Umbilical fistula in infants: causes and stages of the disease, as well as treatment methods. Treatment of paraproctitis in newborns and children
Paraproctitis is a disease that occurs in men aged 20 to 50 years. However, although it is rare, it also occurs in babies some time after their birth. Today medicine has everyone possible methods, with the help of which this unpleasant pathological phenomenon is completely cured. The sooner parents seek qualified medical help, the faster the young child will recover.
So, what contributes to the development of this abnormal phenomenon in a baby, what you need to know about the disease, and what features of the treatment of paraproctitis in infants will be discussed in this article.
Paraproctitis
– a disease that affects fatty tissue lower rectum (sphincter area). In newborns and infants The disease most often occurs in two forms:
- Spicy.
- Chronic.
In addition, in the case of abscess formation, paraproctitis is determined by its location:
- Subcutaneous.
- Ischiorectal.
- Submucosal.
- Retrorectal.
- Pelvic-rectal.
As shown medical practice, the most common form of the disease in children is the acute subcutaneous form. The remaining varieties are observed very rarely.
According to medical statistics:
- 66.6% of children from birth to 14 years of age were ill acute form.
- 33.3% – chronic.
At the same time, children under 6 months make up about 60% of the total number of those who have recovered from the disease.
For purulent paraproctitis:
- 62% – from 0 to 6 months.
- 20% – from 6 to 12 months.
Of the total number of patients, 95% are boys. This is due to the fact that in girls the pressure in the rectum is lower, so the risk of infection is negligible.
As you can see, after the first year of life, the likelihood of contracting this disease decreases significantly.
Why do young children suffer from paraproctitis?
In infants and adults, the disease is provoked by the same factors. Initially, the infection affects the rectal sinuses (crypts) or glands. Then the acute inflammatory process spreads to the cells of the anal area. Further damaged tissue begin to peel off from healthy ones, which contributes to the formation of an abscess (abscess).
In the absence of timely treatment, the abscess can spontaneously open either outward or in subcutaneous tissue, as a result, a fistula is formed.
Paraproctitis in a child
Factors contributing to the appearance of paraproctitis in newborns:
- In adults the disease is caused coli, in children - staphylococci.
- Irregular structure of the anal glands.
- Frequent stools, which is typical for newborns.
- Obstipation is a common phenomenon in children under one year of age.
- Imperfect immune system.
- Availability .
- Transmission of respiratory diseases.
It is worth emphasizing that any infectious agents present in the baby’s body, for example, the presence of tonsillitis or sinusitis, can also provoke the disease. However, the most common cause of pathology is intestinal bacteria.
Symptoms of the disease
The course of the disease in young children is exactly the same as in adults, but with some peculiarities. Besides this, her symptomatic picture It also depends on what form of the disease manifests itself: acute or chronic.
Acute form
For acute paraproctitis characterized by a sudden onset, and its symptoms have a pronounced intensity, depending on how advanced the disease is, its location, the size of the inflammatory focus, the type of infection and the state of the protective properties of the small organism.
In the acute form, the symptoms of paraproctitis in a child under one year old are characterized by:
- Fever.
- Chills.
- Diarrhea or.
- Heat(up to 39 degrees).
- Incorrect functioning of the urinary system.
- Pain when urinating.
- Weakness.
- Headache.
- Purulent discharge from the rectum.
- Soreness in muscles and joints.
- Pain in the rectum and pelvis, which increases during bowel movements.
Fistula in the anus of a baby photo
It is the manifestation of the latter symptom that indicates the development of this disease in the child. Paraproctitis in the child in the photo above has clearly defined symptoms.
It is also worth emphasizing different shapes diseases manifest themselves with some differences, e.g. With subcutaneous paraproctitis, the following anomalies are observed:
- Swelling.
- The presence of seals near the anus.
- Redness of the tissue in the sphincter area.
- Pain on palpation.
- Inability to assume a sitting position.
- The inflammation is quite pronounced.
In the pelvic-rectal form, it is much more difficult to diagnose the pathology, since inflammation develops inside the pelvis, and its symptoms are general.
Often parents cannot determine the cause painful condition baby and attribute his anxiety and whims to a respiratory infection. However, treatment with anti-cold medications does not provide positive result. The child's condition worsens, and the course of paraproctitis becomes more complicated.
In some cases, the baby's condition may suddenly improve and the temperature may return to normal. However, it begins from the rectum abundant leakage of pus with blood particles, which indicates independent rupture of the abscess into the intestine.
Ileorectal form of paraproctitis in initial stage in small children it is detected in isolated cases, while the disease of this form proceeds secretly in the first days, and only after a week can characteristic signs appear:
- Redness of the skin.
- Tissue swelling.
- Incorrect (asymmetrical) size of the buttocks.
Note to parents: Under no circumstances should you open an abscess on your own or engage in any therapeutic measures. This is dangerous development chronic form and various serious complications.
