Intestinal atresia and agenesis of the gallbladder in 2 siblings

Intestinal atresia and gallbladder agenesis are rare congenital malformations usually presenting as isolated and sporadic. We present and discuss the case of 2 sisters affected by a previously unreported association of these 2 anomalies.

[Morgagni's hernia--still a difficult diagnostic problem]

Morgagni's hernia due to its non-specific symptoms and signs along with difficulties to detect it by x-ray imaging is still a disease difficult to diagnose. Patients suffering from this hernia are often treated unsuccessfully because of false diagnosis of other illnesses of the abdomen or thorax. It is only detailed diagnostics that can lead to a proper diagnosis. The authors present the current status of knowledge of Morgagni's hernia, its most common signs and symptoms and available diagnostic and therapeutic methods.

A novel treatment of congenital duodenal stenosis: image-guided treatment of congenital and acquired bowel strictures in children

BACKGROUND

Image-guided balloon dilatation has been used in adults as an alternative to standard surgical treatment of intestinal stricture. The experience in children is limited. We report our results with this procedure in the management of both congenital and acquired intestinal stenosis in children.

MATERIALS AND METHODS

A retrospective analysis was done of children younger than 2 years of age who underwent balloon dilatation of small and large intestinal stenosis between 1994 and 2003.

RESULTS

Eleven children underwent dilatation during the study period. Two of these children had congenital duodenal stenosis, and this represents the first report of nonoperative management of this condition. Three children underwent dilatation of small bowel strictures and 6 had dilatation of colonic and rectal strictures. Necrotizing enterocolitis was the most common (6/9) etiology of stricture. Ten of 11 patients did not require subsequent operative management although 3 children required further dilatations. The mean follow-up was 36.5 months (range, 13 days-103 months). One patient underwent a subsequent dilatation that was unsuccessful, and required operative resection of a 5-cm stricture. There was one complication, a small leak that was managed nonoperatively.

CONCLUSION

Image-guided balloon dilatation holds promise as an alternative to surgical treatment in children with congenital or acquired stenosis of the small or large bowel, and should be considered in select patients with short strictures.

Colour of bile vomiting in intestinal obstruction in the newborn: questionnaire study

OBJECTIVES

To identify the colour that different groups of observers thought represented bile in a newborn's vomit.

DESIGN

Questionnaires displaying eight colours (pale yellow to dark green).

SETTING

General practices in Glasgow, postnatal ward and level III special care baby unit in a university teaching hospital, and mother and toddler groups in Glasgow.

PARTICIPANTS

47 general practitioners, 29 nurses on the baby unit, 48 midwives, and 41 mothers of babies and infants.

OUTCOME MEASURES

Participants indicated which colour would represent bile in a baby's vomit. More than one colour could be chosen. Respondents were also asked to indicate one colour that was the best match for bile.

RESULTS

When any colour could be chosen, 12 (25%) general practitioners, 1 (3%) nurse on the baby unit, 5 (10%) postnatal midwives, and 23 (56%) parents did not consider green an appropriate colour for a baby's vomit containing bile. Twenty three (49%) general practitioners, 7 (24%) neonatal nurses, 15 (31%) postnatal midwives, and 29 (71%) parents thought yellow was the best colour match.

CONCLUSIONS

There is little agreement about the colour of bile vomit in a newborn. It is more pertinent to ask parents about the colour of vomit rather than whether it contained bile. Many general practitioners and parents do not recognise green as an appropriate colour for bile in the vomit of newborns, which may delay surgical referral. Though yellow vomit does not exclude intestinal obstruction, the presence of green vomiting in a baby is a surgical emergency and requires expeditious referral.

Upper gastrointestinal tract obstruction due to congenital duodenal diaphragm

The presence of incomplete upper gastrointestinal obstruction in childhood is a rare condition and usually indicates congenital anomaly. We reported a case of incomplete duodenal obstruction in a 16-year-old girl due to a congenital duodenal diaphragm. A duodenal diaphragm with an eccentric aperture was found by upper gastrointestinal series and endoscopic examination in the second part of the duodenum. The patient made an uncomplicated recovery with relief of the symptoms after duodenotomy and excision of the diaphragm. This case underlines that congenital duodenal diaphragm should be kept in mind as a possibility whenever chronic obstruction of the duodenum in childhood is diagnosed. The prognosis of congenital duodenal diaphragm is usually good after excision of the diaphragm, when not associated with other congenital anomalies.

