Indian if, pediatr. 46 : 215, 1979
P A T E N T V I T E L L O I N T E S T I N A L DUCI"* P.L.N.G, K ^ o , S.K. MITRA AND I.C. PATH^K C!,a~.4igar h
During the 3rd week of intra-uterine life there is a communication between the intraembryonic gut and the yolk sac. As the development proceeds this communication taarrows into a tube known as the vitellointestinal duct. With the establishment of placental nutrition this duct usually becomes obliterated by the end of the 7th week of intrauterine life. In a b o u t 2 % of humans this duct persists and gives rise to a group 0f anomalies of which Meckel's divertiCulum is the commonest a n d complete patency of the duct is the rarest. O u r experience with patent vitello-intestinal duct at the P.G.I., Chandigarh, over the last six years, is presented here. Material and MetlaodJ The clinical notes o f the children admitted to the Nehru Hospital, Chandigarh, since 1973, with a p a t e n t vitello-intestinal duct were reviewed and analysed. During the said period there were 8 cases of patent viteIlo-intestinal duct in a total of 3231 admissions. T h e clinical d a t a of these children are presented in the table. There were $ neonates, 3 infants and 2 children. T h e oldest child was 6 years old. There were 7 males a n d 1 female child *From the Department of Paediatric Surgery, Postgraduate Institute of Medical Education and Research, Chaudigarh, India.
Addras~for cosrtspondence: Dr. I.C. Pathak, Head, Department of Paedialric Surgery, P.G.I.M.E.R.. Chandigarh-160012. Received on July 31, 1975.
(M:F-----7:I). But for the last child the children had symptoms since birth. T h r e e of these children had prolapse of the ileum through the viteilo-intestinal duct, and presented with acute intestinal obstruction. One child (Case 4) had d i a t h e r m y coagulation of an umbilical polyp (?) in infancy, but the symp'toms persisted till the age of 4 years when a correct diagnosis of patent vitellointestinal duct was made. All the children had exploration and excision o f the duct. O n e child died o n the 4th post-operative day due to aspiration whereas the rest had an uneventful recovery. Discussion O f ali the anomalies of the vitellointestinal duct, complete patency of the duct is the rarest (Davis and K e h m 1967). Since the description of the condition by Poussian in 1817 only 151 cases were reported till 1952 (Brown and Glover 1952). The incidence of a completely patent vitellointestinal duct is reported to be 0.0063~ to 0.0r (Brown and Glover 1952, Kittle 1947). T h e condition is mostly seen either in neonates or in infants (Davis a n d K h e m 1967, Kting 1968, Lal and Dhall 1976). However, cases have been reported in young children as well as (Kocher el at. 1972). Six of our children were below the age of 3 months and one was 4 years old, whereas the oldest child was 6 years old. There were 7 male children and one female child in the series. The male preponde-
216
INDIAN JOURNAL OF PIt.DIATRlCS
Table
81. No.
N a m e , Age; Sex
VOL.
46, No..q
Daails of the eight caJr
Clinical presentation
Operation
ResulK 9 |
B/O. j.
.
Faecal discharge from umbilicus of 4 days duration. On examination faecal discharge from umbilicus and cellulitis around the umbilicus were present. Fistulogram confirmed the diagnosis.
Resection of the gut with the duct and end to end anastomosis of the bowel.
Cured
Reddish mass at the umbilicus since birth. O n examination a polypoidal mass at the umbilicus with a minute opening and serous discharge.
Excision of the duct and appendicectomy
Died
1 month Male
P. 2 months Male
Presented with 6" long ileal prolapse through the umbilicus o f one day duration.
Resection and anastomosis of the small bowel.
B.K.
Umbilical discharge since birth; had diathermy coagulation of ? umbilical polyp in infancy.
11 days Malo
S.S.
.
.
4.
4 years Female
Excision of the duct.
2ured
Resection of the gut.
Cured
Faecal discharge from umbilicus since birth.
Resection of the gut along with the duct.
Cured
Presented with prolapse of the ileum through the umbilicus of 2 days duration.
Resection of the small bowel.
Cured ~
.
K . 3 months Muco-purulent discharge from the umbilicus since birth. Ileal prolapse Male through umbilicus of 3 days duration.
.
B/O.K. 1 1 days Male
.
R.L.
289 months Male .
