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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
A Clinicopathological Study of Developmental and Acquired Causes of Intestinal Obstruction in Paediatric Population- A Retrospective Study
Correspondence Address :
Dr. Yasmeen Khatib,
Department of Pathology, C Wing, 1st Floor, Hospital building, Dr RN Cooper hospital, Mumbai-400056, Maharashtra, India.
E-mail: dryasmeenkhatib1965@gmail.com
Introduction: Intestinal Obstruction (IO) in the paediatric age group can be due to a variety of developmental and acquired causes which depend on the age at presentation. Histopathological examination of the resected intestine can provide definite evidence of underlying aetiology.
Aim: To analyse the spectrum of lesions causing IO and it’s relation with clinicopathological features.
Materials and Methods: This was a retrospective study conducted in the Department of Pathology at Seth G.S. Medical College and Dr. R.N. Cooper Hospital, Mumbai, Maharashtra, India. Gross and microscopy of 70 surgically resected specimens of patients with IO, received over a period of five years, from January 2009 to December 2013, data was analysed between January 2021 to June 2021, studied after getting ethical clearance. Clinical details were retrieved from the records. Lesions were classified as developmental and acquired which were further categorised into infective, neoplastic and miscellaneous categories. Data was analysed using Microsoft excel 2010 and was expressed as frequency and percentage.
Results: Out of the 70 cases studied there were 40 males and 30 females. There were 37 cases less than one month old, 13 cases between one month to one year age and 20 cases between 1-12 years of age. The developmental category comprised of 52/70 cases (74.29%) with 17 cases of Meckel’s diverticulum,16 cases of intestinal atresia, three cases each of mesenteric cysts and duplication cysts, five cases of duodenal webs, four cases of congenital bands, one case each of lymphangiectatic cyst, malrotation, blind ileal loop and meconium ileus. In the acquired category, there were three cases of tuberculosis and one case each of fungus and Ascaris infection. In the neoplastic category, there were five cases of polyps and one case each of cystic teratoma and Burkitt’s lymphoma. There were three cases of volvulus, two of perforation and one case of intussusception.
Conclusion: The present study highlights the various causes of IO in children from neonatal period up to 12 years of age. With proper gross and microscopic examination, it was possible to give confirmed diagnosis, which is necessary for further management of the patient.
Cyst, Infection, Intestinal atresia, Meckel’s diverticulum, Neoplasm
The IO in paediatric age group can be due to a variety of developmental and acquired causes which differ in neonatal and older age groups (1). It is one of the most common surgical emergency seen in paediatric age group with significant mortality and morbidity. Mode of presentation is acute in majority of the cases. Patients present with abdominal distension, vomiting, abdominal pain, constipation and failure to pass meconium (2). Common causes of surgical specimens received due to developmental IO which are present mainly in the neonatal period include intestinal atresias, intestinal webs, congenital bands, Meckel’s diverticulum, meconium ileus and malrotation (3). Acquired causes include infections like tuberculosis, worm infestations, neoplasms like polyps, lymphoma and other causes like intussusception, volvulus and perforation (4). Earlier studies done on the causes of IO have focussed on clinical presentation and management (1),(2),(3),(4). However, analysis of gross and histopathological features did not reflect in these studies. Surgical pathology specimens can help to confirm the diagnosis and also unravel the predisposing factors which can lead to IO. Hence, the present study was undertaken to classify, study the various causes and complications of IO in children and also to analyse its relation with clinicopathological features.
This was a retrospective study conducted in the Department of Pathology at Seth G.S. Medical College and Dr. R.N. Cooper Hospital, Mumbai, Maharashtra, India. It was done on all surgical pathology specimens of paediatric patients operated for IO for five years between January 2009 and December 2013. Data was analysed between January 2021 to June 2021. Institutional Ethics Committee (IEC) permission was obtained (ethical clearance number- IEC/171/2012).
Inclusion criteria: Specimen of IO cases, less than 12 years of age were included in the study.
Exclusion criteria: Functional obstructions due to Hirschsprung’s disease were excluded from the study.
Out of a total of 798 paediatric gastrointestinal specimens received during the study period 70 cases showed features of IO and comprised the study population.
Data Collection
The medical records of the patients were retrieved and analysed with respect to age, gender, symptoms of abdominal pain, distension of abdomen, constipation, inability to pass stools, vomiting, X-ray findings, preoperative diagnosis and diagnosis made during exploratory laparotomy. Gross examination of all the specimens was done and the site, size, external appearance, cut surface, cystic change, intussusception, stricture, gangrene, perforation and peritonitis were noted. Representative histopathology sections were studied. Cases were divided based on aetiology into developmental and acquired causes which were further classified into infective, neoplastic and miscellaneous categories (volvulus, perforation and intussusception) (2).
