A case of acquired gastric outlet obstruction diagnosed at 16 years of age

A 16-year-old boy was admitted with an 8-year history of abdominal pain, vomiting, and growth retardation. There was no history of peptic ulcer or caustic ingestion. He was severely cachexic, and barium meal showed a dilated stomach with delayed gastric emptying time and no contrast in the duodenum afterward. Exploratory laparotomy demonstrated a grossly dilated stomach with a smooth wall and a stenotic ring at the pylorus but without any muscular hypertrophy. There was no extrinsic compression of the pylorus or any scarring near it. Heineke–Mikulicz pyloroplasty was performed. Histopathological examination of the pylorus showed normal cellular pattern without any neoplastic or inflammatory cells. The patient improved postoperatively and gained 8 kg in the first month following the operation.     

Electrogastrography in patients after operative repair of gastric rupture

Electrogastrography (EGG) measures the myoelectric and motor activity of the stomach as detected by cutaneous electrodes attached to the epigastrium. The specific frequency of gastric activity is thought to be 3 cycles per minute (cpm) as determined by spectral analysis. EGG was performed to evaluate gastric motor function in 13 patients (mean age 11.6 ± 2.90 years) who had undergone operative repair of a gastric rupture. The EGG results were compared with those of 8 normal, age-matched controls (mean age 9.25 ± 2.14 years). The mean frequency (MSF) (2.84 ± 0.067 cpm) of the postprandial EGG spectra of 5 patients with ruptures at or along the greater curvature was significantly lower (P <0.05) than that of the control subjects (3.18 ± 0.0186 cpm). Similarly, the MSF for 3 patients whose areas of rupture were greater than 20 cm² was 2.75 ± 0.202 cpm in the fasting state (F) and 2.53 ± 0.0385 cpm in the postprandial state (P). These values were significantly lower than those of normal controls (3.29 ± 0.0313 cpm, n = 7 [F]; 3.18 ± 0.0186 cpm, n = 8 [P], respectively). The ratio of fasting to postprandial power was similar between the gastric rupture group and the controls. There was significantly greater variability in the postprandial spectral frequency of the gastric component in the gastric rupture group than in the controls. The results of EGG analysis suggest that the gastric pacemaker and/or gastric motor activity may be disrupted in patients following operative repair of a gastric rupture, although these patients remain asymptomatic.     

新生儿自发性胃穿孔临床病理特点和病因探讨

目的 探讨新生儿自发性胃穿孔的病因和临床病理特点.方法 对本院自2001至2009年,治疗的15例胃穿孔新生儿进行回顾性分析,全部病例采用免疫组织化学方法进行研究.结果 本病典型的临床表现有呕吐、腹胀、呼吸窘迫等,腹部立位X线平片显示膈下游离气体及腹腔积液.穿孔部位大多在胃大弯,本组8例死亡,病死率53.33%,其中6例为出生后1 d内出现症状.镜下观察胃壁肌层变薄、缺损,ICC减少.结论 新生儿自发性胃穿孔与胃壁结构异常和ICC减少有关.预后与发病时间、手术时间等关系更为密切.     

Prenatal detection of isolated gastric duplication cyst

We present a rare case of gastric duplication cyst that was suspected prenatally. A routine prenatal ultrasonography (US) showed an abdominal cyst with peristalsis and a provisional diagnosis of enteric duplication was made. A healthy male infant was born at 39 weeks gestation and postnatal US identified a cyst, 5×3×2 cm in size, adjacent to the pancreas. At laparotomy, a cyst was found located in the lesser sac, but completely separated from the stomach, and partially adhered to the body of the pancreas and the crura of the diaphragm. Total excision of the cyst was successful. Histopathologic examination confirmed that the cyst wall consisted solely of normal gastric tissue with erosions. To the best of our knowledge, this is the first report of an isolated gastric duplication cyst that was detected prenatally and resected during the neonatal period.     

