Sonographic Imaging of the Acute Pediatric Abdomen - HD

Introduction

Hello, my name is Harriet Paul Thiel.

I'm based at Children's Hospital Boston,

and I'll be lecturing today about sonographic imaging

of the acute pediatric abdomen.

Acute Abdominal Pain: Definition and Challenges

Acute abdominal pain is a common non-specific symptom

that is characterized by the development

of severe abdominal pain over several hours.

It's typically associated

with self-limited minor conditions,

particularly gastroenteritis and viral syndromes.

The challenge for us as imagers is

to identify those patients with the following disorders,

namely serious, potentially life-threatening conditions such

as appendicitis and bowel obstruction

infections requiring specific treatment such

as urinary tract infection and pneumonia,

and unusual manifestations of less common diseases such

as hemolytic uremic syndrome and heline perra.

The cause of acute abdominal pain will vary with the age

of the patient, and the role of imaging is

to determine whether this pain requires medical

or surgical intervention.

We try to provide a precise diagnosis if possible,

and generally this will require

the use

of plain radiography, ultrasound,

and at times cross-sectional imaging such as CT

or MRI.

Causes of Acute Abdominal Pain in Infants and Older Children

Causes

of acute abdominal pain in the infant

beyond the neonatal period.

Importantly include trauma,

and this includes inflicted injury into subception,

strangulated, inguinal hernia

and hemolytic uremic syndrome

in the older child and adolescent.

Important causes are trauma, acute appendicitis,

mesenteric, adenitis, inflammatory bowel disease, hen line,

perra, cholelithiasis

and cholecystitis, acute pancreatitis, acute pyelonephritis,

UIs, and pneumonia.

Trauma

Let's talk about trauma.

This includes motor vehicle accidents,

falls and child abuse.

Intraabdominal injuries may be life threatening.

There may be hemorrhage from solid organ laceration

or fluid loss organ ischemia from vascular injury,

infection from perforated hollow viscous

imaging in hemodynamically stable patients is

what we perform, and CT is the usual modality.

The so-called fast scan

or focused abdominal sonography

for trauma performed in emergency departments in adults

has not worked out very well.

For children. It's relatively poor in

in detecting abdominal organ injury in children,

although in the future there may be a role

for the fast scan if it is performed in conjunction

with ultrasound contrast agents,

but that's something for the future

and not the here and now.

I'm not going to

delve in any detail

into,

a discussion of trauma since CT really is

the main imaging modality.

But I would like to point out,

that at times we are on the front lines

and do make the initial assessment with ultrasound.

Here, for example,

is a case of a 10-year-old girl

who had a bicycle handlebar injury to the chest.

And you can see on the far left,

one of her kidneys,

which is swollen in the upper pole

and has a central hyper coic region.

On the transverse image, we see

that right kidney in the gallbladder anterior to it,

and the margins of the kidney are poorly defined

and poorly distinguished from the surrounding soft tissues.

And that's because there is a perren hematoma.

And,

on the image of the bladder, you can see

that there is a fluid debris level

and this is presumably hemorrhage into the bladder,

arising from the,

upper,

upper tract,

the from the kidney and extending down into the bladder.

When we examine this kidney with power doppler, we see

that the lower pole is well perfused,

but there is a perfusion defect in the upper

pole corresponding to the hyper coic region seen

by gray scale ultrasound

and on ct, we can now readily,

visualize the,

intrarenal hematoma as well as the,

prominent pararenal

hemorrhage as well.

Here's another 10-year-old boy who fell,

and had ano had a bicycle handlebar injury this time

to the Epigastrium.

And,

on these,

two images,

obtained in the epigastric region, we can see

that there is a very large complex fluid collection,

anterior to the body of the pancreas, which is compressed.

And,

in the pelvis we can see

that there is a fair amount of,

free fluid.

And this is a patient who developed a pseudocyst as a result

of er rupture or a laceration of the pancreas.