Megacystis microcolon intestinal hypoperistalsis syndrome

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare and the most severe form of functional intestinal obstruction in the newborn. The major features of this congenital and usually lethal anomaly are abdominal distension, bile-stained vomiting, and absent or decreased bowel peristalsis. Abdominal distension is a consequence of the distended, unobstructed urinary bladder with or without upper urinary tract dilation. Most patients with MMIHS are not able to void spontaneously. This article reviews the pathogenesis of MMIHS as well as the clinical, radiological, surgical and histological findings in all reported cases of this syndrome.

Interstitial cells of Cajal in the human normal urinary bladder and in the bladder of patients with megacystis-microcolon intestinal hypoperistalsis syndrome

OBJECTIVE

To investigate the distribution of c-kit-positive interstitial cells of Cajal (ICCs) in normal bladder and bladders from patients with megacystis-microcolon-intestinal peristalsis syndrome (MMIHS, a rare congenital and generally fatal cause of functional intestinal obstruction in the newborn), the most characteristic feature of which is abdominal distension caused by a distended unobstructed urinary bladder.

PATIENTS AND METHODS

Full-thickness bladder specimens were obtained from four infants with MMIHS and four controls, and processed as paraffin-wax and frozen sections. Sections were assessed using single immunohistochemistry with monoclonal and polyclonal anti-c-kit antibodies. Anti-alpha-smooth muscle actin (SMA) antibody was used to investigate the contractile apparatus in smooth muscle cells of the urinary bladder. Specimens were examined using light and confocal scanning microscopy.

RESULTS

There were many c-kit positive ICCs in the normal urinary bladder, appearing as small, long, bipolar cells with only two long and several short processes. In contrast, ICCs were absent in the MMIHS bladder. alpha-SMA immunoreactivity was lower in MMIHS urinary bladder than in control sections.

CONCLUSION

This study shows for the first time the presence of c-kit-positive ICCs in the normal human urinary bladder. The lack of ICCs in the MMIHS bladder may contribute to the voiding dysfunction in this disease.

Annular pancreas combined with distal stenosis. A report of four cases and review of the literature

BACKGROUND

Congenital duodenal obstruction (CDO) in combination with more distal duodenal obstructions is a rare anomaly occurring in 4% of neonates with duodenal atresia. The experience of two European Pediatric Centers in treatment of congenital double duodenal obstruction (CDDO) is reported and the pertinent literature is reviewed.

MATERIALS AND METHODS

During the last 15 years a total of 86 neonates were operated upon for CDO at the department of pediatric surgery of "St. Sophia" Children's Hospital of Athens in Greece and the department of pediatric surgery of "Federico II" Children's University Hospital of Naples in Italy; four of them had a CDDO. These ones presented with nonbilious vomiting and the plain film of the abdomen showed the typical "double bubble". Our cases with CDDO presented annular pancreas causing complete obstruction of the second part of the duodenum and dilatation of the duodenum distal to this obstruction due to an additional congenital stenosis (two cases) or a membranous web (two cases). A diamond shaped duodeno-duodenal (DDD) anastomosis was carried out to relieve the proximal obstruction and a Heinecke-Mikulicz plasty was used to relieve the distal stenosis.

RESULTS

All patients with double obstruction underwent successful surgery with no complications. The postoperative course was uneventfuL An upper gastrointestinal barium study at one month postoperatively showed no blind loop, megaduodenum, anastomotic stenosis or malfunction.

CONCLUSIONS

a) The combination of duodenal atresia with annular pancreas and distal duodenal stenosis or web is extremely rare. b) Patency of the duodenum distal to the usual obstruction should always be checked in order to avoid misdiagnosis of this combination.

Late presentation of a duodenal web in a patient with situs inversus and apple peel jejunal atresia

A 16-year-old girl presented with signs of proximal intestinal obstruction. In the neonatal period, surgical correction of an apple peel atresia had been performed, and she also had a situs inversus abdominalis. Revision of the anastomosis had been done when she was 3 years old. Contrast studies apparently again showed a stricture of the anastomosis, which was treated by stricturoplasty. Because of persistent obstruction, reexploration was done and revealed a duodenal membrane. Anastomotic strictures are very rare several years after the primary operation, so other causes of obstruction should be sought.

