Congenital obstructed megaureters in early infancy: diagnosis and treatment

Fetal screening during maternal ultrasonography has changed the mode and age of presentation of congenital uropathies, particularly congenital obstructed megaureter. We studied 47 infants less than 8 months old with primary obstructed megaureter. Surgical correction in 42 patients with moderate to severe obstruction was performed at a mean age of 1.8 months in those detected prenatally and 3.8 months in those presenting after birth. All infants showed functional and structural urographic improvement with a mean followup of 2.3 years. Reflux was seen postoperatively in 8 patients, which subsided spontaneously in 3, continues to be followed in 2 and resulted in repeat reimplantation in 3. Five infants had mild obstruction, which was managed nonoperatively and 2 showed progressive obstruction, which required repair at ages 20 and 28 months. Repair of obstructed megaureters in early infancy improves renal drainage and offers the potential for preventing renal damage before the development of symptoms or infection. With proper attention to detail, excellent results may be achieved.

Caroli disease: central dot sign in CT

Two adults with communicating cavernous ectasia of the biliary tract (Caroli disease) are described. Both patients had the pure form of the disease, characterized by saccular dilatation of intrahepatic bile ducts, multiple intrahepatic calculi, absence of portal hypertension, and associated cystic renal disease. Computed tomographic (CT) scans of the liver showed tiny dots with strong contrast enhancement within dilated intrahepatic bile ducts (the central dot sign). These intraluminal dots on CT scans corresponded to intraluminal portal veins on sonograms, findings indicating portal radicles surrounded by dilated intrahepatic bile ducts.

Changing concepts in management of primary obstructive megaureter

The management of neonatal urinary tract dilatations represents one of the most challenging dilemmas in pediatric urology today. We have been confronted with 44 renal units in 35 neonates diagnosed as having primary obstructive megaureter during the last 6 years. Of these units 23 in 17 infants were diagnosed antenatally and 20 (87 per cent) have been managed without surgical intervention. Notably, 16 renal units were graded as moderate to severe megaureters by an excretory urogram. The decision to manage conservatively was based on the initial extraction of the 99mdiethylenetriaminepentaacetic acid renal scan (the extraction factor). This estimate of absolute renal function has been used to differentiate dilatations with obstructive implications for the renal parenchyma from those without. Significantly, expectant treatment has resulted in improvement of dilatation on sequential excretory urograms in 15 megaureters and none has shown a deterioration of function by renal scan. Similar diagnostic criterion also has resulted in conservative management for 12 of 21 additional neonatal megaureters seen during this period with symptoms or they were discovered serendipitously. Only 2 of these 12 megaureters required surgical correction. The neonatal primary megaureter appears in many cases to represent a different entity than those that commonly presented before the advent of antenatal and perinatal diagnosis.

Cochlear implants in children with congenital inner ear malformations

OBJECTIVE

To describe clinical experiences with multichannel cochlear implantation in children with inner ear malformations, including surgical indications and techniques, imaging findings, and outcomes.

DESIGN

A retrospective review of a series of 10 consecutive cases with a mean follow-up of 29 months, as well as a review of the literature.

SETTING

Academic referral center.

SUBJECTS

Ten children who underwent multichannel cochlear implantation for inner ear malformations. High-resolution computed tomographic scans demonstrated a common cavity deformity in 3, an incomplete cochlear partition in 4, and an enlarged vestibule in 1. Two had membranous anomalies as indicated by cerebrospinal fluid gushers at surgery, but the results of imaging were normal.

INTERVENTION

All subjects received multichannel cochlear implants. Two subjects underwent mastoid obliteration at the time of implantation owing to preoperative recurrent meningitis or chronic otitis media with episodes of clinical mastoiditis.

MAIN OUTCOME MEASURES

The 10 subjects were evaluated for electrode insertion and stability and auditory function for up to 7 years.

RESULTS

All 22 electrodes are functional in each child with an incomplete partition, an enlarged vestibule, or a membranous anomaly. Of 3 subjects with common cavities, 2 had full insertion of electrodes and 1 had 16 electrodes inserted. All subjects had speech awareness thresholds detected at 25 dB or better. Three (75%) of the 4 subjects with at least 30 months of experience, including 1 subject with a common cavity, have developed open-set word recognition.

CONCLUSIONS

Electrode insertion and hearing results in children with an incomplete partition, an enlarged vestibule, or a membranous anomaly are similar to those in children with normal cochleas. Specific surgical techniques are effective for children with a common cavity, and the results are less certain. Cerebrospinal fluid gushers were encountered frequently but were not difficult to control.

