Pediatric Abdomen Emergencies - HD

Ultrasound in the Evaluation of the Pediatric Abdomen

This is a lecture that falls into ultrasound in the evaluation of the pediatric abdomen.

Don't miss these abnormalities, and I have nothing to disclose in this limited amount of time, which is also one minute less.

Because of this, we will review two to three abnormalities of the pediatric abdomen that are important not to be missed if imaged on an ultrasound exam.

And that can be diagnosed by ultrasound and have important differential considerations that can also be diagnosed by ultrasound only, some of which will be discussed.

The Vomiting Neonate: Beware Midgut Volvulus

The first abnormality not to miss topic is the vomiting neonate, and the key is beware midgut volvulus.

There's a significant differential consideration with regard to the vomiting neonate, which includes malrotation without volvulus and gastroesophageal reflux and hypertrophic pyloric stenosis and pyloric spasm and duodenal atresia duodenal web medical causes.

A number of things we won't discuss.

It is recommended that a neonate with green vomit is thought to have midgut volvulus undergo an emergency upper GI series.

That is what has continued for years and will still continue as the gold standard.

It can be diagnosed via the ultrasound.

Our ultrasound discussion is regarding a neonate who did not present classically or is undergoing an ultrasound exam for an alternative diagnosis.

Vomiting is the forceful extrusion of gastric contents.

It's never normal in the neonate, and it's usually due to partial or complete obstruction somewhere between the stomach and the cecum.

There may be difficulty in differentiating vomiting from the much more common regurgitation, and the goal of imaging is to note if there's an obstruction.

Historical and clinical considerations are very important, and that includes type of vomitus, age of vomiting when it began.

Gestational age of birth of the neonate will help you also figure out whether the aging your differential diagnosis as per the age of the patient is true, based upon whether they were premature.

And therefore, the number of weeks you're looking at is a little bit different.

Fetal imaging review always will help.

That's if you can, if you have that available and a number of diagnoses that cause vomiting, you can see in fetal life, imaging considerations will be discussed.

So I put in this historical image for me.

This was the first a case of mine which did not have a vomiting history.

They ordered this for abdominal distension hepatomegaly, a drop in crit.

The surgeon believed there was a liver injury status post forceps delivery.

This is from 1981 or so.

And we looked, and the ultrasound showed dilated gut and echogenic clumps in it, which I personally believe is hemorrhage.

And here's another image, and one sees a blind ending arrowhead configuration, which is typical of midgut volvulus if one can be fortunate enough to see this.

So newborns with bilious vomiting, it's usually due to sepsis or obstruction.

It's a radiologic emergency because midgut volvulus may result in distal bowel ischemia or necrosis because of twisting of bowel around the SMA.

And this makes the kid a potential gut cripple.

This is despite the fact that Lilienthal and Al noted volvulus is the cause of only 20% of cases of green vomitus in the first 72 hours of life.

And malrotation and a 28 year review.

Also, an old paper, saw midgut volvulus in 62% of neonates, and 20% of those greater than one year.

So you still have to worry about it.

20% had no bile in their vomitus.

This is another case of ultrasound showing a twist in bowel, somewhat dilated, descending duodenum.

You don't see, which what we, we have sometimes seen these irregularities along the edge, similar to what you see in a GI contrast study in which they'll be filling in of what are glandular elements.

Some people say proximal to an obstruction, but you can see the twisted end.

And this is another case of midgut volvulus picked up by the gold standard upper GI series.

You see that the filled bowel does not cross over right to left.

This is a somewhat oblique lateral view, but will not cross over right to left.

And we'll take a descent and not go across and go up to the level of the duodenal bulb, which is the current way of analysis.

One of the ultrasound findings one can use to pick up the possibility of midgut volvulus is the SMA SMV relationship, which Weinberger and others discussed and Weinberger discussed in 1992, in which they saw five of five cases in which the SMV was to the left of the SMA as having a bowel malrotation and midgut volvulus and one of four with SMV enter the SMA having bowel malrotation.

At the same time, one can look for Whirlpool sign.

We saw Whirlpool signs in ovarian torsion and testicular torsion.

And I use it heavily actually with testicular torsion.

And there's a whirlpool sign also with regard to this abnormality in neonates.

This is a case just of an SMA with an SMV anterior to it.

So that's atypical.

And one can see that you can use doppler to figure out which is the artery and which is the vein.

Usually the artery has an echogenic rind around it.

At the same time, you can use ultrasound to see, for example, in this 11 day old green vomitus.

The SMV circling along with bowel the SMA, there's a differential diagnosis to chronic vomiting or regurgitation that's non-US.

There's a list seen over here, which I won't read out 'cause we're running out of time.

It includes just regurgitation, which you can pick up the ultrasound by looking, particularly if you add some fluid to the stomach on this transverse image.

You can see stomach and you can see fluid within the distal esophagus.

On a longitudinal image, you can see stomach and you can see the fluid go from stomach north into the esophagus.

One of the flaws of ultrasound compared to GI is that you can't see the mid esophagus within the thorax.

But if you see a dilated esophagus down low at the diaphragm level, you're pretty much assured that you have significant reflux.

And when it goes out the kid's mouth, then you know that for sure.

But it's you can suggest it.

So one of the other concepts in vomiting is whether the child has HPS or not.

HPS is very nicely seen with linear array probes.

It can obviously be seen with a curved array sector transducer, but you can see the thick pylorus it's elongation.

There are number of signs we won't discuss with regard to making the diagnosis other than I like always showing a bagel or a donut.

'Cause we don't have many bagels down in Memphis that are decent.

Pyloric Spasm

Pyloric spasm is something one should know about.