STATISTICAL ANALYSIS
Data was collected and analysed using Microsoft excel 2010 and was expressed as frequency and percentage for different aetiologies.
Out of a total of 798 paediatric gastrointestinal specimens received during the study period, 70 cases showed features of IO giving an incidence of 8.77%. Majority of the cases were in the age group of less than one month 37/70 (52.86%). There were 13 cases (18.57%) in the age group between one month to one year and 20 cases (28.57%) between 1-12 years. There were 40 males and 30 females children with a male:female ratio of 4:3. Patients presented with the complaints of abdominal distension in 45 cases (64.3%), pain in abdomen in 27 cases (38.6%), vomiting in 35 cases (50%) and inability to pass meconium/constipation in 20 cases (28.56%). There were 61 cases (87.14%) which presented with acute obstruction. Depending on the aetiology the cases were classified as developmental causes in 52 cases (74.29%), acquired in 18 case (25.71%) which were further divided as infective in 5 cases (7.14%), neoplastic in 7 cases (10%) and others in 6 cases (8.57%).
(Table/Fig 1) shows the developmental causes and (Table/Fig 2) depicts the acquired causes of IO along with the frequency, age distribution, male female ratio and salient histopathological findings. (Table/Fig 3)a-d shows the gross appearance of the cases. Meckel’s diverticulum and intestinal atresia showed gangrenous changes. Meckel’s Diverticulum (MD) ranged in size from 1-10 cm with giant MD more than 5 cms long in six out of 17 cases. Mesentric cyst shows a thin wall and duplication cyst is arising from the intestinal wall.
(Table/Fig 4)a-d shows microscopic features of MD, intestinal atresia, mesentric cyst and duplication cyst. There was one case of Burkitt’s lymphoma which presented as ileo-colic intussusception.
(Table/Fig 5)a shows the cut surface of Burkitt’s lymphoma with solid greyish white appearance. (Table/Fig 5)b shows the cut surface of teratoma with solid cystic variegated appearance. (Table/Fig 6)a,b shows the microscopic features of Burkitt’s lymphoma and cystic teratoma.
(Table/Fig 7) shows developmental and acquired causes of IO in children along with their complications like intussusception, structure, perforation gangrene and meconium peritonitis. Out of 70 children, only 62 had secondary complications, rest of the cases did not have any secondary complication. There were nine (12.86) cases of secondary intussusception. Mortality was seen in 3/70 cases (4.28%). In 15 cases, more than one lesion was found. (Table/Fig 8) shows conditions with more than one lesion. (Table/Fig 9) shows the discordant cases with different preoperative/operative and histopathological diagnosis. In eight cases, the final histopathological diagnosis was different from the clinical diagnosis.
A wide spectrum of developmental and acquired causes can be due to IO in paediatric population which requires prompt diagnosis and surgical intervention. These causes vary in the neonatal period and in older children. Regional variation is also seen with more number of infective causes like tuberculosis and ascariasis in developing countries (5). (Table/Fig 10) shows comparison of age, sex ratio and clinical symptoms found in present study as compared to other studies (2),(4),(6). Congenital/developmental causes of obstruction were found in 52/70 cases while acquired causes were divided as infective 5/70, neoplastic 7/70 and others 6/70 cases. Maheshwari M et al., (2) reported 58/94 congenital causes of obstruction and 36/94 as acquired causes in their study which was similar to present study.
Eight out of 10 cases presenting with intussusception were more than one year of age, nine showing lead points formed by Meckel’s diverticulum, polyps and lymphoma while only one case of primary intussuception was found. This is unlike other studies because present study has analysed only surgically resected specimens (2),(4),(5).
Clinical presention and histopathological examination of both developmental and acquired causes of IO were analysed. MD was the commonest developmental abnormality seen in present study. 10/17 cases were seen in children more than one year of age. Soomro S and Mughal SA (4) reported 16.4% cases of MD in their study of intestinal obstruction in children older than one year and Bhedi A et al., (6) reported an incidence of 12% and Gangopadhyay AN and Wardhan H reported incidence of 3.7% (5). Chen JJ et al., have mentioned that age, gender, inflammation and presence of ectopic gastric mucosa are factors associated with symptomatic MD (7). Severity of the symptoms also relates with the size of MD (8). In the present study 6/17 cases showed giant MD with size more than 5 cms long. Demonstration of cases with large size of MD, presence of ectopic gastric mucosa, bands, diverticulitis and leading point were seen in present study which explains the presentation of MD with obstruction, perforation, intussusception and gangrene.
