Introduksjon til pediatrisk radiologi Flashcards
Viktige kilder?
https://radiopaedia.org/articles/respiratory-distress-syndrome?lang=us
https://blog.myesr.org/ecr-2013-focus-justifying-ct-in-paediatric-radiology/
https://www.ajronline.org/doi/pdf/10.2214/AJR.11.8082
https://pubs.rsna.org/doi/10.1148/rg.323115111
https://www.rch.org.au/clinicalguide/guideline_index/Radiology_Guidelines_Acute_indications/
Hva gjør vi?
Classic:
Neonate (first 4 weeks)
Swellling middle sternocleid muscle
Torticollis
Make good / precise / well written referrals («henvisning»).
Diagnosis:
A - Congenital / (early) developmental
B - Acquired
- Inflammatory
- Infectious
- Vascular
- Neoplastic
- Traumatic
Arguments can be made both for and against the need for imaging.
For:
Calm down and educate both parents and clinicans (the latter who havn’t seen this disorder before)
Exclude differential diagnoses (if there are any relevant)
Against:
Really no need in «classical» cases (but: can we be 100% sure if it isn’t antyhing more worriesome?)
Fibromatosis colli:
Fusiform or spindle-shaped mass within the sternocleidomastoid muscle.
Underlying muscle fibril structure is preserved
Can have increased vascularity (↑doppler)
Hva bruker man rtg. til hos barn?
Contraindications:
Few, but of course radiation risk
Foreign bodies:
Accidental or self-inflicted
Fluoroscopy
is a type of medical imaging that shows a continuous X-ray image on a monitor, much like an X-ray movie.
During a fluoroscopy procedure, an X-ray beam is passed through the body. The image is transmitted to a monitor so the movement of a body part or of an instrument or contrast agent (“X-ray dye”) through the body can be seen in detail.
Upper gastrointestinal series to examine the esophagus, stomach and small intestine, or a barium enema to examine the colon.
Hva er et “babygram”?
Very common use in: Neonates (sometimes infants/children)
Head and upper abdomen
Catheters; where is the arterial catheter?
(2 arteries and 1 vein in the umbilical cord; arteries go to both internal iliac arteries + aorta on left side)
Hva ser vi på disse bildene?
Thymus (gland)
It is relatively large in infancy (weighing 25 g at birth) reaching a maximal weight in adolescence between 12 and 19 years (35 g), and gradually involutes with age (between 20 and 60 years)with progressive fatty replacement (15 g at 60 years of age).
There can be a wide variation in size between patients.
Når bruker man UL hos barn?
Contraindications:
Air and bones
Uncooperative patients
User dependent (aka «skillz»)
Hvorfor er det så viktig å være spesifikk når man henviser pas. til radiologi?
I urge you to be precise in you’re clinical information and be specific in what you want me & other radiologist to look for, given the clinical and biochemical context:
e.g.
6 year old boy with acute stomach pain. Elevated leukocytes, CRP < 6. Appendicittis? Mesenteric lymphadenitis?
Don’t dare to ask «other pathology?» at the end of the referal. Have an opinion about you’re diagnosis. We are looking for and will tell you if we find something else that could explain the patients problems.
eFAST (extended focused assessment with sonography for trauma); Checking for pneumothorax and pleural fluid
US abdomen
We don’t routinealy check the internal organs in girls/women (than you have to refer to: US internal genitals)
Når bruker man MR hos barn?
Congenital neurological disorderes in utero (zicca – microcephaly/+++)
Headache and epilepsy
Cancer primary investigation and follow up (lymphoma, sarkoma, …)
**Contraidication:**
1. It’s a giant magnet!
2. Time dependent (even T2 haste sequences)
3. May need some kind of anesthesia (mild sedative to generel anesthesia); esp. in younger children
## Footnote
[https://www.stolav.no/behandlinger/mr-av-barn/](http://)
Når bruker man CT-diagnostikk til barn?
