Chylolymphatic mesenteric cyst: A rare differential diagnosis of cystic mass in abdomen: A case report.

INTRODUCTION: Mesenteric cysts are the rare benign intraperitoneal tumor, which are common in the mesentery of the terminal ileum. Though mesenteric cysts are frequently seen, chylolymphatic mesenteric cysts in children are rare entities. CASE PRESENTATION: Our case is a case of a 3-year-old female child presenting to our center with a complain of abdominal pain. Ultrasonography (USG) of the abdomen revealed a cystic lesion in the right upper abdomen, and computed tomography (CT) scan showed a large homogenous fluid density lesion in the right upper abdomen, giving a provisional diagnosis of mesenteric cyst. She was managed surgically: the cyst was excised, the involved segment of bowel was resected and the remaining was anastomosed. On histopathology, the final diagnosis of a chylolymphatic mesenteric cyst was made. DISCUSSION: Clinical presentations may vary from asymptomatic abdominal lump to features of acute abdomen. Imaging modalities like ultrasonography and computed tomography scans are the mainstay of investigations. Surgical management with excision of cyst, and resection of the involved bowel segment is the treatment of choice, as done in our patient. The final diagnosis is made after the histopathologic examination of the excised specimen. CONCLUSION: Chylolymphatic mesenteric cysts are rare, and have varied clinical presentations. Although rare, chylolymphatic mesenteric cysts should be considered a differential diagnosis in patients presenting with cystic masses in the abdomen.

Isolated pancreatic injury following blunt trauma in a seven-year-old girl: A case report.

INTRODUCTION AND IMPORTANCE: Isolated pancreatic injury following blunt abdominal trauma is rare, and the absence of definite clinical signs and symptoms may delay diagnosis and management. CASE PRESENTATION: We present the case of a seven-year-old girl with a history of progressive, periumbilical abdominal pain and multiple episodes of non-bilious, non-blood mixed vomiting following a road traffic accident. Computed tomography (CT) imaging revealed an isolated grade three pancreatic injury managed conservatively. CLINICAL DISCUSSION: The patient usually presents with epigastric tenderness with or without a rise in pancreatic enzyme levels. CT grading of injury correlates with and guides the management approach, and CT abdomen with contrast is the preferred investigation for diagnosis. Management depends on the grade of injury, the hemodynamic status of the children, and the co-existence of other injuries. CONCLUSION: Isolated pancreatic injury, although rare, can go undiagnosed due to a lack of suspicion from the treating surgeon and may have dire consequences. Conservative management can be a suitable strategy for children with stable hemodynamic status.

Persistent Vitello-Intestinal Duct Masquerading as Acute Appendicitis: A Case Report.

The vitello-intestinal duct normally regresses with the development. But, in certain cases, it could persist and present as Meckel's diverticulum. Here we report a case of an eight-year-old boy presenting with peri-umbilical abdominal pain, vomiting and loose stool. He was initially diagnosed and managed as acute appendicitis but did not improve, rather developed features of intestinal obstruction. Exploratory laparotomy was done which revealed persistent vitello-intestinal duct and was managed surgically. This case report highlights that in any case of suspected acute appendicitis, the complications of persistent vitello-intestinal duct should be considered as one of the differentials. Keywords: appendicitis; case reports; intestinal obstruction; laparotomy; omphalomesenteric duct.

Sleeve gastrectomy for multiple gastric perforations in a preterm: A case report.

Neonatal gastric perforation (NGP) is a rare life-threatening condition among preterm infants. NGP can occur secondary to necrotizing enterocolitis, distal obstruction, or as a result of gastric tube insertion. Sleeve gastrectomy can be a possible therapeutic option for multiple neonatal gastric perforations.

Clinical profile and management of perforation peritonitis in Bharatpur hospital, Nepal: A prospective study.