Atresia can be divided into duodenal, jejunal, ileal and rectal and is an important cause of neonatal obstruction with some patients having associated congenital anomalies. In the present study, 16 cases of atresia all presenting with acute obstruction with 15/16 in neonatal age group were encountered. Subbarayan D et al., have reported association of atresia with duplication cysts and meconium cysts (9). Even in present study cases of ileal atresia were associated with duplication cysts, giant cystic meconium peritonitis and meconium ileus. All were type 1 atresia and showed submucosal fibrosis. Complications seen were perforation, gangrene and meconium peritonitis. According to previous studies Maheshwari M et al., reported an incidence of intestinal atresia to be 10.8% and Bhedi A et al., of 8% in their studies (2),(6).
In the present study, there were two cases of jejunal web, two cases of duodenal web and one case of pyloric web. Histopathology showed submucosal fibrosis. Lin HH et al., have described 37 cases of gastrointestinal webs (10). Duodenal webs were associated with other congenital anomalies in 50% cases. Even in present study, both cases of duodenal web were related with malrotation.
Duplication cysts are spherical structures attached to mesenteric border of the intestine and are lined by intestinal mucosa. According to the studies incidence of duplication cysts is low with obstruction presenting as the common complication (11),(12). Two cases were lined by intestinal mucosa and one with gastric mucosa. One was associated with duodenal band and one with intestinal atresia. All patients presented in the neonatal period. One case presented with meconium peritonitis. One case diagnosed as mesenteric cyst showed features of duplication cyst on histopathological examination. There was a discordance between preoperative and histopathology examination in 2/3rd cases.
Mesenteric cysts are believed to arise due to proliferation of ectopic lymphatic tissue which lack communication with remainder of lymphatics. They are more more common in ileal mesentery. Perrot M et al., reported an incidence of 1 per 20,000. Two out of three cases presented in older children (13). Grossly, they were large in size and showed a columnar/cuboidal lining which is different from intestinal lining of duplication cyst. Tiwari C et al., have described 14 cases of cysts of GIT origin which included mesenteric cysts and duplication cysts (11).
One case of lymphangiectatic cyst was found in present study which is a rare presentation as reported by Prabhakaran K et al., (14). The diagnosis was possible only only on histopathological examination. Hence, histopathological examination of all cystic leisons of GIT is advisable.
Four cases of congenital bands were seen, all in more than one month age group, causing intestinal obstruction. Two of them presented with gangrene and two with perforation. Soomro S and Mughal SA reported an incidence of 7.3% causing IO, while Gangopadhyay AN and Wardhan H reported an incidence of 6.17% causing IO (4),(5).
The acquired causes were more common in older age group. Among the infective causes three cases of tuberculosis presented in the ileo-caecal region with perforation and stricture which is frequently reported (15). Fungal infection presented with complications of perforation, and peritonitis in the neonatal period. Gangopadhyay AN and Wardhan H have reported an incidence of TB in 11% cases and ascariasis in 13.58% cases (5). A higher incidence of ascariasis causing IO has been reported by other studies as compared to the present study. This could be due to regional variation and medical treatment (5),(16).
Polyps in paediatric population are less frequent than in adults (17). All cases presented as lead points causing intussusception. On histopathology one was a Peutz’s-Jeghers polyp which is common in children and the other was an adenomatous polyp. One case of cystic teratoma was diagnosed as duplication cyst preoperatively and is rarely seen (18). The case of Burkitt’s lymphoma presenting as intussusception was identified as a polyp preoperatively. Thus, histopathology was necessary in the correct diagnosis of neoplastic lesions which is necessary for further treatment (19).
Limitation(s)
Cases of functional obstruction like Hirshprung’s disease have not been included in the study. Cases of obstruction with surgical reduction but no excision were also excluded. As it was a retrospective study, no follow-up of these patients could be done.
The present study highlights the various developmental and acquired causes of IO in children found on surgically resected specimens. A detailed gross and microscopic examination can show the exact aetiology of obstruction, type of infection or neoplasm and presence of complications for further management. In some cases, more than one lesion can be found.
DOI: 10.7860/JCDR/2022/53053.16508
Date of Submission: Oct 28, 2021
Date of Peer Review: Dec 28, 2021
Date of Acceptance: Mar 22, 2022
Date of Publishing: Jun 01, 2022
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA
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