Factors for Delayed Diagnosis of Acute Appendicitis in Children / 대한소아소화기영양학회지

PURPOSE: We designed this retrospective study to establish the incidence of diagnosic delay in children diagnosed with acute appendicitis and to identify associated factors with delayed diagnosis and its impact on the clinical course. METHODS: All cases of children under 15 years of age who underwent appendectomy from 1996 to 2001 at Gangneung Asan Hospital were reviewed. We reviewed signs and symptoms, type of health professional first contacted, the advice given by the health professional and a history of appendicitis in first degree relatives. Diagnostic period is the time elapsed between first complaints and definitive diagnosis. Delay was defined as diagnostic period exceeded the 48 hours. Postoperative course and complications were also reviewed. RESULTS: Incidence of diagnostic delay differed by whether diarrhea and fecalith on X-ray were present. Also children whose parents were advised to observe them at home were more likely to have a diagnostic delay. In almost half of the cases in delayed group, initial diagnosis was not acute appendicitis but gastroenteritis. The perforation rate in non-delayed group was 22%, whereas 87% in delayed group. The delayed group showed a higher number of postoperative complication and a longer hospitalization period. CONCLUSIONS: Diarrhea with abdominal pain and fever in children should not be dismissed as gastroenteritis, respiratory infections or other common disorders. Our study suggests that physicians have a responsibility to prevent diagnostic delay and resultant perforation of acute appendicitis in children by having a high index of suspicion about acute appendicitis.

Small Intestinal Infarction Associated with Henoch-Schoenlein Purpura

Henoch-Schoenlein purpura, also known as anaphylactoid purpura, is characterized by palpable purpura, colicky abdominal pain, gastrointestinal hemorrhage, arthralgias, and renal involvement. Histopathologically, the condition represents a vasculitis, and in fact, it may be the most common vasculitis syndrome affecting children. The pathogenesis of Henoch-Schoenlein purpura remains poorly understood, but it is postulated that an unknown antigenic stimulus causes elevation of circulating IgA and that complement activation leads to necrotizing vasculitis. All of its clinical features are attributable to wide spread vasculits. Abdominal pain is the most common gastrointestinal symptom, but intestinal bleeding and intussusception may occur. Mesenteric vasculitis is a rare but potentially serious complication of systemic vasculitis. It is reported in association with rheumatoid arthritis, systemic lupus erythematosus, scleroderma, polyarteritis nodosa, and giant cell arteritis in adult patients. Typical features are diffuse non-specific abdominal pain progressing on occasion to gastrointestinal hemorrhage, perforation, or more rarely infarction. Fortunately intestinal infarction is a rare complications, but if present carries a high chance of mortality, and swift management of the underlying vasculitis is crucial. We describe here an unusual case of a small intestinal infarction associated with Henoch-Schoenlein purpura caused by mesenteric vasculitis.

A Case of Fetal Alcohol Syndrome

The teratogenic effects of alcohol have been recognized in fetal alcohol syndrome (FAS). FAS is a collection of signs and symptoms seen in some children exposed to alcohol in the prenatal period. An 8 month-old-male with an alcoholic mother was diagnosed as a case of FAS according to the following : 1) early-onset intrauterine growth retardation and persistent postnatal growth failure 2) psychomotor retardation 3) craniofacial dysmorphism. Early diagnosis and continued education are advantageous at all levels, benefiting both the individual and all of society. We present this case with a brief review of related literatures.

Thyroid Function Studies in Patients Who Underwent Open Heart Surgery

PURPOSE: Alteration in the serum level of thyroid hormone can occur following open heart surgery due to major stress and hemodilution after extracorporeal circulation but these changes have been ignored. The purpose of this study is to evaluate the changes of thyroid hormone level after open heart surgery and if these changes influence the prognosis. METHODS: We evaluated 26 children who had undergone open heart surgery from Sept. 1994 to Jun. 1996 at Korea University Hospital. Five ml of blood were collected before surgery, immediately after surgery and 24 hours after surgery. The blood was centrifused and the serum stored at -40degrees C until examinations were made. Serum T3, T4, reverse T3 were measured by sensitive and specific radioimmunoassay. RESULTS: The mean T3 level was 1.49 +/- 0.50ng/ml (normal 0.08-2.0ng/ml) at pre op, 0.75 +/- 0.40ng/ ml immediately after surgery and 0.69 +/- 0.50ng/ml 24 hours after surgery. The mean T4 level was 10.73 +/- 4.40ug/dl (normal 6.1-11.8 microgram/dl) at pre op, 5.80 +/- 1.90ug/dl immediately after surgery and 5.60 +/- 2.10ug/dl 24 hours after surgery. The mean TSH level was 1.69 +/- 1.13uIU/ml (normal 0.25-4.0 uIU/ml) at pre op, 1.37 +/- 0.80uIU/ml immediately after surgery and 1.61 +/- 1.00uIU/ml 24 hours after surgery. Serum T3 and T4 levels in cardiac surgical patients were significantly reduced (P<0.01), and serum reverse T3 levels were significantly increased (P<0.05), and serum TSH levels were not significantly different in comparison with the preoperative state. CONCLUSION: We conclued that patients with congenital heart disease who underwent open heart surgery show euthyroid sick states like other severely ill patients. It is likely that reduction in T3 and T4 without increased TSH represents an adaptive response by the body to minimize catabolism when undergoing major stress.