And

here we see it again on ct, a very complex,

fluid collection,

related to,

pancreatic laceration.

Intussusception

Let's move on now to a discussion of intussusception,

which is the most common abdominal

emergency in early childhood.

It usually occurs in children aged,

two months to two years.

And,

intussusception occurs when a proximal bowel

segment, the so-called inci septum

invaginates into a distal bowel segment,

the incipients along with the associated mesentary.

This results in venous

and lymphatic congestion, which can lead to edema, ischemia,

perforation, and peritonitis.

And here we have a surgical,

image

and image obtained at the time of surgery where we can see,

the intussusception

and we see the very distended,

recipient loop,

which is also a little,

slightly dusky in appearance.

The majority of intussusceptions are idiopathic.

A pathological lead point is identified in only about a

quarter of cases, and most commonly,

these lead points are a mekel, diverticulum, a polyp,

and a duplication cyst.

All benign entities

and,

small bowel lymphoma can also occur

as a lead point.

The site of inception is usually near the ileocolic

junction, so-called IOC colic inception.

The classic triad of pain, palpable

sausage shaped abdominal mass

and current jelly stool only occurs in a minority

of patients about 15%.

For those people who are not familiar with current jelly

stool, here is,

an image of,

a patient

who is bleeding from the rectum

and the appearance has been likened

to that of current jelly.

This is a patient with an intussusception.

We see on a plane radiograph

that there's a paucity of bowel gas.

There is a soft tissue mass in the transverse colon,

and if you look very carefully, you can see a rounded,

soft tissue,

structure here with a lower density center.

And that's due to the,

mesentery,

which contains a large amount of fat.

On the right are two images, longitudinal

and transverse of a typical intussusception

where we see multiple layers

of bowel wall.

Everyone knows the bowel is a tube

and ordinarily, normally we can identify multiple layers,

but here there are too many, too many layers

because you have one bowel loop inside another,

so you have twice as many layers

as you would normally expect.

You can also appreciate that there's probably a little bit

of fluid here between the inus and the insum.

Here's the patient at the time of reduction,

which we perform,

with air.

So,

the transverse colon,

you can see the intussusception here is the cecum

and the intussusception is in the region

of the ileocecal valve.

And then on the final image, it has been reduced

and we document this occurrence by the

presence of,

free reflux

of air into the distal small bowel.

As you see here, here's another patient with intussusception

resulting in small bowel obstruction.

On the left, you see multiple dilated small bowel loops.

On the upright view,

you can appreciate multiple air fluid levels,

no air within the rectum.

And here's another typical appearance of intussusception,

the multiple rings,

outlined here,

by the blood vessels within the wall of the bowel.

We see the intussusception with a small,

crescent

of fluid, which is also quite characteristic.

Occasionally, we can suspect that there is a lead point

as we do here on this transverse UI think you would agree

that you can see a lesion on a stock.

Here's the stock and here's the head of the lesion.

This is a patient who was studied with barium.

We see the,

interoception,

as a filling defect within the column of barium.

There's a coiled spring appearance, which is typical

with barium in the interstices of the bowel wall.

And here at surgery,

we see the lesion averted

and inverted, and this was a meles diverticulum.

Inguinal Hernia

Next, let's talk about inguinal hernia.

This occurs in one to 5% of all newborns,

and inguinal hernia repair is the most commonly performed

surgical procedure in children.

Most are minimally symptomatic,

however, incarcerated hernia cannot be reduced

by manipulation,

and the term strangulation is used when there is vascular

compromise of an incarcerated hernia due to edema caused

by venous and lymphatic obstruction.

Prolonged strangulation may lead to necrosis

and bowel perforation.

Here is an image of a child with a very large scrotal

hernia, and on the sagittal image with the head to our left

and the

feet to our right,

we see a bowel loop,

passing through the inguinal canal

through a patent processes vaginalis into the scrotal sac

and abutting the testicle on that.

