Chapter 27. Unique Considerations in the Neonate and Infant 257
FIGURE 27.2. Laparoscopic view of pyloric mass and pyloromyotomy.
splitting of the pyloric muscle resulting in prolonged vomiting and recurrence of pyloric stenosis. Mortality from pyloric stenosis is rare and results from an unrecognized mucosal perforation and subsequent leak of gastric contents.
Medical therapy using IV and oral atropine to treat pyloric stenosis has not gained widespread acceptance due to the longer length of hospital stay required and the 15% failure rate associated with the treatment.
Long term follow up of babies with pyloric stenosis demonstrate no significant side effects or symptoms from this condition.
References
1.To T, Wajja A, Wales PW, et al. Population demographic indicators associated with incidence of pyloric stenosis. Arch Pediatr Adolesc Med. 2005;159:520-525.
2.Carter CO, Evans KA. Inheritance of congenital pyloric stenosis. J Med Genet. 1969;6:233-254.
3.Woolley MM, Felsher BF,Asch J, et al. Jaundice, hypertrophic pyloric stenosis, and hepatic glucuronyl transferase. J Pediatr Surg. 1974;9: 359-363.
4.Hernanz-Schulman M, Sells LL, Ambrosino MM, et al. Hypertrophic pyloric stenosis in the infant without a palpable olive: accuracy of sonographic diagnosis. Radiology. 1994;193:771-776.
258 J.I. Curry and S. Hassett
5.Steven IM, Allen TH, Sweeney DB. Congenital hypertrophic pyloric stenosis: the anaesthetist’s view. Anaesth Intensive Care. 1973;1: 544-546.
6.Tan KC, Bianchi A. Circumumbilical incision for pyloromyotomy. Br J Surg. 1986;73:399.
7.Alain JL, Grousseau D, Terrier G. Extramucosal pyloromyotomy by laparoscopy. Surg Endosc. 1991;5:174-175.
8.Hall NJ, Pacilli M, Eaton S, et al. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet. 2009;373:390-398.
9.Hulka F, Harrison MW, Campbell TJ, et al. Complications of pyloromyotomy for infantile hypertrophic pyloric stenosis. Am J Surg. 1997;173:450-452.
Chapter 28
Unique Considerations
in the Neonate and Infant:
Intussusception
Joseph Ignatius Curry and Sinead Hassett
Key Points
››Peak incidence between 5 and 9 months of age.
››Triad of abdominal colic, vomiting and bleeding PR in 30% of children.
››Delayed diagnosis common due to subtle signs and symptoms.
28.1 Introduction
Intussusception occurs where there is invagination of bowel into its neighboring distal segment (Fig. 28.1a and b) As bowel invagination progresses, its mesentery becomes incorporated and venous outflow is obstructed. Engorgement and swelling of the bowel follows which obstructs the arterial supply with ischemia leading to necrosis. The etiology of this invagination is thought to be due to hyperplastic intestinal Peyer’s patches which act as a lead point. In many cases this hyperplasia occurs secondary to viral infection, typically following an upper respiratory tract infection o r gastroenteritis.
An identifiable lead point is found in only 10% of cases of intussusception. A Meckels diverticulum is the commonest reported lead point.1 Other examples are the appendix, small bowel lymphoma, intestinal polyps and following submucosal
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Surgery in Clinical Practice, DOI: 10.1007/978-1-84996-366-4_28,
© Springer-Verlag London Limited 2011
260 J.I. Curry
a
Large intesine (colon)
Small intesine (ileum)
Appendix
b
Large intestine (colon)
Small intestine (ileum)
Appendix
FIGURE 28.1. (a) normal ileo-caecal region, (b) appearance during intussusception.
intestinal hemorrhage in children with Henoch–Schonlein purpura. 80% of intussusceptions involve a portion of distal ileum invaginating into the colon (ileocolic). Ileoileal, caecocolic, colicocolic and jejenojejunal intussusceptions are less common. The incidence if intussusception is approximately 2 per 1,000 children and is the commonest cause of bowel obstruction in children under 5.2
28.2 Presentation
While intussusception can occur at any age the incidence is greatest between 5 and 9 months. The winter months are the commonest time of presentation due to the higher rate of