Early feeding after percutaneous endoscopic gastrostomy is safe in children.

Most patients are fasted for at least 12 to 24 hours following percutaneous endoscopic gastrostomy. In order to decrease the period of fasting, inadequate nutritional support, and hospitalization time, we began enteral feedings in 24 of 28 consecutive children, aged 4 weeks to 20 years, who were referred for PEG, 6 hours following the procedure. All patients received their full volume of feedings within 24 hours. Twelve of 13 outpatients were discharged in less than 24 hours. There were no complications related to early feeding and no complications that required discontinuation of feedings. Early feeding following PEG insertion is safe in children.

3D MRI of the cervical spine: low flip angle FISP vs. Gd-DTPA TurboFLASH in degenerative disk disease.

The authors undertook this study to compare bright and dark CSF three-dimensional (3D) gradient-echo (GE) MR techniques to answer the following questions: Could a single Gd-DTPA enhanced T1-weighted GE volume sequence (with multiplanar reformats) be diagnostically equivalent for degenerative cervical disk disease to a standard sequence consisting of sagittal T1-weighted spin echo and axial low flip angle volume GE images (with reformatted images)? Does performing oblique coronal reformats perpendicular to the course of exiting cervical nerve roots improve diagnostic confidence over axial images alone? Thirty-one consecutive patients received a "routine" MR examination consisting of a sagittal T1-weighted spin echo and axial low flip angle volume sequence (FISP) [(35/7/5), 64 slices, 2 mm slice thickness, 192 x 256 matrix, 7.2 min]. Each patient was then given 0.1 mmol/kg Gd-DTPA intravenously, and reimaged with a T1-weighted volume GE sequence [(13/6/12), acquired as 128-1.2 mm coronal partitions, 192 x 256 matrix, 5.5 min]. Sequences were reconstructed on the standard diagnostic console in 1 mm increments. Sets of examinations (routine vs T1-weighted volume) were independently interpreted by three neuroradiologists for location, type, and severity of extradural degenerative disease. There was no strong or consistent trend for increased detection of disease by one imaging sequence over the other. For lateral disk disease, only 3% of the observations were in discordance. For disk disease, there was close agreement in the severity scores. All readers indicated that additional information was provided by the reformatted images more frequently with TurboFLASH (fast low angle shot) than with FISP. All readers indicated that increased confidence was provided by the reformatted images more frequently with TurboFLASH than with FISP. A single 3D contrast-enhanced TurboFLASH sequence is diagnostically equivalent to a set of two-dimensional T1-weighted sagittal spin echo and 3D axial low flip angle sequences for assessing the location and degree of cervical extradural degenerative disease. A screening examination of the cervical spine could be performed with a single contrast-enhanced 5.2 min study, and then relying on computer postprocessing to provide additional imaging planes.

Imaging of normal anatomy and anomalies of the brain.

Magnetic resonance imaging permits better delineation of many anatomic structures not resolved with other imaging modalities and, by permitting the behavior of these structures to be observed at different pulse sequences, allows their tissues to be characterized. The literature of the year 1990 to 1991 includes many descriptive reports of normal anatomy, some of which are accompanied by explanations for the MR signal appearance. Familiarity with normal central nervous system structures and with normal MR signal characteristics is essential to avoid mistaking them for pathologic variants.

Flow, radiofrequency pulse sequences, and gradient magnetic fields: basic interactions and adaptations to angiographic imaging.

The basic process of MRI consists of two essential, relatively independent components: (1) excitation in the form of a radiofrequency pulse sequence, and (2) signal sampling and localization, that is, forming the MR image through the use of field gradients. The presence of motion (blood flow) during either excitation or sampling results in two types of corresponding effects: (1) time-of-flight effects, and (2) spin phase phenomena. These effects can be manipulated through the use of special coils, pulse sequences, gradients, and postprocessing techniques to provide angiographic images in which simple motion provides the basis for contrast.

Tuberculous empyema necessitatis. Computed tomography findings.

Two patients who presented with an anterior chest wall mass were evaluated by computed tomography (CT) scan and were found to have an associated thick-walled pleural collection, consistent with empyema necessitatis. In view of the increasing incidence of pulmonary and extrapulmonary Mycobacterium tuberculosis infection, the entity of tuberculous empyema necessitatis should be strongly considered when the described CT findings are present.

