Duplication of the vermiform appendix.

In this brief report, the authors present a case of duplication of the vermiform appendix with appendicitis occurring in both appendices and causing small bowel obstruction.

A case of massive thymolipoma.

A massive anterior mediastinal tumor was discovered in a 9-year-old girl with long-standing symptoms of asthma. Preoperative computed tomography (CT) scan and magnetic resonance imaging (MRI) results suggested the presence of a thymolipoma, a rare benign tumor of the thymus. Few cases have been reported in the literature, although the histological and radiographic features have been well described. This case confirms previously reported characteristics and also illuminates new aspects of clinical presentation and perioperative management.

Spontaneous resolution of antenatally diagnosed adrenal masses.

Four infants had adrenal masses detected prenatally, through ultrasonography, between 18 and 30 weeks' gestation. Two were predominantly cystic, and two were solid. The sizes ranged from 0.8 to 1.5 cm. There were no associated prenatal maternal complications or stress factors. The urine vanillylmandelic acid levels at birth were normal in three infants. Two infants had a documented decrease in mass size at birth (compared with the last intrauterine study). All masses had a progressive decrease in size after birth, and ultrasound results were normal at 6 to 12 weeks of age. All four patients are well, with normal study results, at 2 to 5 years of age.

Primary omental torsion in children.

Primary torsion of the omentum is an unusual cause of an acute abdomen and commonly mimics acute appendicitis. The following report of four obese children is supportive of obesity as a predisposing factor. The paucity of gastrointestinal symptoms, anorexia, nausea, vomiting, and the relatively long duration of symptoms, may increase the index of suspicion. In the majority of cases, the diagnosis is made intraoperatively by digital exploration through the muscle-splitting incision. The torsed omentum is easily delivered through the same incision, and excision results in complete recovery.

Massive chylous ascites and transected pancreas secondary to child abuse: successful non-surgical management.

A case of massive chylous ascites associated with transection of the pancreas secondary to occult child abuse is presented. Computed tomography and ultrasound demonstrated exquisitely the location and extent of the clinically occult pancreatic injury. Also demonstrated was the complete resolution of the chylous ascites and the resolving and later completely resolved pancreatic injury following non-operative conservative treatment with total parenteral nutrition.

Left-sided posterior mediastinal thymus--MRI findings.

Anomalous descent of the thymus may result in ectopic thymic tissue in the neck and/or the mediastinum and can mimic an abnormal mediastinal mass. We present one case of a "posterior mediastinal mass" that was diagnosed as a posterior mediastinal thymus utilizing CT plus MRI.

Therapeutic and diagnostic implications of acquired choledochal obstruction in infancy: spontaneous resolution in three infants.

Three infants aged 2 days to 11 weeks with conjugated hyperbilirubinenemia, had sonographically documented dilated common hepatic bile ducts, and echogenic material in the gallbladder. A 2-day-old infant, born to a diabetic mother, had none of the classic predisposing factors for cholelithiasis, and two infants had received total parenteral nutrition (TPN) and TPN plus furosemide. The first infant after receiving 4 1/2 weeks of TPN and furosemide, developed common duct obstruction with increasing bilirubin and hepatic duct caliber over a 12-day period. An operation was scheduled; however, on the following day the bilirubin dropped abruptly and surgery was canceled. The experience with this infant encouraged conservative management in two subsequent infants with similar clinical and sonographic findings. Spontaneous resolution occurred 9 days after the onset of common duct obstruction in one infant and after 16 days in the other.

Neonatal appendiceal perforation and Hirschsprung's disease.

The case of a boy infant with neonatal appendiceal perforation who presented at 9 years of age with Hirschsprung's disease is reported. A retrospective review of the microscopic sections of the appendix demonstrated periappendicitis without transmural inflammation. The importance of differentiating between true appendicitis and periappendicitis in a neonate with appendiceal perforation is stressed, in order to avoid a missed diagnosis of Hirschsprung's disease.

Retrosternal (Morgagni) hernia with small bowel obstruction secondary to a Richter's incarceration.

Retrosternal (Morgagni) hernias in children are usually asymptomatic or may be associated with mild respiratory distress or gastrointestinal symptoms. Incarceration of bowel in a retrosternal hernia is unusual with only four reported cases, all in adult patients. This report details an unusual case of complete small bowel obstruction in which the Morgagni hernia sac itself contained the defect through which a portion of small bowel incarcerated as a Richter's hernia.

Massive hemoperitoneum following suprapubic bladder aspiration.

Hemoperitoneum in the newborn is usually a result of visceral injury from birth trauma. This report describes an as yet unreported complication of massive hemoperitoneum following suprapubic bladder aspiration.

Prolonged gastric retention of a swallowed coin following pyloromyotomy.

Ingestion of foreign objects is a common problem in children 6 months to 3 years of age. Of swallowed objects reaching the stomach, 97% will pass through the remainder of the gastrointestinal tract. The following is a report of a child who had a pyloromyotomy for pyloric stenosis as an infant and had prolonged retention of a swallowed penny.

