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176

Child with suspected non-accidental injury

PD 1 Suspected non-accidental injury

Clinical history and physical examination

No history of head injury or focal neurological symptoms & signs

Visceral injury

± MRI

CT negative or indeterminate

CT brain

CT positive • Stop • Bonescanifclinicalsignsareminimal,clinically

suspicious or for further documentation

• UScandetectperitoneal fluid • ContrastenhancedCT:Hepatic,splenicor pancreatic trauma Intramural haematoma of bowel

Plain radiograph • Skeletalsurveyif<2yearsold • Selectiveradiographyif>2yearsold

MRI especially if focal neurological signs are present

History of head injuryor the presence of focal

neurological symptoms & signs

177

Paediatric Radiology


REMARKS

1 General 1.1 Child abuse is not an imaging diagnosis. The role of imaging is to support the

clinical diagnosis of child abuse in the proper clinical and social context and also to assist the evaluation of the severity and extent of injury.

2 Musculoskeletal trauma 2.1 Skeletalsurveyincludesskull(frontalandlateral),spine(lateralcervical, thoracic

andlumbar),chest(frontalincludingclavicles,andobliqueviewsofbilateralribs),abdomen(frontal,includingpelvisandbothhips),upperextremities(frontalhumeri,forearms,andhands),andlowerextremities(frontalfemora,lowerlegs,andfeet).

2.2 Conventionalradiographyis theprimaryimagingexaminationformusculoskeletaltrauma.

2.3 Avoid'babygram'asitisdiagnosticallyinadequate. 2.4 Completeskeletalsurveyisnormallyindicatedinchildrenlessthan2yearsofage

whohaveclinicalevidenceofchildabuse,orininfantslessthan1yearofagewhoshowevidenceofsignificantneglectanddeprivation.Inchildrenbetween2yearsand5yearsofage,theskeletalsurveymaybetailoredaccordingtohistoryandphysicalexamination findings.

2.5 For children more than 5 years old, skeletal survey is rarely indicated. 2.6 Bonescansmaybeconsideredforchildreninwhomskeletalsurveyisnegativebut

clinicalsuspicionofnon-accidentalinjury(NAI)ishigh.Bonescanissensitivefortheextentofboneinjury,acutenon-displacedandsubtlehealingfractures.Itspitfallsincludenormaluptakearoundthegrowthplatesleadingtodifficultidentificationofmetaphyseal-epiphysealinjuries,missedsymmetricalfractures,inabilitytodeterminetheageandtypeoffractureandrelativeinsensitivityindetectingskullandvertebralbody fractures. It should be used as a problem-solving study rather than first line.

2.7 RoleofMRIandUSforevaluatingskeletalinjuryinNAIhasnotbeenestablishedwith reference to prevailing international guidelines and recommendations.

3 Skull trauma 3.1 Skullradiographsformpartofthefullskeletalsurveyfornon-accidentalinjury. 3.2 Inchildrenwithheadtraumawhoareat increasedriskofintracranialinjury,CTis

the preferred initial imaging modality and also improves definition of depressed and other complex fractures.

3.3 Bonescanisunreliableinidentifyingskullfractures.

4 Intracranial trauma 4.1 CTisbothsensitiveandspecificindefiningacuteintra-andextra-cerebralinjuries,

especially subarachnoid haemorrhage. 4.2 MRI is useful in the subacute and chronic settings and is superior in detecting subdural

haematomas,corticalcontusionsandshearinginjuries. Itcandeterminetheageofextra-cerebral fluid collections and timing of intracranial haemorrhage.

4.3 MRI should be performed in patients whose clinical symptoms are disproportionate to the CT findings.

178


5 Visceral trauma 5.1 Imaging examinations should be tailored to specific clinical concern. 5.2 AbdominalUSisusefultodetectperitonealfluidbutislesssensitivethanCTtodetect

solid organ injury.

179



REFERENCES

1. TheRoyalCollegeofRadiologists,RoyalCollegeofPaediatricsandChildHealth. StandardsforRadiologicalInvestigationsofSuspectedNon-AccidentalInjury.London:TheRoyalCollegeofRadiologists;2008.

2. Wootton-GorgesSL,SoaresBP,AlazrakiAL.ACRAppropriatenessCriteria®SuspectedPhysicalAbuse–Child.Availableathttps://acsearch.acr.org/docs/69443/Narrative/.AmericanCollegeofRadiology.Accessed2017May17.

3. AmericanCollegeofRadiology.ACR–SPRPracticeParameterForThePerformanceAndInterpretationofSkeletalSurveyinChildren.Revised2016(Resolution10).Reston:AmericanCollegeofRadiology;2016.