R.P.
6 years Male
Cured
Umbilical discharge for 6 days and acu,'.e Excision of the duct and intestinal obstruction of 3 days duration. repositioning Initially treated conservatively. Barium of the caecum studies done later were suggestive of which was intestinal tuberculosis. Only at laparorotated around tomy the patent vitello-intestinal duct the duct. was revealed.
Cured
~aO BT AL.~PATIIN'r VITIXI.LOINTI~I'riNALDUCT
217
rance of the condition is well documented (Davis and K h e m 1967). IIl cases of patent vitello-intestinal duct, by and large the clinical presentation is the same. There will be art opening in the umbilicus with tither mucoid and/or faecal discharge since birth (Elebute and Ran~ome 1965). Even in older children, as seen in
in these children is reported to be as high as 33% (Elebute and Ransome 1965). There was one death in the series and this child died on the 4th postoperative day due to aspir_~ lion.
0ur4thcase, the history could be traced back to the neonatal period. But for our last patient, all others had thi~ cls presentation. The odd presentation of the last patient (Case 8) posed a diagnostic problem. This 6-year-old boy became symptomatic for the first time at the age of 6years and presented as intestinal obstruetlon, The barium studies done were suggestive ofintestlnal tuberculosis (Fig. 1). Only at laparotomy the correct diagnosis of a patent vitello-intestinal duct was possible in this child. This kind of odd presentation .;s rare and we have not been able to trace the record of a similar case in the literature. Prolapse of the ileum through the patent duct is reported to occur in 20% of eases (Scaletter e t a l . t952L and is the commonest cause of intestinal obstruction in these children. This complication carries a high mortality (Kling 19fi8 War) am Singh and Pathak 1958). Such a prolapse
O f all the anomalies of the viteilointestinal duct complete patency of the duct is the rarest. The condition is mostly seen either in neonates or in infants. Eight o f such cases presented to us over the last six years are presented. There were 3 neonates, $ infants and 2 children; the oldest child was 6 years old. There were 7 males and 1 female child. But for one child all the others had ,ymptoms since birth. Three of these children presented with ileal prolapse through the duct and intestinal obstruction. All the children had
or intussusception has been described as a dramatic and terrifying occurrence (Moore 1956). 65 such cases of prolapse through the patent dt~ct are on record (Kling 1968). We h~:d three such cases and all had intestinal obstruction. All these children were below the age of 3 months. However, it is reported to be common in the first 4 weeks of life (Elebute and Ran$ome 1965). All the 3 children underwent surgery, and had resection of the bowel. All of them survived. Mortality
8ummary
excision of the duct. One child died on the 4th post-operative day due to aspiration. References
Brown, K.L., Glovcr= D.M. 0952). Pc-'~istant omphv,lo-mesenteric duct anomalies. Am. J. 8urg. 63, 680.
Davis, R.M., Kehrn, R.W. (1967). Omphaloeele with patent vitelio intestinM duct~ and ileal prolapse. Am. 97. Surg. 113, 571. Elebute, E.A, Ransome, O. (1.o~5), Patent omptxatomesemetic duct with ileal prolap~. Arch. Surg. 91~ 456. Kittle, C.F., .Jenkins, H.P., Dragstedt, L.R. (1917/, Patentomphalome~emeric duct and its relation to diverticutum of Meckel. Arc/:.Surg. 54, 10. Kling, S. (1968). Patent omphalomesenteric duct--A surgical emergency. Arm. Stag. Igi, 545. Kocher, K.S,, Arnarjit Singh, Manmohan Singh. (1952). Patentvitello intestinal duct. Indian 07. Surg. 34, 454.
2[8
INDIAN JOURNAL OF PEDIATRICS
Lal, M.M., Dhall, J.C. (107e). Ileal prolapse through patent vitello-intestinal duct. Indian Pr 15, 571. Moore, T.C. (1056), Omphalomesentcrlc duct anomalies, Surf. Gynecol. Obstet, 103, GGO, $caletier, H.I~., Muzursky, M,M., Raw.off, H,
VOL. 46, No (1952). :Congenital entcro 'umbilical fistula patent vitelline duct. 07. Pr 40, 310. Waryaia Singh, Pathak, I.C, (Ig58). Prols ileum through a pa~ent vitello--iatestinal 'Indian 07. Surf. 20, 296.
