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POST INFLAMMATORY COLONICSTRICTURES IN EARLY CHILDHOODAND THEIR MANAGEMENT

SANGRAM SINGH*, VIKAS G BHOSLE*,DHARMENDRA SINGH*, SJ KARMARKAR**
*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 and anastomosis.

INTRODUCTION

Colonic strictures in early childhood are rare. The causes of colonic strictures are infections, trauma, post inflammatory and neoplasia. Necrotizing enterocolitis (NEC)[1] 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.[4] 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.[3] Strictures studied after 75 days showed few ulcerations and mild fibrosis.

CASE REPORT

Case 1

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).

Fig.1
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.


Case 2

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.

DISCUSSION

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.[5] 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.[6] Gobet,[7] Baudon[8] 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
Fig.2 Technique of stricturoplasty.


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.[9]

REFERENCES

1. Bell MJ, et al. Intestinal stricture in necrotizing enterocolitis. J Paed Surg 1976; 11 : 319.

2. Beardemore HE, Rodgers BM, Outer Bridge E. NEC (Ischemic enteropathy with the sequele of colonic stricture). Gastrology 1978; 74 : 914.

3.Janik JS, Ein SH, Mancer K. Intestinal stricture after necrotizing enterocolitis. J Ped Surgery 1981; 16 : 438.

4. Tan X, Hsuch W, Gonzalez Crussi F. Cellular localisation of tumour necrosis factor - a transcripts in normal bowel and in NEC. Am J Pathology 1993; 142 : 1858.

5.Lamireau T, Lanas B, Chatect JF, et al. Increasing frequency and diagnostic difficulties in intestinal stenosis after necrotizing enterocolitis. Arch Pediatric 1996; 3 : 9-15.

6.Schwartz MZ, Richardson CJ, Hayden CK. Intestinal stenosis following successful medical management of NEC. J Paed Surg 1980; 15 : 890-9.

7. Gobet R, Sacher P, Schwobel MG. Surgery in colonic stricture after NEC. Acta Paediatric suppl. 1994; 396 : 77.

8.Baudon JJ, Josset P, Audry G, et al. Intestinal stenosis during ulceronecrotizing enterocolitis. Arch Pediatr 1997; 4 : 305-10.

9. James A, O Neil Jr, et al. In pediatric surgery : 5th edition : eds. Craig T Abanese, Marc I Rowe : Mobsy. 1998; 1297-1316.



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