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Abdominal pain is a common presenting symptom in children. A substantial percent of unscheduled paediatric office visits and paediatric emergency room visits are due to abdominal pain. Children may present with an acute episode of pain or with chronic, recurrent pain. Only a small fraction of children presenting with abdominal pain will prove to have an organic cause necessitating interventional management. In this essay, a discussion of abdominal pain is presented, with particular emphasis on the role of radiologic imaging tests to investigate potential causes of abdominal pain. The more common and clinically significant causes of abdominal pain in a child will be discussed in greater detail.

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A neonate presented to the C.S. Mott Children's Hospital at the University of Michigan with truncus arteriosus and interrupted left aortic arch, with associated postductal origin of the left carotid, left subclavian, and aberrant retroesophageal right innominate arteries. In addition, the patient was diagnosed with DiGeorge syndrome. This unique anomaly has not been previously reported. The anatomy, pathophysiology, embryology, and successful surgical management of this anomaly are reviewed in this report.

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Midgut malrotation with volvulus is a life-threatening surgical emergency. Prompt diagnosis and treatment is paramount to good outcome. Imaging plays a key role in confirming the diagnosis. A two-day-old male infant presented with bilious vomiting and was diagnosed by upper GI examination to have midgut malrotation and volvulus. The gut was ischaemic but viable at surgery. Radiological features of malrotation and volvulus are presented and discussed.

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Intussusception is a common but life threatening gastrointestinal emergency that occurs in the infant or young child. A three-year-old boy presenting with abdominal pain and vomiting was diagnosed to have the target sign on ultrasonography. An ileocolic intussusception was initially reduced using air enema. Recurrent intussusception 12 hours later was reduced by barium enema. In the proper hands, ultrasonography has a high diagnostic accuracy rate for intussusception. For treatment, air enema is usually perferred to barium enema. Air enema is a safe, rapid, and clean procedure that has been shown to achieve a high reduction rate, comparable to that of barium enema. Ultrasonographically-guided hydrostatic reduction of intussusception has also been recently described and is an effective alternative.

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OBJECTIVE: To evaluate a gadolinium-enhanced MR angiography (Gd-MRA) imaging protocol for the assessment of thoracic vessels using double-dose gadolinium and quiet breathing. An animal model was used to simulate imaging in infants and young children. MATERIAL AND METHODS: Six baboons (Papio anubis), mean weight 5.7 kg, were sedated and intubated. After the injection of double-dose Gd-DTPA (0.2 mmol/kg) through a peripheral vein, a coronal spoiled 3D gradient-echo volume acquisition was obtained during quiet breathing. Two radiologists reviewed the images for visualization of aortic arch, brachiocephalic vessel origins, pulmonary arteries (central, upper lobe and descending branches), and pulmonary veins (upper and lower). RESULTS: Visualization was excellent for the aortic arch, brachiocephalic vessel origins, and pulmonary arteries, including the hilar branches. Visualization was excellent for the lower and right upper pulmonary veins and fair for the left upper pulmonary vein. There was excellent agreement between radiologists. CONCLUSION: Imaging of thoracic vessels with Gd-MRA using double gadolinium during quiet breathing was effective in our animal model. The advantages of this technique include a short imaging time and depiction of vascular segments--branches of pulmonary arteries and intraparenchymal segments of pulmonary veins--not optimally visualized with other non-invasive imaging techniques.