Routine contrast enemas for diagnosing and managing strictures following nonoperative treatment of necrotizing enterocolitis.

A study to determine the value of contrast enemas in diagnosing and managing intestinal strictures following nonoperative treatment of necrotizing enterocolitis was performed from 1978 through 1983. From 1974 through 1977, 17 patients survived nonoperative treatment of NEC and three developed symptomatic strictures, an incidence of 18% (3/17). Since then a total of 31 infants were treated for NEC; three patients survived operation for perforation and there were seven deaths, leaving 21 in the study group. Sixteen patients had contrast enemas three to six weeks after resolution of NEC, which revealed strictures in five patients. Four of the five patients with strictures demonstrated on contrast enema were without obstructive symptoms. Three of the four remained asymptomatic without treatment, and one eventually required surgery for intestinal obstruction. The fifth patient developed intestinal obstruction while still in the nursery and a contrast study demonstrated an ileal stricture. A sixth patient had a normal contrast study and developed intestinal obstruction from an ileal stricture. The incidence of strictures was 38% (6/16). In five patients, appointments for contrast studies were not kept, although clinical follow-up was complete in all. The incidence of symptomatic strictures for the contrast study period was therefore 14% (3/21). Although some authors have recommended routine contrast enemas in patients surviving nonoperative treatment of NEC, contrast enemas had no advantage over clinical follow-up in the management of patients in this study. We have discontinued the use of routine contrast enemas in favor of close follow-up and careful instruction to parents as to the early signs of intestinal obstruction.

Neuroblastoma with intraspinal (dumbbell) extension.

Twenty-three patients with neurogenic tumors having extradural extension (dumbbell tumors) were treated over a 30-year period. Three had ganglioneuroma, 6 had ganglioneuroblastoma, and 14 had neuroblastoma. Nineteen patients with malignant tumors had symptoms of spinal-cord compression; three patients with ganglioneuroma and one with a malignant tumor had no neurologic symptoms. Delays in diagnosis were frequent ranging from 6 weeks to 3 years in 10 patients. Sixteen patients had abnormal x-rays of the spine. All patients with malignant tumors had positive myelograms. Three patients with ganglioneuroma and 13 with malignant tumors are alive and free of disease. Seven patients with malignant tumors died: five with stage IV and 1 with stage III tumors from disease, and 1 with stage II tumor during laminectomy. Age and stage were important prognostic factors; location was not. Treatment consisted of excision and radiation or radiation only. Patients receiving lower-dose (less than 2000 rad) radiation did as well as those receiving much larger doses. Morbidity in patients with malignant tumors was high; 4 have spinal deformity (3 severe) and 8 of 13 surviving patients have residual neurologic deficits. Earlier diagnosis, a surgical approach which does not introduce morbidity, and low-dose radiation in younger patients are important factors in reducing morbidity.

Twenty-three jejunoileal diaphragms in a 12-year-old boy.

A 12-year-old boy with a 5-yr history of unexplained iron deficiency anemia presented with acute abdominal pain and transient small bowel obstruction. At laparotomy he was found to have 23 jejunoileal diaphragms. These were treated by small bowel resection and enterotomy. The patient has remained symptom free without anemia since operation.

The etiology of spontaneous gastric perforation of the newborn: a reevaluation.

Twenty-eight infants with spontaneous neonatal gastric perforation are analyzed along with 10 newborn stomachs experimentally disrupted pneumatically at autopsy. Nineteen infants survived surgical closure of the perforation. Prematurity and delay in diagnosis were significant findings in the nonsurvivors. The location of the perforations and their gross and microscopic appearance led to the assumption that these perforations were mechanical disruptions. Comparison of the clinical material with the experimental material, and proven mechanical disruptions in the literature, along with theoretic considerations, are in support of this hypothesis.

Colonoscopy for rectal bleeding in childhood.

Undiagnosed rectal bleeding can pose a significant problem in the pediatric patient. A systematic and logical approach to the work-up of the child with rectal bleeding is necessary for prompt and accurate diagnosis. It is our impression that the addition of colonscopy in carefully selected patients will decrease the number of children with undiagnosed significant rectal bleeding.

Nonoperative treatment of duodenal hematomata in childhood.

Blunt abdominal trauma, often apparently trivial in nature, may produce intramural hematoma causing complete duodenal obstruction. A child with abdominal pain, persistent vomiting and upper abdominal tenderness should be carefully questioned for a history of trauma. Prompt upper gastrointestinal x-rays will allow early and definitive diagnosis. Previously recommended treatment varies from immediate surgical intervention to observation followed by exploratory laparotomy at a later date. We have treated nine patients with duodenal obstruction caused by intramural hematoma of which eight were successfully managed with nasogastric suction and parenteral fluid administration. One patient had the hematoma evacuated at surgery. This report reviews our experience.