Sonographic findings following appendectomy for uncomplicated appendicitis in children.

BACKGROUND: Little is known about 'normal' local sonographic changes occurring in the postoperative period after an uneventful appendectomy. OBJECTIVE: To analyse the local changes on US examination occurring after uneventful open (OA) or laparoscopic (LA) appendectomy in children with normal histology and with nonperforated acute appendicitis. MATERIALS AND METHODS: US was prospectively performed in 82 children (54 boys and 28 girls) aged 1-16 years (mean 11.6+/-3.2 years), 3 days following LA (n=51, 62%) or OA (n=31, 38%) for nonperforated appendicitis. Multivariate analysis was performed using stepwise logistic regression, with the following starting variables: surgical technique, gender, pathological finding, appendix location, and histology. RESULTS: Of the 82 patients, 35 (42.7%) had postoperative pathological US findings such as peritoneal fluid, oedematous mesenteric fat and thickening of the bowel wall. While the overall incidence of pathological US findings between OA and LA groups was not significantly different, multivariate logistic regression analysis showed that OA is associated with a reduction by a factor of 0.35 in the odds ratio of postoperative pathological US findings (P=0.007). CONCLUSION: Pathological US findings are common in children after appendectomy, particularly after LA. Awareness of these pathological findings might prevent unnecessary postoperative treatment.

Characteristics of thermal burns in children admitted to an Israeli pediatric surgical ward.

BACKGROUND: Reports of burn injuries in children are usually made by highly specialized burn units. Our facility admits children with burns covering < 20% total body surface area, while those with major burns are transferred to burn units at tertiary care facilities. OBJECTIVES: To review our experience with thermal burns. METHODS: We conducted a retrospective review of all thermal burns admitted to our hospital during a 5 year period. RESULTS: Among 266 patients (69.2% boys) aged 3.5 +/- 3.6 years, children < 3 years old were the most frequently injured (64.7%). Scalds (71.4%) were the most common type of burn. Partial thickness burns were sustained by 96.6% of children and TBSA burned was 4.2 +/- 3.6%. The mean hospital stay was 3.8 +/- 4.5 days, and was significantly prolonged in girls (4.6 +/- 4.8 vs. 3.5 +/- 4.3 days, P = 0.01). Percent TBSA burned was correlated with patient age (r = 0.12, P = 0.04) and length of hospital stay (r = 0.6, P < 0.0001). Six patients (2.3%) (mean age 3.4 +/- 2.3 years) were hospitalized in the Pediatric Intensive Care Unit due to toxin-mediated illness. CONCLUSIONS: Children under the age of 3 years are at increased risk for burn injury, but older children sustain more extensive injuries. Prevention and awareness are needed for child safety.

Intestinal obstruction in an autistic adolescent.

Bezoars and foreign bodies are frequently encountered in children with psychiatric disorders. Eating disorder (called pica) occurs predominantly in some high-risk patients such as psychiatric and mentally disabled children. Small-bowel obstruction is an uncommon complication of ingested foreign body because the foreign body is able to cross the whole small intestine and be excreted in the feces.We present the case history of an autistic adolescent who was operated on because of bowel obstruction due to an unusual foreign body.

Early burn related gram positive systemic infection in children admitted to a pediatric surgical ward.

BACKGROUND: Gram positive infections, including toxic shock syndrome (TSS), may be an early complication following burns, especially in children. OBJECTIVE: To identify risk factors associated with early burn related gram positive systemic infection (EBGI) in children admitted to a Pediatric Surgical Ward. METHODS: A retrospective analysis of the records of all EBGI patients treated from January 1995 to December 2004. EBGI patients were defined as having systemic signs of infection appearing in the first 48 h following the burn and associated with: (1) clinical signs of toxin mediated illness and/or (2) positive blood culture of either Staphylococcus aureus or group A beta hemolytic Streptococcus. Demographic and clinical data were also collected from the charts of 150 randomly selected burn patients admitted during the study period. RESULTS: We identified 13 cases of EBGI (2.5%) among 518 children admitted for thermal burns (mean age: 2.4 years). Three had bacteremia without rash. The 10 other patients were diagnosed as having a toxin mediated disease. S. aureus grew from the burn wound in six patients. All EBGI patients recovered following antibiotic therapy. Significant differences between the groups included: percentage of burned body surface area (6.9% versus 3.9%), and head and face localization (64% versus 31%) in the EBGI and control groups, respectively. CONCLUSIONS: EBGI is not rare even in pediatric patients with minor-moderate burns. Burns localized to the face or the head may be predisposing factor for such an infection.

Characteristics of perianal abscess and fistula-in-ano in healthy children.

