Vertebral artery dissection (VAD) has been infrequently recognized in children. The authors have reviewed 68 reported cases of VAD in children in the existing literature. An association between routine types of neck movement in sports and the evolution of VAD was recognized in half of the reported cases. Boys outnumbered girls by a ratio of 6.6 to 1, in contrast to adults, for whom the male to female ratio is approximately equal (1.3 to 1). Neck pain, one of the hallmark symptoms of VAD in adults, was infrequently noted in this young population (12%). Most children presented with various combinations of symptoms and signs, including ataxia (53%), headache (38%) and vomiting (34%). Eye signs or symptoms were noted in 72% of patients, and paresis/paralysis of one or more extremity occurred in 54%. Angiography was the method most frequently used to diagnose VAD (63/68; 93%). Magnetic resonance angiography (MRA) revealed pathognomonic signs of VAD in only 3 out of 13 patients evaluated (23%). In this series of 68 patients, 48 reports failed to indicate whether or not a cervical X-ray was performed, but in the 20 patients for whom such information was recorded, half had skeletal abnormalities in the occipital/atlas/axis region. The most common treatments were antiplatelet therapy (n = 15) and anticoagulation with (n = 8) or without (n = 7) supplemental antiplatelet therapy. Asymptomatic recovery occurred in 12 of the 15 patients (80%) who received antiplatelet therapy compared with 4 of the 15 patients (27%) who received anticoagulation therapy with or without antiplatelet therapy. There is a very high incidence of associated cervical anomalies in children with VAD. Further studies are required to determine if noninvasive examinations such as magnetic resonance imaging, ultrasonography, computed tomography angiography and MRA could replace angiography as the modality of choice in establishing the diagnosis of VAD in children. The role of different therapies for children presenting with symptoms related to VAD is unclear.

The mean +/- S.E.M. ratio of amylase to creatinine clearance significantly increased at 24 hours after operations on the stomach and gallbladder but not after operations at sites remote from the abdominal cavity. Clinically, the elevated amylase to creatinine clearance ratio was not accompanied by pancreatitis. In dogs, surgical handling of the pancreas alone caused a significant increase in this measurement. The amylase to creatinine clearance ratio is not likely to be helpful in predicting the rare, but serious, postoperative complication of pancreatitis.

The clinical, biochemical and radiological findings in 16 patients with carcinoma of the head of the pancreas were compared with that of 13 with cholestatic jaundice due to chronic pancreatitis. Patients presenting with malignancy had more severe hyperbilirubinemia (18.5 +/- 2.1 vs 5.6 +/- 1.6 p to ten days of hospital admission was the single most accurate test distinguishing carcinoma from pancreatitis. The mean bilirubin rose in carcinoma but fell in pancreatitis (mean net change 15.1 +/- 2.9 vs 3.9 +/- 0.6, p less than 0.001). Calcification in the pancreatic region was identified on a flat plate of the abdomen in 8/13 with pancreatitis but 0/16 with malignancy. Preoperative percutaneous transhepatic cholangiography was helpful in defining the site of biliary obstruction but the radiologist was unable to clearly predict the definitive diagnosis in five of the 29 patients. A point score based upon the major significant differences noted, predicted the presence or absence of malignancy in all patients (16/16 vs 0/13, p less than 0.01).

A patient with a history of alcohol abuse, who presented with severe malnutrition, was subjected to serial jejunal biopsies during his hospitalization. The improvement in villous size and absorptive cell ultrastructure paralleled his clinical recovery. It is concluded that the caloric and trophic benefits of food, the pancreatic and vitamin replacement therapy and withdrawal of alcohol, all played an integral part in the regeneration of the jujunal mucosa.

Patients with refractory ascites and HRS should be considered to present an urgent indication for peritoneovenous shunting. The shunt offers a method of continuous reinfusion of ascitic fluid which corrects avid sodium retention, oliguria and azotemia. Severe encephalopathy, jaundice or peritoneal sepsis-common complications of cirrhosis-contraindicate installation of the shunt before improvement occurs. Associated cardiac disease does not contraindicate the use of the shunt provided that ascitic fluid is removed at the time of operation and large amounts of diuretics are used. This operation has also proved useful in ascites attributed to causes other than cirrhosis. The main complications include disseminated intravascular coagulopathy, hepatic coma and sepsis in a few patients. Results of a randomized prospective study indicate that the shunt should probably be considered in patients with diet-resistant massive ascites even before they prove to be refractory to diuretic therapy.