Introduction: The most common surgical emergency in general surgery is perforation peritonitis. It is a serious condition with a mortality rate of up to 20%, and it is the third most common cause of surgical abdomen after appendicitis and intestinal obstruction. The aim of this study to discuss clinical profile and management of perforation peritonitis in a hospital in central Nepal. Methods: This prospective study was done for one year at Bharatpur Hospital, Chitwan Nepal. In our study, only patient above 15 years were included and those who were not fit for anesthesia and surgery were excluded. Most of the patient were diagnosed clinically supported by lab investigations and imaging like X-ray and ultrasonography of abdomen. The variables analyzed were the risk factors of the patient like smoking, alcohol, liver disease and previous abdominal surgeries. Results: The majority of the patients were in the age group 50-59 years in male and 40-49 years in female. Among sixty cases, 31 were female and 29 were male with Female: Male ratio of 1.06:1. The most common cause of perforation found was peptic ulcer compromising 88.3% (53 cases) followed by appendicular perforation accounting 8.3% (5 cases). Similarly, Tubercular perforation was found in 3.3%. Smoking was most common risk factor accounting 88.3%, followed by alcohol consumption (48.33%) while, 15% of patients had positive history of NSAIDs consumption. On imaging, 38.33% patient had air fluid level on X-ray and 78.33% had gas under diaphragm. On blood investigation, leukocytosis was found in 53.33% of patients, hyponatremia in 10% of patients and hypokalemia in 18.33% of patients. While on urine examination, albumin was found in 5% of patients. The repair of perforation along with omentopexy was done in 73.3% of patients while only repair was done in 15% of patients. Only 8.3% opted for appendectomy while a very few patients (3.3%) went for resection with anastomosis. The Postoperative complications found were wound infection (43.3%), paralytic ileus (18.33%), sepsis (15%), followed by electrolyte imbalance (11.6%), postoperative bowel obstruction (6.6%) and burst abdomen (1.6%). While, there were only 3 cases of mortality. Conclusions: Perforation peritonitis is a frequently encountered surgical emergency. Various factors like age, sex, duration, site of perforation, extent of peritonitis and delay in surgical intervention are associated with morbidity and mortality. A successful management depends upon early surgical intervention, source control and exclusive intraoperative peritoneal lavage.

Risk factors for recurrent intussusception after successful reduction in pediatric patients in a tertiary care hospital of Nepal: A prospective study.

Background: Intussusception is defined as the invagination of one segment of intestine into another segment of intestine. It may recur because of persistence or return of some factor responsible for the primary intussusception. Various risk factors have been reported but still not well elucidated. Materials and methods: This is the prospective observational study. In this study, 78 patients, age <16 years with diagnosis of intussusception between June 2019 and April 2020 who had successful reduction with either hydrostatic reduction and/or operative reduction in Teaching Hospital were enrolled in the study. This is study of early recurrence as patients were followed up to a period of 1 month for recurrence of intussusception. The recurrent cases were thus identified and various variables were compared between recurrent and non-recurrent cases by univariable and multivariable analysis. Results: Among 78 patients, 13 patients (16.7%) had recurrent intussusception. In the univariable analysis model, the significant risk factors for recurrence of intussusception analyzed were duration of symptoms of 48 h or more, fever, blood in stool and palpable mass. While after multivariable analysis, we found that the significant risk factors for recurrence of intussusception were duration of symptoms ≥48 h (OR = 5.32, p-value = 0.047), Fever (OR = 17.32, p-value = 0.001), palpable mass (OR = 24.12, p-value = 0.017). Conclusion: Attention and awareness among pediatricians about these sonographic and clinical risk factors especially symptoms for recurrence are needed to minimize pre-hospital delay and identify patients in risk of recurrence. This ultimately helps to improve care for pediatric patients with recurrent intussusception.

Evaluation of portal venous system in post splenectomised beta-thalassemic children: A prospective study in a tertiary care hospital.

