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Scoliosis surgery has been associated with pancreatitis and acalculous cholecystitis, and also has been implicated as a risk factor for cholelithiasis. A prospective study of 36 children and adolescents undergoing scoliosis surgery was performed using ultrasound to determine the incidence of cholelithiasis following spine surgery. The patients underwent abdominal ultrasound exams preoperatively, immediately postoperatively, and then at intervals following surgery with 2-5-year follow-up. Four of 36 patients (11.1%) (one male, three female) developed gallstones, although all had been free of gallstones after surgery. The gallstones appeared between 2 + 5 and 5 years after surgery. Those with gallstones were not different from those without with respect to 14 factors. It is concluded that scoliosis surgery is not a risk factor for gallstones, because of the delay in onset of cholelithiasis after surgery. Furthermore, the prevalence of gallstones in this study sample is not greater than that reported in historical control studies of European young adults.

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Two hundred abdominal computed tomographic (CT) scans in 200 patients, 100 performed with low osmolality contrast (ioversol 68%, 100 ml) and 100 performed with high osmolality contrast (diatrizoate meglumine 60%, 150 ml), were retrospectively evaluated for the presence of renal streak artifact. Contrast was administered by hand injection at a rate of approximately 1-2 ml/s and sequential scanning was employed. Of the scans performed with high osmolality contrast, 70% had no artifact, 28% had minimal artifact, and only 2% had marked artifact. Only 26% of the exams performed with low osmolality contrast were artifact-free, whereas 53% demonstrated minimal artifact and 21% demonstrated marked artifact. The likelihood of encountering renal streak artifact when using low osmolality contrast agents is almost seven times greater than when high osmolality contrast agents are used.

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Two cases of solitary renal vein varices are reported which presented as incidental findings on abdominal computed tomography (CT) and were initially thought to represent retroperitoneal lymph nodes. Contrast-enhanced CT, magnetic resonance imaging (MRI), and Doppler ultrasound (US), all demonstrated the vascular nature of these masses suggesting the correct diagnosis. When a rounded soft tissue density mass is seen on noncontrast-enhanced CT either in or contiguous to the renal hilum, a renal vein varix must be excluded. Doppler US, MRI, or dynamic contrast-enhanced CT should be done to exclude a renal varix as the cause.

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This 12-month prospective study was undertaken to evaluate the cost, risk, and benefit of ultrasound followed by upper gastrointestinal series for the evaluation of the infant who vomits. Results suggest minimal morbidity from the upper gastrointestinal series, only a 33% reduction in the number of upper gastrointestinal series performed, and a 95% increase in cost if this imaging sequence is used. We conclude that the use of ultrasound for the initial evaluation of vomiting in infants substantially increases the cost with no meaningful decrease in morbidity and mortality.

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In a prospective study of 225 consecutive pediatric patients who required sedation for CT imaging, we monitored oral and nasal air flow, transcutaneous oxygen saturation, and cardiac rate and rhythm before and after the administration of IV Nembutal. In addition, the first 50 patients in this series had blood pressures mechanically monitored at 1-min intervals. There was no significant change in the cardiac rate, rhythm, or blood pressure in any patient. Seventeen episodes (7.5%) of transient oxygen desaturation to 80% of baseline or less occurred after sedation. The patterns of oxygen desaturation in this series can be explained by the following mechanisms: (1) hyperventilation leading to hypocapnia with resultant loss of the CO2 stimulus of respiration (12 patients); (2) upper airway obstruction from pharyngeal muscle relaxation (three patients); (3) a shift in sensitivity of CNS CO2 receptors (one patient); and (4) central apnea (one patient). Oxygen desaturation normalized spontaneously in 14 patients. In two patients, oxygen saturations returned to normal after modification of head position to optimize airway patency. In one patient, mild stimulation was required to interrupt transient apnea. All but one patient in whom desaturation occurred showed oxygen desaturation within the first 5 min after IV sedation. At The Children's Hospital of Denver, IV Nembutal has been used in over 870 pediatric patients. No patient required resuscitation, intubation, or assisted ventilation. Only one patient required prolonged observation, and one patient demonstrated an idiosyncratic hyperactive response. The sedation failure rate was less than 1%. The average dose of sedation was reduced when compared with IM Nembutal because the rapid onset of activity after IV administration allowed titration of dose to patient response.

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Four cases of choroid plexus papilloma extending through the foramen of Monro are presented. All four patients were evaluated by contrast-enhanced CT and two of these were also evaluated by neurosonography. No other intraventricular tumor commonly extends through a ventricular outlet. The radiographic demonstration of this extension of an intraventricular mass through the foramen of Monro, cerebral aqueduct, or foramen of Luschka or Magendie represents an ancillary diagnostic sign of choroid plexus papilloma.