The Furosemide Effects on Renal Blood Flow of Cats Treated with Indomethacin / 대한신장학회잡지

Indomethacin, a prostaglandin synthetase inhibitor, is widely used for constriction or closure of patent ductus arteriosus in premature infants. Following indomethacin therapy, a majority of the infants develop transient renal dysfunction, as manifested by decrease in urine output, glomerular filtration rate, fractional excretion of sodium and free water clearance. A decrease in urinary excretion of prostaglandins also has been noted in premature infants following indomethacin therapy. Furosemide , on the other hand, has recently been shown to increase urinary excretion of prostaglandins. The hemodynamic and tubular effects of furosemide have been proposed to be mediated by renal prostaglandins. Therefore, the present study was conducted to determine if furosemide therapy would prevent the changes of renal blood flow which are considered indomethacin effects. The results obtained are as follows : 1) In the non-furosemide group, after indomethacin administration renal blood flow decreased to its lowest level, 30 minutes, and then recovered its baseline level at 90 minutes(P<0.05). But there were no significant changes in the furosemide-treated group. 2) After indomethacin administration, urinary prostaglandin E2 decreased to its lowest level at 90 minutes in the non-furosemide group(P<0.05), but there was no significant changes in the furosemide- treated group. 3) Plasma renin activity did not change in the non-furosemide group, while measuring significantly higher in the treated group(P<0.05). 4) Antidiuretic hormone(ADH) level was increased significantly in the non-furosemide group(P<0.05), while did not change in the furosemide-treated group. 5) There was no significant changes on plasma aldosterone blood pressure, electrolytes, BUN,and creatinine. These findings of our present study may have clinical implications when indomethacin is to be used to close the ductus in premature infants. In such cases, simultaneous administration of furosemide may prevent some effects on renal blood flow of indomethacin but further clinical studies are necessary to recognize whether this furosemide therapy may affect the efficacy of indomethacin in the closure of the ductus arteriosus.

Doppler Analysis of Postprandial Intestinal Blood Flow in Healthy Preterm Infants

PURPOSE: The newborn period is a time of rapid physiological change in the gastrointestinal tract, when adaptation from a state of parenteral nutrition to the demands of enteral feeding take place. little is known about the intestinal vascular responses that accompany intestinal adaptive changes, although there is much speculation about the relationship between entreral feeding, alterations in gut perfusion, and the development of necrotizing enterocolitis.. Doppler ultrasound can be readily used to measure intestinal blood flow velocities in human newborn. It provides a noninvasive technique for investigating adaptive postnatal changes in the intestinal circulation, and, in particular, the response to feeds. In this study, we have measured blood flow indices in both the superior mesenteric artery and ceLiac axis, Looking for postprandial changes in response to feeding in 16 healthy preterm infants. METHODS: By using the Doppler ultrasound, PSV(peak systolic blood flow velocity), EDV(end diastolic blood flow velocity), Pulsatility index and blood flow per minute were measured pre and postprandially on day 1, 3, and 5 of life. Since the postprandial changes were similar during the study periods, the pre- and postfeed values are presented as combined resuLts. RESULTS: 1) The PSV and EDV from the superior mesenteric artery before the feed were 65.12+/-11.16 cm/sec and 15.40+/-3.58 cm/sec, respectively, and rose to 74.55+/-13.11 cm/sec and 19.10+/-4.81 cm/sec (p<0.001)(p<0.001). The pulsatility index fell from 0.761+/-0.053 to 0.735+/-0.055 (p<0.05) and blood flow per minute was increased from 0.110+/-0.032 l/min to 0.123+/-0.027 l/min (p<0.05). 2) Similar results were obtained from the celiac axis : The PSV and EDV increased from 68.23+/-16.29 cm/sec, 16.54+/-5.77 cm/sec to 77.92+/-15.08 cm/sec, 21.14+/-6.95 cm/sec, respectively (p<0.05) (p<0.001). The pulsatility index fell from 0.760+/-0.068 to 0.722+/-0.077 (p<0.001) and blood flow per minute was increased from 0.126+/-0.029 l/min to 0.153+/-0.033 l/min, posprandially (p<0.001). 3) The magnitude of increment in velocity was independent of gestational age, sex, and initial body weignt. CONCLUSIONS: We have measured intestinal blood flow indices in response to feeding by Doppler ultrasound and Doppler ultrasound may be able to provide evidence regarding disturbed perfusion as a potential etiological agent in the pathogenesis of necrotizing enterocolitis.