PSU Vol 05, 1995

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PEDIATRIC SURGERY UPDATE

VOLUME 05, 1995

VOL 05 NO 01 JULY 1995

LC vs. OC

During the past thirty-six month period (April 92 to April 95) we (Avils, Ms, & Lugo) have managed to do 40 cholecystectomies in children between the ages of

10.2). Overall 16 patients underwent open cholecystectomy (OC) and 24 laparoscopic cholecystectomy (LC). Females were represented 60%. The most common

quadrant pain in 83% of cases. The etiology of the cholelithiasis was hemolytic in nine children (23%). Data between the two groups was analyzed using chi-squar

exact test (a p

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2- Liu C, Chin T, Jan SE; Wei C: Intraoperative laparoscopic diagnosis of contralateral patent process us vaginalis in children with unilateral inguinal hernia. Br J Surg 82(1):10 6-8, 1995

3- Lugo-Vicente HL: Impact of Minimal Invasive Surgery in Children. Boletin AMPR 89 (1-2-3): 25-30, 1997

Lap for NUT

The undescended testis identified in 0.28% of males can be palpable (80%) or nonpalpable (20%). It is difficult to determine either location or absence of the non

(NUT) by clinical examination. Imaging studies (US, CT, MRI, gonadal venography, etc.) are not reliable in proving its absence. Diagnostic laparoscopy is reliabl

proving its absence. Furthermore it can be combine to provide surgical management. After reviewing thirtee n series of 613 children with NUT managed by laparo

findings were identified: 1- The testis is present; e ither in an intra-abdominal (38%) or inguinal position (12%). Intrabdominal testis can be managed by first s tag

spermatic vessel clipping and cutting (Stephen-Fowler's), followed by second stage vas-based standard orchiopexy six to nine months later. Inguinal testes are m

orchiopexy. 2- The testis is absent (vanishing testicular syndrome) as proven by blind ending vas and testicular vessels (36%). These children are spare an explo

exit the internal ring, inguinal exploration is indicated to remove any testicular remnant as histologic evidence. The presence of a patent processus vaginalis may

3- The testis is hypoplastic or atrophic (26%), in which case is removed laparoscopically. Exact anatomical localization of the testis by laparoscopy facilitates acc

repair; hence is an effective and safe adjunct in the management of the cryptorchid testis.

References

1- Lugo-Vicente HL: Impact of Minimal Invasive Surgery in Children. Boletin AMPR 89 (1-2-3): 25-30, 1997

AC

Acalculous cholecystitis (AC) is more commonly found in children than adults. Two-third of case s appear as a complication of other illness : trauma, shock, burns,

procedures. Contributing causes mentioned are: obstruction, congenital tortuosity or narrowing of the cystic duct, decreased blood flow to the gallbladder, and lon

Males are more commonly affected than females. Fever, nausea, vomiting, diarrhea, dehydration and marked subhepatic tenderness are the most common sympt

are jaundice, and abdominal mass. Labs show leucocytosis and abnormal liver function tests. Recently (APSA 95), two distinct forms of this disease have been rec

symptom duration les s than one month and chronic, with sx greater than three months. US is diagnostic by demonstrating hydrops of gallbladder, increase wall thi

scan with CCK stimulation may help diagnose chronic cases . In both situations management consist of early cholecyste ctomy which can be exe cuted using laparos

References

1-Imhof M, Raunest J, Ohmann C, Roher HD: Acute acalculous cholecystitis complicating trauma: a prospective sonographic study. World J Surg 16(6):1160-5; discussion 1166, 1992

2- Tsakayannis DE, Kozakewich HP, Lillehei CW: Acalculous cholecystitis in children. J Pediatr Surg 31(1):127-30, 1996; discuss ion 130-1

3- Holcomb GW, O'Neill JA, Holcomb III GW: Cholecystitis, Cholelithiasis and Common Duct Stenosis in Children and Adolescent. Annals Surgery 191(5):626-635, 1980

