Perforated peptic ulcer in an adolescent girl

A perforated peptic ulcer in a child is a rare entity. Severe abdominal pain in an ill-appearing child with a rigid abdomen and possibly with signs of shock is the typical presenting feature of this life-threatening complication of peptic ulcer disease. We present a case of a 14.5-year-old adolescent girl who developed abdominal and shoulder pain that resolved after 1 day. She was then completely well for 2 days until the abdominal and shoulder pain recurred. On examination, she appeared well, but in pain. A chest radiograph revealed a large pneumoperitoneum. She underwent emergent laparoscopic omental patch repair of a perforated ulcer on the anterior wall of her stomach. Result of a urea breath test to detect Helicobacter pylori was negative. The differential diagnosis of pneumoperitoneum in children is discussed, as are childhood perforated peptic ulcer in general, and the unique clinical features present in this case in particular.     

Traumatic aneurysm and arteriovenous fistula of the splenic artery

Aneurysmal arteriovenous fistulas are rare and mostly seen in adults. A 13-year-old girl developed a subcapsular hematoma of the spleen following blunt abdominal trauma. Follow-up ultrasonography 4 months after the trauma revealed an aneurysm at the splenic hilum. Selective splenic angiography demonstrated the lesion to be an aneurysmal arteriovenous fistula. Repeat ultrasonography enabled us to be certain of the traumatic origin of the aneurysm and arteriovenous fistula which are very unusual in the pediatric age group.     

Fetus in fetu: a case report and literature review

Fetus in fetu is a rare condition in which a fetiform calcified mass often is present in the abdomen of its host, a newborn or an infant. We report on a case of a 19-month-old girl whose plain abdominal radiograph, ultrasonography, and computed tomography scan revealed a mass in which the contents favor a fetus in fetu rather than a teratoma. The noncalcified vertebral column invisible on the radiographs was identified by the pathologist; therefore, the nonvisualization of the vertebral axis on radiography or on computed tomography scan does not exclude the diagnosis of fetus in fetu.     

Giant trichophytobezoar in a pediatric patient with trichotillomania

We report a case of a 13-year-old girl with trichotillomania. A plain abdominal radiograph and axial CT scan revealed a well-defined mass within the stomach. Gastrotomy was performed and a 19 x 11 x 2-cm trichophytobezoar was delivered intact.     

Heterotopic pancreatic tissue in the gallbladder

Ectopic pancreatic tissue is found in most cases in the stomach, duodenum, and upper part of the jejunum, but rarely is localized in the gallbladder. We present a 14-year-old girl with episodes of abdominal pain for 2 years who underwent a cholecystectomy. The pathologic examination revealed aberrant pancreatic tissue. This is the 12th case described in the literature, and appears to be the first in a pediatric patient. We recommend cholecystectomy in all patients with symptomatology and the finding of an abnormal gallbladder on a cholecystogram, even without the presence of stones. Correspondence to: L. De Mingo     

Un cas de volvulus aigu de l''estomac chez l''enfant

Gastric volvulus is an abnormal rotation of the stomach around its axis. The acute form is a surgical emergency, which doesn't tolerate any therapeutic delay. We report on a case in a young girl, revealed by painful epigastric mass and distended gastric bubble on abdominal X-ray. This case was been successfully treated by detorsion and gastropexy. The clinical picture of gastric volvulus is characterised by the Borchardt triad of symptoms: upper abdominal pain, vomiting and difficulty to pass a nasogastric tube. The gastrointestinal barium series and CT-scan help to confirm the diagnosis. As was demonstrated in this case, the treatment is surgical by reducing the volvulus and fixing the stomach to prevent recurrence.     

THE STOMACH AND PULMONARY INTERLOBULAR SPACE AS UNUSUAL SITES OF OSTEOSARCOMA

The authors report a girl with high-grade intraosseous osteosarcoma of the left femur who lost one eye during early infancy for an unknown reason. Nine months after treatment, osteosarcoma in the stomach was detected and completely excised when the girl underwent endoscopy for Helicobacter pylori infection. Three years later osteosarcoma in the pulmonary interlobular space was noticed and completely removed. The girl is doing well and free of disease 26 months after the last resection.     

THE STOMACH AND PULMONARY INTERLOBULAR SPACE AS UNUSUAL SITES OF OSTEOSARCOMA

The authors report a girl with high-grade intraosseous osteosarcoma of the left femur who lost one eye during early infancy for an unknown reason. Nine months after treatment, osteosarcoma in the stomach was detected and completely excised when the girl underwent endoscopy for Helicobacter pylori infection. Three years later osteosarcoma in the pulmonary interlobular space was noticed and completely removed. The girl is doing well and free of disease 26 months after the last resection.     

