John L. Gwinn

Diagnosis of biliary atresia: relative accuracy of percutaneous liver biopsy, open liver biopsy, and operative cholangiography.

Following necropsy or a minimum of three years of clinical observation an ultimate diagnosis of either biliary atresia or neonatal hepatitis was established in 108 infants with obstructive neonatal jaundice. In this group, the diagnostic accuracy of contemporary percutaneous (needle) liver biopsy and operative (open) liver biopsy was approximately the same. One third of the cases were not correctly identified. Operative cholangiograms usually dictated a correct course of clinical management, but 20 per cent suggested the incorrect diagnosis.

FUNCTIONAL DRAINAGE OF THE INFERIOR VENA CAVA INTO THE LEFT ATRIUM--THREE CASES.

Abstract Three patients are reported who had functional drainage of the inferior vena cava into the left atrium in addition to an intracardiac left to right shunt at the atrial level. All 3 underwent successful surgical correction. It is stressed that in the presence of the combination of cyanosis, a known left to right intracardiac shunt and near-normal pressures throughout the right side of the heart, drainage of a systemic vein into the left atrium must be strongly considered as the cause of the cyanosis. A strong index of suspicion and specific dye-dilution or angiographic studies are necessary to establish the diagnosis.

A fatal case of inclusion body pneumonia in an infant infected with adenovirus type 3

This report describes the clinical, roentgenologic, pathologic, and virologic findings in a 91/2-month-old girl who died after an illness characterized by severe respiratory distress and fever. Microscopic examination of the tissues revealed acute necrotizing pneumonitis characterized by intranuclear inclusion-bearing cells, perifollicular necrosis of the spleen, and enteritis. Adenovirus type 3 was isolated in high concentration from a suspension of the lung and also “unmasked” from lung tissue cultivated in vitro. No previous report of such “unmasking” of an adenovirus from lung tissue has come to our attention.

Retrosternal dislocation of the clavicle.

Posterior dislocation of the clavicle at the sternoclavicular joint is rare. Nonetheless, prompt diagnosis is important because the posteriorly displaced clavicle may produce serious morbidity and even death. Symptoms are variable, depending on the structures in the superior mediastinum affected. A special simple x-ray projection (the “Heinig” projection) which has been found extremely useful in the diagnosis of sternoclavicular dislocations is described. Radiographs of posterior and anterior dislocations are compared.

Congenital Partial Gastric Antral Obstruction: An Elusive Cause of Abdominal Pain and Vomiting

The patient with partial gastric antral obstruction due to a diaphragm may present with obstructive symptoms at any age in life. Including the four patients presented, there are now 50 reported cases. Since the diagnosis has been unduly delayed in many adults, it is particularly important that those physicians and surgeons caring for infants and children be aware of this entity. If properly treated in infancy and childhood, many years of suffering and debility can be obviated.

PULMONARY ALVEOLAR SEPTAL CALCINOSIS CAUSING PROGRESSIVE RESPIRATORY FAILURE IN ACUTE LYMPHOBLASTIC LEUKEMIA IN CHILDHOOD

A syndrome of pulmonary alveolar septal calcinosis, pneumothorax, and pneumomediastinum, leading to rapidly progressive acute respiratory insufficiency and death was observed in 2 children with acute lymphoblastic leukemia (ALL). Primary clinical and radiological considerations in these patients were pulmonary edema and infection, and the diagnosis of pulmonary alveolar septal calcification was established only at autopsy. One patient, a 15-year-old girl, was found also to have parathyroid hyperplasia typical of familial hyperparathyroidism. The other, a 16-month-old girl, showed osteitis fibrosa of the bones and parathyroid hyperplasia of secondary type, suggesting that the pulmonary calcinosis resulted from hypercalcemia caused by a parathormone or prostaglandin-secreting tumor. The cause of pneumothorax and pneumomediastinum may have been rupture of calcified alveolar septa induced by high PEEP during ventilation of these patients. Other possible mechanisms contributing to hypercalcemia and pulmonary calcinosis in children with acute leukemia include bone resorption due to marrow infiltration, immobilization syndrome, renal failure, and administration of calcium, phosphate, or bicarbonate. This complication of acute leukemia in childhood is rare (2 patients in 430 autopsied over the period 1961-1982 at Childrens Hospital of Los Angeles). How often the process can be reversed if diagnosed before severe respiratory insufficiency is present is not known.

Congenital syphilitic hepatitis: a radionuclide study

A two-month-old girl with congenital syphilitic hepatitis had bizarre liver scintigraphic features showing diminished hepatic uptake of radiocolloid with accentuated pulmonary and bone marrow accumulation. These features were reversible following penicillin therapy and to our knowledge are previously undescribed manifestations of this multisystemic disease.

Urinary Tract Trauma

In the child and teenager, urinary tract trauma is not uncommon, but fortunately severe injury does not occur with the frequency one might expect [10, 20, 21]. There is an increasing incidence due to the greater vehicular mobility and active participation in sports [23].

Injuries to the Liver and Spleen

Hepatic trauma is accompanied by high morbidity and mortality. The frequency is increasing, the majority of injuries being related to automobile accidents [6] although other accidents, child abuse [23], birth trauma [22], and liver biopsies are also responsible [28]. The injuries may be penetrating or blunt — the latter now forming the majority of injuries in children [20]. Many patients incurring severe hepatic injuries do not survive long enough to receive treatment. Among hospital patients, the overall mortality from two large series is around 13% [4, 26], although, for blunt trauma alone, the mortality rises to 32% [4] to 44.8% [3]. However, in one series, 74% of patients who arrived dead from blunt abdominal trauma had liver injuries [6]. The prinicpal causes of death are hemorrhage [26] and multiple injuries, including laceration of the heart and aorta [4]. Infection related to leakage of bile and sequestration of devitalized tissue [27], pulmonary insufficiency, and renal failure add to the mortality [4]. It is in the group of patients with severe blunt abdominal trauma that radiology is challenged to provide information regarding the nature and extent of the hepatic injury. This has become of increasing importance now that a more conservative approach to blunt trauma has been adopted, surgery being reserved for the more severe cases [4].

Pancreatic and Adrenal Trauma

About 4% of children with blunt trauma to the abdomen have significant pancreatic injury [13] which is most frequently nonpenetrating. The pancreas is injured most frequently by automobile accidents and falling on bicycle handlebars [11]. Sporting injuries and child abuse are responsible for some cases [5]. The direction of force will determine to a certain degree the type and extent of the pancreatic injury [2, 10]. With the impact concentrated to the right of the spine, the head of the pancreas is crushed, along with possible avulsion of the common bile duct and gastroduodenal artery and also possible laceration of the superiorly placed liver. The duodenum and colon may also be damaged. With midline compression forces, classical compression damage to the pancreas occurs without associated injury. Injuries to the left of the spine can damage the tail of the pancreas and may be associated with splenic laceration.