CT = x-ray’s big brother (ionization)
Modern CT scanners are so fast that they can scan through large sections of the body in just a few seconds, and even faster in small children. Such speed is beneficial for all patients but especially children, the elderly and critically ill, all of whom may have difficulty in remaining still, even for the brief time necessary to obtain images.
For children, the CT scanner technique will be adjusted to their size and the area of interest to reduce the radiation dose.
Hvilke nuklærmedisinske bildemodaliteter kan man bruke hos barn?
Depending on the type of nuclear medicine exam, the radiotracer is either injected into the body, swallowed or inhaled as a gas and eventually accumulates in the organ or area of the body being examined.
Radioactive emissions from the radiotracer are detected by a special camera or imaging device that produces pictures and provides molecular information.
Nuclear medicine examinations provide unique information—including details on both function and anatomic structure of the body that is often unattainable using other imaging procedures, i.e.:
- Stage cancer by determining the presence or spread of cancer in various parts of the body, evaluate response to therapy & detect the recurrence of cancer
- Evaluate for hypertension related to the kidney arteries & evaluate kidneys for infection versus scar
Hvilke typer barnemishandling forekommer?
Relatively common (in the media we read and hear often of the most fatal incidents). Esp. head injuries (most common cause of death, followed by abdominaly injuries). Underreported.
Types of Abuse:
- Neglect – (omsorgsvikt) = 75%
- Emotional, sexual or physical = 17%
Don’t see psychological and most physical injuries !!!
Infants and pre-school children are at greatest risk.
Hvordan er den radiologiske us. ved mistanke om barnemishandling?
Shaken baby, battered child and other are all terms to describe the complex of non-accidental injuries (NAI) in infants and young children as a result of abuse.
Discrepancy between history and clinical/imaging findings (severity of fractures, fracture mechanism, age of the fractures)
The radiologist can be the first to suggest the diagnosis on the basis of CT studies performed to evaluate for seizures or other neurologic symptoms or on X-rays performed for other reasons.
When we look at X-rays at the emergency department, we have to realize, that the forces needed to break a bone in an infant or young child are enormous. Any fracture in this age group indicates a major traumatic event, not just a fall from a low height.
Detection of occult non-accidental injury
The role of imaging in cases of child abuse is to identify the extent of physical injury when abuse occurs, as well as to elucidate all imaging findings that point to alternative diagnoses.
When viewed in conjunction with clinical and laboratory studies, imaging findings commonly provide support for allegations of abuse (characterisc lesions to support a diagnosis or raise suspicion).
As most conventional imaging studies performed in these settings are noninvasive and entail minimal radiation.
Hvilke radiologiske bileddiagnostikk er akt. ved mistanke om barnemishandling?
Hva er hhv. indikasjon, fordel/ulemper ved disse?
Radiographic skeletal survey is the method of choice for global skeletal imaging in cases of suspected abuse.
Whole body: Appendicular & Axial
Axial:
- Ribs (AP, lateral, left and right obliques)
- Pelvis (AP)
- Lumbosacral spine (AP and lateral)
- Cervical spine (AP and lateral)
- Skull (AP and lateral)
Appendicular
- Humeri (AP)
- Forearms (AP)
- Hands (PA)
- Femurs (AP)
- Lower legs (AP)
- Feet (AP)
All children < 2 years, where physical abuse is suspected, should have a skeletal survey done!
While skeletal surveys are crucial in providing objective evidence, it is important to remember the significance of a good clinical history.
Hvilke typer frakturer forekommer ofte hos et mishandlet barn?
Although skeletal injuries rarely pose a threat to the life of the abused child, they are often the strongest radiologic indicators of abuse (secondly most common 35-88%, 2/3 have multiple injuries).
Cutaneous injuries are the most common (bruises and contusions).
Location (highly specific – metaphyseal and posterior rib fractures)
Patterns (multiplisity)
Acute rib fractures are difficult to visualize since fractures are often incomplete and nondisplaced, and/or in an area with multiple superimposed structures.
Hence they are are the most commonly missed on skeletal surveys so it is important to include oblique views of the chest and do a follow up (2 weeks; callus formation).
