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Surgical experience with peptic ulcer in infancy and childhood
Surgical Experience with Peptic Ulcer in Infancy and Childhood FREDERICK LEIX, M.D. AND E. M. GREANEY, JR., M.D., Los Angeles, From tbe Departments of Surgery, Cbildrens Hospital of Los Angeles and tbe Los Angeles County General Hospital, Los Angeles, California.
VER A CENTURY ago, a French pathoIogist J. CruveiIhier [I] described autopsy fmdings in three infants with muItipIe gastric uIcers. Since then, sporadic reports have been pubhshed concerning peptic uIcer occurring during infancy and chiIdhood. In 1959 Ramos, Kirsner and Palmer [2], in an exceIIent review, reported over 500 cases in the Iiterature and added thirty-two cases of their own chieffy in the oIder age group. Guthrie [3] in 1942 emphasized peptic uIcer as a cause of death during infancy. Our interest in this subject was stimuIated by our experience with operative and other cases seen on the wards of the Los AngeIes ChiIdrens Hospital and the Los AngeIes County Genera1 HospitaI.
0
Culi;fornia
roentgenograms, operation, or autopsy, the case was incIuded in the series. A few were outpatients, but the majority were cared for in the hospitaIs. CLASSIFICATION
In an effort to simpIify anaIysis of the materia1, we have divided our tota number of patients into two age groups, these are, (I) under tweIve months, and (2) one to fifteen years. There were twenty-nine cases in the Iess than a year group and thirty-nine between the ages of one and fifteen. (TabIe I.) Fortytwo were maIe patients and twenty-six were femaIe patients. In the infant group, the ratio was seventeen to twelve. (TabIe II.) In sixtyeight cases, thirty-three were gastric and thirty-five &odenaI. As the picture unfoIds, it is seen that the very young have acute uIcer (singIe or muItipIe) compIicated by hemorrhage or perforation which often foIIows a serious iIIness. After one year of Iife, no year has more than seven cases. As the age increases, a preceding serious iIIness is noted in diminishing frequency, unti1 the age of six and beyond when it is seen to be the ruIe rather than the exception for the uIcer to
SOURCE OF MATERIAL Our series of sixty-eight cases was compiIed from the records of the ChiIdrens HospitaI of Los AngeIes (thirty cases in twenty-five years) and the Los AngeIes County Genera1 HospitaI (thirty-eight cases in thirteen years). Patients operated upon because of compIicating factors are described in greater detai1 than are the others. If the diagnosis was estabIished by
TABLE II SEX INCIDENCE Sex Age
TABLE I AGE INCIDENCE
Data
Male No. of Cases Less than one year.. Over one year..
Under one year of age.. Overoneyearofage..................
Female
...
... .. . . . .. ....
29 TotaI...........................
39
I73
American
Journal of Surgery,
-~
17 25
I2 14
42
26
Volume ro6, Aupst 1963
Leix and
Greaney
TABLE PEPTIC
(AGE
AgeandSex
ULCER
I
Bith Weight if Recorded
AsmciakdIllness
IN
ONE
III
INFANCY DAY
AND
TO ONE
-
Operative Prooedun: (for ulcer)
!
CHILDHOOD
YEAR)
-
Ulcer Site
-
DUOdunal
(
I
-
fIemor.- I ‘erfora,.
Remarks
Result
rhage
tion
Ohstrub tion
x
.. .
..
__ One day, F One day, M Two day. F Two day, F Three day, M Six day, Mj Ten day, M Twelve day, F Fourteen day, M Fifteen day, M Twenty-one day, M Twenty-five day, M Five week, F Six week, M
10 pound, Erythroblastosis fetalii 7 Ounce Erythmblssimis fetalis ... skull fracture 6 pound, Linear 9 O”“CRS 8 pound, Ulcer (1 cm.) Boftpalate 2 ounce Erythroblastosis fetalis 8 pound 5 pound, Jaundice (unknown cause) 3 o”“~q pneumonia,kernicterus Urologic congenitalanomaly ... Meningitis 1.. Encephalitis, pneumonia ... 4 pound, Sepaia 8 ounces Sepsis, bronchopneumonia ..
5 pound, 2 ounce 5 pound, 4 ounoe
Six week, F Six week. M Seven week, M
5 pound 5 pound
x
None NO”l?
x x
x x
None
x
x
None None
None None
Vomiting (since birth)
Pyloroplasty
Diarrhea
None
x
Recovered Death Death
. ..
x
t.. . .
x x x
x . .. x .
x
...
x
x
Death Death Death Death Death
x
x
Death
x
Death
x
x
Suture ligation, pyloroplasty None NO”8
x x x -
elteroidtherapy
Death
x x
x x
x
x x
x x
x
x
x
x
x
x x
x x
Recovered Death
x
x
Death
x
x
RPcovered I Iypernatremis (Na. 172) Death Death . .. Death
x
NOnO Pyloroplssty, suture ligation, vagotomy None
..
Recovered
x
Diseases of pancreas, pneu- None monis None Diarrhea Closure, duodenal Bronchopneumonis Ulcer None Acute pyelonephritis None Diarrhea
.
Death
.
x x x x x x
Pyloric stenasia
.. 4 pound, 5 O”“c.?S 5 pound, Bronchopneumonia,dehyTwo mo., M 13 Ounce dration None know” Two “10.. M 4 pound, Failure to thrive Three mo., M 11 ounce Diarrhea, coryaa Three “10.. F None known Three sod one-half mo.. F Congenitalheart disease Four mo.. M with failure 6 pound, Gangrene of toes due to Fourmo., M saline lysis 9 oune? Cerebralvascularthrombosis Fivem.. M Periarteriti nodoaa . Tenmo., F kseptic meningitis . Oneyr.. F Two mo., F Two mo., F
None
Death Recovered
.
Death Death
.
Death Death Death
x
lo weight gain
P
in three mo.
x x x
. -
. .
-
-
.
-
NOTE:Total of twenty-nine patient+ twenty-two deaths (one year of age and under), and B mortality rate of 76 per cent.
There are many factors, however, which may pIay a roIe in the cause. These are: prematurity, infection, intracrania1 hemorrhage, intracrania1 neopIasm, generaIized trauma, IocaI trauma (as by nasogastric tube) cutaneous burns, and so forth, (TabIes v and VI.) It is apparent that many of these factors produce stress. Stress may cuIminate in acute peptic uIceration. (TabIe VI.) CIassicaIIy, two mechanisms of stress uIcer are those described by CurIing in 1842, and Cushing in 1932. Both are beIieved to invoIve stimuIation of the hypothaImus [5].
conform to the chronic aduIt type. (TabIes III and IV.) Other writers have used three groups: birth to four weeks; four weeks to one year; and over one year, or four groups: (I) neonata1, birth to four weeks; (2) infancy, four weeks to two years; (3) preschoo1 age, three to five years; and (4) schoo1 age, six to fifteen years. CAUSE
The basic cause of peptic uIceration in infancy and childhood, as in aduIts, is unknown. I74
Peptic
UIcer in Infancy TABLE
PEPTIC
ULCER
(AGES:
IN
ONE
Associated Illness
IV
INFANCY ~0
AND
FIFTEEN
-
I
AgeandSex
and ChiIdhood
ulcer
Operative Frocedure (foru1cer)
-
CHILDHOOD
YEARS)
sitm
-
I
Complication -7
3&liO
Results Per-
Duodenal
Remarks
3bStIUc-
tion
__
Thirteen ma., M
Ingestion, shoe polish
Fifteenmo., F Nineteen mo.. M Twoyr.. M Two yr.. F
None known None known None known Waterburns(36 Per cent)
Two yr., M Two and one-half W., F
Iron deficiency anemia Pneumonja preceded lint bleeding episode: second and third bleeding epi. nodes without preceding illness Brain tumor l”, 2”, 3’burea 60 Per cent: Specific diarrhea Mea&a encephalitis Left diaphragmatic hernia
Three yr., M Three yr., F Three yr., F Fouryr.,M Four and one-half yr., F Five yr.,
M Five yr., M Fivev., M Fiveyr., F Six p., M Six yr.. M Six yr., M Seven yr., M Eight yr., F Eight yr., M Eight and one-half yryr.9 M Eight and onehalf fl.3 F Nineyr., F Nine p.. M Eleven yr.. F Eleven yr., M Eleven yr., M Eleven andone-half yrr., F Twelve yr., M Twelve yr., M Twelve yr., M Twelve yr., M Twelve yr., M Twelve yr., M Twelve yr., F Thirteen or., F Fourteen yr.. M
*
. .*
Suture ligation.pylorc PMY None Pyloroplaety. wbgotomJ pyloropla8ty Ckaure, perforated UlCer None None
x
. . .
If
x
. . .
.*. ...
x x
x x
... .
. . .
None None None None Gsstrectomy
x x x x x
x . ...
x .. x x ...
.
... . .. . .. .
I[
x x
x
x
x
.. .
x x ...
. . .
x
x ...
I
x
Mumps Acute pharyngitis, epiglottitis None known Noneknown Brain tumor None known
None None
... x
Suture ligation None None None
. .. x
Meningitis Meningitis, H-Influenza Noneknown None known
None None None N0Ile
x x ... x
Car accident
Suture ligation
Pneumonia None known Chicken pox, encephalitis None known None known None known Addison’s disease None known &ho& Collagen disease Aneurysm sarcoma None known None known None known None known
x ...
. . .
* . . . .
x
. ..
..I
x
I..
.
I(
. ... ... ...
Death Death Recovery Recovery
x
. **
x
...
None None None None None None
x ... ...
*.. x x
... ... ..
x ... ...
I
. . x ... x x
x
...
None None None None None Closure of ulcer None None None None
x ...
. *. x ...
... .. ... . ... x x
x ... x .. .
. . .
.
.
.
.
.
.
.
.
.
..a
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
x x x ... . .
I
Recovery
s..
I..
.
.
.
.
.
.
.
.
.
.
.
.
.
. . .
...
. . .
Recovery Death
x
. . .
.
.
.
Alao avitaminceis Bleeding episodea at eleven mo., fourteen mo. and two andonehalf y+.
Death Death Death Death Recovery
Recovery Recovery Death Recovery
. . ... ... ...
... .. x . x x
. . .
Recovery Recovery
x ...
x x x
x
.
... ..
IL
x
. . .
. . .
. .*. x
I.
I
.
. . .
x x ... x
Recovery Steroid therapy
Trseheostomy
.. . Gastrointestinal bleeding at four and onehalf yr. of age
Splenectomy
Death . ReCOVery 3teroid therapy Death R.XOVerY Recovery Recovery Death Recovery D&b Death Death Death Recovely Recovery Recovery Recovery
... Steroid therapy .. ...
-
NOTEI:Total of thirty-nine patients; deaths. fifteen; and mortality rate of 37.6 Per cent
cause. In severa patients in our group acute Aeration with hemorrhage deveIoped after the administration of steroids. In TabIe III it is shown that onIy two of twenty-eight infants under the age of one year had no stress situation associated with peptic uIceration. Each of these patients had acute uker as determined by autopsy. TabIe IV shows no stress situation associated
We were particuIarIy impressed with the roIe of associated iIIness in the entire infant group and in about haIf of the younger chiIdren as weI1. It is the rare exception when a stress situation of severity such as meningitis, specific enteritis, pneumonia or sepsis does not immediateIy precede peptic uIcer which occurs in infancy. Steroid therapy is another factor in the ‘75
Leix and Greaney TABLE VII COMPLICATIONSIN PEPTIC ULCER
TABLE v BASIC CAUSE
No. of Cases
Cause
Stress ............................... Steroids. ............................ Unknown. ...........................
