Subhasis Roy Choudhury

Conservative management of isolated splenic abscess in children

INTRODUCTION Isolated splenic abscesses (SAs) are rare in children. We report a single-center experience with emphasis on their diagnosis, etiology, treatment, and outcome. METHODS This is a retrospective review. RESULTS Eighteen children (age, 3-16 years; male-female ratio, 5:1) were managed over a period of 8 years in a tertiary-care institution. Presenting symptoms included fever, abdominal pain, and anorexia. Splenomegaly was present in 12 (67%), leukocytosis in 9 (50%), and thrombocytosis in 12 (67%) patients. Associated diseases were thalassemia (1), tuberculosis (1), and typhoid fever (9). Solitary and multiple SAs were seen in equal numbers. Blood culture grew Salmonella paratyphi A in 1 case. Splenic aspirate culture was positive in 3 (Escherichia coli [1], S paratyphi A [1], Acinetobacter [1]). Widal serology was positive in 9 (50%) patients. Management consisted of intravenous broad-spectrum antibiotic therapy in all patients, together with percutaneous aspiration in 10 (56%) cases where the abscess size was greater than 3 cm. All patients responded, and complete resolution was observed. CONCLUSION Isolated SA in children responds favorably to conservative treatment with intravenous broad-spectrum antibiotics and percutaneous drainage without the need for splenectomy.

Intrapericardial diaphragmatic hernia: a rare type of congenital diaphragmatic hernia

An extremely rare case of congenital intrapericardial diaphragmatic hernia is presented. Since 1981, only 14 cases have been reported in the literature. A 5-year-old girl presented with dyspnea on exertion and easy fatigability. Computed tomography was suggestive of an anterior diaphragmatic hernia. Laparoscopy followed by successful open repair of hernia was performed.

Completely isolated enteric duplication cyst associated with a classic enterogenous duplication cyst

This report describes an 18-month-old boy with a completely isolated duplication cyst (CIDC) of the ileum associated with another classic enteric duplication cyst in the adjacent bowel and presenting as an acute abdomen due to torsion of the pedicle of the CIDC. Cysts excision was curative.

Persistent hyperinsulinemic hypoglycemia of infancy: An overview of current concepts

Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is relatively rare but one of the most important causes of severe neonatal hypoglycemia. Recognition of this entity becomes important due to the fact that the hypoglycemia is so severe and frequent that it may lead to severe neurological damage in the infant manifesting as mental or psychomotor retardation or even a life-threatening event if not recognized and treated effectively in time. Near-total pancreatectomy may be required for patients with intractable hypoglycemia despite medical treatment; however, that may result in diabetes mellitus or recurrent postoperative hypoglycemia. This review aims to consolidate the traditional concepts and current information related to the pathogenesis and management of PHHI.

Imaging spectrum of primary malignant renal neoplasms in children.

Wilms’ tumor (WT) is the most common abdominal tumor in children. Many pediatric renal tumors in the past were categorized as WT; however, in recent years, several specific renal tumors have been recognized as distinct pathological entities. The age and clinical presentation of the child and distinctive imaging features may help in reaching a specific diagnosis in most cases. This is important as it has implications on the pre-operative diagnostic work-up and prognosis of the child. However, it is often not possible to differentiate one from the other pediatric renal tumor on the basis of imaging alone, and the final diagnosis is often made at histological examination of the surgical specimen. This article reviews the imaging features of primary malignant renal neoplasms in children along with their clinical presentation and pathological features.

Lesions of the Stomach

Peptic ulcer is defined as an ulcer in the gastroduodenal region due to imbalance in acid-producing and acid-protective mechanisms.

Anorectal agenesis with rectovaginal fistula: A rare/regional variant

Aims and Objectives: The anatomical types of female anorectal malformation (ARM) are complex and include several rare and regional variants. The aim of this report is to highlight the diagnosis and management of cases of anorectal agenesis with rectovaginal fistula (RVF). Materials and Methods: This is a retrospective chart review of cases of RVF who underwent definitive surgery between November 2000 and September 2016 in a single institution. Results: Of the 244 female patients with anorectal anomalies treated in our institution over a 16-year period, there were 15 cases of RVF with anorectal agenesis giving it an incidence of 6%. All cases of RVF with anorectal agenesis presented with absence of anal opening, varying degree of abdominal distension, and history of passage of fecal matter per vaginum. The mean age of presentation was 3 months (newborn to 1 year). Sigmoid colostomy was done in 13 cases. Distal colostogram demonstrated high RVF which was further confirmed by examination under anesthesia (EUA) and endoscopy before definitive surgery. With the posterior sagittal approach, division of the RVF and anorectoplasty was possible in 14 cases; however, one patient required an abdominal mobilization of the colon for pull through due to a very short distal bowel segment. During a mean postoperative follow-up of 5 years, cosmetic and functional results were satisfactory. Conclusion: RVF with anorectal agenesis is a rare/regional variant of female ARMs. Clinical examination along with distal colostogram, EUA, and endoscopy clinches the diagnosis. Anorectal reconstruction by posterior sagittal anorectoplasty results in a satisfactory outcome.

