Infantile pyloric stenosis associated with major anomalies of the alimentary tract

Is screening ultrasound of the urinary tract indicated in infants with hypertrophic pyloric stenosis?

AIM

Few retrospective studies have evaluated infants with hypertrophic pyloric stenosis (HPS) for associated urological anomalies. They have led to contradictory conclusions. The aim of this study was to evaluate the incidence of urinary tract anomalies in infants with HPS and to establish the clinical significance of this association.

METHODS

One hundred and twenty-two infants (100 boys) who underwent pyloromyotomy between 1992 and 2002 were prospectively evaluated. Screening ultrasound (Us) of the urinary tract was performed in 107 infants, while 15 did not attend their ultrasound appointment.

RESULTS

Renal ultrasound was abnormal in 4 (4%) of 107 screened patients with HPS. Three patients were found to have mild hydronephrosis and, in one patient, a small, normal kidney was detected. Two patients with hydronephrosis had Us follow-up and the third patient underwent Tc-99 mercaptoacetyl triglycine (MAG 3) scan. In all three patients, the hydronephrosis resolved completely on follow-up scan.

CONCLUSION

The incidence of abnormal renal ultrasound in children with HPS is similar to the reported incidence of 3-6% determined with routine ultrasound screening of healthy newborns. The abnormalities detected were not clinically relevant and did not require surgical intervention. We do not recommend screening of the urinary tract in infants with HPS.

Further delineation of the phenotype associated with heterozygous mutations in ZFHX1B

Mutations or deletions involving ZFHX1B (previously SIP1) have recently been found to cause one form of syndromic Hirschsprung disease (HSCR), associated with microcephaly, mental retardation, and distinctive facial features. Patients with the characteristic facial phenotype and severe mental retardation, but without HSCR, have now also been shown to have mutations in this gene. Mutations of ZFHX1B are frequently associated with other congenital anomalies, including congenital heart disease, hypospadias, renal tract anomalies, and agenesis of the corpus callosum (ACC). We present the clinical data and mutation analysis results from a series of 23 patients with this clinical syndrome, of whom 21 have proven ZFHX1B mutations or deletions (15 previously unpublished). Two patients with the typical features (one with and one without HSCR) did not have detectable abnormalities of ZFHX1B. We emphasize that this syndrome can be recognized by the facial phenotype in the absence of either HSCR or other congenital anomalies, and needs to be considered in the differential diagnosis of dysmorphism with severe mental retardation +/- epilepsy.

The approach to common abdominal diagnosis in infants and children

This article focuses on salient points in the evaluation of abdominal pain in infants and children. Specifically, the authors address appendicitis and abdominal pain associated with either vomiting, constipation, or gastrointestinal bleeding. A discussion of common abdominal masses, urologic, and gynecologic problems, and considerations in the evaluation of immunologically suppressed or neurologically impaired children, and children with recurrent abdominal pain is also presented. The authors establish logical, focused approaches to the initial evaluation and management of abdominal pain and suggest criteria for timely surgical referral.

Infantile hypertrophic pyloric stenosis and hydronephrosis: is there an association?

Infantile hypertrophic pyloric stenosis is a common condition requiring surgical intervention during the first few weeks of life. The incidence of infantile hypertrophic pyloric stenosis ranges from 0.13 to 0.4% of live births in the United States, Britain and Scandinavia. Associated anomalies have been described in 6 to 33% of the cases in the central nervous system, gastrointestinal tract and heart. An association of infantile hypertrophic pyloric stenosis with urinary tract anomalies has not been previously documented. A review of 422 patients with infantile hypertrophic pyloric stenosis revealed urinary tract anomalies in 6 (10 renal units), including 4 renal units with vesicoureteral reflux and 9 with hydronephrosis. This incidence of 1.4% is greater than the 0.2% incidence expected in the general population. This 7-fold increase in urinary tract anomalies in patients with infantile hypertrophic pyloric stenosis suggests an association between the two and warrants further investigation. Serious consideration should be given to obtaining renal ultrasound examinations in patients with infantile hypertrophic pyloric stenosis.

Infantile hypertrophic pyloric stenosis and congenital diaphragmatic hernia

The association of infantile hypertrophic pyloric stenosis with congenital diaphragmatic hernia is rare. We report three cases of infantile hypertrophic pyloric stenosis who had concomitant congenital diaphragmatic hernia.

Recent results of treatment of infantile hypertrophic pyloric stenosis

During the five year period December 1980 to November 1985, 106 infants with hypertrophic pyloric stenosis were treated. There were no operative deaths, but two late deaths occurred from associated abnormalities. The combination of preoperative rehydration, skilled anaesthesia, and the use of the Fredet-Ramstedt operation (pyloromyotomy) have virtually eliminated mortality from uncomplicated infantile hypertrophic pyloric stenosis. The most common complications were gastro-oesophageal reflux in 11 (11%), perforation of the duodenal fornix in nine (8%), and wound infection in five (5%); no wound dehisced.

Preventable death in oesophageal atresia

We report on experience gained in the treatment of 158 cases of oesophageal atresia presenting during a period of 10 years. The factors influencing mortality were analysed. During the period studied there was a slight improvement in survival, and this was probably due mainly to improved preoperative preparation of those babies undergoing primary repair. At best, 'staging' was thought to have had little influence on the survival of poor risk cases. Midwives, obstetricians, paediatricians, surgeons, and general practitioners did not do all that they could have done to prevent morbidity and mortality in these babies. At least one-third of the 79 deaths could have been prevented, and several deaths were caused solely by lack of awareness of the possible complications and associated abnormalities.

Oesophageal atresia in the South West of England

A retrospective anatomical and family study was made of 345 patients with oesophageal atresia who were born in the South West of England between 1942 and 1973. There were 186 males and 159 females. Twenty-one cases were stillborn. Eighty-five percent of the patients had a combination of oesophageal atresia with a tracheo-oesophageal fistula to the distal oesophageal segment, and 9 percent had atresia without a fistula. Fifty-five per cent of the patients had other congenital malformations and these tended to be multiple rather than single. Thirty-six per cent of singletons had unequivocal fetal growth retardation, and there is some evidence that nearly all cases have poor fetal growth. There appeared to be a maternal age effect, with an excess of mothers under 20 and over 35, and there was an unexplained excess of fathers employed in the Armed Forces. Ten per cent of the cases were illegitimate. There were 21 twins which is nearly three times the expected number; there were two pairs of twins concordant for oesophageal atresia, one being monozygotic and the other dizygotic. In one case there were two sibs with oesophageal atresia. Five out of 365 sibs had anencephaly. The blood group distributions of the patients and their mothers did not significantly differ from the expected distribution. Oesophageal atresia is aetiologically heterogenous. In this series there were at least five, and probably 10 cases of trisomy 18 and four cases of trisomy 21. Five mothers had overt diabetes, and there is some suggestion from other work that maternal diabetes or its treatment may be aetiologically important. Oesophageal atresia was part of a possibly recessively inherited malformation syndrome in two cases. A sibship with a case of rectal atresia, a case of Hirschprung's disease and a case of oesophageal atresia may represent the action of another recessive gene. It seems likely that oesophageal atresia is a rather non-specific consequence of several teratological processes.