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Childhood intussusception: Hydrostatic reducibility and incidence of leading points in different age groups

A series consisting of 658 radiologically diagnosed intussusceptions is analysed. Hydrostatic reduction was successful in 85.2% of cases, the incidence of failure amounting to 14.8%. Analysis demonstrated a marked difference in reduction rate in different age groups. The lowest rate of success was recorded in children over 5 years of age, the group with the highest incidence of leading points. The next lowest rate of success was in those below age 1 year where the frequency of failure was more than 50% higher than in the ages between 1 and 5 years. However, the rate of leading points was approximately the same in both the latter groups and close to the average in entire series. There is no reason to refrain from barium enema reduction in any age group although special care should be exercised in the neonate. With a reasonable experience of method, the risk of overlooking a surgically significant lesion is negligible.

Submucosal perforation of the esophagus in the neonate.

Excessive salivation, with choking, coughing and cyanosis on attempts at feeding in a newborn infant reasonably suggest esophageal atresia. Yet, other less common lesions may present the same signs. Of these, the simple esophagotracheal fistula, without atresia, is well known, while instances of congenital pharyngo-esophageal and true esophageal diverticula, with or without coexisting esophagotracheal fistulae, have only occasionally been reported (BRINTNALL & KRIDELBAUGH 1950, KNOX 1951, ROBB 1952 and GRANT & ARNElL 1959). An apparently even more rare disorder in the neonate with the same symptomatology is submucosal perforation of the esophagus. The clinical features and the radiologic appearances of this lesion on the basis of experience gained from two cases recently studied will be described in this communication. During its preparation, however, the records of a third case treated in another hospital became available and were included in the study. The radiologic features and the findings at operation of this third case well support the etiologic hypothesis for the disorder.

Reliability of the abdominal plain film diagnosis in pediatric patients with suspected intussusception

In order to reassess the diagnostic reliability of the abdominal plain film examination in suspected intussusception, the findings in 100 consecutive cases of this disorder were analysed. Then, these were compared with the same number of cases in which the diagnosis had been rejected by means of barium enema. It was found that a positive plain film diagnosis of intussusception was possible in 89 patients. In 11 cases inconclusive plain film findings called for supplementary barium enemas to establish the diagnosis. In the reference group intussusception was excluded on the basis of plain film findings alone in 74% of cases. In the remaining 26% of patients a barium enema proved necessary to reject the diagnosis of suspected intussusception.

Perinatal haemorrhagic necrosis of the adrenal gland A clinical and radiological evaluation of 24 consecutive cases

Up to 1970 only 13 fully verified and sucessfully treated cases of neonatal adrenal haemorrhage were on record. As uniform diagnostic and therapeutic guiding principles are still lacking, out experience of 24 consecutive cases appears worth presentation. — The most frequent clinical signs were a palpable mass in 21 cases, jaundice in 14 patients and urinary infection or sepsis in 10 neonates. —Intravenous urography revealed the diagnosis with a reasonable degree of reliability in all our cases. No additional information of significance was obtained at aortography, employed in 2 of our cases. — Surgical exploration with drainage of the haematoma or adrenalectomy was performed in 18 cases, 6 were treated conservatively. — Recovery was uneventful in all but for one conservatively treated patient. In this case death was caused by a second profuse bleading, which proved fatal in spite of all life saving efforts.

Barium peritonitis. Experience of five pediatric cases

Barium peritonitis secondary to perforation of the gut is an infrequent complication of radiological G-I tract examinations. It is thought to imply a high mortality rate. However, this conception seems to be based on data obtained during the early 1950s. More recent case reports and small series indicate a more favourable prognosis depending on effective antibiotics and successful maintenance of severily ill patients. The scant information concerning the fate of pediatric cases warranted presentation of the experience of 5 patients, who all survived. Our approach to treatment and the suggested use of barium studies, in particular barium enema, in obscure abdominal emergency cases are offered.

