (July), 1979. The authors reviewed 103 gastrographin-enema films of newborn infants with intestinal obstruction. The x-ray diagnosis of "microeolon" was made when the maximum caliber
ABSTRACTS
junction. Both polyps, removed endoscopically, were identified as inflammatory polyps. Of 15 previously reported cases 12 were in men aged 20-68 yr and common clinical findings included pyrosis or abdominal pain (12), hiatal hernia (11), and dysphagia (4). These two cases represent the first such reported in children. The boy improved on medical management but the girl's symptoms continued but an anti-reflux procedure was refused.--Randall W. Powell
ance 22 showed patchy abnormality, The authors advocate the use of a double port biopsy capsule, which obtains a larger area of mucosa for study. Twelve pieces of mucosa obtained by the double port biopsy capsule would have been graded normal if the other piece in each instance had not been obtained and which was found to be abnormal.--Peter Gornall
Pyloric Diaphragm, Antral Web, Congenital Antral Membrane--A Surgical Rarity? K. G. Mitchell, A. McGowan, D.
Regionalis Enteritis (Crohn's Disease) in Two Twelve-YearOld Sisters. L. Magnus and H. -U. Sauerbrei. P~id und P~idol
C. Smith, et al. Br J Surg 66:572 574, (August), 1979.
14/1: 97-102, 1979.
Three cases of pyloric diaphragm presenting for the first time in late adult life are presented. The diagnosis was made at endoscopic examination in all three cases. Management of this condition is surgical and may consist of either incision or excision of the diaphragm or antrectomy as performed by the authors in this series. Histologic examination showed a central core of submucosa covered on both proximal and distal aspects by normal gastric mucosa, suggesting that the lesion is of congenital rather than acquired origin.--L. Spitz
Familial occurence of Crohn's disease is 10 times as frequent as statistically suspected. In 17% of the cases there is a family history. Constitutional and hereditary factors seem to be important as shown by the authors. They present the history of 2 sisters, who were affected by the disease at the age of 12 yr at an interval of 8 yr.--G. Brandesky
Duplication Cyst of the Ileum in a Newborn Infant. A.
Shibata, et al. J Jpn Soc Pediat Surg 15:761-767, (August), 1979.
The Treatment of Congenital Pyloric Atresia. G. Belloli, G.
Locatelli, L. Bedogni, et al. Ped Med Chir 1:53-56, (January-February), 1979. Three newborn babies weighing 2540 kg, 2180 kg, and 2850 kg were operated upon with the preoperative diagnosis of pyloric atresia. Excision of the diaphragm and dilatation was unsuccessful in the first baby, secondary pylorop)asty was also unsuccessful. A gastrojejunostomy was performed 3~/2 mo later followed by cure. Excision of the pyloric diaphragm associated with pyloroplasty was also unsatisfactory in the second baby and secondary gastrojejunostomy was performed. On the third baby excision of the pyloric diaphragm associated with gastrojejunostomy was successful. An additional 75 cases were reviewed from the literature. The high mortality rate may be mainly attributed to associated congenital anomalies. Gastroduodenostomy and gastrojejunostomy are the methods of choice.--C. A. Montagnani Neonatal Gasless Adbomen: Another Cause. R. L. Siegle.
A m J Roentgenol 133:522-523, (September), 1979. Two premature newborn infants required administration of pancuronium bromide (a curariform blocking agent) to prevent ventilator resistance. Both developed a gasless abdomen which persisted until the neuromuscular blockade was discontinued. The paralysis of muscles involved in swallowing is felt to be the cause. It must be recognized as a benign condition but it m a y mask radiographic changes in the bowel that depend on the presence of intraluminal air.--Randall IV. Powell Patchy Enteropathy in Childhood. P. D. Manuel, J. A.
Walker-Smith, (March), 1979.
and N.
