RESUMEN
PURPOSE: Allograft vascular thrombosis occurs in 5% to 10% of pediatric renal transplants. The hemodynamics of renal allograft immediately after implantation is unclear. High resolution Doppler ultrasound of the renal allograft performed in the operating room after incision closure is an effective and objective method to advance our understanding of baseline renal allograft hemodynamics, and identify unsuspected vascular complications early enough to ensure prompt surgical repair. MATERIALS AND METHODS: Between September 1998 and July 2000 high resolution, color power Doppler ultrasound was prospectively performed on 21 living related renal transplants in the operating room immediately after incision closure. Each ultrasound described allograft anastomotic blood flow, direction of diastolic flow, parenchymal perfusion and resistive indexes. RESULTS: There were 20 (95%) allografts with good power Doppler perfusion that had satisfactory immediate function with no vascular complications at 9 to 26-month followup. Initially, anastomotic turbulence was described in 15 (71%) allografts, and resistive indexes were abnormal in 8 (38%). Turbulence and abnormal resistive index normalized in all allografts by 1-month followup. Ultrasound of 1 allograft identified unsuspected poor perfusion and reversal of diastolic flow in the operating room after incision closure. In another allograft in which a 4-hour post-transplant ultrasound was compared with the baseline study in the operating room an unsuspected thrombosis of the right common iliac vein was confirmed. CONCLUSIONS: Good parenchymal perfusion and forward diastolic flow after renal reperfusion correlated well with immediate graft function. Initial turbulence and abnormal resistive index in the presence of favorable perfusion are misleading and not independent predictors of graft function. Ultrasound performed in the operating room identified 2 unsuspected major vascular complications facilitating prompt surgical correction.
Asunto(s)
Trasplante de Riñón/diagnóstico por imagen , Trasplante de Riñón/fisiología , Ultrasonografía Doppler en Color , Adolescente , Anastomosis Quirúrgica , Niño , Preescolar , Femenino , Hemodinámica , Humanos , Trasplante de Riñón/efectos adversos , Trasplante de Riñón/métodos , Donadores Vivos , Masculino , Estudios Prospectivos , Reperfusión , Trasplante Homólogo , Trombosis de la Vena/diagnóstico por imagen , Trombosis de la Vena/etiologíaRESUMEN
PURPOSE: The treatment of complete pancreatic transection (CPT) from blunt trauma remains controversial. To determine the natural history and long-term outcome of nonoperative management of CPT, we analyzed all such patients over the last 10 years at a level I trauma center. METHODS: Retrospective analysis between 1990 and 1999 was performed on 10 consecutive patients. Complete records were available for 9 patients. Data pertaining to their trauma admission, plus long-term radiologic and clinical outcome were analyzed. RESULTS: There were 6 boys and 3 girls with a median age of 8 years (range, 4 to 16 years) and a median injury severity score (ISS) of 25. All patients displayed CPT on admission computed tomography (CT) scan. Four patients (44%) had associated intraabdominal injuries, but only 2 were significant. All patients were treated nonoperatively. Four patients (44%) had pseudocysts, and 3 required percutaneous drainage. Other complications included a single drainage of subphrenic collection, 1 inadvertent removal of drainage catheter, and 2 cases of line sepsis. The duration of percutaneous drainage was 14 to 60 days. The median length of hospitalization was 24 days (range, 6 to 52 days). After median follow up of 47 months, no patients showed exocrine or endocrine insufficiency. One patient had abdominal pain not related to the pancreatic injury. Follow-up abdominal CT scans in 8 of 9 patients showed complete atrophy of the body and tail in 6 patients and 2 completely normal glands. CONCLUSIONS: Pancreatic transection is rare and commonly is found in isolation of other major abdominal injuries. No patients required surgery for their pancreatic transection. Pseudocysts can be managed effectively with percutaneous drainage. After a median follow-up of 47 months, no patients had endocrine or exocrine dysfunction. Anatomically, the distal body and tail usually atrophies; however, occasionally, the gland can heal and appear to recanalize. To the authors' knowledge, this is the first report to show the effectiveness of nonoperative management after complete pancreatic transection.
