Duodenal manometry in postobstructive enteropathy in infants with a transient enterostomy

Intestinal motility was studied in 11 children with a transient enterostomy secondary to a neonatal organic small intestine obstruction (5 total colon Hirschsprung's disease, 2 necrotizing enterocolitis, 1 intussusception, 3 ileal atresia). Eight children presented with a postobstructive enteropathy (severe grade I [5], moderate grade II [3]) and three were considered as controls (grade III). They were assigned to one of the three groups on the basis of the duration of parenteral nutrition and constant rate enteral nutrition needed and the oral feeding tolerance. Barium small intestine transit showed no persistent partial obstruction or peritoneal adhesions. The abnormal inert marker transit times were statistically correlated with the clinical groups as well as duodenal manometric abnormalities. Manometric recordings were characterised by the absence (grade I) or abnormal phase III (grade II) of the migrating motor complex and decreased motility index (grades I and II). This study confirms that this enteropathy is due to a chronic alteration in motility induced by prenatal or postnatal obstructions.

Congenital diaphragmatic hernia and intrathoracic intestinal volvulus

The main symptom of the congenital diaphragmatic hernia (CDH) is the respiratory distress due to the pulmonary hypoplasia and the persistence of foetal pulmonary circulation. Sometimes the CDH appears outside of the neonatal period with respiratory symptoms, abdominal pain and seldom with intestinal obstruction. A case of CDH presenting with intrathoracic volvulus is reported. This case shows that tendency of delayed repair until the newborn has been recovered, require more attention because the good condition of the patient can be changed not only by the pulmonary hypoplasia and the persistence of the foetal pulmonary circulation but also by the symptoms of the intrathoracic gut complications.

Intestinal atresia and stenosis as seen and treated at Kenyatta National Hospital, Nairobi

In this retrospective study carried out covering the period, 1978-1991, 62 neonates were seen, diagnosed and treated for intestinal atresia which included: duodenal atresia and stenosis, small bowel atresia and atresia of large bowel. Locations of obstruction were duodenal in 17 patients, jejunal in 25 patients, jejuno-ileal in 5 and colon in two. Duodenal atresia was noted in 9 infants and duodenal stenosis due to annular pancreas, Ladd's bands with malrotation of bowel in 8. Associated anomalies which were observed were anorectal malformations in 2 and malrotation in 2 infants. Birth weights ranged from 1450 gm to 3000 gm. Prematurity was recorded in 11 infants. Diagnosis of intestinal atresia in our patients was made clinically and radiologically. Intestinal atresia in neonates was differentiated from other causes of obstruction such as Meconium Ileus, Hirschsprung's disease, neonatal volvulus, rectal atresia in anorectal malformations. Treatment of infants with intestinal atresia was surgical. Surgical techniques used depended on pathological findings. In 36 patients, complications such as functional obstructions with vomiting and failure to thrive, malabsorption, aspiration, bronchopneumonia, sepsis were observed. Overall mortality rate in our cases was 25 (41.9%) out of 62 patients.

Simultaneous laparotomy and intraoperative endoscopy for the treatment of high jejunal membranous stenosis in a 1-year-old boy

A 1-year-old boy with high jejunal membranous stenosis was successfully treated "a minima" by antimesenteric longitudinal enterotomy over the diaphragm, excision of the latter, and transverse closure of the bowel. This was made possible by use of simultaneous peroperative endoscopy, which allowed exact localization of the diaphragm. Peroperative endoscopy is a useful and accurate method for this purpose and should be considered in similar cases.

Prenatal diagnosis and management of congenital volvulus

We present a case of a twin gestation in which one twin developed a complex abdominal mass and signs of small bowel obstruction. Following delivery, an exploratory laparotomy revealed a meconium pseudocyst and midgut volvulus. While the infant survived, a large portion of small bowel was atretic, resulting in short bowel syndrome. The prenatal diagnosis of volvulus is rare. When volvulus is present, the risk of bowel infarction is high, with variable perinatal outcome.

Retroperitoneal jejunal diverticulum: cause of intestinal obstruction

A 3-week-old boy presented with repeated episodes of vomiting and constipation. At laparotomy a jejunal diverticulum arising from its antimesenteric border and extending retroperitoneally was found. The narrow neck of diverticulum caused a situation similar to a Richter's hernia. The fundus of diverticulum was attached to the upper pole of left kidney. A retroperitoneal jejunal diverticulum is a new addition to the cause of neonatal intestinal obstruction.