4- Gomezese S, Garcia F, Echeverry J, de la Cruz R, Villagrasa E, Ceres L, Alonso I, Lopez Perez GA: [New aspects of gallbladder pathology in children] Cir Pediatr 2(3):114-6, 1989

5- Bairov GA, Ergashev NSh, Shamis Aia: [Chronic acalculous cholecystitis in children] Vestn Khir 141(12):42-5, 1988

6- Fabian TC, Hickerson WL, Mangiante EC: Posttraumatic and postoperative acute cholecystitis. Am Surg 52(4):188-92, 1986

7- Nanni G: Acute acalculous cholecystitis in childhood. Postgrad Med 74(5):269-70 , 274 , 1983

8- Howard RJ: Acute acalculous cholecystitis. Am J Surg 141(2):194-8, 1981

VOL 05 NO 03 SEPTEMBER 1995

Infantile Myofibromatosis

The fibromatosis are a heterogenous collection of tumors distinguished by proliferating fibroblast, minimal mitotic and inflammatory activity, limited local fat and

age groups. They originate in the fascial sheath and musculo-aponeurotic tissues, and represent about 12% of soft-tissue tumors in children. Infantile myofibrom

common fibrous tumor of infancy. It is characterized by either a localized or multicentric form, appearance during the first year of life, and myofibroblast cells as

participants. A benign, self limited disease process demonstrating spontaneous regression. It includes the formation of palpable masses in skin, muscle, viscera, b

tissue. The solitary (localized) form is more commonly found in the head, neck and trunk region affecting mainly boys later during infancy. Is twice as common as

Lesions are usually found in skin, muscle and subcutaneous tissue. Prognosis is excellent with a very low recurrence rate after surgical excision. Positive surgical

predict a high probability of recurrence, especially if large number of slit-like blood vessels and undifferentiated mesenchymal cells are identified. The multicentri

tissue, muscle, bone and viscera. Infants are born with the lesions and the prognosis depends on the degree of visceral involvement. Excision is reserved for lesio

structures.

References

1- Wiswell TE, Davis J, Cunningham BE, et al: Infantile myofibromatosis: The most common fibrous tumor of infancy. J Pediatr Surg 23(4):314-318, 1988

2- Azam SH, Nicholas JL: Recurring infantile digital fibromatosis : report of two cases . J Pediatr Surg 30(1):89-90, 1995

3- Hart Isaacs Jr: Tumors of the Newborn and Infant. Chapter 12, Soft Tissue Tumors: Myofibromatosis pag 180-184, 1991

4- Corsi A, Boldrini R, Bosman C: Congenital-infantile fibrosarcoma: study of two cases and review of the literature. Tumori 80(5):392-400, 19945- Coffin CM, Dehner LP: Fibroblastic-myofibroblastic tumors in children and adolescents: a clinicopathologic study of 108 examples in 103 patients. Pediatr Pathol 11(4):569-88, 1991

6- Schmidt D, Klinge P, Leuschner I, Harms D: Infantile desmoid-type fibromatosis. Morphological features correlate with biological behaviour. J Pathol 164(4):315-9, 1991

Lipoblastoma

Tumors of adipose tissue origin are more commonly found in adult than children. They include lipoma, lipoblastoma and angiomyolipoma, to mention a few. Lipobl

fetal-embryonal fat tissue. Age at presentation is usually less than five years (mean 2.5 years) with a slight male predominance. The main clinical picture is that o

peripheral location, mainly the extremity (70%). It can arise within soft tissue. Other places identified are: shoulder, back, omentum, retroperitoneum, mediastin

Lipoblastomas are wellcircumscribed masses made up of immature fat cells. They have the capacity for differentiation. Microscopy will show lipoblasts with vacu

along with primitive mesenchymal cells in a myxoid stroma with plexiform capillaries . Skele tal muscle is sometimes involved. Mitotic figures are normal and rare.

signal in both the T1 and T2 weighted magnetic resonance images. A breakdown in the long arm of chromosome eight (8q11-13) is a consiste nt finding in this tumo

complete surgical removal to prevent local recurrence, avoiding radical mutilating resections whenever possible. The tendency to recur is approximately 15%. Th

excellent.

