Search

The incidence of deep venous thrombosis (DVT) in the pediatric population has been reported to be lower than in adults. Pediatric trauma patients have predisposing risk factors for DVT similar to those in the general trauma population. We reviewed the records of 2746 children under 16 years of age admitted to our Level I pediatric trauma service from 1989 to 1997. Only three cases of DVT were documented, all adolescents. DVT was located in the upper (n = 1) and lower (n = 1) extremity venous system. One patient presented with pulmonary embolism alone without identifiable DVT. Risk factors found were venous system manipulations, including atriocaval shunt, subclavian central line, and hyperinflated medical antishock trousers garment. Therapy consisted of heparin followed by warfarin anticoagulation. A vena cava filter was inserted in one patient for whom systemic anticoagulation was contraindicated. No DVT was seen in 1123 closed head injury patients or 29 spinal cord injury patients without associated risk factors. The thrombotic risk in pediatric trauma patients is low. Routine screening or prophylaxis is not indicated except for patients who are likely to remain immobile for an extended period of time and require prolonged rehabilitation, have venous manipulations, or present with clinical symptoms. Hematologic evaluation in patients with diagnosed DVT is necessary to identify individual risk factors.

The following is a quick guide to the perioperative fluid program discussed 1. Always assess the state of fluid repletion in any patient presenting for surgical management (Note: This does not necessarily mean operative management). 2. If the patient is hypovolemic or if there is the possibility of hypovolemia and you are uncertain, restore volumes equal to 25% of the patient's blood volume with a fluid push made up of an osmotically active electrolyte solution modified for the additional requirements of red cell carrying capacity or clotting factors. If this results in a urine output and correction of hypoperfusion or hypotension, maintain an increased fluid administration program until a stable urine output and good perfusion are achieved. If the patient is normovolemic at the time of presentation, particularly if the patient is having an elective operative procedure and does not have an intravenous line in place, calculate the insensible losses that will occur during the time of fluid restriction before surgery and correct at least 50% of these during the operative procedure. 3. Develop the postoperative fluid program as a combination of 24-hour insensible loss replacement (maintenance fluid), restoration of measured losses, and an estimate (guess) as to the volume requirements for third-space fluid shifts. Restore blood losses if appropriate or administer additional volumes of balanced electrolyte solution at a 3-to-1 ratio to replace measured blood loss. 4. Total the insensible loss measurement, the measured losses, and the estimate of third-space requirement and divide this volume by 24 to get an initial hourly fluid administration rate. 5. Select the most osmotically active fluid that you intend to use and administer it first at the calculated rate. Carefully monitor the patient's urine output. 6. Increase or decrease the fluid administration rate to bring the hourly urine output within the guidelines for the appropriate hourly urine output (milliliters) for the particular patient based on size (kilograms). 7. When the urine output falls within the appropriate range, maintain that rate of fluid administration, and recalculate the volumes required because of insensible loss, measured loss, and third-space shifts by subtracting the amount of fluid already administered from the volume that will be required in the remainder of the 24 hours; this will yield the volumes of additional maintenance, measured loss, and third-space fluids that will make up the remainder of the fluids needed for the 24 hours.(ABSTRACT TRUNCATED AT 400 WORDS)

Laryngeal subglottic hemangioma is a rare but potentially life-threatening congenital lesion that can compromise the infant airway. A multitude of medical and surgical modalities have been used in the treatment of this lesion but no single approach has received universal acceptance. Three infants with subglottic hemangiomas were treated successfully with electrocautery; each was managed without tracheostomy. Bronchoscopic electrocautery appears to be a safe, effective, inexpensive way to manage infantile subglottic hemangioma.

Recent reports have suggested an association between congenital anorectal anomalies and occult spinal dysraphism. Eighty-seven patients with anal agenesis have been treated at this institution over the last 14 years. Two of these patients had spinal cord anomalies recognized at birth (a myelomeningocele and a tethered spinal cord). Two additional patients presented with progressive neurologic deficits in early childhood and were each found to have a tethered spinal cord. To further assess the magnitude of this problem, we have used magnetic resonance imaging (MRI) of the spine to survey prospectively 23 infants with anal agenesis. Twenty-one former patients who were asymptomatic were recalled and also studied. Four of 44 patients (9%) were found to have significant occult spinal dysraphism; each child had undergone neurosurgical operation without morbidity. MRI found each child to have a tethered spinal cord, either as an isolated lesion (2) or in association with a syrinx (1) or lipomyelomeningocele (1). One of these patients had a neurologic deficit detected on careful preoperative evaluation. The other three, two of whom were less than 2 years old, had no detectable deficit. Neither the extent of the anorectal malformation, the absence of associated congenital anomalies, nor the demonstration of normal vertebral anatomy on plain radiographs of the spine precluded the presence of occult spinal dysraphism. Therefore, we recommend that all patients with anorectal anomalies undergo MRI imaging of their spines during initial evaluation to screen for occult spinal dysraphism. In addition, consideration should be given to recalling older patients for MRI evaluation.

