Schmuel Katz

Impaired bacterial clearance and trapping in obstructive jaundice.

Sepsis is a major cause of mortality in patients with common bile duct obstruction. To define possible contributing factors to this phenomenon, this study evaluates the effect of biliary obstruction on the intravascular clearance and organ trapping of viable Escherichia coli using a rat model. Adult male Sprague-Dawley rats were placed in three groups: Group I controls had sham operation, Group II had division and Mgation of common bile duct (CDL), and Group III underwent splenectomy. At 21 days following operation 109 radiolabeled E. coli were injected intravenously. At varying intervals after infusion, blood samples were obtained for clearance study. At 10 minutes, bacterial distribution in the liver, spleen, kidneys, and lungs was determined (expressed as the mean percentage of injected viable E. coli). Intravascular clearance was similar in all groups. There was a significant decrease in the trapping of bacteria by the liver of CDL rats 14.5% ± 4.95 (vs. control = 70.0% ± 13.3) (p < 0.005). A significant increase of bacterial trapping by the lung was observed in the CDL animals: 63.1% ± 7.06 (vs. controls 1.4% ± 0.82) (p < 0.005). There was no significant change in bacterial localization in splenectomized rats. These data suggest that biliary obstruction decreases hepatic phagocytosis and increases pulmonary localization of viable E. coli. As the Kupffer cells of the liver are usually effective in removal of blood borne bacteria, this phagocytic dysfunction may contribute to the increased susceptibility to infection noted in instances of biliary obstruction.

Comparative effects of Indomethacin, Prostaglandin E1, and Ibuprofen on bowel ischemia

This study evaluates the effects of Indomethacin (IND), Prostaglandin E1 (PGE1), and Ibuprofen (IBP) in a bowel ischemia model. Laparotomy was performed in 80-gram rats (n = 260). Transient ischemia was induced by a one minute occlusion of the superior mesenteric artery. Animals were placed in five experimental groups: (I) ischemic controls (n = 80), (II) PGE1, 80 micrograms/kg IV (n = 20), (III) IBP, 12.5 mg/kg IV (n = 60), (IV) IND 15 mg/kg IV (n = 80) and (V) PGE1 + IND (n = 20). All medications were given just prior to laparotomy. Animals were evaluated for survival, length of survival and the presence of bowel necrosis and/or perforation at seven days. Survival was 18% in controls and was reduced to 5% by IND (p less than .005). Improved survival was observed with PGE1 (35%), TBP (31%) and PGE1 + IND (35%). IND resulted in early death, while PGE1, IBP, and PGE1 + IND all increased the length of survival (p less than .05). IND-treated rats had a high incidence of bowel perforation (greater than 40%). PGE1 reversed this effect when given concomitantly with IND. IBP had a significantly lower incidence of intestinal necrosis. These data suggest that infants treated with IND who are at risk for NEC should be carefully monitored for evidence of bowel necrosis. PGE1 and IBP may have a cytoprotective role in subjects at risk for bowel ischemia.

Varicocele in children: “To treat or not to treat” — Venographic and manometric studies

The management of varicocele is still controversial in spite of its high incidence (15%) in prepubertal boys and young adults and although it is believed to represent a major contributing factor to male subfertility. Fifty boys between 6 and 14 years of age were operated on for left varicocele, and a long segment of the left internal spermatic vein was excised. Thirty-four of them underwent preoperative retrograde left renal venography and pressure readings in both renal veins and inferior vena cava. In all 50 patients, intraoperative antegrade (via internal spermatic vein) left renal venography was performed. This examination revealed impaired renal venous drainage in 38 patients (group A) and normal venous return through the left renal vein in 12 patients (group B). In all 34 patients (from both groups) on whom retrograde venography was performed, there was marked renospermatic reflux. The pressure readings in the left renal vein were significantly increased in group A only. Our data strongly suggest that left varicocele is caused by renospermatic venous reflux and that this condition is probably irreversible. The reflux in group A is explained by the impaired venous drainage through the left renal vein. In group B, it is our impression that the reflux is a result of a congenitally valveless left internal spermatic vein. If varicocele is indeed a major cause for infertility, then our data logically point toward surgery.