On the same side, it has been said

that the presence of peristalsis favors viable bowel.

I think we can appreciate peristalsis here in this movie

clip, whereas the absence of peristalsis is,

suggestive of,

strangulation,

compromise of the blood supply,

to the bowel loop.

Here's another,

interesting case of a patient

who had an incarcerated inguinal scrotal hernia.

And,

we can see it here on this transverse image

of the right hemi scrotum.

This,

echogenic tissue is mesenteric fat

that's herniated down into the scrotum,

and this is the right testicle on your right.

You'll notice that the echogenicity of

that right testicle is very,

hypoechoic relative

to the asymptomatic left testis.

And this testicle was in fact ischemic

and the patient complained not only of abdominal pain due

to the incarcerated hernia,

but also had very severe scrotal pain

and was taken to surgery,

because of a clinical diagnosis of testicular torsion.

And had the,

hernia not been repaired in a timely

manner, he almost certainly would've gone on to,

infarct his testicle

because the hernia was compromising the vascular

supply to that testicle.

As you can appreciate well on the color doppler

and notice the,

prominent blood flow

to the normal testis on the left.

Hemolytic Uremic Syndrome

I'd like to turn now to a discussion

of hemolytic uremic syndrome.

This is a disease of infancy in early childhood

that is usually caused by infection

with sugar toxin producing e coli.

It is acquired from contaminated food or water

and occurs five to 10 days

after the onset of bloody diarrhea.

The toxin jam damages the gi endothelial cells

and initiates intravascular thrombosis.

The toxin enters the circulation via the gi mucosa

and localizes in the kidneys and destroys the renal cells.

Cellular damage leads to microvascular thrombosis

and platelet consumption.

There is mechanical damage to the red blood cell circulating

through the partially occluded microcirculation,

and clinically the patients will present

with oliguria hematuria, renal failure, thrombocytopenia,

and microangiopathic hemolytic anemia.

Here is a 6-year-old girl with,

abdominal pain

and bloody diarrhea.

You'll notice that the imaged bowel loops are

very abnormal in appearance.

They're very thickened, particularly at the level

of the submucosa.

This,

echogenic,

layer of the bowel wall

and

there's mark hyperemia as well with color doppler.

Her kidney that we see here,

is very echogenic.

The parenchyma is very echogenic in comparison to that

of the adjacent liver.

Normally the renal parenchymal echogenicity is less than

that of the,

adjacent liver, so this is highly abnormal.

And

over here we have an arterial waveform from

the main renal artery.

Again, highly abnormal instead of seeing

flow throughout diastole,

antegrade flow throughout diastole,

instead we have a systolic peak

and then a very rapid,

diminution of flow

and actual flow reversal through most of diastole.

So a highly abnormal arterial waveform within the kidney

Acute Appendicitis

onto a discussion of acute appendicitis.

This is the most common pediatric surgical emergency

comprising about 80% of

all pediatric surgical emergencies.

And importantly, about one third

of children have an atypical presentation.

The clinical diagnosis is often difficult since many

non-surgical conditions may mimic acute appendicitis.

These patients can be imaged by ultrasound or CT

or even MRI in pregnant patients, for example.

But certainly in the United States,

the majority

of cases,

are studied with ct

and this is a problem in the pediatric population.

Children are particularly sensitive to radiation

and there's a potentially long period

during which radiation induced tumors,

would have an,

opportunity to develop.

So,

certainly,

there is an effort being made on part

of the pediatric radiology,

community,

and I think this is spilling over to,

to the adults

as well to try to optimize the,

performance

and interpretation of,

ultrasound examinations

for acute appendicitis

and to only perform ct,

when it's absolutely necessary.

And there's no other way of obtaining the information

that we need to treat the patients.

So here's an example of a patient

with an acute appendicitis.

You'll notice that the appendix is,

distended with some fluid.

