Malrotation in children with symptoms of gastrointestinal allergy and psychosomatic abdominal pain

Three children with malrotation 4.5, 5 and 9 years old at operation are presented. Their preliminary diagnoses were gastrointestinal (GI) allergy, GI allergy with colon irritable and psychosomatic abdominal pain. They were treated on an outpatient basis under these diagnoses for more than two years before their malrotations were discovered. In two children radiology did not demonstrate any signs of intestinal obstruction and in one of these children repeated radiological examinations were necessary for the diagnosis of malrotation. Operative findings were chronic volvulus with compromised blood flow and obstructive duodenal bands. The third child suffered acute strangulation ileus with gangrene of the intestines before diagnosis was made. We conclude that special consideration must be given to the possibility of malrotation when treating and radiologically investigating children with GI disturbances.     

Midgut malrotation,the reliability of sonographic diagnosis

We are unaware of any other anatomical study which deals with normal variations in the relationship between the superior mesenteric artery (SMA) and the superior mesenteric vein (SMV). In our investigation in the majority of cases, the SMV lies to the right of the SMA. It has been suggested that ultrasonographic demonstration of a left sided SMV, is characteristic of midgut malrotation so a prospective study was undertaken in order to try to correlate the position of the mesenteric vessels on Ultrasound with the radiological diagnosis of midgut malrotation on upper GI series. 427 children (95% infants) who were planned for upper GI investigation, have had color Doppler U.S. of the mesenteric vessels before the barium study. In 67 cases, the mesenteric vessels were obscured by intestinal gas. Among them, there were 2 cases of malrotation. Three different positions of the mesenteric vessels were found in the 360 remaining cases. 1) A left sided SMV was found in 4% of the cases, all had midgut malrotation on X-rays and at surgery. 2) A mesenteric vein anterior to the SMA was found in 5% of the cases, 28% had midgut malrotation. 3) A normal right sided SMV was found in 91% of the cases. However 3% of these had midgut malrotation. There are anatomical variations in the position of the mesenteric vessels and a normal relationship between SMA and SMV does not ecxclude the possibility of intestinal malrotation. Nevertheless, ultrasound remains a useful noninvasive screening technique for the diagnosis of midgut malrotation.Presented at the IPR meeting in Stockholm, May 1991. Selected for publication by an International Group of the ESPR     

婴儿期食物过敏的预后研究

目的了解婴儿期食物过敏（FA）的预后及影响因素。方法对119例患儿进行回顾性研究,采用Kaplan-Meier法计算食物耐受的累积概率,非条件Logistic回归模型分析食物耐受形成的预测因素和其他过敏性疾病发生的影响因素。结果鸡蛋、牛奶耐受的累计概率在诊断后1年分别为31％、42％;2年为62％、63％;3年为80％、77％;4年后均可达100％。牛奶、鸡蛋过敏患儿的皮肤点刺试验阳性强度是持续牛奶、鸡蛋敏感的预测因素（OR=2．535,95％CI：1．159～5．543;OR=2．654,95％CI：1．302～5．410,P均〈0．05）。本组13例患儿发生其他FA,危险因素是持续鸡蛋敏感（OR=6．109,95％CI：1．818～20．527,P〈0．05）;4例发生变态反应性鼻炎,15例发生支气管哮喘,危险因素是持续鸡蛋敏感和呼吸道过敏症状（OR=3．596,95％CI：1．429～9．045;OR：4．235,95％CI：1．152～15．563,P均〈0．05）。结论至少75％的鸡蛋或牛奶过敏患儿在诊断后3年内可获耐受。10．9％、12．6％和3．4％的FA儿童发生其他FA、支气管哮喘和变态反应性鼻炎。加强持续FA高危儿的筛查和管理,可能有助于改善FA的预后。     

National estimates of hospital utilization by children with gastrointestinal disorders: analysis of the 1997 kids' inpatient database