Sometimes you can see a abnormal pylorus that looks thick and it looks elongated, but it doesn't last for the entire exam.

It doesn't last for a long time.

If you see a changeable pylorus and statistically it's just pyloric spasm, the child will not need to be treated.

If I see it before six weeks, I will ask for close clinical follow up and ask them if they need another ultrasound to follow it.

I'm less concerned beyond the typical time that HPS would show up, but this is an example of somewhat thick and elongated pylorus, which looks like HPS, which in minutes doesn't look like HPS as fluid goes into the less thick and less spasmodic pylorus area.

And this is just another example of that in which you can guess maybe that you have the pyloric channel here, and this is the duodenal bulb.

And then you see the pyloric channel is small and duodenal bulb with more fluid within it.

Adolescent Girl with Right Lower Quadrant Pelvic Pain

The second abnormality to not miss is a girl adolescent girl or adolescent with right lower quadrant pelvic pain.

And you're looking for appendicitis, but you have to think Crohn's disease, ovarian torsion, ovarian hemorrhagic cyst.

We won't discuss PID ovarian mass obstructed uterus.

All part of the considerations.

And luckily for me, all the lectures before this have said many of the things that I would've said if I had lots of time to fill this in.

So in 86 Pilar came up with a high frequency linear array compression study for ultrasound work in our institution.

We converted all our initial workups to ultrasound for appendicitis.

I'm happy about that.

We did that with our surgeons, but we had a plan and we did it in controlled time initially.

But now, it's harder to get anyone to consider CT.

We certainly will look at CT, which I think is a great tool.

If we don't have an answer.

And MRI we haven't incorporated because of the timing thing at the moment, but we're in the middle of trying to figure that out.

So anyway, we're looking for a high frequency.

We're using a high frequency probe with compression.

We're looking for a non-compressible, blind ending tube greater than six millimeters, although most people will probably read it at seven millimeters at the moment.

Certainly we're looking for the periappendiceal fat.

Certainly we're looking for increased flow.

This is a 16-year-old 21,000 WBCs.

And the pelvic ultrasound was normal 'cause we always include a pelvic ultrasound, which we know will be helpful for us, particularly with the girls in our right lower quadrant appendix ultrasound work.

And we see this debris filled and echogenic area thickened blind ending appendix.

And this was appendicitis with an appendicolith coming from above.

And this would be use of color around it and some increased fat nearby.

And this is just another example of increased fat near appendix that is tubular blind ending non-compressible had some increased flow in it.

This is just an example of a normal appendix, which you try to find.

You will find much more often than I originally thought.

You can use the cecum to help guide you.

But there are differentials and here is a very thick walled piece of bowel with the lumen seen here, some fluid around it.

And this was a patient with Crohn's disease, very thick bowel And we had some increased flow.

There are other GYN issues and we can look at the most common reason why I'll have an 11 to 11-year-old to 13-year-old come in first time significant pelvic pain, will have a multiple echogenicity within a relatively echoic area with through transmission.

I have to read the O Rad to figure out exactly what words I should say now.

Now I'm nervous saying any word, but that's great.

I'm happy there are definitions.

Hemorrhagic Ovarian Cysts

Hemorrhagic ovarian cysts is not uncommon cause of first time complaints of lower quadrant pelvic pain in peripubertal girls.

The initial bright echogenicity will decrease to less bright and it'll be fluid like material will be, it'll be eventually fluid like as fibrin dissolves and clot lysis.

And one will see reticulation and one can see sometimes echogenic material with through transmission to prove or indicate that it is of relative fluid content.

Ovarian Torsion

Another concern we heard about testicular torsion.

It was really well done.

I love looking at the images, so maybe I'll run through 'em fast 'cause I got 33 seconds.

But that's peripheral cysts, brought to you by the originators of the information in the pediatric slash adolescent population, graph.

And it's rare before menarche and it's common in immediate post menarchal years.

And one can read what says there are complaints of sudden localized sharp pain, extremely important compared to the typical pain of app, which is periumbilical.

One can see that this is an ovarian torsion that or an ovarian twist that had significant echogenic material consistent with teratoma.

And these are the typical peripheral cysts in a very large ovary that was adnexal.

I typically consider torsion most when I have three to four times the volume on one side as they have on another side.

So we can see, for example here, this is a large ovary in part in large because of the contained cyst.

But you can see a quite a difference with regard to the ovary on the opposite side.

Left Kidney Cystic Mass

Third thing we'll talk about in 14 seconds, left kidney cystic mass, upper pole first consideration is that this is a duplication anomaly, typically obstructed up top and refluxing down low.

This is an image of a cystic area, a relatively cystic area up top.

And you can see calyceal regarding some dilation of a refluxing lower moiety, the more classic image, this is a VCUG that shows a drooping lily, but the more typical image is rounder.

I should show you an example of this.

Hopefully this is the right thing that I did.

One of the ways of seeing duplication is to look at the bladder and see ureteroceles.

And when you see ureteroceles, you should make sure that when you turn on the end, it isn't a long tubular structure to suggest it's the ureter and not the typically intraluminal ureterocele.

They can be seen beyond the lumen, and you're just trying to make sure that the central area is not the largest and you're dealing with a typical just obstruction and you're not dealing with renal pyramids, which are commonly seen, and you're not dealing with an MCDK in which there are multiple cysts, but the largest one is not the central one.

And in case you have dilation and you have extrarenal fluid that you're not dealing with the possibility of a forniceal rupture due to posterior urethral valve.

So the gist of this all, and I think it's pronounced gist, in the pediatric slash perinatal abdomen, as in many other areas, ultrasound helps make diagnosis the end.