Asunto(s)
Drenaje/métodos , Páncreas/lesiones , Heridas no Penetrantes/terapia , Adolescente , Atrofia , Niño , Preescolar , Drenaje/efectos adversos , Nutrición Enteral , Femenino , Humanos , Puntaje de Gravedad del Traumatismo , Intubación Gastrointestinal , Tiempo de Internación/estadística & datos numéricos , Masculino , Seudoquiste Pancreático/etiología , Nutrición Parenteral Total , Estudios Retrospectivos , Factores de Tiempo , Tomografía Computarizada por Rayos X , Centros Traumatológicos , Resultado del Tratamiento , Heridas no Penetrantes/complicaciones , Heridas no Penetrantes/diagnósticoRESUMEN
OBJECTIVE: To review the imaging appearances, management and outcome of a large number of children with intussusception owing to pathologic lead points (PLP) in an attempt to define the role of various imaging modalities in this clinical setting. MATERIALS AND METHODS: Review of the records and imaging studies of 43 children with intussusception due to PLP diagnosed between 1986 and 1999. RESULTS: The commonest PLP found were Meckel diverticulum, polyps, Henoch-Schonlein purpura and cystic fibrosis. PLP were depicted on sonography in 23 (66%) of 35 patients, on computed tomography in 5 (71%) of 7, on air enema in 3 (11%) of 28, and on barium enema in 6 (40%) of 15. Air enema successfully reduced 60% of the intussusceptions. Nine children had recurrent intussusceptions. CONCLUSION: Sonography depicted two-thirds of PLP and provided a specific diagnosis in nearly one-third of our series. Our review does not provide sufficient data on how to continue the investigation of those patients in whom sonography does not depict a PLP but in whom there is a high index of suspicion for its presence. It remains a diagnostic challenge as to how to search for PLP in these patients, and other imaging modalities have to be requested according to each particular case.
Asunto(s)
Apéndice , Enfermedades del Ciego/diagnóstico , Enfermedades del Colon/diagnóstico , Enfermedades del Íleon/diagnóstico , Intususcepción/diagnóstico , Adolescente , Aire , Apéndice/diagnóstico por imagen , Sulfato de Bario , Enfermedades del Ciego/diagnóstico por imagen , Enfermedades del Ciego/etiología , Neoplasias del Ciego/complicaciones , Niño , Preescolar , Enfermedades del Colon/diagnóstico por imagen , Enfermedades del Colon/etiología , Fibrosis Quística/complicaciones , Enema , Femenino , Fluoroscopía , Estudios de Seguimiento , Hemangioma/complicaciones , Humanos , Vasculitis por IgA/complicaciones , Enfermedades del Íleon/diagnóstico por imagen , Enfermedades del Íleon/etiología , Neoplasias del Íleon/complicaciones , Lactante , Recién Nacido , Pólipos Intestinales/complicaciones , Intususcepción/diagnóstico por imagen , Intususcepción/etiología , Masculino , Divertículo Ileal/complicaciones , Divertículo Ileal/diagnóstico , Divertículo Ileal/diagnóstico por imagen , Síndrome de Peutz-Jeghers/complicaciones , Cintigrafía , Recurrencia , Factores de Tiempo , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
BACKGROUND: The distinction between ulcerative colitis and Crohn's disease is important, because treatment options and clinical course may vary. Magnetic resonance imaging (MRI) allows noninvasive transmural assessment of the intestine and may facilitate differentiation of ulcerative colitis from Crohn's disease. The objective of this prospective study was to determine whether MRI differentiates Crohn's disease from ulcerative colitis in children as effectively as colonoscopy with mucosal biopsies. METHODS: Fifteen patients underwent colonoscopy with biopsies followed by abdominal MRI. The MRI diagnosis, determined by two radiologists independently completing a standardized form was compared with the gastroenterologic diagnosis. RESULTS: After colonoscopy and review of histology, Crohn's disease was diagnosed in nine patients, ulcerative colitis in five, and indeterminate colitis in one, who was excluded from study. Agreement of the MRI diagnosis with the gastroenterologic diagnosis was 4 of 4 (100%) for ulcerative colitis, 4 of 10 (40%) for Crohn's disease considering both radiologists, and 5 of 10 (50%) for Crohn's disease for each radiologist individually. Percentage of enhancement by MRI did not correlate with the severity of inflammation determined at endoscopy among the patients with Crohn's disease (r = -0.3, P = 0.366). There was agreement on severity of inflammation in three of four patients with ulcerative colitis. CONCLUSIONS: Current MRI interpretation of inflammatory bowel disease did not adequately recognize Crohn's disease in children. Therefore, colonoscopy with biopsy remains the most accurate tool for determining the type and severity of inflammatory bowel disease in children and adolescents.