Perforated gastric ulcer in the child: a rare complication, a case report]

Perforated gastric ulcer is unusual in children. We report a case in a girl with an unexpected evolution. CASE REPORT: A 13-year-old girl was admitted for abdominal pain. She had no particular personal history but her father had a perforated ulcer. On admission she was not painful, her abdomen was soft on palpation. The white blood cell count was 1.7 x 10(3)/mm3. A right pneumoperitoneum was seen on an abdominal X-ray film. Because of her good general status and the normalization of the abdominal X ray film six hours later, no surgical exploration was performed. On the fourth day, a gastrointestinal endoscopy showed an anterior gastric ulcer which was perforated. Biopsies did not isolate H. pylori. The patient was given a treatment with amoxicillin-metronidazole (7 d) and oméprazole (7 weeks). An endoscopic control, one month later, showed a total healing of the gastric ulcer. CONCLUSION: Peptic ulcerations and their complications are underdiagnosed in childhood. This could lead to delay in diagnosis or inappropriate treatment specially in case of perforation.     

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.     

Idiopathic gastric rupture in a 3-month-old girl

This case reports on idiopathic gastric rupture in a 3-mo-old girl who had frequent episodes of vomiting and abdominal distension the day before admission to the clinic. Metabolic acidosis was detected and rotavirus antigen was identified in the stools. Abdominal X-rays and CT scans revealed free air and fluid in the abdominal cavity, leading to a diagnosis of gastrointestinal perforation. During surgery, idiopathic gastric rupture was detected and treated. The postoperative course was uneventful. CONCLUSION: Idiopathic gastric rupture is extremely rare in childhood beyond the neonatal period. Early diagnosis and surgery are mandatory if children with this condition are to be saved.     

Substitution of thoracic oesophagus by interposition of a pedicled gastric tube, preserving LES function: clinical and histological follow-up

Assessment of clinical evolution and histological findings in a group of animals experimentally operated on to substitute the thoracic oesophagus with a gastric tube. Six piglets underwent oesophageal replacement with a gastric tube, constructed from the greater curvature of stomach and pedicled on the gastroepiploic vessels, which was interposed between the oesophageal stumps. At follow-up, all animals were found to be growing and eating normally, apart from case no 1 (stenosis of the lower oesophageal anastomosis). Ph-metry showed a neutral pH on the gastric tube. Postmortem histological analysis of the gastric tube and native oesophagus samples did not show any significant lesions, except in case no 1 (inflammation of the gastric tube and upper oesophagus due to food stasis). The technique of substitution of the oesophagus with an interposed pedicled gastric tube can be a breakthrough in existing surgical methods of oesophageal replacement. Research co-financed by CNR (Consiglio Nazionale delle Ricerche- Italia), and Regione Autonoma della Sardegna – Assessorato Igiene, Sanità e Assistenza Sociale     

Neonatal gastric necrosis]

BACKGROUND. Neonatal necrotizing gastritis is rare. It is usually a complication of acute anoxia or shock and its diagnosis is essentially radiological. CASE REPORTS. Case no. 1: a boy was born at the 36th week of a pregnancy complicated by preeclampsia. Perinatal asphyxia necessitated delivery by cesarean section. He presented with neonatal respiratory distress which was complicated by pneumothorax. On the 5th day of life, the abdomen was distended and the newborn had still not been fed. On the 6th day, X-rays showed pneumatosis of the gastric wall associated with pneumoperitoneum. Surgery showed an area of necrosis on the posterior surface of the stomach with a small perforation, which was stitched. The child was fed 5 days later and was in good condition at the age of 6 months. Case no. 2: a girl was born at the 35th week of a pregnancy complicated by asthma during the second trimester. Perinatal asphyxia and abnormal fetal rhythm led to delivery by cesarean section. At 24 hour of life, she vomited blood and fibroscopy confirmed the presence of blood in the stomach. On the 3rd day, blood vomiting appeared again, associated with abdominal distension. X-rays showed pneumatosis of the gastric wall; fibroscopy showed necrosis of the lower 2/3 of the stomach. Feeding was stopped and the child was given cimetidine. Refeeding was possible when the girl was 10 days old, and she was in good condition at the age of 6 months. CONCLUSION. Neonatal gastric necroses and necrotizing enterocolitis have many similar features. Medical therapy is often effective, but surgery is mandatory when necrotizing gastritis is complicated by perforation.     