Unlike adults, CPR almost never causes fractures in infants. While posterior rib fractures can occur from from CPR, they are rare. Posterior rib fractures are highly specific for abuse.
Hva er CML?
Radiologisk utredning av barnemishandling
CML – classic metaphyseal Lesions = almost pathognomic of abuse (lower extrem.); Series of microfractures in the primary spongiosa of bone, which is the most immature area of mineralized matrix in the growing metaphysis.
Most common location is the lower extremities, especially the knees.
Scapular fracture: although uncommon, it is highly specific for abuse, particularly when it occurs at the acromion.
Mechanism: Shaking an infant and stretching of deltoid muscle.
Avulsion of acromion.
There is no consensus in the literature for the precise dating of fractures. Infant’s fractures heal faster than older children and adults.
Callus in diaphyseal fractures generally forms no earlier than 5 days after a fracture, but will usually form by 14 days. Thus, fractures without visible callus may be up to 14 days old, and fractures which demonstrate a little bit of callus are at least 5 days old.
Large amounts of callus indicate that the fracture is at least 2 weeks old.
Hvor ofte forekommer CNS-skader ved barnemishandling, og hvilken bildemodalitet bruker man?
Ultrasound is way to user and patient depended and should NOT be used in the imaging investigation.
Chronic bilateral subdural hematomas and new subdural hematomas in the right frontal and posterior interhemispheric region.
The bright signal is a result of methemoglobin indicating subacute hematoma ( about one week old).
CNS injury related to non-accidental injury is a leading cause of morbidity and mortality in infants and children. Abusive head trauma, accounts for 80% of deaths from head injury.
All infants and children with suspected intracranial injury must undergo cranial CT or MRI, or both. Strategies should be directed toward the detection of all intracranial sequelae of abuse and neglect with a thorough characterization of the extent and age of the abnormalities.
The CT is readily available and rapidly performed for critically ill patients. The CT is better than MRI for evaluation of acute hemorrhage (SDH); mostly ‘crescent-shape’. Associated skull and facial fractures also can be diagnosed with appropriate bone window setting images
The MRI is the best modality to fully assess intracranial injury, including extra-axial collections, intraparenchymal hemorrhages, contusions, shear injuries, and brain swelling, or edema. Imaging should be performed with T1 and T2 weighting with proton-density or inversion-recovery sequences to differentiate cerebrospinal fluid collections from other water-containing lesions. Gradient echo sequences should be included to detect hemorrhage or mineralization not demonstrable by other MRI techniques. Because MRI may fail to detect acute subarachnoid or subdural hemorrhage, its use should be delayed for 5 to 7 days in acutely ill children. MRI of the spine is also performed in most hospitals.
Hvor ofte forekommer viscerale skader ved barnemishandling, og hvilke bildemodaliteter bruker man å detektere disse?
Retinal hemorrhage is seen in nearly all cases of infant abuse in which shaking is documented.
The overall mortality rate (visceral injuries) is 13-30% due to ‘patients and doctors delay’. It´s the second most common cause of death from abuse.
Visceral perforation or hematoma
- liver- and pancreatic laceration
- adrenal bleeding
Pancreatitis, duodenal hematomas, bowel perforation, and thoracoabdominal injury associated with rib fracture heighten the suspicion of child abuse.
In children, trauma is the leading cause of pancreatic injury.
About 1/3 of all posttraumatic pancreatitis in children is abuse-related.
The most common organs injured in accidental trauma are the spleen – liver – kidneys (in that order)!
Very seldom the panceas and bowels.
How to investigate:
1. If internal chest or abdominal injury is suspected and the patient’s condition is stable, a CT of abdomen and/or thorax with IV contrast should be performed. (Here we as clinicians and diagnosticians should have a low threshold for doing a CT examination)
Vascular injuries and injuries to the liver, spleen, pancreas, and kidneys are best demonstrated after administration of intravenous contrast material.
2. US of abdomen, usually as a follow-up.
Hvilke diff.diagnoser har man til barnemishandling?