References

1- Hart Issaacs jr. Tumors of the Newborn and Infant: Soft Tissue Tumors-Adipose Tissue Tumors pag 209-210, 1991

2-Kransdorf MJ: Benign soft-tissue tumors in a large referral population: distribution of specific diagnoses by age, sex, and location. AJR Am J Roentgenol 164(2):395-402, 1995

3- Dal Cin P, Sci ot R, De Wever I, Van Damme B, Van den Berghe H: New discriminative chromosomal marker in adipose tiss ue tumors. The chromosome 8q11-q13 reg ion in lipoblastoma. Cancer

4- Coffin CM: Lipoblastoma: an embryonal tumor of soft tissue related to organogenesis. Semin Diagn Pathol 11(2):98-103, 1994

5- Mentzel T, Calonje E, Fletcher CD: Lipoblastoma and lipoblastomatosis: a clinicopathological study of 14 cases. Histopathology 23(6):527-33, 1993

6- Merton DA, Needleman L, Alexander AA, Wolfson PJ, Goldberg BB: Lipoblastoma: diagnosis with computed tomography, ultrasonography, and color Doppler imaging. J Ultrasound Med 11(10):5

7- Mahour GH, Bryan BJ, Isaacs H Jr: Lipoblastoma and lipoblastomatosis--a report of six cases. Surgery 104(3):577-9, 1988

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8- Jimenez JF: Lipoblastoma in infancy and childhood. J Surg Oncol 32(4):238-44, 1986

Breast

Most breast disorders in children of either sex are benign. Congenital lesions are: absent or multiple breast. Transplacental hormonal influence in neonates may

tissue with predisposition to infection (Mastitis neonatorum). Premature hyperplasia (thelarche) in females is the most common breas t les ion in children. It occurs

disk-shaped concentric asymptomatic subareolar mass. Remains static until changes occur in the opposite breast 6-12 mo later. It can regress spontaneously or s

Biopsy may mutilate future breast development. On the contrary, discrete breast masses in males cause concern and excision is warranted. Gynecomastia is brea

hormonal imbalance, usually in obese pre-adolescent boys. If spontaneous regression does not occur, it can be managed by simple mastectomy. Virginal hypertro

enlargement after puberty due to e strogen sensitivity. If symptomatic, management is reduction mammoplasty.

References

1- Jones PG, Woodward AA, Clinical Paediatric Surgery: Diagnosis and Management. 3rd ed. Chapter 46: The Breast pag 392-394, 1986

2- Ashcraft, Holder, Pediatric Surgery. 2nd ed. Chapter 74: Breast Les ions pag 935-940 , 1993

3- Wes t KW, Rescorla FJ, Scherer LR 3rd, Grosfeld JL: Diagnosis and treatment of symptomatic breast mass es in the pediatric population. J Pediatr S urg 30 (2):182-6; discuss ion 186-7, 1995

4- Meggiorini ML, Labi FL, Nusiner MP, Tassi P, Figliolini M: An overview of adolescents breast disorders. Clin Exp Obstet Gynecol 18(4):265-9, 1991

5- Greydanus DE, Parks DS , Farrel l EG: Breas t disorders in children and adoles cents . Pediatr Clin North Am 36(3 ):601-38, 1989

6- Dewhurst J: Breast disorders in children and adolescents . Pediatr Clin North Am 28(2):287-308, 1 981

VOL 05 NO 04 OCTOBER 1995

Surgical Responses in NB

The endocrine and metabolic response to surgical stress in newborns (NB) is characterized by catabolic metabolism. An initial elevation in cathecolamines, cortiso

stimulation by noxious stimuli occurs; a defense mechanism of the organism to mobilize stored energy reserves, form new ones and start cellular catabolism. Cortduring the first week of life is diminished, due to inmaturation of the adrenal gland. Cortisol is responsible for protein breakdown, releas e of gluconeogenic amino

lipolysis with release of fatty acids. Glucagon secretion is increased. Plasma insulin increase is a reflex to the hyperglycemic effect, although a resistance to its a