Chronic
Under no circumstances should you open an abscess yourself.
With this form, the presence of a fistula canal is noted, as well as two openings in it: external and internal.
Depending on their location, fistulas are:
- Full (opens into the rectum and onto the skin).
- Incomplete (open, that is, they extend to the skin, but do not affect the rectum, but end in the fat layer).
Some doctors believe that fistulas in young children are congenital anomaly. After infection gets into them, incomplete fistulas transform into complete ones.
Chronic paraproctitis in newborns is indicated by the presence of a fistula tunnel. At the time of exacerbation of chronic paraproctitis, its symptoms are similar to the acute form, but are much milder, and periods of its exacerbation are quite active.
In some cases, the fistula may close spontaneously and not appear for a relatively long time.
Komarovsky about the disease
Komarovsky about paraproctitis in infants: in case of abscess formation, urgent surgical intervention. After the operation you should carefully adhere to the rules of personal hygiene, which will help avoid relapse of the disease, and also be sure to consult with a pediatrician, surgeon or pediatrician about further treatment measures.
Komarovsky for paraproctitis In children we strongly advise:
- Apply Glycerin suppositories which have a complex effect.
- Surgery is the most the best option getting rid of the disease.
- Do not treat the child yourself in any way.
- Although the disease is not fatally serious, it can provoke a number of complications that are life-threatening to the baby.
Treatment of paraproctitis in young patients
Treatment of paraproctitis in infants without surgery is possible, only in those episodes if the disease has not acquired advanced stage. In this case Doctors recommend conservative therapy, which prescribes:
- Antibiotics.
- Ichthyol ointment.
- Rectal suppositories.
- Vishnevsky ointment.
- Microclysters.
- Ultraviolet radiation.
If all these measures do not produce a positive result, emergency surgery is prescribed.
Photo of paraproctitis
If a fistula tract is detected important point is the treatment of paraproctitis in children and preventive measures aimed at preventing infection by bacteria. For this purpose, the doctor recommends:
- Careful hygiene of the anal area.
- Timely elimination of feces and its residues after each act of defecation.
- Sitting baths with a weak solution of potassium permanganate.
- For newborns, bathing 2-3 times a day is recommended, and also with the addition of potassium permanganate.
In most cases, the above measures are quite sufficient and surgical intervention is cancelled. However, if conservative treatment does not give the expected effect, then surgical method is performed after the fistula tract has fully matured, which can finally form only by the child’s second birthday.
During the operation, the fistula tract and scar tissue are removed, or the scars are excised with further ligation of the fistula tunnel. As a rule, after surgery there is a complete recovery.
Conclusion
If you suspect your baby has it, do not self-medicate and especially do not use folk remedies. All these experiments can lead to unexpected disastrous results.
Paraproctitis, like any other pathology in children, can only be treated under the supervision of a pediatrician. The sooner it is appointed effective therapy, the faster the child will recover.
Among surgical diseases in children early age, pathologies of the umbilical ring occupy one of the leading places. Navel fistula occurs in children at an early age; it is dangerous for its development various complications. In order to eliminate the anomaly, it may be necessary surgery, and carried out on an urgent or emergency basis.
If we talk about older children and adolescents, their umbilical fistulas are usually a consequence of surgical interventions, inflammatory processes of the anterior abdominal wall and navel, suppurative pathologies, and to eliminate them you also need surgery, eliminating the affected tissue, the suppurative process and suppressing inflammation. It is carried out in a hospital under general anesthesia.
What does an umbilical fistula look like - types of umbilical fistulas in newborns and older children
Umbilical fistula in newborns or older children is surgical pathology, which looks like a pathological opening connecting the navel area with various internal organs - most often, intestinal loops. But there may be communications with other organs and tissues.
Outwardly, this anomaly looks like a non-healing and constantly weeping wound in the navel area, from which, with the slightest movement or pressure, liquid oozes.
Video: What is the best way to treat a newborn's navel?
According to their structure, navel fistulas can be:
- Incomplete fistulas when there is suppuration of the wound and weeping processes, discharge, but there is no flow of intestinal contents (or the contents of another organ).
- Complete fistulas– with them, the wound constantly becomes wet and the skin around it is sharply irritated; intestinal contents may be discharged through the hole from the place where the intestines are connected to the navel.
It is important to understand that umbilical fistulas are clearly an abnormal phenomenon, a pathological communication between organs, and they can be eliminated only by surgery, there are no medications or other non-surgical treatment methods. All that is necessary is complete excision of the fistula tract with a scalpel.
Types of fistulas in the navel in children of different ages
An umbilical fistula is a pathological canal that connects different cavities of the baby’s body with the external environment:
- In the newborn period this is usually birth defect development if something went wrong during pregnancy.
- But it is also possible to educate and acquired fistulas, which are formed against the background of previous operations or an inflammatory process.
