SUMMARY The sixth documented case of heterotopic gastric mucosa in the large bowel proximal to the rectum is described in a two year old girl with a neural tube defect and recurrent rectal bleeding. Unusual in itself, this case is unique in that the rectal bleeding has been controlled with an H2 receptor antagonist.Heterotopic gastric mucosa involving the hindgut is exceedingly rare, especially at sites other than the rectum. The management of all cases described to date has involved surgical excision of the affected bowel. A new approach to management is presented in this case report. Case historyAfter an uncomplicated pregnancy, this young girl was born at full term, weight 4*5 kg, with a 3x3 cm lumbar myelomeningocoele containing a small neural stalk. This was successfully repaired and moderate hydrocephalus controlled with oral isosorbide dinitrate.An anteriorly placed anus functioned well until six months of age, when bleeding per rectum and constipation developed. An anoplasty was carried out followed by regular dilatation.At one month, two months, four months, and 16 months rectal bleeding recurred. Haemoglobin was 5.4 g/dl. Barium meal and follow through, barium enema, coagulation screen and repeated stool examination for ova, parasites, culture and sensitivity were normal and negative respectively. Technetium scan revealed increased isotope uptake in the right iliac fossa suggestive of Meckel's diverticulum (Fig. 1) Colonoscopy revealed a polypoid oedematous lesion in the rectum, prominent hyperaemic fold in the sigmoid region, and ulcerated swollen mucosa in the ascending colon and caecum. Biopsy of each of these lesions revealed heterotopic body type gastric mucosa (Fig. 2). Oral ranitidine 15 mg bd was started which initially controlled the bleeding. Repeat colonoscopy, four months later, showed a reduction in the size of the lesion and healing of the ulcerated areas. After a small episode of bleeding five months after initiation of therapy, the dose of ranitidine was increased to 30 mg bd (4 mg/kg/day). No further bleeding has recurred. This standard dose of ranitidine has fully controlled the bleeding to date. DiscussionIn this case report, a young girl is described with repeated episodes of rectal bleeding because of heterotopic gastric mucosa present in the rectum, sigmoid colon, ascending colon, and caecum. The widespread distribution of the lesions made conservative surgery difficult. The patient was treated successfully with an H2 receptor antagonist, raniti-848 on 13 May 2018 by guest. Protected by copyright.

Conservative surgical treatment of favorable histology bilateral Wilms tumor may improve the preservation of renal mass and function without impairing patient survival.

Abdominal pain is a frequent symptom in the child with Henoch-Schonlein purpura and raises the suspicion of intussusception or perforation. One hundred and fifty two children with a diagnosis of Henoch-Schonlein purpura over 11 years were reviewed. Of these 60 had abdominal pain, 19 gastrointestinal bleeding, and nine were suspected intussusception. Intussusception was confirmed in two of these cases with ultrasonography.Ultrasound is an important tool in the early diagnosis of intussusception complicating Henoch-Schonlein purpura. Where the intussusception appears loose an expectant policy, with careful monitoring, may allow spontaneous reduction. It may also be used in monitoring patients for postoperative recurrence of intussusception, mural haematoma, and uncomplicated intestinal vasculitis with oedema.Abdominal pain and gastrointestinal bleeding are common manifestations of HenochSchonlein purpura, resulting from vasculitis, intestinal oedema, mural haemorrhage, intussusception, necrosis, and perforation.1-3Intussusception is an uncommon complication, yet its diagnosis is made more difficult in this situation.4 5 Not only is its clinical presentation less distinctive, especially when the child already had abdominal symptoms and signs, but definitive diagnosis and treatment by barium or air enema is made more hazardous in view of the underlying intestinal vasculitis and may not be accessible by the enema as it will usually be in the small intestine.6Ultrasonography was useful in the diagnosis of intussusception in two recent cases. To try to establish the extent of the problem it was decided to review the surgical experience in all patients admitted to the hospital with HenochSchonlein purpura over an 11 year period.19 had gastrointestinal bleeding, and nine were suspected of having intussusception. Intussusception was excluded in most of the cases either by clinical examination, plain film of the abdomen, and more recently by ultrasound in five cases. It was confirmed in two cases by ultrasound, which constituted 1-3% of the patients analysed, and these are reported below. CASE 1A 5 year old boy was admitted in 1989 with a two day history of swelling of the feet and wrists, a purpuric rash on the ankles, scrotal erythema, vomiting, and intermittent abdominal pain. Urine analysis revealed proteinuria. A clinical diagnosis of Henoch-Schonlein purpura was made. His symptoms settled and he was discharged after six days.One week later he was readmitted to the hospital with acute severe abdominal pain, tenderness all over the abdomen but no mass was palpable. A plain film of his abdomen was suggestive of intussusception, which was confirmed by ultrasound (fig 1). Hydrostatic or barometric reduction was not attempted in view of the underlying vasculitis. At laparotomy an ileoileal intussusception was identified and reduced manually with some difficulty. Though the bowel was congested looking it was viable with no perforation, and an appendicectomy was done.Initially he had an uncomplicated recovery,

Postoperative vomiting is a well-recognized problem after Ramstedt's pyloromyotomy, occurring in 65-90 per cent of infants in well-documented series (1 -6). Two different postoperative feeding regimens were used in the hospital and a retrospective review was carried out to see if the method of feeding influenced the incidence and severity of vomiting. Patients and methodsIn regimen A the nasogastric tube was removed 4 h after operation. and a first feed of 5 ml of 5 per cent dextrose was given. An hour later IOml of quarter strength feed were given and 15 ml of half strength after a further hour. If vomiting occurred, the patient was tried on the last tolerated feed again. If progression Was satisfactory the patient was on full strength feeds 3 hourly within 24 h of recommencing feeding.Regimen B entailed removing the nasogastric tube after 12 h. After fasting for 24 h postoperatively, the patient was commenced on half strength feeds on day 2, two-third strength feeds on day 3 and full strength feeds on day 4.Patients were allocated to either group depending on the consultant under whose care they were admitted. In the first year. one consultant used regimen B. while the early feeding method was used by the other two consultants and eventually all three were using the 24-h regimen. Nevertheless, the operative technique was similar in both groups.For purposes of comparison. postoperative vomiting was graded 1-3 as follows:1, No vomiting. 2. Vomiting which required no change in therapy. 3. Vomiting which required a change in therapy. Babies whose vomiting did not modify their feeding regimen were considered to be grade 2. All those who vomited requiring either a further period of fasting, reduced strength feeds or intravenous fluid therapy were regarded as grade 3 . ResultsSixty-seven patients had hypertrophic pyloric stenosis confirmed at operation during [1978][1979]. Sixty patients were male and 7 female, ranging in age from 10 days to 15 weeks. All babies had a nasogastric tube passed on admission and their stomachs were emptied. Five babies in group A and 8 in group B continued to vomit and saline stomach washouts were performed on these. Fluid and electrolyte losses were corrected by intravenous therapy before surgery.Approximately 10 days elapsed between the onset of symptoms and surgery in both groups. Ramstedt's pyloromyotomy was performed in all babies using general anaesthesia and in no case was mucosal perforation noted. Thirty-three patients were fed by regimen A and 34 by regimen B. Four babies in group A and 2 in group B who were vomiting excessively had postoperative saline stomach washouts. All 6 also had their feeding regimens altered and so were considered grade 3.Nine of group A did not vomit at all, 12 had grade 2 vomiting, while a further 12 had grade 3 vomiting requiring a change in therapy (Tuble I). In contrast, 18 of those managed by regimen B had no vomiting, with 12 having mild vomiting