4. CavinessAC.Skullfracturesinchildren.In:UpToDate,PostTW(Ed),UpToDate,Waltham,MA;2014.5. MertenDF,RadkowskiMA,LeonidasJC.Theabusedchild-aradiologicalreappraisal.Radiology.1983;146:377-

381.6. MertenDF,CarpenterBLM.Radiologicimagingof inflictedinjuryin thechildabusesyndrome. PediatrClin

NorthAm.1990;37:815-837.7. MandelstamSA,CookD,FitzgeraldM,DitchfieldMR.Complementaryuseofradiologicalskeletalsurveyand

bonescintigraphyindetectionofbonyinjuriesinsuspectedchildabuse.ArchDisChild.2003;88:387-390.8. ConwayJJ,CollinsM,TanzRR,RadkowskiMA,AnandappaE,HernandezR,etal.Theroleofbonescintigraphy

indetectingchildabuse.SeminNuclMed.1993;23:321-333.9. SatoY,YuhWTC,SmithWL,AlexanderRC,KaoSCS,EllerbroekCJ.Headinjuryinchildabuse-evaluationwith

MRimaging.Radiology.1989;173:653-657.10. KleinmanPK.Diagnosticimagingininfantabuse.AJRAmJRoentgenol.1990;155:703-712.11. HardtN,KuttenbergerJ.Chapter2:RadiologyofCraniofacial fractures.CraniofacialTraumaDiagnosisand

Management.BerlinHeidelberg:Springer-Verlag;2010.p.15-28.12. Stauss J,HahnK,MannM,DePalmaD.Guidelines forpaediatricbone scanningwith99mTc-labelled

radiopharmaceuticalsand18F-fluoride.EurJNuclMedMolImaging.2010;37:1621-1628.13. ConwayJJ,CollinsM,TanzRR,RadkowskiMA,AnandappaE,HemandezR,FreemanEL.TheRoleofBone

ScintigraphyinDetectingChildAbuse.SeminNuclMed.1993;23:321-333.

180

PD 2 Paediatric seizures

US

Neonates Infants and children

Noknownprecipitating event

Cause identified

No cause identified

CT/MRI CT

± MRI CT/MRIMRI

Knownprecipitating event

Partial seizures

Post-traumatic

Febrileseizures

Generalisedseizures

Normal neurological examination

Abnormal neurological examination

Intractable/refractory seizures

MRI±SPECT/

PET

Paediatricseizures

181



REMARKS

1 Indications 1.1 Structuralneuroimagingisrecommendedforallchildrenwithrecentlydiagnosed

localization-relatedorgeneralized epilepsywhodonot have the clinical andelectroencepalogram(EEG) featurescharacteristicofclassical idiopathic focalorgeneralizedepilepsy (benignepilepsywithcentrotemporal spikes (BECTS),childhoodabsenceepilepsy(CAE), juvenileabsenceepilepsy(JAE),or juvenilemyoclonicepilepsy(JME))andforanychildyoungerthan2yearsofage.

1.2 Imaging early in the course of epilepsy is directed at identifying an etiology for seizurethatrequiresothermedicalorsurgicalattention1:

1.2.1 If thereisanyevidencetosuggest theepilepsyis localization-related(e.g.focal),withtheexceptionoftypicalbenignidiopathicpartialepilepsy.

1.2.2 Abnormalneurologicexamination, including focaldeficits, stigmataofneurocutaneoussyndrome,cerebralmalformationsyndrome,orahistoryofsignificantdevelopmentaldelay,arrest,orregression.

1.2.3 Childrenyoungerthan2years,excludingthosewithsimplefebrileseizures. 1.2.4 Childrenwith characteristics of a symptomatic generalized epilepsy

syndrome,includinginfantilespasmsorearlyLennox-Gastautsyndrome. 1.2.5 Failure to control seizures,worsening seizures, changes in seizure

manifestations,ordevelopmentalregressionalsomeritneuroimagingifnotpreviously performed.

1.2.6 New-onset seizure/epilepsy presentingwith evidence for amedicalemergency such as increased intracranial pressure or status epilepticus always merit emergency imaging.

1.3 ImagingstudiesinCAE,JAE,JME,andBECTSdonotidentifysignificantstructuralabnormalities1.

2 Plain radiograph 2.1 Skullradiographsarenotroutinelyindicatedinevaluationofseizuresinchildrenasit

lacksbothsensitivityandspecificity.2

3. US 3.1 USiseffectiveinevaluationofseizuresinneonatalperiodandmayadequatelydefine

treatable pathology to allow management in some cases. 3.2 AnopenfontanelleisnecessaryforUS. 3.3 USDopplerevaluationof intracranialarteries iseffective inassessing regional

cerebral blood flow but its clinical value remains unclear.

4. Nuclear medicine 4.1 Singlephotonemissioncomputedtomography(SPECT). 4.1.1 IctalSPECThasbeenusefulindifferentiatingtemporallobeepilepsyfrom

extra-temporal lobe foci and provides non-invasive imaging information used in planning treatment strategies.3

4.1.2 IctalSPECToptimizationrequiresradiopharmaceutical injection(Tc-99mhexamethylpropyleneamine oxime [HMPAO] or Tc-99m ethyl cysteinate dimer[ECD])withinsecondsofaseizure.