Incarcerated obturator hernia: case diagnosed at barium enema fluoroscopy.

Incarcerated obturator hernia is an uncommon entity that on occasion may produce specific radiographic findings and clinical signs (Howship-Romberg sign) that permit diagnosis prior to celiotomy. A case is reported in which the diagnosis was suggested when pain in the thigh was elicited during the course of a barium enema examination.

Gastrointestinal myoelectric activity in an infant with congenital idiopathic motility disorder.

We investigated myoelectric activity in an 8-month-old male who presented with a perinatal bowel obstruction, duodenal band, congenital short small intestine, and persistent feeding intolerance. Serosal electrodes were surgically implanted on stomach, duodenum, and jejunum during Nissen fundoplication and ileostomy. A 5-cm ileal specimen was taken for in vitro studies. Spontaneous migrating myoelectric complexes (MMC) were present in stomach and small intestine. Bethanechol increased electrical response activity (ERA) in stomach and duodenum. Morphine induced intense ERA and distinct phase III activity. Pentagastrin infusion did not disrupt MMC cycling. Feeding disrupted MMC complex cycling 30-40 min after the meal. Metoclopramide before feeding delayed disruption of the MMC cycling after the feeding. Intermittent gastric arrhythmias were present after the fifth postoperative day. In vitro muscle strips showed spontaneous contractions and electrical control activity (ECA). Bethanechol, McNeil A-343, motilin, and cholecystokinin induced contractions, but pentagastrin had no effect. We conclude that in spite of a major clinical motility dysfunction, several of our findings were normal. The abnormalities include short MMC period, absence of disruption of MMC by pentagastrin, and gastric arrhythmias.

Esophageal bougienage technique for coin ingestion in children.

An analysis was performed of 46 consecutive children who received esophageal bougienage for an ingested coin lodged in the esophagus. All patients met the following clinical criteria necessary for performance of this procedure: an acutely ingested single coin, radiographically localized in the esophagus; no previous history of an esophageal disease process, surgical procedure performed or foreign body removed; and no respiratory compromise upon physical examination. All coins were successfully advanced distally into the stomach after one pass of the bougie dilator. No complications were noted during or after performance of any procedure. Esophageal bougienage is a safe and effective method used to dislodge and pass an ingested coin from the esophagus when criteria for its performance are adhered to rigidly.

The contraindications for blind esophageal bouginage for coin ingestion in children.

Per oral bouginage of the esophagus for coin lodgement in children is a safe and simple mode of therapy. However, our experience with chronically ingested coins, multiple coins ingestion, and ingestion with preexisting esophageal pathology illustrate the potential hazards of such a practice. Intramural perforation, subacute mediastinitis, tracheoesophageal fistula, and long-term residual injury to the esophagus hallmark such cases. We believe that only acutely ingested coins, and only a single coin, can be treated safely by means of "blind" bouginage, provided that no preexisting esophageal disease is present.

Femoral hernias in children. An infrequent problem.

Femoral hernias in children are uncommon and many surgeons have had little exposure to their clinical manifestations. A ten-year survey of our experience with groin hernias in children showed only six children with this condition, which represents 0.12% of this entire population. Definite preoperative diagnosis was made in only two patients, while in the other patients this condition was suspected during herniorrhaphy. Preoperative diagnosis is possible if the bulge appears in a location inferior and lateral to that of the commonly occurring indirect hernia. Any child with early recurrence of a groin swelling after what seems to be an adequate inguinal herniorrhaphy should be suspected of having a femoral hernia.

Wringer washing machine injuries: criteria for obtaining radiological studies.

While the number of wringer washing machine injuries is declining due to the increasing use of automatic washing machines, these injuries still occur. Historically, children with wringer injuries received routine radiographs to diagnose fractures, in spite of the low fracture rate in wringer injuries. Review of the records at Milwaukee Children's Hospital between the years 1973 and 1983 revealed that of the 99 wringer injuries seen, 80 of 99 patients were radiographed and only five fractures were diagnosed. Of these fractures only two were attributable to the wringer device and these two required therapy. Criteria are developed to identify which patients should undergo radiologic studies. Using the criteria of localized pain or tenderness, crepitation, obvious deformity, or abnormal movement in the extremity, the two serious fractures would have been identified, and these two patients would have been radiographed. The other 78 patients would not have been radiographed.

