GI Emergencies - SD

Introduction

Good evening.
I'm Henrietta TLAs Rosenberg.
I'm from Mount Sinai Medical Center in New York City
where I'm director of pediatric radiology.
I'm also professor
of radiology at the Mount Sinai School of Medicine.
I'm very happy to have the chance to speak
with you this evening on GI
emergencies in the pediatric age range.
It is my pleasure to have the opportunity to speak
to you about GI emergencies in children.

They vary according to the age of the patient
and it is extremely important to differentiate diseases
that require medical care versus emergency surgery.
We try to determine the exact etiology whenever possible.
We often will have plain films of the abdomen as well,
a supine, a left lateral de cube particularly to look
for any evidence of interception,
obstruction free air.
At times we'll do a prone cross table lateral view
of the rectum to see if the air column actually extends
to the rectum and what the caliper of this structure is.
Uprights can be done in patients who are able to stand
for the examination
and we always bear in mind
that there may be referred pain from the chest
and the hips, which can masquerade as an abdominal problem.

Learning Objectives

So the learning objectives of this lecture are
that when we're done, you should be able
to list the wide gamut of causes of GI
emergencies in pediatrics.
Describe the ultrasound appearance of pathological processes
that result in abdominal pain
and describe when additional imaging is indicated.

Acute Abdomen in the Premature Infant

Let's start by talking about the acute abdomen in the
premature infant.
The most common acute abdominal problem in the preemies is
necrotizing enterocolitis.
The babies' present with abdominal distension.
They may have feeding intolerance,
they may have increased residuals, heme positive
or bloody stools.
They may become apneic or acidotic.
Their temperature may be unstable and they may be lethargic.
Necrotizing enterocolitis is a process that causes
mucosal inflammation that extends throughout the bowel wall.
The early detection of ischemic or necrotic bowel
before perforation may reduce the morbidity and mortality.
Neck occurs most often in the distal ileum
or the proximal colon
and there is up to a 31% incidence of bowel perforation.

Plain Film Findings in Necrotizing Enterocolitis

Plain film findings
and neck include distended bowel posis intestinalis,
which is intramural air free air
separated bowel loops which may be indicative
of bowel wall thickening edema or hyperemia or free fluid.
There may be gas in the portal venous system.
There may also be bowel wall thinning in the presence
of decreased blood flow to the bowel and ensuing necrosis.
The typical film will have dilatation
of the bowel little tiny rounded lucencies
that look like modeled lucencies indicative of
pneumatosis intestines.
The left lateral decubitus view is helpful to look for air
that is free that may be dissecting between the liver
and the diaphragm and along the paracolic gutter
ultrasound can be used as well to show little dots
of air within the wall of the bowel portal.
Venous air can be seen on a plain film
and here we can see that there are also dots of air within
the liver in this baby with necrotizing enterocolitis
who has very heterogeneous fluid
around the dome of the liver.

Pneumoperitoneum in Necrotizing Enterocolitis

Pneumoperitoneum is not always present in babies
who have necrosis and perforation.
It is an indication for surgery or other interventions.
Here we can see that there is an air collection in the upper
abdomen, which is not part of the gastrointestinal tract,
the so-called football sign in this baby.
There is even more air on this follow-up exam
and we can see that there is outline
of the falciform ligament
and that there is air going all the way
down into the scrotum.
We can see the rlo sign
with air on both sides of the bowel wall.
And here we can see on the left lateral decubitus view
that there's air outlining the liver as well as the bowel.
Here we have air that is actually outside the bowel
on this ultrasound image that is consistent
with pneumoperitoneum fine gold et
all published an article in radiology in 2005
where they talked about the assessment of bowel viability
with color doppler ultrasound in babies
with necrotizing enterocolitis
and demonstrated what the normal bowel would look like
and the normal vascularity of the bowel.

