Ultrasonographic detection of free peritoneal fluid in uncomplicated intussusception

Two cases of intussusception with free peritoneal fluid detected by ultrasound are presented. In neither of these cases was the fluid associated with perforation or intestinal compromise. After assessing the findings in these patients, we believe that small amounts of fluid may well be present in uncomplicated intussusception. Furthermore, we feel that its presence should not constitute a contraindication to nonsurgical reduction if no associated clinical findings to suggest perforation or intestinal compromise are present.     

Gas distended stomach masquerading as free air

Free air can be an ominous sign of bowel perforation with the fear if resulting sepsis. Several radiological signs have been described to aid in interpretation including Rigler's sign. We present a case where a large amount of free air was felt to be present in a 5 year old post craniopharyngima resection. Clinically free air was not expected. To try and acount for these discrepant findings, the nasogastric tube was examined and found to be clogged. Once the nasogastric tube functioned, it became evident that the large amount of air was in the stomach rather than free in the peritoneal cavity. This case demonstrates a potential mimic of free air but also highlights the need to correlate radiographic findings and interpretations to the clinical state of the patient.     

Analysis of bowel perforation in necrotizing enterocolitis

The most severe complication of necrotizing enterocolitis (NEC) is bowel perforation. Identification of neonates at high risk for perforation and optimization of radiologic imaging to identify bowel perforation are necessary to reduce the high mortality rate associated with this catastrophic event. One hundred and fifty-five cases of NEC were seen at our institution during a 5.5 year period. Nineteen (12%) progressed to perforation. A review of surgical findings, autopsy results and radiographs from these patients shows only 63% had radiographic evidence of free air in the peritoneal cavity at the time of perforation. Twenty-one percent had radiographic evidence of ascites but no pneumoperitoneum, and 16% had neither free air nor ascites. Thus purely radiographic criteria for bowel perforation in NEC are imprecise, and paracentesis is mandatory in NEC patients with ascites or clinical findings indicative of peritonitis. Timing of radiographic studies and site of bowel involvement are also important. Seventy-nine percent of perforations occurred by 30 h from confirmation of diagnosis (by clinical or radiographic criteria). Surgery or autopsy revealed involvement of the ileo-cecal region in 89% of cases with the actual site of perforation occurring in this area in 58% of patients.     

Neonatal pneumoperitoneum: a critical appraisal of its causes and subsequent management from a developing country

Background  

The diagnosis and management of neonatal pneumoperitoneum revolves around necrotizing enterocolitis (NEC) in most of the published literature. Although NEC remains the major cause of pneumoperitoneum in a neonate, there are several other causes leading to free air in the peritoneal cavity. A number of case reports have appeared describing pneumoperitoneum in a newborn due to rupture of one particular organ, but there have been only few collective reviews on the subject. The present study shares the experience with neonates admitted with a diagnosis of pneumoperitoneum in a pediatric surgical center of a developing country. The various causes of pneumoperitoneum in a newborn, their management and subsequent outcome are described.     

小儿外伤性小肠穿孔20例诊疗分析

目的：探讨小儿外伤性小肠穿孔的早期诊断及手术方式,以提高诊治水平。方法回顾性分析20例外伤性小肠穿孔患儿的临床资料,包括临床症状、辅助检查、手术方式及诊治结果。结果患儿均有不同程度腹痛及腹膜炎体征,10例腹腔穿刺中,阳性8例（80％）;10例腹部立位片检查中,5例见膈下游离气体（50％）;17例B超检查中,10例有显著腹腔积液（58．8％）;12例CT检查中,9例有异常（75％）,均经手术治愈出院,其中3例出院后1月余出现粘连性肠梗阻,予保守治疗后痊愈出院,1例因乙状结肠造瘘术后再次入院行造瘘口回纳术,术后痊愈出院。结论小儿外伤性小肠穿孔多有腹痛、腹膜炎等临床特点,结合辅助检查有利于早期诊断,选择合适的手术方式是提高治愈率的关键。     

Intra-abdominal Kaposiform hemangioendothelioma and the benefits of laparoscopic surveillance

We report a case of a neonate presenting with the rare vascular tumor, Kaposiform hemangioendothelioma. She had a lesion arising from the left ovary with multiple intraperitoneal metastases causing small bowel obstruction. We managed this case with primary surgical resection followed by laparoscopic surveillance of the peritoneal cavity and metastectomy. The child is fit and well and free of tumor after 32 months. Neither this presentation of this tumor nor this management approach has been previously described in the literature.     

