Pediatric Upper GI Series New Patient

Transcription

1 Pediatric Upper GI Series New Patient

2 Upper GI Series Thought to be malrotation, no evidence of midgut volvulus Needed to repeat UGI Series WHY?

3 Repeat UGI Series

4 Repeat UGI Series

5 Repeat UGI Series No malrotation What was wrong with the 1 st UGI series?

6 Pediatric Upper GI Series First 2 Images Markedly gas-distended stomach

7 Pediatric Upper GI Series Markedly gas-distended stomach May not be able to determine rotation status -Distended stomach exerts mass effect, including mass effect on duodenum -May prevent barium from passing to left of left pedicles and up to level of bulb -Malrotation may or may not be present

8 Pediatric Upper GI Series In this case, repeat UGI series was normal Take-home point: Mass effect from markedly distended stomach may contribute to appearance of malrotation where this is none May need to place an NG tube to decompress stomach before sending patient to fluoroscopy

9 14-year-old boy Previously asymptomatic Hit in abdomen while playing football Now with abdominal pain

10 14-yr-old boy

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16 Previously asymptomatic 14-year-old boy Incidental findings of malrotation and midgut volvulus Marked distention of proximal duodenum Ladd bands found at surgery

17 MALROTATION By itself, may be asymptomatic and may not cause problems Usually accompanied by malfixation: Duodenojejunal junction and ileocecal junction, normal points of fixation of mesentery, are not in their normal location

18 MALFIXATION Mesentery usually has a narrow base Entire jejunum and ileum are attached to narrow pedicle Tendency for intestines to twist around the pedicle

19 MALFIXATION Twisting leads to extrinsic compression of bowel and obstruction at pedicle base If twist persists, mesenteric vessels are occluded and ischemia results

20 MIDGUT VOLVULUS Twist of malfixed intestines around their short mesentery

21 LADD BANDS Patients with malfixation of bowel also frequently have abnormal peritoneal fibrous bands Extend from malpositioned cecum ACROSS DUODENUM and attach to liver, posterior peritoneum, or abdominal wall May contribute to duodenal obstruction

22 Malrotation and Midgut Volvulus

23 Abdominal Pain: Next patient

24 Abdominal Pain: Different patient

25 What do these last 3 cases have in common? All show malrotation and midgut volvulus; malfixed intestines have twisted around their short mesentery

26 INTUSSUSCEPTION coltwell.com yoursurgery.com

27 Intussusception: The Basics thefreedictionary.com

28 Intussusception: The Basics Invagination of a segment of intestine, the intussusceptum, into a distal segment of bowel, the intussuscipiens Mesentery intussuscepts along with bowel Consequences -Obstruction -Ischemia -Necrosis

29 Intussusception: The Basics 90% ileocolic Remainder -Ileoileocolic -Ileoileal -Colocolic (very rare)

30 Intussusception: The Basics In childhood, usually idiopathic At surgery, hypertrophied lymphoid tissue very frequently found in distal small bowel May act as lead point in idiopathic intussusception

31 Intussusception: The Basics In <10% of childhood intussusceptions, some other pathologic lesion serves as leadpoint Leadpoints can occur at any age -More common if <1 month or > 4 years old -In those age groups, may see lead points in up to 50%

32 Intussusception: Leadpoints Most common: Meckel diverticulum Other leadpoints -Enteric duplication cyst -Polyp, ileal or colonic -Inflamed appendix -Bowel wall hemorrhage (HSP)

33 Intussusception: Leadpoints Malignant leadpoints More common in older children -Lymphoma -Lymphosarcoma In cystic fibrosis, abnormal stool can serve as leadpoint

34 Intussusception: Demographics 75% under 2 years old -Majority between 3 months and 3 years Peak incidence between 5 and 9 months Boys > girls

35 Intussusception: Demographics More common in winter and spring -Viral infections more common then In some institutions, intussusception common throughout the year Only minority of patients with intussusception have identifiable viral prodrome

36 Intussusception: The Basics Most develop abdominal pain -Usually intermittent Attacks may be accompanied by drawing up of legs on abdomen -Nonspecific

