Gastrointestinal Basidiobolomycosis: An Emerging, and A Confusing, Disease in Children (A Multicenter Experience).

INTRODUCTION: Gastrointestinal basidiobolomycosis (GIB) is an emerging fungal infection in children that leads to diagnostic confusion. AIM: Our study aim was twofold: a systematic review of published literature and an update of some Saudi Arabia hospital series to analyze their as well as our own experience in diagnosis and management of GIB. MATERIAL AND METHODS: This clinical study included 18 children whose final diagnosis was GIB. The patients, who ranged in age from 5 to 10 years, were admitted between November 2009 and November 2015 with vague abdominal pains with or without abdominal masses for further investigation. RESULTS: Abdominal pain was the most common presenting symptom (94.4%) followed by constipation and abdominal mass (83.3 and 77.8%, respectively); fever was present in only 22.2% of the cases. Elevated inflammatory markers and eosinophilia (94.4%) appeared as prominent laboratory findings. CONCLUSION: We conclude that diagnosing GIB in children requires a high index of suspicion, awareness, and consideration of its possibility in the differential diagnosis in patients with abdominal masses and eosinophilia, particularly in areas where it is endemic. Increased awareness of this clinical entity, early surgical resection of the infected tissue, and prolonged treatment with itraconazole offer the best chance for curing the disease.

One or Two Stages Procedure for Repair of Rectovestibular Fistula: Which is Safer? (A Single Institution Experience).

BACKGROUND: Rectovestibular fistula (RVF) is the most common type of anorectal malformations in females. The need for a diverting colostomy during correction of defect has ignited a heated debate. In this study, we reviewed the girls with RVF that had been treated by either one or two stage procedure in the past 10 years in our institution to define whether one stage or two stage procedures is safer and more beneficial for the patients. MATERIALS AND METHODS: Seventy girls with RVF that had been operated from January 2005 to January 2015 were studied retrospectively. Data were obtained from medical hospital records. The cases were divided into two groups. Group A (46 patients): were operated by two stages technique (simultaneous sigmoid colostomy and anterior sagittal anorectoplasty [ASARP]). Group B (24 patients): were operated by one stage (ASARP without covering colostomy). The short-term outcome as regard wound infection, wound dehiscence, anal stenosis, anal retraction, recurrence of fistula as well as complications of colostomy was reported. The long-term outcome as regard soiling, constipation and voluntary bowel movement was evaluated. RESULTS: The age of patients at the time of surgery ranged from 3 months to 2 years (mean; 9.5 months). In Group A, seven patients (15.2%) developed wound infection, two patients developed wound disruption. One patient developed anterior anal retraction and required redo-operation, anal stenosis was noticed in five (10.9%) patients. Complications from colostomy had occurred in nine patients (19.5%). In Group B, wound infection occurred in ten patients (41.7%). Seven patients (29.2%) developed wound disruption. Anal stenosis occurred in eight patients (33.3%). Five patients required redo-operation because of anal retraction in three patients and recurrence of fistula in the other two patients. Constipation recorded in 15 patients (32.6%) of Group A and in ten patients (41.3%) of Group B. Soiling was reported in six girls (13.04%) of Group A and five girls (20.8%) of Group B. CONCLUSION: The avoidance of colostomy is not outweighed achieving sound operation and continent child. Two stages correction of RVF is safer and more beneficial than one stage procedure, especially in our locality and for our paediatric surgeons during their learning curve.

Evaluation of the use of laparoscopic-guided cholecystocholangiography and liver biopsy in definitive diagnosis of neonatal cholestatic jaundice.