It's not compressible, I don't have calipers here,

but it measured more than six millimeters from

outer wall to outer wall.

On the sagal view of the pelvis, we see a little bit

of free fluid in the cul-de-sac.

This patient is early on in their course,

so when we study the appendix with color doppler, we see

that the appendix is hyperemic.

If the appendix were to become necrotic,

then we would no longer,

be able

to depict blood flow in the wall.

Here's a transverse image of that appendix, again,

non-compressible filled with fluid.

Here's a different patient,

where we see the appendix.

It's quite a long appendix

and it has a stone at the tip, which we see

as an echogenic focus with distal shadowing.

Here's an example of a patient

who had a perforated appendix at surgery.

We can identify the appendix here.

And then at its tip there's a small

irregular fluid collection.

Here we see it in transverse section,

surround the appendix surrounded by a bit of fluid.

With color doppler, there's a little bit

of flow along one edge,

but not uniformly hyperemic,

as we saw in the earlier example.

Here's a patient who had perforated sometime

before the ultrasound study was done.

We were not able to identify the appendix,

although we did see an echogenic focus

with distal shadowing, which may,

have represented the append lying free.

In the peritoneum it is surrounded by,

echogenic fat.

It's become walled off.

There is some fluid

and you'll notice that the bowel loops in that region,

are mildly dilated.

They're atonic. When the color doppler is used,

there's increased blood flow to these tissues.

This is a fairly typical appearance of peritonitis,

following a perforation in this case,

of an appendix.

Here's one patient where ultrasound,

was not helpful,

where we really could not visualize the appendix.

And of course, it's always helpful to try to,

improve visualization.

And one way of doing that is

to turn the patient on their side to compress, to try

to squeeze out any air in the bowel loops to,

improve the,

the accuracy of the study.

Here you can see on this transverse image that there,

here's the bladder, that there's a very large amount

of bowel gas in that right lower quadrant,

and there was no way that we could see the appendix.

Here is,

just another image showing the iliac vessels.

This patient subsequently had a CAT scan,

which very readily showed a retrocecal appendix containing

a stone.

So here CT was immensely helpful in elucidating the

patient's disease.

Mesenteric Adenitis

Let's talk a bit about mesenteric adenitis.

This is an inflammatory condition with symptoms similar to

that of acute appendicitis, namely abdominal pain fever,

and an elevated white blood cell count.

It's the most common diagnosis in children who are found

to have a normal appendix at surgery.

It can be divided into primary and secondary forms.

The primary form is more common in children than adults

and is believed to be related to an underlying infectious

terminal ileitis.

Secondary mesenteric adenitis is quite common.

We often see enlarged,

lymph nodes in conjunction

with other inflammatory processes such as appendicitis

and inflammatory bowel disease.

And the role of imaging is to attempt

to exclude an associated inflammatory process

when these enlarged inflamed lymph nodes are identified.

Here's a 10-year-old boy where there was a question

of an acute appendicitis.

We could see multiple enlarged lymph nodes in the right

lower quadrant, but could not identify the appendix

A CAT scan was done, which did readily show,

the appendix seen here posterior

to the cecum posterolateral.

There are some enlarged right lower quadrant lymph nodes.

Here's another patient with,

a clinical diagnosis

of gastroenteritis.

Again, multiple enlarged hyperemic lymph nodes.

A single bowel loop shown here with a

mildly thickened wall,

which

goes along

with the diagnosis of gastroenteritis.

Here we see some fluid filled bowel loops as well.

Inflammatory Bowel Disease

Crohn's disease and ulcerative colitis are the most common

forms of inflammatory bowel disease that we,

image.

Neither disease usually presents primarily

with acute abdominal pain in children.

The main,

studies,

diagnostic studies include plain films, endoscopy

and contrast radiography,

although we certainly are trying to image more of these

patients with sonography, with color doppler,

and we hope in the future in children to be able

to use contrast agents as well.