We describe our experience with 23 children with sickle cell disease and splenic sequestration crisis, emphasizing our management approaches and the patients' subsequent clinical courses. Our data illustrate that sequestration crisis may occur despite a reduction in hemoglobin S concentration to less than 30% of the total hemoglobin mass. In addition, the risk of recurrent splenic sequestration was similar for patients who received transfusion therapy and for those who were simply observed. We conclude that a short-term transfusion program to prevent recurrent splenic sequestration is of limited benefit.

A 4-year-old boy with symptoms of lead intoxication and confirmatory serum lead levels was eventually found to have a pellet lodged in his appendix. Because laxatives and cathartics did not dislodge the pellet, appendectomy was performed. Arguments for and against this decision are explored.

Sickle hemoglobinopathies include sickle cell disease, sickle-C disease, and sickle-beta thalassemia. Patients with these disorders commonly suffer a multitude of destructive events to vital organs, especially to the central nervous system, the spleen, the kidney, the lung, and the heart as a result of microvascular plugging by the sickled erythrocytes. Thoughtful preparation for anesthesia and operation, especially when directed by experienced individuals, can greatly reduce the hazard of inducing the sickle crises that formerly plagued individuals with sickle hemoglobinopathies who faced major operations under general anesthesia. The patient must be free of any acute illness, especially one involving the respiratory system. Adequate hydration preoperatively combined with avoiding perioperative hypoxia, hypothermia, and acidosis, the triggers for sickling, will go far toward avoiding sickle-induced complications. Modern transfusion therapy, consisting of multiple small transfusions of Hb A erythrocytes administered over several weeks prior to the operation, not only corrects the chronic anemia but suppresses erythropoiesis of cells containing Hb S in the patient's bone marrow and leaves him or her with a majority of cells containing Hb A. This provides a safety net in case a sickle-inducing insult occurs despite the best efforts to avoid one. Individuals with sickle hemoglobinopathies may require any of the operations common to all children, for example, herniorrhaphy, appendectomy, tonsillectomy, and circumcision, but a significant number will develop calcium bilirubinate cholelithiasis and possibly cholecystitis as a result of the continual increased load of bile salts resulting from the shortened lifespan of the cells containing Hb S. Also, although most individuals with Hb S will gradually suffer splenic infarction by late childhood, a significant number of infants will experience acute splenic sequestration crisis, a life-threatening entity, the recurrence of which is prevented by splenectomy. Several publications have demonstrated that such surgical procedures can be performed in large numbers of patients with sickle hemoglobinopathies without deaths and with minimal morbidity.

Common congenital and infectious lesions of the head and neck in infancy and childhood have been discussed. Those that are present at birth, asymptomatic, and frequently cystic are clearly benign lesions that require operative management for the potential complications of enlargement and infection. Solid lesions, particularly those of the lymph nodes, must be differentiated from neoplasms, particularly Hodgkin's disease and non-Hodgkin's lymphoma. Suppurative lymphadenitis is obvious from its local inflammatory signs, but the subacute and chronic adenopathies may be difficult to distinguish from neoplasia. An attitude that unless the benign nature of a lesion is clearly demonstrated, early excisional biopsy for histopathologic evaluation must be the rule will avoid delays in diagnosing those neoplastic lesions that can be treated successfully if managed early and aggressively.

Nine of 35 patients with sickle hemoglobinopathies and cholelithiasis were found to have concomitant common bile duct (CBD) stones. We describe the diagnosis and management of these patients with CBD stones. Historical information, physical examination, and routine laboratory tests were unable to identify accurately the patients with CBD stones. Similarly, ultrasonography of the hepatobiliary system was an insensitive method for detecting CBD stones, as only 3 of 8 patients were correctly identified. In contrast, both an intraoperative cholangiogram and endoscopic retrograde cholangiopancreatography were sensitive procedures for detection of CBD stones. We conclude that CBD stones are relatively common in patients with sickle cell disease and cholelithiasis, and clinicians should have a high index of suspicion for their presence.