Incomplete, complete navel fistulas in newborns and older children - causes of navel fistulas
Usually, umbilical fistulas are detected in newborns during the first weeks of life.
- Causes of formation of incomplete umbilical fistula During early childhood, the connective tissue bridges closing the end opening in the area of the vitelline duct become non-overgrown - this is the opening that was needed in utero to feed the baby through the umbilical cord. In other words, an incomplete umbilical fistula refers to the completely unobliterated urinary and vitelline ducts, which were organized during pregnancy inside the umbilical cord for the full development of the fetus. Similar condition It is not uncommon among newborns, and in the absence of any complications or inflammatory processes, it can resolve on its own within six months.
- If it's a complete fistula, then the hole is not completely closed, a connection is formed between the intestine and the navel (or other organs and the navel). The contents of the intestine or organ flow out through the formed pathological channel. Such an anomaly cannot close on its own, creates a risk of infection of the abdominal cavity and skin, and there is a high risk of complications. It is important to perform surgery to eliminate the fistula (excision it) as soon as possible.
Depending on the factor where the outlet (edge) of the fistula canal is located, fistulas can be divided into internal And external.
In older children and adults, umbilical fistulas are usually associated with long-term, severe and persistent inflammation in the anterior abdominal wall. In addition, they can develop in the area of the opening with the release of purulent masses through the area of the umbilical wound. In the navel area, mucous membrane may be found that bleeds and forms the lining of the pathological fistulous tract.
Variants of umbilical fistulas in children, their features
The most common types of fistulas in childhood are umbilical And umbilical-vesical fistulas This is a pathological anastomosis between the umbilical wound and the intestines, or the umbilical wall and the bladder.
Their origin in newborns varies somewhat; let’s discuss the main points.
Umbilical-intestinal fistulas, or they are also called bile duct fistulas, can form due to the fact that at birth, after cutting the umbilical cord, bile duct not obliterated. In such children, the umbilical cord remnant falls off late, after which the fistula opening occurs, inside which the sharply red mucous membrane lining the fistulous tract is visible. On examination, fluid oozes from it. If this is a complete umbilical-intestinal fistula with a tract opening in the intestinal wall, it may discharge feces, if incomplete, yellowish ichor oozes from it.
Often a complete fistula of this type complicated by serious inflammatory processes in the navel itself, children lose weight and lose a lot of weight. There is also a high probability, therefore, if such anomalies are detected in a baby, immediate surgery is indicated. In case of an incomplete intestinal fistula, a wait-and-see approach is indicated; often it gradually heals on its own, without intervention.
Vesico-umbilical fistulas
develop when the urinary tract is not closed, while they are outwardly similar to the previous ones, but drops of urine are periodically released from the opening of the fistula when the child strains. If the child is not particularly worried and does not cry, urine leaks in droplets, and with strong screaming and tension in the abdominal wall, even streams may be released. If this - big size fistula, urine may flow through it instead of the urethra.
Methods for diagnosing umbilical fistulas: examination of a child
Today it is possible to make a preliminary diagnosis of such an anomaly even before the baby is born, when ultrasound examination fetus in late dates pregnancy.
In addition, an umbilical fistula can be detected at birth, after cutting the umbilical cord, or during the initial medical examination of a newborn after his birth.
It is possible to accurately determine the presence of a fistula, determine its exact size and location, features of its course - or to refute the diagnosis - when Abdominal ultrasound and implementation fistulography.
You can also use the method probing the fistula tract to clarify the diagnosis. If special device– the probe is passed inside the tract a few centimeters, then the diagnosis is considered confirmed.
Treatment method for umbilical fistula in children
If this is an incomplete umbilical fistula, the doctor uses conservative tactics using a number of measures to stimulate healing:
- These include baths with a slightly pink solution of potassium permanganate, and lotions with it.
- Treatment of the navel fistula with a solution of hydrogen peroxide, as well as drying the edges of the tract using aniline dyes, is also indicated.
- Dressings with chlorophyllipt solution can also be used.
In most cases, shallow incomplete fistulas heal on their own in children during the first six months of life. If this does not happen, the fistula does not heal and becomes wet, then a planned operation is indicated.
It is important to understand that incomplete fistulas can be dangerous in terms of development possible complications– inflammatory processes and suppuration. To prevent inflammatory processes in the navel area, daily thorough treatment of the wound, the use of antiseptics and constant monitoring of the condition of the umbilical wound are necessary.
Complete umbilical fistula
Complete umbilical fistulas occur in cases where the vitelline duct remains open along its entire length. In this state the contents ileum excreted through the umbilical wound.
Clinic and diagnostics. In the case of an unobliterated vitelline duct, at the birth of a child, attention is paid to an abnormally thickened umbilical cord and a slightly dilated umbilical cord. ring. The fall of the umbilical cord is often delayed, and after this has happened, a fistula opening with bright mucous membrane and intestinal discharge is found in the center of the umbilical fossa.
