Pediatric Surgery

Thyroglossal duct cyst/Fistula

2011-10-02T11:14:00.000-07:00

Introduction: The thyroglossal duct cyst is the most common congenital neck mass.

Clinical Presentation:

1. Painless mid-line neck swelling
2. Discharging sinus.
3. Painful mass (in c/o infected thyroglossal cyst)

Clinical diagnosis: Mid-line neck swelling moves with swallowing & also moves with protrusion of tongue.

Investigations:
1. Thyroid hormone tests T3,T4,TSH
2. Ultrasonography
3. Thyroid scan to rule out ectopic thyroid tissue.
Beside these tests, other optional tests are
4. CT/MRI
5. Fine needle aspiration cytology
6. Fistulography

Management:

Sistrunk procedure: Principle- excision of cyst along with fistulous tract extending up to the foramen caecum with central portion of hyoid bone (through which the tract goes)

In case of infected thyroglossal cyst, the preoperative antibiotic course is given & then the procedure carried out once the infection settles down.

Hepatoblastoma

2011-09-02T12:03:00.000-07:00

Introduction:
The liver is a large, very important organ situated in the right upper quadrant of abdomen. The normal functions of the liver in the body are: To help store nutrients from food To break down and remove harmful chemicals from the body To build chemicals that the body needs to stay healthy

Hepatoblastoma: The most common type of liver cancer in children is Hepatoblastoma. it occurs most frequently in infants or very young children between 2 months and 2 year.

Symptoms:

Lump in the abdomen (most common)
Reduced appetite
lethargy
nausea / vomiting
Pain in abdomen
Jaundice

Investigations: The following minimal investigations are proposed to diagnose hepatoblastoma

Tumor markers- serum AFP
CT scan of abdomen with Ct guided FNAC or Biopsy
X-ray chest
Complete blood count
Bio chem profile

Treatment:
Surgery & chemotherapy are two treatment options

Surgery: Liver resection according to the location & extent of the tumor. It will be either

Rt hepatectomy Lt hepatectomy
Extended Rt or Lt hepatectomy Bi or trisegmentectomy

If liver resection is not possible because of multicentric disease then liver transplant is the only treatment of option.
Chemotherapy:
Chemotherapy is given before or after surgery. Surgery is done either as a sandwich surgery (in between cycles of chemotherapy) or it is done at the start & then chemotherapy is given.

The drugs used are

Cisplatin

Doxorubicin

Vincristine

5-Fluorouracil

Other less common malignant liver tumor in children:

Hepatocellular carcinoma.

Cystic Hygroma

2011-07-06T05:50:00.000-07:00

Introduction: Cystic hygroma or lymphangioma occurs because of faulty development of lymph vessels.There is either sequestration or obstruction of the developing vessels.It occurs 1 in 12000 of births every year.
Commonest sites are:
Posterior triangle of the neck
Axilla
Groin
Mediastinum
(though it can occur anywhere in the body)
Age at presentation:
It may appear at birth or can rapidly increase in size over first few months of life.Generally it is disease of infants.
Diagnosis:
Prenatal Ultrasonography
swelling at the time of delivery
Complications:
If the swelling is very large,it can cause compression over the trachea & airway compromise
Infection
Hemorrhage
Treatment:
Injection sclerotherapy
Surgical excision
Principle of surgery:
Total removal of all gross disease without damaging vital structures.
Recurrence rate: 20% with subtotal excision.

Anterior Abdominal Wall Defects

2011-03-27T00:34:00.000-07:00

Introduction:

Most common congenital Anterior abdominal wall defects are Omphalocele & Gastroschisis.Combined incidence is 1:2000.It occurs equally in males & females.

Etiology:
Omphalocele: Failure of lateral & caudal folds to unite (which forms anterior abdominal wall) causes intestines to remain outside the body wall.
Gastroschisis: Abnormal involution of right umbilical vein resulting in the mesenchymal defects at the junction of the body stalk & body wall.
Pathology:
Omphalocele: There is anterior midline defect at the base of the umbilicus through which abdominal viscera herniates into an avascular hernial sac composed of peritoneum, wharton's jelly & amnion.

Presence or absence of liver in the sac differentiates between large & small omphalocele respectively.
Gastroschisis: There is a defect in the abdominal wall either on right (commonest) or left side of umbilicus without membranous sac.
Diagnosis:
Antenatal: Ultrasonography
Maternal serum AFP
Acetyl Cholinesterase
Amniocentesis & Chromosomal analysis
Postnatal: Clinical & Ultrasonography
Associated Syndromes:
1) Cantrell Pentalogy: Epigastric omphalocele, Anterior diaphragmatic hernia, Sternal cleft,
Ectopia cordis, Cardiac anomaly.