Management of catastrophic neonatal midgut volvulus with a silo and second-look laparotomy

The case of a neonate with midgut volvulus and severe intestinal ischemia extending from the ligament of Treitz to the midtransverse colon is presented. Management consisted of abdominal silo application at the initial exploration to obviate the adverse physiological consequences of increased intraabdominal pressure from reperfusion edema of the intestine. The majority of the intestine was salvaged, and a short segment of ileum was resected. This method of treatment resulted in optimal ventilatory status, renal function, and cardiac performance. The advantages of temporary prosthetic wound coverage in selected cases of midgut volvulus include greater physiologic stability through the avoidance of "intraabdominal hypertension" and the ability to monitor the status of the intestine at the bedside.

Familial intestinal malrotation with midgut volvulus and facial anomalies: a disorder involving a gene controlling the normal gut rotation?

We report on 2 sisters with congenital midgut volvulus. Both had similar facial changes different from those of their parents and the other 2 unaffected sibs. Both parents had normal barium meal roentgenograms. The occurrence of these abnormalities in sibs born to parents with apparently normal gastrointestinal tract anatomy suggest autosomal recessive inheritance, although a coincidence, multifactorial or autosomal dominant inheritance with nonpenetrance in either of the parents cannot be excluded.

Alimentary tract duplications in infants and children

This is a review of 30 duplications of the alimentary tract in 28 patients treated at the Surgical Unit of the Children's Department of the Medical University of Pécs, Hungary, and at the Department of Pediatric Surgery of the Medical Academy of Dresden, Germany, from 1964 to 1989. The ages of patients ranged from 1 day to 13 years, 80 percent were less than 2 years of age at initial presentation. There were 6 thoracic, 20 abdominal and 2 thoraco-abdominal duplications. Distended abdomen, vomiting, bowel obstruction and palpable abdominal mass were most frequently encountered. Plain thoracic and abdominal x-rays, ultrasonography, barium esophagogram, barium meal and enema were the most common diagnostic procedures. Emergency operative intervention was required in 18 patients. One infant died of an unrelated disease. Twenty-three duplications were cystic and 3 tubular. One patient had an appendiceal duplication, and another patient a flat lumenless duplication located on the perineum close to the anal opening. The surgical procedure--removal of the duplication--should not be more radical than necessary to eliminate the potential complaints and prevent recurrence. During surgery the common blood supply shared between the duplication and the native bowel must be carefully protected to avoid undue sacrifice of normal bowel.

Management and survival of meconium ileus. A 30-year review

Cystic fibrosis patients born with meconium ileus (MI) have had an improved outcome over the last three decades. The authors reviewed the impact of surgical management and long-term nutritional care on the survival of patients with MI. Of the 59 cases of MI seen from 1959 to 1989, 48 cases were managed operatively using either the Bishop-Koop ileostomy (BK), the Mikulicz ileostomy, primary resection and anastomosis (RA), or ileostomy. Six-month survival of MI has improved from 37% to 100%. Nonoperative cases (n = 11) had 100% long-term survival. The RA survivors required less late operative intervention (20%) as compared with other surgical patients (81%). A comparison of serial growth percentiles of CF patients with MI with those of their non-MI CF peers showed similar long-term decreases. These data confirm: (1) There is an improved survival for MI independent of the surgical procedure; (2) The BK ileostomy is an effective and time-tested MI treatment; (3) Primary resection and anastomosis in selected cases may have a lower surgical morbidity rate; and (4) Meconium ileus does not adversely affect the long-term nutritional outcome of CF patients.

Symptomatic congenital lesions of the alimentary tract in adults

Congenital anomalies of the alimentary tract can evade detection into adulthood because they cause only moderate symptoms or they escape purview of a prepared observer. In other instances, evolution or copathogenesis may need to occur before the lesions become manifest. We have managed 17 of these patients presenting at ages 23 to 71 years. The median duration of symptoms was 5 years, ranging from 1 months to 23 years. Defects of foregut embryogenesis predominated (71%). We were able to establish the correct diagnosis before operating on nine patients, but three had already had a previous celiotomy for the same problem so a truly preoperative diagnosis was possible in only six (35%). The literature validates the dominance of foregut anomalies in adults. There is no older age limit that would exclude consideration of these lesions. Endoscopy, computerized tomography, and ultrasonography have greatly facilitated recognition, but our experience suggests that the principal obstacle to timely diagnosis is the reluctance to consider a congenital cause for an adult's symptoms.