182


4.2 PET 4.2.1 PEToffersadirectquantitativecorrelationwithmetabolicactivitiesand

thereforeitispotentiallymorespecificthanSPECT. 4.2.2 BothSPECTandFluorodeoxyglucose(FDG)PEThavebeenusedasapart

of pre-surgical evaluation and planning.

5. CT 5.1 Non-contrastCT iseffective in identifyingsome treatablecausesof seizuresor

emergenciescausingseizures. 5.2 CTconferssomeadvantageswithregardto identifyingbloodandcalcification(as

foundincongenitalinfection).1

5.3 Contrast enhancement in general does not improve the sensitivity in detecting focal intracranial lesionswiththeexceptionofbrainmetastases,whicharerarecausesofseizuresinthepaediatricpopulation.

5.4 CTismorewidelyavailable thanMRI, lessexpensive,and less likely to requiresedation for younger children.

5.5 CT can detect all treatable lesions in the setting of acute mild trauma.3

6. MRI 6.1 MRI has the highest sensitivity in detecting focal intracranial lesions. It is considered

the imaging modality of choice because of superior anatomic resolution and characterizationofpathologicprocesses.1

6.2 Routine administration of gadolinium contrast provides little advantage in children with epilepsy. Administration of gadolinium is of limited value in increasing the sensitivityofMRIexaminationofbrain,althoughthespecificitycanbeimproved.4

Itisreservedforcircumstanceswheretumor,vascularmalformations,inflammation,and infectious concerns arise or are suspected based on review of non-contrast studies.

6.3 ThereisnoagreementonspecificimagingprotocolsorMRIsequences,butthereisgeneral agreement that the following should be performed1:

6.3.1 Anatomic, thin-slice volumetricT1-weighted gradient-recalled-echosequence,

6.3.2 AxialandcoronalT2-weightedsequence, 6.3.3 Fluidattenuatedinversionrecovery(FLAIR)sequence(axial,andcoronalif

possible), 6.3.4 HighresolutionobliquecoronalT2-weightedimagingof thehippocampus

(fastorturbospinechoweightedsequence), 6.3.5 There is debate, and there are limiteddata, about theutilityofnewer

sequences suchasmagnetization transfer imaginganddiffusion tensorimaging,

6.3.6 Whenmetabolicdisordersaresuspected,magneticresonancespectroscopy(MRS)maybehelpful,

6.3.7 FunctionalMRIhasbeenusedasapartofpre-surgical evaluationandplanning.

183


REFERENCES

1. GaillardWD,ChironC,CrossJH,HarveyAS,KuznieckyR,Hertz-Pannier,VezinaLG;ILAE,CommitteeforNeuroimaging,Subcommittee forPediatricNeuroimaging.Guidelines for imaging infantsandchildrenwithrecent-onsetepilepsy.Epilepsia.2009;50:2147–2153.

2. TheRoyalCollegeofRadiologists. iRefer:Makingthebestuseofclinicalradiology.8thed.London:TheRoyalCollegeofRadiologists;2017.SectionP10.

3. DoryCE,ColeyBD,KarmazynB,etal.ACRAppropriatenessCriteria®Seizures-Child.Availableathttps://acsearch.acr.org/docs/69441/Narrative/.AmericanCollegeofRadiology.Accessed2017Jun2.

4. LeeST,LuiTN.Earlyseizuresaftermildclosedheadinjury.JNeurosurg1992;76:435-439.


6.4 Childrenyoungerthan2yearsrequirespecialsequences,as immaturemyelinationaffects the ability to identify common causes of epilepsy1:

6.4.1 Inadditiontoa3Ddataset,imaginginchildrenyoungerthan2yearsshouldincludesagittal,axial,andcoronalT1-weightedsequences.

6.4.2 VolumetricT1-weightedsequencesarelessusefulbeforeoneyearofageduetoincompletemyelinationonT1sequences.

6.4.3 MRimaging(especiallyhigh-resolutionT2images)performedearlyinthefirst year of life in infants with epilepsy is important to identify areas of corticalorsubcorticaldysplasia,whichcanbecomedifficulttoidentifyaftermyelination.

6.4.4 IfMRimagingbeforetheageof2yearsisnormal,andseizurespersist,thenMRImayberepeatedat6-monthintervals,andafterage24–30monthswhenmore mature myelination can reveal otherwise unsuspected cortical dysplasia.

7. Angiography 7.1 Angiography should only be performed with prior imaging suggesting a vascular

lesion.