P A T E N T V I T E L L O I N T E S T I N A L DUCI"* P.L.N.G, K ^ o , S.K. MITRA AND I.C. PATH^K C!,a~.4igar h
During the 3rd week of intra-uterine life there is a communication between the intraembryonic gut and the yolk sac. As the development proceeds this communication taarrows into a tube known as the vitellointestinal duct. With the establishment of placental nutrition this duct usually becomes obliterated by the end of the 7th week of intrauterine life. In a b o u t 2 % of humans this duct persists and gives rise to a group 0f anomalies of which Meckel's divertiCulum is the commonest a n d complete patency of the duct is the rarest. O u r experience with patent vitello-intestinal duct at the P.G.I., Chandigarh, over the last six years, is presented here. Material and MetlaodJ The clinical notes o f the children admitted to the Nehru Hospital, Chandigarh, since 1973, with a p a t e n t vitello-intestinal duct were reviewed and analysed. During the said period there were 8 cases of patent viteIlo-intestinal duct in a total of 3231 admissions. T h e clinical d a t a of these children are presented in the table. There were $ neonates, 3 infants and 2 children. T h e oldest child was 6 years old. There were 7 males a n d 1 female child *From the Department of Paediatric Surgery, Postgraduate Institute of Medical Education and Research, Chaudigarh, India.
Addras~for cosrtspondence: Dr. I.C. Pathak, Head, Department of Paedialric Surgery, P.G.I.M.E.R.. Chandigarh-160012. Received on July 31, 1975.
(M:F-----7:I). But for the last child the children had symptoms since birth. T h r e e of these children had prolapse of the ileum through the viteilo-intestinal duct, and presented with acute intestinal obstruction. One child (Case 4) had d i a t h e r m y coagulation of an umbilical polyp (?) in infancy, but the symp'toms persisted till the age of 4 years when a correct diagnosis of patent vitellointestinal duct was made. All the children had exploration and excision o f the duct. O n e child died o n the 4th post-operative day due to aspiration whereas the rest had an uneventful recovery. Discussion O f ali the anomalies of the vitellointestinal duct, complete patency of the duct is the rarest (Davis and K e h m 1967). Since the description of the condition by Poussian in 1817 only 151 cases were reported till 1952 (Brown and Glover 1952). The incidence of a completely patent vitellointestinal duct is reported to be 0.0063~ to 0.0r (Brown and Glover 1952, Kittle 1947). T h e condition is mostly seen either in neonates or in infants (Davis a n d K h e m 1967, Kting 1968, Lal and Dhall 1976). However, cases have been reported in young children as well as (Kocher el at. 1972). Six of our children were below the age of 3 months and one was 4 years old, whereas the oldest child was 6 years old. There were 7 male children and one female child in the series. The male preponde-
216
INDIAN JOURNAL OF PIt.DIATRlCS
Table
81. No.
N a m e , Age; Sex
VOL.
46, No..q
Daails of the eight caJr
Clinical presentation
Operation
ResulK 9 |
B/O. j.
.
Faecal discharge from umbilicus of 4 days duration. On examination faecal discharge from umbilicus and cellulitis around the umbilicus were present. Fistulogram confirmed the diagnosis.
Resection of the gut with the duct and end to end anastomosis of the bowel.
Cured
Reddish mass at the umbilicus since birth. O n examination a polypoidal mass at the umbilicus with a minute opening and serous discharge.
Excision of the duct and appendicectomy
Died
1 month Male
P. 2 months Male
Presented with 6" long ileal prolapse through the umbilicus o f one day duration.
Resection and anastomosis of the small bowel.
B.K.
Umbilical discharge since birth; had diathermy coagulation of ? umbilical polyp in infancy.
11 days Malo
S.S.
.
.
4.
4 years Female
Excision of the duct.
2ured
Resection of the gut.
Cured
Faecal discharge from umbilicus since birth.
Resection of the gut along with the duct.
Cured
Presented with prolapse of the ileum through the umbilicus of 2 days duration.
Resection of the small bowel.
Cured ~
.
K . 3 months Muco-purulent discharge from the umbilicus since birth. Ileal prolapse Male through umbilicus of 3 days duration.
.
B/O.K. 1 1 days Male
.
R.L.
289 months Male .
R.P.