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A retrospective study of 5,134 consecutive pediatric patients undergoing computed tomographic (CT) evaluation from January 1983 through December 1985 was conducted to analyze the need for sedation in a pediatric population; the safety, efficacy, and efficiency of various sedation regimens; and the pediatric radiologists' changing preference for certain sedatives. A marked preference for intravenous administration of pentobarbital sodium (Nembutal) evolved over the 3-year period analyzed. Intravenous Nembutal facilitated the most efficient use of available CT scanning time. Recovery times were reduced, and patient convenience was augmented. There were only two sedation failures in the 419 patients sedated with intravenous Nembutal, and there were no sedation-related complications.

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An alternative to the endoscopic removal of blunt esophageal foreign bodies is proposed. A Foley catheter is inserted into the esophagus and its balloon is utilized to extract the foreign body under fluoroscopic control. Experience with over 100 children with blunt esophageal foreign bodies has led us to conclude that the technique is easily performed, safe, and highly cost-effective. To protect the esophagus, care must be taken to ensure that the foreign body has no sharp or ragged edges, that it has been in place less than two weeks, and that there is no underlying esophageal disease. To ensure that no compromise of the airway occurs, several safeguards are employed, including orally inserting and withdrawing the catheter, monitoring the procedure fluoroscopically, and placing the patient in a prone oblique position with the fluoroscopic table steeply inverted.

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One hundred consecutive children with blunt esophageal foreign bodies were treated with a non-operative method of foreign body removal utilizing a Foley catheter. Dislodgement was successful in 98 children. There were no complications. Performed properly, the technique is rapid and safe. It precludes hospitalization and the slight hazards of endoscopy and general anesthesia.

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The radiographic appearance of retrothymic pneumomediastinum is quite specific. The findings include elevation of the thymus away from other mediastinal structures with increased lucency beneath it, visualization of a radiodense line extending from the inferior pole of the thymus to the midportion of the heart, and tenting of the pericardium at the point of attachment of this line. This constellation of findings will aid in the differential diagnosis of medial anterior pneumothorax, pneumopericardium, and intrapulmonary cyst in the infant with air block. The paper details the mediastinal anatomy with special emphasis on a previously undescribed layer of connective tissue that accounts for this specific radiographic appearance.

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Between January 1973 and January 1980, 29 patients with biliary atresia treated by Kasai hepatic portoenterostomy were evaluated for deficiencies of vitamin A, D, and E. The mean vitamin A level in 11 patients with successful operations was 25.5 +/- 3.8 (SE) micrograms/100 ml whereas the level was 16.0 +/- 8.8 (SE) micrograms/100 ml in three patients with failed operations (normal: greater than 30 micrograms/100 ml). Vitamin E levels in 6 children (5 with sustained bile drainage) were 2.9 +/- 1.7 (SD) micrograms/ml (normal: greater than 4 micrograms/ml). Vitamin D deficiency was evaluated in 22 patients by serial radiographs of knees and wrists. Four children (18%) had pure osteomalacia and 13 children (59%) had combined osteoporosis and osteomalacia. The four oldest survivors (age 5-5.5 yr) resolved their bone disease without specific treatment. Serologic deficiencies of vitamins A and E and radiographic evidence of vitamin D deficiency exist in patients with biliary atresia despite operative establishment of bile flow. These deficiencies are present in both the younger and the older children. In the case of vitamin D, resolution may occur without specific treatment.

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Blunt trauma to the epigastrum may result in a retroperitoneal hematoma involving the head of the pancreas and descending duodenum. Secondary effects include obstruction of the gastric outlet, obstruction of the biliary tree, and extrinsic compression of the inferior vena cava. Four patients with epigastric trauma were reviewed who had been examined by ultrasound of the abdomen. Ultrasound showed the extent of the retroperitoneal hematoma, its effect on contiguous organs, and was helpful in clinical management.

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Patients imaged with 99mTc pyrophosphate for myocardial infarction between October 1975 and March 1976 were reviewed. There were 103 patients and 114 images obtained. The clinical criteria of either or electrocardiographic changes were used to validate a myocardial infarct. We experienced 92.4% true negatives, 68.7% true positives, 7.5% false positives and 31.3% false negatives. It technically compromised scans were exclude (those with blood-pool activity, overlying costal cartilage), the false-negative rate was 15.4%. These data show that the presence of a negative phosphate scan does not rule out the possibility of a recent small, less than 2.5-cm subendocardial myocardial infarction.

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An intercomparison was made of technetium phosphates, thallium 201, and technetium-labeled MAA to define areas of small myocardial infarction in pigs. Byinstilling 0.01 ml of mercury into the coronary arteries, 2-cm infarcts were created. Several of the infarcts were in the anterior left ventricular wall. None of the infarcts was imaged with 99mTc phosphates. Three of the seven thallium 201 images demonstrated only diffuse right ventricular activity. Three of the seven infarcts were imaged with technetium MAA; a perfusion defect was seen in the area of infarction. Technetium MAA is the most sensitive agent in defining areas of abnormal myocardial perfusion.

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