Prenatal manifestation of superior mesenteric artery syndrome

Intestinal obstruction is not a rarity in the newborn. Its etiology is diverse. Superior mesenteric artery syndrome (SMAS) is a phenomenon in which the duodenum is obstructed by the SMA. This causes bowel obstruction accompanied by duodenal dilatation. It has previously been described in adults and children but rarely in infants. We report for the first time on an intrauterine manifestation of SMAS.

[Congenital gastrointestinal tract obstructions (pictorial essay)]

A wide spectrum of congenital anomalies may cause obstruction in the upper and lower gastrointestinal tract. Neonates with complete upper intestinal obstruction do not usually require further radiological evaluation after radiography. Barium studies are sometimes needed. Barium studies and other comprehensive methods such as ultrasonography, computed tomography and magnetic resonance imaging are usually complementary procedures which are not usually helpful and may even delay surgery, resulting in some complications and death. The decision to perform a given imaging examination should be considered carefully to avoid unnecessary radiation exposure to the patient. The diagnosis of low intestinal obstruction is usually apparent at abdominal radiography because of the presence of many dilated loops. The differentiation between ileal and colonic obstruction can be made with a contrast enema study. Dilute ionic, water-soluble contrast agents and non-balloon tip catheter of appropriate size is preferred for neonatal contrast enemas. Barium sulphate suspensions typically should not be used because of their potential to exacerbate the impaction of meconium plugs in meconium ileus, whereas water-soluble enemas can be therapeutic.

Congenital membranous colonic stenosis--case report of an extremely rare anomaly

Congenital colonic stenosis is a rare anomaly. Congenital membranous colonic stenosis is more rare. The authors experienced a case of congenital membranous colonic stenosis that was diagnosed and treated successfully. To the authors' knowledge, congenital membranous colonic stenosis has not been reported previously in the literature.

Severe megacystis and bilateral hydronephrosis in a female fetus

The differential diagnosis for antenatal bladder dilation and hydronephrosis is extensive, ranging from posterior urethral valves to neurogenic bladder. We present a case of a female fetus diagnosed antenatally with severe megacystis and bilateral hydroureteronephrosis. The patient was found to have megacystis-microcolon-intestinal hypoperistalsis syndrome, a rare, congenital, and generally fatal disorder in which there is functional obstruction of the bladder and intestine.

Hepatic failure with neonatal tissue siderosis of hemochromatotic type in an infant presenting with meconium ileus. Case report and differential diagnosis of the perinatal iron storage disorders

We report on a female preterm infant with hepatic failure and neonatal tissue siderosis of hemochromatotic type diagnosed by using both histochemistry and atomic absorption spectroscopy. The infant presented with meconium ileus, signs of rapidly progressive hepatic failure, and hyperferritinemia (7132 ng/ml). Despite surgery and intensive care the infant died 32 days after birth. Postmortem examination showed a wrinkled liver with extensive collapse of the hepatic architecture and regenerating nodules as well as hepatic and extrahepatic iron accumulation of hemochromatotic type, sparing the reticuloendothelial system. Atomic absorption spectroscopy confirmed an increase in the iron content of various organs: liver, heart, pancreas, oral salivary gland, kidney, and adrenal gland. The increase in the iron content of various organs was determined by comparing the analysis of the propositus with those of 5 gestationally age-related preterm infants who had died in the intensive care unit: 2 died of meconium aspiration syndrome, the other 3 of hyaline membrane disease, bronchopulmonary dysplasia, and immaturity, respectively. We also compared the analysis of 15 fetuses having a a condition predisposing to iron accumulation (trisomy 21, trisomy 18, cytomegalovirus, amnion infection syndrome, Rhesus- and ABO-incompatibility, congenital hemolysis, anti-phospholipid syndrome, congenital heart disease). Delta F508, the most frequent mutation seen in cystic fibrosis patients, was excluded by gene sequencing. Different noxae causing iron accumulation in the neonatal period have led to the statement that neonatal hemochromatosis may collect different etiologies, such as metabolic disorders, infections, chromosomal aberrations, and immunological disorders. In this study, we report the singular evidence of neonatal iron accumulation of hemochromatotic type in an infant presenting with meconium ileus and propose a classification of the neonatal disorders associated with iron accumulation.