E. France. G u t
20:211-215,
O f 278 duodenal biopsies studied by dissecting microscope and histology, 106 were abnormal and 49 of these showed patchy abnormality. Of 33 patients with cow's milk intoler-
A case of duplication cyst of the terminal ileum seen in a 3-day-old male baby was reported and 199 cases of duplication of the alimentary tracts were collected from the Japanese literature. A m o n g 199 cases of duplication of the alirnentrary tract reported in the Japanese literature, 39 cases were newborn infants. Sites of duplication were: duoden u m in 2, jejunum in 7, ileum in 10, terminal ileum or ileo-cecum in 17, transverse colon in 1, total colon in 1, and abdominal cavity in 1 case. Type of duplication was cystic in 37 cases and tubular in 2 cases. Multiple occurrence was seen in two cases. Associated malformations were seen in 13 cases; atresia or stenosis in 9, malrotation in 3, and Meckel's diverticulum in 1 case. Complications were seen in 20 cases; volvulus in 8, intussusception in one, peritonitis in 10, and bleeding in one case. Presenting signs were; vomiting and/or distension in 38, constipation in 4, melena in 4, tumor in 14 cases. Correct diagnosis was made preoperatively in only 2 of these 39 cases. O f these 39 cases, 25 survived. H. S u z u k i Lithiasis Due to Interruption of the Enterohepatic Circulation of Bile Salts. D. R. Kirks. A m J Roentgenol 133:383
388, (September), 1979. A 3-yr-old girl who developed cholesterol cholelithiasis following major small bowel resection for midgut volvulus as a neonate and an I 1-yr-old girl with regional enteritis who developed an obstructing oxalate ureteral calculus are presented. The mechanism for developing cholelithiasis with ileal dysfunction involves inadequate bile salt absorption and the resultant lower bile salt content in the excreted bile. This results in bile which is supersaturated with cholesterol. The development of oxalate urolithiasis probably involves three mechanisms: (1) increased production by bacteria of oxalate from glycine-conjugated bile salts which is converted to oxalate by the liver, (2) binding of calcium by malabsorbed fatty acids that increases unbound dietary oxalate which is then absorbed, and (3) increased permeability of the colon to oxalate due to unabsorbed bile salts. An extensive differen-
ABSTRACTS
tial diagnosis of pediatric cholelithiasis and urolithiasis is also presented.--Randall W. Powell Appendicitis in Acute Leukemia. K. Ver Steeg, A. LaSalle, and L Ratner. Arch Surg 114:632-633, (May), 1979.
Five cases of appendicitis in leukemic children were reviewed. Four children were receiving prednisone. All had appendectomy and survived the immediate postoperative period. One child had a spontaneous remission following appendectomy while two of three children in remission had serious postoperative complications (abscesses). Appendicitis in leukemia should be managed s u r g i c a l l y . ~ d w a r d J. Berman
A Double-Blind Trial of a Single Intravenous Dose of Metronidazole as Prophylaxis Against Wound Infection Following Appendicectomy. M. J. Greenall. A. Bakran, I. R.
