Biomedical subjects
Publications and source records attributed to K T Oldham.
We have used percutaneous transhepatic drainage of pyogenic hepatic abscesses with good result. This technique has been used effectively in adults by several authors. We believe this report represents the first instance of successful percutaneous drainage of a pyogenic liver abscess complicated by a bronchobiliary fistula.
The mechanism of cerulein-induced acute pancreatitis may involve the production of free radicals in excess of the capacity of endogenous intracellular scavengers. These radicals destroy the cellular membranes, releasing digestive enzymes and cellular proteins into the interstitium. Thereafter, a cascade of events, including polymorphonuclear infiltration and complement activation, leads to pancreatic destruction. The present study demonstrates that superoxide dismutase and catalase reduce the ultrastructural and biochemical injury associated with cerulein-induced acute pancreatitis in rats. Pretreatment with superoxide dismutase and catalase 30 minutes before injury did not appear to be protective, presumably because the half-life of intravenous superoxide dismutase is only 6 minutes. This and similar studies suggest a potential clinical role for free radical scavengers in acute established pancreatitis.
Serum hexosaminidase activity (HEX) is elevated with ischemic gut injury. To determine if subsequent decreases in HEX correlate with gut healing, 97 weanling rats were subjected to laparotomy at which alternate vascular bundles were ligated along the base of the entire anterior mesenteric artery arcade. Fifteen rats served as preoperative controls. After recovery, rats were allowed ad lib food and water. Groups were then killed at intervals, blood was drawn for HEX determination, and samples of small bowel were taken for histological evaluation. Microscopically, focal ischemic necrosis began at 6 hr. Between 12 and 48 hr, cellular changes were consistent with progressive ischemic injury. Evidence of healing was apparent beginning at 5 days and these histological changes correlated with changes in HEX. Thus HEX proves useful as a marker for gut healing in this model.
A recurrent tracheoesophageal fistula is generally associated with considerable mediastinal induration and inflammation. The conventional operative approach may be formidable with considerable blood loss and a high complication rate. For two infants with recurrent fistulae, we have employed a simplified low cervical transtracheal approach through noninflamed tissues. This brief atraumatic procedure was followed by gratifying results. Details of the approach are presented.
Pyogenic liver abscesses are rare in previously healthy children. This review reports ten such cases of pyogenic abscess seen between 1963 and 1984. The mean age in these children was 6.3 years. One child died. Of the nine survivors, five had successful open surgical drainage. Two abscesses were drained percutaneously. Another abscess drained spontaneously into the biliary system, and one abscess was treated with antibiotics alone. The single most helpful diagnostic test was abdominal ultrasonography. Our experience is evaluated in the context of other reports of pyogenic abscesses in children.
Malformations of the extrahepatic portal vein are quite rare. A 6-cm aneurysmal malformation of the extrahepatic portal vein, thought to be congenital in origin, is described. An English language literature review yielded only six similar cases, each of which was associated with portal hypertension, primary hepatocellular disease, or both. The patient reported herein had cholelithiasis with chronic cholecystitis, but no primary liver disease or vascular disease. We believe this is the first report of such an anomaly.
One hundred eighty-eight consecutive children with serious blunt abdominal or multisystem trauma were evaluated between August 1981 and July 1985. Of the 188 patients, 53 (28%) were found to have hepatic parenchymal injuries and are the basis of this report. Four of the 53 (8%) underwent emergency laparotomy for exsanguinating hemorrhage; two patients died, both of hepatic vein lacerations, and two are alive and well after right hepatic lobectomy. Forty-nine (92%) of the children with liver injuries did not require operation for hemorrhage. Four of these 49 patients developed serious complications; hemobilia occurred in one patient and bile peritonitis occurred in three. The one case of hemobilia was resolved without surgery. One child underwent a delayed operative biliary tract reconstruction that was successful. The other two children required a combination of debridement and drainage procedures. Fifty-one of the 53 children (96%) are currently alive without morbidity related to their liver injuries. Both children who died had multiple trauma including central nervous system injuries and had exsanguinating hemorrhage that required emergency laparotomy at initial evaluation. There were no children with "late" hemorrhage and none who developed septic complications. Nonoperative management of most childhood blunt abdominal trauma is possible. Widespread use of abdominal computerized tomography scanning has made this approach practical. This large series of consecutive liver injuries from a large pediatric trauma center illustrates the advantages and the risks of a selective but primarily nonoperative approach to liver trauma in children.
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A 15-yr-old girl presented with complaints of right upper quadrant pain and jaundice. Elevation of serum alkaline phosphatase, signs of protal hypertension, and computed tomographic scan findings suggested a diagnosis of primary sclerosing cholangitis. However, cultures of the bile and of the common bile duct specimen obtained during a surgical procedure grew Cryptococcus neoformans. Treatment with amphotericin B was begun. An episode of upper gastrointestinal bleeding, however, led to the hepatorenal syndrome, and the patient died before antifungal therapy was completed. At autopsy, active sclerosing cholangitis associated with cryptococci involved the common bile duct. We suggest that opportunistic infection of the biliary tree should be considered in pediatric patients with presumed primary sclerosing cholangitis.
