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Imaging, Pediatric Respiratory Tract
Ron Cohen 1
Advances and Controversies in Clinical Pediatrics
Go With the Flow: Current Pediatric GU Imaging
Ronald A. Cohen M.D.Children’s Hospital Oakland
Pediatric GU Imaging
Imaging as a tool
Radiography (Fluoroscopy)Radiography (Fluoroscopy)UltrasoundUltrasoundComputed tomographyComputed tomographyNuclear Medicine Nuclear Medicine Magnetic Resonance ImagingMagnetic Resonance Imaging
Imaging, Pediatric Respiratory Tract
Ron Cohen 2
Pediatric GU Imaging
Common conditions Common conditions Congenital, infectious, trauma, neoplasm, misc.Congenital, infectious, trauma, neoplasm, misc.
ControversiesControversiesUTI UTI -- ? VCUG, imaging for renal damage? VCUG, imaging for renal damagePrenatal Prenatal hydronephrosishydronephrosis -- ? Work? Work--up / followup / follow--upup
Advances Advances Magnetic Resonance Magnetic Resonance UrographyUrography (MRU)(MRU)CT angiographyCT angiographyVoiding Voiding urosonographyurosonography
Pediatric GU Imaging
Congenital anomaliesCongenital anomaliesInfectionInfectionTraumaTraumaNeoplasmNeoplasmMisc.Misc.
Duplex Kidney Weigert – Meyer Rule
Multicystic Dysplastic kidney
Imaging, Pediatric Respiratory Tract
Ron Cohen 3
Posterior Urethral Valve unilateral VUR , hydronephrosis
Pediatric GU Imaging
Congenital anomaliesCongenital anomaliesUPJUPJUVJ Congenital UVJ Congenital megauretermegaureterDuplex collecting systemDuplex collecting systemMulticysticMulticystic dysplastic kidneydysplastic kidneyEctopic kidneyEctopic kidneyHorseshoe kidneyHorseshoe kidneyPosterior urethral valvesPosterior urethral valvesUterine anomaliesUterine anomalies
Pediatric GU Imaging
InfectionInfectionUTIUTIRenal Renal abcessabcessTuberculosisTuberculosis
VCUG - Vesicoureteral reflux Nuclear Medicine – Radionuclide cystogram
Post - void
Imaging, Pediatric Respiratory Tract
Ron Cohen 4
pyelonephritis
Renal tuberculosis
5/29/2009
PyelonephritisHx - r/o appy
Sickle cell - renal infarctHx- Abdominal pain
4:14am2:34am
DMSA – Renal scan (cortical imaging
MRU – VUR and reflux nephropathy
Pediatric GU Imaging
TraumaTraumaFracture / lacerationFracture / lacerationVascular injuryVascular injury
Imaging, Pediatric Respiratory Tract
Ron Cohen 5
Renal Trauma
Pediatric GU Imaging
NeoplasmNeoplasmWilmsWilms tumortumorClear cellClear cellRenal cell carcinomaRenal cell carcinomaMedullaryMedullary cystic carcinoma (Sickle Cell trait)cystic carcinoma (Sickle Cell trait)MultilocularMultilocular Cystic Cystic NephromaNephroma
Wilm’s Tumor Multilocular Cystic Nephroma
Rhabdomyosarcoma – bladder baseRenal failure – beware iodinated contrast (CT)
and gadolinium (MR)
CT - dx MR – f/u
Pediatric GU Imaging
Congenital anomaliesCongenital anomaliesInfectionInfectionTraumaTraumaNeoplasmNeoplasmMisc.Misc.
