Arch Dis Child: first published as 10.1136/adc.58.12.1035 on 1 December 1983. Downloaded from

Correspondence 1035 and in 7 of 9 patients with intrahepatic , Changing incidence of infantile proving a poor discriminatory test. As ultrasound is safe, non-invasive, and does not hypertrophic depend on hepatobiliary function we routinely use it to screen all cholestatic patients before proceeding to Sir, biopsy or laparotomy as required. The papers from Birmingham1 and from South Wales2 show an increased incidence of pyloric stenosis. The P SHAW AND D A KELLY authors have various suggestions for this increase; but Departments ofPaediatrics and Medicine, is it anything more than better diagnosis? In most Royal Free Hospital, paediatric units the decision to operate is made on the Pond Street, basis of a convincing history and the finding of a palpable London NW3 pyloric mass. Over the years I have been amazed that, even at times when I have been a little doubtful about the presence of such a pyloric mass, surgeons at operation have always found hypertrophic pyloric stenosis and Drs Mowat Hylton, and Meire comment: performed a Ramstedt's operation. This must mean that, in general, I and perhaps other paediatricians are under- All infants with conjugated hyperbilirubinaemia ad- believe mitted to our unit have ultrasound examination before diagnosing pyloric stenosis, because I cannot If dilated extrahepatic ducts are found, that for any condition I am 100% correct. . In the last 10 years there has been a great increase in laparotomy for presumed choledochal cyst is considered staff in without prior liver biopsy. We would see little prospect both the number and the expertise of paediatric of the extrahepatic biliary tree all British paediatric units, both peripheral and central. of ultrasonography Might not the increased incidence of pyloric stenosis be helping in the differentiation between extrahepatic all, biliary atresia and infants with severe intrahepatic the result of fewer such babies being missed (after bile flow. Even with operative the natural history for the less severe case is for spon- cholestasis with reduced taneous resolution to occur with time). If this is not the cholangiography at laparotomy, experienced surgeons to may make a presumptive diagnosis of atresia in patients explanation, can the authors explain how, in contrast and proceed to unnecessary the rest of my life, I have never been wrong in diagnosing with patent bile ducts, pyloric stenosis ? surgery with deleterious results.3 copyright. The intrahepatic bile ducts in extrahepatic biliary S R MEADOW atresia are commonly very narrow. We have not ob- St James's University Hospital, served dilated intrahepatic ducts on ultrasound in over Beckett Street, 60 infants with extrahepatic biliary atresia, aged less than Leeds LS9 7TF 20 weeks, examined in the last three years. When ultra- sonography of the hepatic parenchyma has been compared with histological observations, marked Drs Webb, Dodge, and Lari comment: discrepancies have emerged.4 Our summary concluded 'In patients in whom genetic Professor Meadow's clinical expertise has never been in disorders, such as alpha-l antitrypsin deficiency had been doubt, but we hasten to assure him that not all paedi- http://adc.bmj.com/ excluded, interpretation of liver biopsy specimens, atricians are quite as good as he at detecting pyloric together with 1311 rose bengal faecal excretion, remains stenosis. He may well be right that pyloric stenosis is the most accurate means of identifying those infants who underdiagnosed, and there is some evidence that silent need surgery for biliary atresia and of avoiding un- cases do occur. ' However, although there has been an necessary laparotomy in infants with intrahepatic increase in the number of paediatric staff throughout the '. Our experience since completing this work country, their expertise in palpation of pyloric tumours reinforces this conclusion but the word 'interpretation' is probably no better than that of their predecessors, and should have been qualified by 'skilled'. we have personally encountered senior registrars who have never felt a pyloric tumour. on September 30, 2021 by guest. Protected Before the abrupt rise in incidence which we and others References have reported, most paediatricians were under the a declining problem and the few 1 Manolaki AG, Larcher VF, Mowat AP, Barrett JJ, impression that it was Portmann B, Howard ER. The prelaparotomy diagnosis epidemiological studies reported would seem to support of extrahepatic biliary atresia. Arch Dis Child 1983;58: this contention.45 There is no evidence from our own 591-4. records that the recent excess of babies with pyloric 2 Gates GF, Sinatra FR, Thomas DW. Cholestatic stenosis are of a milder clinical nature, who would syndromes in infancy and childhood. American Journal formerly have been missed, nor has the increase in ofRadiology 1980;134:1141-8. paediatric manpower been abrupt, at least in this part 3 Markowitz J, Daum F, Kahn El, et al. Arterio-hepatic of the world. One of us (JAD) spent several years dysplasia. Pitfalls in diagnosis and management. all over Belfast, and can 1983 ;3:74-6. actively looking for cases 4 Gosink BB, Lemon SK, Scheible W, Leopold GR. assure Professor Meadow that 'any infant who vomited' Accuracy of ultrasonography in the diagnosis of hepato- was regarded as a potential candidate. In spite of this cellular disease. AJR 1979; 133:19-26. enthusiasm, the recorded incidence of hypertrophic