BACKGROUND: Probably because of the low frequency, perianal abscess (PA) and fistula-in-ano (FIA) in children older than 2 years have not been investigated except in those with a predisposing condition such as Crohn's disease. This study aims to summarize our experience about the characteristics and treatment of PA and FIA in healthy children. METHODS: The charts of all children older than 24 months of age treated for PA and/or FIA from 1990 to 2003 were reviewed. RESULTS: We found 40 patients, 37 of them boys (92.5%), ranging from 2 to 14 years of age (average: 7.19 years). At the first examination, the diagnosis was PA in 36 patients (mean age: 6.8 years; range: 2.3-13 years), and FIA in 4 patients (mean age: 10.8 years; range: 6-14 years). The primary local treatment of PA was drainage (needle aspiration in 26 patients, and incision and drainage in 4 patients) and local care in 6 patients. All patients received antibiotics. Overall, 29 children (80.6%) had primary cure of the abscess. Evolution included recurrent abscess in 3 patients (8.3%) and FIA in 4 patients (11.1%). Crohn's disease was diagnosed in only one boy with an abscess of long duration. No patient developed a new PA in another location or a recurrent FIA. Four male patients aged 6 to 14 years (range: 7.1 years) had a FIA of long duration. One patient underwent a fistulectomy. Crohn's disease was found in three other children and treated conservatively. CONCLUSION: Drainage of PA by needle aspiration associated with antibiotics is effective in children older than 2 years of age with a low rate of evolution toward FIA. Associated pathology must be ruled out in children with FIA.

Serum and peritoneal inflammatory mediators in children with suspected acute appendicitis.

HYPOTHESIS: Inflammatory markers differ between subjects with appendicitis and controls. Markers of inflammation differ in serum compared with intraperitoneal fluid. Among subjects with appendicitis, inflammatory markers differ between subjects with and without perforation. DESIGN: Cross-sectional. SETTING: Hospitalized care. PATIENTS: Twenty-four children who underwent an appendectomy. Group A (n = 19) consisted of patients with appendicitis and group N (n = 5) of patients with normal appendixes. MAIN OUTCOME MEASURES: Serum and peritoneal levels of interleukin (IL)8, IL-10, granulocyte colony-stimulating factor, interferon gamma soluble intercellular adhesion molecule-1, matrix metalloproteinase-9, and tissue inhibitor of metalloproteinases-1 were measured by enzyme-linked immunosorbent assay. RESULTS: Age, sex, complete blood count, C-reactive protein level, and serum cytokines did not significantly differ by group. Peritoneal concentrations of interleukin-8 (mean +/- SD, 1416.8 +/- 1436 pg/mL vs 48 +/- 74.4 pg/mL, P = .001), IL-10 (mean +/- SD, 3085 +/- 5893 pg/mL vs 84 +/- 46 pg/mL, P = .02), matrix metalloproteinase-9 (mean +/- SD, 1784 +/- 1225.1 ng/mL vs 435 +/- 563 ng/mL, P = .03), and tissue inhibitor of metalloproteinases-1 (mean +/- SD, 8939.2 +/- 7312.2 ng/mL vs 602.1 +/- 345.6 ng/mL, P<.001) were significantly different in group A compared with group N. When compared by perforation (n = 8 with perforation vs n = 11 without perforation), peritoneal granulocyte colony-stimulating factor levels were elevated in subjects with perforation (mean +/- SD, 4.3 +/- 14.4 pg/mL vs 62.7 +/- 79.2 pg/mL, P = .02). Although serum tissue inhibitor of metalloproteinases-1 was not different between groups N and A, it was significantly different between group N and patients with a perforated appendicitis (mean +/- SD, 205.9 +/- 43.8 ng/mL vs 3068.9 +/- 5122.4 ng/mL, P = .04). CONCLUSION: Presently, it is not practical to differentiate appendicitis in a pediatric population from other causes of abdominal pain based on the detection of systemic inflammatory response markers.

Perianal abscess and fistula-in-ano in infants: a different entity?

PURPOSE: The features of perianal abscess and fistula-in-ano in infants are different from those of older children, and there is controversy regarding their treatment. The aim of this study was to assess the efficacy of various methods used for their management. METHODS: A retrospective analysis of the records was conducted for all infants younger than 24 months of age treated for perianal abscess, fistula-in-ano, or both from 1990 to 2002. RESULTS: The study included 98 infants. Perianal abscess was found in 77 patients (75 males), and fistula-in-ano in 21. No infant had an underlying illness. Drainage was performed by needle aspiration in 47 patients and by incision and drainage in 5. Following drainage, 43 patients received antibiotics. Altogether, 6 infants were treated with antibiotics alone and 19 with local care alone. Twenty-eight boys (36.4 percent) had an evolution toward fistula-in-ano. Patients who received antibiotics following drainage were less likely to develop fistula-in-ano than were patients who underwent a drainage procedure alone (27.9 percent vs. 66.7 percent, P < 0.05). All patients with fistula-in-ano were male and had been previously treated for perianal abscess (21 patients elsewhere and 28 in our department). Spontaneous cure of fistula-in-ano occurred in 42.9 percent of them (average 3.2 months), and 57.1 percent underwent fistulectomy for persistent fistula-in-ano. Cryptotomy was added when an involved crypt was found (11 patients, 39.3 percent). No recurrence of fistula-in-ano was noted after fistulectomy. CONCLUSIONS: Local treatment for perianal abscess during the early stage and drainage by needle aspiration during the progressive stage are effective. Antibiotics may be considered for patients undergoing drainage of perianal abscess. Fistula-in-ano can be managed conservatively for one to three months. For a persisting fistula, fistulectomy with cryptotomy (when abnormal anal crypts are found) is the preferred treatment.