Pickford, et al. Br J Surg 66:428-429, (June), 1979. One hundred patients (mostly adults) undergoing appendicectomy through a right iliac fossa incision were randomized to receive either normal saline or 500 nag metronidazole as an intravenous infusion during operation. There were 13 wound infections, 12 (out of 51) in the saline group and 1 (out of 49) in the metronidazole group. This work supports the value of metronidazole and suggests that a single-dose regimen is adequate for prophylaxis.--L. Spitz
Intrarectal Metronidazole in the Prevention of Anaerobic Infections A f t e r Emergency Appendicectomy: A Controlled Clinical Trial. J. Rodgers, D. Ross, HI. McNaught, et al. Br J
Surg 66:425-427, (June), 1979. A series of 102 patients with presumptive acute appendicitis were entered into a prospective, randomized, clinical trial of intrarectal metronidazole given over a 48-hr period commencing before surgery. Adequate levels of circulating metronidazole were achieved. A significant reduction in the incidence of anaerobic wound infections was observed in the treated group (p < 0.02).--L. Spitx
Ultrasound Diagnosis of Portal Vein Thrombosis as a Complication of Appendicitis. D. S. Babcock, A m J Roent-
genol 133:317-319, (August), 1979. A 6-yr-old boy presented with a 2-wk history of epigastric and RLQ pain, fever, and increasing hepatosplenomegaly and had been treated at another hospital for 10 days with antibiotics. Physical examination revealed fever, tachycardia, jaundice, and hepatosplenomegaly with moderate liver tenderness. Blood cultures grew E. coli and a liver biopsy revealed acute cholangitis and also grew E. coil He did not respond to intravenous antibiotics and an ultrasonic examination could not demonstrate the portal vein but echogenic material was present in the region of the portal vein. Laparotomy revealed dilated mesenteric and retroperitoneal vessels. The appendix, retrocecal in position, was adherent to the peritoneum but was not acutely inflamed. Pathologic examination revealed resolving acute appendicitis. The
233
patient's postoperative course was complicated by continued fever and positive blood cultures and a repeat ultrasound examination 10 days later revealed an abscess in the right lobe of the liver which was drained. A third examination prior to discharge revealed the portal vein to be filled with echogenic thrombus.--Randall IV. Powell Postoperative Intussusception in Infancy and Childhood: Analysis of 119 Cases. D. L. Mollitt, T. 1I. N. Ballantine,
and J. L. Grosfeld. Surgery 86:402 408, (September), 1979. The authors review 119 cases (including 14 of their own) of postoperative intussusception. Twenty-four (20%) patients had undergone retroperitoneal procedures, 17 (14%) followed pull through procedures, 16 (13%) followed appendectomy, while the remaining instances followed a variety of operations including operative reduction of ileocolic intussusception and other major abdominal procedures as well as some non-abdominal operations. The age range was 1 wk to 15 yr and the sex was evenly distributed. Sixty-four percent were symptomatic within 1 wk with 90% within 2 wk. The prominent symptoms were abdominal distension, prolonged or increasing nasogastric output or vomiting and abdominal pain. Rectal bleeding and abdominal masses were uncommon. The majority of sites of intussusception were in the small bowel with 73 (62%) ileoileal. Manual reduction was successful in 110 patients (95%). This reemphasizes the importance of considering this diagnosis in the postoperative infant or child who has signs of intestinal obstruction in the early postoperative period.--Eugene S. Wiener
Closure of Colostomy in Infants and Children. A. M . K.
Rickwood, V. Hemalatha, and P. Brooman. Br J Surg 66:273-274, (April), 1979. A retrospective study of 100 conservative colostomy closures over a 10-yr period is presented. The majority involved infants with either anorectal anomalies or Hirschsprung's disease. Preoperative bowel preparation varied from nil (6 patients) to mechanical preparation and oral nonabsorbable sulphonamide (69 patients) to radical preparation including mechanical evacuation, low residue diet, sulphonamide, gentamicin and metronidazole (25 patients). Operative closure of the colostomy consisted of an intraperitoneal resection and end-to-end anastomosis. Fecal fistula developed in 5 cases and there were 8 other major complications. Wound infection occurred in 43 infants (45%). The authors claim a greatly reduced incidence of wound infection (16%) following the introduction in 1975 of a more radical bowel preparation prior to closure of the eolostomy. The paper lacks any formal control and merely outlines the experience of the authors with a relatively small number of patients over a long period.--L. Spitz
X-Ray Diagnosis of Hirschsprung's Disease W i t h Total Colonic and Ileal Involvement. H Ohkawa and H. Takaha-
shi. Jpn J Pediatr Surg 11:763-768, (July), 1979. The authors reviewed 103 gastrographin-enema films of newborn infants with intestinal obstruction. The x-ray diagnosis of "microeolon" was made when the maximum caliber