Hemorrhage............................... Perforation.. . Obstruction.. . . . . . Multiple compIications*.
43 5 20
* Ten were hemorrhage
with peptic uIceration in seventeen of thirtynine chiIdren between the ages of one and fourteen years. Beyond the age of six years, it was found that chronic peptic uIcer of the ad& type prevaiIed. In reference to the basic cause of uIcer in the newborn, the studies of R. A. MiIIer [6] in 1941 are of interest. He measured the fasting gastric juice in fifty norma babies during the first ten days of Iife and found the maximum average tota
acidity
in terms
N
of cc. ;
HCI per
100 cc.
Hypernatremia ...............
.
. . . .. .... .. ..
13
and perforation.
Awareness of the Iesion is invaIuabIe in the diagnosis of uIcer disease in this age category. The infant group presents the greater diffrcuIty as shown by the many whose diagnoses are made at autopsy. In nearIy every case, a compIication (TabIe VII) was the basis for suspecting the Iesion. The group over one year of age may show evidence of pyIoric stenosis or intractabiIity of pain and, as age increases, typica or atypica1 symptoms of chronic peptic uIcer appear. Appendicitis may be simuIated by perforated uIcer in young chiIdren as reported by Be11 [a]. The most common cause of massive intestina1 hemorrhage in infancy and chiIdhood is peptic uIceration in MeckeI’s diverticuIum [g]. TypicaIIy, the stoo1 is brick-red in coIor whiIe bIeeding from higher IeveIs is usuaIIy bIack. However, brisk bIeeding from the stomach or duodenum may be passed as red stoo1, and frequentIy hematemesis is absent. Therefore, in view of the increasing recorded incidence of gastric and duodenal uIceration, many of the bIeeders in whom abdomina1 expIoration reveaIed no MeckeI’s diverticuIum may have had uIcer of the stomach or duodenum. The ski11 and interest of the radioIogist is of prime importance. Great patience and experience are heIpfu1 in demonstrating a gastric or
No. of Cases
.. .
32 g 2
DIAGNOSIS
TABLE VI STRESS SITUATION
Infection. ..................... Central nervous system ......... Trauma ....................... Terminal event. ................ Erythroblastosis fetaIis. ....... CoIlagen vascular disease. ..... Genitourinary anomafy........ Cirrhosis. ................... Cardiac ..................... Addison’s disease. ............ Anemia. .................... PyIoric stenosis. .............
.
pIastic gastric mucosa is noted in a newborn chiId of average weight. Most incidence figures of prematurity (Iess than 5.5 pounds or 2,500 gm.) range between 7 and I I per cent [7]. ApproximateIy 50 per cent of the infants under one year, in whom birth weights were recorded in our study, were premature. SeveraI references in the Iiterature [6,7] note this possibIe cause factor. It is generaIIy beIieved that prematurity predisposes to menta1 and physica retardation [7].
to be 40 on the day of birth, dropping to 25 on the third day and to 16 on the seventh day. Other tests showed that acidity remained beIow 20 for the fn-st month of Iife. He aIso determined the infIuence of birth weight, demonstrating that the heavier an infant at birth, the more IikeIy it is to have a more perfectIy deveIoped gastric mucous membrane (histoIogic comparison) and potent gastric secretion. Premature babies reveaIed gastric mucous membrane of primitive character with shaIIow IooseIy packed gIands and reIativeIy few acid-producing ceIIs. OccasionaIIy, hypo-
Data
No.
Comphcation
16 IO 5 I4 4 3 I
I I I I I
I 176
Peptic
UIcer in Infancy and ChiIdhood
TABLE VIII TREATMENT
FOR
PEPTIC
ULCER
No. of Cases
Treatment
MedicaI
26 I2 30
. .
Surgical............................. None...............................
duodenal uker in an infant. FortunateIy, we have had the heIp of radioIogists who meet these requirements. As an exampIe, a duodena1 uIcer crater was demonstrated by barium or gastrografin in eight infants in our series, the youngest onIy five days aid, the oIdest four months of age. Hemorrhage was the compIication that initiated study in al1 of these babies. (Fig. I .) MEDICAL TREATMENT
FIG. I. Roentgenogram of an uIcer crater.
In our series, twenty patients were treated by the usua1 medica means, and tweIve were treated surgicaIIy. Thirty received no treatment specifkalIy directed to the uIcer, only support and treatment of the underIying disease. The resuIts of medica treatment were recovery in seventeen patients with three deaths. (TabIes VIII and IX.) Surgical resuIts are considered separateIy.
Physical examination reveaIed a we11 deveIoped, we11 nourished chiId in no distress exhibiting a wet cough. HemogIobin, 10.4 grams per cent; red bIood ceI1 count, 5.2 per cu. mm.; pIateIets, 310,000 per cu. mm.; white bIood cell count, 8,750 per cu. mm.; differential, normaI. Two upper gastrointestina series were done on JuIy 28 and 31. The Iirst showed irreguIarity of the duodena1 cap and the second, faiIure of the duodenal cap to Ii11weI1. The child was discharged with a diagnosis of hematemesis, secondary to vomiting. He was readmitted on August I I because of vomiting of food and Ioss of weight (8 pounds). On admission, he was lethargic and dehydrated, but otherwise the physica examination was not remarkabIe. He continued to vomit; and, on August 17, a barium study showed compIete pyIoric obstruction. Vagotomy and pyIoropIasty were performed under genera1 anesthesia. His postoperative course was uneventful and he was discharged on the seventh postoperative day.
OPERATIVE EXPERIENCE
The foIIowing tweIve cases are summarized briefly to emphasize the operative experience in the series: CASE I (zo8g52). A nineteen month old Caucasian boy entered the hospita1 for the frrst time on JuIy 21, 1961, with a history of vomiting food and cIotted blood for two days. The chiId was premature at birth, weighing 5 pounds, 2 ounces. Thereafter his deveIopment was not remarkabIe. Two weeks prior to admission, he had a cold which Iasted for one week.
Comment. SurgicaI treatment was advised and performed after a reasonabIe tria1 of medica management.
TABLE IX MEDICAL
TREATMENT
IN
PEPTIC
Data
ULCER
No.
A tweIve year oId boy had CASE II (176209). been under treatment for Ewing’s sarcoma of the
Per cent
ilium, pubis and left femur and biIatera1 hydronephrosis due to metastases. He had received Actinomycin-D and x-ray therapy, and had been on intermittent steroid therapy. He was currentIy receiving Prednisone,@’ 45 mg., four days per week. For severa weeks, he had compiained of epigastric
_____ TotaI cases.. . . Total deaths.. . . MortaIity
. .
. . .
20
.
3 . .
... 15
.
I77
Leix and Greaney pain not reIated to mea1.s and, for the past three days, he had increased epigastric pain with radiation to the back. On examination, he had pain and tenderness in the epigastrium with rebound tenderness. BoweI sounds were normal. An upper gastrointestina1 series revealed an uIcer on the posterior aspect of the stomach. He had severa episodes of hematemesis after admission, cuIminating in operation for uncontroIIed bIeeding. The uIcer was treated by simpIe suture. After a stormy postoperative course, the child was discharged. One year Iater, he died at home. No autopsy was performed. Comment. formed.
Surgery
was
expeditiousIy
per-
CASE III (160822). A two year oId gir1 had received hot water burns of 2’ and 3’ invoIving 35 per cent of the body surface. On the day of admission, she vomited “coffee-ground” materia1. Three days after admission, she passed tarry stooIs and her hemogtobin feI1 from 14 gm. to 6 gm. She continued bIeeding intermittentIy for the next seventeen days, receiving numerous bIood transfusions, her hemogIobin ranging from a high of 16 gm. to a Iow of 5 gm. twenty-four days after admission, a portabIe roentgenogram showed free intraperitoneal air. Operation was performed and a smaI1 perforation of the anterior gastric waI1 was cIosed. An uIcer I cm. diameter was responsibIe for the perforation and there was absence of inffammatory process. Her postoperative course was stormy, requiring severa transfusions, but she toIerated food on the fourth postoperative day. She had wound and urinary tract infection. Skin grafting was necessary. The chiId was discharged two and a haIf months after admission.
Comment. The deIay in operation was justified by serious extensive burns, aIthough, in retrospect, an earIier attack on the massive bIeeding wouId probabIy have prevented the added insuIt of perforation in this seriousIy iI chiId. CASE IV (187762). An eight and one-half year oId Negro boy underwent spIenectomy for traumatic rupture of the spIeen. Transfusions were required. He aIso had a fracture of the uIna. His immediate postoperative course was compIicated by smaI1 bowe1 obstruction which was treated with intubation. On the sixth postoperative day, the obstruction was reIieved; the chiId had hematemesis requiring transfusion and reoperation. A smaI1 ulcer on the posterior waI1 of the stomach was suture-Iigated through a gastrostomy. Postoperative course was uneventfu1.
SurgicaI treatment Comment. tuted as soon as the seriousness Ioss became apparent.
was instiof the bIood
CASE v (197406). A four and one-haIf year oId girI had a transabdomina1 repair of a diaphragmatic hernia of the BochdaIek type. She began to bIeed on the third postoperative day, requiring transfusions and reoperation on the fifth postoperative day. A subtotal gastric resection was performed for a Iarge postbuIbar uIcer. A stick-tie of the uIcer with a 40 per cent BiIIroth II reconstruction incIuding a Hofmeister anterior gastrojejunostomy was performed. The common biIe duct was catheterized for identification of the ampuIIa of Vater. BIeeding ceased. Twenty days Iater the gastrojejunostomy was reconstructed because of stoma1 obstruction. She has since done weII.
SurgicaI attack Comment. point was earIy and energetic.
on the bIeeding
CASE VI (191~75-05). A seven week oId Japanese boy, weighing 4 pounds at birth, was admitted to the hospital. Weight on admission was 5 pounds, 3 ounces. A respiratory infection had deveIoped two days previousIy. Upon examination, he had acute respiratory distress with rapid breathing, expiratory grunt, flaring nostriIs, and subcosta1 retraction. His temperature was 97’F.; puIse rate, 150; and respirations 60 per minute. There were raIes throughout his chest. He had a grand ma1 seizure during examination. FoIIowing intensive treatment for pneumonia, he improved niceIy for five days and then had meIena for the first time. His hemogIobin, which had been 14.0 gm. per cent, feII to 8.5 gm. per cent and then to 7.0 gm. per cent. He was transfused with 50 cc. of bIood. The surgical consuItant made a diagnosis of probable duodena1 uIcer with hemorrhage and advised observation. On the foIlowing day, the radioIogist demonstrated an uIcer crater in the duodena1 buIb. During the next three days, the baby bIed intermittently, then evidence of peritonitis deveIoped. Roentgenograms showed gas under the diaphragm. Operation under genera1 anesthesia reveaIed a I cm. in diameter perforation of an uIcer on the antero-superior aspect of the first portion of the duodenum. The perforation was cIosed with 4-o chromic and 4-o silk sutures. On the foIIowing day, his genera1 condition was good; hemogIobin was 12.5 gm. per cent and eIectroIyte determinations were normaI. Six days after operation wound infection was noted. On the ninth postoperative day, he had wound dehiscence which was treated by adhesive:strapping. Two weeks Iater he was discharged from the hospita1. Six months Iater,
Peptic UIcer in Infancy and ChiIdhood at a fotlow-up visit, study showed norma duodenum. (Fig. 2.)
an upper esophagus,
gastrointestina1 stomach and
Comment. At the time of surgical cons&ation, the hemogIobin had falIen from 14 to 7 gm. per cent. After transfusion, bIeeding continued for three days when perforation occurred and operation was performed. He probabIy shouId have been operated upon earher. CASE VII (191-36-48). A two month oId baby had Iost weight steadiIy from his birth weight of 5 pounds, 13 ounces to his present weight of 5 pounds, o ounces. He had taken formuIa and cerea1 we11 and had no vomiting or diarrhea. Examination of the infant revealed emaciation and dehydration. He had biIatera1 raIes and a chest fiIm showed density in the middIe Iobe of the right lung. On the day after admission, he passed dark blood rectaIIy. His hemogIobin was 11.0 gm. per cent. He was transfused with 25 cc. bIood. On the foIIowing day, an upper gastrointestina1 series showed a 2 mm. crater in the duodena1 bulb. He continued to bIeed for four days requiring 225 cc. of bIood. The surgica1 consultant advised continued medica management incIuding fresh bIood, Vitamin K, and vigorous antacid therapy. He then stopped bIeeding for four days and made good progress. On the tenth hospita1 day, vomiting and diarrhea without blood deveIoped. On the foIIowing day, he had profuse meIena. He was then operated upon with findings of a Iarge ulcer in the posterior waI1 of the first part of the duodenum. A stick-tie was placed in the uIcer base and the mucosa was sutured over the uIcer. A pyIoropIasty was constructed. His postoperative course was poor. He required two more bIood transfusions of 25 cc. each and continued to pass dark red stooIs. He died on the second postoperative day. Autopsy showed bronchopneumonia in the Iower Iobe of the right lung and ateIectasis of the Ieft Iower lobe. No other uIcer than the one treated at operation was found.