Hypertension, Hypertension, UrolithiasisUrolithiasis, Cystic renal disease, , Cystic renal disease, Intersex, Testicular and Ovarian torsionIntersex, Testicular and Ovarian torsion
Imaging, Pediatric Respiratory Tract
Ron Cohen 6
Torsion left testicle – manual detorsion Common Controversies
WorkWork--up of UTIup of UTIVCUG VCUG (Fluoroscopy vs. (Fluoroscopy vs. NucNuc. Med.). Med.)Imaging renal scarring Imaging renal scarring (US (US --NucNuc. Med. . Med. -- MRUMRU))
Prenatal Prenatal hydronephrosishydronephrosis (Ultrasound/VCUG)(Ultrasound/VCUG)Urinary tract obstruction Urinary tract obstruction ((LasixLasix NM vs. MRU)NM vs. MRU)
Common ControversiesWorkWork--up of UTIup of UTIPrenatal Prenatal hydronephrosishydronephrosisUrinary tract obstructionUrinary tract obstruction
Review of literature Review of literature Urology, Nephrology, RadiologyUrology, Nephrology, Radiology-- recommendationsrecommendations
““controversialcontroversial””, , ““unclearunclear””, , ““not well definednot well defined””, , ““varies widelyvaries widely””
UTI - summary
US US –– r/or/o obstruction, anomalies obstruction, anomalies VCUG VCUG
Initial fluoroscopicInitial fluoroscopicFollowFollow--up nuclear medicine (less radiation)up nuclear medicine (less radiation)Trend Trend –– less VCUG for nonless VCUG for non--febrile UTI > 2 febrile UTI > 2 y.oy.o..SonographicSonographic VCU VCU –– Europe Europe
Renal scarring Renal scarring –– US US –– DMSA DMSA -- MRUMRUManagement Management –– VUR VUR --prophylactic antibiotics prophylactic antibiotics (decrease risk of febrile UTI), (decrease risk of febrile UTI), followfollow--up VCUG, ? up VCUG, ? DefluxDeflux or surgeryor surgery
Prenatal Hydronephrosis
11--5 %5 %Severe Severe –– early postearly post--natal USnatal US
UPJ, other anomaliesUPJ, other anomaliesBoys Boys –– posterior urethral valveposterior urethral valve
Mild/moderate Mild/moderate –– wait 1 week for postwait 1 week for post--natal US natal US FollowFollow--up US up US –– VCUG if hydro persistsVCUG if hydro persistsSignificant pathology Significant pathology –– Obstructive Obstructive uropathyuropathy, VUR, VUR
metameta--analysis (Pediatrics 118, 2006 Lee, RS et al) analysis (Pediatrics 118, 2006 Lee, RS et al) Mild 12 %Mild 12 %Mod 45%Mod 45%Severe 88%Severe 88%
Obstructive Uropathy
No clinically useful classificationNo clinically useful classificationObstruction is usually chronic and partial Obstruction is usually chronic and partial
““compensated hydronephrosiscompensated hydronephrosis””balance between urine flow and drainagebalance between urine flow and drainage
Aims of imaging:Aims of imaging:1) to identify children who, if left untreated, will 1) to identify children who, if left untreated, will develop renal damagedevelop renal damage2) estimate how much function is recoverable2) estimate how much function is recoverable
Imaging, Pediatric Respiratory Tract
Ron Cohen 7
Acute-on-Chronic Obstruction
Compensated Hydronephrosis
Low flow rate High flow rate
Decompensated Hydronephrosis
Low flow rate High flow rate
Response to Fluid Challenge
UPJ Obstruction Lasix renogram (Nuclear Medicine)
QuickTime™ and aH.264 decompressor
are needed to see this picture.
Current concepts and Advances
MR MR UrographyUrography (Courtesy Dr. Damien Grattan(Courtesy Dr. Damien Grattan--Smith)Smith)
Anatomic imagingAnatomic imagingFunctional imagingFunctional imaging
MR UrographyAnatomic imagingAnatomic imaging
T2 weighted T2 weighted -- (fluid in collecting system)(fluid in collecting system)dynamic contrast enhanced imagingdynamic contrast enhanced imaging
Functional imagingFunctional imagingdifferential renal functiondifferential renal functionindividual kidney GFR individual kidney GFR -- Patlak PlotPatlak Plotsignal intensity versus time curvessignal intensity versus time curvesassess drainageassess drainage
MRUEvaluate anatomy and physiology simultaneouslyEvaluate anatomy and physiology simultaneouslyNew insightsNew insights
not all UPJnot all UPJ’’s are the sames are the samedifferent prognostic informationdifferent prognostic informationrandomized controlled trialsrandomized controlled trials
•• who will benefit from surgerywho will benefit from surgery•• estimate how much function is recoverableestimate how much function is recoverable
MRU – functional information
Immediate 3 mins 10 mins
Imaging, Pediatric Respiratory Tract
Ron Cohen 8
Pyelonephritis and Scarring - MRU
Acute Pyelonephritis 6/03 Renal Scarring 1/04
MRU – VUR and reflux nephropathy
MRU – Duplex with VUR lower moiety
MRU Hydroureteronephrosis
Current concepts – Pediatric GU Imaging
Imaging recommendations in Imaging recommendations in paediatricpaediatricuroradiologyuroradiology: minutes of the ESPR : minutes of the ESPR workgroup session on urinary tract workgroup session on urinary tract infection, fetal infection, fetal hydronephrosishydronephrosis, urinary tract , urinary tract ultrasonographyultrasonography and voiding and voiding cystourethrographycystourethrography
RiccabonaRiccabona et al Pediatric Radiology 38;2 138et al Pediatric Radiology 38;2 138--145 Feb 2008145 Feb 2008
Pediatric GU Imaging
Imaging toolsImaging toolsUS, CT, NM, MRUS, CT, NM, MR
Pediatric Pediatric dxdxInfection, Tumor,Infection, Tumor,
Congenital, TraumaCongenital, TraumaControversiesControversies
UTIUTIPrenatal Prenatal hydronephrosishydronephrosis
AdvancesAdvancesMRUMRUUS US
Imaging, Pediatric Respiratory Tract
Ron Cohen 9
Nephrogenic systemic fibrosis
NephrogenicNephrogenic systemic fibrosis (NSF)systemic fibrosis (NSF)Serious complication of gadolinium (MR contrast)Serious complication of gadolinium (MR contrast)Renal failure patientsRenal failure patientsMay be fatalMay be fatal
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