Duodenal atresia is rarely associated with anomalous biliary ducts that permit communication between the proximal and distal duodenal segments. Two such cases are presented herein and the literature is reviewed. Although the typical radiographic pattern of duodenal atresia is the "double bubble" sign with absence of distal bowel gas, air may be present in the distal bowel when anomalous bile ducts provide a conduit around the atretic segment. Contrast studies are generally not performed in the typical clinical and radiographic evaluation of duodenal atresia; however, an upper gastrointestinal series may be useful in defining the more complex anomaly. Clinical presentation may occur relatively late if the biliary communication is large enough to permit passage of some milk or formula. Care should be taken at surgery to avoid obstruction or injury to the anomalous bile ducts, and operative cholangiography may be useful to document continued bile duct patency following repair of the atresia. Theories of the etiology of this anomaly relate to interference with recanalization of the duodenum by the process of hepaticopancreatic duct formation and persistence of the primitive "dual duct" stage.

This report describes an infant with gastroschisis who presented with gallbladder evisceration and developed ascites after abdominal wall closure.

The case of a neonate presenting with respiratory distress who had an incarcerated Bochdalek hernia with perforation and meconium peritonitis and pleuritis is reported. The patient had an associated jejunal atresia in an incarcerated segment of intestine, which undoubtedly contributed to the obstruction, strangulation, and perforation in the incarcerated hernia. Gastrointestinal complications attributable to the hernia are most unusual in the neonate, and aggressive preoperative resuscitation and stabilization with the earliest possible surgical intervention are imperative features in management.

The third case of presumably spontaneous rupture of a hypernephroma in a child is reported. This patient remains free of disease more than 5 years following radical nephrectomy, radiation and chemotherapy. Although renal adenocarcinoma in children remains a rare disease, more than 80 cases have appeared in the literature, making it necessary now to consider this tumor in the differential diagnosis of all childhood abdominal masses. Equally significant is the observation that presentation as an acute abdominal crisis in a child can occur, making it important that diagnostic considerations in such situations include hypernephroma, as well as Wilms' tumor. Review of the literature shows that occasional cures from spontaneous retroperitoneal rupture of hypernephromas have been reported in adults, but not in children, although this child has survived in spite of tumor spillage in the free peritoneal cavity.

Fifteen patients with persistent neonatal jaundice were evaluated by sonography and radionuclide scintigraphy. The sonographic features of both neonatal hepatitis and biliary atresia are nonspecific. Hepatobiliary scintigraphy after phenobarbital pretreatment in patients with neonatal hepatitis demonstrates normal hepatic extraction and delayed tracer excretion into the gastrointestinal tract. If there is neonatal hepatitis with severe hepatocellular damage, the hepatic extraction of tracer activity is decreased and excretion may be delayed or absent. Patients under 3 months of age with biliary atresia have normal hepatic extraction of tracer with no excretion into the gastrointestinal tract. Sonography in patients with a choledochal cyst shows a cystic mass in the porta hepatis with associated bile-duct dilatation. Hepatobiliary scintigraphy confirms that the choledochal cyst communicates with the biliary system. Initial sonography demonstrates hepatobiliary anatomy; subsequent phenobarbital-enhanced radionuclide scintigraphy determines hepatobiliary function. An expedient diagnostic approach is recommended for the evaluation of persistent neonatal jaundice.

Thirty-three neonates with disseminated intravascular coagulation were assigned randomly to one of three treatment groups: (1) exchange transfusion, (2) administration of fresh-frozen plasma and platelets, and (3) control (no therapy directed specifically at the coagulopathy). The three groups were comparable for degree of abnormality in initial coagulation studies and underlying pathologic processes. Shock was a common accompaniment of DIC and occurred in 85% of all infants. In all cases, underlying disease states and shock were treated aggressively. Resolution of DIC and survival were not different in the three treatment groups. Outcome of DIC was dependent on the success of treatment of the underlying pathologic process and aggressive supportive care, including restoration of blood pressure, but was not altered by therapy specifically directed at the coagulopathy.