Asunto(s)
Enfermedades Inflamatorias del Intestino/diagnóstico , Imagen por Resonancia Magnética , Adolescente , Biopsia , Niño , Colitis Ulcerosa/diagnóstico , Colitis Ulcerosa/patología , Colon/patología , Colonoscopía , Enfermedad de Crohn/diagnóstico , Enfermedad de Crohn/patología , Diagnóstico Diferencial , Humanos , Íleon/patología , Enfermedades Inflamatorias del Intestino/patología , Mucosa Intestinal/patología , Estudios ProspectivosRESUMEN
OBJECTIVES: DMSA renal scanning is more sensitive than ultrasound in detecting renal parenchymal scars. We proposed to determine the utility of single-photon emission computed tomography (SPECT) dimercaptosuccinic acid (DMSA) renal scanning in children with primary vesicoureteral reflux (VUR). METHODS: During a 24-month period, we evaluated the charts of 368 patients who had undergone SPECT DMSA renal scanning for primary VUR. Patients were divided into three age groups: (a) less than 1 year, (b) between 1 and 5 years, and (c) older than 6 years. Renal scars were deemed severe or focal. The data were analyzed to evaluate the utility of SPECT DMSA scanning in children with primary VUR and to determine the indications for performing SPECT DMSA. We also evaluated the sensitivity of recent renal ultrasound technology in detecting focal and diffuse scars. RESULTS: One hundred twenty-eight patients were younger than 1 year at presentation. These included 24 cases that were detected prenatally. One hundred eighty-five were between the ages of 1 and 5 years, and 55 were 6 years or older. Reflux nephropathy at presentation was found in 99 (26.9%) of 368 patients. DMSA scanning changed the treatment in only 13 patients (3.5%). When scarring was diffuse, ultrasound examination correlated 100% with DMSA scanning; when focal scarring was present, the correlation was poor. CONCLUSIONS: Our results suggest that DMSA scans should be tailored to children who have ultrasound abnormalities, high-grade reflux, or recurrent breakthrough urinary tract infections. These guidelines will result in a substantial cost savings and a significant decrease in radiation exposure.
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Renografía por Radioisótopo , Succímero , Tomografía Computarizada de Emisión de Fotón Único , Reflujo Vesicoureteral/diagnóstico por imagen , Niño , Preescolar , Estudios de Evaluación como Asunto , Femenino , Humanos , Lactante , Masculino , Estudios RetrospectivosRESUMEN
BACKGROUND: Nephrocalcinosis is often associated with a variety of hypercalcemic conditions. Diagnostic ultrasound is often used for assessing nephrocalcinosis in children, but its reliability has not been proven. OBJECTIVE: To determine the reliability of expert interpretation of sonographic films with a grading scale of severity for nephrocalcinosis. MATERIALS AND METHODS: Fifty-eight ultrasonographic films of 30 children with Williams syndrome and other conditions know to be associated with nephrocalcinosis were assessed. We used a blinded randomized design to assess intra- and interobserver reliability. RESULTS: Grades I, II, and III nephrocalcinosis were noted in 13 %, 19 %, and 27 % of the examinations, respectively. The weighted kappa coefficient was 0.80 (standard error 0.12; 95 % confidence interval 0.68-0.92) for intraobserver agreement and 0.76 (standard error 0.13; 95 % confidence interval 0.63 to 0.89) for interobserver agreement. Reliability in assessing change from one examination to the next, with independently graded films, was fair with an unweighted kappa coefficient of 0.68 (95 % confidence interval 0.38-0.96) and 0.51 (95 % confidence interval 0.21-0.80) for intra- and interobserver reliability, respectively. CONCLUSION: The severity of nephrocalcinosis can be reliably interpreted with an ultrasonography grading scale.