The laryngeal mask airway in pediatric anesthesia: Experience with 120 patients undergoing elective groin surgery

The laryngeal mask airway (LMA) was recently introduced in pediatric anesthesia as an alternative to the face mask or tracheal intubation for airway maintenance. The authors report their experience with LMA on 120 consecutively treated children who underwent elective inguinal herniorrhaphy or orchidopexy. The patients were monitored with electrocardiograms, noninvasive blood pressure determinations, pulse oxymetry, and capnometry. Anesthesia was induced and maintained with halothane, nitrous oxide, and oxygen. There were 96 males and 24 females; the age range was 1 month to 14 years (average, 3.2 years). They weighed between 2.5 and 46 kg (mean, 14 kg). Patients were allowed to breath spontaneously until anesthesia was deep enough (average, 6.3 minutes; range, 2 to 15 minutes). The appropriate-size LMA was inserted and inflated, and patients were divided into three groups. Group I patients (n = 24) weighed 2.6 to 6 kg and received LMA size no. 1. Group II (n = 84) weighed 6 to 30 kg and received LMA size no. 2. Group III (n = 12) weighed more than 30 kg and received LMA size no. 3. Patients in groups II and III breathed spontaneously; those in group I were on volume-controlled ventilation. The LMA was easily inserted in 115 patients (95.8%)--on the first attempt in 100, and on the second attempt in 15. In five patients, LMA was successfully inserted on the third attempt. The ease of insertion was not significantly different between the groups. Anesthesia was maintained by halothane (mean, 1.34%; range, 0.8% to 2.54%) for an average of time of 39.2 minutes (range, 15 to 90 minutes).(ABSTRACT TRUNCATED AT 250 WORDS)

Abdominal Injuries caused by Bicycle Handlebars

OBJECTIVE To find out whether the increase in the number of children admitted with injuries from mountain bicycle handlebars is attributed to recent changes in the design of childrens bicycles. DESIGN Retrospective study. SETTING Teaching general hospital, Israel. SUBJECTS 76 children who presented with abdominal injuries caused by bicycle handlebars. RESULTS In 12 of the 76 children, there was an imprint of the handlebar edge on the hypochondrium. The most common injuries were isolated ruptures of spleen or liver, (14 and 11 patients, respectively). Five of the 25 patients were operated on and the rest treated conservatively. CONCLUSIONS Children with an imprint or bruise made by the handlebar edge on the abdominal wall, or who give a clear history of injuries by a bicycle handlebar should be treated with great care. BMX handlebars are relatively high (for young riders) and wide; they also turn freely and are therefore in direct line with the upper abdomen. Prohibiting the use of bicycles with unpadded handlebars may prevent some of these intra-abdominal injuries.

Liver bacterial clearance following hepatic artery ligation and portacaval shunt

The reticuloendothelial system (RES) plays an important role in removing bacteria, endotoxins, and immune complexes from the circulation. Hepatic phagocytosis accounts for more than 80% of RES function. The dual hepatic blood supply (hepatic artery/portal vein) may be altered by pathologic states and surgical procedures. This study evaluates and compares the effect of hepatic artery ligation and portacaval shunt on hepatic trapping of viable Escherichia coli. Thirty rats were placed in three groups: Group I was composed of sham operated controls; Group II underwent end-to-side portacaval shunt (PCS); and in Group III, hepatic artery ligation (HAL) was performed. At 2 weeks following the operation 10(9) 35S-radiolabeled viable E. coli were injected via the tail vein. At 10 min, bacterial distribution in the different organs was determined. Tissue samples were processed for liquid scintillation counting. The final distribution of bacteria was calculated from the input specific activity (dpm/bacteria) and expressed as the mean percentage of injected viable E. coli per gram of tissue and per organ weight. There was a significant decrease of bacterial trapping by the liver in rats following PCS (Group II), 45.0 +/- 10.4% vs controls 77.1 +/- 3.73% (P less than 0.005). This was partially compensated for by a significant increase of bacterial trapping by the lung. The decreased clearance in PCS rats is due to a reduction in liver mass compared to that in controls. Bacterial localization in HAL (Group III) rats was similar to that in controls. These data show that PCS decreases hepatic clearance and increases pulmonary localization of viable E. coli. This phagocytic dysfunction may contribute to increased susceptibility to infection following portacaval shunt.