Pre- and postoperative urographic findings in posterior urethral valves

In a series of 65 male infants and children, all with the diagnosis of posterior urethral valves, pre- and postoperative urographic findings were reviewed. In addition changes occurring in the bladder, and the implication of vesico-ureteral reflux were assessed. — Preoperatively diagnosed impairment of kidney function and concommitant dilatation of the upper urinary tract, with some exceptions, remained fairly unchanged at postoperative examinations In the case of marked vesico-ureteral reflux, permanent kidney function annihilation was significantly commoner than with slight or no reflux. — Although, as a rule, both the upper urinary tract and the bladder were affected, there were cases of posterior urethral valves with a normal appearing bladder. As the intravenous urography do not exclude the urethral abnormality, voiding cysto-urethrography has to be included in the primary radiological exploration of all cases with urological problems.

Large Asymptomatic Adrenal Haematomas in the Neonate

The vast majority of abdominal masses observed in newborn infants derive from the retroperitoneal organs. Urography, the roentgenologic examination of choice in these conditions, typically reveals a deformed renal pelvis or displacement of the kidney or both. These findings, occasionally in combination with coexisting deformities of the ureters or the bladder, may prove to be of high diagnostic significance. Hydronephrosis, nephroblastoma or neuroblastoma are the common causes of these abnormalities, and have been extensively reviewed in the literature. By contrast, bleeding of the suprarenal glands, incidentally observed in the neonate, has attracted only scant consideration (SOMMERSCHIELD 1970), and particularly the haematoma presenting as a palpable mass as the single clinical manifestation. The roentgen findings in 4 recently observed cases of adrenal haematoma, all operatively verified, are now reported. The general diagnostic considerations and their implications as to the choice of therapy are also discussed.

Esophageal Atresia:II. Anastomotic Disruption Following Primary Surgical Management

Among 109 patients subjected to primary repair for esophageal atresia, there were 18 who developed anastomotic disruption. This complication occurred within the first week after operation; in 12 cases during the first two postoperative days. In the majority of cases the occurrence of leak was suspected clinically. Radiological diagnosis proved more reliable, in some cases preceeding the change in clinical behavior. Treatment consisted in pleural drainage, gastrostomy for decompression, omission of oral feedings and administration of antibiotics in each case. In two patients secondary cervical esophagostomy and closure of the distal segment was performed. Ten patients died within a few days from pulmonary complications and sepsis and two died later from causes unrelated to anastomotic disruption. Of the 6 long-term survivors, 4 developed anastomotic strictures which were successfully treated by dilatations (3 cases) or resection (1 case). The remaining 2 patients made an uneventful recovery.

The value of barium enema in establishing nature and level of intestinal obstruction.

In cases with obscure abdominal symptoms, potentially obstructive in nature, barium enema constitutes a valuable supplement to the routine abdominal plain film examination. The method, extended to include a reflux examination of the distal part of the small bowel, offers an important alternative to the frequently employed follow through examination, whenever the indications for immediate surgical exploration remain conditional. In the hands of radiologists accustomed to hydrostatic reduction of intussusception, the procedure yields a fast and safe differentiation between adynamic and mechanical ileus.

Esophageal Atresia:I. Anastomotic Strictures Following Primary Surgical Management

Among 109 patients subjected to primary repair for esophageal atresia, there were 80 survivors and 31 of them developed strictures. Early onset of dysphagia was encountered in 22 patients. In the remaining 9, symptoms appeared several months after esophageal reconstruction. Twenty-five patients were treated by dilatations and six by operation; five with resection of the stricture and one with plastic revision and dilatation during operation. There were four fatalities in the entire series. One was directly related to instrumentation and three to the operative management of the strictures. Of the 27 survivors, 16 achieved a satisfactory esophageal lumen and became asymptomatic. Eight continued to have symptoms in spite of adequate anastomotic width. Three showed neither radiographic nor clinical improvement.