37 Intussusception: The Basics Vomiting frequently present, may be bilious Bowel movements may be normal at first Stool often eventually contains blood

38 Intussusception: The Basics Blood may be occult May be mixed with mucus, producing classic currant jelly stool Currant jelly: pondpond.blogspot.com eatingfloyd.blogspot.com littlecomptommornings.blogspot.com

39 Intussusception May be lethargic; lethargy may be sole or most striking symptom Abdominal palpation may reveal mass -Typically sausage-shaped -Often in RLQ

40 Intussusception Radiologic Diagnosis Evaluation should begin with abdominal x-rays, 2 views, prone and left lateral decub No agreement on utility of x-rays, but necessary to exclude free air May be able to exclude intussusception Most children with intussusception have abnormal abdominal x-rays

41 Intussusception Radiologic Diagnosis Abnormalities on x-ray correctly suggest the diagnosis -Most intussusceptions are ileocolic -Leading edge of intussusceptum usually reaches hepatic flexure or transverse colon Usually will not be able to identify cecum and right colon

42 Intussusception Radiologic Diagnosis Paucity gas in proximal small bowel, Presence of gas in normal or dilated distal small bowel Lateral location (in expected position of right colon) of distal small bowel Very suggestive of intussuception, due to distal small bowel being carried with the intussusceptum

43 Intussusception Radiologic Diagnosis In about 50% of cases, may see the actual mass of the intussusceptum Specificity of this finding is increased by presence of characteristic lucencies within the mass -Occasionally see 2 concentric rings within a soft tissue density

44 Intussusception Radiologic Diagnosis Rings probably represent mesenteric fat trapped in intussusceptum Usually to right of spine, target sign Presence of air outlining leading edge of intussusceptum, crescent sign, is virtually pathognomonic of intussusception

45 Intussusception Diagnosis ULTRASOUND! absolutemed.com

46 Intussusception: Diagnosis WHY ULTRASOUND? Sensitivity: % -In hands that are experienced, sensitivity of ultrasound is essentially 100% Specificity: % False positives -Stool -Inflammatory bowel disease -Intramural hematoma

47 Intussusception: Ultrasound WHAT S NECESSARY On transverse images, look for complex mass with alternating concentric hypoechoic and hyperechoic rings Doughnut or target sign

48 Intussusception: Ultrasound WHY DOES IT LOOK LIKE THAT? Mucosa and submucosa are hyperechoic Muscularis is hypoechoic

49 Intussusception: Ultrasound Diameter of intussuscepted bowel often exceeds 3 cm Intussusception may look like a kidney, pseudokidney sign, with alternating hypoechoic and hyperechoic bands

50 Intussusception: Ultrasound Other findings associated with intussusception -Dilated small bowel proximal to site of obstruction -Peritoneal fluid -Inversion of mesenteric vessels

51 INTUSSUSCEPTION TREATMENT Fluoroscopically-guided air or hydrostatic reduction Presence of blood flow on color Doppler imaging suggests viable bowel and reducible intussusception Absence of blood flow suggests higher likelihood of ischemia and lower likelihood of reduction

52 Intussusception Lower likelihood of reduction Bowel wall thickness greater than 1 cm Large amounts of trapped peritoneal fluid within intussusception Lymph nodes >1cm in diameter

53 Intussusception: Treatment AIR ENEMA CANNOT exceed 120 mm Hg. Period. Why? Rate of perforation increases when pressure exceeds 120 mm Hg spinalneedle.com

54 Intussusception Small Bowel Intussusception Transient small bowel intussusception is common, particularly in children with hyperperistaltic bowel Tends to occur in young children, mean age 4 years Most commonly involves proximal small bowel

55 Intussusception Small Bowel Intussusception Clinical findings similar to those of ileocolic intussusception -Abdominal pain -Vomiting -Diarrhea But no palpable mass or currant jelly stool

56 Intussusception Small Bowel Intussusception If small bowel intussuception persists, patient needs to go to surgery because small bowel intussusception cannot be reduced by air or hydrostatic enemas