OBJECTIVES: To identify and to generate national estimates of the principal gastrointestinal (GI) diagnoses associated with hospital utilization and to describe national hospital utilization patterns associated with pediatric GI disorders. STUDY DESIGN: We analyzed a nationwide and stratified probability sample of 1.9 million hospital discharges from 1997 of children 18 years and younger, weighted to 6.7 million discharges nationally. Principal GI diagnoses were identified through the use of the Clinical Classification Software and Major Diagnostic Categories. RESULTS: In 1997 in the United States, there were 329,825 pediatric discharges associated with a principal GI diagnosis, accounting for more than 2.6 billion US dollars in hospital charges and more than 1.1 million hospital days. Appendicitis, intestinal infection, noninfectious gastroenteritis, abdominal pain, esophageal disorders, and digestive congenital anomalies combined accounted for 75.1% of GI discharge diagnoses, 64.2% of GI hospital charges, and 68.0% of GI hospital days. Excluding normal newborn infants and conditions related to pregnancy, GI disorders were the third leading cause of hospitalization. CONCLUSIONS: GI disorders are a leading cause of hospitalization of children. A minority of GI conditions account for the majority of measures of utilization. Children are hospitalized for GI conditions and at institutions that are distinct from adults.     

Delayed presentation of congenital diaphragmatic hernia

The late-presenting congenital diaphragmatic hernia (CDH) represents a considerable diagnostic challenge. This study was undertaken to define various patterns of delayed presentation and to analyze pitfalls in the diagnosis and treatment of these patients. Thirty-three children with CDH were treated between 1993 and 2000; 15 of these (45.5%) who were diagnosed after the age of 2 months-14 years, median of 2.5 years are reported. Thirteen had a Bochdalek hernia and 2 had a Morgagni hernia. The diaphragmatic defect was right-sided in 6 cases and left-sided in 9. Five patients presented acutely, 3 with respiratory distress and 2 with gastrointestinal (GI) obstruction. The remaining 10 presented with chronic respiratory or GI complaints. Inappropriate insertion of a chest drain occurred in 3 patients misdiagnosed as having pleural effusion (2) and a pneumothorax (1). Two patients had previous chest radiographs reported normal. Plain radiographs were sufficient to make a definitive diagnosis in only 6 patients; GI contrast studies were necessary in the other 9. All patients were treated through an abdominal approach with primary closure of the diaphragmatic defect without a patch. A distinct hernia sac was present in 6 cases, and associated malrotation in 6. All except 1 patient survived the operation with rapid improvement of their GI and respiratory symptoms. We conclude that: (1) late-presenting CDH should be included in the differential diagnosis of any child with persistent GI or respiratory problems associated with an abnormal chest X-ray film; (2) nasogastric tube placement must be considered as an early diagnostic or therapeutic intervention when the diagnosis is suspected; and (3) GI contrast studies should be a part of the diagnostic work-up of these patients.     

大龄儿童肠旋转不良11例诊治分析

目的：探讨大龄儿童肠旋转不良的临床特点及诊治措施。方法回顾性分析2002年1月至2012年1月我们收治的11例大龄儿童肠旋转不良患儿的临床资料。结果11例患儿中,男性6例,女性5例,年龄在2～14岁,中位年龄6岁。11例大龄儿童占先天性肠旋转不良需手术治疗病例总数的5.7％（11／193）。临床表现：反复呕吐7例,腹痛6例,5例既往有反复腹痛病史。11例均行立位 X 线腹部平片检查,4例显示不同程度肠梗阻,7例无阳性表现。消化道造影检查10例,其中钡餐灌肠9例,上消化道造影（经鼻胃管注入碘水）1例,均诊断为先天性肠旋转不良。3例急腹症病例行 CT检查,其中1例平扫误诊为肠套叠;2例 CT 增强扫描确诊为先天性肠旋转不良。11例均行 Ladd’s 术,术后均恢复顺利,痊愈出院,术后随访2～4年未见再次扭转及营养不良病例。结论大龄儿童肠旋转不良临床表现不典型,主要为反复呕吐和腹痛。消化道造影是确诊的重要手段,合并急腹症时行增强CT 扫描有助于明确诊断。腹腔镜下 Ladd’s 术有望成为治疗肠旋转不良的重要方式。     

