Summary Background Aspiration of gastric contents can be a serious anesthetic‐related complication. Gastric antral sonography prior to anesthesia may have a role in identifying pediatric patients at risk of aspiration. We examined the relationship between sonographic antral area and endoscopically suctioned gastric volumes, and whether a 3‐point qualitative grading system is applicable in pediatric patients. Methods Fasted patients presenting to a pediatric hospital for upper gastrointestinal endoscopy were included in the study. Sonographic measurement of the antral cross‐sectional area ( CSA ) in supine (supine CSA ) and right lateral decubitus ( RLD CSA ) position was completed, and the antrum was designated as empty or nonempty. Gastric contents were endoscopically suctioned and measured. Multiple regression analysis was used to fit a mathematical model to estimate gastric volume. Results One hundred patients (aged 11–216 months) were included. The gastric antrum was measured in 94% and 99% of patients in the supine and RLD positions, respectively. Gastric antral CSA correlated with total gastric volume in both supine ( ρ = 0.63) and RLD ( ρ = 0.67) positions. A mathematical model incorporating RLD CSA and age ( R 2 = 0.60) was determined as the best‐fit model to predict gastric volumes. Increasing gastric antral grade (0–2) was associated with increasing gastric fluid volume. Conclusion The results suggest that sonographic assessment of the gastric antrum provides useful information regarding gastric content (empty versus nonempty) and volume (ml·kg −1 ) in pediatric patients. Results suggest that the three‐point grading system may be a valuable tool to assess gastric ‘fullness’ based on a qualitative exam of the antrum.
A 12-year-old girl presented to the emergency department with a three-day history of worsening, colicky periumbilical and lower abdominal pain. Associated symptoms included anorexia, nausea and nocturnal awakening. This was preceded by two days of upper respiratory tract infection symptoms including malaise, cough and fever.
Vital signs demonstrated fever (38.8°C), tachycardia (heart rate 148 beats/min) and tachypnea (respiratory rate 28 breaths/min), but normal blood pressure and oxygen saturation on room air. Abdominal examination demonstrated tenderness in the mid and left lateral abdomen, with palpable fullness in the left lower quadrant.
Elevated white blood cell count (15.7×109/L), platelet count (426×109/L), C-reactive protein level (17 mg/L [161.9 nmol/L]), erythrocyte sedimentation rate (16 mm/h) and normal serum albumin were noted. Abdominal ultrasound identified marked ascites and isolated bowel wall thickening of the sigmoid colon.
The patient was admitted for observation. Gastroenterology and Pediatric Surgery were consulted regarding the abdominal pain and ultrasound findings. On further history, it was discovered that the patient had a five-year history of stereotypical recurrent abdominal pain. These episodes were much milder than at the time of presentation, and they occurred up to twice per month, resolving spontaneously within two days. Further history suggested the underlying diagnosis.
I recently diagnosed an erythema multiforme rash in several patients, two of whom had the major variant, Stevens-Johnson syndrome. Should these patients be managed with corticosteroids?In most cases, mild erythema multiforme is self-limited and resolves in 2 to 4 weeks. Stevens-Johnson syndrome is a serious disease that involves the mucous membranes and lasts up to 6 weeks. There is no indication for using steroids for the mild form. Use of steroids for erythema multiforme major is debatable because no randomized studies clearly indicate which children will benefit from this treatment.
Portosystemic shunts are used to treat portal hypertension arising from extrahepatic portal venous obstruction. They decompress the portal system by allowing intestinal blood to bypass the liver and enter directly into the systemic circulation. These shunts increase the risk of minimal hepatic encephalopathy and altered neurodevelopmental outcomes in affected children. Treatment options are limited and have been extrapolated from those used in cirrhosis. We describe the use of glycerol phenylbutyrate as an alternate management strategy. A 3-year-old boy underwent distal splenorenal shunt for refractory variceal bleeding secondary to portal hypertension. He had neurologic deterioration and hyperammonemia refractory to traditional management strategies. Glycerol phenylbutyrate was initiated and resulted in a sustained improvement in ammonia levels, behavior, and school performance. This case illustrates the successful use of glycerol phenylbutyrate in a noncirrhotic patient with Portosystemic shunt and minimal hepatic encephalopathy refractory to conventional management strategies.
Occlusive central line-related complications are not infrequent in children undergoing cancer therapy, but are generally not associated with life-threatening complications. Thrombosis of the superior vena cava (SVC) is rarely described in such patients, and downhill esophageal varices have been described in children and adults as a complication of altered SVC blood flow. The management of patients with SVC thrombosis and associated varices is complicated by the need to treat the thrombus weighed against bleeding risk. We present a 14-year-old adolescent with a history of acute leukemia and central line-related complications, including SVC thrombosis with subsequent formation of downhill esophageal varices. Conservative management consisting of anticoagulation alone resulted in resolution of the varices with no bleeding complications.
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