Hydatid cyst of liver: Spontaneous rupture and cystocutaneous fistula formation in a child.

A case of spontaneous formation of cutaneous fistula from rupture of an infected hydatid cyst of liver in a female child is reported.

Clinical scoring system for diagnosis of acute appendicitis in children.

OBJECTIVE: Appendicitis is the most common abdominal emergency usually requiring surgery in the pediatric age group. Diagnosis of acute appendicitis can at times be difficult, especially in children. A failure to diagnose can lead to a progression of disease with its associated morbidity and mortality. The authors used a modification of Alvarado scoring system which consists of eight variables and would provide an accurate guide to the preoperative diagnosis of acute appendicitis leading to proper and timely management. METHODS: This was a prospective study conducted from Jan 2005 through Dec 2006 and included 90 consecutive patients with suspected acute appendicitis. They were given specific scores according to variables of scoring system and divided into 3 groups. Group III patients (score 7 or more) underwent surgery, group II (score 5-6) were admitted for close observation and group I (score 4 or less) were discharged home. Patients from group II with increased symptom intensity (score 7 or more) on re-evaluation underwent surgery. Diagnosis was confirmed by operative findings and histopathological examination. Reliability of scoring system was assessed by calculating negative appendicectomy rate and positive predictive value. RESULTS: Out of total 90 patients, 73 patients underwent surgery and appendicitis was confirmed in 68 cases. The negative appendicectomy rate was 6.84%, perforation rate was 36.9%. Positive predictive value was 93.1%. CONCLUSIONS: Our scoring system is useful as a first line, rapid, reliable and economic way of early preoperative diagnosis of acute appendicitis in children and in reducing the incidence of negative appendicectomy rate.

Management of biliary ascariasis in children living in an endemic area.

BACKGROUND: One quarter of the world's population is known to be infected with ascariasis. It is endemic in various parts of the Indian subcontinent with a high incidence in the Kashmir valley. Although intestinal obstruction is the commonest complication of ascariasis in children, biliary ascariasis remains the second most common complication. We aimed to study the various types of clinical presentations, complications and different diagnostic tools and to assess various options for the management of biliary ascariasis. MATERIALS AND METHODS: Sixty-one cases of ultrasound documented hepatobiliary ascariasis were studied prospectively over a period of 3 years from Jan 2003 to Dec 2005 at the Sheri-Kashmir Institute of Medical Sciences in Srinagar, Kashmir. All patients were children aged between 3 and 14 years. All patients were admitted to hospital and put on intravenous fluids, nothing per os until patients were symptom-free, broadspectrum antibiotics and antispasmodics. All patients received antihelminthics in the form of albendazole 400 mg as soon as patients could accept oral medication. Conservative management was continued until the patients were symptom-free. Endoscopic extraction was deferred until 3 weeks later except in patients with pyogenic cholangitis where urgent endoscopic intervention was carried out. Surgical intervention was carried out if both conservative management and endoscopic extraction failed or ERCP could not be performed for technical reasons or complications developed. RESULTS: The most common presentation was upper abdominal pain in 36 (59%) patients followed by vomiting of worms in 20 (33.3%) cases. Complications included cholangitis in 8 (13.1%), obstructive jaundice in 7 (11.4%), acute pancreatitis in 1 (1.6%) and hepatic abscess in 1 (1.6%) patient. Spontaneous passage of worms from the biliary ducts was observed in 44 (72.1%) patients. ERCP was successful in 8 (13.1%) patients, and 9 (14.7%) patients needed surgical intervention. CONCLUSION: In endemic countries, ascariasis should be suspected in patients with biliary disease. Most patients respond to conservative management although a few may need surgical intervention. Although this disease is prevalent in developing countries, because of increased travel and migration, clinicians elsewhere should be aware of the problems associated with ascariasis.

Congenital common bile duct web in association with hepatobiliary pancreatic ductal anomalies.

Congenital webs are extremely rare anomalies of the extrahepatic ductal system. As the vast majority of such cases are asymptomatic, detection is usually incidental during surgery for some other cause. In a young boy presenting with features of cholangitis, a congenital common bile duct web was discovered on T-tube cholangiogram. Further anomalies of the intrahepatic and pancreatic ductal systems were also detected. Since all known causes of acquired web formation were excluded, a congenital origin of the web was assumed and the patient is continuing to do well after a follow-up of 22 months.