Guide Pediatric gastrointestinal imaging and intervention, Volume 1

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Because of the constipation the child will start to vomit. The presence of a microcolon on the colon enema indicates that the meconium has not reached the colon and the obstruction is situated proximal to the colon.

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As with jejunal atresia, ileal atresia results from an in utero ischemic event. More atretic foci can be present simultaneously, but the distal ileum is the most common site to be involved. Radiographs will show multiple dilated bowel loops and absence of air in the colon as seen on the image on the left. A colon enema will show a microcolon with contrast filling ending blind in the ileum arrow on image on the right. Meconium ileus occurs nearly exclusively in patients with cystic fibrosis.

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Due to the exocrine dysfunction of the pancreas and abnormal intestinal secretions, the meconium is abnormally thick and becomes impacted in the ileum. It is the neonatal equivalent of DIOS distal intestinal obstruction syndrome. Sometimes radiographs demonstrate typical 'soap bubbles', which represent captured air between meconium pellets. The tenacious meconium prevents the occurence of air fluid levels on the decubitus image. Bowel loops are usually of different caliber and not all loops are dilated.

Colon enema shows a microcolon with stacked meconium pellets in the ileum. Once you have made the diagnosis of a meconium ileus, you can opt to set in moderately hyperosmolar contrast for therapeutic purposes as this can help to dissolve the meconium and act as an effective enema.

Since the hyperosmolar contrast will create a fluid shift and thereby may cause dehydration, it is of importance to clearly communicate with the clinician to administer extra fluids and secure continuous careful surveillance. Here two cases of meconium ileus. There is a microcolon and there are multiple meconium pellets in the distal small bowel arrows.

Meconium plugging in the left colon occurs when the colon is functionally immature with little motility. There is an association with maternal diabetes and drug use in pregnancy. The condition is temporarily and when the meconium plugs resolve, the colon distends normally and functions normally.

The neonate is otherwise healthy and there is no association with cystic fibrosis. There is no air in the rectum on the radiograph. Colon enema shows a normal rectal diameter which excludes Hirschsprung disease. A microcolon is absent. Meconium is found throughout the colon, but most typically found in the left colon, which may also have a smaller diameter. Just as with a meconium ileus, you may now opt to give a hyperosmolar contrast enema to help resolve the meconium see above.

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In Hirschsprung disease ganglion cells are absent in the distal part of the colon. Because the intestinal ganglion cells migrate in a craniocaudal direction, the area of aganglionosis always involves the rectum. More extensive disease extends orally in a contiguous fashion. The involved bowel has a small diameter and the bowel proximal to the affected segment is dilated. It is important to describe the length of the affected segment. Most cases are short-segment and total aganglionosis is rare.

In case of total aganglionosis the diagnosis is difficult, because the entire colon has a small caliber and resembles a microcolon. Start the enema in the lateral position to evaluate the rectum.

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Save cine images from the first contrast injection, as with progressive filling signs can become obscured by too much bowel distention. Normally the rectum should be wider than the sigmoid. The definitive diagnosis of Hirschsprung disease is confirmed with biopsy. The diagnosis of anal atresia is usually clinically straightforward by inspection and digital palpation. Anal atresia is part of the spectrum of anorectal and cloacal malformations and is a complex disorder. Imaging and treatment should be performed in specialized centers.

Initially plain films and ultrasound can be used to show the position of the malformation and the need for a colostomy.

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At a later stage and prior to definitive surgery a combination of fluoroscopic studies and MRI will be used to show the complex anatomy of anorectal, genitourinary, pelvic and perineal structures and associated fistulas. Necrotizing enterocolitis is a severe bowel inflammation. The etiology is not entirely clear and seems to be a combination of immature bowel mucosa, infection and ischemia. Initially radiographs are nonspecific and may only show bowel dilatation. Absence of a changing bowel pattern over time is worrisome. Pneumatosis intestinalis and portal venous air pneumoportogram can both be seen on radiographs and with ultrasound.

The most feared complication is perforation. NEC occurs most often, but not exclusively, in prematures. Neonates with severe stress, for example with cardiac disease, are also at risk. Clinically, retentions and bloody stools can be a key to the diagnosis. The images show a typical case of NEC with pneumatosis intestinalis. On the horizontal beam image there is no sign of free air. Here images of a neonate who developed NEC. At this early stage the radiograph only shows non-specific bowel dilatation.