Intrauterine volvulus without malrotation

This report describes two cases of intrauterine volvulus without associated intestinal malrotation. Polyhydramnios was present in one neonate; the presentation was very sudden and catastrophic in the other. Neither plain films nor contrast enema indicated the correct preoperative diagnosis in these infants. A "normal" plain film or enema in a suspected case of volvulus may lead to a delay in surgical management resulting in extensive ischemic necrosis of the bowel, often with extremely high mortality. Bile emesis or aspirate in neonates demands a high index of suspicion of intestinal obstruction. Shock, bloody diarrhea, and tense and distended abdomen are ominous, indicating volvulus often with gangrene.

Experimental intestinal obstruction in rats. Studies on structure and disaccharidase activities

An experimental model of congenital intestinal obstruction (CIO) was created in rats by means of fetal intrauterine surgery between the 16th and 20th days of gestation. By the use of a microsurgical technique areas at the mid-jejunum or the jejuno-ileal junction were infarcted by coagulation of mesenteric vessels. Gestation was terminated by Cesarean section within 24 hours before expected term to avoid cannibalism. The structure of the intestinal mucosal cells proximal and distal to the CIO at the light microscopy as well as the ultrastructure level was not changed indicating that the surgical method was successful. The activities of the brush border enzymes, maltase and lactase were significantly reduced distal to the obstruction as compared to controls. Proximal to the obstruction lactase was the only enzyme showing reduced activity in comparison to controls. These findings were not dependent on the localization of the obstruction or when it was performed and suggest that CIO causes selective changes of the biochemical properties of the cell membrane. The results are in agreement with the findings of disaccharidase activities in biopsies taken from human infants with CIO and point to the importance of a normal intestinal passage for the development of brush border enzymes.

[Chilaiditi's colon interposition in a patient with Rett syndrome]

We report on a patient with Rett syndrome associated with Chilaiditis interposition of the colon. Episodes of severe hyperventilation with aerophagia, immobility and obstipation facilitated the occurrence of an interposition of the colon. Conservative therapeutic measures were not successful, surgical intervention was necessary to cure the symptoms.

[Clinical aspects and therapy of intestinal non-rotation in adults]

The intestinal non-rotation is a rare fetal disorder of the gut torsion. Its manifestation is very rarely seen in the adult, either in form of a volvulus of the midgut or ileocecal with an acute onset, or as chronic recurrent abdominal pain. Each diagnostic or therapeutic delay increases the risk of strangulation and may end as an abdominal disaster. We describe three own cases and we try to elucidate the diagnostic and therapeutic problems. Our proceeding: In the acute symptomatic form the explorative laparotomy with a consequent staging of the abdominal situs is the safest way to get an exact diagnosis. Therapeutically the procedure described by LADD is the best torsion prophylaxis; the ascending colon is sawn to the descending colon. Due to a paratopia, the appendectomy is recommended. In the chronic forms the contrast enema and the gastrointestinal barium study are the main diagnostic procedures. In the operation described by Fitzgerald and the ascending colon and the mesentery of the small bowel are--after incision of the common mesentery--fixed at their anatomical site.

[Prenatally diagnosed intestinal obstruction--contribution of pediatric surgery]

The diagnosis of a small intestinal obstruction was made prenatally between the 31st and 36th week of pregnancy in 7 patients with neonatal ileus. Five newborns showed a meconium-peritonitis, a meconium-ileus and the last a ileal atresia. These were compared with newborns with small intestinal obstruction, which had not been diagnosed prenatally. The analysis of our hospital information indicates, that primarily serious forms of ileus and intestinal perforations are diagnosed prenatally, whilst isolated small intestinal obstruction often avoids diagnosis. For this reason, diagnostic punctation of the foetal abdomen contribute little to the establishment of the etiology of the obstruction and should be avoided. On the other hand, punctation of a foetal ascites can, through pressure reduction of the abdomen, lengthen the duration of pregnancy and permit a spontaneous birth.

Gastrointestinal myoelectric activity in an infant with congenital idiopathic motility disorder

We investigated myoelectric activity in an 8-month-old male who presented with a perinatal bowel obstruction, duodenal band, congenital short small intestine, and persistent feeding intolerance. Serosal electrodes were surgically implanted on stomach, duodenum, and jejunum during Nissen fundoplication and ileostomy. A 5-cm ileal specimen was taken for in vitro studies. Spontaneous migrating myoelectric complexes (MMC) were present in stomach and small intestine. Bethanechol increased electrical response activity (ERA) in stomach and duodenum. Morphine induced intense ERA and distinct phase III activity. Pentagastrin infusion did not disrupt MMC cycling. Feeding disrupted MMC complex cycling 30-40 min after the meal. Metoclopramide before feeding delayed disruption of the MMC cycling after the feeding. Intermittent gastric arrhythmias were present after the fifth postoperative day. In vitro muscle strips showed spontaneous contractions and electrical control activity (ECA). Bethanechol, McNeil A-343, motilin, and cholecystokinin induced contractions, but pentagastrin had no effect. We conclude that in spite of a major clinical motility dysfunction, several of our findings were normal. The abnormalities include short MMC period, absence of disruption of MMC by pentagastrin, and gastric arrhythmias.