Primary desmoplastic small round cell tumor of the kidney in a 7-year-old girl

Desmoplastic small round cell tumor (DSRCT) is a rare pathologic entity that most frequently affects the peritoneal cavity and presents in adolescent boys. It often presents at an advanced stage and has a generally poor prognosis. We present an unusual case of DSRCT of the kidney presenting in a young girl. This is the first report of DSRCT of the kidney in the pediatric population, and it suggests that this condition should be a diagnostic consideration when assessing a child with a kidney mass.     

Necrotizing enterocolitis (pediatric review)]

Necrotizing enterocolitis--a highly letal disease in the newborn period--is diagnosed in about 1--2% of the admissions to a nursery. The marcroscopic lesions are basically necroses predominantly found in the ileum, colon and jejunum. Untreated they lead to perforation, peritonitis and sepsis. The predisposing factors include such as perinatal complications, immaturity and umbilical vein catheterization; the main symptoms are bile stained vomiting and blood-streaked diarrhea, followed by signs of fulminant sepsis and peritonitis. The most typical roentgenographic findings are intramural air (pneumatosis intestinalis) and in more advanced cases pneumoperitoneum (free peritoneal air) and portal vein gas. The current plan of management--consisting of immediate withdrawal of oral feeds, gastric suction, intravenous fluid therapy, treatment of shock and administration of antibiotics--and the indication for operation are discussed. Perinatal stress and secondary bacterial invasion of the intestinal lesions seem to play an important role in the etiology of the disease. An early nutrition of the healthy immature with human breast milk seems to reduce the incidence of necrotizing enterocolitis or at least has a mitigating influence on the later course of the disease. The mortality in our own series--as reported--was high (6 patients: 1 survivor, mortality: 83%) as 4 of the patients were admitted with gross symptoms of intestinal perforation and severely shocked.     

腹部超声在新生儿坏死性小肠结肠炎诊断及病情评估中的价值

目的 探讨腹部超声检查对新生儿坏死性小肠结肠炎(NEC)的诊断价值及其在NEC病情评估中的意义。方法 回顾性分析2013年7月至2015年1月84例NEC患儿的临床资料。根据修正Bell-NEC分级诊断标准分为NEC疑似组(n=44)、确诊组(n=40);另根据临床转归分为内科治愈组(n=58)和手术/死亡组(n=26),比较腹部超声及腹部X线平片检查结果在各组中的改变。结果 在确诊组,腹部超声对门静脉积气、肠管扩张的检出率显著高于腹部平片(PPP结论 腹部超声在NEC的诊断中有重要作用;超声表现对预测疾病的严重程度有预测作用。     

A Study of Cartilage Development in Pulmonary Hypoplasia

To discriminate between different forms of pulmonary hypoplasia (PH), 24 hypoplastic lungs were studied for their development of bronchial cartilage plates and peripheral air spaces. In 6 lungs from premature infants with oligohydramnios, normal amounts of immature and irregularly shaped cartilages were distributed with mitoses concentrated toward the periphery of the bronchi. Pulmonary acini appeared markedly immature. In 5 lungs from infants with diaphragmatic hernia, large numbers of cartilage bars were clustered around the proximal bronchi, whose branching was much reduced. Peripheral air spaces were small but structurally mature. In Potter syndrome, small amounts of tiny, mature cartilages were observed irregularly around the proximal bronchi and poorly distributed into the peripheral bronchi. The acinar structure was very immature. In 4 anencephalic infants, a marked decrease in the volume of mature cartilage was present, with cartilage seen only around proximal bronchi; the acini were atelectatic and less well developed. It is suggested that the earlier the action of a teratogen, the greater the abnormality of bronchial branching, cartilage distribution, and later lung development.     