Ultrasound Findings in Necrotizing Enterocolitis

In babies with neck, there is hyperemia in the bowel
and that is an indication that the bowel is viable
and we can correlate that with the
pulse dola wave forms as well.
Some patients though develop particular appearances
that are helpful in calling hypervascular.
This is the so-called Y appearance where we see prominence
of the distal mesentery and subserosal vessels
and the zebra pattern, which is these
multiple color doppler lines indicating hyperemia in the
Valle kase.
When there's no perfusion, we'll be able
to see the distal mesenteric vessel
but no flow within this very thick bowel wall.
With ischemia, the bowel can be quite thin
and with color doppler as well as the pulse doppler,
we can check to see whether
or not there is actually flow in the wall.
And here's the ischemic bowel loop which did not show any
flow when that was intonated.
The specimen that was demonstrated correlated
with a perforation in the bowel as well as bowel
that showed ischemic changes.
And here's the perforation on the pathologic specimen.
A recent baby that we had had extreme hyperemia in the bowel
and also had an abscess in the left lower quadrant.
They concluded that absent bowel wall perfusion at color
doppler ultrasound is more sensitive
and specific than pneumoperitoneum on an x-ray for detection
of necrotic bowel in neck
and that bowel wall thinning was an important sign.

Acute Abdomen in Full Term Infants

So let's move on and talk a little bit about the
acute abdomen.
In a full term infant, the most common
obstruction in a newborn is secondary
to a congenital obstruction of the bowel
little later on strangulated inguinal hernias are an
important cause of obstruction in the babies
and there are other babies who have gastric outlet
obstruction due to hypertrophic pylori stenosis.
Others will present with ous vomiting
who have malrotation and volvulus.
There may be complications
of a mekel diverticulum in the form
of interception or bleeding.
And then there are babies who come in with intermittent pain
and vomiting and lethargy who have intussusception.
Appendicitis is less common in the very young babies.
What we always need to think about it when we don't have
another cause for free fluid and the symptomatology.
And then there is non-surgical causes of acute abdomen
or what seems to be an acute abdomen in the presence
of septicemia, gastroenteritis and colic.

Esophageal Atresia

I'd like to start at the upper part
of the gastrointestinal tract
by talking a little bit about the obstruction
that can happen at the level of the esophagus.
The most common type of esophageal atresia is
that which has a distal tracheal esophageal fistula.
Well these are babies who usually come in
with maternal polyhydramnios and excessive salivation.
They may be choking coughing, having cyanotic episodes
after feeds and develop pneumonitis
and atelectasis associated with
possible abdominal distension
because of all the air that is coming through
the tracheal esophageal fistula.
So here we can see the end of the enteric tube
at the distal esophageal upper esophageal pouch
and there's a lot of gas throughout the gastrointestinal
tract in the baby who has no fistula.
They usually have drooling associated
with a scaphoid abdomen
and they may have other anomalies as well.
And the case that I'm going to show you also had an addition
to an esophageal atia a**l atresia so
that the baby did not have an a**l opening.

Well, ultrasound serves a very important purpose in terms of
being able to assess
what is going on in the abdomen in the baby
who obviously has no connection of the esophageal pouch
to the remainder of the gastrointestinal tract.
First we need to determine the extent of the atresia.
Most people are happy
to just put a little air in through a tube.
Some like to use a little contrast
and we can see this is a very high pouch.
Well, the ultrasound showed all of the intraabdominal organs
and was very helpful in showing that yes,
there was some fluid in the stomach a little bit.
We could see the PS in the descending duodenum
and then we could see the gastroesophageal junction could
actually measure that it was quite small.
It was a little bit over a centimeter here.
And then the baby had some color doppler images
that confirmed that he is a little bit more
fluid in the stomach.
Baby went to the OR and an opening was made into the stomach
and a trocar was put in so that it could be determined
that there was a particular distance
between the upper esophageal pouch
and the distal pouch so that
surgical planning could be accomplished.
This was after the injection of contrast material.
One can see how short that distal esophagus truly is.
And this was the rectum on ultrasound showing
that it was fluid filled and obstructed
and this baby who also had imperforate anus.

Meconium Ileus

Here's another one who came in who didn't pass meconium
and the abdomen was quite distended.
The gas that was present was displaced superiorly
sonography done at the bedside to rule out
what was thought clinically
to possibly be an abdominal mass.
Demonstrated multiple meconium filled
dilated bowel loops.
The pancreas was somewhat echogenic
and a little bit prominent, which raised the question
of fibrous deposition.
And then the baby had some little
tiny stones within the gallbladder that weren't shadowing.
There was also sludge that was dependent in the gallbladder.
All of these findings are highly suspicious
for meconium ileus in a patient with cystic fibrosis.
The contrast enema showed
that there was a very reduced caliber colon
and the contrast only went as far back as the appendix.
The baby had a meconium ileus and an ILE atresia at surgery.