Bacterial clearance in the intact and regenerating liver

The Kupffer cells in the liver play an important role in reticuloendothelial system (RES) function by clearing particulate matter and bacteria from the blood stream. While hepatocyte regeneration and function have been extensively studied following partial hepatectomy, little information is available concerning RES function in the regenerating liver. This study investigates hepatic RES function by evaluating bacterial clearance (live E. coli) in the intact and regenerating liver. Thirty-four young male Sprague Dawley rats were studied. Twenty-two animals underwent a standard 70% partial hepatectomy using ligature technique and 12 had a sham operation. Both groups of rats received 10(9) organism of S35 labeled E coli, intravenously at 24 hours, 72 hours, 2 1/2 weeks, and 6 weeks postoperatively. Rats were killed 10 minutes following injection and liver, lung, spleen, and kidney harvested, fixed, and radioactivity was determined using a scintillation spectrometer interfaced with a micro-computer counting the S35 radiolabel. The total organ count of trapped bacteria in liver in partially hepatectomized rats was lower than intact controls at 24 hours (22.0% v 46.4%, P less than .01), but was similar at 72 hours, 2 1/2 weeks, and 6 weeks. Partial hepatectomy increased the amount of bacterial trapping in the lung at 24 hours (11.3% v 1.7%, P less than .01) and 72 hours (10.1% v 1.7%, P less than .05) and returned to normal at 2 1/2 weeks and 6 weeks. Splenic activity was increased following hepatectomy at 2 1/2 weeks. Renal clearance was increased at 72 hours and 2 1/2 weeks.(ABSTRACT TRUNCATED AT 250 WORDS)

Blue Rubber Bleb Nevi as a cause of intussusception

The Blue Rubber Bleb Nevus syndrome is a rare disease characterized by a distinctive type of hemangioma which involves the skin and the gastrointestinal tract. In the latter location, these lesions are often responsible for chronic blood loss and secondary anemia, and in rare situations may act as a leading point for an intussusception. The diagnosis of intussusception in children older than 3 or 4 yr is frequently difficult and delayed. In a child with typical skin lesions of the Blue Rubber Bleb Nevus syndrome, an acute illness with manifestations of intestinal obstruction should indicate the possibility of an associated intussusception.

Brain concussion produces transient hypokalemia in children

Hyperglycemia and hypokalemia caused by catecholamine discharge have been reported to occur in patients after severe head trauma. The aim of this prospective study was to evaluate whether a similar neuroendocrine and metabolic response is found in children after minor head trauma such as brain concussion (Glasgow Coma Scale (GCS) > or = 13). One hundred fifty patients aged 2 to 14 years (average, 6 years) were divided into three groups (n = 50 in each group). Group 1 included patients admitted to the emergency department for brain concussion (Glasgow Coma Scale (GCS) > or = 13); group 2 included patients admitted for fractures of long bones without head injury; and group 3 were control patients electively admitted for hernia repair. All patients had complete physical and neurological examinations. Complete blood count and blood chemistry were obtained on admission. All blood tests were repeated at 6, 12, and 24 hours in patients belonging to group 1. An electrocardiogram was obtained in selected patients and catecholamine levels were measured in some patients. Statistical analysis was performed using analysis of variance (ANOVA). Serum potassium and sodium levels in patients with brain concussion (group 1) were 3.6 +/- 0.6 and 136 +/- 3 mEq/L, respectively and were significantly lower (P < 0.01) than those in patients belonging to group 2, 4 +/- 0.4 and 138 +/- 3, respectively, and the controls (group 3), 4.2 +/- 0.5 and 140 +/- 2, respectively. Serum glucose level was 124 +/- 34 and 118 +/- 32 mg% in groups 1 and 2 and was significantly higher than that of the controls (group 3), 90 +/- 23 mg%. There was no correlation between serum electrolytes and GCS. No electrocardiogram changes or elevation of serum catecholamines were found. Hypokalemia resolved spontaneously within 24 hours. All patients recovered without neurological sequalae. Transient hypokalemia frequently occurs in children even with minor head trauma. This hypokalemia resolves spontaneously, without treatment and within 24 hours.

Fibrous fusion between the liver and the lung: An unusual complication of right congenital diaphragmatic hernia

A congenital right diaphragmatic hernia was diagnosed in a full-term newborn who presented with respiratory distress at the age of 10 hours. The patient required respiratory support, and was operated on at age 6 days. During surgery, a central defect of the diaphragm was found. The herniated liver was only partially reducible because of intrathoracic adhesions. The patient died at 10 days of age as a result of persistent fetal circulation. Postmortem pathological examination demonstrated a central diaphragmatic defect and a nonseparable fibrous fusion between the liver and the lung.