At this stage you cannot make the diagnosis.

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Notice the air in the portal vein arrow and peripheral portal branches. This is seen on the X-Ray and on ultrasound. In this patient with NEC notice all the airbubbles in the wall of the bowel and within the liver. Sometimes necrotizing enterocolitis can have a subclinical course and strictures are the only sign the newborn has endured the disease.

The image on the left is taken 6 days after birth and shows distended bowel with pneumatosis intestinalis. A colon enema at 6 weeks of age shows a stricture in the colon descendens arrow. Projectile vomiting is the key feature in patients with hypertrophic pyloric stenosis. The cause of the muscle hypertrophy which causes the gastric outlet obstruction is unknown.

There is a familial predisposition and it is more common in boys. Hypertrophic pyloric stenosis typically presents after the neonatal period, at the age of weeks. However early presentation can also occur. Ultrasound in a fasting child will show retained fluid in the stomach. There is no passage along the hypertrophic pyloric muscle. For optimal viewing the child must be positioned right side down and if the stomach is empty it should be filled by drinking Pedialyte or glucose solution during the examination. If the stomach is too full, the child can be placed on the left side to help the pylorus to move anteriorly.

The transversal diameter of the single muscle wall is the most reliable measurement to diagnose pyloric muscle hypertrophy. A measurement of more than 3 mm on a transverse image indicates hypertrophy. A transverse total diameter more than 14 mm and a total length of the pyloric canal more than 15 mm support the diagnosis. Neonates and especially prematures have a relatively weak abdominal wall and inguinal hernias are common, especially in boys. In case of multiple dilated bowel loops on the radiograph, always check the groins for the presence of a hernia containing a bowel loop figure.

Ultrasound is the modality of choice to evaluate hernias, and in girls it is important to look for herniation of the ovaries. Study the image. What are the findings and what is your diagnosis. Then scroll through the images for the diagnosis. Differential diagnosis. The table on the left lists the differential diagnosis for acute abdomen in the neonate. Abdominal radiograph In suspected neonatal obstruction the first step is an abdominal radiograph.

The table shows the normal progression of air in the gastrointestinal tract. On the image on the right there is massive dilatation in a neonate with jejunal atresia. Number of dilated loops? Small bowel or colon? Airfilled rectum? In Hirschsprung's disease there is usually no air in the rectum or only a thin stripe of air. Pneumatosis intestinalis? What are the findings? Then scroll to the next image. Findings: What at first sight looks like granular feces in the bowel yellow arrow is actually caused by gas in the bowel wall seen en face. Air in the bowel wall is most easily recognized when seen in profile as linear black lines that parallels the bowel lumen green arrows.

Free air and ascites? Upper GI study In case of a typical complete high obstruction see below on the radiograph no further imaging is needed and upper GI series are not advised as they may only cause aspiration. In malrotation, which we will discuss later, Treitz is positioned to the right of the spine. Colon enema In cases of suspected low obstruction, a colon enema is indicated.

Ultrasound Ultrasound plays a limited role in depicting GI tract pathology as the gas-filled bowel will strongly reflect the ultrasound beam.

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In case of a volvulus, the bowel is not necessarily dilated and ultrasound can show the twisting of the mesenterial vessels. Pneumatosis intestinalis in NEC can be seen as small echogenic dots within the bowel wall. Hypertrophic pyloric stenosis, which we will discuss later is a typical ultrasound diagnosis. Esophageal atresia First look at the image and describe the findings.

The findings are: Feeding tube cannot be passed and lies in a dilated proximal esophagus Normal air in the abdomen. Diagnosis: esophagus atresia with a distal tracheo-esophageal fistula Esophagus atresia is an anomaly which arises in the fourth week of the embryogenesis, at a stadium in which the trachea and esophagus should separate from each other.

Less common is: no fistula - no air in stomach proximal fistula - no air in stomach two fistulas - air in stomach. First look at the image and describe the findings. The findings are: Feeding tube cannot be passed and lies in the proximal esophagus Gasless abdomen This indicates that there is no distal tracheo-esophageal fistula Cases without a distal fistula can be suspected antenatally when there is a polyhydramnion and an empty stomach. Duodenal atresia In duodenal atresia the duodenum fails to canalize properly late in the first trimester and a web or several webs occur. The findings are: Double bubble without distal bowel gas.