Hypertrophic Pyloric Stenosis

Let's move on and talk a little bit about hypertrophic
pylori stenosis.
We see this in males much more commonly than in females,
A ratio of about four to five to one.
These are healthy babies who present somewhere around two
to six weeks of age.
They usually first born males.
They present with non-US projectile vomiting
and they have a palpable olive in the right upper quadrant,
which may be very difficult to actually feel
because of the obstructed dilated stomach which is oriented
in a rather horizontal position.
Be aware that the Pylori channel should be quite narrow in a
baby and just as we look at the area of the um
duodenal junction, we need to remember that it should be
at the left of the spine at the level of the duodenal bulb
at about the level of L one.
And this is important to remember as we go on
and talk about the babies with ous vomiting.

So there's the Pori channel
and there's the ligament of trites.
Now it used to be that we used barium to examine the stomach
for pori stenosis.
The stomach was usually over distended.
The babies could reflux particularly with a tube down
and one would stand there for quite a while trying
to see if any barium got through the pori channel.
Not very easy in the presence of obstruction
and unnecessary radiation, the typical appearance
of the elongated pori channel
was helpful when it could be demonstrated as well
as the demonstration
of the muscle shoulders from the thickened pyloric muscle
against the duodenum.
Unfortunately with the barium we couldn't really see
the muscle itself.
We were only looking at the channel.
And then there was the beak sign in the pyloric tit sign
that was used to help identify the area
where the hypertrophied muscle
was leaning against the lesser curvature
and then the beak sign where the contrast was coming through
the pyloric channel.

Other causes of gastric outlet obstruction include
PLOS spasm, chronic granulomatous disease,
peptic ulcer disease, prostaglandin induced anthro,
foveal hyperplasia, eosinophilic gastroenteritis
and Crohn's disease.
One would think that a gas filled structure would be
difficult to identify and outline with ultrasound,
but by using sugar water it's possible
to distend the stomach
and see all of these little bubbles that
outline actually the Ps as well as the duodenum.
Now the landmarks that we use
to find the Ps are the gallbladder, the gastric antrum
and the head of the pancreas.

So here we have a normal looking PS very slender muscle.
We can see the mucosal folds in the long axis.
The short axis view looks like a real skinny donut
and here we can see
that there is some retained material in the stomach which
flowed freely into the pylori
and then ultimately into the duodenum.
By giving the baby water to drink,
we have a much better chance of assessing whether
or not the Pylori opens normally and whether
or not there is elongation of the channel length
and thickening of the wall.
Here's a little bit of gas in the duodenum.
So the long axis view,
we will look at the length of the pylori.
The length should be greater than
or equal to 1.4 centimeters to call pori stenosis.
And we're looking for the hypoechoic muscle wall
that is going to measure greater than
or equal to four millimeters.
Here we see it with ultrasound, there's some fluid
and gas in the stomach we see
that there is elongation of the channel.
It's two centimeters.
Here's the gallbladder, this is the head of the pancreas.
Now remember that in very tiny babies, very young babies,
they may not meet these criteria.
So if you see that the pyloric channel does not open
or you think that you may have seen it open,
just wait about 10 minutes and re-scan the baby
and just see whether or not it was spasm.

Now the target sign is the short axis view.
We are looking at the hypo coic ring of hypertrophied muscle
and we are looking at the echogenic mucosa centrally.
If we measure the entire donut, which we see here,
it should measure greater than a equal to 1.5
centimeters in the presence of pylori stenosis.
But this is not one of the major criteria.
In addition to the donut, we may see a little nipple
that protrudes into the gastric antrum
as the baby is uh contracting the stomach.
This is a baby who had clinical suspicion
of pylori stenosis
and the baby had a mound of tissue at the gastric antrum,
which was not due to pylori stenosis.
The baby actually had a large ulcer crater
with duodenal obstruction.

Duodenal Atresia and Obstruction

The babies usually present with ous vomiting
and they may be babies with duodenal atresia.
They may have stenosis, they could be a web,
they may be annular.
Pancreas plain films are usually quite sufficient
to examine for duodenal atresia
by seeing the double bubble sign of air in the stomach
as well as the duodenum and the air fluid levels.
Of course, it doesn't exclude additional atresia
in the remainder of the gastrointestinal tract.
With al Atresia we'll have more than just two bubbles
and then we have to consider other conditions like
malrotation duplication cysts
that might be causing duodenal obstruction
or obstruction elsewhere in the gastrointestinal tract.
Sometimes there's a hematoma
and at times this pre duodenal portal vein.