2) Beckwith Wiedemann syndrome: Exomphalos, macroglossia, gigantism

3) Trisomy syndrome

4) Prune belly Syndrome
Associated Conditions:
Intestinal malrotation, Meckel's diverticulum, Treacheo-esophageal Fistula, Undescended testis,
Small bowel atresia.
Management: Conservative (omphalocele):

1) Topical application of escharotic agents
2) Delayed external compressive reduction of omphalocele
Surgical management:
1) Primary closure of anterior abdominal wall defect
2) Staged silo closure
3) Skin flap closure( ventral hernia)
4) Repair using synthetic grafts

Acute appendicities

2010-02-04T11:43:00.000-08:00

One 16 yrs old female presented with sudden, severe pain around umbilicus along with gastric vomiting. Later on the pain shifted to right side of lower abdomen. She started having frequency of urination. Looking at her condition she was directly admitted in surgical ward. The plain x-ray abdomen showed 2-3 air fluid levels in right lower part of x ray. rest of the parts were normal. Ultrasonography abdomen showed swollen, tubular & tender structure in right iliac fossa.There were dilated bowel loops & minimal fluid in the same site, most probably appendicitis (whenever the ultrasonologist can see the appendix that means it is acutely inflamed, otherwise in majority of the cases, appendix could not be located & there is only probe tenderness). Both the ovaries & adnexae were normal (this is very important in female patients). Total leukocyte counts were high with predominance of neutrophils (S/O infection).

As it was the case of acute appendicitis, patient was immediately taken for surgery. On exploration there was long, inflamed, swollen appendix going into pelvis. There were lot of bowel adhesions & whole area was edematous. But there was no perforation. Rest of the bowel was normal. Ovaries were normal. Appendix removed after ligating & cutting appendicular mesentery. Abdomen sutured in layers.

Patient was kept nil by mouth for 24 hours till abdomen became soft, she passed flatus & bowel sounds became normal. She was started on oral fluids followed by solids & discharged on third day.Subcuticular suture removed on day 7. The wound was perfectly healed.

Small Intestinal obstruction

2010-02-03T23:11:00.000-08:00

A 4 yrs old child is presented with vomiting & pain in abdomen. Initially, vomiting were whitish/or food taken then later on vomitings became yellowish. The child was having severe pain in abdomen. Abdomen was distended. There was tenderness (pain on palpation) all over abdomen. Bowel peristalsis were sluggish.

X-ray abdomen in standing position revealed multiple air fluid levels. Ultrasonography abdomen shows dilated bowel loops with sluggish peristalsis. Minimal fluid was present in peritoneal cavity.All these investigations typically suggestive of intestinal obstruction.

Child was posted for surgery.On exploration there was small intestinal volvulus with a band crossing & obstructing.The band was nothing but a part of small intestine. Once the volvulus derotated & small intestinal band released, obstruction relieved. Some portion of bowel involved in volvulus was looking bluish & preischaemic. After putting hot mops, giving 100% oxygen, the bowel color changed. After inspecting all intestine and other structures in abdomen, abdomen closed in layers.

The child was kept nil by mouth for 48 hours within this period the bowel sounds returned & child passes gases. Then slowly water, liquids introduced & once child started tolerating soft died the child was discharged.

Hirschsprung's Disease

2009-05-26T21:11:00.000-07:00

One 7 months old female child presented with distension of abdomen and intermittent enterocolitis since birth. When I saw the child, she was weighing 4.3 kg which was far less than expected weight for her age. Her abdomen was distended with gas and I could see visible bowel loops. After doing per rectal examination, when I removed my finger, there was gush of liquid stool came with explosion.

This is typical of what it is called as Hirschsprung's disease. In this disease, there is problem in the innervation of part or whole large intestine or rarely extending small intestine. There is absence of ganglion cells in the affected part of intestine (Ganglion cells are required for proper peristalsis of intestine). The child presents with delayed passage of meconium, enterocolitis and distension of abdomen in the neonatal period while chronic constipation and distension of abdomen are presenting features in the older children.

Barium enema & full thickness rectal biopsy are the modalities of diagnosis. Treatment is decompression with colostomy and later pull through procedure or primary pull through procedure.

Meckel's Diverticulum

2009-05-25T22:27:00.000-07:00

Introduction: Meckel's diverticulum is the diverticulum present on the antimesenteric border of terminal part of small intestine also called as ileum. It does not present in all individuals. It is a presistence of vitellointestinal duct in the abdomen.

There is unique 'The rule of two' i.e. Meckel's diverticulum is present in 2% of population, it is 2" long and it is 2 feet away from ileocaecal junction (junction where small intestine joins large intestine).

Clinical presentation:
1. Bleeding per rectum- profuse & painless bleeding
2. Intestinal obstruction- leadiing to vomiting, pain & abdominal distension
3. Infection- symtoms mimicking appendicitis

Diagnosis:
In majority of cases it is diagnosed at exploration when the child is being operated for appendicitis. When it presents as bleeding per rectum then Meckel's scan or RBC tagged scan is useful. Barium meal follow through can also sometimes diagnoses Meckel's Diverticulum.

Managment: Laparoscopic or open Meckel's diverticulectomy is the standard of care. In case of appendicectomy, it is worthwhile to trace aprroximately 2 feet of ileum from ileocaecal junction to rule out uncomplicated Meckel's diverticulum.

Diagnosis of Swine Flu

2009-05-13T05:18:00.000-07:00

For diagnosis of swine influenza A infection, respiratory specimen would generally need to be collected within the first 4 to 5 days of illness (when an infected person is most likely to be shedding virus). However, some persons, especially children, may shed virus for 10 days or longer.

Sample Collection & Laboratory Diagnosis

· Preferred respiratory samples Nasal, Nasopharyngeal & throat swab

· Collection- on vaccine transport media

· Availability- with area & regional coordinator

· Storage of Samples : should be at 2-8⁰C until can be placed at -70⁰C.

· Transportation of Samples : dry ice in triple packaging. All samples should be labeled clearly and include patient’s complete information

· Laboratory biosafety measures should be followed for collections, storage, packaging and courier/ shipping of influenza samples.