Fehldiagnose Anorexia nervosa bei 2 Patienten mit Malignom

Pathologic weight loss can be caused by organic and psychiatric disorders. A 14-year-old girl lost 14 kg of her body weight within 4 weeks and anorexia nervosa was diagnosed. Ultrasound was performed for the first time after 4 weeks of recurrent vomiting and revealed a huge abdominal rhabdomyosarcoma. The tumor compressed the esophagus and stomach, and hence, was leading to vomiting and weight loss. A 13 year-old girl lost 17 kg (40% of her body weight) over a period of 16 months and was treated for anorexia nervosa during this time. The appearance of additional neurological symptoms let to a cranial magnetic resonance imaging which revealed a cerebello-spinal tumor. These cases underscore the importance of excluding organic disorders before diagnosing and treating anorexia nervosa. Imaging techniques, such as ultrasound or magnetic resonance imaging, could reveal life-threatening diseases at an early stage and prevent useless therapeutic procedures.     

Lethal gastric rupture caused by acute gastric ulcer in a 6-year-old girl

Gastric rupture is extremely rare in childhood beyond the neonatal period. We describe a previously healthy 6-year-old girl with a large laceration along the greater curvature on the posterior wall of the stomach. The patient was admitted to a neighboring hospital because of vertigo with 1-day history of intractable vomiting and epigastric pain. Although abdominal distension was noticed during the physical examination, muscular rigidity was not detected on palpation. Laboratory data showed severe hypotonic dehydration and moderate metabolic acidosis with hyperkalemia. She suddenly developed cardiac arrest within an hour after admission. After resuscitation, surgical consultation was obtained. Abdominal X-ray and ultrasound revealed abdominal free air and massive cloudy ascites. At laparotomy, there was a large laceration on the greater curvature of the stomach. Pathology of the gastric wall showed mucosal necrosis while the musculature remained intact consistent with an acute gastric ulcer. Since clinical condition of gastric rupture deteriorates rapidly, early diagnosis and appropriate treatment is essential for good prognosis. One should consider that ulcer formation might cause gastric rupture in childhood.     

Gallstone pancreatitis in children: atypical presentation and review

Pancreatitis in children is less common than in adults and is mostly related to trauma, infection and anatomical anomalies. Gallstone pancreatitis is an even rarer entity in infants and children. We present an unusual case of gallstone pancreatitis in a 17- month-old girl who presented with jaundice of 1 month duration. The laboratory studies showed conjugated hyperbilirubinaemia with associated acute pancreatitis and pseudo-hyponatraemia secondary to the markedly elevated lipid profile. Further evaluations revealed obstruction at the Ampulla of Vater with no evidence of a choledochal cyst and no mass lesion seen in the pancreas. The patient initially underwent urgent decompressive cholecystostomy with intraoperative cholecystography. When the biochemical parameters improved, the patient underwent formal cholecystectomy with common bile duct exploration, extraction of multiple impacted stones in the ampullary region and Fogarty balloon sphincterotomy. The post-operative course was uneventful. Conclusion:Acute gallstone pancreatitis in children may present as jaundice or abdominal pain. Recognition, early diagnosis and surgical intervention are the mainstay for a good outcome.     

Common bile duct obstruction due to an intraluminal mass of candidiasis in a previously healthy child

A 3 6/12-year-old previously healthy girl had intermittent attacks of abdominal pain following a blunt abdominal trauma. At admission to the hospital, she had jaundice and hepatomegaly. Results of laboratory tests indicated an obstructive pattern, and ultrasonography revealed an intraluminal mass in the distal common bile duct. At surgery, the mass was confirmed as the cause of obstruction, and it was removed. Microscopic analysis indicated that the amorphous material was fungi infested. Growth cultures from bile and feces yielded Candida albicans. Postoperative treatment with T-tube drainage and antimycotic drugs led to an uneventful recovery. Clinical, biochemical, and ultrasonographic follow-up have shown no evidence of recurrence. A possible cause and effect relationship between the trauma and the development of biliary obstruction is suggested.     

Intra-rachidian disorders: two unusual cases of recurrent abdominal pain in children

Recurrent abdominal pain (RAP) is generally thought to be of psychological origin but organic aetiologies are increasingly being identified. The cases of two children with vertebral disorders revealed by recurrent abdominal pain are reported. A 14-y-old girl presented with RAP associated with scoliosis, due to a T8-T9 intra-dural extra-medullary tumour. A 7-y-old girl who suffered from nocturnal RAP located in the right iliac fossa for 1 y had decreased muscular strength, pyramidal signs, and a 10 degree Lassègue sign in the right lower limb, revealing a vascular malformation extending from T12 to L2. Conclusion: Atypical pain and associated neurological signs or scoliosis must raise the possibility of intra-rachidian disorders. Magnetic resonance examination will then precisely state the location and nature of the pathological process, avoiding excessive delay in therapeutic management.     