Total gastric replacement following gas bloat in a 21-month-old child

A 21-month-old child with a previously repaired left congenital diaphragmatic hernia underwent a 360° `loose-wrap' Nissen fundoplication for gastroesophageal reflux. Failure to replace the dislodged nasogastric tube on the 2nd night led to severe gas bloat and total gastric infarction. A 30-cm retrocolic, N-shaped, isoperistaltic jejunal pouch was constructed for gastric replacement. A pyloromyotomy ensured free emptying and a pouchostomy secured the pouch to the abdominal wall. At 8 months all nutrition was oral except for a biannual vitamin B₁₂ injection, there was no dumping, and the pouchostomy was removed. By 18 months growth, originally along the 10th centile, was sustained at the 50th centile. Our early impression recommends a 30-cm retrocolic, isoperistaltic, N-shaped jejunal pouch similar to that of Hays and Clark as a safe and effective replacement for the stomach in children. Accepted: 5 May 1998     

Spontaneous neonatal gastric perforation

Over a 7-year period (1990-1997) spontaneous gastric perforation was diagnosed in five neonates. The mean gestational age and birth weight were 33/40 weeks and 1.83 kg, respectively. All patients presented with severe abdominal distention and frank pneumoperitoneum on roentgenograms. All perforations were on the anterior wall of the greater curvature and were managed by prompt laparotomy and primary closure of the perforation. No gastrostomy was used, however, peritoneal drainage was used in all cases. There was no mortality or morbidity. An attempt to understand the possible etiology together with a review of the literature is presented.     

Immature Gastric Teratoma in an Infant

A 45 day old boy presented with progressive abdominal distension, tarry stools and anemia. A plain roentgenogram of the abdomen showed irregular, coarse calcifications in the left upper quadrant. The ultrasonography and computerized tomography of the abdomen revealed a large heterogeneous tumor with calcified parts in the left hemiabdomen. At operation, a 12 cm × 11 cm × 10 cm, multilobular, exogastric and endogastric tumor, including a portion of the anterior wall of the stomach, was extirpated. The pathological examination revealed a gastric teratoma with immature neural elements. Eight years after the total excision of the tumor there has not been any recurrence.
This study includes a review of 88 cases (including the present case) of gastric teratoma reported in the English and Japanese literature.     

Spontaneous rupture of the stomach — low insertion of the esophagus on the lesser curvature as a predisposing factor

Summary A case of spontaneous rupture of the stomach in a child is reported. It is suggested that a very low insertion of the esophagus on the lesser curvature could have been a predisposing factor in preventing escape of gas from a stomach overdistended due to a large intake of sausages and akali-containing drinks. To prevent recurrence we recommend that a pyloroplasty be done. Offprint requests to: P. Juul     

Stapled gastroplasty for antral stricture after repair of neonatal gastric rupture: report of a case

The patient was the second of twin girls born at 32 weeks gestation, weighing 1736 g. Abdominal distention was noted the day after birth, and abdominal x-ray showed free air in the abdomen. An emergent laparotomy with debridement and primary closure were performed for spontaneous gastric rupture. From the age of 8 months, the infant sometimes vomited after meals and was unable to gain weight. She was diagnosed, by upper gastrointestinal series and gastroscopy, with antral stricture with a normal prepyloric area and pylorus. The presence of an antral web, ulcers, or ectopic pancreatic tissue was excluded. There was sufficient distance between the stricture area and the pylorus. Stapled gastroplasty using an Endopath linear cutter stapler and a Proximate linear stapler was performed safely and quickly without injury to the normal pylorus or branches of the vagal nerve at the lesser curvature. The childs postoperative course was uneventful.     

Idiopathic gastric rupture in toddler: case report

Idiopathic gastric rupture is rare in children. Most of them occur in newborn. The authors report the case of a 2-year-old female toddler with no significant medical records. Clinical picture began 48 h before with abdominal pain, nausea and vomiting. She was admitted to the Emergency Room in poor general condition, with abdominal distension and rebound tenderness. Laparotomy was performed immediately show-ing multiple perforations in the posterior wall of the stomach. Partial gastrectomy was performed. Afterwards, she was admitted to ICU in shock. She received mechanical ventilation, intravenous fluid administration (260 ml/kg in 12 h), vasoactive support and antibacterial therapy (cefotaxime and metronidazole). Laboratory showed leukopenia and thrombocytopenia. Etiological study was entirely negative for toxic and drug consumption. Collagen disease was ruled out and serum level of gastrin was normal. Her post operative course was characterized by persistent fever caused by left subphrenic collection (positive culture for Candida galabrata). Peritoneal lavage via laparotomy and percutaneous drainage of the residual collections were performed. She completed 3 weeks of antibacterial and antifungal therapies with adequate outcome. Her follow-up in 12 months was uneventful.     

