Imaging, Pediatric Respiratory Tract

Ron Cohen 1

Advances and Controversies in Clinical Pediatrics

Go With the Flow: Current Pediatric GU Imaging

Ronald A. Cohen M.D.Children’s Hospital Oakland

Pediatric GU Imaging

Imaging as a tool

Radiography (Fluoroscopy)Radiography (Fluoroscopy)UltrasoundUltrasoundComputed tomographyComputed tomographyNuclear Medicine Nuclear Medicine Magnetic Resonance ImagingMagnetic Resonance Imaging

Imaging, Pediatric Respiratory Tract

Ron Cohen 2

Pediatric GU Imaging

Common conditions Common conditions Congenital, infectious, trauma, neoplasm, misc.Congenital, infectious, trauma, neoplasm, misc.

ControversiesControversiesUTI UTI -- ? VCUG, imaging for renal damage? VCUG, imaging for renal damagePrenatal Prenatal hydronephrosishydronephrosis -- ? Work? Work--up / followup / follow--upup

Advances Advances Magnetic Resonance Magnetic Resonance UrographyUrography (MRU)(MRU)CT angiographyCT angiographyVoiding Voiding urosonographyurosonography

Pediatric GU Imaging

Congenital anomaliesCongenital anomaliesInfectionInfectionTraumaTraumaNeoplasmNeoplasmMisc.Misc.

Duplex Kidney Weigert – Meyer Rule

Multicystic Dysplastic kidney

Imaging, Pediatric Respiratory Tract

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Posterior Urethral Valve unilateral VUR , hydronephrosis

Pediatric GU Imaging

Congenital anomaliesCongenital anomaliesUPJUPJUVJ Congenital UVJ Congenital megauretermegaureterDuplex collecting systemDuplex collecting systemMulticysticMulticystic dysplastic kidneydysplastic kidneyEctopic kidneyEctopic kidneyHorseshoe kidneyHorseshoe kidneyPosterior urethral valvesPosterior urethral valvesUterine anomaliesUterine anomalies

Pediatric GU Imaging

InfectionInfectionUTIUTIRenal Renal abcessabcessTuberculosisTuberculosis

VCUG - Vesicoureteral reflux Nuclear Medicine – Radionuclide cystogram

Post - void

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pyelonephritis

Renal tuberculosis

5/29/2009

PyelonephritisHx - r/o appy

Sickle cell - renal infarctHx- Abdominal pain

4:14am2:34am

DMSA – Renal scan (cortical imaging

MRU – VUR and reflux nephropathy

Pediatric GU Imaging

TraumaTraumaFracture / lacerationFracture / lacerationVascular injuryVascular injury

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Renal Trauma

Pediatric GU Imaging

NeoplasmNeoplasmWilmsWilms tumortumorClear cellClear cellRenal cell carcinomaRenal cell carcinomaMedullaryMedullary cystic carcinoma (Sickle Cell trait)cystic carcinoma (Sickle Cell trait)MultilocularMultilocular Cystic Cystic NephromaNephroma

Wilm’s Tumor Multilocular Cystic Nephroma

Rhabdomyosarcoma – bladder baseRenal failure – beware iodinated contrast (CT)

and gadolinium (MR)

CT - dx MR – f/u

Pediatric GU Imaging

Congenital anomaliesCongenital anomaliesInfectionInfectionTraumaTraumaNeoplasmNeoplasmMisc.Misc.

Hypertension, Hypertension, UrolithiasisUrolithiasis, Cystic renal disease, , Cystic renal disease, Intersex, Testicular and Ovarian torsionIntersex, Testicular and Ovarian torsion

Imaging, Pediatric Respiratory Tract

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Torsion left testicle – manual detorsion Common Controversies

WorkWork--up of UTIup of UTIVCUG VCUG (Fluoroscopy vs. (Fluoroscopy vs. NucNuc. Med.). Med.)Imaging renal scarring Imaging renal scarring (US (US --NucNuc. Med. . Med. -- MRUMRU))

Prenatal Prenatal hydronephrosishydronephrosis (Ultrasound/VCUG)(Ultrasound/VCUG)Urinary tract obstruction Urinary tract obstruction ((LasixLasix NM vs. MRU)NM vs. MRU)

Common ControversiesWorkWork--up of UTIup of UTIPrenatal Prenatal hydronephrosishydronephrosisUrinary tract obstructionUrinary tract obstruction

Review of literature Review of literature Urology, Nephrology, RadiologyUrology, Nephrology, Radiology-- recommendationsrecommendations

““controversialcontroversial””, , ““unclearunclear””, , ““not well definednot well defined””, , ““varies widelyvaries widely””

UTI - summary

US US –– r/or/o obstruction, anomalies obstruction, anomalies VCUG VCUG

Initial fluoroscopicInitial fluoroscopicFollowFollow--up nuclear medicine (less radiation)up nuclear medicine (less radiation)Trend Trend –– less VCUG for nonless VCUG for non--febrile UTI > 2 febrile UTI > 2 y.oy.o..SonographicSonographic VCU VCU –– Europe Europe

