A congenital condition

A 4 year-old child from Marsabit has been admitted in Chaaria due to severe malnutrition and dehydration. The small patient was in fact vomiting everything and was not passing stool.

Communication with the child and his father was very difficult because of language barrier: actually both were talking only Borana and they did not understand either English or Kiswahili. Sometimes we have been communicating though the help of other patients of the same tribe but able to speak Kiswahili. Some other times we have been using signs language: for instance, when trying to explain to the father the need of operation, Dr Khadija has been using a knife and showing with the mouvements that we wanted to cut the abdomen of the child.

According to what we managed to understand, the vomiting had been on-off for years, since the early days of life of the child.

The general conditions were actually quite poor; there was anemia and important electrolyte imbalance: we have therefore transfused and tried to correct hypokalemia and hyponatremia by all possible means.

Later we have performed barium meal and barium enema: the barium meal and follow through indicated the presence of duodenal stricture, although later on during the test there was contrast media found in the small intestine. The barium enema was suggestive of irritable bowel syndrome.

Stenosis of the duodenum is rare and very difficult to approach surgically: out of fear we have therefore tried to manage the patient conservatively. The child was actually not vomiting when he was on “nil per os”, but of course that could not be a permanent solution.

We have thereafter consulted Dr Nyaga who has much experience in cases like the one we were dealing with: after getting the necessary information, he did not have any doubt on the need of operation. 

The father immediately consented through the translation of a relative whom we had called in order to explain the situation to the parent. 

In theater we found a very complex congenital malformation: there were congenital bands on the second portion of the duodenum causing stenosis. There was also malrotation of the whole intestine (both small intestine and colon), with the result that the coecum was in the left inguinal fossa.

With precision and expertise, Dr Nyaga was able to cut the bands and to reposition the rotated intestine. He also performed prophylactic appendicectomy, as it is indicated in the cases of congenital malrotation of the gut, and finally he anchored the coecum and ascending colon to the right pariental peritoneum, in order to avoid a relapse of the malrotation.

It was a courageous and very successful operation which has certainly saved the life of the young patient.

I want to express my heartfelt gratitude to Dr Nyaga, always so humble and so excellent in his performances, to Dr Khadija, always so cooperative and helpful in difficult operations, to Dr Michelle, a senior anesthetist from the U.K. always so good to us in theater, and, last but not least, to all my theater staff, wonderful as usual.

Today we have done other 12 operations on top of the one described above, but this first one at 6.30a.m. has certainly been a good kick start for all other procedures.

Bro Dr Beppe Gaido