challenges of imaging pediatric abdominal emergencies
TRANSCRIPT
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Challenges of Imaging Challenges of Imaging Pediatric Abdominal Pediatric Abdominal
EmergenciesEmergencies
Susan D. John, M.D.
RSNA 2013
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Challenges of Imaging ChildrenChallenges of Imaging Children
• History and physical exam less reliable – Site of pain may be very misleading
• Choosing the best initial modality – Organ of interest – Age of the patient
• Differing pathology • Patient cooperation
• Safety issues
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Learning ObjectivesLearning Objectives
• Understand the variations of pathology that cause abdominal pain and vomiting in infants and children
• Plan safe and effective imaging protocols using US, CT, and MRI
• Recognize pitfalls in the diagnosis of pediatric abdominal emergencies with imaging
www.uth.tmc.edu/radiology
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What percentage of patients in your What percentage of patients in your practice are practice are < < 15 15 years of ageyears of age??
• 80 - 100% • 50 – 79% • 25 – 49% • 5 – 25% • < 5%
1
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Abdominal Pain in Infants and ChildrenAbdominal Pain in Infants and Children
• History and physical findings overlap – Diarrhea – Blood in stool – Episodic crying – Poorly localized pain
• Pathologies cluster in specific age groups – Newborn – 1 week – 2 months – 2 - 5 months – 5 months – 2 years – 2 yrs - adolescence
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11 to to 88 Weeks of AgeWeeks of Age • Gastroesophageal reflux • Gastric outlet obstruction
– Pyloric muscle • Spasm • Hypertrophy
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Hypertrophic Pyloric StenosisHypertrophic Pyloric Stenosis
• Infants 3-6 weeks of age – Younger patients
increasing • Projectile vomiting
– Non-specfic • US is best modality
– 7-12 mHz transducer – Fluid-filled stomach
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Normal Normal PylorusPylorus
• 1-2 mm muscle
• Length negligible
• Opens frequently
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TransverseTransverse
Longitudinal
Hypertrophic Pyloric Stenosis
• 3 mm + muscle • 1.5 cm + length • Little or no emptying
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Pitfall Pitfall –– the empty stomachthe empty stomach!!
• Administer fluid (sugar water), if needed
• Oblique patient to right
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CongenitalCongenital//Developmental Developmental Abnormalities Abnormalities
• Incomplete duodenal obstruction – Diaphragm – Stenosis
• Acute duodenal obstruction – Midgut volvulus
• Colon obstruction – Hirschprung disease
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3 month old with increasing vomiting
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Early incomplete obstruction can progress to complete obstruction later
Duodenal Web
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Duodenal Web
• Incomplete obstructing band
• Second portion of duodenum
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Annular PancreasAnnular Pancreas
7 week old with vomiting
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17 17 year old with new year old with new onset abdominal pain onset abdominal pain
with mealswith meals Annular Pancreas
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Midgut Midgut VolvulusVolvulus
• Acute obstruction
• Minimal findings on radiographs
• Contrast exams versus US
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Obstruction 3rd portion of duodenum = midgut volvulus
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1 week old with vomiting
Recurrent vomiting 2 wks s/p Ladd’s procedure
Midgut Volvulus
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Abdominal Heterotaxy and VolvulusAbdominal Heterotaxy and Volvulus • High incidence of
malrotation in children with abdominal heterotaxy
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Duodenojejunal junction and Duodenojejunal junction and cecum on same side of cecum on same side of
abdomen may indicate riskabdomen may indicate risk
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Duodenal obstruction in infants and Duodenal obstruction in infants and childrenchildren::
1) Cannot be evaluated with US. 2) Always requires emergent surgery. 3) Requires emergent surgery when complete obstruction occurs in the 2nd portion of the duodenum. 4) Requires emergent surgery when complete obstruction occurs in 3rd portion of duodenum.
2
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55 months to months to 22 yearsyears • Ileocolic intussusception
– Episodes of crying – Vomiting – Drawing up legs – Lethargy – Bloody (current jelly)
stools – Palpable abdominal
mass
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IntussusceptionIntussusception • Causes
– Lead points • Meckel’s diverticulum • Polyps • Intestinal duplication cyst
– Lymphoma – Henoch-Schoenlein purpura – Post-operative
• Most are idiopathic – Gastroenteritis/hyperperistalsis
• Consider a lead point if repeated recurrences or age over 4 years
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RadiographsRadiographs
• May be suggestive but often non-specific – Mass effect
along course of colon
– Target sign – Small bowel
obstruction
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Ultrasound for IntussusceptionUltrasound for Intussusception • High frequency (7-12 mHz) transducer • Complex mass
– Target, donut appearance
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• High sensitivity and specificity • If US negative, contrast enema
not needed
Lack of flow with Doppler suggests ischemia, but not a contraindication to non-surgical reduction
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Transient IntussusceptionTransient Intussusception • Common in patients with hyperperistalsis
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NonNon--surgical Reductionsurgical Reduction
• Few contraindications – Peritoneal signs – Free air on radiographs
• Free fluid not a contraindication
• Enema reduction – Hydrostatic
• Fluoroscopy vs. US – Air
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Air Air Enema ReductionEnema Reduction • Advantages
– Faster (less radiation) – Less messy – Higher reduction rate – Smaller hole and less
contamination with perforation
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Can be more difficult to identify residual ileo-ileal intussusception
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PerforationPerforation • Keep below 120
mm Hg to avoid perforation
• Keep 21 g spinal needle handy, in case acute decompression is needed
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22 yrs old and greateryrs old and greater
• Inflammatory conditions predominate – Appendicitis – Mesenteric adenitis – Ileocolitis/gastroenteritis – Henoch-Schoenlein purpura – Hemolytic uremic syndrome – Regional enteritis
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In my practiceIn my practice, , the initial imaging study the initial imaging study performed on children with suspected performed on children with suspected
appendicitis isappendicitis is::
1) Abdomen radiographs 2) Complete abdomen US 3) Right lower quadrant US 4) Contrast-enhanced abdomen US 5) Abdomen/pelvis CT without contrast 6) Abdomen/pelvis CT with contrast
3
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US for AppendicitisUS for Appendicitis • Still accepted as best
first screening exam • Staged approach
using CT for equivocal cases highly accurate – Sensitivity 98.6% – Specificity 90.6% – CT avoided in 53%
Krishnamoorthi, Radiol Jan. 2011
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Appendix Size in AppendicitisAppendix Size in Appendicitis
• 6 mm or > in diameter “abnormal” – PPV – 63% – NPV – 100% – More useful for excluding
appendicitis Rettenbacher, Radiology 2011;
218: 757. • 7 mm or >
– Similar accuracy Goldin, Pediatr Radiol 2011; 41:
993.