· Available Laboratory tests:

- Rapid Antigen Tests: not as sensitive as other available tests.

- RT-PCR, Virus isolation, Virus Genome Sequencing, Four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies

Treatment of Wilms' tumor

2009-05-11T02:42:00.000-07:00

Wilms' tumor is the commonest kidney tumor in childhood. It is also called nephroblastoma.

Treatment for wilms' tumor is multidisciplinary.It includes surgery, chemotherapy & radiotherapy

Surgery- includes radical nephrectomy with lymph node sampling

Chemotherapy- combination of drugs like Vincristine / Actinomycin- D/ Cyclophosphamide.

Radiotherapy- is given to the flank in advanced disease or to the chest if there are metastasis.

Prognosis:This is one of the most curable cancer. the cure rate is more than 80% with multimodality treatment.

Other tumors of kidney in childhood
1. Clear cell sarcoma
2. Rhabdoid tumor
3. Renal cell carcinoma
4. Primitive neuroectodermal tumor
5. Infantile osteoid producing kidney tumor.

Laparoscopic Appendicectomy

2009-05-08T22:42:00.000-07:00

First laparoscopic appendicectomy was performed by Dr Kurt Semm (A German gynecologist) & Dr Philippe Mouret (A French surgeon & gynecologist) in beginnings of1980's.

Laparoscopic instruments required for appendictomy:
1. Trocar & Cannula
2. Telscope
3. Grasping forceps
4. Dissector
5. Monopolar/ Bipolar cautery/ Harmonic scalpel
6. Clip applicator with clips
7. Endoloop introducer with endoloops
8. Suction cannula

Surgical procedure:
1. Hasson's/ open technique- umbilical port for camera
2. Suprapubic & Left side of abdomen in line with umbilical port for working instruments
3. Telescope introduced through umbilical port by Hasson's technique
4. CO2 insufflation done & pressure kept at 8-10 mm Hg
5. Working ports introduced
6. Appendix visualized in RIF by moving away all the small bowel loops
7. Trendelenberg's position with left tilt given
8. Appendix tip grasped & mesoappendix either cauterized & endoclips are put
9. Endoloops introduced at the base of appendix & appendix is cut in between the loops
10. Appendix removed through the umbilical port after checking haemostasis.

Swine Flu Vaccine

2009-05-07T03:24:00.000-07:00

WHO: Questions and Answers related to Vaccines for the new Influenza A (H1N1)

From World Health Organization- May 2, 2009

Is an effective vaccine already available against the new Influenza A(H1N1) virus?

No, but work is already underway to develop such a vaccine. Influenza vaccines generally contain a dead or weakened form of a circulating virus. The vaccine prepares the body’s immune system to defend against a true infection. For the vaccine to protect as well as possible, the virus in it should match the circulating “wild-type” virus relatively closely. Since this H1N1 virus is new, there is no vaccine currently available made with this particular virus. Making a completely new influenza vaccine can take five to six months.

What implications does the declaration of a pandemic have on influenza vaccine production?

Declaration by WHO of phase 6 of pandemic alert does not by itself automatically translate into a request for vaccine manufacturers to immediately stop production of seasonal influenza vaccine and to start production of a pandemic vaccine. Since seasonal influenza can also cause severe disease, WHO will take several important considerations such as the epidemiology and the severity of the disease when deciding when to formally make recommendations on this matter. In the meantime, WHO will continue to interact very closely with regulatory and other agencies and influenza vaccine manufacturers.

How important will Influenza A(H1N1) vaccines be for reducing pandemic disease?

Vaccines are one of the most valuable ways to protect people during influenza epidemics and pandemics. Other measures include anti-viral drugs, social distancing and personal hygiene.

Will currently available seasonal vaccine confer protection against Influenza A(H1N1)?

The best scientific evidence available today is incomplete but suggests that seasonal vaccines will confer little or no protection against Influenza A(H1N1).

What is WHO doing to facilitate production of Influenza A(H1N1) vaccines?

As soon as the first human cases of new Influenza A(H1N1) infection became known to WHO, the WHO Collaborating Center in Atlanta (The Centers for Disease Control and Prevention (CDC) in the United States of America) took immediate action and began the work to develop candidate vaccine viruses. WHO also initiated consultations with vaccine manufacturers worldwide to facilitate the availability of all necessary material to start production of Influenza A(H1N1) vaccine. In parallel, WHO is working with national regulatory authorities to ensure that the new Influenza A(H1N1) vaccine will meet all safety criteria and be made available as soon as possible.

Why is WHO not asking vaccine manufacturers to switch production from seasonal vaccine to a Influenza A(H1N1) vaccine yet?

WHO has not recommended stopping production of seasonal influenza vaccine because this seasonal influenza causes 3 million to 5 million cases of severe illness each year, and kills from 250,000 to 500,000 people. Continued immunization against seasonal influenza is therefore important. Moreover, stopping seasonal vaccine production immediately would not allow a pandemic vaccine to be made quicker. At this time, WHO is liaising closely with vaccine manufacturers so large-scale vaccine production can start as soon as indicated.

Is it possible that manufacturers produce both seasonal and pandemic vaccines at the same time?

There are several potential options which must be considered based on all available evidence.

What is the process for developing a pandemic vaccine? Has a vaccine strain been identified, and if so by whom?

