Anaphylaxis: an allergic reaction

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

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

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

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

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

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.

Colostomy in Anorectal malformation

Colostomy means surgically created stoma through the abdominal wall for the passage of stool.

This is done in many congenital anomalies. To name some of them are anorectal malformation (ARM), Hirschsprung's disease, Necrotizing enterocolitis (NEC) etc. The colostomy in ARM is usually temporary i.e. until the definite anal passage is created in the perineum. Colostomy is done as a first stage in high and intermediate type of ARM.

The types of colostomy are loop colostomy and completely divided skin bridge colostomy according to the way it is created. It can be transverse or high sigmoid colostomy according to the sit. Transverse loop colostomy is simple and rapid to create so preferred in emergency situation. In addition, it leaves large part of the colon for reconstruction. However, majority of times, high sigmoid colostomy is all that needed. High sigmoid colostomy is easy to maintain for longer period and easier for giving a distal colonic wash which is required for definite management of ARM.

The complications of colostomy are skin excoriation, colostomy prolapse, colostomy stenosis, colostomy retraction and pericolostomy herniation.

The distal loop washes are given until the definite management of ARM. Just before the reconstruction, distal loopogram is done to delineate the anatomy, which is useful for the final surgical repair. Colostomy is closed in third stage after 4-6 weeks of final reconstruction.

Omphalocoele

Introduction:

External herniation of abdominal viscera through a central defect into the base of the umbilical cord.It is also called as Exomphalos.It can be minor exomphalos or major exomphalos according to defect size & contents.Umbilical cord is inserted into the crown of covering or sac.Incidence is 1-5,000-10,000 live births.

Etiology:

Because of failure of migration and fusion of cranial, caudal and/or lateral folds because of which there is failure of intestines to return into abdominal cavity.

Associated Congenital Anomalies: 75-80%

trisomy 13, 15, 21
cardiac anomalies
craniofacial
gastrointestinal
Beckwith-Wiedeman Syndrome
Pentalogy of Cantrell
Epigastric omphalocoele
Sternum cleft
Diaphragmatic defect
Ectopia cordis
Cardiac anomaly

Survival: 20% with heart disease
70% without heart disease

Treatment:

1.surgical repair of defect in minor type after repositioning of abdominal contents
inside the cavity.
2.In major type more conservative approach towards slow and continuous
reduction of contents by traction.

Hirschsprung's disease

Introduction:It is due to absence of autonomic ganglion cells in Auerbach's plexus of distal large intestine. It commences at internal sphincter and progresses for variable distance proximally. Lack of peristalsis causes colonic obstruction. It affects 1 in 5000 live births. Male : female ratio 4:1.75% cases confined to recto-sigmoid, 10% cases have total colonic involvement. 80% present in neonatal period with delayed passage of meconium followed by increasing abdominal distension and vomiting.

Symptoms:

Neonatal age:

1. Delayed Passage of meconium
2. Constipation
3. Progressive abdominal distension
4. Vomitings
5. Enterocolitis

Older child:

1. Constipation
2. Abdominal distension

Investigations:

Plain abdominal x-ray will confirm intestinal obstruction.
Barium enema - Contracted rectum, cone shaped transitional zone and proximal dilatation.
Anorectal manometry - No recto-sphincteric inhibition reflex on rectal distension
Rectal biopsy shows: Absent ganglion cells in submucosa, Increased acetylcholinesterase
cells in muscularis mucosa, Increased unmyelinated nerves in bowel wall.

Treatment:

Initial defunctioning colostomy to relieve obstruction & then definitive pull through procedure with excision of aganglionic segment.

Hookworm Infestation in Children

Two species of hookworms commonly infect humans, Ancylostoma duodenale and Necator americanus. These species are found throughout the tropics and subtropics.Most people who are infected are asymptomatic. The most significant risk of hookworm infection is anemia secondary to loss of iron into the gut.

Hookworm larvae emerge from passed eggs within 24 hours. Molt to an infective filariform larval stage in another 24 hours. After molting, larvae are able to penetrate intact skin. Walking barefoot in soil contaminated with feces - most common method of exposure.