Esophageal pH study and symptomatology of gastroesophageal reflux in newborn infants.

A retrospective study was undertaken to assess the association between esophageal pH monitoring variables and signs such as regurgitation, vomiting, apnea, bradycardia, and cyanotic episodes attributable to gastroesophageal reflux (GER) in neonates. One hundred thirty-four infants with one or more of the above-described signs underwent 24-hour distal esophageal pH monitoring in the neonatal intensive care unit, and were divided into 2 groups by gestational age. Group 1 (preterm infant group) consisted of infants aged 25 to 36 weeks of gestation ( n = 45) and group 2 (term infant group) consisted of infants aged 37 to 42 weeks gestation ( n = 89). Esophageal pH monitoring variables were compared by gestational age group and within preterm infants by theophylline treatment and, separately, by nasogastric tube using the Mann-Whitney U test. Comparisons of nominal data were made using the chi square test. Logistic regression analysis was used to assess the net effect of each independent variable on the risk of developing GER. The prevalence of GER was not influenced by gestational age. The prevalence of gastrointestinal signs did not differ between groups. Cardiorespiratory signs attributed to GER were more frequent in preterm infants than in term infants. The number of episodes with pH < 4 in 24 hours was greater in the term compared with the preterm infant groups. Logistic regression analysis failed to detect an association between acid GER and gestational age, apnea, bradycardia, cyanotic episodes, vomiting, or regurgitation. Theophylline treatment and the presence of a nasogastric tube did not significantly affect the esophageal pH monitoring variables in preterm infants. Preterm infants have a smaller number of reflux episodes compared with term infants. In addition, treatment with theophylline for apnea of prematurity and the presence of a nasogastric tube in preterm infants did not significantly affect pH-monitoring variables in preterm infants.

Acute epididymitis in boys: evidence of a post-infectious etiology.

PURPOSE: We studied the etiology and management of pediatric epididymitis. MATERIAL AND METHODS: We performed 1-year prospective study in children with epididymitis. All patients underwent an immediate sonographic study of the scrotum. Microbiological studies included throat and urine cultures as well as viral cultures of nasopharyngeal and stool specimens. Serological tests for group A streptococcus and Mycoplasma pneumoniae as well as for enteroviruses, adenoviruses, influenza and parainfluenza viruses in the appropriate seasons were performed in patients and controls. RESULTS: A total of 44 patients 2 to 14 years old (mean age 9.8 +/- 3.2) were studied. Hospital admissions peaked during the summer and winter. The incidence of epididymitis was around 1.2/1,000 boys yearly. One patient had familial Mediterranean fever and another had Henoch-Schonlein purpura. Microbiological studies of the urine, throat, nasopharynx and stool yielded bacterial/viral growth in 9 patients (20.4%). Serological studies revealed significantly elevated titers to certain pathogens in patients with epididymitis compared with controls, including M. pneumoniae (53% vs 20%), enteroviruses (62.5% vs 10%) and adenoviruses (20% vs 0%). Most patients were treated with analgesics and 3 patients received antibiotics intravenously. Systemic and local signs and symptoms resolved gradually in 1 to 7 days. CONCLUSIONS: Our results suggest that epididymitis in boys is not rare and it is mostly an inflammatory phenomenon (presumably post-infectious) with a benign course. The treatment of these patients is basically with analgesics with a little role for antibiotics.

Intussusception in children: can we rely on screening sonography performed by junior residents?