[Anal sphincter-CT and dorsal sphincteropexy - a new approach in therapy of obstructive defecation disorder]

The dysplasia of anal sphincter represents an obstructive defecation disorder. The disease is known as "anterior displaced anus" in pediatric surgery. An anorectal malformation with missing dorsal osseous fixation of the sphincter complex is the underlying cause. Beyond clinical symptoms and examination result (anterior displaced anus with palpable dorsal gap) the defect can be visualized by computered tomography. A surgical correction is possible by the simple intervention of dorsal sphincteropexy. In our trial with 48 patients (male n = 12, female n = 36, mean age 51 +/- 17 years, follow-up in 39 patients) a significant improvement of defecation could be achieved in 46 % of the patients. In correlation to a good clinical outcome a significant reduction in the defecation score was observed. 10 % of the patients had only small changes in symptoms. However, the proportion of dissatisfied patients was relatively high with 44 %. In this group patients with long-standing chronic constipation and laxative abusus were found more often and the rate of previous anal or abdominal surgery was quite higher. Dissatisfied patients showed a higher variation in symptoms of pelvic floor disorders (e. g. anal pain syndrome) besides the rectal evacuation disorder. In addition to the heterogenity of symptoms chronic alterations of pelvic floor structures might create worse results in patients with chronic constipation. In spite of a lot of publications dealing with the functional anatomy of the pelvic floor only a few investigations on the dorsal sphincter dysplasia in patients with rectal evacuation disorder are found in the literature. Further investigations on this disorder are necessary.

Surgical treatment for congenital duodenal obstruction

Thirty-four congenital duodenal obstructions (19 duodenal atresia, 7 duodenal web, 7 annular pancreas and one duodenal stenosis) were surgically treated in Siriraj Hospital between 1990 and 1999. Eleven per cent of duodenal atresia had no bile-stained vomiting. Duodenal web which received web excision and duodenoplasty in 43 per cent of cases, also presented with bile-stained vomiting. Duodeno-duodenostomy, duodeno-jejunostomy and web excision with duodenoplasty were performed in 29, 2 and 3 patients respectively. Duodeno-duodenostomy and web excision with duodenoplasty had no difference in the feeding capability. There was no statistically significant difference in duration of TPN, ability to be early fed, post-operative onset of full feeding and hospital stay between diamond-shaped (n = 18) and side-to-side (n = 11) duodeno-duodenostomy. Although transanastomotic feeding tube (n = 4) decreased a percentage of TPN requirement and made early feeding possible, the onset of full feeding, duration of TPN and hospital stay were not different from those who had no transanastomotic tube (n = 30).

Segmental dilatation of the jejunum resembling prenatal volvulus

A case of prenatally diagnosed intestinal obstruction caused by segmental dilatation of the jejunum is presented. Routine ultrasound scan showed mild polyhydramnios, a dilated small bowel loop, and scoliosis. On repeat ultrasound scan a volvulus was suspected, which led to cesarean section and laparotomy of the newborn, revealing the underlying pathology. Segmental resection and end-to-end anastomosis were followed by an uneventful recovery. Segmental dilatation of the intestine should be considered as a cause of prenatally manifested intestinal obstruction. Concomitant anomalies are frequent and may be helpful in making the correct diagnosis. J Pediatr Surg 36:927-929.

Congenital alveolar capillary dysplasia with misalignment of pulmonary veins associated with hypoplastic left heart syndrome

Three full-term infants died in the first month of life with hypoplastic left heart syndrome (HLH) and persistent pulmonary hypertension (PPH). At postmortem examination, they were found to have alveolar capillary dysplasia with misalignment of pulmonary veins (ACD with MPV). The association of HLH syndrome, and ACD with MPV with intestinal malrotation and/or obstruction, is unique. Decreased blood flow in the ascending aorta in fetuses with left outflow tract obstruction might cause vasoconstriction of pulmonary arterioles to maintain cerebral perfusion. Vasoconstriction early during embryogenesis might lead to decreased growth and development of alveolar capillaries and pulmonary veins. This results in pulmonary hypertension, and the arterial blood is forced to bypass the deficient capillary bed and can drain only via the anomalous bronchial veins.