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OBJECTIVE: To evaluate the effect of recombinant human deoxyribonuclease I (rhDNase) in shortening the length of the hospitalization and improving the chest radiographs (CXRs) in hospitalized infants with respiratory syncytial virus (RSV) infection as a result of its mucolytic properties. METHODS: Randomized, double-blind, placebo-controlled investigation of 75 patients with RSV bronchiolitis. The study was conducted at the University of Michigan Medical Center and St. Joseph Mercy Hospital, both in Ann Arbor, MI. RESULTS: The respiratory rate, wheezing, and retraction difference scores, obtained by subtracting the hospital discharge score from the corresponding hospital admission score, show no difference between the two groups, but the CXR difference scores show that the rhDNase group improved by 0.46 while the placebo group worsened by 0.60 (p < 0.001). Analysis of covariance for the hospital discharge CXR score after adjusting for the hospital admission score for both groups was done. There was a difference in scores between the two groups, with adjusted mean for the study group of 2.03, and 2.76 for the placebo group (p < 0.001). Paired t test statistics in each of the two groups were computed. For the placebo group, the mean increase of 0.60 was significant (p = 0.02), and the mean decrease of 0.46 for the rhDNase group was also significant (p = 0.02). A one-way analysis of covariance with the hospital discharge CXR scores as the dependent variable and the hospital admission score as the covariate showed that there was a significant difference between the groups (p = 0.01). CONCLUSION: In patients with RSV bronchiolitis, there was significant improvement in the CXRs with the use of rhDNase compared to significant worsening in the placebo group. To our knowledge, this is the first report of the use of rhDNase to treat RSV bronchiolitis.

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The aim of this study was to evaluate the ability of high-resolution computerized tomography (HRCT) of the chest and chest x-rays (CXR) to determine efficacy of inhaled recombinant human DNase (rhDNase) in cystic fibrosis (CF) patients younger than 5 years of age. A randomized, double-blind, placebo-controlled pilot study of 12 patients with CF younger than 5 years of age, attending the University of Michigan Cystic Fibrosis Center (Ann Arbor, MI) was conducted. The changes in the HRCT and CXR score from baseline to day 100 of therapy were assessed using a previously validated scoring system. The mean changes of HRCT scores between the rhDNase and placebo groups were found to be significant at the 95% level, with mean change +/- SE mean of - 1.00 +/- 0.53 and 0.58 +/- 0.24 for rhDNase and placebo groups, respectively (P = 0.02). The difference in CXR score was not significant between the two groups. An analysis was performed to relate HRCT subscores to CXR score; only thickening of the intra-interlobular septae was significantly correlated with the total CXR score (r = - 0.7, P < 0.01). There was improvement in the parents' assessments of the patients' well-being, with improvement in physical activity, decreased cough, sleep quality, and appetite in those subjects receiving rhDNase. We conclude that the administration of rhDNase was associated with improvement in the HRCT scan in CF patients younger than 5 years of age. Findings indicate that HRCT of the chest is useful and sensitive in studying responses to therapy in patients with CF lung disease. To our knowledge, this is the first report of the use of HRCT to assess the effectiveness of a therapeutic modality in so young a CF patient population.

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The aim of this study was to assess physeal fractures of the pediatric knee identified by MR imaging and to describe the MR findings of such fractures. The authors reviewed 315 consecutive pediatric knee MR examinations done to assess for traumatic injury. The MR images were reviewed for evidence of physeal fracture. Fractures were classified by the Salter-Harris system, and associated findings and injuries were noted. Plain radiographs and medical records were reviewed. Seven distal femoral physeal fractures (Salter II, n = 6; Salter III, n = 1) and two proximal tibia physeal fractures (Salter III, n = 1; complex Salter IV, n = 1) were identified. Magnetic resonance demonstrated widening of a portion of the physis with visualization of a metaphyseal/epiphyseal fracture line. Periosteal elevation was observed in six cases. Four patients had associated ligamentous or meniscal injuries. Plain radiographs were available for review in eight patients. Bone abnormalities suggesting fracture were evident in six of eight patients; however, the fracture was fully delineated in only one patient. The diagnosis or confirmation of fracture by MR changed clinical management in seven of eight patients in whom follow-up was available. Physeal fractures of the pediatric knee are occasionally diagnosed by MR. Magnetic resonance provides improved delineation of non-displaced physeal fractures of the knee, while simultaneously allowing for evaluation of soft tissue structures.

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A 9-month-old boy had bruising and petechiae. Investigation revealed a Coombs-positive hemolytic anemia and immune-mediated thrombocytopenia. The infant was treated with intravenous immunoglobulin and steroids. The infant eventually had recurrent fevers, hepatosplenomegaly, pulmonary nodules, and parenchymal central nervous system (CNS) lesions develop. Results of a lung biopsy revealed a polyclonal lymphoproliferative disease. Polymerase chain reaction analysis showed the presence of the Epstein-Barr (EB) viral genome in the lung nodules. The infant died from progressive lung disease 6 months after the initial symptoms of Evans syndrome. Lymphoproliferative disease is known to occur in a variety of settings after immunosuppression, especially in solid organ transplant recipients. We report a case of polyclonal lymphocyte proliferation in a patient with Evans syndrome.

