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