A vaccine for the Influenza A(H1N1) virus will be produced using licensed influenza vaccine processes in which the vaccine viruses are grown either in eggs or cells. Candidate vaccine strains have been identified and prepared by the WHO Collaborating Center in Atlanta (The Centers for Disease Control and Prevention (CDC) in the United States of America)¹. These strains have now been received by the other WHO Collaborating Centers which have also started preparation of vaccine candidate viruses. Once developed, these strains will be distributed to all interested manufacturers on request. Availability is anticipated by mid-May.

How quickly will Influenza A(H1N1) vaccines be available?

The first doses of Influenza A(H1N1) vaccine could be available in five to six months from identification of the pandemic strain. The regulatory approval will be conducted in parallel with the manufacturing process. Regulatory authorities have put into place expedited processes that do not compromise on the quality and safety of the vaccine. Delays in production could result from poor growth of the virus strain used to make the vaccine.

How would manufacturers be selected?

There are currently more than a dozen vaccine manufacturers with licenses to produce influenza vaccines. The vaccine strain will be available to each of them for vaccine production.

What is the global manufacturing capacity for a potential Influenza A(H1N1) pandemic vaccine?

While this cannot be assessed precisely since there is much uncertainty regarding the appropriate formulation for an effective and protective vaccine, a conservative estimate of global capacity is at least 1 to 2 billion doses per year.

How is production capacity for influenza vaccines distributed geographically?

More that 90% of the global capacity today is located in Europe and in North America. However, during the past five years, other regions have begun to acquire the technology to produce influenza vaccines. Six manufacturers in developing countries have done so with technical and financial support from WHO.

What will be the storage requirements for Influenza A(H1N1) vaccine?

The vaccine should be stored under refrigerated conditions at between 2°C and 8°C.

It has been impossible so far to develop vaccines for major killers such as HIV and malaria. How sure are we that there will not be scientific or other hurdles in developing an effective Influenza A(H1N1) vaccine?

Typically, development of influenza vaccines has not posed a problem. Influenza vaccines have been used in humans for many years and are known to be immunogenic and effective. Each year seasonal influenza vaccines with varying composition are produced for the northern and southern hemisphere influenza seasons. Vaccine manufacturers will employ a number of different technologies to develop their vaccines. They will take advantage, notably, of novel approaches that were developed over the past years for H5N1 avian influenza vaccines. One key unknown is yield of vaccine virus production, since some strains grow better than others and the behavior of the new Influenza A(H1N1) strain in manufacturers’ systems is not yet known. New recombinant technologies are under development, but have not yet been approved for use.

Will Influenza A(H1N1) vaccines be effective in all population groups?

There are not data on this but there also is no reason to expect that they would not, given current information.

Will the Influenza A(H1N1) vaccine be safe?

Licensed vaccines are held to a very high standard of safety. All possible precautions will be taken to ensure safety and new Influenza A(H1N1) vaccines.

How can a repeat of the 1976 swine flu vaccine complications (Guillain-Barré syndrome) experienced in the United States of America be avoided?

Guillain-Barré syndrome is an acute disorder of the nervous system. It is observed following a variety of infections, including influenza. Studies suggest that regular seasonal influenza vaccines could be associated with an increased risk of Guillain-Barré syndrome on the order of one to two cases per million vaccinated persons. During the 1976 influenza vaccination campaign, this risk increased to around 10 cases per million vaccinated persons which led to the withdrawal of the vaccine.

Pandemic vaccines will be manufactured according to established standards. However, they are new products so there is an inherent risk that they will cause slightly differently reactions in humans. Close monitoring and investigation of all serious adverse events following administration of vaccine is essential. The systems for monitoring safety are an integral part of the strategies for the implementation of the new pandemic influenza vaccines. Quality control for the production of influenza vaccines has improved substantially since the 1970s.

Will it be possible to deliver new Influenza A(H1N1) vaccine simultaneously with other vaccines?

Inactivated influenza vaccine can be given at the same time as other injectable vaccines, but the vaccines should be administered at different injection sites.

If the virus causes a mild pandemic in the warmer months and changes into something much more severe in, say, 6 months, will vaccines being developed now be effective?

It is too early to be able to predict changes in the Influenza A(H1N1) virus as it continues to circulate in humans or how similar a mutated virus might be to the current virus. Careful surveillance for changes in the Influenza A(H1N1) virus is ongoing. This close and constant monitoring will support a quick response should important changes in the virus be detected.

Will there be enough Influenza A(H1N1) vaccine for everyone?

The estimated time to make enough vaccine to vaccinate the world's population against pandemic influenza will not be known until vaccine manufacturers will have been able to determine how much active ingredient (antigen) is needed to make one dose of effective Influenza A(H1N1) vaccine.

In the past two years, influenza vaccine production capacity has increased sharply due to expansion of production facilities as well as advances in research, including the discovery and use of adjuvants. Adjuvants are substances added to a vaccine to make it more effective, thus conserving the active ingredient (antigen).

What is WHO's perspective on fairness and equity for vaccine availability?

The WHO Director-General has called for international solidarity in the response to the current situation. WHO regards the goal of ensuring fair and equitable access by all countries to response measures to be among the highest priorities. WHO is working very closely with partners including the vaccine manufacturing industry on this.

Who is likely to receive priority for vaccination with a future pandemic vaccine?