FIG. 2. Roentgenogram
showing air in rib carriage.
times “coffee-ground,” and Iost ten pounds in weight. After admission, he continued to vomit forcefuIIy even after taking clear Iiquids onIy, and hypochIoremic aIkaIosis deveIoped. Hematemesis and meIena were noted with a faI1 in hemogIobin from I 1.0 gm. to 8.3 gm. per cent. Upper gastrointestina1 series showed pyIoric obstruction. The radioIogist’s impression incIuded hypertrophic pyIoric stenosis, annuIar pancreas, or anomaIous bands, or reduplication of the upper part of smaI1 bowe1. After preparation, operation was performed with findings of a I cm. in diameter uIcer in the pyIoric canaI. There was edema of the pyIorus and the uIcer base was bIeeding. The ulcer was suture-Iigated, and a Heineke-Mikulicz pyIoropIasty was performed. Recovery was uneventfu1 and the child was discharged on the eighth postoperative day. In 1959, five years after the operation, the patient was deveIoping weI1, and had no uIcer symptoms.
Comment. This 5 pound baby had required 225 cc. bIood; duodena1 uIcer had been demonstrated by roentgenogram when he was seen by the surgical consuItant. He shouId have been operated upon at that time, rather than six days Iater when he had another massive hemorrhage. CASE VIII (96647). A twenty-four month old Caucasian boy was perfectIy we11 unti1 three weeks prior to entry when he vomited food streaked with bIood. Thereafter he vomited frequentIy, some-
Comment. SurgicaI and performed after medica management. I79
treatment was advised a reasonable tria1 of
Leix
and Greaney Comment. Surgery was advised because of obstruction despite negative x-ray findings, except for spasm of the pyIorus. ExpIanation of this child’s death is not cIearIy expIained on either the operative or autopsy findings.
CASE IX (220667). A five year oId Caucasian boy was admitted to the hospita1 with a chief CompIaint of joint pain for approximateIy two weeks. He had been seen one week prior to admission by his physician with the compIaint of stomach pain, periumbilical, associated with vomiting. There was no bIood in the emesis. Vomiting persisted over the next twenty-four hours. When admitted to the hospita1, his temperature was IOI’F.; hemoglobin, 14.3 gm. per cent; and white bIood ceI1 count, I 1,650. No melena was evident. On the second day of hospitaIization he had a considerabIe number of bIoody emeses and bloody bowe1 movements. HemogIobin feI1 to 9.8 gm. per cent; he was transfused with 1,250 cc. of whoIe bIood. BIood loss continued and the child was taken to the operating room without roentgenographic diagnosis. At surgery, the stomach and intestine were found to be fiIIed with bIood, and there was great diffrcuIty in locating the bIeeding point. A postbuIbar uIcer Iocated cIose to the ampuIIa of Vater was finaIIy identified and the bIeeding point was suture-Iigated. Gastrostomy was performed. No further bIeeding occurred; the patient was discharged from the hospita1 seventeen days after the operation. Subsequent x-ray examinations have not reveaIed any ulceration.
CASE XI (204-26-13). A thirteen months old Negro boy who had weighed 4 pounds, 7 ounces at birth entered the hospital on September 25, following shoe poIish ingestion. He was acutely iI1, in shock, and dehydrated, dyspneic and anemic (hemogIobin of 5 gm. per cent couId not be explained on basis of poisoning). Immediate treatment incIuded cut-down, pIasma, eIectroIytes and antibiotics. Because of his poor genera1 condition and pneumonitis tracheostomy was performed. On the foIlowing day, SoIu-cortef@ was started. On September 30 (five days after admission) hematochezia was noted. GastrointestinaI bIeeding resuIted in numerous episodes of shock requiring in excess of I, IOO cc. of bIood, unti1 a duodenal uIcer was shown by roentgenograms on October 2; evidence of perforation was noted a few hours Iater. He was taken to surgery and operation resulted in cIosure of perforation, suture-Iigation of the bIeeding point, pyIoropIasty and gastrostomy. SoIucortef was given postoperativeIy (25 mg. every eight hours for the first day, IO mg. every eight hours for the second day, and 5 mg. every eight hours for the third and fourth days), and then stopped. AIthough convaIescence was marked by dermatitis, bronchitis and sIow progress, he required no more bIood and was discharged on November IO (thirty-nine days postoperative), in good condition.
EarIy surgery was performed Comment. without roentgenographic diagnosis because of massive hemorrhage in the gastrointestina1 tract. CASE x (173568). A five week oId infant, one of identica1 twins, weighed 5 pounds, 2 ounces at birth. She was admitted because of severe vomiting and dehydration. After birth, the patient was kept in the hospita1 for two weeks because of poor weight gain and vomiting. She was discharged, but because of the same symptoms, was rehospitaIized. At that time a gastrointestina1 series reveaIed pyIorospasm. Three days before transfer here, severe cyanotic speIIs deveIoped. She received Hydrocortisone,@ IO mg. every tweIve hours. Upon admission, the infant appeared maInourished and acutely, chronicaIIy iI1. There was dehydration with CO2 - 34, and CI - 52. Gastric contraction waves were seen. Upper gastrointestinal series reveaIed pyIoro and antra1 spasm. A pyIoric tumor was feIt by severa examiners and expIoration was advised. SurgicaI findings were those of a constricted inflamed pyIoric ring with uIcer on the posterior waI1 of the pyIorus. A pyIoropIasty was performed. PostoperativeIy, the baby did poorIy in spite of a11 measures and died on the second postoperative day. Autopsy reveaIed ateIectasis and IobuIar hemorrhages, pyIoropIasty and duodena uIcer.
Comment. A thirteen month oId baby had numerous episodes of shock and received I, IOO cc. of bIood before diagnosis of duodena1 uIcer was made. Even then he wouId not have been operated upon except for perforation. CASE XII (142185). A three month oId Caucasian gir1 with a one day history of vomiting and tarry stoo1 was admitted to the hospita1. On admission, the infant was ashen-coIored and lethargic. HemogIobin on admission was 6.8 gm. per cent. Laboratory studies faiIed to revea1 any blood dyscrasia. She was treated with transfusions and her shock-Iike picture improved. A gastrointestina1 series reveaIed deformed duodenal bulb. During the first four days of hospitalization, improvement was noted, but gastrointestinal bIeeding was thought to persist. By the sixth hospita1 day, the patient’s condition deteriorated with convuIsions that were thought to be on a metaboIic intoxication basis. She was prepared for surgery and transfused again. At surgery, the infant’s 180
Peptic
UIcer in Infancy
and ChiIdhood TABLE x SURGICAL PROCEDURE IN PEPTIC ULCER
condition was precarious. ExpIoration reveared a large duodenal ulcer. The base was suture-Iigated, and a pyloropIasty and vagotomy performed. Her immediate postoperative course was stormy and, despite bIood, vasopressors, and supportive therapy, the infant expired six hours Iater.
Type
of
No.
Procedure
SutureIigature............................. PyIoropIasty.. . SimpIe closure. . Vagotomy and pyloropIasty..
Comment. There was a deIay in operation because the chiId’s condition was precarious. The diagnosis was made earIy, but the operation was performed Iate. (TabIes x, XI and XII.)
Gastric
s*
In summary, sixty-eight cases of peptic uIcer in infancy and chiIdhood are presented. The diagnosis was estabIished by roentgenograms, autopsy or operation. The charts were carefuIIy reviewed from the standpoint of age, sex incidence, precipitating factors, method of treatment and results. ParticuIar attention is given to operative experience in tweIve cases. DeIay in surgica1 treatment was obvious and unavoidabIe in twenty patients (ranging in age from three days to five years) whose perforated uIcers was not diagnosed unti1 autopsy. Two infants, seven weeks and thirteen months of age, survived closure of perforated ulcer diagnosed by roentgenograms. Each of these babies (Cases VI and XI) had adequate indication for operation because of massive hemorrhage and roentgenographic diagnosis of duodenal uIcer. Conservative treatment was advised in both cases by the surgica1 consuItant unti1 perforation had occurred. The thirteen month old infant had received I, IOO cc. of bIood. An exampIe of fata deIay in operative treatment is shown in Case XII, a three month oId infant who had meIena causing her hemogIobin to faI1 to 6 gm. per cent. Roentgenographic study indicated duodena1 ulcer. In spite of continued bIeeding, she was repeatedIy transfused for six days, then operated upon.
2 I
resection..
* Gastrostomy performed in three pyloroplasty performed in two patients.
SUMMARY
2 2
. .
patients
and
TABLE XI MORTALITY OF OPERATIVE CASES
Data
No.
Per cent
_F
.
TotaI operated on.. TotaI deaths*. . MortaEty.. ..
12
. .:
2;’
* Suture ligature, one; pyIoropIasty, one; and suture ligation, vagotomy and pyIoropIasty one. TABLE XII MORTALITY IN PEPTIC ULCER No.
Data
Per cent
~___ TotaI series.. Deaths........................... Mortality (per cent) .
68 37 53.6
3. Acute uIcer due to stress in susceptible individuals occurs more frequentIy than is generaIIy recognized. Diagnosis is suspected as a resuIt of ulcer compIications: hemorrhage, perforation and obstruction, in order of frequency. Diagnosis is estabIished by competent radioIogic study. Treatment is medica in most Too often, surgica1 treatment is instances. deIayed beyond the point of no return. 4. Chronic
CONCLUSIONS
peptic
uIcer
occurs more fre-
quentIy than acute uIcer or stress ulcer after the age of six years. Symptoms and findings in this group correIate cIoseIy with those in aduIts.
I. Sixty-eight cases of peptic uIceration in patients from one day to fifteen years of age have been reviewed. 2. The stress uIcer associated with acute major disease, the acute uIcer without associated major disease, and chronic uIcer are identified. A transition that occurs with advancing age at onset is apparent.
