paton pcw handout 20180430 · specific radiology examinations • chest x-ray (cxr) • abdominal...

3/30/18

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Common Radiology Studies in Pediatric Surgery

A Scenario Based Approach to Interpretation for the Pediatric Nurse and Provider

presented byElizabeth A. Paton, DNP, RN-BC, PNP-A, PPCNP-BC, CPEN, FAEN

Disclosure Information

I have no disclosures

Objectives

By the end of this presentation, the learner will be able to:1. Discuss a basic approach to interpreting common radiology

studies, including chest and abdominal X-rays, upper GIs, and CT scans.

2. Discuss key radiographic findings exhibited by patients with congenital abnormalities.

3. Recognize key abnormal radiological findings with acquired surgical diagnoses.

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Specific Radiology Examinations

• Chest X-ray (CXR)• Abdominal X-ray (KUB)• Computerized topography (CT)

o Chest o Abdomen

• Ultrasound• Upper gastrointestinal series (UGI)• Contrast enema• Esophagram

Chest X-rayQuality:

RotationInclusionPenetrationExpansion

Interpretation:AirwayBoneCardiacDiaphragmExtrathoracic tissuesFieldsGastric bubbleHilum and mediastinumInstrumentation

Abdominal X-ray

Interpretation:• Air• Bowel• Calcifications• Diaphragm• Everything else

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Normal Abdominal X-ray

Air?

Calcifications?

Diaphragm

Everything else

Flat Upright

Bowel

Axial- Abdominal WindowAxial- Lung WindowCoronalSagittal

Computerized Topography (CT) Abdomen

Ultrasound

May be used for diagnosis or evaluation of:• Masses• Appendicitis• Intussusception• Cholelithiasis/cholecystitis• Hypertrophic pyloric stenosis• Malrotation• Ovarian pathologies

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SMA/SMV to Evaluate for Malrotation

SMA= Superior Mesenteric Artery

SMV= Superior Mesenteric Vein

Esophagram

May be used for:• Evaluation for esophageal stricture• Integrity of anastomosis after TE fistula repair• Retained food bolus• Esophageal damage after caustic ingestion (e.g. battery)• Other congenital abnormalities

Esophagram

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Upper Gastrointestinal Series (UGI)

Used to evaluate for:• Duodenal atresia• Malrotation• Strictures or atresias of small bowel• Hypertrophic pyloric stenosis (not modality of choice)

Normal UGI

Normal UGI

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Contrast Enema

Used to evaluate for:• Hirschprung disease• Strictures or atresias of colon• Other reasons for delayed passage of meconium

Treatment for intussusceptionMay use:

• Air• Water soluble contrast• Barium

Normal Contrast Enema

PLACEMEN RADIOLOGICAL FINDINGS OF SPECIFIC SURGICAL DIAGNOSES

MEDICAL DEVICES

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Case Scenario 1

15 year old male presents with acute onset of left sided chest pain• History• PMHx• Vital Signs

o Temperature 37.0 ºCo Heart Rate 84 bpmo Respiratory Rate 36 bpmo Pulse Ox 95% room air

Case Progression

What are your differential diagnoses?• Costochondritis• Trauma• Pneumonia• Pneumothorax• Cardiac processWhat test(s) do you want to order?

Chest X-rayQuality:

RotationInclusionPenetrationExpansion

Interpretation:AirwayBoneCardiacDiaphragmExtrathoracic tissuesFieldsGastric bubbleHilum and mediastinumInstrumentation

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Pneumothorax

Pneumothorax

Case Progression

• What are your interventions?o Chest tube?o Oxygen?o Incentive spirometry?

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Pneumothorax

Case Progression

• What are your interventions?o Chest tube?o Oxygen?o Incentive spirometry?

Pneumothorax

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Chest Tube Placement

(Chest X-ray: Tubes- chest drains-position, 2017)

Case Scenario 2

18 month old female presents with an acute onset of difficulty swallowing

• History• PMHx• Vital Signs


Esophageal Foreign Body

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Why obtain 2 view X-ray?



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Bronchial Foreign Body

Case Scenario 3

9 year old female presents with 1 day history of abdominal pain• History• PMHx• Vital Signs


Case Progression

What are your differential diagnoses?• Gastroenteritis• Constipation• Urinary Tract Infection• Ovarian pathology• AppendicitisWhat test(s) do you want to order?

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Appendicitis

Diagnostic Criteria:• Enlarged >6mm diameter• Wall thickening >2mm• Wall enhancement• Fat stranding• Appendicolith• Fluid filled

Appendicitis

Appendicitis

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Appendicitis

Case Scenario 4

5 week old male presents with vomiting• History• PMHx• Vital Signs


Case Progression

What are your differential diagnoses?• Gastroesophageal reflux• Formula intolerance• Malrotation• Pyloric stenosisWhat test(s) do you want to order?

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Pyloric Stenosis

Diagnostic Criteria:• Muscle Thickness >3mm• Channel Length >14mm• Failure of channel to open and stomach contents to empty

Pyloric Stenosis

Pyloric Stenosis

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Case Progression

• What are your interventions?o Fluid resuscitationo NPOo Monitoring of electrolytes until corrected

§ CO2 <30, Chloride >100o Surgery- pyloromyotomy

Case Scenario 5

15 month old male presents with crampy, intermittent abdominal pain• History• PMHx• Vital Signs


Case Progression

What are your differential diagnoses?• Gastroesophageal reflux• Gastroenteritis• Constipation• IntussusceptionWhat test(s) do you want to order?

