Dear all, help much appreciated concerning a 5 yr. old African male who presented nearly 4 weeks ago malnourished, pyrexial, bile vomiting, distended abdomen, tender. One of my Registrars took him to OT but found nothing, took a lymph node Bx - reactive changes only on histo.
Post op no change except temp settled. Commenced NG feeds with semi elemental formula, but still vomited, started TPN and tolerated some NG feeds, vomiting occasionally. Contrast follow through - some hold up in stomach, abnormal proximal ileum, long partial stricture, ulcerative mucosal pattern, bowel distal normal with good eventual transit distally. Sat and waited but failed to improve, back to OT today for a relap. Belly clean, organs normal, but from pylorus to end of first 30cm of jejunum serosa a bit red, muscularis grossly thickened and on wedge biopsy mucosa appeared completely absent and replaced by granulation tissue. Lumen Patent but only about 5mm diam. A few fleshy nodes, but unremarkable.
It seems some agent has badly damaged a segment of this child's proximal small bowel. No oesophageal or gastric damage to suggest a caustic agent, therefore presumably infective. I have seen 2 similar cases in the past year but both these affected the mid jejunum or prox ileum, one presenting with a perforation. One died, the other recovered after a protracted illness and prolonged diarrhoea (not a feature of this present case).
1) I am unfamiliar with this pathology. Can anyone shed any light on possible causative agents
2) The lesion here, involving as it does the duodenum, is unresectable, I put in a feeding jejunostomy, but presumably if the child survives it will stricture.
Any suggestions as to further surgical management