The majority of lesions in the neck of children will prove to be benign and of congenital origin arising from such structures as the thyroglossal duct and the branchial clefts in addition to hemangiomas and lymphangiomas. However, it is essential that lymphadenopathy be proven infectious and any asymptomatic lymph node enlargement must be considered Hodgkin's disease until proven otherwise. The occasional neuroblastoma or rhabdomyosarcoma presenting in the neck can usually be identified as solid by sonography, leading to early investigation and biopsy. Because of the abundance of important structures that course through the neck, surgery should be conducted in an operating suite with sophisticated, modern anesthetic techniques and with a surgeon experienced in dealing with the full array of lesions that occur.

A quadrant scheme is presented for estimating postoperative fluid volumes for replacement of internal fluid shifts (third space losses) in pediatric surgical patients undergoing major intraabdominal surgery. The benefits derived from using a prescribed postoperative fluid management program that includes this quadrant scheme are determined by analyzing a series of 50 consecutive patients managed by five senior general and thoracic surgical house officers. Although the program tended to overestimate the fluid needs of the patients relative to a predetermined optimal urine output level, all but two patients with septic complications were hemodynamically stable and none had complications due to the fluid administration program.

Inversion of the appendix does not guarantee that it will slough and a remnant has led to intussusception in two patients. Incidental elimination of the appendix by inversion plus ligation of the base and inversion of the stump appears to be safe, simple, and uncomplicated. This method eliminates the appendix without contamination of the operative field. Such appendectomies are now done in all age groups if the surgical exposure allows ready access to the appendix and cecum.

Since Raffensperger and Jona reported an 80% success rate with primary skin closure including a 16% rate of complete fascial closure in 24 patients with gastroschisis in 1974, primary fascial closure has been the author's preferred method. It has been possible to achieve complete fascial and skin closure in 17 of the last 21 patients (81%). Four infants in this series, one of whom was initially managed by another surgeon, were treated with brief application of a silon prosthesis with subsequent reduction and closure. The two keys to success of this method are thorough wash out of the meconium from the entire intestine and vigorous stretching of the abdominal wall. Assisted ventilation may be needed for 24 to 48 hours after operation and has been well tolerated. Transposition of an umbilical artery for cannulation and blood gas monitoring has been an important adjunct. The one death (5% mortality) resulted from prolonged bowel dysfunction and liver failure three months after operation. Other complications have been few and mild. Since some recent reports have indicated that primary closure is not being widely used in the treatment of gastroschisis, this series is presented to emphasize that this method can be used in most infants and with a very low complication rate.

In recent years, the surgical correction of esophageal atresia with distal tracheoesophageal fistula (TEF) has become increasingly successful. However, there remains a group of high-risk patients with specific anatomical abnormalities in whom the mortality remains appreciable. These associated disorders include cardiac, renal, and chromosomal anomalies as well as severe respiratory distress syndrome. These factors, rather than low birth weight or early gestational age, are primarily responsible for surgical mortality. Preoperative telescopic bronchoscopy has been a useful adjuvant confirming the diagnosis, identifying unusual variants, and permitting the proper anatomic placement of the endotracheal tube. A Fogarty balloon catheter can be passed bronchoscopically into the distal TEF in patients with severe respiratory distress syndrome to occlude the fistula and facilitate effective positive pressure ventilation. Thirty-two patients were treated for esophageal atresia among whom 28 had esophageal atresia with distal TEF, three had esophageal atresia alone, and one had esophageal atresia with proximal TEF. The higher-risk group comprised those with severe respiratory insufficiency as evidenced by a room air paO2 of less than 60 mmHg; this group accounted for nine of the ten deaths in the total series. There was one late death following surgical correction. In summary, in the absence of severe respiratory insufficiency or associated life-threatening congenital anomalies, the results of surgical correction for esophageal atresia are remarkably good and survival in this group approximates 100%.

The Currarino triad is a unique complex of congenital caudal anomalies including anorectal malformation, sacral bony abnormality, and presacral mass. The usual symptomatology is constipation due to anorectal stenosis. Contrast enema and computed tomographic myelography are the imaging modalities of choice for diagnostic confirmation and clarification of the anomalies. The clinical features, unique radiologic appearance, and importance of a correct diagnosis of the Currarino triad are reviewed.

Although anomalies of rotation and fixation of the gastrointestinal tract are recognized to be associated frequently with anomalies of the abdominal wall and diaphragmatic hernia, the frequency with which these common anomalies are associated with other congenital and acquired lesions of the gastrointestinal tract has not been sufficiently emphasized. Sixty-two percent of our series of 34 patients were associated with such lesions as upper gastrointestinal atresias and stenoses, intussusception, and Hirschsprung's disease. The embryologic and anatomic features of rotational anomalies, their clinical presentation, and radiologic features are presented with the suggestion that knowledge of this information, along with the appreciation of the frequent association of malrotation with other common congenital and acquired abnormalities, will help to prevent the devastating morbidity and mortality of undiagnosed midgut volvulus.