Gastrointestinal hemorrhage in infants and children is notable for its association with benign disease and its varied, age-dependent etiologies. We have presented these in brief. Much of the information presented, particularly that related to diagnostic endoscopy and sclerotherapy, represents extension of commonly used adult techniques to the pediatric population. Guidelines for resuscitation and diagnosis are provided with the expectation that an individual clinical assessment will lead to modification. Rigidity in approach is to be avoided. Notable recent changes in the management of children with GI hemorrhage are summarized and placed in perspective.
Peritonitis-induced septic shock in the neonate is associated with a high mortality. Because there exists no clinically relevant model to study resuscitation of these patients, a model using the neonatal pig was developed. After arterial and central venous cannulation, and placement of a left pulmonary-artery thermodilution catheter, 12 anesthetized neonatal pigs were "resuscitated" with fluids (5% albumin in lactated Ringer's solution at 15 ml/kg/hr), antibiotics, and correction of acidemia. The pigs were divided into two groups: a control group (n = 5), which was not subjected to peritonitis and which was killed after 6 hours of monitoring, and a septic group (n = 7), which was inoculated with an intraperitoneal injection of sterile pig feces and Escherichia coli and was monitored until death (mean survival time (S.D.) 546(159) minutes). Serial measurements of hemodynamic and laboratory data were obtained. While pigs in the control group showed no significant changes in these data as measured against time, the pigs in the experimental group showed an early transient rise in cardiac index which was significant (p less than .05) and which was followed by a steady decline in cardiac index until death. These changes in cardiac index were accompanied by a continuous decline in mean arterial pressure, central venous pressure, pulmonary artery pressure, and systemic vascular resistance index, while pulmonary vascular resistance index showed a gradual continuous rise. The observed changes in hemodynamic and laboratory data mimic those anticipated in the human neonate with peritonitis-induced septic shock. This model proves reliable and reproducible, and shows promise as a tool to study the resuscitation of neonates with septic shock.
During a recent prospective nonrandomized comparison of noninvasive imaging techniques in 100 children with suspected major blunt abdominal injury, an interesting subset of patients was defined. Of 95 hemodynamically stable patients, 44 were found to have immediate elevation of hepatic enzymes (SGOT, SGPT greater than 30 IU). Nineteen of these children (43%) were subsequently shown to have significant liver injuries. No child with a liver injury had normal enzymes on admission. The level of enzyme elevation (SGOT chi 890 +/- 142 IU, SGPT chi 536 +/- 105 IU) in those with liver injuries is significantly greater than those without injury (SGOT chi 273 +/- 44 IU, SGPT chi 115 +/- 19 IU) (P less than or equal to 0.0001 SGOT. P less than or equal to 0.0001 SGPT). Our study has allowed definition of a group of children who are at significant risk for liver injury based on immediately available serum determinations of GOT and GPT. We have begun to use this information in our institution to select children for further noninvasive imaging. We recommend that these studies be obtained emergently in all children with suspected upper abdominal trauma.
One hundred consecutive children with serious blunt upper-abdominal injury were evaluated prospectively to assess the accuracy and usefulness of emergency computed tomography (CT) compared with liver-spleen scintigraphy and sonography. Ninety-five hemodynamically stable patients were imaged. The results of this 20-month study indicate that CT has fewer false negatives and false positives than scintigraphy or sonography, that CT is useful in abdominal trauma, and that CT provides the most information of any single diagnostic imaging test commonly available.
Of 43 patients undergoing operation for ulcerative colitis or polyposis, we found staging of the operation advisable in 7 instances. The initial operation consisted of subtotal colectomy with a Hartman's pouch and an ileostomy. The second procedure was a mucosal proctectomy, ileoanal anastomosis, and construction of a pelvic reservoir into the terminal ileum. The ileostomy was closed as a third procedure with approximately 6 months between each operation. Staging is recommended when emergency operation is required because of bleeding, perforation, or toxic megacolon; when significant technical problems are encountered with the mucosal stripping; or when the surgeon has had limited experience with the procedure. With the addition of staging to the surgeon's armamentarium, it is now possible to offer total colectomy with preservation of rectal continence to virtually all patients suffering from chronic ulcerative colitis.
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Primary excision is well accepted in children. Although the length of follow-up is inadequate, our review of the literature and experience with five patients suggests primary excision as the procedure of choice in older children and adults. Although the number of cases is too small and the follow-up too sporadic to draw statistically valid conclusions, excision has a lower morbidity, mortality and reoperation rate than internal cyst drainage, and definitive removal of tissue at risk for malignant degeneration seems intuitively more appealing.
A 15-year-old boy with Marshall-Smith syndrome presented with increased frequency and urgency of stooling, hematochezia, and rectal pain. A polypoid mass was found at the anorectal junction and excised. Microscopically, the lesion was covered by both squamous and columnar mucosa. It was villiform in configuration with focal ulceration and strands of smooth muscle in the lamina propria. These features are characteristic of an inflammatory cloacogenic polyp, a lesion not previously reported in the pediatric age group. Inflammatory cloacogenic polyp is related to solitary rectal ulcer syndrome and is most likely due to prolapse of the anorectal transition zone. Although rare in this age group, solitary rectal ulcer and its variants should be considered in the differential diagnosis of anorectal and rectal lesions in the pediatric patient.