Asunto(s)
Nefrocalcinosis/diagnóstico por imagen , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Nefrocalcinosis/complicaciones , Variaciones Dependientes del Observador , Reproducibilidad de los Resultados , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Ultrasonografía , Síndrome de Williams/complicacionesRESUMEN
BACKGROUND: Children with fibrosing pancreatitis are conventionally treated surgically to relieve common bile duct (CBD) obstruction caused by pancreatic compression. Residual pancreatic function has not been formally tested in these patients. AIMS: To evaluate the usefulness of non-surgical temporary drainage in children with fibrosing pancreatitis and to assess pancreatic function after resolution of their CBD obstruction. PATIENTS: Four children (1.5-13 years; three girls). METHODS AND RESULTS: Abdominal sonography and computed tomography revealed diffuse enlargement of the pancreas, predominantly the head. The CBD was dilated due to compression by the head of the pancreas. Pancreatic biopsy specimens obtained in three patients showed notable acinar cell atrophy and extensive fibrosis. Cystic fibrosis was excluded. No other cause of pancreatitis was identified. Pancreatic tissue from one patient contained viral DNA sequences for parvovirus B19 detected by polymerase chain reaction; serum IgM to parvovirus was positive. Three patients had temporary drainage of the CBD and one patient underwent a choledochojejunostomy. Serial imaging studies revealed resolution of the CBD obstruction with reduction in pancreatic size. Exocrine pancreatic function deteriorated. Three patients developed pancreatic insufficiency within two to four months of presentation. The fourth patient has notably diminished pancreatic function, but remains pancreatic sufficient. None has diabetes mellitus. CONCLUSIONS: Temporary drainage of the CBD obstruction is recommended in fibrosing pancreatitis in children along with close monitoring of the clinical course, before considering surgery.
Asunto(s)
Colestasis/etiología , Pancreatitis/terapia , Adolescente , Biopsia , Niño , Preescolar , Colangiopancreatografia Retrógrada Endoscópica , Colestasis/patología , Colestasis/terapia , Drenaje , Femenino , Fibrosis/patología , Humanos , Lactante , Masculino , Pancreatitis/complicaciones , Pancreatitis/patología , Stents , Tomografía Computarizada por Rayos XRESUMEN
PURPOSE: Computerized artificial neural networks are analogous to biological neuronal systems. Since they may be trained to recognize the relevance of complex patterns in data, neural networks may be useful for decision making in the multifactorial management of ureteropelvic junction obstruction. We determine the ability of a customized neural network to predict sonographic outcome after pyeloplasty in children with ureteropelvic junction obstruction. MATERIALS AND METHODS: A data set was constructed with 242 demographic, clinical, radiological and surgical elements. We analyzed the available retrospective data in 100 consecutive children who underwent unilateral pyeloplasty for ureteropelvic junction obstruction chosen from all 144 surgically treated for ureteropelvic junction obstruction between 1993 and 1995. One radiologist reviewed all film data and provided a final sonographic outcome designation in each case. We wrote a set of computer programs to construct a neural network. A composite 4-layer network was built with output nodes representing 4 possible sonographic outcomes. The 100 patient data set was randomly divided into 84 training and 16 testing examples. RESULTS: The neural network correctly predicted all 5 of 5 significantly improved, 7 of 7 improved, 2 of 2 same and 2 of 2 worse sonogram results after pyeloplasty. Therefore, sensitivity and specificity were 100% for all 4 outcomes. Linear regression analysis of the data yielded inferior sensitivity and specificity values (52 to 94%), confirming that ureteropelvic junction obstruction is a nonlinear data analysis problem. CONCLUSIONS: The 100% accuracy, sensitivity and specificity of our neural network in this pilot study provide evidence of the value of the neural computational approach for the modern exploration and modeling of the clinical problem of pediatric ureteropelvic junction obstruction.