184

Clinical history and physical examinationsuggestingGIcause

PD 3 Vomiting in infants

Non-bilious vomiting

New onset projectile

Biliousvomiting

Vomiting in infants

Plain supine AXR

Intermittent since birth

USabdomen

UpperIOpattern

Hypertrophic pyloric stenosis

Equivocalforpyloric stenosis

Negative/Non-specific

LowerIOpattern

Otherfindings:gastric

pylorospasm,intussusception

No microcolon Manage accordingly

Manage accordingly

Excludemalrotation

Microcolon

ExtendedpHprobe+/-contrastupperGI

series/Tc-99msulphurcolloid

Contrast enema Contrast upper GIseries

RepeatUSabdomen+/-

UpperGIseriesin48hours

185


PD 3 Vomiting in infants

REMARKS

1 Malrotation / midgut volvulus 1.1 Midgut volvulus is an emergency situation. It should be considered in patients with

bilious vomiting. 1.2 ContrastupperGIseriesisthepreferredexamination.Bariumisusuallyused,except

insuspectedperforationorhighriskofaspiration.Low-osmolaritycontrastmediaareused in extremely ill or premature neonates.

1.3 USislimitedbyoperatorexperienceandincompleteexaminationduetooverlyinggas.

2 Gastroesophageal reflux (GER) 2.1 ExtendedpHprobeiscurrentlythegoldstandardfordiagnosis. Preferenceforthe

othermethods in thediagnosticwork-upofGERvariesamongdifferentcentresdepending on expertise and availability.

2.2 GERisthecommonestcauseofrecurrentnon-biliousvomiting. AbdominalX-ray(AXR)doesnothavea role indiagnosisofGER,and is indicatedforadditionalclinicalconditions,e.g.obstruction.

2.3 ContrastupperGIseriesornuclearmedicineexaminationareadvocatedonlywhenfailureofconservativetreatment,developmentofcomplicationsor life threateningsymptoms occur.

2.4 UpperGIseriesandnuclearmedicineexamination(Tc-99m-labelledsulphurcolloidscan)showsimilarsensitivity,andupperGIseriesallowsanatomicalevaluatione.g.obstruction and structural abnormalities.

2.5 UScanprovidefunctionalandmorphologic information. However, itsdiagnosticperformanceonGERisvariable.

3 Hypertrophic pyloric stenosis 3.1 AXR should not be routinely obtained when the diagnosis is strongly suspected. 3.2 USis thepreferredmethodfordiagnosisbut it requiresconsiderableexperience.

RepeatUSin48hoursisrecommendedincaseofdoubt.ContrastupperGIseriesislimitedbyitsionizingradiation,andshouldbeusedwhenothercausesaresuspected.

4 Intussusception 4.1 Intussusception is a frequent causeof crampyabdominal pain,which canbe

accompanied by vomiting in children. 4.2 Themainreasonforobtainingplainradiographsistolookforthepresenceoffreeintra-

peritonealairanddegreeofsmallbowelobstruction.USisasensitivediagnosticmethod. 4.3 Pneumaticreductionunderfluoroscopicguidanceisusedtoreduceintussusception,

onlywherespecialistequipmentandexpertiseisavailable.

REFERENCES

1. AmericanCollegeofRadiology.ACRAppropriateCriteria–VomitinginInfantsupto3MonthsofAge.Reston:AmericanCollegeofRadiology,2014

2. TheRoyalCollegeofRadiologists. iRefer:Making thebestuseofclinical radiology.8thed.London:TheRoyalCollegeofRadiologists;2017.SectionP24.



5. VandenplasY,RudolphCD,DiLorenzoC,HassallE,LiptakG,MazurL,etal.PediatricGastroesophagealRefluxClinicalPracticeGuidelines:JointRecommendationsof theNorthAmericanSocietyforPediatricGastroenterology,Hepatology,andNutrition(NASPGHAN)and theEuropeanSociety forPediatricGastroenterology,Hepatology,andNutrition (ESPGHAN). JPediatrGastroenterolNutr.2009;49:498-547.

6. VinocurDN,LeeEY,EisenbergRL.NeonatalIntestinalObstruction.AJRAmJRoentegenol.2012;198:W1-10.7. CohenHL,GreeneEB,BouldenTP.TheVomitingNeonateorYoungInfant.UltrasoundClin.2010;5:97-112.

186

Acute(onset<24hours)

PD 4 Non-traumatic abdominal pain

Chronic recurrentRef4

Non-traumatic abdominal pain in children

Grey-scaleUSwith colour DopplerUS

GItractdisease

Ref2

Biliarydisease

Testicular torsion

Ref 1

Mass,renal/biliary

colic

Neoplasm

Gynaecologicalcause(includingovariantorsion)

Extra-abdominalRemarks

Chronic inflammatory boweldisease/

irritablebowelsyndrome/abdominalmigraine/

other specific diagnosis

Abdominal

Acute appendicitis

Ref3

IntussusceptionVolvulusPepticulcer,

gastritisHirschsprung

Urinarytractstone,hydronephrosis

Grey-scaleUSwith colour DopplerUS

US

AXR (supine&erect/

decubitus)

US/diagnosticcontrast enema

Smallbowelcontrast study

Endoscopy/barium meal

CT (ifequivocalresult after

US)

SupineAXRRef 8

Inselectedcases,endoscopy/

BariumGIstudy(non-toxicpatientonly)

Ref 8

CT/MRI

USwithgradedcompression

Barium/water

soluble contrast enema

Reduction under imaging guidance (pneumatic

or hydrostatic reduction)

Other diagnosis

Management

187



REMARKS

1 Inallchildrenpresentedwithabdominalpain,historyandphysicalexaminationshouldbecarefullyassessedforevidenceofsignificanttrauma(bothaccidentalandnon-accidental).

