POST INFLAMMATORY COLONICSTRICTURES
IN EARLY CHILDHOODAND THEIR MANAGEMENT
SANGRAM SINGH*, VIKAS G BHOSLE*,DHARMENDRA SINGH*, SJ
*Resident; **Associate Professor
and Unit Head, Department and Institution, Department of Paediatric Surgery,
BJ Wadia Hospital for Children, Parel, Mumbai - 12.
Colonic stricture in early childhood
is rare. Most common cause for colonic stricture is post NEC, other less common
causes are trauma and malignancy. The clinical presentation of colonic stricture
ranges from subacute intestinal obstruction to the perforation peritonitis.
Recently we have treated two cases of colonic stricture successfully. Both the
patients were having different clinical presentation, one patient presented
as intestinal obstruction mimicking Hirschsprung’s disease and other as perforation
peritonitis. We have treated colonic stricture by stricturoplasty and resection
Colonic strictures in early childhood are rare. The causes of colonic strictures
are infections, trauma, post inflammatory and neoplasia. Necrotizing enterocolitis
(NEC) is the most common cause of stricture. About 10% to
25% of infants with neonatal enterocolitis develops colonic stricture.[2,3]
In NEC the cause of stricture formation is excessive local production of tumour
necrosis factor-A. Following an attack of NEC a stricture
forms within three months. Most common site of colonic stricture is sigmoid
colon but any part of intestine may be involved, especially the intraperitoneal
colon and ileum being most vulnerable. These colonic stricture can present as
subacute or acute intestinal obstruction or as perforation. We are reporting
two cases of colonic strictures recently treated by us. Usually, histopathological
examination of these strictures shows ulceration, granulation with moderate
fibrosis within 75 days of NEC. Strictures studied after
75 days showed few ulcerations and mild fibrosis.
A 41/2 months old female child presented with a seven day history of gradual
abdominal distension and constipation. The patient was in shock and sepsis.
Child was not passing stool for 4-5 days. Per abdomen examination revealed distended
abdomen with palpable colon. The clinical findings were suggestive of Hirschsprung’s
disease. An emergency laparotomy was performed. The operative findings were
dilated colon and thus a transverse loop colostomy was done to save the life
of patient. The child improved, later a full thickness rectal biopsy done, which
showed a ganglionated rectum. Distal colonic washes were started but there was
a return of wash fluid coming out through the same stoma. A distal cologram
demonstrated stricture at two sites near each other, one at transverse colon
near splenic flexure and other in the proximal descending colon (Fig. 1).
Stricture seen at transverse colon.
A long stricturoplasty was done and later the colostomy was closed. The patient
is doing well on long term follow up. Histopathology of the colostomy site was
normal ganglionated colon. In this case there was past history hospitalization
during neonatal period with birthweight of 2 kg and treatment took for refusal
to feel and distension of abdomen, suggestive of NEC.
A 16 months old male child presented with the complaints of distension of
abdomen and fever. The general condition was fair, haemodynamics were stable
and per abdomen examination revealed mild to moderate distension with a vague
lump palpable in the it lumbar region. On per rectal examination there was soft
faecal matter present. An X-ray of the abdomen showed free gas under the diaphragm.
An exploratory laparotomy was done. There was a perforation at the splenic flexure
of colon (size 2 x 1 cm). Distal to the perforation there was tight stricture.
Ileal loops were adherent around the perforation to localize the infection.
Adhesions were removed. Local resection of the pathological bowel - with stricture
and perforation - was done and primary colo-colic anastomasis performed. The
post operative recovery was uneventful. Histo-pathology of the resected colon
showed a post inflammatory stricture. In this patient there was no history of
NEC accept patient was treated for some minor illness during neonatal period.
Though colonic strictures are rare but when we are treating an infant with colonic
obstruction, colonic stricture should be one of the differential diagnosis.
Intestinal stenosis after NEC is not easy to diagnose without high degree of
suspicion. Other diseases with similar presentation are
Hirschsprung’s disease, congenital bands and adhesions. In the first case clinical
and operative findings were suggestive of Hirschsprung’s disease and the colonic
stricture was diagnosed on a distal cologram. The past history of the child
was suggestive of NEC for which the child had been treated earlier.
Gobet, Baudon have reported child with
colonic stricture previously treated for NEC. In second case perforation was
present proximal to stricture. There was no definite history suggestive of NEC
in neonatal period. Histopathological examination was suggestive of post inflammatory
stricture. Strictures can be treated either by stricturoplasty or resection
and anastamosis. In stricturoplasty stricture is cut longitudinally and closed
transversely, bowel is not lost. If small segment of bowel is involved stricturoplasty
is better option (Fig. 2).
| Fig.2 Technique
If strictures are multiple and involving long segment resection and anastomosis
is better option. In resection and anastomosis segment of bowel is resected
and end to end anastamosis done. In stricturoplasty chances of development of
stricture are very less once disease process has stopped.
We can prevent stricture formation after NEC by augmenting the host defense,
immunoglobulin supplementation, corticosteroid therapy, enteral (oral) antibiotics
and use of inflammatory mediator antagonist.
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