A technique for successful and consistent cannulation of extremity veins of neonates using a plastic catheter with inner needle stylet has been used in over 150 neonates for surgical and postoperative management at the Children's Hospital of Philadelphia and has all but eliminated the use of the incisional "cut-down." Advantages of this method over the incisional "cut-down" include: ease of changing insertion sites, preservation of function and subsequent usefulness of the veins, the ability to use larger caliber cannulas, increased duration of function without phlebitis, and the elimination of the unsightly "cut-down" scars. Although meticulous attention to the details of insertion and immobilization are essential for success with this technique, it has been easily taught to our rotating junior level surgical residents and to many of the pediatric interns and pediatric residents.

Bronchopulmonary foregut malformations are a group of related disorders with a common embryologic pathogenesis. Two bronchopulmonary foregut malformations may occur concomitantly in the same patient.

Twenty-seven children with major sickle hemoglobinopathies underwent elective cholecystectomy for cholelithiasis. All were managed with a preoperative transfusion regimen to achieve a hemoglobin concentration of 11-14 g/dl with greater than 65% hemoglobin A. Intraoperative cholangiography revealed common bile duct stones in five patients, although only one case was diagnosed by preoperative ultrasonographic examination. Twenty-four children underwent incidental appendectomy by total intussusception. There were no vaso-occlusive events nor any other perioperative morbidity or mortality. Four months after cholecystectomy, one boy had a small bowel obstruction requiring surgical re-exploration. No patients had transfusion-acquired infection, although one boy had erythrocyte allosensitization to Lewis A antigen. This preoperative transfusion regimen and careful perioperative management permits safe elective cholecystectomy in children with sickle cell disease.

Although histopathologically benign, cutaneous hemangiomas may be pathophysiologically malignant if they are associated with significant arteriovenous malformation that is hemodynamically compromising. Rapid surgical intervention may be required to prevent clinical deterioration from congestive heart failure as in the case reported here. Angiography may directly influence the surgical approach to the lesion.

To avoid an unnecessary second thoracotomy, unequivocal demonstration of a recurrent tracheoesophageal fistula after repair of esophageal atresia with tracheoesophageal fistula is mandatory. Transesophageal selective catheterization of the fistula during cineesophagography may resolve the ambiguities of routine cineesophagography and rod lens telescopic bronchoscopy.

Selective bronchial occlusion for the treatment of localized cystic pulmonary interstitial emphysema (PIE) offers a means to facilitate weaning from ventilatory support and to preserve potentially functional lung parenchyma. We employed a commercially manufactured balloon catheter, placed under direct visualization to occlude a left mainstem bronchus in two cases of localized PIE. This is the safest method for selective bronchial occlusion so far reported. Therapeutic success was achieved with either continuous or intermittent bronchial occlusion. Evaluation of pulmonary function with nuclear scintigraphy aids in determining the most appropriate position for the occluding catheter and permits assessment of the resultant improvements in pulmonary function.

Myoclonic encephalopathy is a unique clinical syndrome of infants and children that is associated with a neurogenic tumor of ganglion-cell origin in approximately half of cases. A review of the literature as well as our personal experience with two recent infants suggests an imaging approach that includes chest radiography and abdominal computed tomography (CT). Ultrasonography, neck CT, and chest CT myelography may be required in selected patients. An expedient clinical and imaging evaluation of infants and children with opsomyoclonus is important to detect those patients with neurogenic tumors.

Central venous catheters have proven to be an important aid for the care of pediatric patients with malignancies receiving chemotherapy. A rare complication of such catheters is pulmonary septic emboli. This report describes a 15-year-old white girl with rhabdomyosarcoma who developed pulmonary nodules while on chemotherapy. These lesions appeared to be metastatic rhabdomyosarcoma. However, an excisional biopsy showed the lesions to be septic emboli. The patient was placed on antibiotic therapy and responded well. She was able to continue with her "front-line" therapy because the nodules were confirmed not to be metastatic disease.