Contrast meals and malrotation in children—metal markers for improved accuracy

Upper gastrointestinal contrast studies in children may cause false-positive or -negative diagnosis of intestinal malrotation from rotation of the patient. To alleviate this problem, skin markers can be used to reduce rotation of children undergoing this procedure, e.g., two metal markers (sheathed and sealed hypodermic needles) can be fixed onto the skin for gastro-intestinal contrast studies. We reviewed two Katz criteria influenced by patient rotation: duodenojejunal junction on or to the right of the left pedicle and pylorus to the left of the midline. A test group was positioned using markers; a control group without markers was positioned conventionally. Markers during a pilot study were applied, but positioning was done by helpers who had no on-screen visualization. In the test group, only 1 child (3%; n?=?39) had a feature of malrotation. In the control group, there were features of malrotation in 12 children (25%; n?=?48). No other features of malrotation were seen. The pilot study showed radiographic rotation with markers projecting off the midline in 78% of 58 children. This resulted in 48% of 58 patients having false features of malrotation. The use of metal skin markers results in reduction of rotational errors that could have caused false diagnosis of intestinal malrotation in children.     

Antenatal diagnosis of intestinal malrotation on fetal MRI

We report a case of intestinal malrotation without any associated GI tract complications diagnosed antenatally by fetal MRI. Antenatal US revealed a midline stomach. Subsequent fetal MRI confirmed the midline stomach and, in addition, revealed all loops of small bowel to the right of the midline and all large bowel to the left. All these features were consistent with intestinal malrotation. There was no abnormal bowel wall thickening, bowel dilatation, ascites or polyhydramnios. To our knowledge, this is a unique case of intestinal malrotation without associated GI tract complications diagnosed antenatally on fetal MRI.     

Beta lactam allergy in children from two ethnically different populations

Background:  The effects of ethnicity on beta lactam allergy have not been reported. The Negev Desert in Southern Israel is inhabited by two ethnically distinct populations: Jews and Bedouin Muslims. Approximately 60% of the pediatric population of the area is Jewish. Whereas most Jews live in Westernized urban centers, Bedouins are in the process of transition from semi-nomadic conditions to a sedentary lifestyle and the majority of them now live in towns and villages. We sought to determine the rate and characteristics of physician-reported beta lactam allergy in Jewish and Bedouin children.
Methods:  The medical records of all children registered in five primary community clinics were reviewed and screened for allergy to beta lactam antibiotics.
Results:  A total of 26 655 medical records were reviewed: of 11 069 Jewish children and 15 586 Bedouin children. Beta lactam allergy was registered in 344 records (1.3%), and was more frequent in Jewish ( n = 226, 2.1%) than in Bedouin children ( n = 118, 0.8%, P < 0.0001). Beta lactam allergy was more common in boys in both populations ( P < 0.01). The clinical features of the reaction that led to the diagnosis of beta lactam allergy were not significantly different between the two ethnic populations, although the specific antibiotics prescribed and the diagnoses for which they were prescribed were different in the two ethnic populations.
Conclusions:  We concluded in this study that pediatric beta lactam allergy was registered more frequently in Jewish than in Bedouin children, and in boys more than in girls.     

Malrotatie van de dunne darm zonder andere aangeboren afwijkingen

The subject of malrotation in infants and children without other congenital anatomical abnormalities is reviewed from the perspective of experience with 97 patients operated in eleven years. Fifty-five patients were younger than six weeks at operation. They often presented with bilious vomiting, in contrast to older children who presented with non-bilious vomiting or feeding problems. Patients younger than six weeks were operated more often acutely than older patients. Volvulus was more common in infants younger than six weeks. Two patients with a resulting short bowel syndrome died. The problems disappeared in 73 (76.8%) of the 95 remaining children. In the children younger than six weeks persisting abdominal symptoms were significantly less frequent than in older children. In the children presenting with proven gastro-esophageal reflux disease before the malrotation operation, abdominal symptoms and/or complaints persisted significantly more often. Although there remains considerable controversy regarding the management of older children without signs of vascular problems, failure to respond to radiographic evidence of malrotation could be considered malpractice if volvulus was to occur subsequently. For this reason, every patient with a radiological proven malrotation merits diagnostic laparoscopy.     