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RATIONALE AND OBJECTIVES: The purpose of this study was to quantitate the interspinous distances in a group of children as they underwent flexion during lateral radiography. MATERIALS AND METHODS: The cases of 59 children with minor trauma who underwent lateral flexion radiography were studied retrospectively. Measurements of each cervical interspinous distance and anteroposterior diameter of the adjacent body were used to calculate a ratio of interspinous distance to vertebral body diameter at each level. Linear regression analyses of each ratio to patient age were performed, and means and standard deviations of the ratios at each level were calculated. RESULTS: The ratios did not correlate in a statistically significant manner at any level with age. Therefore, data from all 59 children were used to calculate the mean and standard deviation at each cervical level. Most children with severe ligamentous injury who were considered for fusion had interspinous ratios greater than 2 standard deviations above the mean for the control group. CONCLUSION: Standards for interspinous distances during flexion by children are presented. These standards may prove to be helpful in the evaluation of children for cervical ligamentous injury.

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OBJECTIVE: The purpose of this study was to determine whether MR imaging features can reliably distinguish hemangiomas from malignant soft-tissue masses. MATERIALS AND METHODS: We retrospectively reviewed MR imaging studies of 22 patients with soft-tissue hemangiomas and 22 patients with malignant soft-tissue masses. Images were reviewed and agreement reached by a consensus interpretation of two observers and by an independent observer. Masses were evaluated for signal intensity on T1- and T2-weighted images, for enhancement with gadolinium administration, and for morphology (lobulation, septation, central low-intensity dots). Lesion T2 signal and lesion enhancement with gadolinium administration were also objectively measured using regions of interest and comparison with skeletal muscle. RESULTS: Signal intensity on T1-weighted imaging of hemangiomas and malignant soft-tissue masses was similar. Subjective analysis showed greater T2 signal and gadolinium enhancement in hemangiomas; however, the differences were not statistically significant on objective analysis. Lobulation, septation, and central low-signal-intensity dots were all more common in hemangiomas, with statistical significance achieved; the combination of all three findings was specific for hemangioma. CONCLUSION: Although no single MR imaging feature was diagnostic in this study, analysis of lesion morphology, signal intensity, and enhancement with gadolinium allowed MR imaging differentiation of hemangiomas from malignant soft-tissue masses.

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Leiomyomatosis is a rare neoplastic condition of the pediatric esophagus. Presenting symptoms usually overlap with more common esophageal disorders, namely, gastroesophageal reflux. A patient is presented in whom leiomyomatosis progressed to the point of causing cachexia and respiratory compromise.

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Although most traumatic abdominal injuries in children are treated with conservative nonsurgical management, traumatic perforation or infarction of the gastrointestinal tract still necessitates surgical management. It is imperative to recognize the often subtle computed tomographic (CT) findings of bowel or mesenteric trauma in children. Pediatric patients with bowel perforation or infarction due to trauma usually demonstrate multiple abnormalities at CT. A specific history of lap belt injury, bicycle handlebar injury, or child abuse with an abdominal injury should heighten suspicion for a bowel injury. CT findings in children with bowel or mesenteric trauma include free intraperitoneal air, free retroperitoneal air, extraluminal oral contrast material, free intraperitoneal fluid, bowel wall defect, bowel wall thickening, mesenteric stranding, fluid at the mesenteric root, focal hematoma, active hemorrhage, and mesenteric pseudoaneurysm. Some findings, such as free intraperitoneal air and focal bowel wall thickening, are associated with a strong likelihood of a bowel injury that requires surgical repair. Other findings, such as free intraperitoneal fluid, mesenteric stranding, fluid at the mesenteric root, and focal hematoma, are less specific for an injury that requires surgical repair. The hypoperfusion complex can usually be differentiated from a traumatic bowel injury; however, in some patients the imaging findings overlap.