Clinical outcome and management of prenatally diagnosed primary megaureters

The objective of this study was to evaluate the clinical outcome of infants diagnosed perinatally with primary obstructive megaureter, and to determine which anatomical and physiological indexes best predict such outcome. A total of 67 megaureters thought to be due to primary vesicoureteral junction obstruction was detected in 53 newborns as a result of prenatally diagnosed hydronephrosis or hydroureteronephrosis. These patients were followed nonoperatively using periodic ultrasound and 99mtechnetium-diethylenetriaminepentaacetic acid (Tc-DTPA) renal scans. After a mean followup period of 3.1 years 23 dilated ureters (34%) spontaneously resolved while 33 (49%) persisted. Repair was performed on 11 megaureters (17%) because of breakthrough urinary infections in 3 and deteriorating renal function in 8. Postoperatively, all renal units showed improved drainage on 99mTc-DTPA renal scan, while half of those with decreased renal function regained the lost function. None had further deterioration in renal function. Of the clinical indexes studied ultrasonographic ureteral diameter (less than 6 mm. good, greater than 10 mm. poor prognosis) and drainage on 99mTc-DTPA renal scan correlated best with outcome. We conclude that the majority of primary megaureters detected in the perinatal period can be followed conservatively using periodic ultrasound and 99mTc-DTPA renal scans. Relatively few cases required surgical intervention and those at risk were identifiable by a diameter greater than 10 mm. and poor drainage on 99mTc-DTPA renal scan.

Congenital hepatic fibrosis: CT findings in 18 adults

PURPOSE

To evaluate the computed tomographic (CT) findings in adult patients with pathologically proved congenital hepatic fibrosis.

MATERIALS AND METHODS

This was a retrospective review of congenital hepatic fibrosis cases identified at two institutions over the course of 8 years. Eight men and 10 women with an age range of 22-72 years (mean age, 39 years) were included. Contrast material-enhanced and unenhanced CT scans were obtained through the liver in all patients. Two radiologists evaluated size of and morphologic findings (atrophy or hypertrophy localized according to hepatic segments) in the liver; increased diameter or number of hepatic arteries at the hilum; presence of hepatic nodules, varices, spontaneous splenorenal shunts, and splenomegaly; and association with other hepatic ductal plate malformations and renal abnormalities.

RESULTS

Sixteen patients had morphologic abnormalities in the liver, 15 had splenomegaly (three underwent splenectomy for portal hypertension), and 14 had varices or spontaneous splenorenal shunts. An enlarged hepatic artery and a tangle of abnormally enlarged arterial vessels were identified in five and four patients, respectively, and four of these nine patients had large benign regenerative nodules. Ten patients had renal abnormalities and nine had an associated ductal plate malformation.

CONCLUSION

This retrospective study shows that certain findings (ie, liver morphologic and associated ductal plate abnormalities, varices, splenomegaly, and renal abnormalities) are frequently observed in combination in patients with congenital hepatic fibrosis.

Preterm brain injury: Germinal matrix-intraventricular hemorrhage and post-hemorrhagic ventricular dilatation

Germinal matrix hemorrhage and intraventricular hemorrhages (GMH-IVH) remain a common and clinically significant problem in preterm infants, particularly extremely preterm infants. A large GMH-IVH is often complicated by posthemorrhagic ventricular dilation (PHVD) or parenchymal hemorrhagic infarction and is associated with an increased risk of adverse neurologic sequelae. The widespread use of cranial ultrasonography since the early 1980s has shown a gradual decrease in the incidence of GMH-IVH and has helped with the identification of antenatal and perinatal risk factors and timing of the lesion. The increased use of magnetic resonance imaging (MRI) has contributed to more detailed visualization of the site and extent of the GMH-IVH. In addition, MRI has contributed to the awareness of associated white matter changes as well as associated cerebellar hemorrhages. Although GMH-IVH and PHVD still cannot be prevented, cerebrospinal fluid drainage initiated in the early stage of PHVD development seems to be associated with a better neurodevelopmental outcome. Further studies are underway to improve treatment strategies for PHVD and to potentially prevent and repair GMH-IVH and PHVD and associated brain injury. This chapter discusses the pathogenesis, incidence, risk factors, and management, including preventive measures, of GHM-IVH and PHVD.