2 Insignificantabdominaltrauma,furtherinvestigationswithradiograph,USandsometimesCTarenecessarytoexcludepneumothorax,perforationofhollowviscusorcontusion/laceration of solid organs.

3 Inpre-schoolchildren,abdominalpain is rarelyofpsychogenicoriginandanorganicsource should be carefully sought.7

4 A period of observation is important in those with non-specific symptoms and absent physicalsigns. Subsequentchangeinsymptomsordevelopmentofspecificsignsmaypoint to the diagnosis.

5 Gynaecological causes 5.1 Recurrentpainrelatedtomenstruationcanbeduetoendometriosis,whilechronicpain

andvaginaldischargearesuggestiveofchronicpelvicinflammatorydisease.Foracuteonsetofabdominalpaininsexuallyactivefemales,thepossibilityofectopicpregnancyor other pregnancy-related complications as well as acute pelvic inflammation should beconsidered.AlltheseconditionswarrantfurtherinvestigationbyUS.5,6

5.2 Gastroenteritisandconstipationareclinicaldiagnoses. Radiographsareusuallyunnecessary.5

5.3 Forsuspectednon-accidentalinjury,pleaserefertotheguidelinePD1.

6 Extra-abdominal causes 6.1 Diabeticketoacidosis,porphyria, leadpoisoning, inwhichbiochemical testsare

needed for diagnosis. 6.2 Pneumonia,bronchiolitis,asthma, inwhichchestX-ray(CXR)willbeuseful for

diagnosis.5

7 Acute appendicitis3

7.1 Meta-analysisshowedUS isnearlyasgoodasCT inexperiencedhands,withapooledsensitivityof88%andspecificityof94%,ascomparedwithCT,withapooledsensitivityof94%andspecificityof95%.Giventhelackofionizingradiation,USisthepreferredexaminationinchildren,particularlyifequivocalresultsarefollowedupby CT.

7.2 CT-after-USapproachhasexcellentaccuracy,withreportedsensitivityandspecificityof94%.

7.3 IfCT isperformed,useof intravenous (IV)contrast is recommended;however,theuseofentericcontrast,suchasoralor rectalcontrast,hasnotbeenshowntosignificantly increase sensitivity in children and should be left to the discretion of individual department and hospital policy.

7.4 Non-visualizationof theappendixonnormalCThasbeenshowntohaveahighnegative predictive value of 98.7%.9

188

8 Hirschsprung Disease2

8.1 Bariumorwater-solublecontrastsaretheroutinecontrastmediausedforevaluatingchildhood Hirschsprung disease.

8.2 Intheneonateorinfant,water-solublemediadilutedtonear-isotonicoriso-osmolarconcentrationispreferred,astheremaybepotentialforbowelperforation.


189


REFERENCES

1. HartmanMS,LeyendeckerJR,FriedmanB,etal.ACRAppropriatenessCriteria®AcuteOnsetofScrotalPain–WithoutTrauma,WithoutAntecedentMass.Availableathttps://acsearch.acr.org/docs/69363/Narrative/.AmericanCollegeofRadiology.Accessed2017April10.

2. AmericanCollegeofRadiology.ACR–SPRpracticeparameter for theperformanceofpediatric fluoroscopiccontrastenemaexaminations.Revised2016(Resolution9).Reston:AmericanCollegeofRadiology;2016.

3. SmithMP,KatzDS,RosenMP,etal.ACRAppropriatenessCriteria®RightLowerQuadrantPain–SuspectedAppendicitis.Availableathttps://acsearch.acr.org/docs/69357/Narrative/.AmericanCollegeofRadiology.Accessed2017April10.

4. RalphPinnock.AbdominalPain,Chronic.RaewynGavin,editor.StarshipChildren’sHealthClinicalGuideline;2012April.

5. GrisantiKA.Gastrointestinaldisorders:abdominalpain.In:BarkinRM,AschSM,CaputoGL,JaffeDM,KnappJ,SchafermeyerRW,SeidelJS,editors.Paediatricemergencymedicine-conceptsandclinicalpractice.St.Louis:Mosby;1992.p.726-795.

6. RuddyRM.Abdominalpain.In:FleisherGR,LudwigS,editors.Textbookofpediatricemergencymedicine.2ndedition.Baltimore:Williams&Wilkins;1988.p.70-77.

7. FirstLR,SnyderJ.Gastroenterology-approachtoabdominalpain.In:AveryME,FirstLW,editors. Paediatricmedicine.Baltimore:Williams&Wilkins;1989.p.401-413.