57 11 month-old male Supine abdominal radiograph from OSH

58 11 month-old male Ultrasound from OSH

59 Ultrasound >3 hours later

60 Abdominal radiographs

61 Air enema reduction of intussusception Scout image

62 Successful reduction of intussusception with air enema

63 Repeat ultrasound No residual intussusception

64 Next patient: 18-month-old male with vomiting and somnolence Acute abdomen, 2 views

65 18-month-old male with vomiting and somnolence Ultrasound

66 18-month-old male with vomiting and somnolence Ultrasound

67 scout image Air enema: Scout image

68 Air enema

69 Repeat Ultrasound Residual intussusception

70 Left lateral decubitus view Residual intussusception, no free air

71 Air enema Intussusception successfully reduced

72 Repeat Ultrasound No intussusception

73 Urinary Tract Infection health-reply.com

74 . ACR (American College of Radiology) Appropriateness Criteria American College of Radiology ACR Appropriateness Criteria Clinical Condition: Urinary Tract Infection Child Variant 1: Age <2 months, febrile urinary tract infection Radiologic Procedure Rating Comments RRL* US kidneys and bladder 9 O X-ray voiding cystourethrography 6 Consider in boys and in presence of sonographic abnormality. Radionuclide cystography 5 Consider in girls. Renal cortical scintigraphy 3 Not a first-line test. Could be used 4-6 months after UTI to detect scarring. Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

75 ACR (American College of Radiology) Appropriateness Criteria American College of Radiology ACR Appropriateness Criteria Clinical Condition: Urinary Tract Infection Child Variant 2: Age >2 months and 3 years, febrile urinary tract infection with good response to treatment Radiologic Procedure Rating Comments RRL* US kidneys and bladder 9 Renal cortical scintigraphy 5 X-ray voiding cystourethrography 5 May be unnecessary if US in third trimester is normal. Not a first line test. Could be used 4-6 months after UTI to detect scarring. Consider if US or renal cortical scintigraphy is abnormal. O Radionuclide cystography 4 Consider in girls. Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

76 ACR (American College of Radiology) Appropriateness Criteria American College of Radiology ACR Appropriateness Criteria Clinical Condition: Urinary Tract Infection Child Variant 3: Age >3 years, febrile urinary tract infection with good response to treatment Radiologic Procedure Rating Comments RRL* US kidneys and bladder 6 Yield decreases with age. O Renal cortical scintigraphy 3 Not a first-line test. Could be used 4-6 months after UTI to detect scarring. X-ray voiding cystourethrography 3 Consider if abnormal US. Radionuclide cystography 3 Consider in girls. Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

77 ACR (American College of Radiology) Appropriateness Criteria American College of Radiology ACR Appropriateness Criteria Clinical Condition: Urinary Tract Infection Child Variant 4: Atypical (poor response to antibiotics within 48 hours, sepsis, urinary retention, poor urine stream, raised creatinine, or non-e. coli UTI) or recurrent febrile urinary tract infection Radiologic Procedure Rating Comments RRL* US kidneys and bladder 9 O X-ray voiding cystourethrography 7 Radionuclide cystography 7 Consider in girls. Renal cortical scintigraphy 6 CT abdomen and pelvis with contrast 3 CT abdomen and pelvis without contrast 2 CT abdomen and pelvis without and with contrast 1 Could be used 4-6 months after UTI to detect scarring. Not a first-line test. If abscess is suspected based on US imaging. May be useful in rare cases when stone disease suspected. Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate *Relative Radiation Level

78 Today s Discussion I. Clinically important demographics pertaining to children in this region II. The most common and important studies in pediatric imaging, e.g,. x-rays, fluoro, ultrasound, CT, and MRI III. Relative costs of imaging studies: $ MRI CT > US > IV. American College of Radiology (ACR) Appropriateness Criteria for Pediatric Imaging and how to access them

79 Today s Discussion V. Using the ACR Appropriateness Criteria, selecting best study(ies) to order for a particular clinical scenario, e.g., Vomiting -Appropriate use of upper GI series, barium swallow, and modified barium swallow -Findings in hypertrophic pyloric stenosis, malrotation and midgut volvulus, and intussusception Urinary tract infection

80 That s all for today!

81 Any questions?