In cases where the fistula is wide and long enough, if the child is worried, intestinal evagination may occur, accompanied by intestinal obstruction. Early cutting of the umbilical cord on the 2-3rd day of life in the case of a non-obliterated vitelline duct is often complicated by eventration of intestinal loops through a peritoneal defect in the umbilical fossa. An intestinal loop strangulated in the umbilical ring can become necrotic.
Diagnosis A complete umbilical fistula is not difficult and, in case of a wide fistula, it is placed on the basis of characteristic discharge. Fistulography is a valuable diagnostic technique.
Treatment. The only way to treat complete umbilical fistulas is surgery, which is performed immediately after diagnosis to avoid complications (evagination, infection, bleeding).
The operation consists of excision of the fistula tract along its entire length from the navel to the ileum using a laparoscopic approach.
Incomplete umbilical fistula
Incomplete umbilical fistulas are formed when the obliteration of the distal vitelline duct is disrupted and are observed much more often than complete ones.
Clinic and diagnostics. Scanty discharge from the umbilical fossa is typical, as a result of which children are treated for a long time for a “wet navel.” When an infection occurs, the discharge becomes purulent. Examination of the umbilical fossa reveals a pinpoint fistula opening with scanty discharge among the sparse granulations. To confirm the diagnosis, probing of the fistula tract is performed. If the button probe can be passed to a depth of 1-2 cm, the diagnosis of a fistula becomes undoubted.
Differential diagnosis must be made with umbilical fungus, which is characterized by the proliferation of granulation tissue at the bottom of the umbilical fossa due to infection and delayed epithelization.
Treatment incomplete umbilical fistula always begins with such conservative measures as daily baths with a weak solution of potassium permanganate, treatment of the fistulous tract with a solution of hydrogen peroxide and 3% tincture of iodine, bandages with antiseptics (1% solution chlorophyllipt). In case of ineffective conservative treatment, surgery is indicated starting from 6 months of age.
9. Developmental defects manifested by acute respiratory failure. Diaphragmatic hernia. Classification. Congenital lobar emphysema. Clinical and radiological picture. Pathanatomical substantiation of the concept of “asphyxial strangulation.” Medical tactics. Indications for preoperative preparation. Timing and methods of surgical correction of defects. Postoperative management.
Diaphragmatic hernia
Diaphragmatic hernia refers to the movement of abdominal organs into the chest through a defect in the diaphragm. Unlike other hernias, they do not always have a hernial sac.
In children, congenital hernias are mainly detected - malformations of the diaphragm. The incidence of diaphragmatic hernia varies widely - from 1 in 2000 to 1 in 4000 newborns; this does not take into account a large group of stillborns with malformations of the diaphragm.
Classification
The defect begins to form in the embryo at the 4th week of gestation, when the rudiment of the septum forms between the pericardial cavity and the body of the embryo. Underdevelopment of muscles in certain areas of the thoraco-abdominal barrier leads to the appearance of hernias with a sac, the walls of which consist of serous covers - the peritoneal and pleural layers. Such hernias are called true. At false In hernias, there is a through hole in the diaphragm, formed as a result of underdevelopment of the pleuroperitoneal membrane or due to its rupture due to overstretching.
Congenital diaphragmatic hernia:
diaphragmatic-pleural (false and true);
parasternal;
phrenopericardial;
hernias hiatus.
Acquired hernias are traumatic.
Most often in children, diaphragmatic-pleural hernias and hiatal hernias occur. Parasternal hernias are encountered much less frequently, and phrenopericardial hernias, in essence, can be considered casuistry.
Paresis of the diaphragm is a separate nosological form of the disease that is not included in this classification.
Diaphragmatic-pleural hernia
Diaphragmatic-pleural hernias can be either true or false. More often they are left-sided. False hernias on the right are observed very rarely. True hernias can occupy a limited part of the diaphragm, be large and complete. In the latter cases, when a high standing of the entire dome of the diaphragm with the absence of the muscle layer is detected, this type of diaphragmatic hernia is called relaxation of the diaphragm.
With false hernias, the defect in the diaphragm is most often slit-like, located in the costovertebral region (hernia
Bochdalek). As a result of the absence of a hernial sac in these types of diaphragmatic hernias, the organs of the abdominal cavity move into the thoracic cavity without restriction, which often leads to intrathoracic tension syndrome. A similar situation is typical for true hernias, when a high position of the diaphragm is noted.
Parasternal hernias
Parasternal hernias usually have a hernial sac and are divided into retrosternal and retrosternal-costal. These hernias penetrate into the chest cavity through a thinned section of the diaphragm in the anterior section (Larrey's fissure). A hernia that is located more to the right of the sternum is called Morgagni's hernia by some authors.