The charts of 30 consecutive patients who underwent implantation of a LeVeen type of peritoneal-venous (P-V) shunt were reviewed. 29 patients had Laennec's cirrhosis and ascites refractory to medical therapy. Of these, 7 or 24% had hepatorenal syndrome (HRS), i.e. creatininemia and azotemia, a low urinary sodium (UNa), and no other apparent cause for renal failure. In these patients with plasma creatinine (pCr) > 1.6 mg/dl and BUN > 30 mg/dl and UNa < 10 mEq/1, the P-V shunt s ingificantly improved all 3 measures of renal function: pCr decreased from 4.3 to 2.7 mg/dl (p < 0.025) BUN decreased from 79 to 38 mg/dl (p < 0.025) and UNa increased to 70 mEq/1. 4 of these patients are still alive, a mean of 418 days after being shunted (preshunt BUN = 60 mg/dl). 3 patients died a mean of 81.7 days after shunt implantation (preshunt BUN = 83 mg/dl), none from renal failure. Of the 29 patients with refractory ascites, + / – HRS, the implantation of this shunt was associated with a significant increase in renal sodium clearance (CNa) and fraction of the filtered sodium being excreted CNa/Ccr. The CNa/Ccr increased after shunting in patients studied while off diuretics from 0.21 to 1.45% (p < 0.025). The avid renal salt adsorption characteristic of refractory ascites and HRS appears to have been reversed. The P-V shunt appears to be beneficial therapy, especially in preterminal HRS, and appears to function in a physiologic manner, by decreasing the renal reabsorption of sodium and water.

Percutaneous transhepatic cholangiography (PTC) with a "skinny" Chiba needle identified the biliary tree in 30 of 31 patients (97%) with extrahepatic obstructive cholestasis (EHC). The method was successful in only eight of 18 patients who had cirrhosis with unexplained jaundice. The biliary tree was visualized after one or two attempts in 23 of 31 patients with EHC (74%). The success rate was significantly greater (p greater than 0.001) in those patients with EHC than in those with EHC, in whom the biliary tree was visualized in 9 of 27 (33%). Difficulties in correctly interpreting the PTC findings in four patients are described.

The results of a randomized prospective preoperative antibiotic study in colon surgery is presented. Antibiotics were given by mouth for 2 days prior to operation: kanamycin (1 gm four times a day) and erythromycin (750 mg three times a day). Kanamycin combined with erythromycin significantly reduced wound infection as compared to kanamycin with a placebo (three of 38 vs. 16 of 39, P less than 0.001). Thus oral aminoglycoside given alone appears to be inadequate to offer protection against postoperative infection in elective colon surgery.

Wapnick, Simon M.B., Ch.B., F.R.C.S.1,2,3; Grosberg, Saul M.D.1,2,3; Farman, Jack M.B., Ch.B., M.Med.1,2,3 Author Information

In 31 patients with pancreatitis, the amylase to creatinine clearance ratio (CACR) was significantly greater than for controls (10.7 +/- 1.7 vs. 2.6 +/- 0.3, P less than .001). Sixteen pancreatitis patients with serum amylase (SAm) within the normal range had a mean CACR significantly greater than that of 19 hospital control patients with normal SAm (9.2 +/- 1.5 vs. 3.0 +/- 0.4, P less than .001). For control patients a highly significant inverse correlation between SAm and CACR was observed. No relationship was detected between these parameters for pancreatitis patients. The results suggest that the CACR may be of aid in establishing the diagnosis of pancreatitis even in patients without hyperamylasemia.

A prospective randomized matched pair study was designed to test the efficacy of the peritoneovenous (LeVeen) shunt as a treatment for massive cirrhotic ascites compared with traditional medical therapy. Patients who failed to lose weight while on a low salt diet and fluids restricted to 1000 ml daily were placed in the study group. Weight loss, decrease in abdominal girth and diuresis were significantly greater (P less than 0.01) for surgical patients than for their medically treated counterparts. The surgical technique is simple, quick and inexpensive. The surgical patients outlived their matched partners in 12 of 14 pairs where a definitive comparison was possible (P less than 0.02). The median stay in hospital after randomization was shortened from 32 days with medical therapy to 15 days for those undergoing the shunt operation. Those treated medically experienced a significant rise in mean blood urea nitrogen and K+ (P less than 0.02). Patients with alcoholic hepatitis, hyperbilirubinaemia (bilirubin greater than 154 mumol/l), peritoneal sepsis, severe coagulopathy and those who had recently bled from oesophageal varices are poor risks for the surgical procedure.

Renal failure occurs in ascites of diverse causes. Functional renal failure (the hepatorenal syndrome) in cirrhotic patients is usually progressive and rapidly fatal. Insertion of a LeVeen shunt significantly reduces weight, as well as abdominal girth, and improves preoperative urine flow (488 vs 2,318 ml/24 hr; P less than .001) and natriuresis (12 +/- 15 vs 45 +/- 33 mEq/liter; P less than .003). The shunt should not be inserted in patients with alcoholic hepatitis (bilirubin level greater than 8 mg/100 ml). Ascitic fluid should be discarded at the time of surgery in patients with impaired cardiac function, a bleeding diathesis, and when liver function is more severely deranged.