Right retrocolic intrasaccular duodenum: Is it a novel variant of isolated duodenal nonrotation? A case report

Background: Almost all of the studies on anomalies of the midgut rotation and fixation in the literature and related sections in textbooks were designed according to Dott's classification. Focusing only on common rotation anomalies has led to the exclusion and neglect of other rare variants. Isolated pure duodenal nonrotation is such a variant. Case Presentation: We report a case of an unusual form of isolated pure duodenal nonrotation, in a 3-day-old newborn presenting with bilious vomiting. Ultrasonographic examination revealed the sign of 'whirlpool'. When this finding was evaluated together with bilious vomiting, midgut volvulus was considered and the patient was operated on urgently. Peroperatively, it was observed that the jejunum entered between the leaves of the terminal ileum mesentery. Proximally, the duodenum was located posterior to the right colon in a "sack". This "sack" was surrounded by thick Ladd's bands laterally, mesentery of the ascending colon medially, the posterior surface of the cecum and ascending colon anteriorly, and by the posterior abdominal wall posteriorly. Conclusion: In isolated duodenal nonrotation, the duodenum may be completely retro-colic. Consequently, the duodenojejunal junction and the ileocecal region may almost overlap. Unlike isolated duodenal nonrotation cases, in the surgical treatment of this variant, separation of Ladd bands alone is not sufficient, additionally, the right colon should be placed in a nonrotation position and care should be taken not to kink the terminal ileum under the cecum.

P082 Appendicular syndrome revealing Kawasaki-like syndrome: a case report

Background With the wide spread of the current SARS-CoV-2, It was found that about 2% of children was affected according to several studies, However, a small number of children with Covid-19 develop a significant systemic inflammatory response similar to Kawasaki disease, a new disease entity called multisystem inflammatory syndrome. Methods A 12-year-old child, without a notable pathological history, who presented to the emergency, during the SARS-CoV-2 pandemic, for management of a pseudo-appendicular syndrome. Our patient was initially assessed by the surgical team due to his query acute abdomen. The pain had been evolving for 3 days associated with several episodes of bilious vomiting in a context of fever at 38.5°. Abdominal examination noted abdominal tenderness and defence. Extradigestive signs were not reported, The Lab Testing objectified a CRP at 235, elevated white blood cells at 18 180, an abdominal ultrasound was requested returning without particularities. Faced with the persistence of bilious vomiting, surgical exploration was indicated objectifying a catarrhal appendix. A pediatric opinion was requested, the clinical examination shows conscious child who presents infra cervical lymphadenopathy with a fever at 38 associated with an erythematous skin rash on the back and aseptic conjunctivitis. The Lab Testing objectified an important inflammatory syndrome, a acute kidney and heart failure a Covid 19 serology was requested with positive IGG, négative IGM, PCR covid test was negative, given the unavailability of In immunoglobulins, the treatment was based on corticosteroid bolus then relay by oral corticosteroid associated with an anti-inflammatory treatment, gastric protection by proton pump inhibitors, treatment of heart and acute kidney failure. The evolution was marked by clinical and biological improvement Discussion Coronavirus 2 (SARS-CoV-2) infection among children and adolescents, is mainly responsible for mild respiratory symptoms, in contrast to the severe forms reported in adults [7]. A systemic inflammatory syndrome mimicking kDa, temporally associated with infection with SARS-CoV-2 (Kawa-COVID-19) has recently been described as a serious illness sometimes requiring intensive care (44%). The median age is older (> 5 years), the frequency and severity of myocarditis are very different from classic kDa, abdominal pain and/or diarrhea were more frequently (81%) reported than in classic kDa, heart failure, pneumonia, neurological and renal impairment, associated with elevated CRP, hyperferritinemia are more common in Kawasaki-Like syndrome [10]. Some investigations must be systematically realized urgently to diagnose potentially fatal complications. These include testing for myocarditis, patients should benefit from careful monitoring and treatment with IV Ig 2 g/kg should be administered rapidly and seems to be effective in the majority of cases, associated anti-inflammatory therapy, such as steroids is necessary Conclusion Pediatricians should be aware of these atypical presentations of COVID-19 infection for early diagnosis.

Low incidence of surgical pathology in infants with bilious vomiting

Background: Bilious vomiting in the neonate is an important presenting sign of intestinal obstruction. We conducted a review of the presentation and management of term neonates admitted with bilious vomiting (BV) to determine the incidence of a surgical pathology in our population. Design: Retrospective cohort study using a prospectively maintained database. Participants: All term infants admitted to NICU with BV at the Royal Women’s Hospital Melbourne during a 5-calendar year period. Results: All 153 babies had at least one imaging study. 128 (83.7%) had plain abdominal radiographs. 127 (83%) underwent upper gastrointestinal contrast scan (UGI) and 103 (67.3%) had both. 6 (3.9%) UGI studies were abnormal, with 3 babies (1.9%) subsequently having surgical pathology (2 volvulus, 1 Hirschsprung disease). Only 6 (3.9%) babies in our cohort had a surgical pathology identified (4 Hirschsprung disease, 2 malrotation). Babies with surgical pathology were more likely to present later (median 40 hours versus 23 hours). Abdominal distension was highly sensitive for surgical pathology. Conclusion: The incidence of surgical pathology in this cohort was low compared to other studies. It is more likely in infants presenting with BV after 24 hours.

Intraluminal pyloric duplication cyst- a rare cause of non-bilious vomiting in a neonate: A case report

Background: Duplications of the alimentary tract are rare congenital malformations, out of which, true pyloric duplications constitute only 2.2%. They present with non-bilious vomiting and mimic hypertrophic pyloric stenosis (HPS). Pyloric duplications that are intraluminal are not separately visible at laparotomy, making their diagnosis difficult. Case presentation: Our case is a neonate with an intraluminal pyloric duplication cyst who presented with recurrent vomiting. The radiological evaluation suggested a duplication cyst medial to the second part of the duodenum towards the stomach’s lesser curvature with features of gastric outlet obstruction. Intraoperatively, a cystic mass of 1 x 2 cm intraluminally was found on opening the pylorus which was excised and pyloroplasty was done. Postoperatively the baby was discharged in a stable condition. Conclusion: Intraluminal pyloric duplication cysts are rare and the clinical presentation mimics HPS. They should be considered as a differential diagnosis in a neonate presenting with features of gastric outlet obstruction.

Enterobius vermicularis infestation causing terminal ileal gangrene

Enterobius vermicularis is one of the most common nematode infestations seen worldwide. This condition is commonly seen in children. Although asymptomatic, they present with symptoms of perianal itching commonly at night with perianal excoriations. In this case report we present a case 79 years old man with multiple co-morbidities who presented with non-bilious vomiting and severe abdominal pain. Emergency laparotomy was performed during which terminal ileal gangrene was noted. Ileo-caecal wall revealed multiple parasites (enterobius).

Pseudo-Bartter Syndrome as an Atypical Presentation of Intestinal Malrotation: A Case Report

Intestinal malrotation is a congenital intestinal rotation anomaly and can present with various symptoms. Electrolyte disorders are very common in childhood. Pseudo-Bartter syndrome (PBS) is one of the conditions that causes electrolyte disorders and can be seen due to intestinal malrotation in children.A 3.5-month-old boy who was diagnosed as having malrotation is reported. The patient had PBS because of non-bilious vomiting. We could find only two reports on PBS related to malrotation. It is emphasized that intestinal malrotation should be considered in patients presenting with gastrointestinal symptoms such as vomiting, abdominal pain, and also PBS.