888 colon

atretic segment, which is totally free and mobile by virtue of the associated mesenteric defect. This disorder will be extensively considered subsequently in association with diseases of all age groups. The only special comment necessary here is that the exact prognosis in children is uncertain, since statistics on longterm cases are meager. The danger of subsequent development of carcinoma is remote but has been recorded.

Imperforate Anus (to be considered subsequently) Hirschsprungs Disease with Aganglionosis (to be considered subsequently]
It should be noted here, however, that there is an acquired form of megacolon in Chagas disease, and there is also a degenerate form of megacolon that is acquired due to an anoxic damage to ganglion cells.

Necrotizing Enterocolitis
This has been referred to previously and illustrated, but further comment is justified here, especially for children. Over 80 per cent of affected infants are premature by weight or gestation, and stress from some adjoining or other illness may play a part. The diagnosis can very often be rendered radiologically by examination of the plain films (Fig. 8-41/4, B, C), and when bubbles of gas are demonstrated in the distribution of the involved colon. Occasionally, this intramural gas pattern is associated with a pneumoperitoneum and rarely with air in the portal venous system. If a contrast enema is performed, a shaggy mucosal pattern and narrowed bowel lumen are demonstrated, in association with the pneumatosis intestinalis. The mortality in this condition is high (35 to 75 per cent in various series [Franken]). The pneumatosis intestinalis that is so characteristic of necrotizing enterocolitis may be associated with other disease entities, particularly obstructive bowel disease (intestinal atresia), congenital megacolon, obstructive lung disease secondary to dissection of mediastinal air into the intestinal mesentery, collagen disease, and leukemia. Radiologic Features. The radiographic findings of necrotizing enterocolitis in acute leukemia have been well documented by Archibald and Nelson. Apart from the necrotizing enterocolitis there is usually a nonspecific hepatosplenomegaly and occasionally a pericecal abscess. Incidentally, leukemic infiltration of the colon has also been reported (Limberakis et al). In these instances there is usually an associated thickening of the bowel wall manifest not only by added contrast but by the gas contrast of a plain abdominal film. Scalloping of the bowel and separation of bowel loons are. also manifpctotinnc *

Idiopathic or Psychogenic Megacolon

Children with this disorder give a history of chronic constipation with fecal soiling and occasional voluminous bowel movements. It is thought that this disorder is often related to a psychogenic disturbance in the child, perhaps related to a disturbed parent-child relationship. It must be carefully differentiated from true congenital megacolon and aganglionosis. Radiologic Features. The colon in these cases is observed to be markedly elongated and redundant, simulating a malrotation and extending to the anal canal. In the differential diagnosis one must also consider hypothyroidism and perhaps other endocrine disorders that can result in chronic constipation. In most children with chronic dilatation of the colon, irrespective of the cause, there may be an associated hydronephrosis and/or ureteral reflux secondary to the distortion of the urinary bladder trigone by the feces-filled rectum.

Meconium-Plug Syndrome (to be

considered subsequently]

Ulcerative Colitis in Childhood

Ulcerative colitis probably has its onset in child- lood in about 15 per cent of cases (Franken). The eft half of the colon and rectum is affected in practically all cases, but there may be involvement }f the entire colon. In general, the clinical features )f ulcerative colitis in the child are similar to those >f the adult; hence, further discussion of this entity vill be deferred. Extracolonic symptoms, however, nay occur, such as arthritis, in about 25 per cent; ind retardation in growth and maturation. >trangely, the roentgenographic findings may be lormal at the time of the first examination in 20 to 10 per cent of children. This may be related to the lifficulty in performance of the examination in children, with relatively poor preparation. The comol' cations in children are anorectal fistulae; fissure formation; toxic megacolon; very rarely, stricture formation (more common in Crohns disease); and carcinoma as a late complication in those individuals who have had ulcerative colitis usually for 10 years or more. Carcinoma in these cases usually resembles a stricture but has a marked mucosal irregularity and there is usually a colonic obstruction. A 10-year survival of 78 per cent and 20-year survival of 58 per cent have been reported (Devroede et al).

Granulomatous Colitis (Crohn's Disease]