This decision is made by national authorities. As guidance, WHO will be tracking the evolution of the pandemic in real-time and making its findings public. As information becomes available, it may be possible to better define high-risk groups and to target vaccination for those groups, thus ensuring that limited supplies are used to greatest effect.

Will WHO be conducting mass Influenza A(H1N1) vaccination campaigns?

No. National authorities will implement vaccination campaigns according to their national pandemic preparedness plans. WHO is exploring whether the vaccine can be packaged, for example, in multi-dose vials, to facilitate the rapid and efficient vaccination of large numbers of people.

Developing countries are very experienced in administering population-wide vaccination campaigns during public health emergencies caused by infectious diseases, including diseases like epidemic meningitis and yellow fever, as well as for polio eradication and measles control programmes.

How feasible will it be to immunize large numbers of people in developing countries against a pandemic virus?

Developing countries have considerable strategic and practical experience in delivering vaccines in mass campaigns. The main issue is not feasibility, but how to ensure timely access to adequate quantities of vaccine.

What is the estimated global number of doses of seasonal vaccine used annually?

The current annual demand is for less than 500 million doses per year.

Will seasonal influenza vaccine continue to be available?

At this time there is no recommendation to stop production of seasonal influenza vaccine.

¹National Institute for Biological Standards and Control (UK), Food and Drug Administration/Center for Biologics Evaluation and Research (USA), New York Medical College (USA), Victorian Infectious Diseases Research Laboratory (Australia)

How to investigate a suspected c/o Neuroblastoma

2009-05-06T09:26:00.000-07:00

Neuroblastoma arises from adrenal medulla in majority of cases, however it may arise from any organ having neural crest cells.

Hematological & Biochemical tests:
Complete blood count
Biochemistry including serum LDH & serum ferritin

Diagnostic & Prognostic tests:
CT Scan of primary region
Urinary VMA (Vanillyl mandelic acid) and HMV (Homovanillic acid)
MIBG (131I-meta-iodobenzyl guanidine) scan
Tru-cut needle biopsy of the tumor
N-myc amplification
DNA index

Metastatic Work-up
Chest X-Ray
Bone marrow aspiration & Biopsy
MRI spine ( If neurological symptoms)
Bone scan

Inhaled Foreign Body

2009-05-04T08:32:00.000-07:00

( CT chest with virtual bronchoscopy showing cut off in
left main bronchus with left lung collapse & shift of mediastinum)

Inhalation of foreign body (FB) is the commonest cause of acute respiratory distress in children. 'Peanuts' is the commonest FB to be inhaled. It is important that these type of objects are kept away from children< 5 yrs. The other FBs are metal pins, vegetative FB, plastic objects, seeds, pen tops etc.

Presentation: The child presents with acute onset of respiratory distress started with coughing, choking & may lead to cynosis & respiratory arrest. There may be h/o inhalation of FB if parents or relatives are around the child. This is an emergency situation.

Management: The child needs to be resuscitated first. If the child cant breath or make a sound, invert the child & give 3/4 forceful back slaps. The child may cough out FB. But if the child can breath or make a sound then this procedure should not be done as it may dislodge FB & increase the obstruction. The child needs to be shifted to the hospital as early as possible. X-ray of chest will show FB ( if it is radio opaque), portion of lung or whole lung may look overinflated, there may be collapse of lung & mediastinal shift. CT chest with virtual bronchoscopy will exactly locate radiolucent FB & help in uncertain cases. Bronchosopy & removal of FB is the definitive management.

Pneumothorax in children

2009-05-03T07:57:00.000-07:00

Pneumothorax in children may be because of one of the following causes

1. Hyaline membrane disease
2. Positive pressure ventilation
3. Obstructive respiratory disease
4. Trauma to the chest wall or oesophagus
5. Staphylococcal pneumonia
6. Cystic fibrosis
7. Diaphragmatic hernia
8. Tracheotomy
9. Spontaneous

A small pneumothorax may be without any symptoms & may be spontaneously absorbed. Tension pneumothorax with respiratory distress, lung collapse & mediastinal shift is a surgical emergency and needs an immediate intervention as it is life threatening condition. Emergency needle aspiration (through the second intercostal space) or intercostal chest drainage is the life saving procedure which can immediately bring back the patient to normal.

Causes of scrotal swelling in children

2009-05-02T11:34:00.000-07:00

Causes of scrotal swelling in children:

1. Inguinoscrotal hernia
2. Congenital hydrocele
3. Acute epididymo-orchitis
4. Testicular torsion
5. Obsructed hernia
6. Testicular tumor
7. Lymphoma of testis
8. Haematocele
9.Trauma
10. Cellulitis of scrotum
11. Scrotal abscess

Out of these, Testicular torsion & obstructed inguinoscrotal hernia are surgical emergencies. In case of congenital hydrocele, there is possibility of spontaneous resolution till 1 year of age. Inguinoscrotal hernia & testicular tumor are surgical semiemergencies while lymphoma is an oncological emergency. In case of acute epididymo-orchitis, one should rule out testicular torsion & then start on antibiotics. Similarly cellulitis, trauma & haematocele can be treated conservatively. The child who progressed to scrotal abscess (rare) will need incision & drainage (again a surgical emergency).

Guidelines for Rotavirus Vaccination

2009-04-05T11:14:00.000-07:00

New recommendations advises the use of 2 rotavirus vaccine in infants i.e. RV5 and RV1.

. Administration schedule are different for RV5 and RV1.