Malrotation and Volvulus

Now ous vomiting is a dire emergency.
I would not depend on ultrasound alone at this time.
Although work is being done in Chicago by Dr.
Yusef Sada to prove that ultrasound is sufficient
to make the diagnosis, we do use barium to look for the
Mel position of the bowel.
Now Mel rotation will manifest itself by showing
that instead of the C loop coursing to the left
of the spine at the level of the duodenal bulb,
that it is somewhere more medial and inferior.
And we see the same thing on this upper gi.

The rotation and fixation of the bowel
usually begins at six, the sixth week of gestational life.
The bowel is growing so rapidly
that there is insufficient room in the abdomen
for the entire bowel.
And so the bowel actually undergoes a counterclockwise
rotation around the SMA so
that it moves into the umbilical cord
and the cranial limb is to the right
and the codal limb is to the left.
Ultimately the intestines return to the abdomen.
The cecum returning last
and the bowel undergoes further counterclockwise rotation
to a total of 270 degrees.
With the duodenal junction to the left of the spine
and the cecum in the right lower quadrant.
When there is disordered rotation,
the babies are much more at risk for ulu.

We can use ultrasound to evaluate the relationship
of the superior mesenteric artery and vein
and we can also look for the whirlpool sign of ulus.
In the normal situation, the SMA with a little bit of fat
around it is to the left
and the SMV is to the right slightly more anteriorly.
When there is inversion of the SMV in relationship
to the SMA, we need to think about mal rotation
and here we can see in this baby with a mal rotation,
this SMV is slightly to the left and anterior to the SMA.
When the SMV is to the left of the SMA, it's been shown
that there is malrotation in a hundred percent of patients.
When the SMV is anterior to the SMA,
72% are normal
and when the SMV is to the right of the SMA, 97%
of the patients are normal with no evidence of malrotation.
The whirlpool sign as described by
nuki is very helpful in terms of looking for the whirling
and swirling of the blood.
In the SMV as it is
around the SMA, which is central in the patient who has
volvulus small bowel hematomas usually occur
secondary to blunt trauma.

Small Bowel Hematoma

They may be accidental, they may be non-accidental.
Sometimes he sheline pur is the underlying problem.
There may be a bleeding diathesis, there may be leukemia.
The most common site is
that the fixed retroperitoneal portion of the duodenum
where the proximal jejunum is fixed
by the ligament of trites.
We may see circumferential wall thickening.
We may see an extrinsic mass narrowing the lumen.
Many facilities use CT to make the diagnosis As we see here.
There's also some free fluid in the abdomen.
It makes very pretty pictures,
but you can show exactly the same thing with the ultrasound
and actually use it
to show the regression without exposing the child
to radiation or contrast material

Duplication Cysts

duplication cysts may present as an acute abdomen in babies
who have vomiting and obstruction,
they may have abdominal pain, they may present
with hemorrhage due to peptic ulceration.
When the duplication contains gastric mucosa,
sometimes it's not easy
to differentiate them from a mesenteric or a mental cyst.
Cholo docal cyst can be differentiated
by showing the communication with the biliary ductal system.
Pancreatic pseudo pseudocyst may be confused, abscess may,
mekel diverticulum
and ovarian cyst, they are typically
anti coic, although they may be hypoechoic or hypoechoic.
They should demonstrate a muscular rim sign
with the echogenic inner rim
and the hypoechoic outer rim,
the echogenic inner rim representing the mucosal surface.
And this is the hypoechoic muscular wall.
They may have internal debris, hemorrhage,
inspissated mucus.
They may contain septations at times solid components.
There may be multiple unsuspected cysts they may perforate
and over time they may decrease in size.
So if surgery is contemplated,
repeat sonography should be done prior to the surgery
to be sure that the cyst is still demonstrable.