Laryngoceles and saccular cysts in infants and children

Laryngoceles and saccular cysts are an unusual cause of respiratory obstruction in infants and children. Laryngoceles in particular are less common in the pediatric population than in adults. They typically produce intermittent upper airway obstruction and hoarseness (due to episodic filling with air), and are, therefore, difficult to diagnose. Saccular cysts produce similar symptoms but are not episodic. While smaller anterior saccular cysts are readily managed by endoscopic excision, larger saccular cysts tend to recur repeatedly. Review of experience with 20 infants and children having saccular pathologic changes (17 saccular cysts and three laryngoceles) suggests that saccular lesions are more troublesome than is generally appreciated. The clinical course is typically a lengthy one, with multiple endoscopic procedures. Most patients required tracheotomy, some under emergent conditions. Three patients acquired subglottic stenosis; one was clinically significant. A fourth patient had a congenital subglottic stenosis. Saccular cysts can be managed endoscopically in many cases, but if persistent after two or three endoscopic procedures, a prolonged course can be anticipated. Complete excision, endoscopically or through an external surgical approach, may shorten the clinical course.

The relation between carcinoma of the gallbladder and an anomalous connection between the choledochus and the pancreatic duct

An anomalous connection between the choledochus and the pancreatic duct may be associated etiologically or pathogenetically with congenital biliary dilation and carcinoma of the dilated bile duct. During the past 10 years, a total of 14 cases of carcinoma of the gallbladder with an anomalous connection between the choledochus and the pancreatic duct were encountered. These cases were studied in reference to their clinical features and histological findings. An experimental model of pancreatic juice inflow into the gallbladder of mongrel dogs was produced and the histological changes of the mucosa of that organ was observed. The intent was to elucidate the relationship between carcinoma of the gallbladder and this anomaly. The results of this clinical and experimental study suggest that reflux and stasis of pancreatic juice in the gallbladder induce chronic cholecystitis with intestinal metaplasia. This may be important in the pathogenesis of well-differentiated carcinoma of the gallbladder.

Intrahepatic cholangiocarcinoma arising 10 years after the excision of congenital extrahepatic biliary dilation

A 52-year-old woman was found to have a liver tumor during treatment for a liver abscess. The tumor was diagnosed as intrahepatic cholangiocarcinoma by closer examinations, including a percutaneous needle biopsy. Ten years previously, she had undergone excision of a choledochal cyst, with reconstruction by Roux-en-Y hepaticojejunostomy, as treatment for Todani's type Ia congenital biliary dilation, which had been confined only to the extrahepatic bile duct. The significant association between congenital biliary dilation and hepatobiliary malignancies is well known. Some patients have been reported to develop biliary cancer long after the excision of the entire extrahepatic bile duct and hepaticoenterostomy. However, in these patients, the development mostly took place in the remnant choledochal cyst, the anastomotic site, or in the dilated intrahepatic bile duct of Todani's type IV-A congenital biliary dilation. The development of intrahepatic cholangiocarcinoma after operation has not been reported previously in a patient with Todani's type I congenital biliary dilation. This case suggests that the entire biliary tree may have a high risk of field cancerization, even in extrahepatic congenital biliary dilation.

Apoptosis and cell proliferation in biliary atresia

Biliary atresia (BA), which is thought to result from progressive destruction of the bile ducts by a necroinflammatory process, is the most common cause of obstructive jaundice in infancy. Abnormalities in the cell turnover of remodelling ductal plates are considered one of the important aetiological factors in this disorder, but little work has been done on this topic. Programmed cell death or apoptosis was therefore examined by TdT-mediated dUTP biotin nick end labelling (TUNEL) and cell proliferation by Ki67 immunostaining in 34 cases of BA. The results were compared with normal control liver (five cases) and congenital dilatation of the bile ducts (CDB, five cases) in order to study the cell turnover or tissue dynamics of BA. The TUNEL labelling index (LI) in bile ducts (48.9 +/- 13.2 per cent) was significantly higher than that of the control normal liver (3.6 +/- 2.8 per cent) and of CDB (2.5 +/- 5.1 per cent). The Ki67 LI in the bile ducts of BA (15.0 +/- 5.57 per cent) was also significantly higher than that of CDB (8.6 +/- 5.4 per cent). No significant differences of the TUNEL and Ki67 LIs in hepatocytes were, however, observed between BA, CDB, and normal liver. The TUNEL LI was significantly higher than the Ki67 LI in the bile ducts of BA. BA is therefore associated with increased and disorganized cell turnover of the bile ducts, which is related to malformation of the ductal plate or abnormal bile duct development.