BACKGROUND: Once it is established that a jaundiced infant has direct hyperbilirubinemia, the principal diagnostic concern is to differentiate hepatocellular from obstructive cholestasis. Traditional tests such as ultrasonography, percutaneous liver biopsy and technetium 99 m hepatobiliary iminodiacetic acid (HIDA) scan are often not sufficiently discriminating. Definitive exclusion of biliary atresia (BA) in the infant with cholestatic jaundice usually requires mini-laparotomy and intra-operative cholangiography. This approach has many drawbacks because those sick infants are subjected to a time-consuming procedure with the probability of negative surgical exploration. AIM OF THE STUDY: The aim of this study was to determine the feasibility of laparoscopic-guided cholecystocholangiography (LGCC) and its accuracy and safety in the diagnosis of BA and thus preventing unnecessary laparotomy in infants whose cholestasis is caused by diseases other than BA. PATIENTS AND METHODS: Twelve cholestatic infants with direct hyperbilirubinemia subjected to LGCC (age, 7-98 days; mean, 56 days) after ultrasound scan and (99 mTc) HIDA scan and percutaneous liver biopsy failed to provide the definitive diagnosis. RESULTS: One patient had completely absent gall bladder (GB) so the laparoscopic procedure was terminated and laparotomy was done (Kasai operation). Four patients had small size GB; they underwent LGCC that showed patent common bile duct with atresia of common hepatic duct, so laparotomy and Kasai operation was performed. Seven patients had well-developed GB, LGCC revealed patent biliary tree, so laparoscopic liver biopsies were taken for histopathology. Five of those patients had neonatal hepatitis, and two had cholestasis as a complication of prolonged TPN. No perioperative complications or mortalities were recorded. CONCLUSION: When the diagnosis neonatal cholestasis remains elusive after traditional investigations, LGCC is an accurate and simple method for differentiating BA from hepatocellular causes.

Propranolol in treatment of huge and complicated infantile hemangiomas in egyptian children.

Background. Infantile hemangiomas (IHs) are the most common benign tumours of infancy. Propranolol has recently been reported to be a highly effective treatment for IHs. This study aimed to evaluate the efficacy and side effects of propranolol for treatment of complicated cases of IHs. Patients and Methods. This prospective clinical study included 30 children with huge or complicated IHs; their ages ranged from 2 months to 1 year. They were treated by oral propranolol. Treatment outcomes were clinically evaluated. Results. Superficial cutaneous hemangiomas began to respond to propranolol therapy within one to two weeks after the onset of treatment. The mean treatment period that was needed for the occurrence of complete resolution was 9.4 months. Treatment with propranolol was well tolerated and had few side effects. No rebound growth of the tumors was noted when propranolol dosing stopped except in one case. Conclusion. Propranolol is a promising treatment for IHs without obvious side effects. However, further studies with longer follow-up periods are needed.

Alvarado score as an admission criterion in children with pain in right iliac fossa.

BACKGROUND: Acute appendicitis is an important differential diagnosis in children with pain in the right iliac fossa. Some patients have equivocal signs that make the diagnosis difficult. Many patients with suspected acute appendicitis are admitted for observation and finally discharged because they did not have appendicitis. We decided to design this study to investigate whether the Alvarado score could be used by emergency room doctors as a criterion for admission to hospital. PATIENTS AND METHODS: This is a prospective study comprising 350 patients who attended the emergency department with suspected acute appendicitis in the period from May 2007 to April 2009. All patients were scored by Alvarado score in the emergency department before admission. The Alvarado score is based on three symptoms, three signs and two laboratory findings. The decision for admission and surgery was made independent of the score. The diagnosis of patients who underwent appendicectomy was confirmed by both operative findings and postoperative histopathology. RESULTS: We studied the Alvarado scores of 350 patients who presented to the emergency department with pain in the right iliac fossa; their age ranged from 8 to 14 years; 182 patients (52%) operated with the aim to treat acute appendicitis, 168 patients (48%) were discharged without surgical intervention and advised to attend the out-patient clinic after 24 hours for re-evaluation. we have found that patients with a low Alvarado score (less than 6) did not have acute appendicitis. CONCLUSION: Patients with equivocal signs can present a diagnostic challenge and are very often admitted to the surgical department for observation. The Alvarado score can be used as a scoring system that help in taking the decision for admission of cases with suspected acute appendicitis especially by primary healthcare providers.