An unusual cause of gastric perforation in childhood: trichobezoar (Rapunzel syndrome). A case report

Trichobezoars are hair balls found in the stomach and formed following trichitillomania and trichopaghia. Rapunzel syndrome is a rare condition in which the presence of giant trichobezoars causes mechanical obstruction. To date, only two cases of stomach perforation caused by trichobezoars have been reported among pediatric patients. We report a 14-year-old female patient who experienced nausea, vomiting and severe abdominal pain for 1 month. Physical examination revealed diffuse abdominal distension. Palpation detected a mobile and sensitive mass, 15 × 15 cm , which filled the upper quadrant. Urgent surgery revealed that the stomach was perforated by the trichobezoar ball. This trichobezoar mass was totally excised by expanding the perforation area. Conclusion This is the reported third case of gastric perforation caused by trichobezoar in a pediatric patient. Among acute abdominal cases, gastric perforation should remain a possibility in differential diagnosis.     

Laparoscopic suture repair of idiopathic gastric perforation in Duchenne muscular dystrophy

We report herein an adolescent case of Duchenne muscular dystrophy (DMD) with idiopathic gastric perforation, in which emergency surgical repair was performed laparoscopically. A 14-year-old nonambulatory boy with DMD was brought to our emergency department with sudden onset of severe abdominal pain and distention. Plain radiograph and computed tomography confirmed the presence of free intraperitoneal air and intrapelvic effusion. The patient elected to undergo laparoscopic inspection with 4 trocars, revealing a focal perforation, 3-4 cm in diameter, on the upper gastric body near the diaphragm. The stomach was also found to have a thin wall without evidence of peptic ulcer disease or other abnormalities. An interrupted suture was placed using 4-0 PDS. The abdomen was extensively irrigated, and multiple J-Vac drains were left in situ. Total operation time was 90 min, and no intraoperative complications were encountered. Enteral feeding through a nasogastric tube was started on postoperative day 7. The postoperative course has been uneventful as of the 12-month follow-up. Pediatric surgeons should be aware of the increased risk of gastric perforation associated with DMD, and that laparoscopic repair can be safely performed even in emergency settings.Key words: Duchenne muscular dystrophy, gastric perforation, laparoscopic repair     

Intrathoracic gastric volvulus in an infant

Intrathoracic gastric volvulus in infants is a rare surgical emergency. Delays in diagnosis and treatment are life-threatening due to progressive deterioration of the gastric walls. A 3-month-old female was admitted with severe blood-stained vomiting. A radiologic contrast study showed a complete organoaxial intrathoracic gastric volvulus. The stomach was pulled into the abdomen through a xiphoumbilical incision and a Nissen fundoplication was performed. The 3- and 6-month follows-up examinations showed a thriving, asymptomatic child. Correspondence to: C. Del Rossi     

Localised gastric ileus in Klebsiella sepsis

A full-term neonate with perinatal asphyxia (no hypoxic ischaemic encephalopathy and meconium aspiration syndrome who developed klebsiella sepsis on D2 of life was documented to have a massively dilated stomach on abdominal X-ray and large gastric aspirates. A gastroconray study ruled out gastric outlet obstruction. As the sepsis settled the gastric aspiratres and the gastric size decreased suggesting that klebsiella sepsis was the cause for localised gastric ileus that resulted in massive gastric dilation. The aetiopathogenesis and differential diagnosis of localised gastric ileus are discussed.     

Usefulness of ultrasonography in gastric foreign body retention

Foreign-body ingestion occurs frequently in childhood. The diagnosis of ingestion is usually made by plain film radiography. Ultrasound is not routinely used in the investigation of gastric foreign bodies because of the limitations imposed by intestinal gas. This drawback can be overcome by distending the stomach with an anechoic liquid, which acts as an acoustic window. In a child who had ingested a coin, US performed after drinking tea was diagnostic and showed a hyperechoic image with an acoustic shadow inside the stomach. We believe that US is an appropriate technique for follow-up of gastric foreign bodies. Received: 1 June 1999/Accepted: 27 March 2000