During surgical stress NB release glucose, fatty acids, ketone bodies, and amino acids; necessary to meet body energy needs in time of increase metabolic dema

parenteral nutrition can result in s ignificant rate of weight gain due to solid tissue and water accumulation. Factors correlating with a prolonged catabolic response

degree of neuroendocrinological maturation, duration of operation, amount of blood loss , type of surgical procedure, exte nt of surgical trauma, and associated con

prematurity, e tc.). They could be detrimental due to the NB limited rese rves of nutrients, the high metabolic demands impose by growth, organ maturation and ad

Anesthetics such as halothane and fentanyl can suppress such response in NB.

References

1- Boix-Ochoa J, Martinez Ibaez, Potau N, Lloret J: Cortisol res ponse to s urgical s tress in neonates. Pediatr Surg Int 2:267-270, 1987

2- Winthrop AL, Jones PJH, Schoeller DA, Filler RM, Heim T: Changes in the Body Composition of the Surgical Infant in the Early Postoperative Period. J Pediatr Surg 22(6):546-549, 1987

3- Anand KJS, Aynsley-Green A: Measuring the Severity of Surgicl Stress in Newborn Infants. J Pediatr Surg 23(4):297-305 , 1988

4- Chuang JH, Lin JN, Lee JH, Jawan B, Fung ST, Wang PW: Endorphin and cortisol responses to surgical stress in newborns and infants. Preliminary report. Pediatr Surg Int 5:100-102, 1990

5- Schmeling DJ, Coran AG: The hormonal and metabolic response to stress in the neonate. Pediatr Surg Int 5:307-321, 1990

6- Okur H, Kucukaydin M, Muzaffer-Ustdal K: The Endocrine and Metabolic Response to Surgical Stress in the Neonate. J Pediatr Surg 30(4):626-630, 1995

Physiology of Pneumoperitoneum

A potential working space during video-laparoscopic abdominal procedures in adults and children is established with the help of a carbon dioxide pneumoperitone

open or close d (Veress needle) technique will cause an increase in intrabdominal pressure (IAP). Studies during abdominal wall defects closure has shown that the

decrease venous return, decrease renal perfusion, low splanchnic flow, and increased airway pressures. The cardiac afterload will increase, an effect magnified b

absorbed into the bloodstream transperitoneally causing hypercapnia and acidosis, an effect controlled by increasing minute ventilation by the anesthesiologist. H

effect can be potentiate further are those with pre-existent cardio-respiratory conditions causing increase dead space, decrease pulmonary compliance and increa

and resistance. Hypotension during the e stablishment of the pneumoperitoneum could be the result of vascular injury, arrhythmia, too much CO2, impending hear

pneumothorax.

References

1- Lugo-Vicente HL: Impact of Minimally Invasive Surgery in Children. Boletin Asoc Med PR 89 (1-2 -3): 25-30 , 1997

Laparoscopic Splenectomy

Laparoscopic splenectomy is another safe and technically feasible video-endoscopic procedures in children. Indications are usually hematological disorders such

Hodgkin's staging. Technical considerations of the procedure are based on anatomical facts such as the variability in the splenic blood supply, the ligaments anch

of the diseased spleen. Generally the avascular splenophrenic and colic ligaments are cauterized, the short gastric and hilar vessels are individually ligated with

(Endo-GIA), and the spleen is placed in a plastic bag and fracture until it is removed through the navel. Advantages of the procedure are: improved e xposure, dec

pulmonary function, shortened hospitalization, more rapid return to normal activities and exce llent cosmetic appearance. Disadvantages are longer operating time

to open 5-20% of cases due to uncontrolled hemorrhage.

