»ÃÐÇѵԻѨ¨ØºÑ¹: 2 ÊÑ»´ÒËì¡è͹ ¶èÒÂÍب¨ÒÃÐ 2 ¤ÃÑé§/Çѹ à»ç¹ÊÕá´§»¹´Ó äÁèÁÕä¢é äÁèÁÕÍÒà¨Õ¹ äÁèÁջǴ·éͧ äÁèÁÕ·éͧÍ×´ ÁÒµÃǨ·Õè OPD ÈÑÅ¡ÃÃÁ PE : abdomen - unremarkable, PR - normal anus
- Hegar dilator No.11 ãÊèä´é Êдǡ äÁè¤Ñº - ä´é Black + mahogany feces
stool exam : soft, black, no cell, occult bl. + ve; á¾·Âì¹Ñ´·Ó Barium enema
Underlying Imperforate anus (Intermediate type)
with rectovestibular fistula ¼èҵѴ·Ó colostomy µÑé§áµèááà¡Ô´
ÍÒÂØ 4 à´×͹ posterior sagittal anorectoplasty
ÍÒÂØ 8 à´×͹ closure of colostomy
ËÅѧ¼èҵѴʺÒÂ´Õ ¶èÒÂà»ç¹à¹×éÍ 2 ¤ÃÑé§ / Çѹ
Feeding: exclusive breast feeding ááà¡Ô´; ÍÒÂØ
6 à´×͹; ¢³Ð¹Õé ¡Ô¹¹ÁáÁè + ¢éÒÇ 2 Á×éÍ ãÊèä¡è »ÅÒá«ÅÁ͹ ä¢è·Ñ駿ͧ
»ÃÐÇѵԤÃͺ¤ÃÑÇ : ºÔ´Òà»ç¹ÀÙÁÔá¾éÍÒ¡ÒÈ ÁÒôÒá¾é¢¹áÁÇ
GA: active, markedly pale,
no jaundice
VS: T 36.7 C, P 130 / min, RR 30 / min, BP
92/55 mmHg, BW 7,145 g. ,Ht 67 cm., W/A 89% , H/A 94% , W/H 100 %
HEENT: normal
RS: Normal breath sound, no adventitious
sound
CVS: normal S1 S2 , no murmur
Abdomen: soft, no distension, not tender,
no guarding, no rigidity, BS-active, liver and spleen – not palpable
Extremities: No edema, no rash, no BCG scar
PR: fresh blood
CBC
: Hct 25.9%, wbc
10,800/cumm (N 26, Eo 5, L 58, M 9, ATL 2) Plt 387,000/cumm
Coagulogram : PT 12.5 s, INR 1.0, PTT 35
s
>>ÁÒôÒà¤ÂãËé¡Ô¹¹ÁÇÑÇ áÅéÇÁÕ¼×è¹à»ç¹¨Ø´á´§æ ¢Öé¹Ãͺ»Ò¡ ËÅѧ¡Ô¹¹Á·Ø¡¤ÃÑé§ (à¤Âà»ÅÕè¹ÂÕèËé͹Á 3 ÂÕèËéÍ ÁÕÍÒ¡ÒÃàªè¹à´ÕÂǡѹ·Ø¡¤ÃÑé§)
>>ÁÒôÒäÁèä´é¡Ô¹¹ÁÇÑÇ ¡Ô¹áµè¹éÓàµéÒËÙé
>>2 Çѹ¡è͹ ¶èÒÂà»ç¹àÅ×Í´¤ÃÑé§áá ¼Ùé»èÇ ¡Ô¹à¤é¡, âÂà¡ÔÃìµ
>>2 Çѹ¡è͹ ¶èÒÂà»ç¹àÅ×Í´¤ÃÑ駹Õé ¼Ùé»èÇ ¡Ô¹¹Áà»ÃÕéÂÇà¢éÒä»
>>¼Ùé»èÇ à¤ÂµÃǨ CBC µÍ¹ÍÒÂØ 4 à´×͹ áÅÐÍÒÂØ 8 à´×͹
Hct 32% , wbc 8,500 (N19, L69, E8, ATL1, B1, M2) plt 216,000
Hct 30% , wbc 7,900 (N15, E4, L78, M3) plt 250,000
Problem lists:
1. Lower GI bleeding with anemia
2. Chronic mild PEM
3. Family history of allergy
4. Eosinophilia
5. Underlying imperforate anus
- Cow’s milk protein allergy
- Eosinophilic colitis
- Meckel's diverticulum
Further investigations:
Stool culture - no growth
Double air contrast barium enema :
>>Numerous small nodular lesions along surface of colonic mucosa, predominately on left sided colon. A lot of them show central umbilication.
Imp : Numerous lymphoid hyperplasia.
Specific Ig E for cow’s milk : low specific IgE (class I)
Precipitin test : negative
Colonoscopy with biopsy:
>>Multiple lymphoid hyperplasia entire colon.
Biopsy: Submucosal lymphoid hyperplasia, superficial ulceration and acute inflammation.
Colonic Lymphonodular hyperplasia
- breast feeding + nutramigen àÊÃÔÁ¹ÁáÁè
ãËéÁÒôҧ´¹ÁÇÑÇ, ä¢è, ¶ÑèÇ, ÍÒËÒ÷ÐàÅ
áµèÍÒ¡ÒÃäÁè´Õ¢Öé¹ ÂѧÁÕ¶èÒÂà»ç¹àÅ×Í´Ê´·Ø¡Çѹ - Add - Prednisolone (5 mg) 1 x 2 pc. ËÅѧä´éÂÒ 2 Çѹ äÁèÁÕ¶èÒÂà»ç¹ àÅ×Í´ÍÕ¡
- ¢³ÐÁÒ follow up off prednisolone ä´é
¢³Ð¹ÕéÍÒÂØ 1 2/12 »Õ BW 8.5 kg ãËé BF+Nutramigen äÁèÁÕ¶èÒÂà»ç¹àÅ×Í´ÍÕ¡
>>most commom presentation : abdominal pain (periumbilical
and dull cramping, not radiate, not relieved by defecation, eating or
body position, never nocturnal) 58%, hematochezia 32% (streaky,red to
dark red blood , mixed with mucous,
and coating stool)
>>Clinical patterns :
1. < 1 year: male (72%) with painless hematochezia (72%) and
pancolonic LNH distribution (78%)
2. 2-6 years : abdominal pain and hematochezia, colonic 80%
3. > 7 years : abdominal pain (82%) with mixed LNH distribution,
small bowel 44%, large bowel 56%
>>Barium enema:
Superficial, uniform 1-3 mm. nodular filling defects, vary 1-5 nodules/cm.
Classical central umbilication.
Segmental or pancolonic.
>>Endoscopy :
Smooth 1-2 mm. nodule, yellow to pink to white, small reddish dot or punctate
spot.
>>Pathology :
Typical lymphoid follicles just below the mucosa, No parasitic, eosinophilic
or exudative
>>Etiology:
Unknown (allergic response, Ig A def.
with giardiasis and chronic diarrhea, Crohn’s D., lymphoma in adults)
Treatment :
>> Pain/ bleeding treated with Cyproheptadine -->symptoms cleared
in 14-21 d.
>> Prednisolone (0.5 mg/kg) 3-6 wk.
REFERENCE:
Colon AR, DiPalma JS, Leftridge CA. Intestinal lymphonodular hyperplasia
of childhood: patterns of presentation. J Clin Gastroenterol 1991;13:163-6.