Knees x-ray: Classical appearances of severe rickets (rakitt; Vit.D mangel), at the commonest site – the knees. Severe “cupping” and “fraying” of the femoral, tibial and fibular metaphysis with widening of the physis. Underlying subchondral sclerosis.
Chest x-ray: 1 day old child with multiple fractures after a problematic delivery.
Femur x-ray: Bowing deformity and osteopenia in the femur. Multiple dense lines in the distal femur and proximal tibia associated with dense metaphyseal bands along the cartilaginous plates related to biphosphonate therapy.
A variety of coagulopathies is associated with intracranial hemorrhage in infants, including hemophilia and hypoprothrombinemia caused by vitamin K deficiency. These disorders are suggested by the clinical history, physical findings, and laboratory tests
Osteogenesis imperfecta is a rare inherited disorder of connective tissue. Other skeletal findings in these patients are generalized osteoporosis, wormian bones, bowing and angulation of healed fractures and progressive scoliosis. In addition to fractures, suggestive findings include blue sclerae, hearing impairment, dentinogenesis imperfecta, hypermobility of the joints, bruising and short stature.Subdural hemorrhage is a rare complication of the disease.
Menkes disease is a rare X-linked genetic disorder with image similarities to non-accidental injuries. Lethal condition and affected males typically die by age 2-3 years.
Hvorfor bruker man kontrast ved bildediagnostikk?
Contrast materials are not dyes that permanently discolor internal organs. They are substances that temporarily change the way x-rays or other imaging tools interact with the body.
Following an imaging exam with contrast material, the material is absorbed by the body or eliminated through urine or bowel movements.
Hvilke typer kontrasmedier bruker man ved rtg. og CT?
Iodine-based and barium-sulfate compounds are used in x-ray and computed tomography.
When iodine-based and barium-sulfate contrast materials are present in a specific area of the body, they block or limit the ability of x-rays to pass through. As a result, blood vessels, organs and other body tissue that temporarily contain iodine-based or barium compounds change their
appearance on x-ray or CT images.
Hvilke typer kontrastmedium brukes ved MR?
Gadolinium is the key component of the contrast material most often used in magnetic resonance (MR) exams.
When this substance is present in the body, it alters the magnetic properties of
nearby water molecules, which enhances the quality of MR images.
Hvilke typer kontrast kan man bruke ved UL-us.?
Microbubble contrast materials are tiny bubbles of an injectable gas held in a supporting shell. They are extremely small —smaller than a red blood cell— and have a high degree of “echogenicity”, or ability to
reflect ultrasound waves. Structures with higher echogenicity will appear brighter on ultrasound.
Only approved for clinical use in children under age of 18 years in Europe for examination of vesicoureteral reflux (VUR).
Hvorfor er det så viktig å vite om kontrastmidler?
Contrast materials are safe drugs; adverse reactions ranging from mild to severe do occur but severe reactions are very uncommon.
Treatment: Reassurance
Prevention strategy: None
Side effects and adverse and allergic reactions
Patients with impaired kidney (renal) function should be given special consideration before receiving iodine-based contrast materials by vein or artery. Such patients are at risk for developing contrast-induced
nephropathy, in which the pre-existing kidney damage is worsened
Nephrogenic systemic fibrosis (NSF), a thickening of the skin, organs and other tissues, is a rare complication in patients with kidney disease that undergo an MR with contrast materials.
Hva viser bildene?
MRI abdomen by age 1 ½ years (large expansion in the left kidney)
US and MRI by age 4 ½ years (large expansion centrally located in right kidney, growth affecting renal pelvis)
Wilms tumor, also called nephroblastoma, isa malignant (cancerous) tumor originating in the cells of the kidney. It is the most common type of renal (kidney) cancer and accounts for about 7% of all childhood cancers.
They typically occur in early childhood (1-11 years) with peak incidence between 3 and 4 years of age. Approximately 80% of these tumors are found before the age of 5 years
Hva er det alltid snakk om når det kommer til bildediagnostikk og pas.?
Spesielt yngre pas. og barn
Nytte vs. risiko!