After skin penetration, the venous circulation carries larvae to the pulmonary bed, where they lodge in pulmonary capillaries. Within 3-5 days, the larvae break through into alveoli & travel up from the lungs into the bronchi, the trachea, and the pharynx. Upon reaching the pharynx, larvae are swallowed and gain access to the GI tract. Once in the GI tract, worms attach to the wall of the intestine and begin to feed on the blood of the host. Chronic loss of blood and serum proteins leads to hookworm anemia and impaired nutrition.

Though rare, hookworm infestation should be suspected as a cause of gastrointestinal bleeding in infants in communities with a high risk of infestation. Prognosis is excellent with proper antihelminthic treatment.

Lymphangioma

Introduction: It is also called cystic hygroma. It arise as the result of abnormality of the development of lymphatic system.This is soft,multicystic, ill defined cystic mass that is brilliantly transilluminant

Sites: It can occur in any part of the body but the neck is the most commonest part. Other areas which gets affected are axillae,mediastinum, groin, and retroperitoneum.

Symptoms & signs: The presenting symptoms is usually soft, non tender swelling rarely evident at birth but may become evident as the child grows. The swelling may be subcutaneous deep or may be in the facial planes or in the muscular plane. There swelling is multicystic & cyst varies in size from macrocystic to microcystic in nature. The swelling is compressible & may be minimally reducible. It is brilliantly transilluminant.

Investigations:
Ultrasonography
CT scan/ MRI

Treatment:
1. Injection sclerotherapy: Aspiration of fluid & injection of sclerosants inside the cysts is the treatment advisable where the surgical excision is not possible.

2. Surgical excision: Excision of lymphangioms is the best form of treatment. This is benign lesion which can be excised without the margin of normal tissue. Wherever it is close to the vital structures, the cyst can be marsupilized, provided by all macroscopically abnormal lymphatics are removed.

Congenital Diaphragmatic Hernia

Introduction:

Congenital diaphragmatic hernia is a birth defect in which there is hole in a portion of diaphragm causing abdominal organs to go up in the thoracic cavity.This causes lung compression & respiratory distress in a newborn.

Incidence:

1 : 2000-5000 live birth
8 % of all major congenital anomalies
The cause of CDH is largely unknown

Prenatal Diagnosis:

Fetal USG shows stomach, intestines, liver, kidneys & spleen in the chest cavity
Abnormal position of certain viscera inside the abdomen
Stomach visualization out of its usual position
Intrauterine growth retardation
Polyhydramnios, Fetal hydrops

Clinical Presentation:

The newborn presents with severe respiratory distress

On examination:

Respiratory distress
Scaphoid abdomen
Auscultation of the lungs reveals poor air entry
Shift of the heart to the side opposite

Diagnosis:

Plain X-ray abdomen (erect) - shows the bowel loops in the thoracic cavity with compression of ipsilateral lung.

Ultrasonography of chest - will confirm the presence of the bowel & other viscera

2-D echo & Renal USG- To rule out associated cardiac & renal anomalies.

Management:

Mechanical ventilation
Nitric Oxide
Surfactant
ECMO
Surgery

Surgical management: By abdominal or thoracic approach the intestinal contents are placed in the abdomen & the hole in the diaphragm is sutured.

Juvenile Polyposis Syndrome

Introduction: Juvenile polyposis syndrome consists of three conditions, diffuse juvenile polyposis of infancy, diffuse juvenile polyposis & juvenile polyposis coli. These syndrome is characterised by multiple polyps in the gastrointestinal tract.

1.Diffuse juvenile polyposis of infancy: This occurs in first few months of life. The child presents with loose motions, blood in stool, protein loosing enteropathy, tendency for intussusception & hypotonia. On investigation, there are multiple polyps through out gastrointestinal tract. The treatment is keeping the baby nil by mouth & starting her/him on total parenteral nutrition.Once the condition stabilizes, then segmental resection. In spite of all the efforts, the prognosis of this condition is dismal.

2.Diffuse juvenile polyposis: This condition occurs at the age of 6 months to 5 years. The child presents with recurrent rectal bleeding & prolapse.There may be signs of malnutrition. The polyps are found in stomach, small intestine & large intestine including rectum. The treatment is either endoscopic polypectomies, open polypectomies and/or segmental resection. The prognosis is better though the need of long term follow-up for recurrence is high.