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Intussusception

Intussusception

Intussusception

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Case Scenario 6

5 day old, 29 week preemie, presents with feeding intolerance and blood in stool

• History• PMHx• Vital Signs


Case Progression

What are your differential diagnoses?• Milk protein intolerance• Anal fissure• Sepsis• Non-accidental trauma• Necrotizing Enterocolitis (NEC)What test(s) do you want to order?

Necrotizing Enterocolitis

Modified Bell Staging Criteria:

• IA: Signs of sepsis, abdominal distention, guaiac positive stools, KUB with normal gas pattern or mildly dilated loops of bowel

• IB: Same except bright blood from rectum

• IIA: Same except pneumatosis intestinalis noted on KUB

• IIB: Thrombocytopenia, abdominal tenderness, portal venous gas

• IIIA: Severely ill, acidotic, neutropenia, DIC, peritonitis, portal venous gas + ascites

• IIIB: Same as IIIA but KUB demonstrates pneumoperitoneum

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Pneumatosis


PLACEMENT OF MEDICAL DEVICESMEDICAL DEVICES

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Central Venous Line Placement

Superior Vena Cava

Right Atrium

Tip of CVL should be in the superior vena cava or at the cavo-atrial junction

(Chest X-ray: Tubes- CVL lines position, 2017)



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Lines!!!!

ETT

NGT

UAC

Leadwire Leadwire

Temperature Probe

Nasogastric Tube Placement

Note position of side holes

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Post-Pyloric Tube

Weighted feeding tube

Nasojejunal Tube

Gastrostomy Tube Placement

Contrast within stomach

Contrast outside stomach

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CONGENITAL ABNORMALITIESMEDICAL DEVICES

Duodenal Atresia

Coiled Orogastric Tube (OGT)

Absence of distal bowel gas

What is your diagnosis?

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Long Gap Esophageal Atresia

Long Gap Esophageal Atresia

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Coiled OGT

Presence of distal bowel gas

What is your diagnosis?

Esophageal Atresia with Distal Fistula (C)

Work Up for Midline Defects

• Esophageal Atresia +/- Tracheoesophageal Fistula• Imperforate Anus +/- Fistula• Omphalocele

Work Up for Midline Defects

• Physical Exam• Echocardiogram• Renal Ultrasound• Spinal Ultrasound +/- Delayed MRI• Skeletal Survey

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Imperforate Anus with Bucket Handle

Cross-table Lateral

Skeletal Survey

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Skeletal Survey

High Pressure Distal Colostogram

Malrotation

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Malrotation with Midgut Volvulus

Hirschsprung Disease

Hirschsprung Disease

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TRAUMA RADIOGRAPHSMEDICAL DEVICES

AAST Liver Trauma ClassificationGrade I:• Subcapsular hematoma <10% surface area, capsular tear <1cmGrade II:• Subcapsular hematoma 10-50% surface area, capsular tear 1-3 cmGrade III:• Subcapsular hematoma >50%, capsular tear >3cmGrade IV:• Parenchymal disruption 25-76% hepatic lobe or 1-3 segmentsGrade V: • Parenchymal disruption >75% hepatic lobe or >3 segmentsGrade VI:• Hepatic avulsion

(Khan, 2017)

Grade III Liver Laceration

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Grade IV Liver Laceration

Grade V Liver Laceration

MISCELLANEOUS ABNORMALITIESMEDICAL DEVICES

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Pectus Excavatum

Haller Index:243/72 = 3.37

Bezoar

Esophageal Stricture

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LET’S REVIEW SOME IMAGES….

Free Air

Free Air

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Pneumothorax


Right Sided Congenital Diaphragmatic Hernia

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Portal Venous Gas and Pneumatosis

Appendicitis

Radiation Exposure

Radiation exposure may lead to:Increased cancer risk throughout lifetime

Pediatric considerationsChildren are more radiation sensitivePotential for radiation exposure over lifetime

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Radiation Exposure

Radiation exposure expressed as effective doseMillisievert (mSv)Considered whole body dose of radiation in relation to environmental exposureTypical environmental exposure is 3 mSv/year

Qualitative risk levelsNegligible- less than 2 days background exposureMinimal- more than 2 days, less than 1 month background exposureVery low- more than 1 month, less than 8 monthsLow- 8 months to 6 yearsModerate- more than 6 years

Radiation Exposure

Type of Exam Months of Annual Background Radiation2 view CXR 10 daysCT scan of abdomen and pelvis 3 yearsUpper GI 2 yearsCT chest 2 yearsCT head 8 months

Radiation Exposure

Helpful websites regarding guidelines for pediatrics:• American College of Radiology

• www.acr.org• Image Gently

• www.imagegently.org• The Society for Pediatric Radiology

• www.pedrad.org

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One last story…..

Special thanks to Tom Boulden, MD for his help and review

References

Chest X-ray: Tubes- chest drains-position. (n.d.). In Radiology Masterclass online. Retrieved from http://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_chest_drain

Chest X-ray:Tubes-CVL catheters-position. (n.d.). In Radiology Masterclass online. Retrieved from http://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_central_line_anatomy

Khan, A.N. (2017). Liver trauma imaging. Medscape. Retrieved from https://emedicine.medscape.com/article/370508-overview

Murphy, A. & Hartley, L. (n.d.). Lines and tubes (chest radiograph). In Radiopaedia. Retrieved from https://radiopaedia.org/articles/lines-and-tubes-chest-radiograph

http://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_chest_drain

http://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_central_line_anatomy

https://emedicine.medscape.com/article/370508-overview

https://radiopaedia.org/articles/lines-and-tubes-chest-radiograph

paton pcw handout 20180430 · specific radiology examinations • chest x-ray (cxr) • abdominal...

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