Determination of the normal position of the anus (with reference to idiopathic constipation)

The position of the normal anus was numerically defined by the ano-genital index, which is the distance from the anus to the vagina or scrotum divided by the distance between the vagina or scrotum and the coccyx. In idiopathic constipation, one must look for an anterior displacement of the anus, which might be the cause of the constipation.

Congenital stenosis of the esophagus due to tracheobronchial remnants: a missed diagnosis

Lower esophageal strictures in infants in more than 90% of cases are related to reflux esophagitis, while the remainder are congenital or induced by injuries such as penetrating trauma or corrosion by caustic agents. Among congenital disorders cartilaginous remnants in the esophagus are very rare, but it is a possibility that should always be considered, especially if signs of esophagitis are not seen on esophagoscopy. The first aim, when evaluating the vomiting or regurgitating infant, is to establish whether this is due to an organic disorder. When stricture of the esophagus becomes evident following prolonged vomiting, clinicians tend to attribute this to reflux with peptic injury, and in most of the cases that will be correct (1). Carefully performed investigation will bring forth those rare etiologic factors that can be easily overlooked (2). The investigation has to include radiographic studies, esophagoscopy, pH monitoring, and in selected cases, manometry. Recognition of the correct etiologic factor that caused the stricture will pave the way for adequate management. We report on two patients with congenital stenosis of the lower esophagus due to cartilaginous rings, one of which was diagnosed preoperatively.

Unconjugated hyperbilirubinaemia in hypertrophic pyloric stenosis, an enigma

In a search of features that might be relevant to the understanding of the hyperbilirubinaemia of infants with hypertrophic pyloric stenosis (HPS), we examined the duodenal fluid in 11 infants with this condition. Four (36%) had an unconjugated bilirubin level above 2.5 mg/dl in the serum. Levels of electrolytes, bicarbonate, liver function tests and cholesterol were similar in the jaundiced and the non-icteric infants. Examination of duodenal fluid for pH, concentration of bilirubin, bile salts, electrolytes and beta-glucuronidase levels also did not disclose any significant differences between the HPS patients and the controls. Bacterial culture of the fluid yielded similar results in both groups. We may conclude that the unconjugated hyperbilirubinaemia observed in some patients with HPS is not associated with overgrowth of bacteria, changes in glucuronidase levels, pH, electrolytes or biliary obstruction.

Hyperchloremic metabolic acidosis as a clue to recto-urethral fistula in an infant with anal atresia

An infant with high anal atresia and transverse colostomy, in whom initial radiologic evaluation of the urinary tract had been normal, developed hyperchloremic metabolic acidosis at 24 days of age. Gastroenteritis and renal tubular acidosis as possible causes for this metabolic disturbance were excluded, which prompted a repeat investigation of the possibility of a communication between the urinary tract and the rectum. A recto-urethral fistula was demonstrated by urethrography. Analysis of the fluid obtained from the left colon as compared to urine in the bladder and voided urine demonstrated that electrolyte exchange was taking place in the colon, resulting in hyperchloremic hypokalemic acidosis. Treatment with oral sodium bicarbonate and daily lavage of the left colon resulted in normalization of the acid-base status and catch-up growth of the baby. Hyperchloremic acidosis associated with anal atresia and recto-urinary communication appears to be uncommon. However, early diagnosis and treatment of the metabolic derangement are of importance as it may determine the infant's overall prognosis.

Partial splenectomy in children with Gaucher's disease

Because of hypersplenism and mechanical problems, partial splenectomy was performed in four children with Gaucher's disease. Subsequently, one of the patients underwent a total splenectomy due to bleeding from the remnant of the spleen. At the follow-up of the other three patients, an isotope scan showed that the remaining spleen was functioning well.

Tubular duplication of the jejunum and ileum lined entirely by gastric mucosa

A 3-year-old boy who suffered from severe colicky abdominal pain is presented. Laboratory studies, including ultrasound, upper gastrointestinal films, and 99mTc-scan, were interpreted as normal. On exploration of the abdomen a tubular duplication of the small bowel was found. The duplication had a common mesentery with the normal bowel. By meticulous dissection the duplication was resected without interfering with the blood supply of the normal bowel. The entire duplication was found to be covered by gastric mucosa.

Idiopathic cricopharyngeal achalasia

Two neonates with cricopharyngeal achalasia are presented. In one of them myotomy of the cricopharyngeus relieved the obstruction. In the other baby, the symptoms disappeared without surgical treatment.

The Ale-Calo syndrome in monozygotic twins associated with bilateral cryptorchidism--case report

A case report of identical male twins with the clinical and radiological features of the rare Ale - Calo or M.E.M.R. (Multiple Exostoses - Mental Retardation) or Langer-Giedion's syndrome - is presented. The additional finding of bilateral cryptorchidism in our case is also very rare in twins, and has hitherto not been described in association with the Ale - Calo syndrome. Differential diagnosis is reviewed briefly.