Ultrasound contrast agents,

although at this point

we here in America have

don't have that,

option,

readily available to us.

Acute presentations in patients

with inflammatory bowel disease,

in childhood are usually due to complications,

in patients who have chronic disease

and these,

complications,

include postoperative adhesions

and abscess due to perforation or a fistula

and toxic mega in patients with ulcerative colitis.

Here's a patient who did present,

for the first time acutely with abdominal pain

and weight loss, and we can see that there are

thickened bowel loops.

Notice the OSA is quite,

thickened

and with color doppler hyperemic,

and we do see this fat,

adjacent

to the inflamed,

bowel,

which is also characteristic

of Crohn's disease.

Here are some CT images of the same patient,

a very typical appearance of terminal ileitis.

We do see enlarged,

lymph nodes

and the prominent,

vasculature

and

mesenteric vessels and nodes as well.

Here's a different patient who presented with abdominal pain

as part of a Crohn's flare and peri rectal pain.

These are images of the perineum, the patient is prone.

The skin surface is,

superiorly here.

There's a large,

abscess,

fluid, abnormal fluid collection.

Here we see a,

fistula extending,

to the skin surface

in real time, and of course,

hyperemia

of the soft tissues.

This patient did go on to have a CAT scan.

We can see the,

abscess

and

fistula as well to the skin.

Henoch-Schönlein Purpura

Heline perra is an immune complex mediated vasculitis

of small vessels that affects multiple organ systems.

It's the most common vasculitis of childhood

and 50 to 60%

of patients develop abdominal pain from intestinal

intramural hemorrhage

and they can hemorrhage from the stomach into the stomach,

the small intestine and the colon.

The GI tract symptoms may proceed.

The characteristic per peric skin rash,

which you can see here on the right, a very florid example

of that ultrasound depicts intramural hemorrhage

and is useful in follow-up

and small bowel interception is a common complication.

These are images of 4-year-old boy with,

he perra

and abdominal pain in his left upper quadrant.

He had this peculiar,

appearance of the bowel.

Here we see it,

again and with real time.

We can appreciate,

that this patient does indeed have,

a in an intussusception.

It's a small bowel to small bowel intussusception

Cholelithiasis and Cholecystitis

Onto cholelithiasis and cholecystitis.

Gallstones are relatively uncommon in children only

affecting about 1.5% and occur mainly in adolescent girls.

There's often an identifiable underlying cause.

Patients who are treated with TPN are prone

to develop stones

that resolve when oral feeding is instituted.

Acute cholecystitis is much less common than in adults

with an absence of gallstones in about half the cases.

And a, a calculus cholecystitis often occurs in

critically ill patients.

Here are images of three-year-old boy who was being

weaned off TPN

and he developed acute abdominal pain and fever.

You can see that his gallbladder is distended with fluid.

The wall is thick, his common bile duct is dilated

and he has a small gallstone.

This psychogenic focus

with distal shadowing a small gallstone in the neck

of his gallbladder.

With color doppler, we can see

that the wall is quite hyperemic

and this patient ultimately needed surgery

for acute appendicitis.

There's also some sludge within the gallbladder lumen.

This is a different child, a 7-year-old boy who had been

otherwise well when he developed severe right upper quadrant

pain,

had cholestasis and abnormal liver function tests.

And here's his gallbladder,

which is strikingly abnormal in appearance

of very thickened, heterogeneous,

wall, lots

of internal,

debris and,

mar hyperemia.

He also required cholecystectomy

and had a pathological diagnosis of a calculus sitis.

Acute Pancreatitis

Acute pancreatitis is characterized by the sudden onset

of abdominal pain and a rise in serum levels

of amylase and lipase.

A significant proportion

of patients initially have normal serum enzymes,

and by definition, these patients,

eventually will undergo a complete structural

and functional recovery.

About a quarter of the cases in children are idiopathic.