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.

Noninvasive visualization of the dilated main coronary arteries in coronary artery fistulas by cross-sectional echocardiography

Real-time cross-sectional echocardiographic studies of the main coronary arteries were performed in 20 normal subjects, 12 patients with patent ductus arteriosus and 14 patients with coronary artery fistula in whom the diagnosis was established by angiography. In 12 patients, the coronary artery that formed the fistula was dilated: The right coronary artery was involved in eight and the left coronary artery in four. The dilated coronary artery appeared as two dominant parallel echoes of wide lumen originating from the aorta in the region of the involved artery. Th echo diameter of the coronary artery correlated well with the angiographically estimated diameter of the artery. In the normal subjects and the patients with patent ductus arteriosus, we found no echocardiographic findings of coronary artery dilatation. This study demonstrates that cross-sectional echocardiography is useful in identifying the dilated coronary artery in coronary artery fistula and distinguishing this entity from patent ductus arteriosus.

Symptomatic and complicated adult and adolescent primary obstructive megaureter--indications for surgery: analysis, outcome, and follow-up

OBJECTIVES

Primary obstructive megaureter is an uncommon presentation in adult patients. Although not reported frequently in published studies, the anomaly exists and warrants aggressive surgical management in contrast to its presentation in children.

METHODS

This study was composed of 55 patients (47 with unilateral and 8 with bilateral megaureters) with adult primary obstructive megaureter who were treated from January 1989 to December 2001. Their clinical presentation, renal function, radiologic data, treatment, complications, and follow-up were studied.

RESULTS

Of the 55 patients, 36 were male and 19 were female (age range 13 to 52 years). All patients were symptomatic except two. Forty-four patients (50 renoureteral units) required ureteral reimplantation, with tailoring in 33. Five patients were treated with endoscopic techniques (ureteral meatotomy in 3 and ureteroscopic retrieval of ureteral calculi in 2). Four patients required nephroureterectomy for nonfunctioning kidneys. Associated renal calculi were managed by extracorporeal shock wave lithotripsy and pyelolithotomy and ureteral calculi by endoscopic methods or calculi removed at the time of ureteroneocystostomy. All but 4 patients showed improvement in hydroureter and hydronephrosis and developed no complications during the follow-up period of 1 to 12 years (mean 7). Five patients with bilateral megaureters had uremia. Only one improved after surgery with adequate drainage and 2 patients died despite reimplantation.

CONCLUSIONS

Most adult patients with megaureter are symptomatic. Complications such as stone formation and deranged function of the affected kidney are common and almost all require surgical intervention. Surgery in those with bilateral megaureters with advanced renal failure is mostly unrewarding.

Congenital intrahepatic bile duct dilatation is a potentially curable disease: long-term results of a multi-institutional study

OBJECTIVE

To report clinical presentation, perioperative outcome, and long-term results of surgical management of congenital intrahepatic bile duct (IHBD) dilatations (including Caroli disease) in a multi-institutional setting.

SUMMARY BACKGROUND DATA

Congenital IHBD dilatations are a rare congenital disorder predisposing to intrahepatic stones, cholangitis, and cholangiocarcinoma. The management remains difficult and controversial for bilobar forms of the disease or when concurrent congenital hepatic fibrosis is associated.

METHODS

From 1976 to 2004, 33 patients (range 11 to 79 years) were retrospectively enrolled. Disease extent into the liver was unilobar in 26 patients and bilobar in 7 patients (21%). Cholangiocarcinoma, congenital hepatic fibrosis, and intrahepatic stones were present in 2, 10, and 20 patients, respectively. Transplantations or liver resections were performed in 5 and 27 patients, respectively, whereas 1 asymptomatic patient was managed conservatively.

RESULTS

Postoperative mortality was nil. Postoperative complications occurred in 16 of 32 operated patients (50%) and additional procedures for residual stones were required in 5 patients. During a median follow-up of 80 months (1 patient being lost for follow-up) no patient developed metachronous carcinoma. Six patients (30%) developed recurrent intrahepatic stones but satisfactory late outcome was achieved in 27 patients (87%).

CONCLUSIONS

Partial or total liver resection achieves satisfactory late outcome in congenital IHBD dilatations, when the affection is treated at an early stage and when the extent of liver resection is tailored to intrahepatic disease extent and takes into consideration the presence and severity of underlying chronic liver and renal diseases.