· Schedule for RV5 is a 3-dose series, with doses given at ages 2, 4, and 6 months

· Schedule for RV1 is a 2-dose series, with doses to be given at ages 2 and 4 months

The revise recommendations are;

· The minimum age for dose 1 of rotavirus vaccine is now 14 weeks and 6 days, increased from the previous recommendation of 12 weeks.

· The maximum age for the last dose of rotavirus vaccine is now to 8 months and 0 days, whereas the previous recommendation was 32 weeks.

· Between doses of rotavirus vaccine, the minimum interval is now 4 weeks, and no maximum interval is set.

· Although the 2006 statement recommended deferring vaccination, if possible, for 42 days after receiving an antibody-containing product, the current statement allows for the administration of rotavirus vaccine at any time before, concurrent with, or after administration of any blood product, including antibody-containing products, following the routinely recommended schedule for rotavirus vaccine.

· Vaccine can be administered to breast-fed infants.

· Vaccine can be administered to infants with mild GE or other mild illness.

Preauricular Sinus

2009-03-21T01:40:00.000-07:00

Introduction: Preauricular sinus is a congenital deformity.It is identified as a small dell adjacent to the external ear, usually at the anterior margin of ascending helix i.e. in preauricular space.

Clinical features: Preauricular sinus is generally noted as a pit in front of the pinna.It is pathological when it starts pouring out serous/ seropurulent or purulent discharge.There can be redness and swelling around the pit. The child cries excessively because of the pain. On examination, the discharging sinus is seen in preauricular space. The signs of inflammation are seen as described above. Sometimes the discharge may not be seen but it can be expressed by gentle pressure. It is a clinical diagnosis & may not need specific investigations.

Investigations: The total white cell counts as well as neutrophils are increased on blood examinations. The pus can be sent for culture and sensitivity to give specific antibiotics.

Treatment: In acute case i.e. during active infection, the condition is treated conservatively with antibiotics and anti inflammatory drugs. Once the infection is eradicated, the elective excision of preauricular sinus is mandatory.The sinus should be excised in total or else there is chance of recurrence.

A Baby with Tracheoesophageal fistula

2009-01-01T11:34:00.000-08:00

One 1600 gm baby delivered 9 days back. It was full term normal delivery.Because of the low birth weight the baby was kept in the neonatal intensive care unit. After some time, nurse noticed lot of frothy secretions coming out from mouth of baby. She did suctioning of oral cavity and called the on duty doctor.The doctor noticed that there is continuous salivary secretions coming out from the mouth of the baby in spite of repeated suction. He then tried to put a nasogastric tube from one of the nasal cavity but the tube kept coming out of mouth.

I received the call from the NICU. When I took an x-ray, I noticed that there is coiling of nasogastric tube into the upper part of thorax. It did not reach the stomach. As I thought, it was a case of Tracheoesophageal fistula. The child underwent some more tests.

Now the main task was to disclose the diagnosis with parents immediately as such children needs an emergency operation.I called the father/close relatives in the cabin & told them condition of the child & that the baby needs an operation. As usual the first reaction was emotional shock through which they slowly recovered & gave consent for operation. I gave them a brief idea about the problem, the operation required, postoperative course etc. As it is major operation in a small baby, it is always better to discuss the success rate, possible postoperative complications, hospital stay & the cost involved.

In meantime anaesthetist examined the child & the baby shifted to operation room. In 2 hours baby was shifted back after undergoing an uneventful operation. He was kept on elective ventilation (respiratory machine) for 48 hours. After 48 hours the baby was started on feed through the orogastric tube.The water contrast dye study done at day 7 showed intact anastomosis without any leakage. baby was first put on test feeds & then shifted to breast feeds. Yesterday he was discharged from the NICU with smile on face of parents & a new year gift for them as well as for me. For more information on this problem click here.

Happy New Year to everybody!!!

Anaphylaxis: an allergic reaction

2008-12-28T12:57:00.000-08:00

Anaphylactic shock is an allergic reaction of the body which can at times lead to death if not recognized early. It can be to the drug or food. Anaphylaxis ranges from mild symptom like itching to the fatal death. So one has to be very careful & fully aware of this entity.It is a medical emergency.

It is mediated by Immunoglobulin E (IgE) antibody mediated and causes increased vasodilatation, increased vascular permeability & bronchospasm. Vasodialation occurs in many system of the body like skin & subcutaneous tissue, respiratory system, cardiovascular system & gastrointestinal system resulting in shock. Involvement of heart & lungs can give rise to cardiogenic & respiratory shock which is potentially fatal.

Clinical features:

It starts within few minutes of exposure to the allergic substance and responses well with immediate treatment. Recognision of anaphylactic shock is thus very important.

1. Urticaria
2. Difficulty in breathing
3. Sweating
4. Hypotension
5. Altered sensorium
5. Shock

Immediate treatment:

1. Patient should be immediately admitted in intensive care unit.

2. Airway restoration: monitor airways and if it is compromised then immediate intubation with endotracheal tube & ventilatory support

3. Oxygen by mask/ nasal prongs/ ventilator

4. Circulation: Intravenous access & intravenous fluids according to central line monitoring.

5. Intensive monitoring of pulse, Blood pressure, oxygen saturation, respiratory rate, urine output.

6. Adrenaline:Drug of choice

It causes vasoconstriction, bronchodilatation & relief of angioedema.It should be administered in the doses 0.01 ml/kg of of 1:1000 solution subcutaneously.It can be repeated after 15 minutes if required.