Long-term complications following operative intervention for intestinal malrotation: a 10-year review

Intestinal malrotation associated with a volvulus requires immediate surgical intervention. The long-term sequelae of Ladd’s procedure and its complications are not well defined. We designed this study to investigate the long-term complications following operative intervention for intestinal malrotation. Patients who have undergone a Ladd’s procedure for malrotation from January 1999 till December 2008, from two tertiary centres, were identified using the Hospital Inpatient Enquiry system. Charts were analysed to obtain information about mode of presentation, method of diagnosis and postoperative outcomes. Patients were contacted for follow-up. One hundred and sixty-one patients were identified over the 10-year period with a postoperative follow-up time ranging from 2 months to 10 years. The median age at surgery was 9 days (1 day–12 years); 38 (23%) underwent elective Ladd’s procedure for malrotation. Thirty-eight patients had intraoperative incidental findings of a malrotation during different procedures; 120 (74.5%) patients were performed as an emergency procedure. Fourteen patients (8.7%) developed complications following surgery. Nine patients developed adhesive small bowel obstruction, five required operative adhesiolysis having failed conservative treatment. There was one case of recurrent volvulus and three mortalities in our series. In our experience, looking at 161 patients with a mean follow-up of 5 years Ladd’s procedure has a low postoperative morbidity and remains a vital treatment for malrotation in children.     

A Prospective 12-Year Follow-up Study of Children with Wheezy Bronchitis

Eighty children with wheezy bronchitis were followed prospectively for 12 years. At the end of the follow-up period only 22 (28 %) still had symptoms of asthma. Forty-three children (54 %) had ceased to wheeze before the age of 3 years, four children between 3 and 7 years of age and 11 children between 7 and 11 years of age. Of the 22 children who still had asthma, all but one were much improved, although 70 % of them noticed asthmatic symptoms during exercise. Heredity for asthma/wheezing, allergy, the occurrence of eczema, and onset of wheezing after 18 months of age were associated with an increased risk of persistent asthma. Allergy had developed in 59 % of the children with persistent asthma and in 10 % of those who had stopped wheezing. Serum IgE was above the mean +1 SD in 45 % and above the mean +2 SD in 24 % of the children at the end of the 12-year follow-up. A serum IgE above the mean +2 SD was found in 8 of 13 children with asthma combined with proven allergy, but only in 1 of 9 children with asthma without allergy. Surprisingly, 8 of 48 children who had stopped wheezing and had no clinical allergy had as high IgE levels as the children with asthma and allergy, which reduced the allergy predictive value of a high serum IgE to 36 %. Some of these high IgE levels seemed to be a family trait.     

The evaluation and treatment of gastrointestinal disease in children with cystinosis receiving cysteamine

OBJECTIVES: Cysteamine prevents organ damage in children with cystinosis, but may cause gastrointestinal (GI) symptoms. In this study we evaluated the nature of GI disease, and the value of omeprazole in controlling GI symptoms in these children. STUDY DESIGN: Upper GI disease was evaluated with endoscopy, gastrin levels, and acid secretion studies after oral administration of cysteamine, before and after 16 weeks of therapy with omeprazole. A symptom score was devised. RESULTS: Eleven children (mean age, 5.7 years) were studied. After cysteamine ingestion, before and after omeprazole therapy, the mean maximum acid output was significantly higher than the mean basal acid output. The maximum acid output was measured within 60 minutes of cysteamine ingestion and was reduced by omeprazole therapy (P<.01). The mean peak gastrin level was 30 minutes postcysteamine and was higher than baseline (P<.01). The initial mean symptom score (maximum score, 14) was 6.9 and fell to 0.7 (P<.0001) after 16 weeks of omeprazole therapy. At endoscopy, two children had diffuse gastric nodularity, and nearly all had cystine crystal deposits. CONCLUSIONS: GI symptoms in children with cystinosis receiving cysteamine are often acid-mediated and improve with omeprazole. Cystine crystals were detected in the GI tract and may signify inadequate treatment with cysteamine.     

