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The diagnostic significance of cholescintigraphy and ultrasound examination in cholestatic syndromes in infancy
1082
Choledochal Cyst in an Identical Twin, N. Urushihara, T. Todani,
Y. Watanabe, et al. Pediatr Surg Internat 3:I89-192, (March), 1988. A 15-year-old girl underwent excision of a choledochal cyst with an anomalous pancreatobiliary junction. Her sister, an identical twin, was perfectly healthy without any abnormality in the hepatobiliary system as demonstrated by ultrasound, ERCP, and infusion cholangiography. Choledochal cysts and pancreatobiliary malunions are probably caused by developmental accidents in early intrauterine life rather than by genetic factors. The rarity of familial development and lack of occurrence in both members of a pair of identical twins supports this thesis.--Prem Puri The Diagnostic Significance of Cholescintigraphy and Ultrasound Examination in Cholestatic Syndromes in Infancy, 1t. Peters, 19.
Eibner, D. Weitzel, et al. Pediatr Surg Internat 3:37-42, (January), 1988. Thirty-three neonates and infants with cholestatic syndromes of various etiologies and evaluated by cholescintigraphy and ultrasound examinations. The results of these two diagnostic procedures were compared with the final diagnosis as confirmed by liver biopsy and/or laparotomy and the clinical follow-up of the infants. Fourteen patients had an obstructive cholangiopathy (11 biliary atresia, 2 choledochal cysts, 1 congenital choledochal stenosis), 13 had neonatal hepatitis, and six had cholestasis of another etiology. Typical ultrasonic and/or scintigraphic findings confirmed or excluded the need for surgical exploration in 28 patients. Thus, for most infants with cholestatic syndromes, it is possible to differentiate the cause without invasive diagnostic techniques, such as liver biopsy or exploratory laparotomy.--Prem Purl Hepatobiliary Scintigraphy With ~mTc-DISIDA in lnfantile Obstructive Cholangiography. J. Verreault, S. Danais, H. Blanchard, et al.,
Clair Pediatr 28:1-7, (January), 1987. This is a retrospective study of the value of technetium 99m labeled disopropyl iminodiacetic acid hepatobiliary scintigraphy. Twenty-six patients with infantile obstructive cholangiopathy were studied. Phenobarbital stimulation was used five days before examination. Criteria were of two types in 17 cases of biliary atresia. Type 1 involved hepatocyte clearance, hepatobiliarytransit time, and the visualization of intestinal activity. Type 2 involved the presence or absence of intestinal radioactivity during 24 hours and birth weight. Sensitivity, specificity, and positive and negative predictive values were 88.2%, 88.9%, 93.8%, and 80.0%, respectively for the two types of criteria. In cases of neonatal hepatitis (7), criteria were only of type 1, and the respective parameters were 57.1%, 94.7%, 80% and 85.7%. These results are inferior to many reported in the literature, but the methodology seems better. The authors state that even though there were two false-negative cases (10%), biliary scintigraphy remains an important diagnostic test for biliary atresia.--J.M. Guys Liver Abscess in Childhood: A 13-Year Review. S. Moore, A J . W .
Millar, and S. Cywes. Pediatr Surg Internat 3:27-32, (January), 1988. Seventy-five children with pyogenic liver abscess are reviewed and compared with 21 with ameobic liver abscess occurring within the same l 3-year period (1974 to 1986): Both groups presented with a similar syndrome complex: Noted differences were age at presentation (pyogenic, mean age 4.5 years; amoebic, mean age 2 years), the association of dysentery in 43% of the amoebic group, and a 76% incidence of Ascaris infestation in the pyogenic group. Predisposing disease was uncommon. Diagnosis was often delayed, which led to
INTERNATIONAL ABSTRACTS
four deaths in the pyogenic group (overall mortality 4%). Diagnosis was confirmed with ultrasound or nucleotide liver scan. Nonoperatire management with antibiotics and metronidazole was successful in 37% of pyogenic and 43% of amoebic abscesses. Laparotomy and open drainage was performed for clinical evidence of peritonitis or failure to improve within 48 to 72 hours of commencing therapy. There was no operative mortality and little morbidity in either group.--Prem Purl Splenic Abscess in Children: Aspects of Management. C.S. Grant, A. AI Salem, M.S. Khwaja, et al. J R Coil Surg Edinb 32:342-345, (December), 1987.
During a 2-year period, four male Saudi children presented with splenic abscess. All had a febrile illness with a tender enlarged spleen. Three had sickle cell disease. Abscess formation was confirmed by both ultrasound and computed tomography scan, the latter being the most accurate. In each case, splenectomy and drainage was carried out, 500 to 900 mL pus removed, and the splenic bed irrigated with saline and povidone iodine. Prophylactic pneumococcal vaccine and antibiotics were given. All recovered and remained on long-term penicillin. The authors recommend splenectomy rather than percutaneous drainage in splenic abscess in children.--W.G. Scobie Pancreatitis in Childhood: Experience With 49 Patients. D.W.