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Riñón/diagnóstico por imagen , Riñón/cirugía , Redes Neurales de la Computación , Cálculos Ureterales/diagnóstico por imagen , Cálculos Ureterales/cirugía , Niño , Humanos , Modelos Lineales , Proyectos Piloto , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , UltrasonografíaRESUMEN
BACKGROUND: Complicated Meckel diverticulum (MD) in children does not always present with painless rectal bleeding and its presentation can then produce a difficult diagnostic dilemma. In this clinical setting, sonography (US), CT or even air enema may be the first modality chosen to evaluate these children rather than the radionuclide Meckel scan (RNMS). PURPOSE: To assess the value of US, CT and air enema for detection of complicated MD. MATERIALS AND METHODS: Review of clinical, imaging, surgical and pathological findings in 64 children (55 males, 9 females) aged 4 days -14 years (mean = 3.7 years) with MD seen during an 8-year period, 1990-1997. RESULTS: (a) In 33 patients with rectal bleeding, MD was detected on RNMS in 32. Ten of these 32 had other imaging studies, all of which were negative. (b) The other 31 patients, with varied clinical presentations, did not undergo RNMS. In these 31 and the 1 with a negative RNMS, 14 (44 %) had imaging features highly suggestive for the diagnosis of MD on US in all 14, on CT in 1, and on air enema in 3. The radiological spectrum of the inflamed, hemorrhagic MD is illustrated. CONCLUSION: The inflamed, hemorrhagic and the inverted, intussuscepted MD have a spectrum of features recognizable on US, CT and air enema. Some of these appearances are specific, others are not. Knowledge of and recognition of these features will facilitate detection of complicated MD in larger numbers of children presenting with symptoms other than the classic history of painless rectal bleeding and also in those with normal RNMS.
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Divertículo Ileal/diagnóstico , Adolescente , Niño , Preescolar , Enema , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Divertículo Ileal/diagnóstico por imagen , Neumorradiografía , Estudios Retrospectivos , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
This study illustrates the sonographic findings of inverted Meckel diverticulum acting as a lead point of an intussusception in five patients. In four patients, the inverted diverticulum was seen as a segment of blind-ending, thick-walled bowel projecting for a variable distance from the apex of the intussusceptum. The larger diverticula had a characteristic bulbous shape. The central serosal surface of the inverted diverticulum was filled with fluid in one patient, with fluid and fat in another, and with echogenic fat only in the other two. The presence of fat was confirmed by CT in one patient. The features illustrated in these four patients appear to be specific. In the fifth patient, the sonogram revealed a nonspecific echogenic mass at the apex of the intussusceptum. Recognition of these features on sonography may obviate the need for further investigation.
Asunto(s)
Intususcepción/diagnóstico por imagen , Divertículo Ileal/diagnóstico por imagen , Niño , Preescolar , Femenino , Humanos , Íleon/diagnóstico por imagen , Lactante , Masculino , UltrasonografíaRESUMEN
OBJECTIVE: This study was conducted to determine the reliability of detecting features and making diagnoses of lower respiratory infections from chest radiograms in young infants. METHODS: Forty chest radiograms of infants younger than 6 months of age admitted with lower respiratory tract infection to a tertiary care pediatric hospital were independently reviewed on two separate occasions by three pediatric radiologists blinded to the patients' clinical diagnoses. For each radiograph the radiologists noted whether a feature was present, absent or equivocal on a standardized form. The features examined were hyperinflation, peribronchial thickening, perihilar linear opacities, atelectasis and consolidation. On the same form each radiologist indicated whether the radiograph was normal or showed airways and/or airspace disease. Within and between observer agreement were calculated by the average weighted kappa statistic. RESULTS: Within observer agreement for the radiologic features of hyperinflation, peribronchial wall thickening, perihilar linear opacities, atelectasis and consolidation were 0.85, 0.76, 0.87, 0.86 and 0.91, respectively. The between observer kappa results for these features were 0.83, 0.55, 0.82, 0.78 and 0.79, respectively. The within and between observer kappa statistics for interpretation of the radiographic features were best for airspace disease (within, 0.92; between, 0.91), and lower for normal (within, 0.80; between, 0.66) radiogram and for airways disease (within, 0.68; between, 0.48). The presence of consolidation was highly correlated with a diagnosis of airspace disease by all three radiologists. CONCLUSIONS: Clinicians basing the diagnosis of lower respiratory infections in young infants on radiographic diagnosis should be aware that there is variation in intraobserver and interobserver agreement among radiologists on the radiographic features used for diagnosis. There is also variation in how specific radiologic features are used in interpreting the radiogram. However, the cardial finding of consolidation for the diagnosis of pneumonia appears to be highly reliable.