Background: Splenectomy is a palliative management technique in children with ß-thalassemia. Portal thrombosis is the most dreaded complication after splenectomy that requires fast diagnosis, effective therapy, and good follow-up to prevent protal hypertension. Thus, there is the importance of constant evaluation of portal venous system through Color Doppler Ultrasound. This cohort study aimed to observe the changes in the portal venous system in post-splenectomised ß-thalassemic children. Material and methods: This is a prospective observational cohort study carried out on all the pediatric patients who have undergone splenectomy in Bangabandhu Sheikh Mujib Medical University, Dhaka Bangladesh from 2017 to 2019 for ß-thalassemia. The color doppler of the portal venous system was done within the 7th to 10th post-operative day and after 3 months. Outcomes like mean the caliber of the portal vein, mean velocity within the portal vein, and color Doppler findings like Portal Vein Thrombosis (PVT) and Pathological change in Mean Volume (PMV) were calculated and compared in two headings: pre-operative period and postoperative period (7-10 POD and 3 months) with the help of paired t-test. Results: Twenty-Eight ß-thalassemia patients with a mean age of 10.43 ± 3.91 years planned to undergo splenectomy were included in our study. The pre-operative mean caliber and mean velocity of the portal vein were not statistically significant when compared after the postoperative period (7-10 POD and 3 months). But, continuous changes in portal vein were seen that could lead to normalization or pathological changes. Conclusion: There are physiological and pathological changes in portal vein following splenectomy that could lead to varied complications like portal vein thrombosis and portal hypertension. Color Doppler Ultrasound findings along with close follow-up help in minimizing the pathological changes and complications.

Large intestine as content of congenital inguinal hernia: A case report of intestinal obstruction.

Introduction and importance: Hernias containing appendix, caecum and transverse colon are uncommon in contrast with usual inguinal hernias containing small intestine. The patient usually presents with inguinoscrotal swelling. Case presentation: We present a case of a 2 months old male child presented with inguinoscrotal swelling, vomiting with abdominal distention. On Ultrasonography (USG) of the scrotum, protrusion of the abdominal cavity contents through the right inguinal canal into the scrotum of approximately 3.4 cm × 0.7 cm was found which indicates right inguinal hernia. On the opening of the hernia sac during surgical management, the appendix, caecum and transverse colon were lying inside the hernia sac. Open Herniotomy was performed and the abdomen was closed in layers. Postoperative period of the patient was uneventful. Discussion: Congenital inguinal hernia in the child occurs mostly due to persistent processus vaginalis. History and clinical examination reveals the appearance of lump in the inguinal region or scrotum. Preoperative Ultrasonography can be used to supplement the physical examination and increase the accuracy of its diagnosis. Although the laparoscopic approach is increasingly used nowadays, open hernia repair is preferred in young children. Conclusion: Appendix, caecum and transverse colon are unusual contents of an inguinal hernia. Open herniotomy combined with relieving of the intestinal obstruction is the treatment of choice in young children.

Role of Hyperbilirubinaemia as a Predictor of Complicated Appendicitis in Paediatric Population.

BACKGROUND: Acute appendicitis is a common surgical emergency amongst the paediatric population. Available diagnostic tools are focussed to make a diagnosis of acute appendicitis. A definitive predictive factor for the diagnosis of complicated appendicitis is lacking. Thus, this aims to analyse hyperbilirubinaemia as a predictor of complicated appendicitis amongst the paediatric population. MATERIALS AND METHODS: A prospective observational study was conducted in a tertiary hospital from November 2018 to October 2019. All children undergoing emergency appendectomy were included in the study. Preoperatively, patients were evaluated clinically, and routine investigations including total and direct serum bilirubin were sent. All patients were grouped as 'simple appendicitis' or 'complicated appendicitis' based on intra-operative and histological findings. Bilirubin level was compared between these groups and analysed. RESULTS: A total of 52 children fulfilling the inclusion criteria were included. The mean age was 13.2 ± 4.2 years, and the male: female ratio was 2.1:1. Thirty-four (65.4%) had simple appendicitis and 18 (34.6%) had complicated appendicitis. Total bilirubin was 23.83 ± 5.94 mmol/L in the complicated appendicitis group and 13.15 ± 3.29 mmol/L in the simple appendicitis group. Direct bilirubin was 5.28 ± 2.22 mmol/L in complicated appendicitis and 2.62 ± 0.83 mmol/L in simple one. Both total and direct bilirubin were significantly high in the complicated group (P < 0.001) compared to the simple appendicitis group. On the Receiver operating curve (ROC), the best cutoff value for total and direct bilirubin was 21 and 5.5 mmol/L, respectively. The sensitivity and specificity of total and direct bilirubin were 72.2%, 100%, and 61.1%, and 85.3%, respectively. CONCLUSION: It is concluded that hyperbilirubinaemia is a good predictor for paediatric complicated appendicitis.