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Compressibility Compressibility –– can be difficult can be difficult to to demonstrate with normal appendixdemonstrate with normal appendix
Normal Appendicitis
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Lymphoid Hyperplasia of the Lymphoid Hyperplasia of the AppendixAppendix
• Enlarged lymphoid tissue in the wall of appendix – Response to viral infection
• Can mimic a fluid-filled appendix – Look for central mucosal
stripe • May result in increased
size
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Perforated Perforated AppendixAppendix
• Dilated small bowel • RLQ mass • Colon cut-off • Flank stripe
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Signs of Active or Signs of Active or
Impending Impending PerforationPerforation
• Loss of mucosal lining • Edematous fat • Adjacent fluid
collections
Secondary findings can be strong indicators of appendicitis Wiersma, Eur Radiol 2009; 19: 455.
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Thickened Echogenic Fat = Inflammation
Complex free fluid = peritonitis
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Abscesses Mimic Other PathologiesAbscesses Mimic Other Pathologies
Hematometrocolpos
Abscess from perforated appendicitis
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Appendiceal Abscess
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AbdominalAbdominal//Pelvic CT in ChildrenPelvic CT in Children
• IV contrast – 2cc/kg • Oral or rectal contrast often not needed
– Oral water may be a good alternative • Coronal reconstruction • Take measures to reduce radiation
exposure
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Advice for Decreasing Dose in Advice for Decreasing Dose in Pediatric CT Pediatric CT Goske et alGoske et al, , AJR AJR ((20082008))
• “Child-size” your CT (kVp, mA) • Pediatric protocols on IG website
(www.imagegently.org) • Scan only when necessary • Scan only the indicated region
– Requires point of care protocoling • Scan only once
– Delayed imaging not needed for abdominal pain; for trauma scans should be restricted to those cases with high risk injuries on initial pass images
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Challenges with CTChallenges with CT • Lack of intra-abdominal fat
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Planar ReformattingPlanar Reformatting
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Ultrafast Ultrafast 33T MRI for AppendicitisT MRI for Appendicitis • 42 children
– Ages 4-17 • No sedation or contrast • TSE sequences w/wo fat
saturation • Scan times less than 9
minutes • Normal appendix seen 43%
of the time • Sens/spec 100/99%
– PPV 98% – NPV 100%
Johnson, AJR 2012, Jun 198:1424
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MRI for Pediatric AppendicitisMRI for Pediatric Appendicitis • Moore, Pediatr Radiol, Mar
2012; 42:1056. – 208 patients, 4-17 years – 4 sequences 1.5T (cor T2,
axial T2 w/wo fat sat, cor SPAIR)
– Scan time mean = 14.2 mins – Normal appendix seen in
36% of true negative cases – Sens/spec 97.6/97.0 %
• PPV 88.9% • NPV 99.4%
• Herliczek, AJR, May 2013; 200: 969. – 60 patients, 7-17 years – Multiple sequences, 1.5 and
3T (T2 TSE, HASTE, STIR, T1, T1 in/out phase)
– Scan time mean = 30.5 mins – Normal appendix seen in 83-
88% of cases – Sens/spec 100/96
• PPV 83% • NPV 100%
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AppendicitisAppendicitis
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Calcified appendicolith with distal Calcified appendicolith with distal obstructionobstruction
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3 3 yr yr 11 11 month old with normal appendixmonth old with normal appendix
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Normal appendix
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Which of the following statements is Which of the following statements is correctcorrect??
1) Appendiceal diameter of 6 mm is a strong positive predictor of appendicitis. 2) Ultrafast MRI for appendicitis can be performed without sedation in children under the age of 6 years. 3) US for pyloric stenosis should be performed after fasting. 4) Air enema reduction of intussusception should not be performed if US shows bowel obstruction and free fluid.
4
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Unexpected DiagnosesUnexpected Diagnoses
5 yr old with abdominal pain, fever, and vomiting
Left Lower Lobe Pneumonia
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4 4 year old with abdominal painyear old with abdominal pain
3 weeks later
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Leukemia with pathologic compression fractures
Young children localize pain poorly; “abdominal pain often reflects pathology in spine, pelvis, or chest
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Abdominal Emergencies in Abdominal Emergencies in ChildrenChildren
• Age appropriate diagnoses • Multi-modality imaging often
needed – Use ultrasound whenever possible – Lower the dose when using CT – Consider MRI when US not diagnostic
RSNA 2013
www.uth.tmc.edu/radiology