Another significant proportion, almost a quarter are

traumatic in etiology with structural anomalies,

a multi-systemic disease, drugs and toxins

and viral infection accounting.

For the remainder, unfortunately there is a recurrence in

about 9% of patients with acute pancreatitis

and this can be really a devastating,

illness

with a mortality rate in children of about 10%.

These are images of a 4-year-old girl with

with leukemia treated with asparaginase.

On the left, we see,

the right kidney, the liver,

and some free fluid in Morrison's pouch.

On this middle image, we see the pancreas, which is swollen,

it's mildly echogenic.

And on the right we see that there's a large amount

of ascites within the abdomen.

Here are some images of her CAT scan.

Here's the very abnormal swollen pancreas.

We can appreciate that.

There are foci of non enhancement,

after contrast administration

and this was due to necrotizing pancreatitis

and really a tremendous amount

of ascites within the abdomen.

This is another girl, 17 years old, also with leukemia,

treated with asparaginase.

She has a very large,

extra pancreatic fluid collection, A pseudocyst,

very

heterogeneous

and appearance,

due to acute pancreatitis.

Here is her bladder

and her uterus with free fluid in the pelvis

and also in,

the right pleural space.

Urinary Tract Disorders

A few words about urinary tract disorders that can present

with pain, acute pain in children urinary tract infection,

uli ssis and ureteral pelvic junction obstruction.

Ultrasound is used in the workup

of initial urinary tract infections in children,

in urinary tract infections with palpable

with a palpable abdominal mass

or a UTI unresponsive to treatment

in the older child.

An adolescent poly nephritis often presents with fever,

vomiting, flank pain, and an elevated white blood cell count

in the younger child.

The

symptoms are, are generally nonspecific.

A right-sided acute pyelonephritis may mimic

acute appendicitis.

And importantly,

acutely infected kidneys are often,

or I would say almost always normal by ultrasound.

Sometimes they may be a little swollen,

but that's usually the only finding that we see.

We do,

reserve,

and perform CT evaluation for imaging

of suspected complications

of pyelonephritis such as abscess.

Here's a 4-year-old girl in whom an abscess with suspected,

here's her normal right kidney

and her left kidney, which

demonstrates a very swollen lower pole.

The right kidney when studied with power doppler,

shows,

symmetric homogeneous blood flow,

whereas there's very patchy flow on the affected side.

But we don't see anything

that suggests an abscess on the ultrasound.

And this was confirmed on a CT which was

subsequently performed.

You'll notice that the involved kidney is much more swollen

than the right and it has the characteristic,

wedge shaped,

foci of,

diminished perfusion

that we see in pyelonephritis.

Here's a, a different patient, a 6-year-old girl with fever,

abdominal and flank pain, not responding to antibiotics.

On the ultrasound examination,

the upper pole is very swollen,

and now we can see in this patient

that there is also a fluid,

component,

to,

the abnormality in the upper pole.

With power doppler.

We see that this area is minimally perfused.

A large amount of fluid seen here on the transverse fuse,

and this was an abscess.

Urolithiasis

UIs,

is another topic to consider.

Stones are usually due to infection with proteus

or Klebsiella or metabolic disease in children.

There is an increased frequency of stones in children

who have anatomical or neurogenic urinary tract obstruction.

An acute presentation in children is relatively uncommon

and is usually discovered during investigation

of non-specific abdominal pain.

Or UTI ultrasound is the first line imaging tool

with CT reserv for those patients who may be very obese

and it's hard to study them with ultrasound patients

with severe scoliosis, again, where it's hard

to get a good ultrasound image

or,

in those cases

where the renal ultrasound is negative

and clinical suspicion for stone is high.

These are images of an 8-year-old boy with,

mental retardation, cerebral palsy and scoliosis.

You can see that in the images

of the left kidney there's an echogenic focus With distal

shadowing, the right kidney appears to be normal.

