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A child with cystic fibrosis developed the meconium ileus equivalent in the postappendectomy period. This problem has not been emphasized in patients with cystic fibrosis. Operative evacuation only partially relieved the obstruction. Transient upper gastrointestinal bleeding fortuitously produced beneficial effect, which completely resolved the persisting ileus.

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In a retrospective study of 300 children who underwent placement or revision of cerebrospinal fluid (CSF)-peritoneal shunts during a 10-year period, 15 (5%) developed shunt-related abdominal complications with ventricular sepsis and two developed acute perforated appendicitis. Abdominal complications and associated shunt infections suggested two potential modes of development: (1) descent of contaminated CSF from an infected shunt into the abdomen (CSF ascites--four patients, CSF pseudocysts--four patients, and shunt-induced abscess/peritonitis--five patients); and (2) ascent of bacteria into the shunt from an abdominal source (visceral perforation by the shunt catheter--two patients and acute perforated appendicitis--two patients). Three types of shunt systems were placed during the study period; five of the seven (71%) most serious septic complications were associated with the use of Raimondi spring-reinforced catheters. Bacteria isolated in this series were associated with differing modes of sepsis: those involving descent of bacteria into the abdomen from an infected shunt were predominantly gram-positive, cutaneous microorganisms, whereas those associated with ascent of bacteria from the abdomen into the shunt were mixed, gram-negative intestinal microorganisms. Appendicitis did not result in shunt infections. Aggressive treatment resulted in no operative or complication-related deaths. Removal of the shunt catheter from the abdomen and intravenous antibiotics were essential for eradication of sepsis; laparatomy was required only for cases with suspected peritonitis. In eight of the 17 (47%) patients, reestablishment of CSF-peritoneal shunts was performed after resolution of shunt-related complications. In recent years improved shunting materials and supportive care have reduced the incidence of the most serious of these complications.

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Midgestation ovine fetal thyroidectomy resulted in profound congenital hypothyroidism and severe respiratory distress at term. Amniotic fluid obtained at delivery revealed low lecithin: sphingomyelin (L:S) ratios in all animals with a predominantly acidic phosphatide pulmonary phospholipid profile. Surfactant was diminished in the lung effluent of cretins at birth as compared with normal lambs. The acidic phosphatides and low L:S ratios persisted in the pharyngeal aspirates of the cretin lambs following attempted air breathing and the onset of severe respiratory distress. Conversely, normal lambs released considerable surfactant at birth that contained nonacidic phosphatides dominated by dipalmitoyl lecithin and yielding strongly positive L:S ratios. Comparative histologic studies revealed poor alveolar differentiation in certain lambs and persistence of the midgestation canalicular stage of lung development.

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The present report is a retrospective review of 23 patients admitted to the University of Kentucky Medical Center during 1975 and 1976, selected because they had sustained renal trauma as ascertained by hematuria, intravenous pyelography (IVP), or operative intervention. The value of IVP was determined by the patients' eventual hospital course. Of five patients with penetrating injuries, all had hematuria and an intravenous pyelogram on admission. One of these patients did not require an operation. Among the 18 patients with blunt abdominal trauma, six of the 14 patients who had hematuria and an IVP on admission were spared operation. Four patients did not have hematuria, but all four had a renal lesion. Two of these patients required an operation: one for inspection of a traumatic left nephrectomy; the other for bilateral renal artery occlusion, successfully repaired after 16 hours. Whenever feasible all patients sustaining abdominal trauma should have an IVP regardless of whether or not hematuria is present.

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This is a report of the fourth known case of intramural TEF with diaphragmatic esophageal atresia. These patients present clinically as a typical esophageal atresia with tracheoesophageal fistula, but in effect have the following unusual features: 1) high TEF entering the trachea in the neck; 2) diaphragmatic-type atresia of the esophagus with uninterrupted muscular coat; 3) the location of this diaphragm is at the level of the carina producing in effect a long intramural fistulous tract. It is believed that faulty recannulization of a segment of the esophagus in association with H-type TEF may explain this uncommon anomaly.

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Diagnostic barium enema is not a substitution for well executed physical examination, and its use should be reserved only for obscure situations. An abnormal roentgenogram provides valuable information, since the fear of missing acute appendicitis in these children is minimized. When normal, this diagnostic test may bring to early operation those with minimal symptoms or unusual presentations, thus avoiding the possibility of prolonged observation and perforation. In children with known associated severe medical maladies, diagnostic barium enema can serve to reaffirm the diagnosis prior to the hazardous operative intervention. It may also eliminate the need for operation in those conditions which mimic acute appendicitis. The use of diagnostic barium enema in the past three and a half years significantly improved our diagnostic capabilities in children with abdominal pain. There was a corresponding reduction in the number of normal appendixes removed. The efficancy and, above all, the safety of this procedure make it a valuable diagnostic aid in the care of children.