Inadvertent chest tube insertion in congenital cystic adenomatoid malformation and congenital lobar emphysema-highlighting an important problem

Background: Chest tube insertion in congenital cystic lung lesions is an important problem in children with acute respiratory distress having a cystic lucent lesion on chest radiograph. Objective: To evaluate the imaging findings and complications in cases of congenital cystic lung lesions with chest tube insertion and suggest the role of appropriate imaging for management of these patients. Materials and Methods: Chest radiographs and CT scans of children with congenital cystic lung lesions who had inadvertent chest tube insertion preoperatively were retrospectively reviewed for imaging appearances and complications. Results: Fifteen patients comprising 10 cases of congenital cystic adenomatoid malformation (CCAM) and 5 cases of congenital lobar emphysema (CLE) were included. Majority of the cases were infants. CCAM was misdiagnosed as complicated pneumatocele (n = 5) and pneumothorax (n = 5), while CLE was misdiagnosed as tension pneumothorax (n = 5) on the chest radiograph findings. Final diagnosis was made on CT and operative findings with histopathology. Complications noted were pneumothorax, hydropneumothorax, and infection in cases of CCAM, and change in imaging appearance and pneumothorax in cases of CLE. Conclusion: Chest tube insertion in congenital cystic lesions increases the rate of associated complications. Chest CT has a definite role in early diagnosis and deciding appropriate management in these cases.

Multifocal intrathoracic inflammatory myofibroblastic tumour in children

Pulmonary inflammatory myofibroblastic tumour is the most common benign pulmonary tumour in childhood; however it is seldom diagnosed radiologically. We report three cases of biopsy-proven inflammatory myofibroblastic tumour that presented as large aggressive intrathoracic masses mimicking a malignant process. Two cases also had multifocal areas of origin. The possibility of inflammatory myofibroblastic tumour should be considered in a child presenting with a large aggressive pleuropulmonary mass lesion even with multifocal origin.

The anomalous clinical anatomy of congenital pouch colon in girls.

BACKGROUND/PURPOSE The aim of this study was to evaluate the anomalous clinical anatomy of congenital pouch colon (CPC) associated with anorectal agenesis in 22 consecutive girls managed over a study period of 7 years. METHODS The 22 patients were categorized into 2 groups. Group A consisted of 10 patients who presented during the neonatal period (n = 9) or as a young infant (n = 1). In these patients, only preliminary assessment results were available. Group B (12 patients) comprised 5 newborns who remained on follow-up and 7 patients who presented after the age of 1 year. These 12 patients were assessed and investigated in more detail. RESULTS In group A patients, apart from absence of the normal anal opening, the appearance of the external genitalia and perineum was essentially normal. Retraction of the labial folds showed radiation of folds inward from the margins of the vulval vestibule toward the center, at a point of confluence located at a higher level. At laparotomy, the subtypes of CPC were type I (n = 4), type II (n = 5), and type III (n = 1). In 8 patients, uterus didelphys was present. In all group B patients, the appearance of the external genitalia was similar to that in group A patients. However, separate openings of the urethra, septate vagina, and vestibular fistula (if present) were visible in 5 patients, whereas in 3 patients, a single perineal opening was identified. A total of 9/12 patients (75%) had urinary incontinence. Examination under anesthesia and endoscopy revealed a septate vagina in all 12 patients and an open, incompetent bladder neck with reduced bladder capacity in the 9 patients with urinary incontinence. The terminal fistula of the colonic pouch opened just distal to the bladder neck (n = 1), just posterior and cephalad to the urethral opening (n = 2), low in the vestibule (n = 5), and undetermined (n = 4). The subtypes of CPC were type I CPC (n = 2), type II CPC (n = 9), and type III CPC (n = 1). All 12 patients had uterus didelphys. CONCLUSIONS The characteristics in the anomalous clinical anatomy of CPC in girls, as described here, appear to be almost invariable and, especially in regions where CPC is common, should alert the clinician to the presence of this malformation.