Frenopericardial hernia
Phrenopericardial hernia -* false hernia with a defect, dis- ! located in the tendon part of the diaphragm and the adjacent pericardium. Through this defect, intestinal loops can move into the pericardial cavity; sometimes the opposite phenomenon is possible - dislocation of the heart into the abdominal cavity.
Hiatal hernia
Hiatal hernias are divided into two large groups - paraesophageal and esophageal. Paraesophageal hernias are characterized by upward displacement of the stomach with its location next to the esophagus. In esophageal hernias, the esophagogastric junction is located above the level of the diaphragm. In this case, the degree of displacement of the stomach can be different and even change depending on the position of the child and the volume of filling of the stomach.
Associated defects
The severity of the condition and the severity of clinical manifestations are determined not only by the degree and volume of organs displaced into the chest cavity, but also by associated developmental defects. With diaphragmatic-pleural hernias, underdevelopment of the lungs, heart defects, central nervous system and gastrointestinal tract diseases are often encountered. Particular severity is determined by the degree of underdevelopment of the lungs and morphofunctional disorders in them, leading to impaired circulation in the pulmonary circle with the development of hypertension and the occurrence of a right-to-left shunt with blood discharge at the level ductus arteriosus or intracardiac. It is possible that blood is shunted in the lungs due to functioning fetal communications. Children with such severe developmental defects are often stillborn or die soon after birth.
Clinical picture
Each type of diaphragmatic hernia has quite specific symptoms, although two leading symptom complexes can be distinguished: cardiopulmonary disorders that occur with diaphragmatic-pleural hernias, accompanied by intrathoracic tension, and gastroesophageal reflux with hiatal hernias.
With false diaphragmatic-pleural hernias or true hernias with significant bulging of the hernial sac into the pleural cavity, when almost the entire intestine moves there, clinical manifestations of respiratory failure occur early. Shortness of breath and cyanosis develop immediately after birth or within a few hours. Skin and the mucous membrane is dark blue and even “cast iron” in color. Acute respiratory failure progresses very quickly. On examination, in addition to cyanosis, asymmetry attracts attention chest with bulging of the affected side (usually on the left) and lack of excursion of this half. A very characteristic symptom is a sunken navicular abdomen. By percussion over the corresponding area of the chest, tympanitis is determined, and by auscultation - a sharp weakening of breathing. Heart sounds (with a left-sided hernia) on the left are almost not detectable, but on the right they are loud, which indicates a displacement of the heart to the healthy side. Sometimes through the chest wall it is possible to listen to the peristalsis of displaced intestinal loops and the sound of splashing.
With smaller hernias, clinical manifestations are less pronounced; respiratory disorders in the form of cyanosis and shortness of breath more often develop when the child is restless, screaming, feeding, or changing position. Sometimes a deterioration in the condition occurs in children of toddler and even school age against the background of apparent complete health, when the gastric wall is pinched in a hernia.
the gate or its inversion. In this case, the child complains of vague abdominal pain, nausea and vomiting appear, and anxiety gradually increases.
With true small diaphragmatic hernias, especially with protrusion of a limited part of the diaphragm on the right, when the contents constitute the embedded portion of the liver, there are no clinical symptoms. Children are no different from healthy ones; they develop well, keeping up with their peers. With such hernias localized on the left, despite the absence of visible clinical manifestations, there is some displacement of the heart with its rotation, which can cause hidden cardiovascular disorders. To identify them, tests with functional loads and additional research methods should be carried out.
With parasternal hernias, the symptoms are not pronounced and inconsistent; they are more often detected in children of toddler or school age,
when they begin to complain of painful discomfort in the epigastric region. Sometimes nausea and vomiting occur. Respiratory and cardiovascular disorders are not typical for this type of hernia. In almost half of all cases, children do not complain. With the help of percussion and auscultation, it is possible to determine tympanitis and weakening of heart sounds in this area.
In case of hiatal hernia, especially in the esophageal form, clinical manifestations are associated with the presence of gastroesophageal reflux, resulting from dysfunction of the cardiac part of the esophagus (reflux esophagitis occurs). In the paraesophageal form, the symptoms of the disease are often not associated with the presence of gastroesophageal reflux, but depend on a violation of the evacuation of food from the stomach, its inflection, volvulus, trauma; Cardiovascular disorders are possible due to displacement and compression of the heart. Sometimes paraesophageal hernias are detected by chance during X-ray examination.
Diagnostics
Diagnosis of diaphragmatic hernia is not always simple. The greatest importance should be given to x-ray examination. Diaphragmatic-pleural hernias are characterized by ring-shaped clearings over the entire left half of the chest, usually having a spotted pattern; the transparency of these cavities is more pronounced at the periphery (Fig. 4-47). Characteristic is the variability of the position and shape of the areas of clearing and shading, which can be seen when comparing two radiographs taken at different times.
The mixing of the organs of the mediastinum and the heart depends on the number of intestinal loops that have prolapsed into the chest cavity. In newborns and children in the first months of life, the confusion is so significant that it is not even possible to identify the shadow of a collapsed lung.