References

1- 1- Lugo-Vicente HL: Impact of Minimally Invasive Surgery in Children. Boletin Asoc Med PR 89 (1-2 -3): 25-30 , 1997

VOL 05 NO 05 NOVEMBER 1995

GB Disorders

Gallbladder (GB) disorders in children are increas ing and laparoscopic cholecyste ctomy (LC) is rapidly becoming the procedure of choice. From 1990 through 199

between 21 mo. and 18 yrs. of age underwent cholecystectomy at San Pablo Medical Center. Mean age was 14.8 years and females with classic biliary symptoms

and fatty food intolerance). 12% developed gallstone pancreatitis, and 7% jaundice. Indications for surgery were cholelithiasis in 71 (86%) children, GB dyskines

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sludge/polyp in 2. Fifty-nine cholecystectomies (71%) were done laparoscopically and 24 (29%) open. Choledocholithiasis (CBD stones) in six children (7%) was

with t-tube placement or endoscopic papillotomy followed by LC. No major ductal complication occurred. Predominant pathologic findings were chronic cholecystit

surgical stay, length of stay, diet resumption, use of pain medication, operating time, and cosmesis to the open procedure. Modern diet, overweight and abnormal

the main predisposing conditions of GB disorders in children during this decade. Females in their teenage ye ars with typical symptoms continue to be the most co

Persistent biliary symptoms associated to low GB ejection fraction during hepatobiliary CCK stimulated scan may be cause by dyskinesia. The method of choice t

children is LC: is safe, efficient, and superior to the conventional method. CBD stones can be managed with simultaneous endoscopic papillotomy. Costs of LC ar

equipment and selective cholangiographic indications.

References

1- Lugo-Vicente HL: Trends in Management of Gallbladder Disorders in Children. Pediatric Surgery International 12 (5-6): 348-352, 1997

SBS

The short bowel syndrome (SBS) is a permanent malabsorption caused by loss of small bowel, leaving a res idual jejuno-ileal length of less than 75 cm. During the

commonly results from neonatal necrotizing enterocolitis, intestinal atresia or midgut volvulus. Survival depends on remnant length and presence of ileo-cecal val

management consists of parenteral nutrition, elemental diet and predigested formulas. Management should focus on the rapid intestinal transit time, decreased

ineffective peristalsis, and short bowel length of these patients. Despite significant morbidity, the general outcome is favorable and warrants aggressive nutrition

and surgical intervention in selected patients. Patients with symptomatic dilated intestinal segments and stasis hooked on TPN may benefit from intestinal taperi

lengthening (Bianchi) procedures . Other alternatives are home parenteral nutrition or bowel transplantation.

NOTE: To see a graph of normal intes tinal lenght in fetus, infants and children clickhere.References

1- Vanderhoof JA: Short bowel syndrome in children. Curr Opin Pediatr 7(5):560-8, 1995

2- Collins JB, Georges on KE, Vicente Y, Kelly DR, Figueroa R: Short bowel syndrome. Semin Pediatr S urg 4(1):60-72 , 199 5; discussion 72-3

3- Shanbhogue LK, Molenaar JC: Short bowel syndrome: metabolic and surgical management. Br J Surg 81(4):486-99, 1994

4-Lentze MJ: Intestinal adaptation in short-bowel syndrome. Eur J Pediatr 148(4):294-9, 1989

5- Schwartz MZ, Maeda K: Short bowel syndrome in infants and children. Pediatr Clin North Am 32(5):1265-79, 1985

6- Mitchell A, Watkins RM, Collin J: Surgical treatment of the short bowel s yndrome. Br J Surg 71 (5):329-33, 1984

Umbilicus

Few conditions plague the umbilicus of the young infant. These are: hernias, umbilical granulomas, infectious process (omphalitis), patent urachus or omphalo-mes