5. Suture Iigation of a bIeeding point or simpIe cIosure of perforation is the treatment of choice in acute uIceration. 6. Vagotomy and pyIoropIasty is the treatment of choice in chronic uIceration. 181
Leix and Greaney 7. We can estabIish no ruIes to dictate indications for operation, but we urge a more aggressive attitude on the part of surgeons. An understanding of the uIcer probIem great benefit to the surgeon who edge of peptic uIceration in chiIdhood.
and surgeons reIative to the number of infants and chiIdren they had seen with peptic ulcer. Most of these had had no personal experience with this probIem. FortunateIy, two of my PortIand friends, Dr. RusseII Gustavson and Dr. Richard Warrington, during the past year completed a study of this condition based, IargeIy, on records, over a tweIve year period, from Providence, EmanueI, St. Vincent, Good Samaritan, and the University of Oregon MedicaI SchooI hospitaIs. They discovered thirty-nine cases of peptic uIcer. Thirty-four of these were in the chiIdhood group; onIy five were in the infantiIe group. Otherwise their findings paraIIeIed cIoseIy those of Doctors Leix and Greaney. The sex incidence in the PortIand study was twenty-four boys to fifteen girIs (five to three ratio) compared to forty-two boys to twenty-six girIs (five to three ratio) in the study of Doctors Leix and Greaney. In the PortIand series thirty-six uIcers were duodena1 and three gastric. In both groups studied the compIications of hemorrhage and perforation were common. In the infantile group the first sign of an uIcer was usuaIIy the compIication of either perforation or bIeeding. In tweIve cases in the Portland series the ulcers were secondary to sepsis, major burns, centra1 nervous system trauma or disease, or other severe stress. Of particuIar interest was the association of a relativeIy miId upper respiratory infection compIicated by the appearance of an acute uIcer. There were eight such cases, and in six of these there was bIeeding. Most of the patients (thirty-three) in the PortIand series were treated nonsurgicaIIy. Twenty-nine of these did weI1. Six patients were operated on. Three had cIosure of perforation. One had pyIoropIasty and vagotomy. One had resection and vagotomy. One had suturing of the bIeeding vessel. There was no operative mortality in this smaI1 series. AI1 have done we11 postoperativeIy. It may be worth stressing that microsections of uIcers in neonata1 and infantiIe patients show an acute process with IittIe ceIIuIar reaction, no bacteria1 invasion and no evidence of heaIing. These patients present as emergencies either because of perforation or severe hemorrhage. It is significant that onIy two cases of massive bIeeding from peptic uIcer in chiIdren under one year of age, foIIowed by recovery, have been reported. Both of these chiIdren were treated surgicaIIy. I wouId Iike to ask Doctors Leix and Greaney if their five infants with hemorrhage, who recovered without operation, had massive or onIy miId hemorrhage. FinaIIy, I wish to commend the authors for the thorough study of their sixty-eight cases. It was a pIeasure to read and to hear their paper. HARRY E. PETERS, JR. (OakIand, CaIif.): We have a modest number of cases to report from Children’s HospitaI in the East Bay, and not to
in aduIts is of seeks knowlinfancy and
REFERENCES I. CRWEILHIER, J. Anatomie Pathologique du Corps Humain. Paris, 1829. J. B. BarhEre. Vol. 2, p. 6. 2. RAMOS, A. R., KORSNER, J. B. and PALMER, W. L. Peptic ulcer in children. J. Dis. Child., 99: 135. 1960. 3. GUTHRIE, K. J. Peptic uIcer in infancy and chiIdhood with a review of the Iiterature. Arch. Dis. Cbildbood, 17: 82, 1942. 4. CUSHING, H. Peptic uIcers and the interbrain. surg. Gynec. e? -Obst., 45: 134, 1932. 5. ALLEN. J. G.. HARKINS. H. N.. MOYER. C. A. and RHO&J: E. Surgery, Principles and Practice, p. 640. PhiIadeIphia, 1957. J. B. Lippincott Co. 6. MILLER, R. A. Observations on the gastric acidity during the first month of Iife. Arcb.rDis. Cbildbood, 16: 22, 1941. 7. SHAFFER, A. J. Diseases of the Newborn. PhiIadeIphia. 1960. W. B. Saunders Co. 8. BELL, D. M. Perforated duodena1 uIcer in chiIdren. Lancet, 2: 810, 1953. 9. BRA~TON, D. and NORRIS, W. J. GastrointestinaI hemorrhage in infancy and childhood. J. A. M. A., 15;: 668, rg52.IO. MARTIN. F. J. and SAUNDERS. H. F. Gastric ulcer in childhood. Radiology, 55:‘728, 1955. II. FISHER, J. H. DuodenaI ulcers in infants. Am. J. Dis. Cbild., 79: 50, 1950. 12. KENNEDY, R. L. Peptic ulcer in chiIdren. J. Pediat., 2: 641, 1933. 13. ABRAMSON, D. W. and FOSTON, M. J. Gastric perforation in the newborn. J. Dis. Child., 94: 252, 1957.
14. CASTLETON, K. B. and HATCH, F. F. Idiopathic
perforation of the stomach in the newborn. Arch.
&rg.,
76: 874,
1958.
BIRD. C. E.. LIMPER. M. A. and MAYER. J. M. Surgery in peptic uIceration in infants and chiIdren. Ann. Surg., I 14: 526, 1941. 16. MOORE, 0. M. Peptic uIcer in chiIdren. Canad. M. A. J., 44: 462, 1941. ‘5.
DISCUSSION JOSEPH W. NADAL
(PortIand, Ore.): During the past twenty years there has been increasing interest in peptic uIcer in infants and chiIdren. This is evidenced by the growing:voIume of Iiterature on the subject. Even Newsweek devoted severa coIumns to it just a few years ago. No individua1 physician is IikeIy to encounter many infants and chiIdren with peptic uIcer because of its reIative infrequency in these age groups. In fact, after I was asked to discuss the paper by Doctors Leix and Greeney, I quizzed severa PortIand gastroenteroIogists, pediatricians 182
Peptic UIcer in Infancy and ChiIdhood bring up the issue as to whether Iife in the South is Iess uIcerogenic than it is in the Bay Area, I wouId Iike to show you some of the figures that we have. We have had a tota of eighty-four cases with distribution as noted. Fifty-six per cent were boys and 44 per cent were girIs. I did not break it down into those under the age of one year. Under the age of four there were Ig per cent, and over the age of four there were 81 per cent. ExcIuding those perforations in newborn infants, al1 of the uIcers in this group were duodena1. I might add that fifty of the tota series have been diagnosed radioIogicaIIy in the Iast seven years; and of these, two-thirds have had a crater demonstrated. In others, due to bulb deformity or irritabiIity (often evident on repeat roentgenograms), the diagnosis of an uIcer was made. The incidence in this group of perforations was 4.7 per cent, just four of a tota of eighty-four. With hemorrhage, there were twenty-one, or 25 per cent of the whoIe group; the distribution, thirteen boys and eight girIs. Of the boys, nine presented with hematemesis and four presented either with meIena or hematochetia. In the femaIe group, four presented with hematemesis, and four with meIena or hematochezia. There were other associated conditions. It might be of interest to note, in view of the fact that it has been postuIated that chiIdren with pyIoric stenosis may have an ulcerogenic diathesis; in this group, there were two such instances. There was aIso one with a severe burn, one was a hemophihac and one had cystic fibrosis. In this tota group which we have, a11 from Children’s HospitaI, only six have been operated on. Four were operated on because of acute perforations; one had expIoratory surgery because of meIena with presumptive indications of MeckeI’s diverticuIum, but none was found. OnIy one chiId who was bIeeding required emergency surgery; a gastric resection was performed. There was no mortality in the bIeeding group. On the basis of our series, we believe that conservative management has been successful in those who have presented with hemorrhage. MURRAY L. JOHNSON (Tacoma, Wash.): I thought it would be rather interesting to take a little different approach to this subject and review, instead of the experiences primariIy in the hospitals, the experiences of a community. Coming, as I do, from a reIativeIy smaI1 community, it is not too diffrcuIt to get an accurate cross-section of what is going on in the general population. I did much as the essayists mentioned, surveying the one to fifteen age group, from pediatricians, radiologists and surgeons. Of five pediatricians who constitute over 50 per cent of our active pediatric practice in Tacoma, a11 had seen one or more cases of peptic ulcer, but onIy one reported
any Iarge number; he stated that he had seen tweIve to fifteen cases. However, he said only four of these were proved radioIogicaIIy. One went to surgery. It is of interest that one genera1 practitioner saw three radioIogicaIIy proved peptic ulcers in chiIdren in Iess than two years. Five radiologists were surveyed, two-thirds of the specialists in this category. One, our most active radiologist, reported ten cases seen in the last ten years. I reviewed some of his records, and most of these are Iisted as a rather minima1 thing, simply a “fleck” persisting in the duodena1 100~. Another radioIogist reported he had seen between five and ten. Three of the radioIogists, however, have been in practice over ten years and have seen none in their entire practice. I talked to ten of our Board, qualified surgeons, who had been in practice an average of ten years or more, which wouId indicate over IOO years of surgica1 practice. Six of these had never seen peptic ulcers in children in their own practice. TWO of these mentioned that during surgica1 residency they had seen newborn infants with perforations. This was not in our community. Five patients were seen by four surgeons and operated upon. Four of these were for bleeding; one was nonresponsive to medica management. In summary, therefore, I wouId say that peptic uIcer must be more common than many realize. Its occurrence depends on the accuracy of diagnosis. Some radioIogists pay particuIar attention to this disease and make many more diagnoses. CertainIy from the surgical aspect it is a rare condition. ARTHUR J. HUNNICUTT (OakIand, CaIif.): In our Alameda County Hospital, we had a ten year old boy who iIIustrated an interesting sequence of events. He came in with a fractured femur foIIowing an auto accident. The femur showed poor healing and the orthopedist beIieved it was on the way to nonunion. In the course of this, the boy vomited bIood. GastrointestinaI series showed a duodenal uIcer. A few days Iater I removed an adenoma of the parathyroid; the ulcer and the fracture heaIed promptIy. I mention this to aIert us to think about the possibiIity of parathyroid adenoma in peptic ulcer disease. EDWARD M. GREANEY, JR. (cIosing): I would Iike to thank the discussants for their kind appraisaI of our work, and to answer Dr. NadaI by saying that the five chiIdren who did recover had In other words, we conmuItipIe transfusions. sidered them to be massive bIeeders. To Dr. Peters’ statements, I take some exception for the folIowing reasons: In our surgica1 experience in these twelve children at the two hospitaIs, we had five with suture Iigatures, two pyforoplasties, and so forth. There were three deaths in this group. 183
Leix and Greaney The mortality rate was 25 per cent, but it is to be emphasized that three of these tweIve children represented surgica1 faiIures, and were done on moribund chiIdren in whom medica measures had faiIed. We would Iike to stress that in one of the so-caIIed medicaIIy treated cases a chiId received 1,100 cc. of blood. The chiId weighed seventeen pounds. This is carrying conservatism too far, we beIieve, when a simple suture Iigature of the bIeeding point in an infant one year or under couId be done with a negIigibIe mortaIity. For example, two of the patients at the County HospitaI were decIared to be too iI to have surgery whiIe they were bIeeding. When the uIcer perforated, they were accepted as surgica1 candidates, and one of them was saved. In concIusion, then, when we went over this
184
series of cases it seemed cIear to us that one year of age or under, most of these infants had some stress situation accounting for the bleeding episodes or the episode that Ied to the diagnosis. In diagnosis under one year of age, Dr. Johnson brings up a point that a radiologist had not seen an uIcer in a chiId under one year of age. Dr. Mikity at Genera1 HospitaI did 450 gastrointestina1 series in a year and a half to perfect this technic; thus, there is a direct reIationship to the amount of experience the radioIogist has. Over a year of age, if the uIcer is chronic, it probabIy shouId be treated much as in an aduIt, if it is not a simpIe stress uIcer. We have had a few of this type; vagotomy and pyIoropIasty is our choice of operation when such becomes necessary.