3. Juvenile polyposis coli: This is a genetic disorder with an autosomal dominant gene. The polyps are present in colon though mainly in sigmoid colon & rectum. The treatment is debatable as one school of thought is total colectomy, rectal mucosectomy & endoanal pull-through while other school of thought is endoscopic resection of polyps & regular colonoscopy. If one finds mucosal changes or dysplasia then resection is done.

In juvenile polyposis syndrome, the chances of development of carcinoma in later life is high even if the treatment is completed so the long term follow-up is mandatory.

Torsion of the testis

Introduction: Rotation of the testis on the spermatic cord causing interference with the blood supply is called torsion of the testis. It is an acute surgical emergency. If not operated within 6 hours, there can be irreversible damage to the testis.

Clinical presentation:
1. Painful swelling of the scrotum with redness
2. Onset is sudden
3. Lower abdominal pain
4. reflex vomiting

Diagnosis:
1. Clinically scrotum is red, tender
2. Doppler of testis reveal decreased blood supply in the affected testis

Treatment: Emergency surgery with derotation of testis and orchiopexy. At the same time other testis is also fixed (orchiopexy) as chances of torsion is high in contra lateral testis.

Differential diagnosis:
1. Epididymo-orchitis
2. Idiopathic scrotal edema

Choledochal cyst

Introduction: Choledochal cyst is congenital anomaly, where there is cystic dilatation of extrahepatic biliary duct, intrahepatic biliary duct or both.

Pathogenesis: Causative factors are

1.Congenital segmental weakness of the wall of biliary duct

2. Inflammatory degeneration of the wall of biliary duct (same as in biliary atresia)

Types:

Type I - Dilatation of entire or segment of common hepatic duct or coomon bile duct

a- Saccular

b- Fusiform

Type II - Diverticulum from common bile duct either sessile or pedunculated

Type III- Also called as choledochocele. Dilatation of intraduodenal portion of CBD

Type IV - Multiple cysts involving both intrahepatic & extrahepatic duct

Type V - Multiple cysts involving only intrahepatic ducts

Clinical presentation:

1. Abdominal pain

2. Mass in upper abdomen

3. Jaundice

Diagnosis:

1. Liver function tests

2. Ultrasonography of abdomen

3. Magnetic resonance cholangiopancreatography

4. Intraoperative cholangiogram

Treatment:

1. Excision of cyst & Roux-en-Y choledochojejunostomy

2. Excision of mucosa & anastomosis between side of the cyst & the jejunum

Tracheoesophageal Fistula

Introduction:

Tracheoesophageal fistula (TEF)is the congenital anomaly where there is abnormal fistulous connection between trachea & esophagus.The incidence of TEF is 1 in 2000-4000 live births.

Associated Anomalies:

Duodenal atresia
Down syndrome,
Ventricular septal defect

Age:

Congenital Tracheoesophageal fistula (TEF) present immediately after birth. H-type of fistula may present in neonates or in infancy.

Classification:

Type 1- Esophageal atresia with distal TEF - 87%
Type 2- Isolated esophageal atresia without TEF - 8%
Type 3- Isolated TEF-4%
Type 4- Esophageal atresia with proximal TEF-1%
Type 5- Esophageal atresia with proximal and distal TEF-1%

Symptoms:

1. Copious white frothy secretions comes out through mouth.
2. Coughing & choking while taking breast feed
3. Cynosis
4. increased respiratory rate

Diagnosis:

1. Plain X-ray chest shows coiling of infant feeding tube in mediastinum.
2. Stomach bubble is not seen in pure esophageal atresia
3. 2-D Echo- for associated cardiac anomalies
4. Ultrasonography of abdomen- to exclude renal / other abdominal anomalies

Treatment:

Thoracotomy, division of fistula & esophago-esophageal anastomosis is the primary line of treatment. If the child is premature with low birth weight & respiratory distress syndrome then one can do the staged procedures. Initially gastrostomy & esophagostomy. After stabilization primary repair. In pure esophageal atresia, initially gastrostomy & esophagostomy then esophageal replacement by gastric pull up,reverse gastric tube, colon transposition or ileal transposition.