BACKGROUND: Ultrasonography is an important tool in the screening and diagnosis of patients with suspected intussusception. OBJECTIVE: To retrospectively evaluate the accuracy and performance of junior residents and compare it to that of senior residents and staff radiologists. MATERIALS AND METHODS: Between January 1999 and February 2003, 151 patients with suspected intussusception underwent screening US. The mean age of the patients was 13.8 months. Patients were divided into three groups according to examiner: staff radiologist, senior resident or junior resident. RESULTS: Sixty-five patients had both US and air enema. Forty-four patients had a positive US result; 37 (84%) were true positive and 7 (16%) were false positive. Twenty-one patients had a negative US result; 18 (86%) were true negative and 3 (14%) were false negative. Eighty-six patients underwent screening US only and were then kept under observation in the emergency room. They were all diagnosed as having a non-surgical condition. The total accuracy rate was 93%, sensitivity was 84%, specificity was 97%, positive predictive value was 93% and negative predictive value was 94%. Accuracy rate, sensitivity and specificity were 92%, 85% and 98% for staff radiologists, 94%, 75% and 96% for senior residents and 95%, 83% and 97% for junior residents, respectively. CONCLUSIONS: Junior residents perform as well as staff radiologists in screening US for suspected intussusception and have gained both the respect and confidence of the paediatricians.

[Reduction of intussusception by air enema in children--experience over a 13-year period].

PURPOSE: Intussusception is a relatively common pediatric emergency. The accepted treatment is closed reduction using barium or air enema and surgery when it has failed. We present our 13-year experience using air enema for treatment of intussusception, emphasizing the reduction with repeated delayed air enema. METHODS: Between February 1990 and December 2002, air enema procedures were performed in pediatric patients in cases with suspected intussusception. Prior to the procedure, all patients were sedated with meperidine hydrochloride (0.5 mg/kg) or morphine (0.1 mg/kg). Before 1993, surgery was performed after the first ineffective attempt of air enema reduction. Since 1993, in the case of failure of the first attempt, two additional trials of air reduction were performed at an interval of 45-60 minutes prior to surgery. RESULTS: A total of 225 air enema procedures were performed in 201 children (129 males, aged 10.4 +/- 9.1 months, range 8-63 months) with suspicion of intussusception. The diagnosis was confirmed in 148 (66%) out of the 225 procedures performed. A successful reduction of intussusception (by one attempt or more) was achieved in 125 (86%) out of the 148 procedures with proved intussusception. Twenty-one (14%) patients were operated on after the failure of closed reduction. Spontaneous reduction was demonstrated under fluoroscopy in two (0.8%) studies. No complications of the air enema were noted. During 1990-1993, a single reduction attempt of the intussusception by air enema was performed. Successful reduction during this period was achieved in 19 (70%) out of 27 patients and 8 (30%) children were operated on. During the period 1993-2002, we used repeated delayed attempts to obtain reduction of intussusception among 174 patients. The success rate was 89% (108 out of 121 patients) and only 13 (11%) children were operated on. CONCLUSION: Air enema is an efficient and safe diagnostic and therapeutic tool for intussusception in the pediatric population.

Severity of acid gastroesophageal reflux assessed by pH metry: is it associated with respiratory disease?

About 50% of children with chronic respiratory diseases (RD) have "silent" gastroesophageal reflux (GER). Our purpose was to evaluate the possibility that RD in patients with GER reflects the presence of more severe acid reflux. We compared the severity of parameters from pH studies in children with chronic RD and "silent" GER, to children with signs of symptomatic gastrointestinal (GI) GER with and without RD. This study included 236 children (aged 1 month to 15 years) with abnormal 24-hr pH monitoring among 718 patients studied for suspected diagnosis of GER. Patients were divided into three groups. Group 1 consisted of children with chronic RD but without any GI symptoms of GER. Group 2 was comprised of children with symptomatic GI presentation of GER such as regurgitation, vomiting, heartburn, and failure to thrive, but without any signs or symptoms of RD. Group 3 included children with prevalent RD and concomitant signs of symptomatic GER. Patients with predominant GI manifestations (group 2) had a significantly higher fraction of time with pH <4 (P < 0.01), total time value of pH <4 (P < 0.05), and longest episode with pH <4 (P < 0.05). Esophageal clearance was significantly longer in group 1 patients than in the other two groups (P < 0.05). Patients with mixed disease (group 3) were similar to patients in group 2. Patients with GI symptoms had significantly worse scores for all parameters evaluated except esophageal clearance score, compared to patients without GI symptoms. Longer esophageal clearance was the only parameter associated with respiratory signs in patients with respiratory symptoms compared to those without. In conclusion, the presence of RD in pediatric patients with silent GER is related to longer esophageal clearance, but is not related to severity of reflux.

Needle aspiration for suppurative cervical lymphadenitis.

In a 10-year prospective study, we used needle aspiration as the treatment of suppurative cervical lymphadenitis that required drainage procedure in 35 consecutive children aged 4 months to 13 years (mean 2.2 years). Twenty-seven patients underwent 1 puncture, 7 patients had 2 punctures, and 1 had 3 punctures. There were no major complications. Patients were followed up for 2-6 months. None required an open drainage of the cervical abscess. There was complete regression of the nodes in all patients within 21 days, with no relapse or scar formation. Needle aspiration seems to be an effective and safe treatment of suppurative cervical lymphadenitis that may avoid open drainage.