VER A CENTURY ago, a French pathoIogist J. CruveiIhier [I] described autopsy fmdings in three infants with muItipIe gastric uIcers. Since then, sporadic reports have been pubhshed concerning peptic uIcer occurring during infancy and chiIdhood. In 1959 Ramos, Kirsner and Palmer [2], in an exceIIent review, reported over 500 cases in the Iiterature and added thirty-two cases of their own chieffy in the oIder age group. Guthrie [3] in 1942 emphasized peptic uIcer as a cause of death during infancy. Our interest in this subject was stimuIated by our experience with operative and other cases seen on the wards of the Los AngeIes ChiIdrens Hospital and the Los AngeIes County Genera1 HospitaI.
0
Culi;fornia
roentgenograms, operation, or autopsy, the case was incIuded in the series. A few were outpatients, but the majority were cared for in the hospitaIs. CLASSIFICATION
In an effort to simpIify anaIysis of the materia1, we have divided our tota number of patients into two age groups, these are, (I) under tweIve months, and (2) one to fifteen years. There were twenty-nine cases in the Iess than a year group and thirty-nine between the ages of one and fifteen. (TabIe I.) Fortytwo were maIe patients and twenty-six were femaIe patients. In the infant group, the ratio was seventeen to twelve. (TabIe II.) In sixtyeight cases, thirty-three were gastric and thirty-five &odenaI. As the picture unfoIds, it is seen that the very young have acute uIcer (singIe or muItipIe) compIicated by hemorrhage or perforation which often foIIows a serious iIIness. After one year of Iife, no year has more than seven cases. As the age increases, a preceding serious iIIness is noted in diminishing frequency, unti1 the age of six and beyond when it is seen to be the ruIe rather than the exception for the uIcer to
SOURCE OF MATERIAL Our series of sixty-eight cases was compiIed from the records of the ChiIdrens HospitaI of Los AngeIes (thirty cases in twenty-five years) and the Los AngeIes County Genera1 HospitaI (thirty-eight cases in thirteen years). Patients operated upon because of compIicating factors are described in greater detai1 than are the others. If the diagnosis was estabIished by
TABLE II SEX INCIDENCE Sex Age
TABLE I AGE INCIDENCE
Data
Male No. of Cases Less than one year.. Over one year..
Under one year of age.. Overoneyearofage..................
Female
...
... .. . . . .. ....
29 TotaI...........................
39
I73
American
Journal of Surgery,
-~
17 25
I2 14
42
26
Volume ro6, Aupst 1963
Leix and
Greaney
TABLE PEPTIC
(AGE
AgeandSex
ULCER
I
Bith Weight if Recorded
AsmciakdIllness
IN
ONE
III
INFANCY DAY
AND
TO ONE
-
Operative Prooedun: (for ulcer)
!
CHILDHOOD
YEAR)
-
Ulcer Site
-
DUOdunal
(
I
-
fIemor.- I ‘erfora,.
Remarks
Result
rhage
tion
Ohstrub tion
x
.. .
..
__ One day, F One day, M Two day. F Two day, F Three day, M Six day, Mj Ten day, M Twelve day, F Fourteen day, M Fifteen day, M Twenty-one day, M Twenty-five day, M Five week, F Six week, M
10 pound, Erythroblastosis fetalii 7 Ounce Erythmblssimis fetalis ... skull fracture 6 pound, Linear 9 O”“CRS 8 pound, Ulcer (1 cm.) Boftpalate 2 ounce Erythroblastosis fetalis 8 pound 5 pound, Jaundice (unknown cause) 3 o”“~q pneumonia,kernicterus Urologic congenitalanomaly ... Meningitis 1.. Encephalitis, pneumonia ... 4 pound, Sepaia 8 ounces Sepsis, bronchopneumonia ..
5 pound, 2 ounce 5 pound, 4 ounoe
Six week, F Six week. M Seven week, M
5 pound 5 pound
x
None NO”l?
x x
x x
None
x
x
None None
None None
Vomiting (since birth)
Pyloroplasty
Diarrhea
None
x
Recovered Death Death
. ..
x
t.. . .
x x x
x . .. x .
x
...
x
x
Death Death Death Death Death
x
x
Death
x
Death
x
x
Suture ligation, pyloroplasty None NO”8
x x x -
elteroidtherapy
Death
x x
x x
x
x x
x x
x
x
x
x
x
x x
x x
Recovered Death
x
x
Death
x
x
RPcovered I Iypernatremis (Na. 172) Death Death . .. Death
x
NOnO Pyloroplssty, suture ligation, vagotomy None
..
Recovered
x
Diseases of pancreas, pneu- None monis None Diarrhea Closure, duodenal Bronchopneumonis Ulcer None Acute pyelonephritis None Diarrhea
.
Death
.
x x x x x x
Pyloric stenasia
.. 4 pound, 5 O”“c.?S 5 pound, Bronchopneumonia,dehyTwo mo., M 13 Ounce dration None know” Two “10.. M 4 pound, Failure to thrive Three mo., M 11 ounce Diarrhea, coryaa Three “10.. F None known Three sod one-half mo.. F Congenitalheart disease Four mo.. M with failure 6 pound, Gangrene of toes due to Fourmo., M saline lysis 9 oune? Cerebralvascularthrombosis Fivem.. M Periarteriti nodoaa . Tenmo., F kseptic meningitis . Oneyr.. F Two mo., F Two mo., F
None
Death Recovered
.
Death Death
.
Death Death Death
x
lo weight gain
P
in three mo.
x x x
. -
. .
-
-
.
-
NOTE:Total of twenty-nine patient+ twenty-two deaths (one year of age and under), and B mortality rate of 76 per cent.
There are many factors, however, which may pIay a roIe in the cause. These are: prematurity, infection, intracrania1 hemorrhage, intracrania1 neopIasm, generaIized trauma, IocaI trauma (as by nasogastric tube) cutaneous burns, and so forth, (TabIes v and VI.) It is apparent that many of these factors produce stress. Stress may cuIminate in acute peptic uIceration. (TabIe VI.) CIassicaIIy, two mechanisms of stress uIcer are those described by CurIing in 1842, and Cushing in 1932. Both are beIieved to invoIve stimuIation of the hypothaImus [5].
conform to the chronic aduIt type. (TabIes III and IV.) Other writers have used three groups: birth to four weeks; four weeks to one year; and over one year, or four groups: (I) neonata1, birth to four weeks; (2) infancy, four weeks to two years; (3) preschoo1 age, three to five years; and (4) schoo1 age, six to fifteen years. CAUSE
The basic cause of peptic uIceration in infancy and childhood, as in aduIts, is unknown. I74
Peptic
UIcer in Infancy TABLE
PEPTIC
ULCER
(AGES:
IN
ONE
Associated Illness
IV
INFANCY ~0
AND
FIFTEEN
-
I
AgeandSex
and ChiIdhood
ulcer
Operative Frocedure (foru1cer)
-
CHILDHOOD
YEARS)
sitm
-
I
Complication -7
3&liO
Results Per-
Duodenal
Remarks
3bStIUc-
tion
__
Thirteen ma., M
Ingestion, shoe polish
Fifteenmo., F Nineteen mo.. M Twoyr.. M Two yr.. F
None known None known None known Waterburns(36 Per cent)
Two yr., M Two and one-half W., F
Iron deficiency anemia Pneumonja preceded lint bleeding episode: second and third bleeding epi. nodes without preceding illness Brain tumor l”, 2”, 3’burea 60 Per cent: Specific diarrhea Mea&a encephalitis Left diaphragmatic hernia
Three yr., M Three yr., F Three yr., F Fouryr.,M Four and one-half yr., F Five yr.,
M Five yr., M Fivev., M Fiveyr., F Six p., M Six yr.. M Six yr., M Seven yr., M Eight yr., F Eight yr., M Eight and one-half yryr.9 M Eight and onehalf fl.3 F Nineyr., F Nine p.. M Eleven yr.. F Eleven yr., M Eleven yr., M Eleven andone-half yrr., F Twelve yr., M Twelve yr., M Twelve yr., M Twelve yr., M Twelve yr., M Twelve yr., M Twelve yr., F Thirteen or., F Fourteen yr.. M
*
. .*
Suture ligation.pylorc PMY None Pyloroplaety. wbgotomJ pyloropla8ty Ckaure, perforated UlCer None None
x
. . .
If
x
. . .
.*. ...
x x
x x
... .
. . .
None None None None Gsstrectomy
x x x x x
x . ...
x .. x x ...
.
... . .. . .. .
I[
x x
x
x
x
.. .
x x ...
. . .
x
x ...
I
x
Mumps Acute pharyngitis, epiglottitis None known Noneknown Brain tumor None known
None None
... x
Suture ligation None None None
. .. x
Meningitis Meningitis, H-Influenza Noneknown None known
None None None N0Ile
x x ... x
Car accident
Suture ligation
Pneumonia None known Chicken pox, encephalitis None known None known None known Addison’s disease None known &ho& Collagen disease Aneurysm sarcoma None known None known None known None known
x ...
. . .
* . . . .
x
. ..
..I
x
I..
.
I(
. ... ... ...
Death Death Recovery Recovery
x
. **
x
...
None None None None None None
x ... ...
*.. x x
... ... ..
x ... ...
I
. . x ... x x
x
...
None None None None None Closure of ulcer None None None None
x ...
. *. x ...
... .. ... . ... x x
x ... x .. .
. . .
.
.
.
.
.
.
.
.
.
..a
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
x x x ... . .
I
Recovery
s..
I..
.
.
.
.
.
.
.
.
.
.
.
.
.
. . .
...
. . .
Recovery Death
x
. . .
.
.
.
Alao avitaminceis Bleeding episodea at eleven mo., fourteen mo. and two andonehalf y+.
Death Death Death Death Recovery
Recovery Recovery Death Recovery
. . ... ... ...
... .. x . x x
. . .
Recovery Recovery
x ...
x x x
x
.
... ..
IL
x
. . .
. . .
. .*. x
I.
I
.
. . .
x x ... x
Recovery Steroid therapy
Trseheostomy
.. . Gastrointestinal bleeding at four and onehalf yr. of age
Splenectomy
Death . ReCOVery 3teroid therapy Death R.XOVerY Recovery Recovery Death Recovery D&b Death Death Death Recovely Recovery Recovery Recovery
... Steroid therapy .. ...
-
NOTEI:Total of thirty-nine patients; deaths. fifteen; and mortality rate of 37.6 Per cent
cause. In severa patients in our group acute Aeration with hemorrhage deveIoped after the administration of steroids. In TabIe III it is shown that onIy two of twenty-eight infants under the age of one year had no stress situation associated with peptic uIceration. Each of these patients had acute uker as determined by autopsy. TabIe IV shows no stress situation associated
We were particuIarIy impressed with the roIe of associated iIIness in the entire infant group and in about haIf of the younger chiIdren as weI1. It is the rare exception when a stress situation of severity such as meningitis, specific enteritis, pneumonia or sepsis does not immediateIy precede peptic uIcer which occurs in infancy. Steroid therapy is another factor in the ‘75
Leix and Greaney TABLE VII COMPLICATIONSIN PEPTIC ULCER
TABLE v BASIC CAUSE
No. of Cases
Cause
Stress ............................... Steroids. ............................ Unknown. ...........................
Hemorrhage............................... Perforation.. . Obstruction.. . . . . . Multiple compIications*.