Intrahepatic biliary tract abnormalities in children with corrected extrahepatic biliary atresia.

Three children with surgically corrected extrahepatic biliary atresia developed recurrent cholangitis associated with bile lakes that failed to drain via the hepatoportoenterostomy. Surgical or percutaneous drainage of these cysts was followed by both resolution of the infection and spontaneous internal drainage. We postulate that the ongoing inflammatory process resulted in intrahepatic biliary obstruction, which caused cholangitis and bile cysts. Successful treatment required not only antibiotics but drainage of the bile lakes. Development of bile cysts is a new cause of recurrent cholangitis seen in extrahepatic biliary atresia.

Doxorubicin-vincristine therapy for Wilms' tumor: a pilot study.

Doxorubicin plus vincristine chemotherapy was given to 31 children following nephrectomy for Wilms' tumor. Radiation therapy was used as indicated. Disease-free survival by stage is: eight of nine patients (stage I), eight of nine (stage II), nine of ten (stage III), and two of three (stage IV). Median follow-up of survivors is 28 months (range, 2-67); for all but four patients, follow-up is greater than 12 months. Two of the three stage I-III failures occurred in children with unfavorable histologies; the third failure was due to fatal anthracycline cardiomyopathy. Lowering the maximal cumulative doxorubicin dose from 450 to 240 mg/m2 did not increase failures. Doxorubicin-vincristine appears to be effective chemotherapy for Wilms' tumor.

A precise technique to localize pulmonary-pleural air leaks.

A bubblegram technique is described for identification of air leaks in persistent pneumothorax by introducing water-soluble contrast medium into the pleural space. The technique proved useful in eight children examined for persistent air leaks.

Technetium-99m biliary imaging in pediatric surgical problems.

The results of scintigraphic imaging of the hepatobiliary system with 99mTc-PIPIDA (IDA derivative p-isopropylacetanilidoiminodiacetic acid) in forty children are reported. 99mTc-PIPIDA imaging is a noninvasive, rapid, safe examination that provides both functional and anatomical information about the hepatobiliary system. Although interpretation is limited by elevated direct serum bilirubin, this agent allows diagnostic information to be obtained with direct serum bilirubin levels up to 8 mg/dl.

Esophageal function in esophageal atresia.

In order to determine the spectrum of esophageal dysfunction in repaired esophageal atresia, 14 patients were evaluated with esophageal manometry, intraluminal pH recording, and radiology. Nine patients had no difficulty in swallowing but six had symptoms suggestive of gastroesophageal (GE) reflux. On pH recording, six had evidence of GE reflux. Basal sphincter pressure was 22 mm Hg in both reflux and nonreflux patients. No patient had manometric evidence of peristalsis in the proximal esophagus, but six had peristalsis in the distal esophagus. On radiology all had a normal peristaltic stripping wave in the cervical esophagus, and peristalsis was absent in the proximal thoracic esophagus in all patients but present in the distal esophagus in five of the 10 patients studied. Esophageal dysfunction is present in all patients with repaired esophageal atresia even when symptoms are absent.

Simplified radioisotope technique for assessing gastroesophageal reflux in children.

There were 125 children with a strong clinical suspicion of gastroesophageal reflux and/or aspiration evaluated with gastroesophageal scintigrams. We found this examination to be more sensitive than the standard barium radiography and highly specific in detecting aspiration of gastric contents. This procedure is simple, safe and more physiologic than other available examinations. However, since gastroesophageal scintigraphy does not delineate anatomic changes as well as barium studies, structural abnormalities of the esophagus and stomach should be evaluated with barium esophagrams and upper GI series.

Ulcerative eosinophilic granuloma of the tongue. A light- and electron-microscopic study.

Ulcerative eosinophilic granuloma of the tongue simulates histiocytosis X or cancerous lesions, and may be subjected to unnecessary excessive treatment. This case report illustrates its benign, self-limited nature, discussed the differential diagnosis, and postulates its pathogenesis on the basis of light- and electron-microscopic findings.