Distinguish false diaphragmatic hernia from the true one it is difficult, especially if the pleural cavity is filled with implanted loops of intestines. Usually, with true hernias, it is possible to radiologically trace the upper contour of the hernial sac, limiting the prolapsed loops of intestine into the chest cavity.
If the patient’s condition allows and there are difficulties in differential diagnosis with diseases such as polycystic lung disease or limited pneumothorax, contrasting the gastrointestinal tract with barium sulfate should be performed. In this case, it is clearly established which part of the intestine is located in the chest cavity. Sometimes gastric catheterization is sufficient. Such a manipulation can alleviate the patient’s condition to some extent, since it decompresses the stomach.
When a true hernia is located on the right, usually its contents are part of the liver, so radiologically the shadow of the hernial protrusion will have a dense intensity, merging into lower parts with the main shadow of the liver, and the upper contour of the hernia will be spherical, i.e. one gets the impression of having a dense, round lung tumor adjacent to the diaphragm.
Differential diagnosis
Ultrasound and CT can be used for differential diagnosis. In case of parasternal hernia of the diaphragm, a semi-oval or pear-shaped shadow with large-celled ring-shaped clearings projected onto the shadow of the heart in a direct projection is revealed. In the lateral projection, the shadow of the hernia seems to be wedged between the shadow of the heart and the anterior chest wall. It is not possible to differentiate a parasternal hernia from a phrenopericardial hernia radiographically. In case of parasternal hernias, to establish the hernial contents, an X-ray contrast examination of the gastrointestinal tract with a barium suspension is performed. It is better to start with irrigography, since most often the contents of the hernia are the transverse colon.
The radiographic appearance of hiatal hernias depends on their shape. With paraesophageal hernias in the chest cavity to the right or left of the midline, a cavity with a fluid level is detected, while the gas bubble of the stomach located in the abdominal cavity is reduced or absent. A contrast study with a barium suspension reveals an “hourglass” type stomach, upper section which is located in the chest cavity, and the lower one in the abdominal cavity, and the barium suspension can flow from one part of the stomach to another. An esophageal hernia, as a rule, can be detected only with contrasting of the gastrointestinal tract.
Treatment
Treatment of congenital diaphragmatic hernias is surgical. The exception is asymptomatic small hernias localized on the right, when the contents are part of the liver. The urgency of treatment depends on the severity of symptoms of respiratory failure and cardiovascular disorders.
Usually, with false diaphragmatic-pleural or true large hernias, respiratory and cardiovascular disorders are so pronounced that quite lengthy preoperative preparation is necessary, consisting of decompression of the stomach with a catheter, nasotracheal intubation, transfer of the child to mechanical ventilation with the creation of positive expiratory pressure, which should be minimal - no more than 20 cm water column, otherwise pneumothorax may develop . Eliminate metabolic disorders. Infusion and drug therapy should be aimed at improving the rheological properties of the blood and restoring homeostasis. In this case, it is very important to use medications that reduce pressure in the pulmonary circulation (dopamine). It should be emphasized that children with such disorders tolerate transportation very poorly, so this therapy should begin in the maternity hospital and continue in special machines. Only after homeostasis has improved, cardiovascular disorders and hypoxia have been eliminated, the child can be operated on.
The principle of surgical intervention is to bring down the organs into the abdominal cavity, suturing the diaphragm defect for false diaphragmatic hernias and diaphragm repair for true hernias. Sometimes, with aplasia of the diaphragmatic muscles and the presence of only a pleural layer, plastic material is used. The operation can be performed either through the abdominal or through the thoracic cavity, but it is extremely important that there is no significant intra-abdominal pressure in the postoperative period, so gastrointestinal CT decompression is performed during the operation. In the postoperative period, fairly long-term mechanical ventilation is carried out until hemodynamics and homeostasis improve.
The results of the operation are mainly related to the severity of the patient’s condition upon admission and the degree of lung underdevelopment. In addition, the quality of transportation and preparation of the newborn for surgery is of great importance. In case of severe cardiovascular and respiratory disorders, children are taken to the clinic on the first day after birth, and the prognosis in more than 50% of cases is unfavorable.
In case of hiatal hernia, the urgency of surgery depends on the severity of clinical manifestations and the effectiveness of conservative treatment. For paraesophageal hernias in the absence of obvious clinical symptoms, surgery can be performed even after the child reaches toddler age. In children with gastroesophageal reflux if there is no improvement after conservative treatment Surgical treatment is indicated within 2-3 weeks. Currently, these interventions are performed during laparoscopy.