This confirms the diagnosis of duodenal atresia and no further imaging is needed. Here another case of duodenal atresia with the typical double bubble sign. Duodenal web First look at the image and describe the findings. The findings are: Dilated stomach To a lesser extent dilated proximal duodendum Distal bowel gas is present indicating an incomplete duodenal obstruction. Radiographs may show a double bubble, but with distal bowel gas being present.

Here another case of a duodenal web. The findings are: Dilated proximal duodenum asterix Small amount of contrast passes through the duodenal web to the distal duodenum arrow. Malrotation In the developing embryo growth of the bowel requires herniation into the omphalomesenteric sac.

Left Normal situation with the duodenum retroperitoneal. Treitz ligament is on the left side of the spine. The small intestine is predominantly on the left. The cecum is in the right lower quadrant There is a long mesentery. Middle Displacement of Treitz inferiorly and rightward. The small intestine is found predominantly on the right. Fibrous bands course over the vertical portion of the duodenum causing obstruction. Right Volvulus due to short mesentery.

Ischemic bowel. The abdominal radiograph is non-specific image on the left The upper GI study clearly demonstrates that the small bowel projects to the right of the spine. The malrotation will become symptomatic only when a volvulus occurs due to the short mesentery or when the Ladd's band obstruct the duodenum Both presentations are most common in the neonatal period. Acute volvolus is a life-threatening presentation and requires prompt surgical intervention.

The upper GI-study shows a malrotation complicated by a volvulus. This results in the typical corkscrew or reversed 3 sign. Jejunal atresia Jejunal atresia is the most frequent cause of upper intestinal obstruction. Ileal atresia As with jejunal atresia, ileal atresia results from an in utero ischemic event. Meconium ileus Meconium ileus occurs nearly exclusively in patients with cystic fibrosis. Meconium plug syndrome Meconium plug syndrome is also known as small left colon syndrome. Hirschsprung disease In Hirschsprung disease ganglion cells are absent in the distal part of the colon.

Here another case of Hirschsprung disease. Anal atresia The diagnosis of anal atresia is usually clinically straightforward by inspection and digital palpation. Necrotizing enterocolitis Necrotizing enterocolitis is a severe bowel inflammation. Here another typical case of NEC. Angiographically negative acute arterial upper and lower gastrointestinal bleeding: Incidence, predictive factors, and clinical outcomes. Shin JH.

Recent update of embolization of upper gastrointestinal tract bleeding. Korean J Radiol ;13 Suppl 1:S Transcatheter arterial embolization in gastric cancer patients with acute bleeding. Eur Radiol ; Arterial embolotherapy for upper gastrointestinal hemorrhage: Outcome assessment. J Vasc Interv Radiol ; Kerr SF, Puppala S. Acute gastrointestinal haemorrhage: The role of the radiologist. Postgrad Med J ; Clinical variables associated with positive angiographic localization of lower gastrointestinal bleeding.

ANZ J Surg ; Safety and efficacy of superselective angioembolization in control of lower gastrointestinal hemorrhage. Am J Surg ; Arterial embolotherapy for endoscopically unmanageable acute gastroduodenal hemorrhage: Predictors of early rebleeding. Clin Gastroenterol Hepatol ; Angiographic embolization for gastroduodenal hemorrhage: Safety, efficacy, and predictors of outcome.

Arch Surg ; Upper gastrointestinal hemorrhage and transcatheter embolotherapy: Clinical and technical factors impacting success and survival. Transarterial embolization of nonvariceal gastrointestinal bleeding: Our experience. West Afr J Radiol ; Table 4: Flow chart of the result Click here to view. Figure 1: Right hepatic artery aneurysm a with active extravasations into duodenum, b postcoil embolization Click here to view. Figure 2: Multiple aneurysms in patients with rectal bleeding: a Left colic artery aneurysm pre-embolization, b common hepatic artery aneurysm for which patient was asymptomatic, c microcoils deployed in left colic artery aneurysm Click here to view.

Figure 3: Right hepatic artery aneurysm a pre-embolization, b thrombin injection into aneurysm under combined sonographic and DSA guidance, c postthrombin injection image showing only residual contrast within aneurysm Click here to view.