Asunto(s)
Reproducibilidad de los Resultados , Infecciones del Sistema Respiratorio/diagnóstico por imagen , Bronquiolitis/diagnóstico por imagen , Bronquiolitis/fisiopatología , Estudios de Evaluación como Asunto , Femenino , Humanos , Lactante , Masculino , Variaciones Dependientes del Observador , Neumonía/diagnóstico por imagen , Neumonía/fisiopatología , Radiografía , Infecciones del Sistema Respiratorio/diagnóstico , Infecciones del Sistema Respiratorio/fisiopatología , Sensibilidad y EspecificidadAsunto(s)
Pulmón/patología , Enfermedades de Niemann-Pick/patología , Preescolar , Humanos , MasculinoAsunto(s)
Quiste Broncogénico/diagnóstico por imagen , Enfermedades Fetales/diagnóstico por imagen , Ultrasonografía Prenatal , Adulto , Quiste Broncogénico/diagnóstico , Quiste Broncogénico/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Lactante , Recién Nacido , Masculino , Quiste Mediastínico/diagnóstico , Embarazo , Ultrasonografía Doppler en ColorRESUMEN
The detection of systemic venous gas due to pneumatosis intestinalis in patients with portal hypertension has not been described. Since sonography is commonly used to investigate conditions associated with pneumatosis intestinalis, it is important to recognize their sonographic appearance and clinical implications.
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Embolia Aérea/diagnóstico por imagen , Neumatosis Cistoide Intestinal/diagnóstico por imagen , Vena Porta/diagnóstico por imagen , Adolescente , Embolia Aérea/etiología , Humanos , Masculino , Neumatosis Cistoide Intestinal/complicaciones , UltrasonografíaAsunto(s)
Insuficiencia Pancreática Exocrina/etiología , Hepatopatías/diagnóstico , Esplenomegalia/diagnóstico , Biopsia , Diarrea , Insuficiencia Pancreática Exocrina/diagnóstico por imagen , Humanos , Lactante , Hígado/diagnóstico por imagen , Hígado/patología , Hígado/fisiopatología , Hepatopatías/patología , Hepatopatías/fisiopatología , Masculino , Páncreas/diagnóstico por imagen , Esplenomegalia/patología , Esplenomegalia/fisiopatología , Síndrome , Tomografía Computarizada por Rayos X , UltrasonografíaRESUMEN
Colonic atresia is a rare cause of congenital bowel obstruction. We have recently encountered two neonates with colonic atresia in whom the colon was displaced entirely to the midline on contrast enema examination. At surgery both patients had type III atresias (blind ends with a mesenteric defect), and were found to have non-fixation of the colon, accounting for its unusual midline positioning. This has not been previously described in the literature. In addition, one of the patients had a stormy post-operative course due to unsuspected Hirschsprung's disease. This represents the eighth case of associated colonic atresia and Hirschsprung's disease in the literature.
Asunto(s)
Colon/anomalías , Colon/diagnóstico por imagen , Enfermedad de Hirschsprung/etiología , Humanos , Recién Nacido , Masculino , RadiografíaRESUMEN
Pneumatosis Intestinalis (gas in the bowel wall) is uncommon in children and is associated with a number of clinical conditions most notably necrotizing enterocolitis in sick neonates. We observed portal venous gas on sonography and benign pneumatosis intestinalis on abdominal radiography in two children who had recently undergone liver transplantation. Asymptomatic portal venous gas and pneumatosis intestinalis has not been described previously in pediatric liver transplant patients. It is important to recognize the sonographic appearance of portal venous gas since sonography is the imaging modality most frequently utilized for monitoring the allograft post liver transplantation.