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Knowledge of the embryonic developments of the umbilicus and its contents assists the physician in correctly assessing the various anomalies found in this area. Although some will require specialized facilities and care, the majority of these anomalies can be corrected by simple operative means.

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Serious complications of ascariasis are varied and occur at all stages of worm development. The acute condition within the abdomen heralds the presence of intestinal, pancreatic, or biliary tract obstruction secondary to the physical presence of the adult parasites. Larvae may be responsible for acute respiratory disease, either as a direct allergic phenomenon or as a pneumonic infiltrative process secondary to fellow traveler bacteria. Deposition of ova in the liver allows for intrahepatic and pericholangitic abscesses with resultant parenchymal destruction and scarring. Though primary therapy is medical, specific indications for surgical intervention are discussed. These unusual but life-threatening sequelae are typified in the case presentation of a critically ill child.

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Twelve children with abdominal complaints had lymphoid hyperplasia of the bowel presenting in an acute or chronic form. The etiology is obscure. An infectious process is thought to precipitate the acute form of the disease. Parasites were identified in two patients with the chronic disease. The acute form, with involvement of the appendix or terminal ileum, presents commonly as acute appendicitis. Because of its self-limiting nature, appendectomy with perservation of the terminal ileum is appropriate. When intussusception is present, resection of the ileum is advisable. The chronic form, which is also common in the terminal ileum, produces disabling symptoms, recurrent intussusception, chronic anemia, and weight loss and is, therefore, amenable to surgical resection.

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A 10% soybean oil emulsion (Intralipid) has been demonstrated to be an effective means of delivering an adequate caloric intake via a peripheral vein. This emulsion has generally been considered safe and free of significant complications. This is a report of a child who initially thrived on this intravenously administered fat emulsion, then suddenly developed a lifethreatening intolerance to the infusion, which appeared to be the "fat overload syndrome." This syndrome, seen frequently with earlier fat emulsions, has not been reported previously as a complication of the 10% soybean oil emulsion.

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The results of the surgical correction of congenital duodenal anomalies in infants free of severe prematurity, mongolism or other intestinal anomalies are most favorable. Several uncommon defects involving the second part of the duodenum, which required special attention to the anatomic proximity of the ampulla of Vater and the terminal portion of the common bile ducts have been encountered. The recognition of this intimate relationship may prevent inadvertent injuries to these structures, further improving the results of operative procedures for these difficult congenital malformations.

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Three children had eosinophilic infiltration of the gastrointestinal tract. This entity has two forms--diffuse and circumscribed. The diffuse lesion is confined mainly to the gastric antrum. Surgical resection of this form is seldom necessary. Involvement of the appendix with this form has not been previously described. The polypoid lesion, which may arise in any segment of the gastrointestinal tract, commonly produces secondary gastrointestinal symptoms and is amenable to local surgical excision.

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The accuracy of diagnostic peritoneal lavage is compared to that of initial clinical evaluation in 46 pediatric patients with blunt abdominal trauma. The peritoneal lavage accuracy was 97.8%; the clinical accuracy was 71%. The use of a specially prepared 14-gauge trocar has made this technique safe for even very small children. The reliability and safety of diagnostic peritoneal lavage in this as well as in other series suggests that nonoperative or expectant treatment of the patient with blunt abdominal trauma can be safely substituted when peritoneal lavage is negative.

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Two children with unusual infiltration of the ileocecal valve by lymphoid tissue are described. The large filling defect identified on barium enema may suggest a number of conditions. Operative resection will exclude the possibility of a malignant process and will reduce the chance of recurrent intussusception.

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Twelve children with acute abdominal pain, which was suspected of being acute appendicitis, were subsequently found to have lower lobe pneumonia. Diagnostic barium enema or operative exploration failed to demonstrate any appendiceal abnormality. The abdominal symptoms and the ileus subsided soon after the initiation of antibiotic therapy. Contrary to common belief, it was observed that left-sided pneumonia is capable of mimicking appendicitis almost as frequently as right-sided pneumonia. Since the likelihood of acute appendicitis accompanying pneumonia is small, operative intervention is rarely indicated and should be undertaken only after careful and intensive investigation.

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