Carcinoma of the breast in the child is a rare pathologic entity, constitutes less than 1% of all breast lesions in this age group. The case of a girl with a left breast mass first noticed at 4.5 years of age is presented. An eccentric subareolar mass was excised at 6 years of age, sparing her breast bud. This biopsy contained juvenile secretory carcinoma, with additional pathologic changes characteristic of juvenile papillomatosis. Both the juvenile papillomatosis component as well as the juvenile secretory carcinoma component were devoid of estrogen and progesterone receptors in contrast to nondiseased breast tissue. The assay for these receptors was performed using a new antireceptor monoclonal antibody technique. Simple mastectomy was performed after completion excision demonstrated tumor at the pectoralis major fascia.

An 1 1 -year-old girl was evaluated because of vomiting, abdominal distension, and hypoactive bowel sounds. She was admitted to Duke University Medical Center initially with anoxic encephalopathy and severe central nervous system dysfunction. One week after placement of a feeding gastrostomy, she became distended and was unable to tolerate gastric feedings. Physical examination revealed a comatose child responsive only to pain, spastic quadriparesis, and flexion contractures. There was moderate distension of the abdomen, no palpable abdominal masses, and decreased bowel sounds. The temperature, blood pressure, pulse, respiratory rate, complete blood count, serum electrolyes, and urinalysis were normal. An abdominal radiograph showed a dilated loop of bowel in the upper midabdomen (figs. 1 A and 1 B). A water-soluble contrast enema confirmed a volvulus of the cecum and ascending colon (figs. 1 C and 1 D). Through a right transverse incision at laparotomy, the cecal volvulus was easily palpable. After decompression by sump drainage through a 1 6 gauge needle, there was easy detorsion of the volvulus of the right colon. Malrotation (incomplete rotation) was present with the duodenojejunal junction in the midline. Ladd bands or midgut volulus were not present. A cecostomy tube was placed and the cecum was sutured to the ventral peritoneum; the tube was removed 3 weeks after surgery. An upper gastrointestinal series with small bowel follow-through 2 months after surgery was normal except for the abnormal position of the duodenojejunal junction.

Internal pancreatic fistulas have only recently been recognized as distinct entities in children. Unless their pathophysiology is understood they can present the clinician with a diagnostic dilemma. Recently, these entities have been better defined in the adult literature and significant improvement made in treatment. We report a case of a child with pancreatic ascites in whom endoscopic retrograde cholangiopancreatography significantly aided the diagnosis and the operative management. An outline of recommended management of pancreatic lesions in children is presented including internal pancreatic fistulas.

Malignant undifferentiated sarcoma (mesenchymoma) of the liver is a rare tumor of childhood, with fewer than 100 cases reported in the literature. The overall prognosis for patients with this malignancy is poor. In this report, two children with hepatic mesenchymoma underwent surgical excision followed by 2 years of adjuvant chemotherapy. Rotating cycles of cisplatinum, vincristine/doxorubicin, vincristine/cyclophosphamide, and vincristine/actinomycin D were given with minimal toxicity. Both patients are alive, with no evidence of disease at least 5 years from diagnosis. Previous reports of treatment are reviewed.

Primary abdominal lymphoma in children is an uncommon and frequently rapidly progressive disease with a generally grave prognosis. Four cases are presented, emphasizing the varied clinical presentation and the need for increased awareness of this process if currently intolerable mortality rates are to be reduced.

Among the causes of obstructive jaundice in childhood, a foreign body of the gastrointestinal tract is rare. Biliary tract obstruction can be caused by a foreign body large enough to occlude the periampullary portion of the duodenum and ampulla of Vater. When this occurs, obstructive symptoms of the proximal GI tract usually dominate the clinical picture. Gastric bezoars have been known to attain enormous size and frequently have “tails” that extend into the small bowel. Common complications of gastric and intestinal bezoars are obstruction, ulceration, and perforation, but biliary tract obstruction to our knowledge has not yet been reported. The atypical history and confusing laboratory tests in a jaundiced infant delayed diagnosis and treatment.

polysaccharide/diphtheria toxoid conjugate vaccine. Lancet 1985;1:1184-6. 13. Anderson P, Pichiechero M, Edwards K, et al. Priming and induction of Haemophilus influenzae type b capsular antibodies in early infancy by Dpo20, an oligosaccharide-protein conjugate vaccine. J PEDIATR 1987;111:644-50. 14. Letson GW, Santosham N, Reid R, et al. Comparison of active and combined active-passive immunization of Navajo children against diseases caused by Haemophilus influenzae type b. Pediatr Infect Dis (in press).