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OBJECTIVE: To study the power Doppler findings of septic arthritis and noninfectious synovitis in an animal model. MATERIALS AND METHODS: The right knees of 10 rabbits were inoculated with an aqueous suspension of Staphylococcus aureus. The right knees of 5 rabbits were injected with talc suspension. The right knees of 5 rabbits were injected with saline. All 20 left knees were injected with saline. Serial power Doppler images were obtained using constant-imaging parameters. Images were reviewed by blinded observers who assessed for increased power Doppler signal. RESULTS: All 10 knees inoculated with S. aureus developed septic arthritis. Each infected rabbit knee demonstrated increased signal on power Doppler on at least one examination, ranging from 1-6 days after inoculation. Only 23 of 45 examinations of infected knees were unequivocally positive by power Doppler on examinations performed 1 to 6 days after inoculation. No knee with talc synovitis demonstrated increased power Doppler signal. No control knee demonstrated increased power Doppler signal. CONCLUSION: Increased power Doppler signal may be seen with septic arthritis; however, its intensity and timing may vary from subject to subject. A normal power Doppler examination does not exclude septic arthritis.

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BACKGROUND: Literature on magnetic resonance imaging (MR) evaluation of inflammatory joint effusions is sparse. OBJECTIVE: To describe an animal model for studying infectious and non-infectious joint effusions with magnetic resonance imaging. MATERIALS AND METHODS: Ten rabbit knees with septic arthritis and four with talc synovitis were imaged with MR. Contralateral knees injected with saline served as controls. Fat saturation T2-weighted and gadolinium-enhanced T1-weighted images were assessed for joint effusion, and periarticular and adjacent intraosseous increased signal or enhancement. Each knee was cultured and underwent pathologic examination. RESULTS: Both Staphylococcus aureus and talc produced effusions in all knees. The degree of periarticular signal and enhancement was greater in infected knees than talc-injected knees. No abnormal enhancement was seen within bone. Pathologic examination showed a greater degree of inflammation and joint destruction in the infected knees, but no evidence of osteomyelitis. CONCLUSION: A greater degree of abnormal signal and enhancement seen on MR suggests a more vigorous inflammatory process, as seen with septic arthritis. In spite of advanced septic arthritis, no enhancement was evident within bone, suggesting that enhancement within bone is not an expected finding in isolated septic arthritis and should raise concern for osteomyelitis.

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Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) offer several techniques to evaluate the hepatic vasculature. These techniques are briefly reviewed with reference to the pediatric population. Examples of MRI and MRA in the evaluation of the hepatic vasculature in pediatric patients are presented.

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STUDY DESIGN: This radiographic study was designed to attempt to develop standards of facet coverage (overlap) on lateral cervical radiographs during voluntary flexion. OBJECTIVE: To produce normative standards for minimum facet coverage in children. SUMMARY OF BACKGROUND DATA: Previous studies on normative standards of facet coverage have been performed only in adults. METHODS: Thirty-six children with minor trauma had lateral flexion-extension radiographs. A standard filming sequence was used in all. Facet joint overlap at each level was divided by the anteroposterior diameter of the upper adjacent cervical body at each level. RESULTS: On linear regression analysis, these ratios did not vary significantly with age at C2-C3 through C6-C7. Means and standard deviations were determined for C2-C7. CONCLUSIONS: These ratios may prove useful in evaluation of children with possible ligamentous injury.

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OBJECTIVE: To determine if extracranial soft-tissue swelling is an expected postmortem finding or a sign of trauma. MATERIALS AND METHODS: Extracranial soft-tissue thickness was measured at 5 standardized locations on postmortem skull films obtained of 18 infants with no evidence of trauma on autopsy. The same measurements were performed on the skull films of 100 living children, all less than 3 years old and without clinical history of trauma. RESULTS: Extracranial soft tissues measured only slightly greater in the postmortem group than on films of living children; however, the difference did achieve statistical significance. CONCLUSION: Minimal extracranial soft-tissue swelling is a normal finding on a postmortem skeletal survey. The presence of substantial or asymmetric extracranial soft-tissue swelling should be viewed with suspicion for trauma.

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