Hypospadias

Introduction:Hypospadias is the congenital anomaly where the urethral opening is situated on the under surface of stomach instead of at the tip of the glance. In the fetal life there is aberration in the development of the urethral tube. Therefore, the development of the urethral tube is incomplete.

Types: The hypospadias may be distal & proximal or glanular, coronal, mid penile, proximal penile, penoscrotal & scrotal according to the site of urethral meatus.

Parts: Dorsal hood is formed by incomplete prepuce, chordee i.e.ventral curvature of penis, hypospadiac meatus, urethral plate. All or some components are present in any given case.

Investigations: The diagnosis is usually clinical. The more proximal hypospadias are evaluated to rule out intersex. In this context the descent of testes is important. If both the testis are fully descended then the possibility of intersex is less but if one or both testes are undescended then the possibility of intersex should thought of.

Management: The repair of hypospadias involves correction of chordee & formation of urethral tube. This can be done in one stage or in stages. There are many types of repair, Duckett's island prepucial flap, Byer's repair, Snodgrass (TIPS) repair are few of them.

Bladder calculus

Bladder stone is one of the common diseases children suffer from. The causes for this condition are many. The most important factor is infection. The stasis of infected urine gives rise to stone formation. The symptoms are dysuria, pain in lower abdomen, sometimes blood in urine, urinary retention etc. When one examines the child there will be slight tenderness in the suprapubic region i.e. lowermost central part of abdomen. This is because of bladder inflammation associated with bladder calculus.

Urine routine and microscopy shows pus cells indicating urinary tract infection. Plain X-ray abdomen shows bladder calculus in pelvic region if the calculus is radio opaque but if the calculus is radiolucent then X-ray will not show it. Ultrasonography of the pelvic region picks up these types of stones. It also shows the presence of cystitis & if there is any bladder outlet obstruction. Bladder outlet obstruction convincingly ruled out by doing micturating cystourethrogram (MCU). The dye is injected into the bladder by passing a small infant tube or bladder catheter. After injecting dye to fill up the bladder, the tube is taken out. The child is told to void and pictures are taken. If there is any bladder outlet obstruction like posterior urethral valves, it is immediately diagnosed. If it present, one has to deal with it along with removal of calculus.

Bladder calculus is removed by endoscopically (if the stone is soft and small) but majority of times it is removed surgically. The procedure is called as cystolithotomy. Through a small incision over the lower abdomen, the bladder is approached (after filling up with saline through bladder catheter), bladder is then opened, stone removed & bladder stitched back. The catheter is kept for 3-5 days after procedure.

Foreign body (FB) in stomach

Children in the age group of infancy to preschool age, has tendency to put anything in the mouth. In the older age group, the non-eatables are accidentally swallowed. The foreign body (FB) can be of two main types, sharp & blunt. Sharp FBs are commonly pins of any types & blunt FB are commonly coins.

The child usually has history of accidental ingestion of FB. The presentations ranges from asymptomatic i.e. no complaints to pin in abdomen, vomitings rarely distension of abdomen. The plain X-ray abdomen standing shows the radio opaque FB, the site, shape etc. If there are signs of perforation then gas under diaphragm. If the FB is blunt, seen in plain X-ray & child is not having any problem then laxatives & observation is recommended. The majority of times the FB passes in stool without any problem.

In case of sharp FB, one should not wait until symptoms appear. Further investigations like ultrasonography or CT scan is done. If the FB is in the stomach then it can be removed through the flexible gastroenteroscope while if it is the intestine then exploratory laparotomy to remove FB is recommended.

Sternocleidomastoid tumor of infancy

Sternocleidomastoid tumor of infancy is the most commonest neck mass found in perinatal period. The term 'tumor' is misnomer as the it is muscle fibrosis and not the tumor. The child usually present with a spindle shaped mass on the lateral aspect of the neck with restriction of neck movements (torticollis). The possible cause of Sternocleidomastoid tumor may be injury to the neck during delivery causing muscle injury and subsequent fibrosis.