Renal scarring Renal scarring –– US US –– DMSA DMSA -- MRUMRUManagement Management –– VUR VUR --prophylactic antibiotics prophylactic antibiotics (decrease risk of febrile UTI), (decrease risk of febrile UTI), followfollow--up VCUG, ? up VCUG, ? DefluxDeflux or surgeryor surgery

Prenatal Hydronephrosis

11--5 %5 %Severe Severe –– early postearly post--natal USnatal US

UPJ, other anomaliesUPJ, other anomaliesBoys Boys –– posterior urethral valveposterior urethral valve

Mild/moderate Mild/moderate –– wait 1 week for postwait 1 week for post--natal US natal US FollowFollow--up US up US –– VCUG if hydro persistsVCUG if hydro persistsSignificant pathology Significant pathology –– Obstructive Obstructive uropathyuropathy, VUR, VUR

metameta--analysis (Pediatrics 118, 2006 Lee, RS et al) analysis (Pediatrics 118, 2006 Lee, RS et al) Mild 12 %Mild 12 %Mod 45%Mod 45%Severe 88%Severe 88%

Obstructive Uropathy

No clinically useful classificationNo clinically useful classificationObstruction is usually chronic and partial Obstruction is usually chronic and partial

““compensated hydronephrosiscompensated hydronephrosis””balance between urine flow and drainagebalance between urine flow and drainage

Aims of imaging:Aims of imaging:1) to identify children who, if left untreated, will 1) to identify children who, if left untreated, will develop renal damagedevelop renal damage2) estimate how much function is recoverable2) estimate how much function is recoverable

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Acute-on-Chronic Obstruction

Compensated Hydronephrosis

Low flow rate High flow rate

Decompensated Hydronephrosis

Low flow rate High flow rate

Response to Fluid Challenge

UPJ Obstruction Lasix renogram (Nuclear Medicine)

QuickTime™ and aH.264 decompressor

are needed to see this picture.

Current concepts and Advances

MR MR UrographyUrography (Courtesy Dr. Damien Grattan(Courtesy Dr. Damien Grattan--Smith)Smith)

Anatomic imagingAnatomic imagingFunctional imagingFunctional imaging

MR UrographyAnatomic imagingAnatomic imaging

T2 weighted T2 weighted -- (fluid in collecting system)(fluid in collecting system)dynamic contrast enhanced imagingdynamic contrast enhanced imaging

Functional imagingFunctional imagingdifferential renal functiondifferential renal functionindividual kidney GFR individual kidney GFR -- Patlak PlotPatlak Plotsignal intensity versus time curvessignal intensity versus time curvesassess drainageassess drainage

MRUEvaluate anatomy and physiology simultaneouslyEvaluate anatomy and physiology simultaneouslyNew insightsNew insights

not all UPJnot all UPJ’’s are the sames are the samedifferent prognostic informationdifferent prognostic informationrandomized controlled trialsrandomized controlled trials

•• who will benefit from surgerywho will benefit from surgery•• estimate how much function is recoverableestimate how much function is recoverable

MRU – functional information

Immediate 3 mins 10 mins

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Pyelonephritis and Scarring - MRU

Acute Pyelonephritis 6/03 Renal Scarring 1/04

MRU – VUR and reflux nephropathy

MRU – Duplex with VUR lower moiety

MRU Hydroureteronephrosis

Current concepts – Pediatric GU Imaging

Imaging recommendations in Imaging recommendations in paediatricpaediatricuroradiologyuroradiology: minutes of the ESPR : minutes of the ESPR workgroup session on urinary tract workgroup session on urinary tract infection, fetal infection, fetal hydronephrosishydronephrosis, urinary tract , urinary tract ultrasonographyultrasonography and voiding and voiding cystourethrographycystourethrography

RiccabonaRiccabona et al Pediatric Radiology 38;2 138et al Pediatric Radiology 38;2 138--145 Feb 2008145 Feb 2008

Pediatric GU Imaging

Imaging toolsImaging toolsUS, CT, NM, MRUS, CT, NM, MR

Pediatric Pediatric dxdxInfection, Tumor,Infection, Tumor,

Congenital, TraumaCongenital, TraumaControversiesControversies

UTIUTIPrenatal Prenatal hydronephrosishydronephrosis

AdvancesAdvancesMRUMRUUS US

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Nephrogenic systemic fibrosis

NephrogenicNephrogenic systemic fibrosis (NSF)systemic fibrosis (NSF)Serious complication of gadolinium (MR contrast)Serious complication of gadolinium (MR contrast)Renal failure patientsRenal failure patientsMay be fatalMay be fatal

Imaging, Pediatric Respiratory Tract

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