Ramnik V Patel

Omental infarct in a hernia: an unusual cause of paediatric acute scrotum

We report a case of paediatric acute scrotum due to segmental haemorrhagic infarct of the omentum secondary to strangulation in the left inguinal hernia in a toddler as initial presentation after hernia being noticed by mother once earlier. A 4-year-old boy with non-traumatic acute left scrotum who had a history of left inguinal swelling once earlier presented with massively swollen, painful and discoloured left hemiscrotum extending into the groin simulating acute testicular torsion. Interestingly, there was a segmental omental infarct which precipitated the emergency and had ipsilateral testicular ascent and atrophy as long-term sequelae. Strangulated segmental omental infarct is a rare cause of acute abdomen/scrotum in children. Omentum is a very rare content of inguinal hernia in a toddler and infarct is exceptional. The diagnosis is usually not established before surgery in children. It should be included in the differential diagnoses of acute scrotum, especially in patients with untreated inguinal hernia.

Sigmoid volvulus in an adolescent girl: staged management with emergency colonoscopic reduction and decompression followed by elective sigmoid colectomy

A case of acute sigmoid volvulus in a 14-year-old adolescent girl presenting with acute low large bowel obstruction with a background of chronic constipation has been presented. Abdominal radiograph and CT scan helped in diagnosis. She underwent emergency colonoscopic detorsion and decompression uneventfully. Lower gastrointestinal contrast study showed very redundant sigmoid colonic loop without any transition zone and she subsequently underwent elective sigmoid colectomy with good outcome. The sigmoid volvulus should be considered in the differential diagnosis of paediatric acute abdomen presenting with marked abdominal distention, absolute constipation and pain but without vomiting. Plain abdominal radiograph and the CT scan are helpful to confirm the diagnosis. Early colonoscopic detorsion and decompression allows direct visualisation of the vascular compromise, assessment of band width of the volvulus and can reduce complications and mortality. Associated Hirschsprungs disease should be suspected if clinical and radiological features are suggestive in which case a rectal biopsy before definitive surgery should be considered.

Neonatal prolapsed patent vitellointestinal duct

A case of a prolapsed patent vitellointestinal duct (PVID) in a 10-day-old neonate who presented with vomiting and poor weight gain with partial intestinal obstruction and a flower like pink, prolapsing lesion at his umbilicus has been reported. A limited contrast study through the tubular structure confirmed it to be a PVID. He underwent transumbilical exploration and resection and anastomosis uneventfully. Persistence of the vitellointestinal duct as a whole or part of it leads to a wide variety of anomalies–Meckels diverticulum is the commonest lesion and a PVID is the rarest. Umbilical cord clamping flush with the abdominal wall may convert a Meckels diverticulum prolapsing in the base of umbilical ring into a PVID. Careful assessment should be made for associated anomalies. Transumbilical exploration gives the best cosmetic and functional results.

Periurethral and vulval condylomata acuminata: an unusual juvenile venereal disease in a 3-year-old girl.

We present a case of giant condyloma acuminatum (CA) in a 3-year-old girl with rapidly growing vulval and periurethral lesions, which was investigated thoroughly and successfully treated with excision biopsy. Genital warts in the form of giant alarming vestibular, vulval and periurethral lesions of CA are very rare in children. There is need for a multidisciplinary approach with potential sociomedicolegal implications. Surgical excision is safe, effective and provides an opportunity to assess the extent of the lesion and tissue for accurate diagnosis. Genital warts in the form of giant alarming vestibular, vulval and periurethral lesions of CA are very rare in children. Indications for surgical treatment include large, recurrent or refractory lesions, as well as the need for histological identification and acquiring tissue for immunotherapy when necessary. The strategy of an extended follow-up is recommended so as to ensure identification of any risk situations.

Closing left gastroschisis with vanishing left testis

We report a baby boy with gastroschisis with left non-palpable undescended testis who had a defect on the left side of an intact and normal umbilical cord and had associated testicular atrophy and abnormalities of the ductus deferens. They were successfully managed by primary repair and had uneventful recovery. Subsequent inguinal exploration confirmed blind ending vas deferens and vanishing left undescended testis. Our case confirms vascular accidents at the narrow abdominal wall defect can lead to vanishing testis following attempts at closing gastroschisis making the defect narrow and compromising the blood supply to the testis.