7. Vasopressors for hypotension

8. Anti-histaminics

9. Steroids, Aminophylline

10. Nebulization with bronchodilators

Constipation in Children

2008-12-26T09:22:00.000-08:00

Difficulty in passing stool which is firm to hard in consistency is called constipation.If untreated, it can lead to rectal impaction of feces and overflow incontinence (encopresis). Constipation is seen more common in male children than female children.

Causes of Constipation:

1. Dietary cause- Change from breast feeding to bottle feeding or introduction of solid food can cause constipation. Even if the formula feed is not mixed with sufficient quantity of water can give rise to constipation.

2. Cow's milk is itself a constipatory agent. If given in excess, can lead to hard stool.

3. Cystic fibrosis which is a genetic disease can cause constipation.

4. Anorectal problems- Anorectal problems like Anal stenosis, anterior ectopic anus, Anal fissure, Presacral mass can cause constipation.

5. Neurological problems- Meningomyelocele can involve the bowel leading to constipation.

6. Local intrinsic neuronal problems like Hirschsprung's disease, meconium plug syndrome or colonic dysmotility can cause constipation.

7. Metabolic problems like hypothyroidism.

8. Functional Constipation (most common)

Clinical features:

1. Chronic recurrent, nonspecific pain in abdomen
2. Difficulty in passage of stool
3. Eneurosis
4. Soiling of stool
5. Hard stool
6. Perianal pain/ Fissure-in- ano

On Examination:

1. Abdominal Examination: On examination, abdomen will be soft, non-tender, mildly distended. Fecolomas may be palpable.

2. Peri-anal & Anal examination: Fissure, anal stenosis, rectal mucosal prolapse can be seen on perianal examination.

3. Per-rectal examination: Decreased anal tone, shortened anal canal & distended rectal ampulla with full of stools.

Diagnosis:

1. Abdominal X-ray- Fecal matter, vertebral anomalies

2. Contrast Enema- Dilatation of colon & rectum up to the anal verge is suggestive of functional constipation while narrow rectum/ recto sigmoid with dilated proximal colon is suggestive of Hirschsprung's disease.

3. Cinedefecography

4. Anorectal manometry with electromyography can differentiates between Hirschsprung's disease and functional constipation.

5. CT/ MRI- For anatomical problems

6. Rectal full thickness biopsy- To rule out Hirschsprung's disease.

Treatment:

Treatment of underlying cause is the mainstay of management.

1. Correction of anatomical anomalies like dilatation in case of anal stenosis, anoplasty in case of ectopic anal opening.

2. Colostomy followed by pull-through surgery in case of Hirschsprung's disease.

3. Enemas, laxatives, stool softeners, toilet training

4. High fiber diet, plenty of liquids

5. Avoidance of milk or milk related products.

Meningomyelocele or Spina Bifida Manifesta

2008-12-25T13:45:00.000-08:00

Introduction:

Herniation of only meninges (covering over the spinal cord) or meninges along with neural elements (spinal cord elements) is called meningocele or meningomyelocele (MMC) respectively. This occurs due to failure of closure of the neural tube during the third week of foetal life. There is defect in the spine through which the meningomyelocele is open to the surface of the skin. The children born with this defect are prone to have bacterial meningitis due to the leak of cerebrospinal fluid (CSF) though the spinal defect. Therefore the child should be operated within 48 hours of delivery to prevent meningitis.The neurological deficit caused by MMC is irreversible and very rarely improves following repair. The further deterioration, however, can be prevented with the surgical repair of MMC.

Clinical presentation:

1. Prenatal diagnosis of MMC by ultrasound during pregnancy is one of the commonest mode of presentation. In such cases maternal serum alpha-fetoprotein is raised.
2. After birth, mid-line spinal swelling which is covered with the meninges. It can be cystic or some neural plaque can be seen into the swelling after trans-illumination test.
3. There may be weakness in the lower limbs i.e. legs or paralysis of lower limbs.
4. Bladder and bowel involvement may be seen in some cases with incontinence of passage of meconium & full bladder.
5. If MMC is associated with hydrocephalus then there is enlarged head with increased head circumference.

Diagnosis:

1. Prenatal - Fetal USG shows the spinal swelling and there is increased maternal serum alpha-fetoprotein.
2. Postnatal- X-ray spine- defect in spinal arch with soft tissue swelling
3. MRI spine- swelling content may be only CSF or neural strands or sometimes whole spinal cord.
4. USG/ CT scan Head- to rule out associated hydrocephalus.

Treatment:

Surgical repair of MMC is done within 48 hours of birth to prevent infection. MMC repair includes dissection & restoration of neural plaque in to spinal cord. Closure of dura followed by skin mobilization & skin closure.If there is associated hydrocephalus then ventriculoperitoneal shunting is also required.

Varicocele Can be Cause of Male Infertility

2008-12-24T07:43:00.000-08:00

Introduction:

Varicocele is dilatation of pampiniform plexus (testicular veins). Because of dilatation of veins there is increased temperature inside the scrotum which may cause testicular insufficiency leading to testicular atrophy and subsequent infertility.

In smaller children, varicocele may be caused by kidney tumors like Wilms' tumor, Neuroblastoma or hydronephrosis. The mass effect causes obstruction to the testicular venous return which opens into renal vein.