They can manifest as either purulent, urinary or intes tinal discharge. Hernias can wait until the child is older (5 y/o), since most will disappear with time. Granulo

care with silver nitrate applications. Omphalitis during the neonatal period are caused by staph. or strep. organisms invading underneath the granulation tissue of

be take n lightly, and spreading infection may involve the superficial lymphatic or lower abdomen. Treatment consis ts of local or syste mic antibiotics. Urachal rem

urinary tract abnormalities (distal lower obstruction) and are managed with excision after urinary investigation. O-P remnants clearly describe a communication b

umbilicus, manifesting as ducts, sinus, cysts or bands. Surgical excision and thorough search for discontinuous segments of the track are necessary. This may incl

References

1- Scherer LR 3d, Grosfeld JL: Inguinal hernia and umbili cal anomalies .Pediatr Clin North Am 40(6 ):1121-31 , 1993

2- Yamada T, Seiki Y, Ueda M, Yoshikawa T, Sempuku S, Kurokawa A, Nakata K: Patent omphalomesenteric duct: a case report and review of Japanese literature. Asia Oceania J Obstet Gynaecol 153-Elhassani S B: The umbilical cord: care, anomalies, and diseases . South Med J 77(6):730-6, 1984

4- Moore TC: Omphalomesenter ic duct malformations. Semin Pediatr Surg 5(2):11 6-23 , 1996

VOL 05 NO 06 DECEMBER 1995

Rectal Prolapse

Rectal prolapse refers to a mucosal or full-thickness herniation of rectum through the anal canal that starts as an intussusception that fully develops. Most cases

preschool children after prolonged straining of stools. Other cases may be associated with acute diarrheal episodes, cystic fibrosis, malnutrition, parasitosis, and

anomalies. Initial management consists of manual reduction with buttock s trapping for 24-48 hours. Recurrent episodes may be managed with outpatient submuco

agents (5% phenol in almond oil). More aggressive surgical effort may be needed for recalcitrant recurrences and children with pelvic anatomic distortion caused

Surgical choice of procedure is controversial and may encompass s imple e ncircling of anus (Thiersch's) with suture, poste rior plication, mucosal stripping, and tra

rectopexy, to mention a few. Prognosis is frequently excellent.

References

1- Schepens MA, Verhelst AA: Reappraisal of Ekehorn's rectopexy in the management of rectal prolapse in children. J Pediatr Surg 28(11):1494-7, 1993

2-Fehri M, Harouchi A, Reffas, el Andaloussi M, Benbachir M, Guessous N: [Rectal prolapse in children. Review of 260 cases] Chir Pediatr 29(6):313-7, 1988

3- Lukram AS: Management of complete rectal prolapse.J Indian Med Assoc 87(12):284-5, 1989

4- Chwals WJ, Brennan LP, Weitzman JJ, Woolley MM: Transanal Mucosal Sleeve Resection for the Treatment of Rectal Prolapse in Children. J Pediatr Surg 25(7): 715-718 , 199 0

5- Corman ML: Rectal prolapse in children. Dis Colon Rectum 1985 Jul;28(7):535-9

6- Wyllie GG: The Injection Treatment of rectal Prolapse. J Pediatr Surg 14: 62 -64, 1979

7- Pearl RH, Ein SH, Churchill B: Posterior Sagittal Anorectoplasty for Pediatric Recurrent Rectal Prolapse. J Pediatr Surg 24(10): 1100-1102, 19 89

8- Qvist N, Rasmussen L, Klaaborg KE, Hansen LP, Pedersen SA: Rectal Prolapse in Infancy: Conservative versus Operative Treatment. J Pediatr Surg 21(10): 887-888, 1986