43 5 20
* Ten were hemorrhage
with peptic uIceration in seventeen of thirtynine chiIdren between the ages of one and fourteen years. Beyond the age of six years, it was found that chronic peptic uIcer of the ad& type prevaiIed. In reference to the basic cause of uIcer in the newborn, the studies of R. A. MiIIer [6] in 1941 are of interest. He measured the fasting gastric juice in fifty norma babies during the first ten days of Iife and found the maximum average tota
acidity
in terms
N
of cc. ;
HCI per
100 cc.
Hypernatremia ...............
.
. . . .. .... .. ..
13
and perforation.
Awareness of the Iesion is invaIuabIe in the diagnosis of uIcer disease in this age category. The infant group presents the greater diffrcuIty as shown by the many whose diagnoses are made at autopsy. In nearIy every case, a compIication (TabIe VII) was the basis for suspecting the Iesion. The group over one year of age may show evidence of pyIoric stenosis or intractabiIity of pain and, as age increases, typica or atypica1 symptoms of chronic peptic uIcer appear. Appendicitis may be simuIated by perforated uIcer in young chiIdren as reported by Be11 [a]. The most common cause of massive intestina1 hemorrhage in infancy and chiIdhood is peptic uIceration in MeckeI’s diverticuIum [g]. TypicaIIy, the stoo1 is brick-red in coIor whiIe bIeeding from higher IeveIs is usuaIIy bIack. However, brisk bIeeding from the stomach or duodenum may be passed as red stoo1, and frequentIy hematemesis is absent. Therefore, in view of the increasing recorded incidence of gastric and duodenal uIceration, many of the bIeeders in whom abdomina1 expIoration reveaIed no MeckeI’s diverticuIum may have had uIcer of the stomach or duodenum. The ski11 and interest of the radioIogist is of prime importance. Great patience and experience are heIpfu1 in demonstrating a gastric or
No. of Cases
.. .
32 g 2
DIAGNOSIS
TABLE VI STRESS SITUATION
Infection. ..................... Central nervous system ......... Trauma ....................... Terminal event. ................ Erythroblastosis fetaIis. ....... CoIlagen vascular disease. ..... Genitourinary anomafy........ Cirrhosis. ................... Cardiac ..................... Addison’s disease. ............ Anemia. .................... PyIoric stenosis. .............
.
pIastic gastric mucosa is noted in a newborn chiId of average weight. Most incidence figures of prematurity (Iess than 5.5 pounds or 2,500 gm.) range between 7 and I I per cent [7]. ApproximateIy 50 per cent of the infants under one year, in whom birth weights were recorded in our study, were premature. SeveraI references in the Iiterature [6,7] note this possibIe cause factor. It is generaIIy beIieved that prematurity predisposes to menta1 and physica retardation [7].
to be 40 on the day of birth, dropping to 25 on the third day and to 16 on the seventh day. Other tests showed that acidity remained beIow 20 for the fn-st month of Iife. He aIso determined the infIuence of birth weight, demonstrating that the heavier an infant at birth, the more IikeIy it is to have a more perfectIy deveIoped gastric mucous membrane (histoIogic comparison) and potent gastric secretion. Premature babies reveaIed gastric mucous membrane of primitive character with shaIIow IooseIy packed gIands and reIativeIy few acid-producing ceIIs. OccasionaIIy, hypo-
Data
No.
Comphcation
16 IO 5 I4 4 3 I
I I I I I
I 176
Peptic
UIcer in Infancy and ChiIdhood
TABLE VIII TREATMENT
FOR
PEPTIC
ULCER
No. of Cases
Treatment
MedicaI
26 I2 30
. .
Surgical............................. None...............................
duodenal uker in an infant. FortunateIy, we have had the heIp of radioIogists who meet these requirements. As an exampIe, a duodena1 uIcer crater was demonstrated by barium or gastrografin in eight infants in our series, the youngest onIy five days aid, the oIdest four months of age. Hemorrhage was the compIication that initiated study in al1 of these babies. (Fig. I .) MEDICAL TREATMENT
FIG. I. Roentgenogram of an uIcer crater.
In our series, twenty patients were treated by the usua1 medica means, and tweIve were treated surgicaIIy. Thirty received no treatment specifkalIy directed to the uIcer, only support and treatment of the underIying disease. The resuIts of medica treatment were recovery in seventeen patients with three deaths. (TabIes VIII and IX.) Surgical resuIts are considered separateIy.
Physical examination reveaIed a we11 deveIoped, we11 nourished chiId in no distress exhibiting a wet cough. HemogIobin, 10.4 grams per cent; red bIood ceI1 count, 5.2 per cu. mm.; pIateIets, 310,000 per cu. mm.; white bIood cell count, 8,750 per cu. mm.; differential, normaI. Two upper gastrointestina series were done on JuIy 28 and 31. The Iirst showed irreguIarity of the duodena1 cap and the second, faiIure of the duodenal cap to Ii11weI1. The child was discharged with a diagnosis of hematemesis, secondary to vomiting. He was readmitted on August I I because of vomiting of food and Ioss of weight (8 pounds). On admission, he was lethargic and dehydrated, but otherwise the physica examination was not remarkabIe. He continued to vomit; and, on August 17, a barium study showed compIete pyIoric obstruction. Vagotomy and pyIoropIasty were performed under genera1 anesthesia. His postoperative course was uneventful and he was discharged on the seventh postoperative day.
OPERATIVE EXPERIENCE
The foIIowing tweIve cases are summarized briefly to emphasize the operative experience in the series: CASE I (zo8g52). A nineteen month old Caucasian boy entered the hospita1 for the frrst time on JuIy 21, 1961, with a history of vomiting food and cIotted blood for two days. The chiId was premature at birth, weighing 5 pounds, 2 ounces. Thereafter his deveIopment was not remarkabIe. Two weeks prior to admission, he had a cold which Iasted for one week.
Comment. SurgicaI treatment was advised and performed after a reasonabIe tria1 of medica management.
TABLE IX MEDICAL
TREATMENT
IN
PEPTIC
Data
ULCER
No.
A tweIve year oId boy had CASE II (176209). been under treatment for Ewing’s sarcoma of the
Per cent
ilium, pubis and left femur and biIatera1 hydronephrosis due to metastases. He had received Actinomycin-D and x-ray therapy, and had been on intermittent steroid therapy. He was currentIy receiving Prednisone,@’ 45 mg., four days per week. For severa weeks, he had compiained of epigastric
_____ TotaI cases.. . . Total deaths.. . . MortaIity
. .
. . .
20
.
3 . .
... 15
.
I77
Leix and Greaney pain not reIated to mea1.s and, for the past three days, he had increased epigastric pain with radiation to the back. On examination, he had pain and tenderness in the epigastrium with rebound tenderness. BoweI sounds were normal. An upper gastrointestina1 series revealed an uIcer on the posterior aspect of the stomach. He had severa episodes of hematemesis after admission, cuIminating in operation for uncontroIIed bIeeding. The uIcer was treated by simpIe suture. After a stormy postoperative course, the child was discharged. One year Iater, he died at home. No autopsy was performed. Comment. formed.
Surgery
was
expeditiousIy
per-
CASE III (160822). A two year oId gir1 had received hot water burns of 2’ and 3’ invoIving 35 per cent of the body surface. On the day of admission, she vomited “coffee-ground” materia1. Three days after admission, she passed tarry stooIs and her hemogtobin feI1 from 14 gm. to 6 gm. She continued bIeeding intermittentIy for the next seventeen days, receiving numerous bIood transfusions, her hemogIobin ranging from a high of 16 gm. to a Iow of 5 gm. twenty-four days after admission, a portabIe roentgenogram showed free intraperitoneal air. Operation was performed and a smaI1 perforation of the anterior gastric waI1 was cIosed. An uIcer I cm. diameter was responsibIe for the perforation and there was absence of inffammatory process. Her postoperative course was stormy, requiring severa transfusions, but she toIerated food on the fourth postoperative day. She had wound and urinary tract infection. Skin grafting was necessary. The chiId was discharged two and a haIf months after admission.
Comment. The deIay in operation was justified by serious extensive burns, aIthough, in retrospect, an earIier attack on the massive bIeeding wouId probabIy have prevented the added insuIt of perforation in this seriousIy iI chiId. CASE IV (187762). An eight and one-half year oId Negro boy underwent spIenectomy for traumatic rupture of the spIeen. Transfusions were required. He aIso had a fracture of the uIna. His immediate postoperative course was compIicated by smaI1 bowe1 obstruction which was treated with intubation. On the sixth postoperative day, the obstruction was reIieved; the chiId had hematemesis requiring transfusion and reoperation. A smaI1 ulcer on the posterior waI1 of the stomach was suture-Iigated through a gastrostomy. Postoperative course was uneventfu1.
SurgicaI treatment Comment. tuted as soon as the seriousness Ioss became apparent.
was instiof the bIood
CASE v (197406). A four and one-haIf year oId girI had a transabdomina1 repair of a diaphragmatic hernia of the BochdaIek type. She began to bIeed on the third postoperative day, requiring transfusions and reoperation on the fifth postoperative day. A subtotal gastric resection was performed for a Iarge postbuIbar uIcer. A stick-tie of the uIcer with a 40 per cent BiIIroth II reconstruction incIuding a Hofmeister anterior gastrojejunostomy was performed. The common biIe duct was catheterized for identification of the ampuIIa of Vater. BIeeding ceased. Twenty days Iater the gastrojejunostomy was reconstructed because of stoma1 obstruction. She has since done weII.
SurgicaI attack Comment. point was earIy and energetic.
on the bIeeding
CASE VI (191~75-05). A seven week oId Japanese boy, weighing 4 pounds at birth, was admitted to the hospital. Weight on admission was 5 pounds, 3 ounces. A respiratory infection had deveIoped two days previousIy. Upon examination, he had acute respiratory distress with rapid breathing, expiratory grunt, flaring nostriIs, and subcosta1 retraction. His temperature was 97’F.; puIse rate, 150; and respirations 60 per minute. There were raIes throughout his chest. He had a grand ma1 seizure during examination. FoIIowing intensive treatment for pneumonia, he improved niceIy for five days and then had meIena for the first time. His hemogIobin, which had been 14.0 gm. per cent, feII to 8.5 gm. per cent and then to 7.0 gm. per cent. He was transfused with 50 cc. of bIood. The surgical consuItant made a diagnosis of probable duodena1 uIcer with hemorrhage and advised observation. On the foIlowing day, the radioIogist demonstrated an uIcer crater in the duodena1 buIb. During the next three days, the baby bIed intermittently, then evidence of peritonitis deveIoped. Roentgenograms showed gas under the diaphragm. Operation under genera1 anesthesia reveaIed a I cm. in diameter perforation of an uIcer on the antero-superior aspect of the first portion of the duodenum. The perforation was cIosed with 4-o chromic and 4-o silk sutures. On the foIIowing day, his genera1 condition was good; hemogIobin was 12.5 gm. per cent and eIectroIyte determinations were normaI. Six days after operation wound infection was noted. On the ninth postoperative day, he had wound dehiscence which was treated by adhesive:strapping. Two weeks Iater he was discharged from the hospita1. Six months Iater,
Peptic UIcer in Infancy and ChiIdhood at a fotlow-up visit, study showed norma duodenum. (Fig. 2.)
an upper esophagus,
gastrointestina1 stomach and
Comment. At the time of surgical cons&ation, the hemogIobin had falIen from 14 to 7 gm. per cent. After transfusion, bIeeding continued for three days when perforation occurred and operation was performed. He probabIy shouId have been operated upon earher. CASE VII (191-36-48). A two month oId baby had Iost weight steadiIy from his birth weight of 5 pounds, 13 ounces to his present weight of 5 pounds, o ounces. He had taken formuIa and cerea1 we11 and had no vomiting or diarrhea. Examination of the infant revealed emaciation and dehydration. He had biIatera1 raIes and a chest fiIm showed density in the middIe Iobe of the right lung. On the day after admission, he passed dark blood rectaIIy. His hemogIobin was 11.0 gm. per cent. He was transfused with 25 cc. bIood. On the foIIowing day, an upper gastrointestina1 series showed a 2 mm. crater in the duodena1 bulb. He continued to bIeed for four days requiring 225 cc. of bIood. The surgica1 consultant advised continued medica management incIuding fresh bIood, Vitamin K, and vigorous antacid therapy. He then stopped bIeeding for four days and made good progress. On the tenth hospita1 day, vomiting and diarrhea without blood deveIoped. On the foIIowing day, he had profuse meIena. He was then operated upon with findings of a Iarge ulcer in the posterior waI1 of the first part of the duodenum. A stick-tie was placed in the uIcer base and the mucosa was sutured over the uIcer. A pyIoropIasty was constructed. His postoperative course was poor. He required two more bIood transfusions of 25 cc. each and continued to pass dark red stooIs. He died on the second postoperative day. Autopsy showed bronchopneumonia in the Iower Iobe of the right lung and ateIectasis of the Ieft Iower lobe. No other uIcer than the one treated at operation was found.