Here's an example of a baby who was a newborn,
presented with ous vomiting.
Had a study to look for malrotation.
That was definitely an abnormally inferior medial
position to the expected position of the ligament of trites
and there was a mass effect
of this bowel loop in the left side of the abdomen.
Ultrasound was done.
There was a huge cystic mass occupying most
of the abdomen going all the way down to the pelvis,
butting the bladder and we could see there was a hint
of a muscular rim sign.
The superior mesenteric vein was noted to be anterior to the
superior mesenteric artery
and we can see in addition there was peristalsis within this
cystic structure that extended all the
way down to the pelvis.
This is the bladder and here's the uterus.
And this was a huge al duplication cyst.

Intussusception

Now moving on to intussusception.
This is a condition in which the bowel prolapses into a more
codal segment.
It occurs in babies who are three months
to two years of age.
Most commonly they present in almost all babies
with paroxysmal abdominal pain.
About two thirds have a red current jelly stool
and up to two thirds have a palpable abdominal mass.
Intussusception is most often ileocolic
and more than 90% have no pathologic lead point
but have enlarged lymphoid follicles in the terminal ileum.
Those with lead points may be due to lymph nodes,
maybe a meles diverticulum could have cystic fibrosis
with inspissated stool, could be lymphoma hematoma,
maybe polyps duplication cyst
and heline perra sonography is the modality of choice
for diagnosis of intussusception.

First we examine the pelvis with a curved probe.
We're looking for a localized or a free fluid collection.
We're looking for the inus septum
and vaccinated into the incipients
and we're going to examine the entire course of the colon
as well as all four quadrants.
Single, the linear probe and graded compression.
This is an example of how we follow the colon around
and look at the entire colon and rectum
and then fill in the quadrants to be sure
that we've seen every part of the abdomen
because there could be an ileo ileal interception
or one even more proximally.

We look for the pseudo kidney sign, which is a result
of the scanning plane in a patient
who actually has an invagination of the bowel.
Typically we'll see a target
or a donut sign due to the central donut
that is due to the inus septum
and the more peripheral donut due to the incipients,
the receiving bowel loop.
Here's an example of the incipients.
This is the inus septum
and this is the central dot representing the mucosa.
This patient had free fluid. Here's the pseudo kidney sign.
It's not the patient's kidney
free fluid is not a contraindication
to doing an attempt at a reduction.
It's important to look for blood flow in the loops so
that there is less chance of perforation.
Many centers are using contrast material
to reduce an intussusception.
Here's an example of a patient
who had multiple nodes in the right lower quadrant who had
nodes inside the donut.
And here's the pseudo kidney sign
and this was the lead point for the intussusception.

If the child has profound shock peritonitis
or perforation, they're gonna go immediately to surgery
from the ultrasound
and if not, we do a pneumatic reduction attempt.
We use a technique
where we don't use more than 120 millimeters of mercury
and we are looking to show that we can move the head
of the interception all the way back into the region
of the cecum
and that we can show that there is air that actually cause
from the ascending colon and cecum into the small bowel.
And finally this defect gets smaller
and smaller until it finally pops back
into the small bowel successfully reduced.

When we see thickening of the bowel wall In a patient
who has symptomatology of intussusception, we need
to be very concerned about lymphoma.
There are some patients who come in
with right lower quadrant pain where they
have mesenteric adenitis.
They may have acute appendicitis,
they may have Crohn's disease.

Mesenteric Adenitis

Mesenteric adenitis is one of the most common causes
of acute abdominal pain In pediatrics.
Plain film can be entirely normal,
but we're looking for a cluster of nodes
and we are looking with Klo Doppler to show whether
or not the nodes have flow in the hilum
or if they're hypervascular.
We don't find an inflamed appendix with mesenteric adenitis.

Acute Appendicitis

Acute appendicitis is the most common cause
of the pediatric surgical abdomen
and childhood between six and 12 years.
But if the patient presents with classic signs
and symptoms, there is no need to image for confirmation.
Ultrasound is a great modality in the right hands To make
the diagnosis, we use graded compression
of the maximum point of tenderness and pain.
We start by examining the pelvis
for fluid using a curved probe
and then we use a linear probe to examine
for the appendix.
If the patient is extremely obese
or very large, we may use a curve nine, four or five two.
We identify the SOAs muscle, the iliac vessels,
and we try to find the cecum
and look for the appendix arising from the cecum.
The tip of the appendix in terms
of its location is quite variable.
We are looking for a tubular structure that terminates
as a blind pouch.
The inner part will represent the mucosal surface
and then there will be a hypoechoic wall
that represents the muscle of the appendix.
A normal appendix or an abnormal appendix neither will
demonstrate peristalsis.
The maximum outer diameter
of the appendix should be less than
or equal to six millimeters
and the maximum thickness of the append,
the appendic seal wall should be less than
or equal to two millimeters.