8. deBruynR,MillaP.Gastrointestinal tract. In:GordonI,editor.Diagnostic imaging inpaediatrics. London:Chapman&Hall;1987.p.217-244.

9. GarciaK,Hernanz-SchulmanM,BennettDL,MorrowSE,YuC,KanJH.Suspectedappendicitis inchildren:diagnosticimportanceofnormalabdominopelvicCTfindingswithnonvisualizedappendix.Radiology.2009;250:531-537.


190

PD 5 Abdominal mass

No intestinal obstruction

AXR

Clinical follow upNormal

Intestinal obstruction

Child with abdominal mass

US Contrast study or CT

Reduction under imaging guidance

CT SerialUS

CT/MRI USfollowup

Tc-99m-IDAscan/MRCPCT/MRI

Pelvic

Intussusception Appendix abscess

Enteric/duplication/mesenteric

cyst

Mass

Hepatic/splenic/pancreaticmass or complicated cystic

lesions

Choledochal cyst

Hepatic/splenic/pancreatic simple

cysts

Solid/complicatedcysticlesion

Forhydronephrosisand/orUTI

If negative

Simplecysts

USfollowupMAG3orDTPAscan+/-diuretic and indirect voiding

cystogram

CT

USfollowup

MIBGscan

FollowupMCUorradionuclidecystogram for more detailed

assessmentofVUR+/-

FollowupMAG3orDTPAscanforfunction monitoring

+/-DMSAscanforacutepyelonephritis

or scarring

± MRI to assess IVC extension

Bonescan

Hydronephrosis/multicysticdysplastickidney

Abnormal

Non-renal retroperitonealRenalHepatobiliaryGastrointestinal

(Neonatal)Adrenal

haemorrhage

Mass lesione.g.neuroblastoma/

enlarged lymph node/cysticlesione.g.lymphangioma

Cystic and benign

•Solid•Malignant

If diagnosis is neuroblastoma

191


PD 5 Abdominal mass

REMARKS

1 Plain radiograph 1.1 PlainabdominalX-ray(AXR)isusefultoexcludeintestinalobstructioninchildren

withconstipationorabdominaldistension,tolocatemass,todetectanycalcification,andtolookforanyskeletalinvolvement.

2 US 2.1 UShelps todetermine theorganoforigin, todefine themass, to look forany

metastasesandtoassessthevascularityofthemasswithcolourDoppler. Alikelydiagnosis can usually be made.

3 Nuclear medicine 3.1 Technetium99m -Mercaptoacetyltriglycine (Tc-99m-MAG3) is thepreferred

radiotracer for renal scan.1

3.2 Tc-99m-MAG3 renography is able to provide informationon renal position,perfusion,differentialfunctionandtransittimes.Ifhydronephrosisisseen,diureticscan be administered to evaluate functional significance of hydronephrosis.1

3.3 Indirect radionuclide cystography can be performed in the same setting as renography,although itssensitivity is lower thandirect radionuclidecystography(DRC),2 therefore followupDRCormicturatingcystourethrography (MCU) isrequiredforpatientswithhydronephrosis,whetherornotvesicouretericreflux(VUR)was detected on indirect radionuclide cystography.

3.4 NuclearmedicinecystographycarriesalowerradiationdosethanMCU.3

3.5 Metaiodobenzylguanidine(MIBG)scanisusedindiagnosis,stagingandfollowupofneuroblastoma.

3.6 MIBGhashighersensitivitythanbonescanforskeletalmetastases.However,bonescanisneededforpatientwhosetumourisMIBGnegative.4

3.7 DynamicTc-99m - iminodiacetic acid (IDA) scanmay be used to diagnosecholedochal cyst.

4 CT 4.1 CT isused for anatomical andmorphological characterizationofmass and in

assessing the involvement of adjacent structures and distant metastases. 4.2 Sedationisoftenrequiredtoreducemovementartefacts.

5 MRI 5.1 MRI provides excellent contrast resolution of soft tissues and is the best study to

excludeintraduralextensionofmass.Statusofvasculaturecanalsobeevaluated. 5.2 MRIisnonionizingbutexpensive.Sedationofthechildrenisrequired. 5.3 Magneticresonancecholangiopancreatography(MRCP)isanon-invasivebiliarystudy.

REFERENCES

1. ShulkinBL,MandellGA,CooperJA,LeonardJC,MajdM,ParisiMT,etal.ProcedureGuidelineforDiureticRenographyinChildren,JournalofNuclearMedicineTechnology.2008,36:162-168.

2. LimR.VesicoureteralRefluxandUrinaryTractInfection:EvolvingPracticesandCurrentControversiesinPediatricImaging.AJRAmJRoentgenol.2009;192:1197–1208.

3. TheRoyalCollegeofRadiologists. iRefer:Making thebestuseofclinical radiology.7thed.London:TheRoyalCollegeofRadiologists;2012.SectionP21-P30.