A prospective 12-year follow-up study of children with wheezy bronchitis

Eighty children with wheezy bronchitis were followed prospectively for 12 years. At the end of the follow-up period only 22 (28%) still had symptoms of asthma. Forty-three children (54%) had ceased to wheeze before the age of 3 years, four children between 3 and 7 years of age and 11 children between 7 and 11 years of age. Of the 22 children who still had asthma, all but one were much improved, although 70% of them noticed asthmatic symptoms during exercise. Heredity for asthma/wheezing, allergy, the occurrence of eczema, and onset of wheezing after 18 months of age were associated with an increased risk of persistent asthma. Allergy had developed in 59% of the children with persistent asthma and in 10% of those who had stopped wheezing. Serum IgE was above the mean +1 SD in 45% and above the mean +2 SD in 24% of the children at the end of the 12-year follow-up. A serum IgE above the mean +2 SD was found in 8 of 13 children with asthma combined with proven allergy, but only in 1 of 9 children with asthma without allergy. Surprisingly, 8 of 48 children who had stopped wheezing and had no clinical allergy had as high IgE levels as the children with asthma and allergy, which reduced the allergy predictive value of a high serum IgE to 36%. Some of these high IgE levels seemed to be a family trait.     

Delayed gastric emptying in gastroesophageal reflux disease: the role of malrotation

The association between gastroesophageal reflux (GER) and intestinal malrotation (IM) has been well described. Delayed or impaired gastric emptying in IM is thought to be a contributing factor in the development of gastroesophageal reflux disease (GERD). The current study assessed the role of malrotation in delayed gastric emptying in children with GERD. We also evaluated the interactions between GERD, malrotation, gastric pH abnormalities, and gastric dysmotility. Sixty-seven patients between 1 and 5 years of age (mean 3.08±1.2) and with symptoms of GER, such as emesis, reactive or recurrent lung disease, and/or growth retardation, were studied in 2001–2005. Upper and lower gastrointestinal contrast studies were performed for the diagnosis of malrotation. Gastric motility was evaluated with a liquid gastric emptying protocol. GER was documented by upper gastrointestinal studies, scintigraphy, and/or 24-h pH monitoring. In our series of 44 children with GERD, there was an unexpectedly high incidence of IM: 54.5% (24/44). IM has previously been known to occur in 25% of patients with GERD. GERD was found in 24 (82.7%) of 29 patients with IM. Mean nuclear gastric emptying (MNGE) was 51.6±8.04 min in patients with isolated GERD and 96.6±20.5 min in children with IM and GERD. There was a statistically significant difference in MNGE time (p<0.05) between children with primary GERD and in those with GERD and IM. Esophageal pH monitoring showed that mean fraction time below pH 4 was 7.06±1.1% in patients with isolated GERD and 14.7±4.1% in patients with IM and GERD. GERD is common in children between 1 and 5 years old. Using gastric emptying studies and esophageal pH monitoring, we have shown that gastric dysmotility and esophageal pH abnormalities are highly prevalent, especially in children with malrotation compared with children with isolated GERD. These findings suggest that malrotation is an important factor responsible for delayed gastric emptying in GERD. Hence, we recommend that all infants and children with GERD and delayed gastric emptying undergo careful evaluation for malrotation.     

Impact du régime d''éviction sur la néophobie dans le cadre d''une allergie alimentaire chez l''enfant : étude exploratoire

OBJECTIVES: This study was designed to analyse the impact of an elimination diet in children with food allergy, and its perception by their parents on the later reticence of children to test unknown foods, food neophobia. METHODS: The degree of food neophobia of children having outgrown their allergy (mean age, 7 years 2 months) was compared to that of a sibling (9 years 5 months) using a standardized scale and a questionnaire of food friendliness. Parents were also asked to fill in a questionnaire on the disease and its burden on the family. RESULTS: Children having outgrown their allergy are more reluctant to test new foods than their non-allergic brother or sister, as shown by their scoring on the food neophobia scale and the number of unknown foods following the cure of the disease. Two factors increase the level of food neophobia, the distressing effect and the duration of the period elapsed until the diagnosis was made, as well as the distressing effect and the lack of variety in the meal preparation. CONCLUSION: Food neophobia, a normal phase between 2 and 10 years, is worsened by the elimination diet required by food allergy, especially in case of late diagnosis and when the time elapsed before diagnosis and the preparation of meals were perceived as difficult to bear.     