Torsed gangrenous Meckel's diverticulum causing gangrenous ileal segment: A rare case report of small bowel obstruction in children.

INTRODUCTION: Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal system. It is caused by an incomplete obliteration of the vitelline duct. Rarely, it can present with complications like torsion and gangrene formation. CASE PRESENTATION: A 13-year previously healthy girl presented with sudden onset periumbilical pain and bilious vomiting who was subsequently diagnosed with Meckel's diverticulum. Intraoperatively, torsed gangrenous diverticulum forming band adhesion was found. Resection of Meckel's diverticulum along with gangrenous ileal segment followed by ileoileal anastomosis was done. DISCUSSION: Axial torsion of Meckel's diverticulum with gangrene formation is a rare occurrence. Mesodiverticular band adhesion along with herniation of small bowel segments under it endangers viability of herniating segments. Preoperative diagnosis of complicated MD is difficult as it mimics other common acute abdominal conditions. CT scan and enteroclysis are imaging modalities of choice. Surgical resection of MD along with resection and anastomosis of gangrenous bowel segment results in complete cure. CONCLUSION: Meckel's diverticulum with complications should be kept in the differential of acute abdominal conditions presenting with atypical symptoms. Surgical resection ensures complete cure.

Heterotaxy syndrome with complex congenital heart disease, facial palsy, and asplenia: A rare newborn finding.

Heterotaxy syndrome is associated with asplenia/polysplenia and complex congenital heart disease. Facial palsy in heterotaxy is very rare. The management is still challenging with a poor prognosis. Proper counseling to the family about the disease course, treatment modalities, and outcomes is essential.

Forshal type IE appendiceal intussusception: A case report.

INTRODUCTION: Appendiceal intussusception is a rare condition. Clinical features are not specific for it. Patients may present with abdominal pain and vomiting. These symptoms represent a variety of abdominal pathology. Preoperative diagnosis is difficult because of the non-specific clinical features. We present a case report of a child who initially presented with ileocolic intussusception. CASE PRESENTATION: This is a case report of a 5-years-old boy with abdominal pain and vomiting. He had an ileocolic intussusception 2 days back, and was successfully managed by hydrostatic reduction and discharged. On ultrasonography, an intussusception was identified in the ileocaecal region. Hydrostatic reduction failed this time and laparotomy was performed. On laparotomy, there was complete intussusception of the appendix with normal ileocaecal junction. Appendectomy was performed. Post-operative period was uneventful. DISCUSSION: Appendiceal intussusceptions are mostly diagnosed intra-operatively. The clinical features may mimic various other acute and chronic abdominal conditions. Type IE appendiceal intussusception, as described by Forshal, is a rare condition. Appendectomy with a rim of the caecum is the procedure of choice. CONCLUSION: Though ileocaecal intussusceptions are common in children, appendiceal intussusceptions are rare and are usually diagnosed during the operative procedure. Radiologists and pediatric surgeons should be aware of this rare entity. Appendectomy is the treatment of choice in most of the appendiceal intussusceptions.

Symptomatic familial adenomatous polyposis in an adolescent: A case report.