4. MatthayKK,ShulkinB,LadenstineR,MichonJ,GiammarileF,LewingtonV,etal.Criteriaforevaluationofdiseaseextentby123I-metaiodobenzylguanidinescans inneuroblastoma:areport for theInternationalNeuroblastomaRiskGroup(INRG)TaskForce.BrJCancer.2010;102:1319–1326.

5. SteinR,DoqanHS,HoebekeP,KocVaraR,NijmanRJ,RadmayrC,etal.Urinary tract infections inchildren:EAU/ESPUguidelines.EurUrol.2015;67:546-558.

6. GordonI,PiepszA,RuneS.Guidelinesforstandardanddiureticrenograminchildren.EurJNuclMedMolImaging.2011;38:1175-1188.

192

Childwithurinarytractinfection(UTI)

PD 6 Urinary tract infection

Atypicalb/Recurrentc

1st episode <2months

1. US2. +/-MCUa(if

USabnormalormale)

US

USMCUd

DMSA(4-6monthsafteracuteinfection)

1st episode 2monthsto

6 years

1st episode >6years

No routine imaging

a. Radionuclide cystography or contrast-enhanced voiding urosonography may be alternative to MCU in initial assessment of girls or follow up studies (see Remarks)

b. DefinitionofatypicalUTI:poorresponsetoantibioticswithin48hours,poorurinestream,sepsis,raisedcreatinine,nonE-coliUTI

c. DefinitionofrecurrentUTI:twoormoreacutepyelonephritis/upperurinarytractinfection,ORoneacutepyelonephritis/upperurinarytractinfectionplusoneormorecystitis/lowerurinarytractinfection,ORthreeormorecystitis/lowerurinarytractinfection

d. Inatypical/recurrentUTI,NICEguideline2016reservesMCUinchild<6monthsorchildbetween6monthsto3yearswiththefollowing:

• DilatationonUS • Poorurineflow • NonE-coliinfection • FamilyhistoryofVUR

Respond well to treatment within48hours

193



REMARKS

Imaging protocol of febrile urinary tract infection (UTI) in children

UTIisafrequentindicationforimagingevaluationofpaediatricurinarytract.Thegoalofallimaging has been to improve outcome and prevent end-stage renal failure due to scarring from latediagnosisandinadequatetreatment.1

ImagingapproachofUTIinchildrenyoungerthan2monthsmayneedtobemoreaggressive,asthereislimitedresearchonthisagegroupandneonateswithUTIhaveahighincidenceofrenalanomaliesandaremorelikelytobecomplicatedwithsepsis.2

USofkidneys andbladder isusually appropriate2 and it is recommended in National InstituteforHealthandCareExcellence(NICE)guideline.3 Micturating cystourethrography (MCU)maybeappropriateandcanbeconsideredinboysandinpresenceofsonographicabnormality. Radionuclide cystography may be appropriate and can be considered in girls.2 Contrast-enhancedVoidingUrosonography(ceVUS)isavalidandradiation-freealternativeexaminationforMCUandradionuclidecystography.1,4

AmericanAcademyofPediatrics(AAP)2011guidelinesrecommendsUSforallchildrenbetweenagesof2monthsand2yearsafterfirstepisodeofUTI.3,5 AAP2011recommendsthatMCUis indicatedifUSrevealshydronephrosis,scarringorotherfindings thatwouldsuggesthighgradevesicouretericreflux(VUR)orobstructiveuropathyorinotheratypicalandcomplexclinicalcircumstances. ItshouldalsobeperformedforrecurrentUTI.5 NICE2007recommendsthatMCUshouldbeconsideredifseveralclinicalandimagingfeaturesarepresent.GuidelinefromItaliangrouprecommendsMCUforpatientswithabnormalUSfindings,riskfactorsorrecurrentUTI.6

Risk factors are derived fromNICE 2016,AmericanCollege ofRadiology (ACR)AppropriatenessGuidelineandItalianGuideline2,3,6: • FirstdegreerelativewithVUR • Septicemia • Urinaryretention • Poorurinestream • Raisedcreatinine • Noorpoorresponsetoantibioticstreatmentwithin48hours • BacteriaotherthanE.Coli

NICE2016definedRecurrentUTIasfollows:3 • 2ormoreepisodesofUTIwithacutepyelonephritis/upperurinarytractinfection,or • 1episodeofUTIwithacutepyelonephritis/upperurinarytractinfectionplusoneor

moreepisodeofUTIwithcystitis/lowerurinarytractinfection,or • 3ormoreepisodesofUTIwithcystitis/lowerurinarytractinfection

Renal cortical scintigraphy (withdimercaptosuccinic acid [DMSA]) in sixmonths isrecommendedinpatientwithhighriskfactors,recurrentUTI,abnormalUSorVURshowntoevaluate for renal parenchymal defects and relative renal function.3,6

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1 MCU ThemainroleofMCUistodetectVUR.PatientwithhighgradeVUR(grade3-5)are

morelikelytohaverecurrentUTIandscarring.2Itcanalsodetectobstructiveanomalies,such as posterior urethral valves or ectopic ureterocoele.