Clinical presentation:

1. Soft, painless, compressible swelling at the upper part of scrotum above testis.
2. This swelling gives characteristic 'Bag of worms' appearance.
3. Dragging sensation into scrotum.

Etiology:
1. Absence of valves in testicular veins.
2. Perpendicular entry of left testicular vein into high-pressure left renal venous system.
3. External pressure of loaded sigmoid colon on testicular vein.
4. Left adrenal veins also opens into left renal vein exactly opposite to the entry of left testicular vein. Because of adrenaline secreted by adrenal gland, there is spasm at the origin of vein.

Effects of Varicocele:

Testicular atrophy and subsequent infertility in adult life.

Investigations:

The indications for surgical treatment for varicocele are,
1. Chronic pain and discomfort
2. Sub-infertility in adults
3. Atrophy of the testis
4. 10% difference in volume of both testis measured by orchidometer

Surgical treatment:

1. Palomo's procedure:
Mass ligation of testicular vein and artery in the retro peritoneum above the internal ring.

2. Laparoscopic varicocelectomy

Complications:

1. Recurrence
2. Testicular atrophy
3. Nerve Injury
4. Injury to vas
5. Reactive hydrocele

Vitello-intestinal Duct Remnants

2008-12-23T09:47:00.000-08:00

Introduction:

Vitello-intestinal duct or omphalo-mesenteric duct connects the midgut to the yolk sac during early embryonic life. It gets obliterated and disappears during fifth to sixth week of intrauterine life.If the remnants persists then following abnormalities can occur:

1. Umbilical Polyp:

Umbilical polyp occur because of persistance of small portion of vitello-intestinal duct epithelium at the base of umbilicus. Clinically, a polyp is seen at the base of umbilicus after the umbilical cord falls off. This differs from umbilical granuloma in the sense that it does not respond to electrical or chemical cauterization like granuloma. The polyp can be pedunculated or sessile and treatment is excision of polyp.

2. Umbilical Sinus:

When umbilical portion of vitello-intestinal duct remains patent, an umbilical sinus forms. There is foul smelling persistent pus or mucoid discharge from umbilicus. On close examination an opening is seen in the umbilicus. Ultrasonography may reveal collection just below the umbilicus. The treatment is exploration and excision of sinus. The peritoneal cavity also opened to look for any fibrous strand connected with ileus.

3. Fibrous remnant of vitello-intestinal duct:

Whole vitello-intestinal duct become fibrous strand but does not disappear. This can cause mechanical intestinal obstruction at any age of the life. Exploratory laparotomy and excision of strand is all that is required.

4. Meckel's Diverticulum:
It is very well known terminology. The ileal portion of vitello-intestinal duct remains patent and form a diverticulum, called as Meckel's diverticulum. This diverticulum characteristically arises from the antimesenteric border of the ileum within 20 cm of ileo-caecal junction. It can present with infection, bleeding or obstruction.

5. Patent Vitello-intestinal duct:
When whole vitello-intestinal duct remains patent cause fistulous connection between umbilicus and ileum. There is discharge of either meconium or flatus or both per umbilicus. This is tackled surgically as an emergency. The treatment is exploratory laparotomy, in toto excision of fistulous tract with the portion of the ileum attached with ileo-ileal anastomosis

Urinary Stones in Children

2008-12-22T07:40:00.000-08:00

Introduction:

Childhood urolithiasis or urinary tract stones is common problem in children.The causes are anatomical abnormalities of urinary tract giving rise to stasis of urine, urinary infection, change in pH of urine etc.

Classification:

1. Anatomic

Pelviureteric junction obstruction
Vesicoureteral reflux
Neurogenic bladder
Extrophy of bladder
Ureterocele
Urethral diverticulum

2. Infection:

Stasis of urine causes infection. These infective stones are called as struvite stones.

3. Metabolic:

Cystinuria
Hyperoxaluria
Renal tubular acidosis
Urine acid stones
Hypercalciuria

4. Idiopathic:

In 20% of cases the exact cause of urolithiasis is unknown. Low intake of milk/animal proteins may be one of the cause.

Clinical presentation: Girls> Boys

1. Colicky pain in abdomen
2. Frequency of urination
3. Hematuria
4. Recurrent UTI
5. Passage of stones in urine

Diagnosis:

1. Urine Routine & Microscopy
2. Urine Culture
3. Serum Electrolytes
4. Serum Uric Acid
5. Serum Creatinine
6. Serum Calcium
7. Serum phosphorus
8. Serum Magnesium
9. Ultrasonography- Abdomen & Pelvis
10. Intravenous Pyelography
11. CT Scan Abdomen in some cases)

Treatment:

1. Conservative - in tiny stones. Plenty of liquids orally with antibiotics or IV fluids with diuretics
2. Extracorporeal Shock Wave lithotripsy - ESWL- It is used in renal pelvic stones, calyceal stones or upper ureteral stones which are less than 2 cm in diameter.
3. Percutaneus nephrostolithotripsy- Percutaneus access of calyx by making a puncture then tract is dilated with serial dilators. This tract is used to for use of lithotripter. The PCNL is used for stones more than 2 cm or hard stones. It is also used in combination with ESWL.
4. Ureteroscopic extraction of stone- small stones in lower ureters can be removed with ureteroscopic extraction.
5. Cystolithopaxy- Transurethral defragmentation of bladder stones with electrohydraulic lithotripter.
6. Open surgeries like nephrolithotomy or cystolithotomy.