[Prenatal diagnosis: intestinal obstruction]

We present 4 cases of fetal intestinal obstruction and their ultrasonographical findings. With regard to the reported cases we discuss the diagnostic and differential-diagnostic considerations of this rare but not uncommon fetal malformation.

Allergic eosinophilic gastroenteritis in a boy with congenital duodenal obstruction

Eosinophilic gastroenteritis (EG) is a rare allergy-related disease, especially in early childhood. We present the case of a 1 year 4 month old boy with congenital duodenal obstruction who developed EG. That diagnosis of EG was made by a series of imaging studies and was confirmed by upper gastrointestinal (UGI) endoscopic biopsy studies which showed significant tissue eosinophilia in both mucosal and submucosal layers. No evidence of parasite segment or ova was found in the stool and biopsy specimen. Specific IgE antibodies to milk were estimated to be 2 + (CAP system). Cow's milk allergy was highly suspected but not confirmed by consecutive elimination and challenge tests since the child was too much suffered to be tested. There was partial response to the 2-week treatment with Alfare (semi-elemental formula) and oral prednisolone 1 mg/kg/day. One month after initial examination, perforation of the stomach occurred and exploratory laparotomy disclosed stenosis of the duodenum. Congenital duodenal obstruction was diagnosed based on operative findings and previous sonographic findings. There has been only one report of EG in an infant with congenital duodenal obstruction. The nature of the relationships among cow's milk allergy as a possible etiologic factor, congenital duodenal obstruction as an predisposing factor and EG involvement at both mucosal and submucosal layers remains unclear.

Neonatal intestinal obstruction in Zaria, Nigeria

OBJECTIVE

To study the aetiology, morbidity and mortality of neonatal intestinal obstruction.

DESIGN

A retrospective study.

SETTING

Ahmadu Bello University Teaching Hospital, Zaria, Nigeria.

SUBJECTS

One hundred and fifty one neonates (< or = 28 days) undergoing surgery for mechanical intestinal obstruction.

RESULTS

The male/female ratio was 3:1 and median age at presentation was four days (range five hours-28 days). Anorectal malformation was the commonest cause, 104 (68.9%), 86.5% of which were high anomalies and 13.5% low; the median age at presentation was three days. Fifty two per cent of colostomies for the high anomalies were performed using general anaesthesia and 48% local anaesthetic, but there was an increasing use of local anaesthesia over the years. Hirschsprung's disease accounted for 11 (7.3%) of the cases, representing 20% of all patients presenting with Hirschsprung's disease to this hospital; the median age was six days and in two patients the caecum and sigmoid colon respectively had perforated; nine patients had colostomy, one caecostomy and one ileostomy (total colonic aganglionosis). Eleven (7.3%) patients had incarcerated or strangulated ingunial hernia (ten) and congenital ventral hernia (one); the hernias were repaired in all patients and three required intestinal resection for gangrene, two of which had ipsilateral testicular gangrene, necessitating orchidectomy. Intestinal atresia was the fourth common cause of obstruction ten (6.7%), eight of which were jejunoileal atresias and two duodenal and the median age was seven days; one atresia was associated with Hirschsprung's disease and had ileostomy, all other jejunoileal atresias were resected and duodenoduodenostomy was performed for the duodenal atresias. Other less common causes of neonatal intestinal obstruction were incarcerated exomphalos, malrotation, hypertrophic pyloric stenosis, annular pancreas, and idiopathic ileal volvulus and meconium ileus respectively. Postoperative complications occurred in sixteen of 95 patients (16.8%) including colostomy or ileostomy complications 11, wound infection three and anastomotic dehiscence (two). The overall mortality was 21.1%, 70% from overwhelming infection and 30% respiratory embarrassment; the mortality from the various conditions were Hirschsprung's disease 43%, intestinal atresia 40%, incarcerated exomphalos 40%, anorectal malformation 18.5% and the only patient with volvulus died.

CONCLUSION

The morbidity and mortality of neonatal intestinal obstruction in this hospital has improved over previous years due largely to meticulous resuscitation before surgery but the problems of late presentation and poor neonatal intensive care facilities persist. The findings are at variance with those in developed countries.