Acute Pancreatitis in Childhood: A 10-Year Experience From A Thai University Surgical Center.

OBJECTIVES: This study aimed to describe etiology, management, and health outcomes of children developing acute pancreatitis at a tertiary Thailand pediatric surgery center. METHODS: Medical case records of all index cases during 2006-2016 were analyzed and reported. RESULTS: There were 42 male and 37 female patients, with a mean (standard deviation) age of 10.4 (4.5) years, included in the study. Medications were the commonest etiology for 39.3% of acute pancreatitis attacks, 11.4% for biliary tract disease cases, and 8% for postinterventional studies. In 30% of cases, no cause(s) was defined. Sixty-two patients (78.5%) had elevated serum lipase on hospital admission, whereas only 30.4% showed a raised amylase. Hospital stay was 15 days (interquartile range, 6-27 days). Two major complications in the series were pseudocysts (8.8%) and necrotizing pancreatitis (7.6%). Etiological factors and/or antibiotics were not directly linked to any specific complications. Seventeen children (22.8%) had 1 recurrent episode of acute pancreatitis documented. Mortality rate in index cases was 28%, with a higher percentage harboring a preexisting illness (34.4% vs 5.6%; P = 0.01) and in male than in female patients (41% vs 14%; P = 0.01). CONCLUSIONS: Deaths from pediatric acute pancreatitis are more prevalent in male individuals and those with a preexisting illness. Targeted strategies aimed at "highest-risk" patients may potentially offset mortality.

Polyarteritis Nodosa with Cytomegalovirus Enteritis and Jejunoileal Perforation: Report of a Case with a Literature Review.

Polyarteritis nodosa (PAN) is a rare systemic necrotizing vasculitis affecting small- to medium-sized arteries. The most common gastrointestinal manifestation of PAN is postprandial abdominal pain from mesenteric arteritis causing bowel ischemia. When transmural ischemia develops, there may be ischemic necrosis and perforation of the bowel wall, which are life-threatening. Severe, life-threatening gastrointestinal involvement is relatively rare in pediatric PAN and may require different management in adult patients. We report a pediatric PAN case in a patient who presented with acute abdominal pain and superimposed cytomegalovirus enteritis with jejunoileal perforation. The patient improved with emergency small intestinal resection followed by conventional immunosuppressive drugs of a corticosteroid and cyclophosphamide, and anti-viral drugs. Before increasing the immunosuppressive drug dosage, initial screening of infectious cytomegalovirus and comprehensive evaluation for surgical conditions are essential in pediatric PAN with severe gastrointestinal involvement. Early aggressive treatment for acute abdomen is useful in reducing morbidity and mortality in pediatric PAN.

A rare cause of multiple small bowel ulcers and strictures in a 10-year-old child.

Enteritis and small bowel ulcers can be caused by inflammatory bowel disease, drug-induced enteritis, cytomegalovirus, tuberculosis, or intestinal lymphoma. Cryptogenic multifocal ulcerous stenosing enteritis (CMUSE) is an uncommon idiopathic cause of ulceration and stricture of the small bowel. CMUSE can occur in adults, but only few pediatric cases have been reported. Inflammatory bowel disease and other causes should be carefully sought first before the diagnosis of CMUSE can be made. Previous reports demonstrated that surgical intervention may be necessary for both diagnostic and therapeutic purposes. With regard to the management, systemic corticosteroids may help, and surgery plays a role in patients present with signs of intestinal obstruction. We report a young girl who presented with a prolonged history of refractory iron deficiency anemia with protein-losing enteropathy without other obvious gastrointestinal symptoms. She underwent several laboratory and endoscopic investigations as well as histopathology of the resected full-thickness small bowel area before a proposed diagnosis of CMUSE was made. A trial of immunosuppression (both prednisolone and azathioprine) was initiated that provided a relatively satisfactory result.

Immature gastric teratoma in an infant: a case report and review of the literatures.

Immature gastric teratoma is an uncommon germ cell tumor of the stomach. We report a rare case of immature gastric teratoma in an infant with down syndrome with clinically presenting with hematemesis and severe anemia. Complete surgical resection remains the cornerstone of treatment.

Abnormal layering of muscularis propria as a cause of chronic intestinal pseudo-obstruction: A case report and literature review.

Visceral myopathy is one of the causes of chronic intestinal pseudo-obstruction. Most cases pathologically reveal degenerative changes of myocytes or muscularis propia atrophy and fibrosis. Abnormal layering of muscularis propria is extremely rare. We report a case of a 9-mo-old Thai male baby who presented with chronic intestinal pseudo-obstruction. Histologic findings showed abnormal layering of small intestinal muscularis propria with an additional oblique layer and aberrant muscularization in serosa. The patient also had a short small bowel without malrotation, brachydactyly, and absence of the 2(nd) to 4(th) middle phalanges of both hands. The patient was treated with cisapride and combined parenteral and enteral nutritional support. He had gradual clinical improvement and gained body weight. Subsequently, the parenteral nutrition was discontinued. The previously reported cases are reviewed and discussed.

Fungal appendicitis: a case series and review of the literature.

Appendicitis is a condition characterized by inflammation of the vermiform appendix, which is commonly caused by bacterial infections and rarely caused by fungal organisms. In the present study, we reviewed the prevalence, clinicopathological features, and therapeutic management of fungal appendicitis. During July 2010 to June 2011, the pathology of 262 resected vermiform appendices was reviewed. Fungal appendicitis occurred in 1.15%, including two cases of Candida spp and one case of Aspergillus spp infection. All patients were immunocompromised and presented with the classical signs and symptoms of appendicitis with the onset of illness less than two days. They were considered for acute appendicitis and underwent appendectomy. The histopathology of the resected vermiform appendix showed fungal organisms with suppurative inflammation and secondary periappendiceal peritonitis. The curative treatment was presented in 1-out-of-3 cases. One patient was alive during a follow-up of eight months. Two patients died, and an autopsy was performed in one case. Although fungal appendicitis was uncommon, the disease might occur among immunosuppressed patients who have developed classical signs and symptoms of appendicitis. Early diagnosis and prompt surgery with medical treatment are associated with a survival advantage.

Acute suppurative thyroiditis in young children.

We report two children with acute suppurative thyroiditis (AST). They presented with typical features of AST, which include fever, painful goiter and biochemical euthyroidism. An anatomical defect predisposed to thyroid infection, pyriform sinus fistula, was identified in one patient. Both patients responded well to surgical pus drainage and antibiotic treatment. Anatomical defects must be sought in all children with AST to perform specific surgical treatment and prevent recurrent infection.