Paediatric recurrent herpetic whitlow

We present a case of recurrent painful blisters of middle phalanx of the left ring finger of a 15-month-old previously healthy and immunocompetent female child. These lesions initially were confused with infective bacterial whitlow, treated with incision and drainage, and later with cigarette burns which led to referral to child protection team. Paediatric dermatologist finally diagnosed after scrapping and virology culture. The patient had recovery following full treatment with topical and systemic acyclovir. She presented again at the age of 4 with recurrence which required topical and systemic acyclovir therapy with good recovery. It is important to be aware of the danger of incorrect diagnosis, raising child protection concerns and management leading to danger of cross infection and serious illness especially in the immunocompromised patients.

Neonatal-perforated appendix forming antibioma masquerading as duodenal duplication.

A 17-day-old previously healthy breastfed neonate with normal antenatal scans born at full term by an emergency caesarean section for failure to progress and passed meconium in the first 2 h of life, became irritable with vomiting, refusal of feeds and fever. On examination, he was febrile (38.5), tachycardic with a tender abdomen. He underwent a partial septic screen at the district general hospital which showed normal urine, cerebrospinal fluid (CSF) and chest X-ray and the white blood cell count was 26×109/L, neutrophils 16.4×109/L and C reactive protein (CRP) 283 mg/L. He was resuscitated and started on …

Trilogy of foregut atresia without genetic abnormality: exception to the Martinez-Frias syndrome.

We present a case of oesophageal atresia with distal tracheo-oesophageal fistula and duodenal atresia, which later on was detected to have cystic variant of biliary atresia. He underwent primacy repair of oesophageal atresia with ligation of distal tracheo-oesophageal fistula and duodenoduodenostomy. He later developed features of obstructive jaundice, and on investigation was diagnosed to have cystic variant of biliary atresia which was initially confused with iatrogenic biliary obstruction. Exploration and operative cholangiogram with biopsy confirmed cystic variant of biliary atresia and underwent successful Kasai procedure. Our case effectively demonstrates a rare triology of foregut atresia without an apparent genetic association. It highlights stepwise systematic management of foregut atresias in this patient and demonstration of cystic variant of biliary atresia. Even though these are rarely seen, still the clinician should be aware of such a possibility and should adopt a multimodality approach to diagnose and an aggressive approach to manage the condition.

Paediatric caecal volvulus with perforation and faecal peritonitis

A 7-year-old boy presented to the paediatric department of district general hospital with persistent and diffuse abdominal pain, bilious vomiting, constipation and abdominal distention of about 24 h duration. He had a background of prematurity, developmental delay, and chronic constipation with chronic recurrent unexplained abdominal pain. He had undergone an uneventful percutaneous endoscopic gastrostomy 5 years ago for feeding difficulty and failure to thrive. During the abdominal examination, a palpable, firm and tympanitic mass was identified in the mid-portion of the upper abdomen, and diffuse tenderness with peritoneal irritation was noted. The plain …

Ileal atresia secondary to antenatal strangulation of Littre's hernia in an exomphalos minor

We describe an unusual case of ileal atresia, resulting from antenatal strangulation of a Meckel’s diverticulum in an exomphalos minor. This is a rare antenatal complication of Littre’s hernia, which has not been previously described. A small exomphalos minor at the base of umbilical cord and late onset vascular accident at the narrow defect leading to ileal atresia may be missed in the prenatal diagnosis. The triad of exomphalos minor, Meckels diverticulum and terminal ileal atresia secondary to antenatal strangulation of Littres hernia is very rare to find in the same patient. A small exomphalos minor at the base of the umbilical cord can be missed even in the postnatal period. Our case lends direct evidence of vascular accident as a cause of ileal atresia and supports vascular theory. Whenever possible umbilicus should be preserved naturally and exomphalos sac should be opened higher up for excellent cosmetic results.