Ziegler, J.A. Long, A.I. Philippart, et al. Ann Surg 207:257-261, (March), 1988. Pancreatitis in children is rare. Forty-nine children with pancreatitis from 1974 to 1986 were retrospectively reviewed. Pancreatitis was diagnosed with amylase measurements in 27 patients and by intraoperative impression in 22 patients. The patients ranged in age from 1 month to 18 years and included 27 males and 22 females. Etiology included trauma (33%), biliary tract disease (33%), systemic diseases (12%), congenital anomalies (16%), and idiopathic (6%). Presenting symptoms included pain (82%), vomiting (53%), mass (16%), fever(10%), and abdominal distention (37%). Younger patients often presented without pain and were more likely to have abdominal distention. Thirty-four patients underwent ultrasound evaluation with a pancreatic mass identified in ten and an enlarged pancreas in 13. In nine patients, the pancreas could not be identified with ultrasound. Twelve patients underwent a computed tomography examination with demonstration of pancreatic mass in six, an enlarged pancreas in nine, and a normal pancreas in two. Fourteen patients were treated with intravenous (IV) fluids and nothing by mouth; six required operative intervention. Seventeen patients were treated with IV fluids and nasogastric suction; 11 required surgery. Eighteen patients were treated with IV fluids, nasogastric suction, and hyperalimentation, 12 of whom required surgical intervention. Fifteen of 16 patients with biliary tract disease required operation. Five patients required reoperation for recurrence. None of the patients with systemic disease as etiology to pancreatitis required operation. The authors conclude ultrasound is a useful diagnostic adjunct in evaluation of pancreatitis and avoids the more expensive CT with its higher radiation. In all patients under 4 years of age, pancreatitis was caused by congenital anomalies or trauma. Elevated amylase alone is not an independent risk factor for predicting severity of disease. Risk factor analysis is helpful in predicting who will develop complications. Aggressive diagnostic evaluation showed the cause of pancreatitis in 94% of patients. A low mortality rate may be due to early diagnosis and expedient surgical intervention.--Edward G. Ford Pancreatitis in Childhood. R.D. Spieer and S. Cywes. Pediatr Surg
lnternat 3:33-36~ (January), i988.
Choledochal Cyst in an Identical Twin, N. Urushihara, T. Todani,
Y. Watanabe, et al. Pediatr Surg Internat 3:I89-192, (March), 1988. A 15-year-old girl underwent excision of a choledochal cyst with an anomalous pancreatobiliary junction. Her sister, an identical twin, was perfectly healthy without any abnormality in the hepatobiliary system as demonstrated by ultrasound, ERCP, and infusion cholangiography. Choledochal cysts and pancreatobiliary malunions are probably caused by developmental accidents in early intrauterine life rather than by genetic factors. The rarity of familial development and lack of occurrence in both members of a pair of identical twins supports this thesis.--Prem Puri The Diagnostic Significance of Cholescintigraphy and Ultrasound Examination in Cholestatic Syndromes in Infancy, 1t. Peters, 19.
Eibner, D. Weitzel, et al. Pediatr Surg Internat 3:37-42, (January), 1988. Thirty-three neonates and infants with cholestatic syndromes of various etiologies and evaluated by cholescintigraphy and ultrasound examinations. The results of these two diagnostic procedures were compared with the final diagnosis as confirmed by liver biopsy and/or laparotomy and the clinical follow-up of the infants. Fourteen patients had an obstructive cholangiopathy (11 biliary atresia, 2 choledochal cysts, 1 congenital choledochal stenosis), 13 had neonatal hepatitis, and six had cholestasis of another etiology. Typical ultrasonic and/or scintigraphic findings confirmed or excluded the need for surgical exploration in 28 patients. Thus, for most infants with cholestatic syndromes, it is possible to differentiate the cause without invasive diagnostic techniques, such as liver biopsy or exploratory laparotomy.--Prem Purl Hepatobiliary Scintigraphy With ~mTc-DISIDA in lnfantile Obstructive Cholangiography. J. Verreault, S. Danais, H. Blanchard, et al.,
Clair Pediatr 28:1-7, (January), 1987. This is a retrospective study of the value of technetium 99m labeled disopropyl iminodiacetic acid hepatobiliary scintigraphy. Twenty-six patients with infantile obstructive cholangiopathy were studied. Phenobarbital stimulation was used five days before examination. Criteria were of two types in 17 cases of biliary atresia. Type 1 involved hepatocyte clearance, hepatobiliarytransit time, and the visualization of intestinal activity. Type 2 involved the presence or absence of intestinal radioactivity during 24 hours and birth weight. Sensitivity, specificity, and positive and negative predictive values were 88.2%, 88.9%, 93.8%, and 80.0%, respectively for the two types of criteria. In cases of neonatal hepatitis (7), criteria were only of type 1, and the respective parameters were 57.1%, 94.7%, 80% and 85.7%. These results are inferior to many reported in the literature, but the methodology seems better. The authors state that even though there were two false-negative cases (10%), biliary scintigraphy remains an important diagnostic test for biliary atresia.--J.M. Guys Liver Abscess in Childhood: A 13-Year Review. S. Moore, A J . W .