腹腔镜下肠旋转不良的诊断与治疗

目的 评价腹腔镜对肠旋转不良的诊断与治疗效果并探讨纠正中肠扭转的适合条件.方法 2002年7月至2008年3月对23例临床拟诊的肠旋转不良进行腹腔镜手术.男13例,女10例.年龄5 d～12岁,平均1.9岁.采用三孔技术,腹腔镜确诊后,牵拉肠管纠正中肠扭转复位,切断Ladd索带、游离十二指肠及空肠起始部,发现合并畸形同时处理.结果 23例均在腹腔镜下确定诊断并顺利完成Ladd手术,18例并发中肠扭转270°～960°,予以复位;其中2例合并十二指肠旁疝、1例十二指肠隔膜、1例空肠异位胰腺和1例梅克尔憩室同时完成手术.手术时间35～150 min,平均(65.2±15.8)min.术后1～3 d进食,没有手术并发症.1例术后2个月因近端空肠粘连再次手术.21例获得随诊1个月～5年,生长发育良好.结论 腹腔镜可明确诊治肠旋转不良,可以在新生儿期安全实施,适用于并发亚急性中肠扭转的患儿,具有创伤小、进食早、恢复快和美容效果好的优点.     

婴儿和儿童胸骨后疝

目的 探讨罕见的婴儿和儿童胸骨后疝的诊断和治疗.方法 收集了36年间(1978年3月至2014年6月)上海交通大学医学院附属新华医院小儿外科收治的8例胸骨后疝患儿的资料,复习了患儿明确诊断时年龄、性别、临床症状、伴发畸形、手术方式及转归.其中男3例,女5例,年龄2d至8岁,7例胸骨后疝位于右侧,左侧1例.伴发其他畸形4例,2例为先天性心脏病、脐膨出和肠旋转不良,异位肾和右腹股沟疝各1例.结果 8例均经手术证实,疝内容物为横结肠、小肠、肝左叶、胃、大网膜.早先4例采用传统经腹开放入路,后4例选择腹腔镜下修补,其中1例同时作右腹股沟疝修补.8例中4例有疝囊.行疝囊切除1例,除1例2d新生儿伴脐膨出和肠旋转不良术后夭折外,余7例随访复查胸片未见复发.结论 胸骨后疝为罕见的先天性膈疝的一种类型,临床表现各异,伴发其他畸形的比率较高,以先天性心脏病最为常见.推荐经腹入路手术,腹腔镜下修补为首选.相比开放手术其手术创伤小,恢复快,早期能进食,缩短了住院时间且外观更美观.     

Children with abdominal pain: evaluation in the pediatric emergency department

In a retrospective study of children with abdominal pain in a pediatric emergency department, 371 children were identified during four seasonally diverse months. Half of the children were two to six years old, 32% were seven to 11 years old, and 19% were 12 to 16 years old. Forty-eight different diagnoses were made, but 10 diagnoses were given to 83% of the patients. We found an increased frequency of respiratory illnesses (12%) as compared to other studies. Appendicitis was the only surgical problem that occurred in more than one percent of the children. The diagnoses were classified as medical (64.4%), surgical (6.5%), and nonspecific (29.1%). chi 2 and multinomial logit analysis revealed that guarding and abdominal tenderness were the two symptoms which were most strongly associated with a surgical diagnosis. The goal of this work is to assist the busy emergency clinician with the difficult task of making expeditious and accurate diagnoses for children with abdominal pain.     

Segmental small-bowel volvulus not associated with malrotation in childhood

During the last 15 years, 38 children with volvulus of the intestine were treated in our hospital. Twenty-eight (73.7%) had midgut volvulus with malrotation, including 2 cases of isolated incomplete rotation of the duodenum; 10 (26.3%) had segmental volvulus of the ileum without malrotation, 3 of them assumed to be secondary to a duplication cyst, retroperitoneal band, or meconium plug; in the remaining 7 no causative abnormality was found. Nine were neonates, 8 of whom presented within the first 48 h after birth. The remaining patient was a 5-year-old girl. In all cases the correct preoperative diagnosis was not made, but obstruction or coiling of the distal ileum was demonstrated by contrast enemas in 5. Ischemic changes of the affected bowel were seen in 90% of the cases without malrotation. This contrasts with an 18% incidence in the cases with malrotation, and indicates the necessity of early diagnosis and operation. All patients required bowel resection and 2 died of sepsis after the operation, however, none suffered from short-bowel syndrome.