Endoscopic retrograde cholangiopancreatography in infants and children

A single institutional experience with endoscopic retrograde cholangiopancreatography (ERCP) in pediatric patients was reviewed, focusing on the method of anesthesia, choice of an endoscope, indications, and complications. The medical records of 50 ERCPs performed in 42 infants and children (14 male and 28 female) were reviewed retrospectively. The patients' ages ranged from 57 days to 15 years. Forty-four ERCPs were diagnostic and 6 were therapeutic, including incision of choledochocele, and sphincterotomy and extraction of pancreatic stones. All procedures were successful. The most common indication for ERCP was to evaluate congenital biliary dilatation, in 28 patients (67%). Mild cholangitis occurred as a complication in 1 patient, but was alleviated with medication. A conventional duodenoscope could be used in patients older than 10 years. A pediatric duodenoscope was always used in patients under 1 year of age. Either type was chosen individually for those aged 1 to 10 years depending on the purpose, diagnostic or therapeutic. It is noteworthy that ERCP and/or sphincterotomy in a 1-year-old infant and two 2-year-old children were safely performed with the conventional endoscope. General anesthesia was employed in those younger than 9 years and intravenous sedation and local anesthesia in those older than 11 years. For children aged 9 to 11 years, anesthesia was chosen individually. We concluded that ERCP is a relatively easy and safe technique even for infants and children when performed by skilled hands with an appropriate duodenoscope under suitable anesthesia. The minimum age for use of the conventional duodenoscope may be 1 year.

Successful treatment of Caroli's disease by hepatic resection. Report of six patients

Caroli's disease is a congenital disease of cystic or saccular dilatation of the intrahepatic bile ducts. There are two disease entities: a simple type and a periportal fibrosis type. Frequent complications with the simple type are recurrent cholangitis, liver abscess, intraductal lithiasis, abdominal pain, and fever that often lead to fatal sepsis. Development of portal hypertension and esophageal varices is usually a final feature of the periportal fibrosis type. Malignancies are also possible complications with Caroli's disease. During the recent 13 years, the author had experiences with eight patients with Caroli's disease of the simple type; six of these eight underwent hepatic resection: right lobectomy in two, left lobectomy in three, and left lateral segmentectomy in one. Other two patients died of sepsis and cholangiocellular carcinoma, respectively. All six patients with hepatic resections were relieved from the disabling symptoms after surgery and have had no recurrent hepatobiliary problems for 3 months to 13 years. Hepatic resection may be indicated for more patients than previously assumed in the treatment of Caroli's disease of the simple type.

Segmental up-regulation of transforming growth factor-beta in the pathogenesis of primary megaureter. An immunocytochemical study

OBJECTIVE

To examine the maturational-delay hypothesis of primary megaureter (PM), i.e. that the condition arises by a segmental maturational delay of the ureteric wall that can resolve spontaneously within the first year of life, using comparative immunocytochemistry of ureters resected from infants and from homologous pre-natal ureters.

MATERIALS AND METHODS

Seventeen distal urinary tracts were obtained from children with PM who were referred for surgery (aged 6 months to 8 years, mean 2.1 years). These were compared with ureteric buds obtained from 11-week-old human and 11- to 38-week-old calf fetuses. The samples were immunostained using a monoclonal antibody specific for transforming growth factor beta (TGF-beta).

RESULTS

The histological appearances of the narrowed ureteric segments from patients under 18 months old were like the fetal ureteric buds at 26-38 weeks of gestation. Positive TGF-beta immunoreactions were detected in the longitudinal muscle layer in the ureter from patients 6-12 months old. Such reactions weakened progressively in those patients older than 1 year, becoming negative in all children older than 3 years. The TGF-beta immunolabelling in resected ureters was closely similar to that in fetal ureters from 20 to 26-week old calves.

CONCLUSIONS

From these results, PM should be ascribed to a segmental developmental delay of the terminal ureter arising at about 20 weeks of gestation, with a possible pathogenetic involvement of autocrine TGF-beta overexpression.