Millar, and S. Cywes. Pediatr Surg Internat 3:27-32, (January), 1988. Seventy-five children with pyogenic liver abscess are reviewed and compared with 21 with ameobic liver abscess occurring within the same l 3-year period (1974 to 1986): Both groups presented with a similar syndrome complex: Noted differences were age at presentation (pyogenic, mean age 4.5 years; amoebic, mean age 2 years), the association of dysentery in 43% of the amoebic group, and a 76% incidence of Ascaris infestation in the pyogenic group. Predisposing disease was uncommon. Diagnosis was often delayed, which led to
INTERNATIONAL ABSTRACTS
four deaths in the pyogenic group (overall mortality 4%). Diagnosis was confirmed with ultrasound or nucleotide liver scan. Nonoperatire management with antibiotics and metronidazole was successful in 37% of pyogenic and 43% of amoebic abscesses. Laparotomy and open drainage was performed for clinical evidence of peritonitis or failure to improve within 48 to 72 hours of commencing therapy. There was no operative mortality and little morbidity in either group.--Prem Purl Splenic Abscess in Children: Aspects of Management. C.S. Grant, A. AI Salem, M.S. Khwaja, et al. J R Coil Surg Edinb 32:342-345, (December), 1987.
During a 2-year period, four male Saudi children presented with splenic abscess. All had a febrile illness with a tender enlarged spleen. Three had sickle cell disease. Abscess formation was confirmed by both ultrasound and computed tomography scan, the latter being the most accurate. In each case, splenectomy and drainage was carried out, 500 to 900 mL pus removed, and the splenic bed irrigated with saline and povidone iodine. Prophylactic pneumococcal vaccine and antibiotics were given. All recovered and remained on long-term penicillin. The authors recommend splenectomy rather than percutaneous drainage in splenic abscess in children.--W.G. Scobie Pancreatitis in Childhood: Experience With 49 Patients. D.W.
Ziegler, J.A. Long, A.I. Philippart, et al. Ann Surg 207:257-261, (March), 1988. Pancreatitis in children is rare. Forty-nine children with pancreatitis from 1974 to 1986 were retrospectively reviewed. Pancreatitis was diagnosed with amylase measurements in 27 patients and by intraoperative impression in 22 patients. The patients ranged in age from 1 month to 18 years and included 27 males and 22 females. Etiology included trauma (33%), biliary tract disease (33%), systemic diseases (12%), congenital anomalies (16%), and idiopathic (6%). Presenting symptoms included pain (82%), vomiting (53%), mass (16%), fever(10%), and abdominal distention (37%). Younger patients often presented without pain and were more likely to have abdominal distention. Thirty-four patients underwent ultrasound evaluation with a pancreatic mass identified in ten and an enlarged pancreas in 13. In nine patients, the pancreas could not be identified with ultrasound. Twelve patients underwent a computed tomography examination with demonstration of pancreatic mass in six, an enlarged pancreas in nine, and a normal pancreas in two. Fourteen patients were treated with intravenous (IV) fluids and nothing by mouth; six required operative intervention. Seventeen patients were treated with IV fluids and nasogastric suction; 11 required surgery. Eighteen patients were treated with IV fluids, nasogastric suction, and hyperalimentation, 12 of whom required surgical intervention. Fifteen of 16 patients with biliary tract disease required operation. Five patients required reoperation for recurrence. None of the patients with systemic disease as etiology to pancreatitis required operation. The authors conclude ultrasound is a useful diagnostic adjunct in evaluation of pancreatitis and avoids the more expensive CT with its higher radiation. In all patients under 4 years of age, pancreatitis was caused by congenital anomalies or trauma. Elevated amylase alone is not an independent risk factor for predicting severity of disease. Risk factor analysis is helpful in predicting who will develop complications. Aggressive diagnostic evaluation showed the cause of pancreatitis in 94% of patients. A low mortality rate may be due to early diagnosis and expedient surgical intervention.--Edward G. Ford Pancreatitis in Childhood. R.D. Spieer and S. Cywes. Pediatr Surg
lnternat 3:33-36~ (January), i988.