A study of cartilage development in pulmonary hypoplasia

To discriminate between different forms of pulmonary hypoplasia (PH), 24 hypoplastic lungs were studied for their development of bronchial cartilage plates and peripheral air spaces. In 6 lungs from premature infants with oligohydramnios, normal amounts of immature and irregularly shaped cartilages were distributed with mitoses concentrated toward the periphery of the bronchi. Pulmonary acini appeared markedly immature. In 5 lungs from infants with diaphragmatic hernia, large numbers of cartilage bars were clustered around the proximal bronchi, whose branching was much reduced. Peripheral air spaces were small but structurally mature. In Potter syndrome, small amounts of tiny, mature cartilages were observed irregularly around the proximal bronchi and poorly distributed into the peripheral bronchi. The acinar structure was very immature. In 4 anencephalic infants, a marked decrease in the volume of mature cartilage was present, with cartilage seen only around proximal bronchi; the acini were atelectatic and less well developed. It is suggested that the earlier the action of a teratogen, the greater the abnormality of bronchial branching, cartilage distribution, and later lung development.     

Air Leak Syndrome (ALS) as Complication of Asthma

Twenty-eight patients suffered 32 episodes of ALS (air leak syndrome) between 1974 and 1985 at the Department of Pediatrics of the National Minami-Fukuoka Chest Hospital. The highest incidence was observed between ten and twelve years of age and in the autumn. Their chief complaints were chest pain, sore throat and some pains in other parts. Pneumo-mediastinum associated with subcutaneous emphysema was observed in 50%; this was the most common type of ALS. Chest X-ray findings showed free air in the left mediastinurn in 20 of 22 patients with pneumomediastinum. Free air in the left mediastinum is considered to be a diagnostic finding for ALS.     

The Treatment of Peritonitis by Post-operative Peritoneal Lavage in the Small Infant

Wynne, J. M. (1979) Aust. Paediatr. J. , 15, 118–119. The treatment of peritonitis by post-operative peritoneal lavage in the small infant. Peritonitis in early life is a highly lethal condition. Continued post-operative peritoneal lavage with large quantities of fluid containing antibiotics has been shown to be beneficial in adults. Two small infants with peritonitis were successfully treated in this way. No problems were experienced due to the small size of the abdomen when a modified technique was employed.     

Isolated ruptured appendicitis presenting as pneumatosis intestinalis in a premature neonate

We report a novel case of ruptured appendicitis in a premature neonate which radiographically mimicked necrotizing enterocolitis with free intraperitoneal air. On exploratory laparotomy, both the large and small intestines were normal.     

Spontaneous perforation of choledochal cyst: a case with unusual distribution of fluid in the retroperitoneal space

Images of perforated choledochal cysts typically show an intraperitoneal fluid collection. We report a case with, in addition to free intraperitoneal fluid, fluid collection in the right-side anterior pararenal and perirenal spaces. Surgery confirmed the presence of a perforation at the junction of the cystic duct and the common bile duct. This perforation may explain the biliary leakage extending into the free peritoneal space as well as into the anterior pararenal space and the hepatoduodenal ligament. Anterior pararenal and perirenal spaces communicate with the infrarenal space, and this may result in extension of the fluid into the perirenal space from the anterior pararenal space.     

Does pneumoperitoneum always require laparotomy? Report of six cases and review of the literature

The presence of intraperitoneal free air signals perforation of a hollow viscus in over 90% of the patients. Rarely, however, the presence of pneumoperitoneum may not indicate an intra-abdominal perforation and thus may not require laparotomy. This condition, which poses a dilemma to the surgeon faced with this problem, is termed “nonsurgical", “spontaneous” or “idiopathic" pneumoperitoneum. Six cases of nonsurgical pneumoperitoneum admitted over a 2-year period to our institution are reported, and the etiological mechanisms and the pathophysiology of the appearance of intra-abdominal free gas are reviewed. Two of the six children with nonsurgical pneumoperitoneum underwent exploratory laparotomy when clinical examination suggested an acute abdomen; no intra-abdominal pathology was documented in one of these patients. In the other children, malrotation was found. Four patients, on ventilatory support, were managed conservatively after performing a diagnostic peritoneal lavage and/or contrast studies those were negative. An appreciation of the condition and its likely etiological factors should improve awareness and possibly reduce the imperative to perform emergency laparotomy on an otherwise well patient with an unexplained pneumoperitoneum. An erratum to this article can be found at     

Neonatal ascites and hyponatraemia following umbilical venous catheterization

The complications associated with umbilical venous catheterization in neonates range from pericardial effusion, portal hypertension, and peritoneal perforation with ascites, to Wharton's jelly embolism. The case of a term neonate who developed ascites and severe hyponatraemia (serum sodium 119 mmol/L) most probably following peritoneal perforation by an umbilical venous catheter is reported. The presenting feature was convulsions associated with dilutional hyponatraemia, probably following absorption of a large quantity of ascitic fluid across the peritoneum. Conservative management was associated with gradual recovery over 24 h. The case highlights that, irrespective of the route, excessive administration of salt-free fluids can lead to dilutional hyponatraemia with adverse consequences. The present case illustrates the importance of confirming intravascular positioning of umbilical catheters by ensuring free flow of blood on aspiration, to prevent/detect inadvertent peritoneal perforation. Ideally, echocardiographic confirmation of optimal intravascular placement of such catheters is preferred as radiographic confirmation is reported to be unreliable.     