It is commonly seen on right side, more in male children & in breech delivery. After clinical examination, ultrasonography is done to confirm the diagnosis. It arises from the middle or inferior portion of the lateral muscle of neck i.e. sternocleidomastoid muscle. The biopsy is not needed unless the USG shows different picture.

Treatment is conservative with physiotherapy of the neck. Passive movements of the neck allows mass to resolve by the age of six months. The indications for surgery are craniofacial asymmetry, persistent torticollis for more than one year and when physiotherapy fails.

Urethral Diverticulum

Urethral diverticulum is the bag like sac arises from male urethra can be classified as congenital or acquired and further be subdivided into posterior or anterior. Congenital diverticula of anterior urethra are very rare and typically occur at the penoscrotal junctions.They are usually wide-mouthed and the distal edge may act as a valve that can obstruct the urine flow.Etiological factors in congenital diverticula include intrauterine distal urethral stenosis; lesser degree hypospadiasis or congenital cystic dilatation of the normal or accessory periurethral glands.

These anomalies are rare with no genetic predisposition. The clinical presentation depends upon the age & degree of presentation. In neonatal & infancy, symptoms related to urinary infection predominate while in older children voiding problems are presenting complaints.Usually the diverticula are saccular, communicating with urethral lumen. They are present on the ventral aspect of the urethra and are of variable size. During micturition urine enters into diverticulum distending it resulting in the obstruction to the flow of urine, more so when anterior urethral valves are associated with it.

The diagnosis depends essentially on voiding cystourethrography, which must opacify the whole of the urethra. Retrograde urethrography is sometimes needed in case of a giant diverticulum. The treatment of the diverticula is excision with urthroplasty or if associated with valves then endscopic resection of the valves.

Posterior urethral valves

Posterior urethral valves are the commonest cause of urethral obstruction in male children. These valves are situated at the distal most portion of prostatic urethra i.e. proximal urethra causing the obstruction in the flow of urine. This results in dilatation of prostatic urethra.

Posterior urethral valves have various presentations. It can be diagnosed antenatally when the maternal ultrasonography is done. It shows bilateral hydronephrosis, an enlarged bladder & oligohydramnios. After birth, the child present with repeated urinary tract infections, dribbling of urine or straining during micturition.

The urine routine & microscopic examination shows the pus cells because of infection. The diagnostic investigation is micturating cystourethrogram (MCU), which is usually done after infection is treated with antibiotics. MCU shows dilated prostatic urethra. The treatment is cystoscopic valve fulguration

Use warm IV fluids & Blood especially in neonates & children with Thermal Angel

During major surgical procedures in neonates & children, to avoid the hypothermia, anesthesiologist prefers to infuse warm IV fluids or blood products. In adults, during resuscitation in major trauma or hemorrhagic shock, one needs to infuse the IV fluids & blood rapidly. These are some areas of use for Thermal angel. It is a portable, lightweight, disposable & battery powered device, which helps in warming the IV fluid/ blood products & thus preventing hypothermia.

Previously, IV fluids & blood products, used to make warm by dipping them into the hot water. It was time consuming in an emergency & there used to be no hold on the temperature. Apart from this, there are many warming technologies came into use.But compare to older technologies, thermal angel provides warm fluid within 45 seconds & it is safe to use. There is no complexity of instrument, no maintenance required & because of its lightweight it can be carried anywhere in the remote areas.

Thermal Angel Blood Warmer Details are it is safe to use with temperature control, quick to use within 45 seconds, easy to use because of simple instrument, easy to carry as it is lightweight & no maintenance required because it is disposable. Thus, truly speaking it is an ‘angel’, which will help in emergency.

Undescended Testis

Undescended testis means absence of one or both of the testes into the scrotum since birth. A doctor will detect it immediately after birth during complete examination of child or the parents usually notice this while bathing the child. There may or may not be a history of reducible swelling in the inguino-scrotal region indicating associated hernia. Apart from this, there are no other complaints.