When we look with color doppler at

that focus in the lower pole, we see a twinkle sign,

which is very characteristic of renal stone.

The patient went on to have a CAT scan.

We can appreciate the scoliosis and the lower pole stone,

but in addition,

CT did detect tiny stones both in the left

and right kidneys, which were not apparent,

from the ultrasound.

In this particular case,

I'm not sure it changed the management,

but,

CT was helpful in elucidating the entirety

of this patient's stone burden.

Ureteropelvic Junction Obstruction

UPJ obstruction is the most common cause

of congenital urinary tract obstruction,

due

to an abnormal development of a short segment

of smooth muscle At the UPJ

extrinsic lesions are responsible for some cases,

and these lesions include iber vessels,

fibrous bands, or adhesions.

Nowadays most cases

of UPJ obstruction are diagnosed prenatally,

on prenatal sonography.

However,

it can, it is an entity

that can present at any age.

And clinical findings in the older child include abdominal

pain, hematuria, UTI, recurrent

and recurrent flank pain,

that may be associated

with increased fluid intake.

For example, adolescents who are drinking beer,

may develop sudden pain due to the stress of the,

fluid overload.

Patients engaged in sports who may get a blow

to the flank and may bleed a little bit

and that can cause acute obstruction.

Here's a 6-year-old boy who had a urinary tract infection,

hematuria, dysuria and flank pain.

We see his,

dilated kidney.

The CAEs are filled with fluid.

The lower pole calyx has a fluid debris level,

perhaps related to hemorrhage.

You can see there's echogenic material,

but it could just be,

debris related to stasis.

Doesn't necessarily have to be hemorrhage.

Here's a transverse view,

of the lower pole

and we see the dilated renal pelvis.

And here's the bladder.

There's a very slight dilation of the distal ureter

that's not commensurate with the collecting system dilation.

So these findings are in keeping with,

a acute UPJ

obstruction.

Pneumonia

Finally, I'd like to talk a little bit about pneumonia.

Lower lobe pneumonia is well-recognized cause

of abdominal pain

and when abdominal pain is accompanied by fever,

a chest radiograph should be obtained.

Atelectatic or consolidated lung,

permits transmission

of the ultrasound beam

and the echogenicity

of non-rated lung is very similar to that of the liver.

Air and fluid filled bronchi can be depicted

and pulmonary necrosis, abscess

and pleural fluid are also readily identified.

This is the chest radiograph of a 15-year-old girl

who had pneumonia and bilateral pleural effusions

that were not responsive to conventional treatment.

It's hard to appreciate,

but there actually is a little

pigtail catheter here on the right.

Here are her,

ultrasound images

of the right and left chest.

On the right you can see that there's a,

a pleural effusion,

which is complex.

It has a lot of echoes in it.

We can look at it in real time here

and you can,

appreciate the,

echogenic material

and,

it, these findings are even more striking.

On the left here we have a consolidated lung,

a few little air bro,

a few little fluid broncho grahams

and a very complex,

pleural fluid again,

which we can appreciate very well,

in real time.

So these were ated, pleural effusions.

Another patient also not responding

to conventional therapy has,

an area

of a ification at the left lung base.

Not a big change,

on a decubitus film.

This patient had a very complex,

collection within the plural space.

We can appreciate,

its adherence

to the underlying lung, but is separate from it.

Here we see it in,

real time

and

at ct,

again,

we can see this very complex fluid collection,

adjacent

to the inferior portion of the left lung.

And this was an ema.

Conclusion

So in conclusion, I have reviewed with you,

the ultrasound features of the most common

and important pathological entities in the infant

and older child.

And important points to remember are that the cause

of acute abdominal pain varies according to patient age,

and that ultrasound is a very useful modality in evaluation

of acute abdominal pain.

It's not invasive, it does not involve ionizing radiation,

and a specific diagnosis is often possible.

Thank you.