Congenital localized emphysema
This malformation is characterized by stretching (emphysema) of part of the lung (usually one lobe). The terms “congenital lobar emphysema”, “localized emphysema”, “obstructive emphysema”, “hypertrophic emphysema” are also used to designate it. The true causes of the defect remain unclear. However, some authors associate its occurrence with aplasia of the cartilaginous elements of the bronchi, hypoplasia of elastic fibers and smooth muscles of the terminal and respiratory bronchioles and other disorders in the structural units lung tissue. These factors create the prerequisites for the emergence of a valve mechanism that promotes excessive inflation of the corresponding part of the lung and the development of respiratory disorders.
Clinical picture and diagnosis
Clinical disorders are caused by the presence and severity of symptoms of respiratory and cardiovascular failure. The following factors play a role in the pathogenesis of respiratory failure: exclusion of a large volume of lung tissue from the respiratory function (lack of respiratory function in the viciously developed part of the lung and collapse of normally formed parts as a result of compression of them by overstretched parts of the vicious lung), as well as shunting of blood in the collapsed part of the lung .
Increased intrathoracic pressure and mediastinal confusion, often found in this malformation, become another pathogenetic mechanism causing cardiovascular disorders in such patients.
There are decompensated, subcompensated and compensated forms of congenital lobar emphysema. In the decompensated form, the defect manifests itself from birth. Quite often, general cyanosis, shortness of breath, respiratory asymmetry (lag in the act of breathing of the swollen half of the chest), child anxiety, frequent dry cough, and attacks of asphyxia during feeding can be expressed.
X-ray examination becomes decisive in diagnosis, in which it is possible to detect an increase in the transparency of the lung tissue up to the complete disappearance of the pulmonary pattern, displacement of the mediastinum, sometimes with the presence of a “mediastinal hernia”, compression of healthy parts of the lung in the form of a triangular shadow of atelectasis. The last sign is extremely important in the differential diagnosis of pneumothorax (Fig. 4-23). Most Convincing signs of the localization of emphysema are detected with CT and radioisotope studies of the lungs In the compensated form of congenital lobar emphysema, the listed symptoms can be extremely mild, inconsistent, and noticeable only to an experienced clinician. Often, only the occurrence of inflammatory changes in the vicious part of the lung or collapse in other parts becomes the reason for an x-ray examination, which makes it possible to make an accurate diagnosis.
Treatment
The only correct method of treating this malformation is surgical (removal of the malformed lobe).
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Navel fistulas in children are often observed, especially in infancy. They are the remains of the embryonic ducts functioning in the first 2 - 5 months of intrauterine life: the vitelline duct, through which the embryo receives nutrition from yolk sac, connected to the small intestine, and urinary, from which the fetal urine drains into amniotic fluid. By the time the child is born, these ducts undergo reverse development, but sometimes remain partially (incomplete fistulas) or along their entire length (complete fistulas). In addition, in the navel area there may be fistulas of the stomach, gall bladder, appendix, etc., which are formed as a result of infringement of these organs by a ligature during ligation of the umbilical cord containing a small and unrecognized embryonic hernia.
Incomplete umbilical fistulas in children
Incomplete fistulas(Fig. 74) are observed more often than full
Clinical picture. The unobliterated umbilical end of the duct, lined with mucous membrane, secretes. The accumulated fluid is released through the umbilical fossa. The existence of a fistula in itself does not cause concern to the child. The main complaints of parents boil down to the existence of an umbilical wound that does not heal for a long time, the discharge from which stains the laundry. Upon examination, a small area of pale granulations is found at the bottom of the umbilical fossa, among which a pinpoint fistula opening can be seen. When you press on the umbilical area, a droplet appears from the fistula serous fluid. In some cases, you can feel the cord running from the navel towards the bladder.
Course of incomplete fistulas long lasting. In some cases, as a result of infection, an inflammatory process develops in the wall of the fistula, and then the discharge takes on a purulent character. Inflammatory process prone to relapse. There are cases when, after long-term treatment, the fistula opening is closed, the wound is epithelialized, but then, as a result of the accumulation of secretion in a closed cavity, it suddenly breaks into the umbilical fossa with copious discharge of serous or serous-purulent fluid. The fistula appears again, and the picture repeats itself. Sometimes after one or two suppurations of the fistula, the discharge from the umbilical wound becomes more and more scanty, the wound closes, and the fistula heals itself. The process of spontaneous closure of the fistula occurs more often in the interval between the 2nd and 6th months of life.
Recognizing incomplete umbilical fistula not difficult. It should be suspected in all cases where there are indications of a long-term non-healing umbilical wound. To confirm the diagnosis, the area of the umbilical fossa is examined with a thin button-shaped probe, which is used to find the fistula opening among the granulations. Typically the probe penetrates to a depth of 1.5 - 2 cm vertically or towards suprapubic region. The direction of the fistula tract gives grounds to judge its origin. If the fistula penetrates to a great depth, then it is advisable to perform x-ray fistulography by injecting a 20% solution of sergosine or iodolipol (0.5 - 1 ml) into the fistula tract through a blunt needle. Such a study is necessary in order to exclude the presence of a complete fistula and to form an accurate idea of the fistula course. Sometimes, deep in the tissues, the fistula tract ends in a cystic expansion of larger or smaller sizes. For shallow (up to 2 cm) fistulas, there is no need for x-ray examination.