On examination, the scrotum feels empty & undeveloped. The testis can be felt in the groin as a nodular structure slipping beneath the hand while doing gentle palpation in different positions like lying down or squatting position. This is called palpable testis. Some cases, the testis is not palpable in groin but can be found in other ectopic sites like perineum, root of the penis, medial side of the thigh or other side of the scrotum. These are called ectopic testis. In some cases, the testis is not palpable anywhere from groin to ectopic sites, then it may be in the abdomen on his descended route. This is called non-palpable testis.

The palpable testis are directly subjected for orchiopexy i.e. fixation of testis into the scrotum after mobilizing length of the cord through a groin incision. The non-palpable testis are subjected to further investigation to find out whether it is present or absent, exact position & size. Though ultrasonography, CAT scan or MRI imagings are done to look for this testis, the best investigation is diagnostic laparoscopy.

During the laparoscopy, one can trace the testis & at the same time bring back the testis into scrotum after mobilization. This can be done in one stage if the testis is not far away from the groin or in two stages if the testis is far away up into the abdomen.

Fissure-in ano

Blood in stool occur because of many causes. One of the cause is fissure-in-ano. Fissure in ano means cut into anal mucosa. This occur because of hard motion. When a child is suffering from constipation, he tries to pass the hard motion resulting into cut in anal mucosa. This may lead to bleeding while passing subsequent motion & severe pain. The child cries or tries to hold the motion because of fear of pain. It again leads to more constipation & the cycle becomes vicious. On examination, there is redness & fissure (cut) in the anal mucosa. The immediate treatment is oral laxatives to make the motion soft, local application of analgesic jelly & oral metronidazole/ ornidazole, dietary modification. Long term treatment is dietary modification. Diet should contain high fiber diet, green leafy vegetables, milk intake should be less & lot of water. It helps to make the stool soft. The junk foods containing bread, pizza etc should be avoided. Avoid spicy food & lot of milk. If the child is older, then let him/her play outdoor games, exercises & cycling which helps in regulation of digestive system. Once the cut heals, then even enemas or suppository helps in softening of stool. Remember, the diet change & regular exercise needs lot of motivation. If you are doing it, then child adopt it very quickly so you need to change yourself first if you want your little one pain free.

Acute Appendicitis

Acute appendicitis that is inflammation of appendix is common in school going children & less likely occur at preschool age. The child usually complaints of pain around the umbilicus or in the right side of the lower abdomen. There may be h/o bowel disturbances in the form of constipation or diarrhoea i.e loose motions. They refused to eat because of vomiting sensation (nausea). If it progresses then the child starts vomitings & fever. You should immediately see a surgeon as it requires immediate medical attention. On examination, there is pain after touching/ on pressure in right side of the lower abdomen as the hand touches the inflammed appendix. There may pain all over the abdomen in the advanced stage. The blood test reveals increased leukocytes i.e. white blood cells in the body. X-ray abdomen may be suggestive of some air fluid levels in right iliac fossa. Ultrasonography is not the diagnostic of appendicitis unless it is ruptured but it may rule out other pathology like kidney stones, ureteric calculi, adnexal pathology (female child) etc. Though early presentation may be cured with oral or intravenous antibiotics, the majority of children requires appendicectomy. It can be done either by open or laparoscopic method.

Hydrocephalus

Hydrocephalus is enlargement of head because of increase in cerebrospinal fluid in the brain. There is increased intra cerebral pressure because of enlarged ventricular system. The child presented with enlarged head circumference, vomitings and eye abnormality (Sunset sign). The hydrocephalus may be congenital i.e. from birth because of the obstruction in the CSF pathway (Congenital aqueductal stenosis) or it may be acquired because of bacterial or tuberculous meningitis. The CAT scan of the brain shows enlarged ventricles. Anterior cerebral artery index (Resistive index) shows there is increased pressure inside the brain. Brain cortex gets compressed. The eye examination reveals papilloedema suggestive of increased intra cranial tension. The treatment is ventriculo-peritoneal shunt (VP shunt), in which the CSF is diverted from brain to the peritoneal cavity with a shunt tube. Shunt tube is placed in the subcutaneous space over the anterior chest wall. In obstructive hydrocephalus, third ventriculoscopy & removal of aqueductal diaphragm by fogarthy catheter is curative treatment.