FIG. 2. Roentgenogram
showing air in rib carriage.
times “coffee-ground,” and Iost ten pounds in weight. After admission, he continued to vomit forcefuIIy even after taking clear Iiquids onIy, and hypochIoremic aIkaIosis deveIoped. Hematemesis and meIena were noted with a faI1 in hemogIobin from I 1.0 gm. to 8.3 gm. per cent. Upper gastrointestina1 series showed pyIoric obstruction. The radioIogist’s impression incIuded hypertrophic pyIoric stenosis, annuIar pancreas, or anomaIous bands, or reduplication of the upper part of smaI1 bowe1. After preparation, operation was performed with findings of a I cm. in diameter uIcer in the pyIoric canaI. There was edema of the pyIorus and the uIcer base was bIeeding. The ulcer was suture-Iigated, and a Heineke-Mikulicz pyIoropIasty was performed. Recovery was uneventfu1 and the child was discharged on the eighth postoperative day. In 1959, five years after the operation, the patient was deveIoping weI1, and had no uIcer symptoms.
Comment. This 5 pound baby had required 225 cc. bIood; duodena1 uIcer had been demonstrated by roentgenogram when he was seen by the surgical consuItant. He shouId have been operated upon at that time, rather than six days Iater when he had another massive hemorrhage. CASE VIII (96647). A twenty-four month old Caucasian boy was perfectIy we11 unti1 three weeks prior to entry when he vomited food streaked with bIood. Thereafter he vomited frequentIy, some-
Comment. SurgicaI and performed after medica management. I79
treatment was advised a reasonable tria1 of
Leix
and Greaney Comment. Surgery was advised because of obstruction despite negative x-ray findings, except for spasm of the pyIorus. ExpIanation of this child’s death is not cIearIy expIained on either the operative or autopsy findings.
CASE IX (220667). A five year oId Caucasian boy was admitted to the hospita1 with a chief CompIaint of joint pain for approximateIy two weeks. He had been seen one week prior to admission by his physician with the compIaint of stomach pain, periumbilical, associated with vomiting. There was no bIood in the emesis. Vomiting persisted over the next twenty-four hours. When admitted to the hospita1, his temperature was IOI’F.; hemoglobin, 14.3 gm. per cent; and white bIood ceI1 count, I 1,650. No melena was evident. On the second day of hospitaIization he had a considerabIe number of bIoody emeses and bloody bowe1 movements. HemogIobin feI1 to 9.8 gm. per cent; he was transfused with 1,250 cc. of whoIe bIood. BIood loss continued and the child was taken to the operating room without roentgenographic diagnosis. At surgery, the stomach and intestine were found to be fiIIed with bIood, and there was great diffrcuIty in locating the bIeeding point. A postbuIbar uIcer Iocated cIose to the ampuIIa of Vater was finaIIy identified and the bIeeding point was suture-Iigated. Gastrostomy was performed. No further bIeeding occurred; the patient was discharged from the hospita1 seventeen days after the operation. Subsequent x-ray examinations have not reveaIed any ulceration.
CASE XI (204-26-13). A thirteen months old Negro boy who had weighed 4 pounds, 7 ounces at birth entered the hospital on September 25, following shoe poIish ingestion. He was acutely iI1, in shock, and dehydrated, dyspneic and anemic (hemogIobin of 5 gm. per cent couId not be explained on basis of poisoning). Immediate treatment incIuded cut-down, pIasma, eIectroIytes and antibiotics. Because of his poor genera1 condition and pneumonitis tracheostomy was performed. On the foIlowing day, SoIu-cortef@ was started. On September 30 (five days after admission) hematochezia was noted. GastrointestinaI bIeeding resuIted in numerous episodes of shock requiring in excess of I, IOO cc. of bIood, unti1 a duodenal uIcer was shown by roentgenograms on October 2; evidence of perforation was noted a few hours Iater. He was taken to surgery and operation resulted in cIosure of perforation, suture-Iigation of the bIeeding point, pyIoropIasty and gastrostomy. SoIucortef was given postoperativeIy (25 mg. every eight hours for the first day, IO mg. every eight hours for the second day, and 5 mg. every eight hours for the third and fourth days), and then stopped. AIthough convaIescence was marked by dermatitis, bronchitis and sIow progress, he required no more bIood and was discharged on November IO (thirty-nine days postoperative), in good condition.
EarIy surgery was performed Comment. without roentgenographic diagnosis because of massive hemorrhage in the gastrointestina1 tract. CASE x (173568). A five week oId infant, one of identica1 twins, weighed 5 pounds, 2 ounces at birth. She was admitted because of severe vomiting and dehydration. After birth, the patient was kept in the hospita1 for two weeks because of poor weight gain and vomiting. She was discharged, but because of the same symptoms, was rehospitaIized. At that time a gastrointestina1 series reveaIed pyIorospasm. Three days before transfer here, severe cyanotic speIIs deveIoped. She received Hydrocortisone,@ IO mg. every tweIve hours. Upon admission, the infant appeared maInourished and acutely, chronicaIIy iI1. There was dehydration with CO2 - 34, and CI - 52. Gastric contraction waves were seen. Upper gastrointestinal series reveaIed pyIoro and antra1 spasm. A pyIoric tumor was feIt by severa examiners and expIoration was advised. SurgicaI findings were those of a constricted inflamed pyIoric ring with uIcer on the posterior waI1 of the pyIorus. A pyIoropIasty was performed. PostoperativeIy, the baby did poorIy in spite of a11 measures and died on the second postoperative day. Autopsy reveaIed ateIectasis and IobuIar hemorrhages, pyIoropIasty and duodena uIcer.
Comment. A thirteen month oId baby had numerous episodes of shock and received I, IOO cc. of bIood before diagnosis of duodena1 uIcer was made. Even then he wouId not have been operated upon except for perforation. CASE XII (142185). A three month oId Caucasian gir1 with a one day history of vomiting and tarry stoo1 was admitted to the hospita1. On admission, the infant was ashen-coIored and lethargic. HemogIobin on admission was 6.8 gm. per cent. Laboratory studies faiIed to revea1 any blood dyscrasia. She was treated with transfusions and her shock-Iike picture improved. A gastrointestina1 series reveaIed deformed duodenal bulb. During the first four days of hospitalization, improvement was noted, but gastrointestinal bIeeding was thought to persist. By the sixth hospita1 day, the patient’s condition deteriorated with convuIsions that were thought to be on a metaboIic intoxication basis. She was prepared for surgery and transfused again. At surgery, the infant’s 180
Peptic
UIcer in Infancy
and ChiIdhood TABLE x SURGICAL PROCEDURE IN PEPTIC ULCER
condition was precarious. ExpIoration reveared a large duodenal ulcer. The base was suture-Iigated, and a pyloropIasty and vagotomy performed. Her immediate postoperative course was stormy and, despite bIood, vasopressors, and supportive therapy, the infant expired six hours Iater.
Type
of
No.
Procedure
SutureIigature............................. PyIoropIasty.. . SimpIe closure. . Vagotomy and pyloropIasty..
Comment. There was a deIay in operation because the chiId’s condition was precarious. The diagnosis was made earIy, but the operation was performed Iate. (TabIes x, XI and XII.)
Gastric
s*
In summary, sixty-eight cases of peptic uIcer in infancy and chiIdhood are presented. The diagnosis was estabIished by roentgenograms, autopsy or operation. The charts were carefuIIy reviewed from the standpoint of age, sex incidence, precipitating factors, method of treatment and results. ParticuIar attention is given to operative experience in tweIve cases. DeIay in surgica1 treatment was obvious and unavoidabIe in twenty patients (ranging in age from three days to five years) whose perforated uIcers was not diagnosed unti1 autopsy. Two infants, seven weeks and thirteen months of age, survived closure of perforated ulcer diagnosed by roentgenograms. Each of these babies (Cases VI and XI) had adequate indication for operation because of massive hemorrhage and roentgenographic diagnosis of duodenal uIcer. Conservative treatment was advised in both cases by the surgica1 consuItant unti1 perforation had occurred. The thirteen month old infant had received I, IOO cc. of bIood. An exampIe of fata deIay in operative treatment is shown in Case XII, a three month oId infant who had meIena causing her hemogIobin to faI1 to 6 gm. per cent. Roentgenographic study indicated duodena1 ulcer. In spite of continued bIeeding, she was repeatedIy transfused for six days, then operated upon.
2 I
resection..
* Gastrostomy performed in three pyloroplasty performed in two patients.
SUMMARY
2 2
. .
patients
and
TABLE XI MORTALITY OF OPERATIVE CASES
Data
No.
Per cent
_F
.
TotaI operated on.. TotaI deaths*. . MortaEty.. ..
12
. .:
2;’
* Suture ligature, one; pyIoropIasty, one; and suture ligation, vagotomy and pyIoropIasty one. TABLE XII MORTALITY IN PEPTIC ULCER No.
Data
Per cent
~___ TotaI series.. Deaths........................... Mortality (per cent) .
68 37 53.6
3. Acute uIcer due to stress in susceptible individuals occurs more frequentIy than is generaIIy recognized. Diagnosis is suspected as a resuIt of ulcer compIications: hemorrhage, perforation and obstruction, in order of frequency. Diagnosis is estabIished by competent radioIogic study. Treatment is medica in most Too often, surgica1 treatment is instances. deIayed beyond the point of no return. 4. Chronic
CONCLUSIONS
peptic
uIcer
occurs more fre-
quentIy than acute uIcer or stress ulcer after the age of six years. Symptoms and findings in this group correIate cIoseIy with those in aduIts.
I. Sixty-eight cases of peptic uIceration in patients from one day to fifteen years of age have been reviewed. 2. The stress uIcer associated with acute major disease, the acute uIcer without associated major disease, and chronic uIcer are identified. A transition that occurs with advancing age at onset is apparent.