Echo in CDH

Congenital Diaphragmatic Hernia (CDH) management has evolve d during the past few years. Immediate surgical repair of critically ill neonates with severe lung

pulmonary arterial pressure (PAP), and persistent fetal circulation is non-productive. Repair of the defect should be done afte r preoperative stabilization, no matt

the objective of improving acid-base status and pulmonary mechanics. This stabilization takes the form of mechanical ventilation and muscle paralysis mostly (EC

respiratory failure, where available). Although clinical judgement decides timing of surgical repair, a question often raise d is for how long we should avoid surgery

studies have focused on methods to decide the degree of pulmonary hypoplasia as useful alternatives of answering that question and assessing prognosis. This ha

changes in PAP, the bi-directionality of the patent ductus arteriosus (PDA), the left ventricular mass index, and rece ntly the left to right main pulmonary artery ra

surgical repair using these parameters are: evidence of reducing PAP, reducing pulmonary vascular res istance, and predominant left to right flow changes of the

associated with reduced left ventricular mass index (also predicts use of ECMO) and decreas e left to right main pulmonary arterial ratio.

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References:

1-Schwartz SM, Vermilion RP, Hirschl RB: Evaluation of left ventricular mass in children with left-sided congenital diaphragmatic hernia. J Pediatr 125(3):447-51, 1994

2-Hasegawa S, Kohno S, Sugiyama T, Sato Y, Seki S, Yagyu M, Saito A: Usefulness of echocardiographic measurement of bilateral pulmonary artery dimensions in congenital diaphragmatic hernia.

3-Haugen SE, Linker D, Eik-Nes S, Kufaas T, Vik T, Eggen BM, Brubakk AM: Congenital diaphragmatic hernia: determination of the optimal time for operation by echocardiographic monitoring of

Pediatr Surg 26(5):560-2, 1991

4-Hazebroek FW, Tibboel D, Bos AP, Pattenier AW, Madern GC, Bergmeijer JH, Molenaar JC: Congenital diaphragmatic hernia: impact of preoperative stabilization. A prospective pilot study in 13

23(12):1139-46, 198 8

5- Langer JC, Filler RM, Bohn DJ, Shandling B, Ein SH, Wesson DE, Superina RA: Timing of surgery for congenital diaphragmatic hernia: is emergency operation necessary? J Pediatr Surg 23(8

Cat Scratch Disease

Cat Scratch Disease (CSD) is a self-limited condition transmitted by a Bartonella species (Rochalimaea henselae) present in unaffected kitten paws. Following in

one to two weeks of incubation period, malaise, fever, headache, anorexia and swelling of the regional lymph nodes follow. The adenopathy generally develops in(epitrochlear, axilla) or head/neck areas, is minimally tender and can develop fluctuation. Median age is 14 years with highest attack rate in children less than te

relies on the presence of symptoms, signs, physical exam (characteristic papule at the site of the scratch), history of exposure to a cat, and a positive immunofluo

antibodies. Most patients with clinically diagnosed CSD developed an immunologic response to Bartonella species. Conservative symptomatic management is rec

since the node will eventually disappear spontaneously. In other cases' aspiration of fluctuant nodes is alleviating. Antibiotics are recommended during severe cas

good.

References

1- Hamilton DH, Zangwill KM, Hadler JL, Cartter ML: Cat-scratch disease--Connecticut, 1992-1993. J Infect Dis 172(2):570-3, 1995

2- Dong PR, Seeger LL, Yao L, Panosian CB, Johnson BL Jr, Eckardt JJ: Uncomplicated cat-scratch disease: findings at CT, MR imaging, and radiography.Radiology 195(3):837-9, 1995

3- Dangman BC, Albanese BA, Kacica MA, Lepow ML, Wallach MT: Cat scratch disease in two children presenting with fever of unknown origin: imaging features and association with a new causat

henselae.Pediatrics 95(5):767-71, 1995

4- Doyle D, Eppes SC, Klein JD: Atypical cat-scratch disease : diagnosis by a serologic tes t for Rochalimaea species. South Med J 87 (4):485-7, 1994

5- Jacks on LA, Perk ins BA, Wenger J D: Cat scratch disease in the United States: an analysis of three national databases . Am J Public Health 83(12):1707-11, 1993

References?

Specific or general references on any subject discussed in `Pediatric Surgery Update' can either be mail, faxed, or E-mail to you upon request.

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