6 years Male
Cured
Umbilical discharge for 6 days and acu,'.e Excision of the duct and intestinal obstruction of 3 days duration. repositioning Initially treated conservatively. Barium of the caecum studies done later were suggestive of which was intestinal tuberculosis. Only at laparorotated around tomy the patent vitello-intestinal duct the duct. was revealed.
Cured
~aO BT AL.~PATIIN'r VITIXI.LOINTI~I'riNALDUCT
217
rance of the condition is well documented (Davis and K h e m 1967). IIl cases of patent vitello-intestinal duct, by and large the clinical presentation is the same. There will be art opening in the umbilicus with tither mucoid and/or faecal discharge since birth (Elebute and Ran~ome 1965). Even in older children, as seen in
in these children is reported to be as high as 33% (Elebute and Ransome 1965). There was one death in the series and this child died on the 4th postoperative day due to aspir_~ lion.
0ur4thcase, the history could be traced back to the neonatal period. But for our last patient, all others had thi~ cls presentation. The odd presentation of the last patient (Case 8) posed a diagnostic problem. This 6-year-old boy became symptomatic for the first time at the age of 6years and presented as intestinal obstruetlon, The barium studies done were suggestive ofintestlnal tuberculosis (Fig. 1). Only at laparotomy the correct diagnosis of a patent vitello-intestinal duct was possible in this child. This kind of odd presentation .;s rare and we have not been able to trace the record of a similar case in the literature. Prolapse of the ileum through the patent duct is reported to occur in 20% of eases (Scaletter e t a l . t952L and is the commonest cause of intestinal obstruction in these children. This complication carries a high mortality (Kling 19fi8 War) am Singh and Pathak 1958). Such a prolapse
O f all the anomalies of the viteilointestinal duct complete patency of the duct is the rarest. The condition is mostly seen either in neonates or in infants. Eight o f such cases presented to us over the last six years are presented. There were 3 neonates, $ infants and 2 children; the oldest child was 6 years old. There were 7 males and 1 female child. But for one child all the others had ,ymptoms since birth. Three of these children presented with ileal prolapse through the duct and intestinal obstruction. All the children had
or intussusception has been described as a dramatic and terrifying occurrence (Moore 1956). 65 such cases of prolapse through the patent dt~ct are on record (Kling 1968). We h~:d three such cases and all had intestinal obstruction. All these children were below the age of 3 months. However, it is reported to be common in the first 4 weeks of life (Elebute and Ran$ome 1965). All the 3 children underwent surgery, and had resection of the bowel. All of them survived. Mortality
8ummary
excision of the duct. One child died on the 4th post-operative day due to aspiration. References
Brown, K.L., Glovcr= D.M. 0952). Pc-'~istant omphv,lo-mesenteric duct anomalies. Am. J. 8urg. 63, 680.
Davis, R.M., Kehrn, R.W. (1967). Omphaloeele with patent vitelio intestinM duct~ and ileal prolapse. Am. 97. Surg. 113, 571. Elebute, E.A, Ransome, O. (1.o~5), Patent omptxatomesemetic duct with ileal prolap~. Arch. Surg. 91~ 456. Kittle, C.F., .Jenkins, H.P., Dragstedt, L.R. (1917/, Patentomphalome~emeric duct and its relation to diverticutum of Meckel. Arc/:.Surg. 54, 10. Kling, S. (1968). Patent omphalomesenteric duct--A surgical emergency. Arm. Stag. Igi, 545. Kocher, K.S,, Arnarjit Singh, Manmohan Singh. (1952). Patentvitello intestinal duct. Indian 07. Surg. 34, 454.
2[8
INDIAN JOURNAL OF PEDIATRICS
Lal, M.M., Dhall, J.C. (107e). Ileal prolapse through patent vitello-intestinal duct. Indian Pr 15, 571. Moore, T.C. (1056), Omphalomesentcrlc duct anomalies, Surf. Gynecol. Obstet, 103, GGO, $caletier, H.I~., Muzursky, M,M., Raw.off, H,
VOL. 46, No (1952). :Congenital entcro 'umbilical fistula patent vitelline duct. 07. Pr 40, 310. Waryaia Singh, Pathak, I.C, (Ig58). Prols ileum through a pa~ent vitello--iatestinal 'Indian 07. Surf. 20, 296.