Anorectal Malformation or Imperforate anus

Anorectal malformation is a birth defect in which the anus and rectum do not developed properly. Anus is opening through which stool is passed and the rectum is the lowest part of large intestine just above the anus. When the child is born, he/she will have one of the following abnormalities

1. No anal opening

2. A membrane may be present over the anal opening

3. Misplaced anal opening

4. Anal opening near to the vaginal opening in female child

5. Stool is passed through by way of vagina, base of the penis or scrotum or urethra

6. Abdominal distension with no passage of stool in 24 to 48 hours after birth.

Commonly it is diagnosed at birth, when your doctor examines the baby or if the baby fails to pass stool in 48 hours or passes but through abnormal opening. There is no need to become scared, this is correctable deformity. If you are in the hospital, your doctor will immediately consult to the pediatric surgeon. If by any chance (in case of home delivery or delivery in remote areas), you need to consult nearest pediatric surgeon immediately. Like majority of birth defects, there is no particular cause for this defect also.It occurs in about 1 out of 5000 newborns. Boys are at a slightly higher risk than girls.

Along with the physical examination to check the patency of anus and other anomalies, some tests are performed to further evaluate problem:

1. Abdominal X-ray

2. Ultrasonography of abdomen

3. Echocardiography to rule out heart problem

As soon as the problem is detected, the child undergoes some necessary tests.Surgical reconstruction of the anus is the aim of treatment. In low variety, it can be done immediately without the need of colostomy. But in other severe variety initially temporary colostomy is needed before definitive operation.

Tounge Tie

Tounge tie should be suspected when child cannot protrude his tounge out of oral cavity as his tip of tounge is held back with a tight band on the undersurface of tounge. Tip cannot reach the palate.There is problem in speech & swallowing. If you see carefully a white band of tissue is seen on the undersurface of tounge which limits it's mobility. This problem should be diagnosed as early as possible. Otherwise, the child can loose his/her confidence because he may not be able to speak properly. This is not a major problem. You need to see a pediatric surgeon & under general anaethesia surgeon cuts the band. This makes the tounge free. This is day care surgery or require one night stay. The child may need to take 2/3 sittings of speech therapy after a week of surgical procedure.

Cleft Lip

Cleft lip is the congenital deformity wherein the newborn born with the deformed lip. There is cleft in the upper lip. It may on one side or both the sides. It may or may not associated with cleft in palate also. This is psychological shock to all family members as they do not expect to take home the child with an abnormality on the exposed part of face. But this deformity is fully correctable & after surgery your child is as normal as any other child. Do not get depressed. You see a surgeon who is specialized in pediatric surgery or plastic surgery. Usually the repair is done at the age of 3 months when the child gains satisfactory weight, his/her Hb% are above 10 gm%. 10 kg/10weeks/10 gm% haemoglobin is the usual formula. The child with only cleft lip does not have any problems with sucking/ swallowing so breast feed can be continued. The aim of surgical treatment is to produce a intact lip with minimal or no cosmetic deformity, normal speech & normal dentition.The procedure is done under general anaesthesia.

Congenital Inguinal Hernia/ Hydrocele

Congenital inguinal hernia or hydrocele is because of the patent processus vaginalis. Processus vaginalis is the tract, which extends from groin to the scrotal sac. After birt, this tract gets fused. If this processus vaginalis remains patent then hernia or hydrocele develops. If the tract is wide enough to allow the intestines then hernia develops but if the tract is narrow which allow only fluid then hydrocele develops.

In case of hernia, the parents usually notice the bulge limited to the groin or extending into scrotal sac. This swelling comes after straining, crying, jumping, playing & reduces spontaneously or after lying down. It is not painful. In case of hydrocele, the swelling is limited to the scrotum & it does not reduces.The size remains almost same.

The diagnosis is by simply clinical examination and does not require any special test.

The management of hernia and hydrocele differs.In cases of hydrocele, one can wait till one year of age as there is chance of spontaneous regression while in case of hernia, the child needs to be operated as early as possible as there are chances of obstruction. The best person to treat this type of cases is the surgeons who are specialized in paediatric surgery.The operation can be done as a day care surgery or will require one day hospitalization. It is done under general anaesthesia and the child can be fed 4 hours after surgery.