Coexistent carcinoma in congenital dilatation of the bile duct and anomalous arrangement of the pancreatico-bile duct. Carcinogenesis of coexistent gall bladder carcinoma

From 1972 to 1985, 40 cases of congenital dilatation of the bile duct (CDBD) were experienced in the department of the authors. Those consisted of 19 cases of anomalous arrangement of the pancreatico-bile duct (P-B anomaly), five of bile duct carcinoma, and two of gall bladder carcinoma. In addition, four patients who showed no dilatation of the bile duct in spite of the presence of a P-B anomaly were experienced, and coexistent gall bladder carcinoma was present in three of four cases. The incidence of bile duct carcinoma associated with CDBD is very high. However, coexistent gall bladder carcinoma in CDBD is a new topic, and coexistent intrahepatic bile duct carcinoma in CDBD is extremely rare. This report presents interesting and rare cases of coexistent carcinomas in these anomalies and investigates their carcinogenesis, particularly that of gall bladder carcinoma.

Megacystis, microcolon, intestinal hypoperistalsis syndrome: possible pathogenesis

Two cases of "Megacystis-microcolon-intestinal hypoperistalsis syndrome" are described. These appear to be the seventh and eighth cases in published literature. Consistent with the two published reports, both our patients were newborn female infants who manifested a large bladder, associated with unused colon and functional intestinal obstruction. While the earlier published reports mention a full complement of normal mature ganglion cells in all parts of the bowel, the two cases described here showed " dysganglionosis " to some extent, in the form of fewer and shrunken neurones along with other mature-looking neurones in some parts of the bowel. The bladder was available for histologic examination only in the second case and showed apparently normal innervation. Hence, it is felt that the intestinal obstruction in these cases could have been due to a disturbance in bowel innervation.

Congenital cystic dilatation of the common bile duct as a cause of primary bile duct stone

Of the 101 patients with congenital cystic dilatation of the common bile duct, eighty-eight with adult-type cysts are reported on. The association of primary bile duct stone and adult-type cyst of this anomaly is discussed and found to be higher than previously recognized. In the cases without calculi, abnormal arrangement of the pancreaticobiliary ductal system is indicated to play an important role in the manifestation of the symptom. The anatomic and clinical features and the results of treatment for this type of cyst are reviewed.

Cranial arteriovenous malformations in neonates: color Doppler imaging with angiographic correlation

Five neonates with cranial arteriovenous malformations were studied with color Doppler sonography. Excellent correlation was found between sonography and subsequent angiography. In three patients with vein of Galen aneurysms, sonography showed a cystic structure with rapid or swirling flow. Careful adjustment of the color Doppler system was required to demonstrate flow in another patient with a dural arteriovenous malformation. An arteriovenous fistula in a fifth patient appeared as an area of increased flow. Arterial feeders and major draining veins were visualized in all five patients. Color Doppler imaging also was used to assess the effect of embolic or operative therapy in three of the patients. We conclude that color Doppler sonography is able reliably to characterize flow patterns in neonatal cranial arteriovenous malformations. Color Doppler imaging also is helpful in assessing flow after embolic or surgical therapy.

Segmental dilatation of the small bowel: report of three cases and literature review

Segmental dilatation of the small bowel is a rare congenital abnormality that occurs mainly in children and produces significant nonspecific symptoms. The authors reviewed 33 cases reported in the literature and present three new cases in which the lesion was demonstrated on radiographs obtained before laparotomy. These cases showed the spectrum of symptoms and characteristic radiologic features of this condition in both plain abdominal radiographs and barium studies. Plain radiographs of the abdomen may show an isolated loop of bowel containing an air-fluid level. The characteristic finding in barium studies of the small bowel is a localized dilatation of the small bowel lumen with afferent and efferent loops. In the absence of a complication or coexistent cause of obstruction, the transit time of contrast medium through the small bowel is not delayed. The radiologic examination is useful in diagnosis, and the condition is cured with surgery.

Congenital segmental dilatation of the colon

Segmental dilatation of the colon with bowel wall muscle hypertrophy has been described in children 6 mo and older presenting with constipation since birth. A case of segmental dilatation of the colon without muscle hypertrophy in a newborn argues for the congenital origin of the dilatation and for the muscle hypertrophy being acquired.

Phlebectasia of left anterior jugular vein

We present a rare case of unilateral phlebectasia of the anterior jugular vein in a 56-year-old male patient whose complaint is a neck swelling that appears during talking. Although in this age group the most common cause of such a mass in the anterior aspect of the neck increasing in size during any type of straining or Valsalva manoeuvre is a laryngocele, phlebectasia of the anterior jugular vein should be considered in the differential diagnosis. Doppler ultrasound and computed tomography are the most useful and non-invasive methods to use for the investigation. Treatment should be conservative.