Abdominal aortic injury in a child: intravenous digital subtraction angiogram (IVDSA) for the diagnosis of pediatric vascular trauma

Abdominal aortic injury due to trauma is a rare entity, especially in the pediatric population. We report a 6-year-old girl with partial transection of the abdominal aorta as a result of a motor vehicle accident. The diagnosis was made with IVDSA. The patient survived the injury. We discuss the imaging findings, mechanisms, and associated injuries of abdominal aortic trauma in children.     

Evaluation of pediatric bladder reservoir trauma

We present a case where computed tomographic cystography of the bladder failed to identify a bladder rupture in a girl with an Indiana pouch after falling from her bicycle. Despite the normal cystogram, surgery was performed because of unresolving abdominal pain and free fluid identified on abdominal computed tomography. Upon exploration, 2 intraperitoneal ruptures were identified. While computed tomographic cystography is accurate for the evaluation of trauma in a normal bladder, emergency room physicians should be aware of its potential inaccuracy in patients with bladder reservoirs.     

Spigelian hernia in children,two cases of unusual etiology

A 5-year-old girl with blunt trauma to the abdomen and a 3-month-old boy after abdominal surgery were found to have a spigelian hernia. The pathogenesis of these rare hernias is discussed. Our first case is the third recorded traumatic spigelian hernia occuring in a child, and the second is the first postoperative case described after abdominal repair of a Bochdalek hernia. Offprint requests to: J. A. Bar-Maor     

Recurrent bowel intussusception and celiac disease

We report a 1-year-old girl with acute abdominal pain. Clinical examination revealed distended abdomen with increased intestinal peristalsis without other pathologic signs. Ultrasound of the abdomen showed a small bowel intussusception. Seven days later, after a new episode of sudden acute abdominal pain, ultrasound revealed a new bowel intussusception. Ig A and Ig G antigliadin-antibodies were elevated and intestinal biopsy revealed total villous atrophy. After being placed on a gluten-free diet the girl was free of colicky complaints and on repeated ultrasound there was no sign of intussusception. With recurrent intussusception, celiac disease should be considered as a cause.     

Association of a fetus in fetu and two teratomas: US and MRI

We report a case of an abdominal mass in a newborn girl containing a fetus in fetu and two teratomas. Obstetrical sonography revealed the abnormality at 28 weeks of gestation. Post-natal US examination suggested the diagnosis of a fetus in fetu upon the finding of a vertebral column and fetal skeletal bones. US also showed two other rounded masses connected to the main lesion by vascular bundles. Preoperative MRI examination supplied further information regarding tissue composition and vascularisation of the mass lesion. The diagnosis was confirmed by pathological examination. Aetiological factors and radiological diagnosis of this rare tumour are reviewed and discussed. Received: 29 January 1996 Accepted: 2 February 1996     

Anorectal injuries in children

 Anorectal injuries (ARI) are uncommon in children in civil practice. In developed countries the injuries are mainly due to sexual abuse and firearms. This report reviews the experience in tropical Africa. A retrospective study of children aged 12 years or less managed for ARI over 10 years was undertaken. There were seven children, four girls and three boys. Four injuries were due to blunt trauma and three to penetrating trauma. Six patients presented within 6 h of injury and one after 24 h. Five had rectal bleeding, which was associated with vaginal bleeding in one girl. One girl each had vaginal bleeding and vaginal discharge without rectal bleeding. Diagnosis was by rectal examination and proctoscopy. In three patients a laparotomy was necessary to exclude an intraperitoneal rectal injury (IRI); this was positive in one case. One patient with abdominal findings had a laparotomy as the primary procedure. Overall, five patients had rectal injuries (extraperitoneal 3, intraperitoneal 2), which were associated with an anal injury in three while one patient had only an anal injury. An IRI was missed at initial assessment in one girl. Associated injuries were to the vaginal wall (3), urethra (1) and head (1). IRIs were treated by repair and proximal colostomy. Extraperitoneal injuries were treated by colostomy and drainage; in two patients the injuries were accessible and were repaired. Anal and external-sphincter injuries were repaired in two cases. Vaginal lacerations were repaired and other associated injuries treated accordingly. Three patients had wound infections. Faecal continence was maintained in all patients who had anal and external-sphincter injuries. One girl died of peritonitis from a missed IRI. It is concluded that ARI remains uncommon in children. Morbidity and mortality can, however, be high. Meticulous rectal palpation and visualisation is necessary to avoid missing injuries. Accepted: 9 September 1999     

Traumatic abdominal wall hernia: an unusual bicycle handlebar injury

Traumatic hernia of the abdominal wall is rare. The mechanism of injury can be severe such as a motor vehicle accident or relatively minor such as a fall onto a bicycle handlebar. In children traumatic abdominal wall hernia can occur even after relatively minor trauma and these cases typically have no associated intra-abdominal injury. We report a traumatic hernia of the anterior abdominal wall in a 7-year-old boy following a fall from a bicycle. A review of the literature revealed only nine similar reports. The presence of localised pain, bruising, and a reducible swelling or a cough impulse suggests the diagnosis. Primary repair with prosthetic material is the preferred treatment.