5. Suture Iigation of a bIeeding point or simpIe cIosure of perforation is the treatment of choice in acute uIceration. 6. Vagotomy and pyIoropIasty is the treatment of choice in chronic uIceration. 181
Leix and Greaney 7. We can estabIish no ruIes to dictate indications for operation, but we urge a more aggressive attitude on the part of surgeons. An understanding of the uIcer probIem great benefit to the surgeon who edge of peptic uIceration in chiIdhood.
and surgeons reIative to the number of infants and chiIdren they had seen with peptic ulcer. Most of these had had no personal experience with this probIem. FortunateIy, two of my PortIand friends, Dr. RusseII Gustavson and Dr. Richard Warrington, during the past year completed a study of this condition based, IargeIy, on records, over a tweIve year period, from Providence, EmanueI, St. Vincent, Good Samaritan, and the University of Oregon MedicaI SchooI hospitaIs. They discovered thirty-nine cases of peptic uIcer. Thirty-four of these were in the chiIdhood group; onIy five were in the infantiIe group. Otherwise their findings paraIIeIed cIoseIy those of Doctors Leix and Greaney. The sex incidence in the PortIand study was twenty-four boys to fifteen girIs (five to three ratio) compared to forty-two boys to twenty-six girIs (five to three ratio) in the study of Doctors Leix and Greaney. In the PortIand series thirty-six uIcers were duodena1 and three gastric. In both groups studied the compIications of hemorrhage and perforation were common. In the infantile group the first sign of an uIcer was usuaIIy the compIication of either perforation or bIeeding. In tweIve cases in the Portland series the ulcers were secondary to sepsis, major burns, centra1 nervous system trauma or disease, or other severe stress. Of particuIar interest was the association of a relativeIy miId upper respiratory infection compIicated by the appearance of an acute uIcer. There were eight such cases, and in six of these there was bIeeding. Most of the patients (thirty-three) in the PortIand series were treated nonsurgicaIIy. Twenty-nine of these did weI1. Six patients were operated on. Three had cIosure of perforation. One had pyIoropIasty and vagotomy. One had resection and vagotomy. One had suturing of the bIeeding vessel. There was no operative mortality in this smaI1 series. AI1 have done we11 postoperativeIy. It may be worth stressing that microsections of uIcers in neonata1 and infantiIe patients show an acute process with IittIe ceIIuIar reaction, no bacteria1 invasion and no evidence of heaIing. These patients present as emergencies either because of perforation or severe hemorrhage. It is significant that onIy two cases of massive bIeeding from peptic uIcer in chiIdren under one year of age, foIIowed by recovery, have been reported. Both of these chiIdren were treated surgicaIIy. I wouId Iike to ask Doctors Leix and Greaney if their five infants with hemorrhage, who recovered without operation, had massive or onIy miId hemorrhage. FinaIIy, I wish to commend the authors for the thorough study of their sixty-eight cases. It was a pIeasure to read and to hear their paper. HARRY E. PETERS, JR. (OakIand, CaIif.): We have a modest number of cases to report from Children’s HospitaI in the East Bay, and not to
in aduIts is of seeks knowlinfancy and
REFERENCES I. CRWEILHIER, J. Anatomie Pathologique du Corps Humain. Paris, 1829. J. B. BarhEre. Vol. 2, p. 6. 2. RAMOS, A. R., KORSNER, J. B. and PALMER, W. L. Peptic ulcer in children. J. Dis. Child., 99: 135. 1960. 3. GUTHRIE, K. J. Peptic uIcer in infancy and chiIdhood with a review of the Iiterature. Arch. Dis. Cbildbood, 17: 82, 1942. 4. CUSHING, H. Peptic uIcers and the interbrain. surg. Gynec. e? -Obst., 45: 134, 1932. 5. ALLEN. J. G.. HARKINS. H. N.. MOYER. C. A. and RHO&J: E. Surgery, Principles and Practice, p. 640. PhiIadeIphia, 1957. J. B. Lippincott Co. 6. MILLER, R. A. Observations on the gastric acidity during the first month of Iife. Arcb.rDis. Cbildbood, 16: 22, 1941. 7. SHAFFER, A. J. Diseases of the Newborn. PhiIadeIphia. 1960. W. B. Saunders Co. 8. BELL, D. M. Perforated duodena1 uIcer in chiIdren. Lancet, 2: 810, 1953. 9. BRA~TON, D. and NORRIS, W. J. GastrointestinaI hemorrhage in infancy and childhood. J. A. M. A., 15;: 668, rg52.IO. MARTIN. F. J. and SAUNDERS. H. F. Gastric ulcer in childhood. Radiology, 55:‘728, 1955. II. FISHER, J. H. DuodenaI ulcers in infants. Am. J. Dis. Cbild., 79: 50, 1950. 12. KENNEDY, R. L. Peptic ulcer in chiIdren. J. Pediat., 2: 641, 1933. 13. ABRAMSON, D. W. and FOSTON, M. J. Gastric perforation in the newborn. J. Dis. Child., 94: 252, 1957.
14. CASTLETON, K. B. and HATCH, F. F. Idiopathic
perforation of the stomach in the newborn. Arch.
&rg.,
76: 874,
1958.
BIRD. C. E.. LIMPER. M. A. and MAYER. J. M. Surgery in peptic uIceration in infants and chiIdren. Ann. Surg., I 14: 526, 1941. 16. MOORE, 0. M. Peptic uIcer in chiIdren. Canad. M. A. J., 44: 462, 1941. ‘5.
DISCUSSION JOSEPH W. NADAL
(PortIand, Ore.): During the past twenty years there has been increasing interest in peptic uIcer in infants and chiIdren. This is evidenced by the growing:voIume of Iiterature on the subject. Even Newsweek devoted severa coIumns to it just a few years ago. No individua1 physician is IikeIy to encounter many infants and chiIdren with peptic uIcer because of its reIative infrequency in these age groups. In fact, after I was asked to discuss the paper by Doctors Leix and Greeney, I quizzed severa PortIand gastroenteroIogists, pediatricians 182
Peptic UIcer in Infancy and ChiIdhood bring up the issue as to whether Iife in the South is Iess uIcerogenic than it is in the Bay Area, I wouId Iike to show you some of the figures that we have. We have had a tota of eighty-four cases with distribution as noted. Fifty-six per cent were boys and 44 per cent were girIs. I did not break it down into those under the age of one year. Under the age of four there were Ig per cent, and over the age of four there were 81 per cent. ExcIuding those perforations in newborn infants, al1 of the uIcers in this group were duodena1. I might add that fifty of the tota series have been diagnosed radioIogicaIIy in the Iast seven years; and of these, two-thirds have had a crater demonstrated. In others, due to bulb deformity or irritabiIity (often evident on repeat roentgenograms), the diagnosis of an uIcer was made. The incidence in this group of perforations was 4.7 per cent, just four of a tota of eighty-four. With hemorrhage, there were twenty-one, or 25 per cent of the whoIe group; the distribution, thirteen boys and eight girIs. Of the boys, nine presented with hematemesis and four presented either with meIena or hematochetia. In the femaIe group, four presented with hematemesis, and four with meIena or hematochezia. There were other associated conditions. It might be of interest to note, in view of the fact that it has been postuIated that chiIdren with pyIoric stenosis may have an ulcerogenic diathesis; in this group, there were two such instances. There was aIso one with a severe burn, one was a hemophihac and one had cystic fibrosis. In this tota group which we have, a11 from Children’s HospitaI, only six have been operated on. Four were operated on because of acute perforations; one had expIoratory surgery because of meIena with presumptive indications of MeckeI’s diverticuIum, but none was found. OnIy one chiId who was bIeeding required emergency surgery; a gastric resection was performed. There was no mortality in the bIeeding group. On the basis of our series, we believe that conservative management has been successful in those who have presented with hemorrhage. MURRAY L. JOHNSON (Tacoma, Wash.): I thought it would be rather interesting to take a little different approach to this subject and review, instead of the experiences primariIy in the hospitals, the experiences of a community. Coming, as I do, from a reIativeIy smaI1 community, it is not too diffrcuIt to get an accurate cross-section of what is going on in the general population. I did much as the essayists mentioned, surveying the one to fifteen age group, from pediatricians, radiologists and surgeons. Of five pediatricians who constitute over 50 per cent of our active pediatric practice in Tacoma, a11 had seen one or more cases of peptic ulcer, but onIy one reported
any Iarge number; he stated that he had seen tweIve to fifteen cases. However, he said only four of these were proved radioIogicaIIy. One went to surgery. It is of interest that one genera1 practitioner saw three radioIogicaIIy proved peptic ulcers in chiIdren in Iess than two years. Five radiologists were surveyed, two-thirds of the specialists in this category. One, our most active radiologist, reported ten cases seen in the last ten years. I reviewed some of his records, and most of these are Iisted as a rather minima1 thing, simply a “fleck” persisting in the duodena1 100~. Another radioIogist reported he had seen between five and ten. Three of the radioIogists, however, have been in practice over ten years and have seen none in their entire practice. I talked to ten of our Board, qualified surgeons, who had been in practice an average of ten years or more, which wouId indicate over IOO years of surgica1 practice. Six of these had never seen peptic ulcers in children in their own practice. TWO of these mentioned that during surgica1 residency they had seen newborn infants with perforations. This was not in our community. Five patients were seen by four surgeons and operated upon. Four of these were for bleeding; one was nonresponsive to medica management. In summary, therefore, I wouId say that peptic uIcer must be more common than many realize. Its occurrence depends on the accuracy of diagnosis. Some radioIogists pay particuIar attention to this disease and make many more diagnoses. CertainIy from the surgical aspect it is a rare condition. ARTHUR J. HUNNICUTT (OakIand, CaIif.): In our Alameda County Hospital, we had a ten year old boy who iIIustrated an interesting sequence of events. He came in with a fractured femur foIIowing an auto accident. The femur showed poor healing and the orthopedist beIieved it was on the way to nonunion. In the course of this, the boy vomited bIood. GastrointestinaI series showed a duodenal uIcer. A few days Iater I removed an adenoma of the parathyroid; the ulcer and the fracture heaIed promptIy. I mention this to aIert us to think about the possibiIity of parathyroid adenoma in peptic ulcer disease. EDWARD M. GREANEY, JR. (cIosing): I would Iike to thank the discussants for their kind appraisaI of our work, and to answer Dr. NadaI by saying that the five chiIdren who did recover had In other words, we conmuItipIe transfusions. sidered them to be massive bIeeders. To Dr. Peters’ statements, I take some exception for the folIowing reasons: In our surgica1 experience in these twelve children at the two hospitaIs, we had five with suture Iigatures, two pyforoplasties, and so forth. There were three deaths in this group. 183
Leix and Greaney The mortality rate was 25 per cent, but it is to be emphasized that three of these tweIve children represented surgica1 faiIures, and were done on moribund chiIdren in whom medica measures had faiIed. We would Iike to stress that in one of the so-caIIed medicaIIy treated cases a chiId received 1,100 cc. of blood. The chiId weighed seventeen pounds. This is carrying conservatism too far, we beIieve, when a simple suture Iigature of the bIeeding point in an infant one year or under couId be done with a negIigibIe mortaIity. For example, two of the patients at the County HospitaI were decIared to be too iI to have surgery whiIe they were bIeeding. When the uIcer perforated, they were accepted as surgica1 candidates, and one of them was saved. In concIusion, then, when we went over this
184
series of cases it seemed cIear to us that one year of age or under, most of these infants had some stress situation accounting for the bleeding episodes or the episode that Ied to the diagnosis. In diagnosis under one year of age, Dr. Johnson brings up a point that a radiologist had not seen an uIcer in a chiId under one year of age. Dr. Mikity at Genera1 HospitaI did 450 gastrointestina1 series in a year and a half to perfect this technic; thus, there is a direct reIationship to the amount of experience the radioIogist has. Over a year of age, if the uIcer is chronic, it probabIy shouId be treated much as in an aduIt, if it is not a simpIe stress uIcer. We have had a few of this type; vagotomy and pyIoropIasty is our choice of operation when such becomes necessary.