Sonographic and radiographic imaging features of the neonate with necrotizing enterocolitis: correlating findings with outcomes

Background

Abdominal radiography is the reference standard in imaging neonates with necrotizing enterocolitis (NEC); however, ultrasound of the abdomen including bowel may be of value in this setting.

Objective

To correlate sonographic and radiographic findings with patient outcomes in NEC.

Materials and methods

We reviewed sonographic and radiographic exams, as well as clinical, pathological and laboratory records. Ultrasound images were reviewed for free intraperitoneal gas, peritoneal fluid, pneumatosis intestinalis, portal gas, bowel vascularity, bowel wall thickness and echogenicity, peristalsis and the presence of dilated bowel with anechoic contents. Contemporaneously acquired radiographs were reviewed for intraperitoneal gas, pneumatosis intestinalis, portal gas, the sentinel loop sign and gas pattern. Patients were categorized into two groups based on clinical outcome.

Results

Forty-four neonates receiving 55 sonograms were included. Focal fluid collections, echogenic free fluid, increased bowel wall echogenicity and increased bowel wall thickness were statistically significant in predicting an unfavorable outcome. Other features approached significance in predicting poor outcomes: free peritoneal gas, pneumatosis intestinalis, aperistalsis, bowel wall thinning and absent bowel perfusion. Anechoic free peritoneal fluid predicted a good outcome. The sentinel loop sign on radiographs predicted an unfavorable outcome.

Conclusions

Abdominal sonography and radiography in patients with NEC can help prognosticate the outcome.     

Significance of age,duration, obstruction and the dissection sign in intussusception

A retrospective study of sixty consecutive cases of proven intussusception with attempt at contrast enema reduction was performed to evaluate currently proposed contraindications to such reduction. When patient age, duration of symptoms, presence of small bowel obstruction and presence of a dissection sign were considered alone, none of the findings indicated irreducibility. Our overall reduction rate was 72% with a complication rate of 3%. This is similar to previously reported series and we concur with more recent publications that the only contraindications to non-surgical reduction of intussusception are free intraperitoneal air, peritonitis or evidence of infarcted bowel. Only when we encountered a combination of symptoms being present for greater than 48 hours and the presence of both small bowel obstruction and a dissection sign was reduction likely to be unsuccessful. However, the presence of a prognostic indicator occurring alone should not be considered a contraindication.From the Department of Radiology, University of Texas Medical Branch, Galveston, Texas     

An unusual pneumomediastinum case in a child caused by spontaneous bronchial rupture

We report a case of spontaneous pneumomediastinum (SPM) in a 3 year-old child, admitted to the emergency department because he presented dyspnea for a few hours, after a paroxysm of cough. The SPM is rare in children; the term "spontaneous" is reserved for cases of pneumomediastinum that haven't a traumatic cause. SPM is seen most commonly in asthmatics and in any patient who induces a Valsalva maneuver. The clinical diagnosis is confirmed by chest radiograph. When the diagnosis is uncertain, the chest CT scan is considered the gold standard of imaging tests, capable of detecting pneumomediastinum even in patients with small amounts of mediastinal air. In this case CT images showed the cause: spontaneous bronchial rupture. The direct sign of bronchial injury is the contiguity of the luminal air with that in the mediastinum. In the literature SPM cases are very rare, at least in health patients without tracheobronchial anomalies. The SPM is generally a benign entity that requires supportive care, and resolution occurs spontaneously, such as in our patient. In this article we want to explain the main clinical, diagnostic and therapeutic aspects of SPM, because, even if it's rare in children, it must be considered in the differential diagnosis of dyspnea; then we want to demonstrate as, in this case, a TC scan was important to identifying the SPM cause: a bronchial rupture.