2 US UScandetecturinary tractanomalies suchashydronephrosis,duplex renal system,

hydroureterandureterocele.SensitivityofUSfordetectingVURandrenalscarringislow.2

3 Nuclear medicine 3.1 Renal cortical scintigraphy RenalcorticalscintigraphywithDMSAhasgreatersensitivityfordetectionofacute

pyelonephritisandrenalscarring thandoeseitherUSorMCU. Thefindingsonnuclearscansrarelyaffectacuteclinicalmanagement.Hence,itisnotrecommendedaspartofroutineevaluationofinfantswiththeirfirstfebrileUTI.5 It is recommended 6monthsafterthefebrileUTItoobtainamorphologicalandfunctionalevaluationofthe renal parenchyma.6

3.2 Radionuclidecystography(RNC) DirectRNCiscomparableinsensitivitytoMCUindetectingVUR.RNChasalower

absorbedradiationdosethanMCUbutitdoesnothavethespatialresolutionneededtoidentifyanatomicalabnormalitiesofurethra,bladderandureters.InitialevaluationofVURingirlsandfollow-upstudiesmaybedonebyRNC.2

4 Contrast-enhanced voiding urosonography (ceVUS) ceVUSisanultrasound-basedrefluxexamination, involvingintravesical instillationof

ultrasoundcontrastandcontinuousalternativesonographicexaminationof thekidneys,bladderandurethra. Ithasbeenapplied inEurope for twodecades. Theprocedureis similar toMCUexcept the replacementwithultrasoundcontrastandsonographicexamination.4 ceVUShasbeenconsideredasasafe, reliable, radiation-freeandvalidalternative toMCUorRNC,andhasahigher refluxdetectionrate thanMCUdue tostabilityofultrasoundcontrastmicrobubbles,advances inultrasound technology,andlonger examination time.1,7ThecurrentlyusedstabilizedultrasoundcontrastagenthasbeenapprovedinpaediatricusebytheU.S.FoodandDrugAdministrationin2016,thoughtheintravesicalapplicationinceVUSisstilloff-label.8

ceVUScanbeconsideredasanalternativetoMCUinthefollowingconditions: 4.1 Firstexaminationforvesicouretericrefluxingirls 4.2 Followupexaminationforvesicouretericrefluxinboysandgirlsafterconservativeor

surgical treatment 4.3 Screeninghigh-riskpatientsforvesicouretericreflux ApplicationofceVUSinmaleurethralassessmentisfeasibleandaccurate,8-9 and expanded

useofceVUSinfirstexaminationinboyswillbefurthervalidated.

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REFERENCES

1. RicacabonaM,AvniFE,BlickmanJG,DacherJN,DargeK,LoboML,etal. Imagingrecommendations inpaediatricuroradiology:minutesoftheESPRworkgroupsessiononurinarytractinfection,fetalhydronephrosis,urinarytractultrasonographyandvoidingcystourethrography,Barcelona,Spain,June2007.PediatrRadiol.2008;38:138-145.

2. KarmazynBK,AlazrakiAL,AnupindiSA,etal.ACRAppropriatenessCriteria®UrinaryTractInfection–Child.Availableathttps://acsearch.acr.org/docs/69444/Narrative/.AmericanCollegeofRadiology.Accessed2017May17.

3. National InstituteforHealthandCareExcellence(2016).Urinary tract infection inunder16s:diagnosisandmanagement.NICEguideline(CG54).

4. DargeK.VoidingUrosonographywithultrasoundcontrastagentsfor thediagnosisofvesicouretericrefluxinchildren.I.Procedure.PediatrRadiol.2008;38:40-53.

5. SubcommitteeonUrinaryTractInfection,SteeringCommitteeonQualityImprovementandManagement.UrinaryTractInfection:ClinicalPracticeGuidelinefortheDiagnosisandManagementoftheInitialUTIinFebrileInfantsandChildren2to24Months.Pediatrics.2011;128:595-610.

6. AmmentiA,CataldiL,ChemenzR,FanosV,LaMannaA,MarraG,etal.Febrileurinarytractinfectionsinyoungchildren:recommendationsforthediagnosis,treatmentandfollow-up.ActaPaediatr.2012;101:451-457.

7. PiscagliaF,NolsoeC,DietrichCF,CosgroveDO,GiljaOH,BachmannNielsenM,etal.TheEFSUMBguidelinesandrecommendationson theclinicalpracticeofcontrastenhancedultrasound(CEUS):Update2011onnon-hepaticapplications.UltrashchallMed.2012;33:33-59.

8. SeitzK,StrobelD.Amilestone:ApprovalofCEUSfordiagnosticliverimaginginadultsandchildrenintheUSA.UltraschallMed.2016;37:229-232.

9. DuranC,ValeraA,AlquersuariA,BallesterosE,RieraL,MartinC,etal.VoidingUrosonography:Thestudyoftheurethraisnolongeralimitationofthetechnique.PediatrRadiol.2009;39:124-131.

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