INTRODUCTION: Familial adenomatous polyposis (FAP) is an inherited colorectal cancer syndrome characterized by several adenomatous polyps of the gastrointestinal mucosa with a universal risk of colorectal cancer in a lifetime. FAP is usually asymptomatic in the first decade of life. CASE PRESENTATION: We report a case of a 13-year-old girl diagnosed with FAP who presented in our center with symptoms of hematochezia along with a positive history of the untimely demise of her father and elder sister with similar symptoms. DISCUSSION: FAP is an autosomal dominant disease affecting both male and female equally with variable penetrance. Diagnosis is made by finding hundreds to thousands of adenomatous polyps in the colon and rectum, and molecular analysis of the APC gene which forms the definitive diagnosis. Prophylactic laparoscopic total proctocolectomy with ileorectal anastomosis is a safe and feasible surgical option with a low risk of complications among adolescents. An endoscopic/colonoscopic procedure is recommended every 6 to 12 months after surgery to assess the anastomosis site, pouch, and residual rectum. CONCLUSION: FAP, a rare disease entity in adolescents should be managed by appropriate diagnostic procedures, early prophylactic surgery, and regular lifelong follow-up.

Hirschsprung disease with Edward syndrome: A rare association: A case report.

INTRODUCTION AND IMPORTANCE: Edward's syndrome (ES) occurs as a result of trisomy of chromosome 18 and is associated with multisystem congenital anomalies. The association of ES with various gastrointestinal malformations but Hirschsprung disease (HD) is well documented. CASE PRESENTATION: A female infant on her 5th day of life presented with episodes of bilious vomiting along with abdominal distension and no passage of stool. The child had a small head and prominent occiput, low set abnormal ears, small jaw, upturned nose, widely spaced eyes, small neck with widely spaced nipples, clenched hands with overlapping fingers, flexed big toe, and prominent heels. CLINICAL DISCUSSION: Edward syndrome is associated with multisystem congenital abnormalities of which gastrointestinal abnormalities make up the most part. The condition can be identified by fetal ultrasound screening. Surgical correction of associated congenital anomalies at different times along with lifelong supportive management is important. CONCLUSIONS: Edward syndrome can present as Hirschsprung disease as a part of associated gastrointestinal Malformation. Often, early identification and termination of the pregnancy in antenatal life can reduce the suffering. Surgical correction of associated anomalies along with supportive care forms the cornerstone of management. However, the prognosis remains poor.

Perforation of gastroesophageal junction, stomach, and diaphragm following blunt abdominal trauma: A near miss: A case report.

INTRODUCTION: Blunt abdominal trauma causing Gastro-esophageal junction (GEJ), diaphragm, and gastric perforation in children is a very rare occurrence. However, the injury is serious and life-threatening with significant morbidity and mortality. PRESENTATION OF CASE: We report an unusual case of a 14-year-old boy with an accidental fall from the tree with blunt abdomen trauma with a perforating injury to GEJ, stomach, and diaphragm. DISCUSSION: Multiple vital organs in the abdominal cavity are vulnerable to damage in blunt abdominal trauma. The rarity of perforation, diagnostic delay, and early septic occurrence sums up to higher patient morbidity and mortality. A high degree of suspicion and urgent laparotomy and surgical repair forms the cornerstone in management. CONCLUSION: Early suspicion along with effective resuscitation and early laparotomy and surgical repair is crucial for survival and optimal outcome of the patient.

Impalement injury of the perineum with an iron rod with a minimal injury: A near miss: A case report.

INTRODUCTION AND IMPORTANCE: Penetrating perineal injury in children is uncommon. However, the injury is serious and life-threatening with significant morbidity and mortality. CASE PRESENTATION: We report an unusual case of a 13-year-old boy with an accidental perineal impalement injury by an iron rod, which pierced through the perineum and exited through the left loin, however with minimal external and internal injuries. CLINICAL DISCUSSION: Multiple vital organs in the pelvic space are vulnerable to damage in perineal impalement injury. Vital organ injury, amount of blood loss, and effectiveness of the resuscitation determine the outcome of an impalement injury. Urgent laparotomy forms the cornerstone in management as all the potential injuries can be identified and managed immediately. CONCLUSION: Effective resuscitation and accurate assessment of the associated injuries along with proper pre-hospital care with a multidisciplinary approach is crucial for the survival and optimum outcome of the victim.