Gastrografin treatment of intestinal obstruction due to Ascaris lumbricoides

Gastrografin was used to relieve subacute intestinal obstruction due to Ascaris lumbricoides in children. This hyperosmolar and wetting agent proved to be highly efficient to achieve this goal. Statistical evaluation of the hospital stay and first bowel action showed a significant difference between the treated "gastrografin group' and the untreated by gastrografin "control group,' in favor of the "gastrografin group.' Our data strongly suggest the use of Gastrografin in subacute intestinal obstruction due to Ascaris lumbricoides. This treatment should be instituted provided the patient has been adequately hydrated prior to administration.

Craniofacial microsomia in a parasite of a heteropagus conjoined twin: a clinical and histopathologic evaluation

This report evaluates a rare case of craniofacial microsomia in a partially developed, malformed heteropagus conjoined twin. In this instance, several major components of the craniofacial complex were involved: bones, cartilage, teeth, salivary glands, auditory apparatus, cerebrum, cranial nerves, and ocular neuroepithelium. In addition, cervical vertebrae and appendicular long bones were markedly affected. To date, the underlying disorder (whether genetic, metabolic, or environmental) responsible for the development of this congenital malformation is not fully understood. Our clinical and pathologic examinations tend to suggest that an apparent lack of an adequate arterial blood supply to the growing embryo could have contributed to the elaboration of this complex syndrome. The fact that the parasite's blood supply relied mainly upon a single, medium-sized artery (1.5 mm in diameter) could have brought about local ischemic milieus during the critical phases of embryogenesis; hence, impeding the preprogrammed migration of neural crest cells to their end targets in the upper branchial arches. In such a case, the normal sequence of cell differentiation is damaged, which in turn imposes a severe impact on the morphogenesis of the various tissues composing the craniofacial complex.

Leiomyosarcoma of the colon in an infant. A case report and review of the literature

A rare case of leiomyosarcoma of the sigmoid colon in a 7-week-old infant presenting with signs of intestinal obstruction followed by colonic perforation and peritonitis is reported, and the literature pertaining to childhood colorectal leiomyosarcoma is reviewed.

Heredity in anal atresia

Although anal atresia is known to occur occasionally in families and as part of genetically determined syndromes, the role of genetics in its causation is highly disputable. In this paper evidence is presented for multifactorial genetic determination as the mode of inheritance in anal atresia. This conclusion is argued as based on evidence from the literature as well as findings in an additional series of 48 cases which were collected as a family study.

Prolactin binding by testes of unilaterally cryptorchid rats: the effect of hCG, testosterone, prolactin and orchiopexy

The effect of unilateral cryptorchidism on prolactin binding to the testes was studied in the rat. Cryptorchidism was rendered surgically for 3 weeks and 3, 6 and 9 weeks later prolactin binding was measured in testicular homogenates. Prolactin binding to the cryptorchid testes decreased significantly at 3 weeks with a further decrease at 6 and 9 weeks. Binding by the contralateral testes decreased at 3 weeks and increased at 6 and 9 weeks. To examine the possible mechanism of these changes one group of rats was treated for 5 weeks with testosterone and another with hCG. Testosterone treatment resulted in a significant fall in prolactin binding to normal, cryptorchid and contralateral testes. hCG also produced a slight but significant reduction in prolactin binding. To study the effect of surgical relocation of the testes into the scrotum, orchiopexy was performed in another group of rats. Orchiopexy increased prolactin binding only if performed 3 weeks after cryptorchidism. At 6 and 9 weeks after cryptorchidism orchiopexy did not increase prolactin binding. Treatment of cryptorchid rats with prolactin for 5 weeks induced an increase in prolactin binding to control, cryptorchid and contralateral testes. It is concluded that testicular atrophy follows upon placement of a testis within the peritoneal cavity. This atrophy lowers the total amount of prolactin binding and increases binding to the contralateral testes. Intratesticular concentration of testosterone may play a major role in the decrease of prolactin binding. Orchiopexy improves prolactin binding only if performed before 6 weeks of age. Administration of prolactin augments prolactin binding to the testes, irrespective of their location.

Repeated endotracheal intubations and bronchial lavage in the postoperative treatment of tracheoesophageal fistula

Recurrent pulmonary atelectasis occurs often in neonates following primary repair of esophageal atresia, leading to massive pneumonia and respiratory failure. The atelectasis is caused by tenacious mucous plugs which are presumably formed as a result of ciliary mucosal damage secondary to reflux of gastric fluid through a tracheo-esophageal fistula. Early aggressive treatment of the atelectasis by repeated gentle tracheal intubation with bronchial lavage and suction is advocated. This treatment is well tolerated and is preferred to continuous intubation with its inherent dangers for the neonatal patient.