Differential diagnosis between vitelline duct and urinary tract fistula in outpatient setting doesn't have of great importance, because tactics and therapeutic measures united with them.
Rice. 74. Incomplete umbilical fistulas (a-b). Scheme
Treatment: for incomplete fistulas a wait-and-see approach should be followed. Experience shows that sometimes some of them close on their own by 6 months of life. Parents should be explained that the existence of an uncomplicated fistula does not cause harm to health. The danger arises only when it suppurates. In order to prevent suppuration, it is important to keep the umbilical fossa clean. In addition to general hygienic baths, it is recommended to wipe the navel several times a day with a cotton swab dipped in a weak solution of potassium permanganate.
To speed up the process of obliteration of the fistula tract, cauterizing and disinfecting substances can be successfully introduced into the fistula tract. The most accessible and safest of them are 5% iodine tincture or 10% silver nitrate solution.
Through a cannula carefully inserted into the fistula tract, 0.2 - 0.3 ml of the substance is injected once every 7 - 10 days. The course of treatment consists of 4 - 5 injections. If there is no effect, the course is repeated after 2 - 3 weeks.
If the treatment is not successful, surgical removal of the fistula should be recommended. The operation, which consists of excision of the navel along with the fistulous tract, is indicated after the age of 6 months. It is produced in inpatient conditions. Indications for earlier intervention are given when the fistulous tract is long and ends in a cyst-like expansion.
Complete umbilical fistulas in children
Complete fistulas(Fig. 75) are characterized by the fact that the contents of the organ bearing the fistula constantly flow through them. Their clinic is quite typical.
Clinical picture. In case of vitelline fistula, leakage of contents is noticed in the next few days after the umbilical remnant falls off small intestine through the umbilical fossa. On examination, an infiltrated and hyperemic navel is found, from which the navel sometimes protrudes. bright red the mucous membrane of the fistula and liquid intestinal contents flow out. Over time, the constant leakage of intestinal contents leads to malnutrition and suppuration of the navel. The child does not gain weight well and is lagging behind in physical development. A wide fistula can be early complicated by eversion of the intestinal wall opposite the duct (evagination), which is facilitated by an increase in intra-abdominal pressure during screaming and straining. Evaginate has the appearance of a bright red protrusion with a bluish tint, irregular or oval in shape, and soft-elastic consistency. Evagination is accompanied by phenomena intestinal obstruction(vomiting, bloating, stool retention, etc.), the strangulated intestine becomes necrotic.
Rice. 75. Complete navel fistulas (a-b). Scheme.
Urinary tract fistula is observed less frequently. With it, through the umbilical fossa, it is released drop by drop clear liquid(urine). If the fistula tract has a wide opening, urine is released in a stream when screaming and straining. By pressing on the bladder area, you can almost completely empty the organ.
As a result of constant exposure to intestinal juice or urine in complete fistulas, the skin around the navel becomes macerated, ulcerated, and infected. The inflammatory process also develops in the wall of the fistula tract. All this poses a great danger of developing a toxic-septic condition.
Recognizing a complete umbilical fistula As a rule, it does not cause any difficulties. Just by the nature of the discharge, one can quite accurately establish the existence of one or another type of fistula. But sometimes, if the fistula opening is narrow, this data is not enough for an accurate diagnosis. Complete fistulas of the vitelline duct are observed, in which only a cloudy liquid resembling urine is released through a narrow passage. In these cases, diagnosis is helped by probing the fistula (the button-shaped probe “falls” into the intestinal lumen), or even better, X-ray fistulography. It is advisable to carry out the latter in a hospital, because it has great differential diagnostic significance, especially if we keep in mind the possibility of the existence of a fistula of the gallbladder, stomach, etc., resulting from the application of a ligature to these organs during ligation of the umbilical cord.
In case of complete fistula of the urinary tract, to clarify the diagnosis, it is also more correct to resort to x-ray fistulography in the hospital. In the clinic, you can perform a color test: a dye (methylene blue solution) is injected into the fistula through a thin polyethylene tube and the diagnosis is confirmed by its presence in the urine. You can inject paint into bladder through a soft catheter and monitor its release from the fistula opening.
Treatment: complete fistulas They do not close on their own, so treatment is only surgical, in a hospital. Given the risk of severe complications with them, surgery should be recommended as soon as possible after diagnosis. There are no age-related contraindications to surgery. In particular, surgery for intestinal fistula should not be delayed. Only with a narrow fistula of the urinary tract can surgery be postponed until 6 months of age.
Guide children's polyclinic surgery.-L.: Medicine. -1986