Prenatal ultrasound diagnosis of intestinal obstruction: a case report

A case of intrauterine intestinal obstruction diagnosed at 31 weeks' gestation by sonographic examination is presented. Unlike other reported cases, the diagnosis was made early in the third trimester and before the development of polyhydramnios. The patient was managed conservatively until delivery at 33.5 weeks. At exploratory laparotomy, immediately after birth, ileal atresia was found and resected. The infant recovered uneventfully.

Clinical and genetic comparisons of patients with cystic fibrosis, with or without meconium ileus

We set out to determine if the clinical course or genetic profiles of patients with cystic fibrosis who had meconium ileus differed from those of other patients with cystic fibrosis. Since 1950 we have followed 158 patients with meconium ileus among 1175 patients with cystic fibrosis (13.4%). Patients with meconium ileus had lower birth weight (3026 +/- 610 gm) than patients with no meconium ileus (3169 +/- 534 gm; p less than 0.008); the deficit was especially evident in female patients. Survival in the first year of life increased from 55% in those born between 1958 and 1972 to 96% in those born between 1973 and 1987. Since 1973 the median survival of male and female patients with meconium ileus was similar to that in female patients with no meconium ileus (21 years), whereas 78% of males with no meconium ileus survived to this age (p less than 0.0001). Patients with meconium ileus born before 1972 had lower weight and height percentiles at age 13 years compared with patients with no meconium ileus, but this difference was not as apparent in patients born after 1973. There were no differences between the two groups in forced vital capacity, forced expiratory volume in 1 second, or forced expiratory flow in the middle half of forced vital capacity. Patients with meconium ileus acquired Pseudomonas aeruginosa at a younger age than did patients with no meconium ileus (4.20 +/- 4.67 vs 7.18 +/- 5.19 years), but there was no difference in age of acquisition of P. cepacia. In families in which the first child had meconium ileus, 29% of subsequent siblings with cystic fibrosis had meconium ileus, compared with 6% of siblings born to families in which the first child did not have meconium ileus. Allelic frequencies and haplotypic variants for cystic fibrosis chromosomes with respect to DNA markers closely linked to the cystic fibrosis locus were similar in families with cystic fibrosis with meconium ileus and those with no meconium ileus. These findings suggest that patients with cystic fibrosis and those without meconium ileus do not have major intrinsic differences and that the previously poor outlook in patients with meconium ileus has improved greatly.

Extensive intestinal aganglionosis

Extensive aganglionosis very close to the ligament of Treitz and total intestinal aganglionosis are rare forms of Hirschsprung's disease. In these cases, nutrition, fluid, and electrolyte balance are a problem. Although the myectomy-myotomy technique of Ziegler appears hopeful, no effective surgical method has been put into the practice for the treatment of these rare forms of Hirschsprung's disease. We report four cases with extensive intestinal aganglionosis, one of which was total intestinal aganglionosis with involvement of the stomach.

[Determination of protein nitrogen utilization with (15N) yeast protein in short bowel syndrome]

The digestive and absorptive capacity for food protein was studied in 8 infants with short bowel syndrome by means of [15N] yeast protein as a tracer substance. The extent of resection ranged from total removal of the small bowel to partial closures of the large bowel by colostomies. The tracer substance was administered as single oral pulse labeling in a dosage of 5 mg 15N/kg. The fecal losses of 15N were extremely high in cases of total and subtotal resection of the small bowel as well as after operative removal of the Bauhins valve. In the entirety they ranged between 3 and 95% of the intake. The corresponding 15N-retention in the protein pool was in the range between 0.1 and 91.6%. Operative findings, nutritional state and passage time were of limited value for the prediction of food protein assimilation. Even residual lengths of 25 cm of the small bowel turned out to be compensated, which was shown in one of the infants by an absorption of 97% and a retention rate of 84%. The oral [15N] yeast protein loading can be considered a reliable test for the evaluation of protein nitrogen absorption and utilization in short bowel syndromes.