Sonographic criteria
for acute appendicitis include a non-compressible appendix
with an outer diameter of seven millimeters or more
and a wall thickness of three millimeters
or more color doppler
or power doppler may show increased flow
with uncomplicated appendicitis.
That is acute Absence of flow raises the question
of a perforated appendix and if we see an abscess
but we don't see the appendix, we need to be concerned
that there may have been appendicitis with perforation.
We also look for append callus.

Here's an 8-year-old who came in
with right lower quadrant pain.
We looked at the bladder,
we then found there was no evidence of fluid.
Then we found a blind ending tubular structure
that was eight millimeters in cross-sectional diameter.
There was some material within it with compression.
There was no significant change.
This is the cross-sectional view and here's the hyperemia.

Another patient here was the append, this dilated
blind ending tubular structure that we couldn't compress
and we can see the material in here as well
as the hyper vascularity of the wall due to hyperemia.

Another child with a two-day history
of vomiting in right lower quadrant pain had fluid in the
pelvis that appeared to be free.
The appendix was non-compressible filled
with echogenic material wide cross-sectional diameter
of 1.2 centimeters and hyperemia.

Another patient had an abscess with an append nicoli
that must have been extruded from a ruptured appendix.
Be careful in girls because this could mimic a dermoid cyst.

Another patient had extreme pain, fever, vomiting,
white count, no bowel gas on the right side of the abdomen.
Had an abscess just below the liver, another
above the bladder, and another one in the mid abdomen.
And this patient had three abscesses.
Could not find the appendix.

Sometimes the appendix actually dips down into the pelvis
and can be confused with acute.
PID.
it's important
to assess whether you believe you're looking at the appendix
or a fallopian tube.
His hyperemia around this tubular structure
that was right near the ovary.
And we can see on this additional view
that there's a blind ending tubular structure
that has the hyperemic wall.
And it turned out that this was the tip
of the appendix demonstrated with endo vaginal scanning.

Another patient we couldn't find the appendix on
but there was a rounded heterogeneous mass
behind the bladder using water in the rectum
as a water enema we could demonstrate clearly
that this was an abscess
and in a boy the first thing we'll think about
is a ruptured appendix.

At times acute appendicitis can present as a lead point
for intussusception.
As we see in this case. There are some pitfalls.
Appendicitis can be confined
to the tip may be difficult to see.
Retrocecal appendix can be obscured by gas.
There may be perforation of the appendix
and we won't find it.
If the appendix is filled with gas, we may not see it
and there could be spontaneous resolution.

Inflammatory Bowel Disease

And then just a few words about inflammatory bowel disease.
This is something that we may use ultrasound for very well
to look for the bowel wall thickening
as we see in this case.
We can look for matted inflamed bowel loops,
lymphadenopathy abscess, the secondary hydronephrosis.

And here's a case of a patient who presented
with worsening pain with a history of Crohn's disease,
a big dilated bowel loops, several bowel loops in the pelvis
and the lower part of the right side of the abdomen.
We could see that there is a change in caliber
of this bowel loop
as it gets towards this very thickened bowel loop.
The content of the dilated portion is analogous to
what we see on CT with a small bowel feces sign.
There was also a little rounded structure
that was contiguous with this long stricted area of bowel
that on ct as I'll show you turned out to be
a little abscess.
We could also see the creeping fat
and the hypervascular with the ultrasound.
And here we see the dilated loop in the pelvis.
We see it extending toward the right lower quadrant
to this long stricture distal terminal ileum
and the small abscess.

Referred Pain

Remember too that there can be referred pain to the abdomen
that can present as an acute abdomen from pneumonia,
from acute chest syndrome in patients
with sickle cell disease.
Could be referred pain from the spine,
may be referred pain from hip disease such
as leg perthes disease
and may also be due at to an abdominal problem as simple
as constipation.

Summary

So in summary, we discussed a wide gamut of causes of GI
emergencies in pediatrics.
We described the ultrasound appearance
of pathological processes that result in abdominal pain
and discussed when additional imaging is indicated.
So thank you very much
and I hope this information will be useful to you.