BMUS Summer School 2017
Martijn Verhagen
Radiologist
Fellow Paediatric Radiology at GOSH, London, UK
Paediatric ultrasound: Something slightlydifferent!
• First choice imaging modality in paediatric radiology• CT and MRI only in selected cases
• Different diseases, e.g.:• Intussusception
• Malrotation and volvulus
• Appendicitis
• Different proportions
• Smaller
• Less fat!
Paediatric ultrasound: Something slightlydifferent!
• First choice imaging modality in paediatric radiology• CT and MRI only in selected cases
• Different diseases, e.g.:• Intussusception
• Malrotation and volvulus
• Appendicitis
• Different proportions
• Smaller
• Less fat!
The right approach
• Patience
• Involve the parents/guardians• Get them to help
• It might make or break the examiation
• Be gentle but diagnostic
• Use warm gel
• Keep thinking (goes for adult as well)
• Use high frequency probes (it’s amazing)
What to consider…
Neonates
•Atresia (oesophagus,
stomach, bowel)
•Malrotation with volvulus
•Hirschsprung disease
•Meconium plug syndrome
•Meconium ileus
•Necrotising enterocolitis
(NEC)
Toddlers/Infants
•Gastroenteritis
•Intussusception
•Malrotation and volvulus
•Appendicitis
•Abdominal malignancy
•Meckels diverticulum
•Hemolytic uremic
syndrome
Children/Adolescents
•Appendicitis
•Inflammatory bowel disease
•IgA vasculitis
•Ovarium torsion
•Meckels diverticulum
•Abdominal malignancy
•Pancreatitis
•Distal intestinal obstruction
syndrome
Case 1
• GA 37 weeks
• 2 days old
• Bilious vomiting since 1 day
• Abdominal distension
• No fever
Differential diagnosis?
• Malrotation with volvulus
• Proximal bowel obstruction• Duodenal/jejunal atresia/stenosis
• Annular pancreas
• Distal bowel obstruction• Meconium ileus
• M. Hirshsprung
• Atresia
• Sepsis
Volvulus or atresia?
• a
Different patient
Normal
Applegate et al. Intestinal Malrotation in Children: A Problem-solvingApproach to the Upper Gastrointestinal Series
• 720° volvulus
• Ladds procedure with derotation
• No bowel necrosis and good recovery
Case 2
• GA 35 weeks
• 2 days old
• Weight 1300 grams
• Respiratory distress (saturation 85%)
• Abdominal distension
Differential diagnosis?
• Necrotising enterocolitis (NEC)
• Sepsis
• Bowel obstruction
• Tumor
• 24 uur postpartum
Pneumatosis intestinalis
Met dank aan Simon Robben, MUMC Courtesy of prof. Simon Robben
Over time…
• Progressive abdominal distension
• Blood in stool
• 1 dag later
Necrotising enterocolitis (NEC)
http://www.chla.org/necrotizing-enterocolitis
Case 3
• 1 year old boy
• Flown in from St. Maarten
• Cystic Nephroma seen on ultrasound
Courtesy of dr. Eric Beek
Differential diagnosis?
• Hydronephrosis
• Cyst originating from…• Kidney
• Spleen
• Pancreas
• Duplication
• Mesenteric cyst
• (multilocular) Cystic nephroma?
High frequency probe! (12 MhZ)
Case 4
• 9 year old boy
• Blood in stool
Between umbilicus and bladder
Courtesy of dr. Eric Beek
Bowel wall layers
Between umbilicus and bladder
Courtesy of dr. Eric Beek
Differential diagnosis
• Duplication cyst
• (inflamed) Meckels diverticulum
Johann Friedrich Meckel (1781-1833)
Complications
• Hemorrhage
• Volvulus
• Intussusception
• Inflammation
• Confused with appendicitis
Ayati et al. Delayed Imaging for Detection of Meckel's Diverticulum in Tc99m Pertechnetate Scintigraphy
99m Tc pertechnetate scintigraphy
Case 5
• 4 year old
• Got hit by a car (5 miles/hour), hit on the leg
• 7 days ago
• Pain started 2 days after the accident
• Persisting severe abdominal pain
Normal appendix
Keep thinking
• Read the request form
• Talk to the clinician
• Ask critical questions
• Talk to the child• Where does it hurt?
• Keep an open mind
Case 6
• 3 year old girl
• Intermittent abdominal pain for 2 days
• No fever
• Bloody stool
Ultrasound!
Large bowel intussusception
• Diameter≥ 2.5 cm
• Intussusception includes mesenterial fat and lymph nodes
• Most commonly ileocolic
Small bowel intussusception
• Almost always an incidental finding• Asymptomatic
• Resolves during examination
• Associated with celiac disease and malabsorption syndromes
Treatment
• Repositioning• Spontaneous
• Pneumatic
• Hydrostatic
• Surgery
• Aim: overflow of air/fluid in small bowel• Ileocecal valve is usally edematous
• Complication: Perforation
Treatment
• Repositioning• Spontaneous
• Pneumatic• Hydrostatic
• Surgery
• Aim: overflow of air/fluid in small bowel• Ileocecal valve is usally edematous
• Complication: Perforation5 attempts, 3 mins, 3 mins breakPressure 80 -100 - 120 mm Hg
Pneumatic
Treatment
• Repositioning• Spontaneous
• Pneumatic
• Hydrostatic• Surgery
• Aim: overflow of air/fluid in small bowel• Ileocecal valve is usally edematous
• Complication: Perforation Rule of 3• 3 feet• 3 minutes• 3 times
Hydrostatic
Treatment
• Repositioning• Spontaneous
• Pneumatic
• Hydrostatic
• Surgery
• Aim: overflow of air/fluid in small bowel• Ileocecal valve is usally edematous
• Complication: Perforation
Key points
• Use high frequency probes
• Involve the parents
• Be aware of specific paediatric diseases
• Keep thinking!
Thank you and good luck!
Malrotation and volvulus