A substantial fraction of radiologic examinations (over 30%) are of questionable merit and may not provide a net benefit to patient health care; unnecessary procedures.
Hva er stråling?
The relevant biological effect of x-rays and gamma rays is secondary to ionization.
Ionization of water molecules can create hydroxyl radicals that may interact with DNA to cause strand breaks or base damage; DNA can also be ionized directly. Although most radiation-induced damage is rapidly repaired, misrepair can lead to point mutations, chromosome translocations, and gene fusions that are linked to cancer induction.
This effect is typically thought to be stochastic, ie, it can occur at any level of radiation exposure, with the likelihood increasing as the dose increases.
The typical lag period between radiation exposure and cancer diagnosis is at least 5 years, and in most cases, the lag period may be 1 or 2 decades or longer.
Life-long cumulative effect in children.
Hvordan måler man stråling?
Bq = unit of radioactivity. One bequerel is defined as the activity of a quantity of radioactive material in which one nucleus decays per second.
Gy = quantifies the energy deposited per unit mass
Because not all types of radiation produce the same biological effect, the dose equivalent is often used instead of the absorbed dose
The dose equivalent is the product of the absorbed dose and a radiation weighting factor and is expressed in sieverts (Sv).
Because the radiation weighting factor for x-rays and gamma rays is 1.0, 1 Gy is equivalent to 1 Sv in medical imaging.
Radiation doses in medical imaging are typically expressed as millisieverts (mSv).
For reference, the average yearly background radiation dose (primarily from radon gas in the home) is around 4,5 mSv.
Radiation-induced risk is more controversial at doses between 10 and 100 mSv, the dose range relevant to medical imaging and in particular CT.
A single CT of the abdomen may have a dose of around 10 mSv, and patients who undergo multiple CTs or a single multiphasic CT fall into this dose range.
Nuclear cardiology examinations also typically fall in this dose range.
Hva er “bakgrunnstråling”?
50%-33% is coming from radon (percent wise declining).
12,5%-50% is coming from medical imaging (increasing world wide of the last decade)
Medical radiation currently accounts for an increasing percentage (approximately 50%) of the total radiation exposure for the US population (previously about 15%).
Hvilke grupper i populasjonen er mer sensitiv for ioniserende stråling?
Children are 2–3 times more sensitive to radiation than adults. And they have a longer life expactancy.
There are no data that prove a direct link between low-level radiation from diagnostic imaging and cancer.
The best data regarding long-term effects of low-level radiation (100–150mSv) exposure come from the longitudinal survivor study (LSS) of atomic bomb survivors .
The lifetime risk of fatal cancer from a single (relatively high dose) CT in a child has been estimated to be 1:1000
Hvordan kan man sette medisinsk stråling i kontekst vs. normale aktiviteter?
Dental x-ray exams up to 0,015 mSv.
Worldwide 40% medical imaging exams are chest x-rays (low rad. dose). CT about 6% of total. And up to 10% of CT exams are done to patients younger than 18 years.
A useful way to understand radiation doses from diagnostic examinations is to compare them to average natural background radiation (4,5 - 6 mSv per year)
A whole-body dose of~ 5,000 mGyis considered the humanLD50/30, that is, the lethal dose for 50% of the population in 30 days.
International Commission on Radiation Protection uses the concept of effective dose.
The effective dose is not measured but is a theoretical calculated dose based on the organs exposed by the applied radiation multiplied by tissue-weighting factors. Because the tissue-weighting factors can change with new data and continuing analysis of existing data, the effective dose estimates can change over time. It should be noted that dose estimates are generally given for an adult of typical size and may vary substantially depending on patient size and imaging technique. Effective dose estimates are best used to assess the general level of radiation risk and not to determine the exact radiation dose from an imaging study. Effective dose estimates for individual patients are subject to a substantial level of uncertainty.
Radiation dose from an imaging study can be reduced by 3 methods. First, one can decide not to perform the study at all. Such a decision should be based on proper understanding of the indications of the study, review of any previous imaging that might have already reasonably answered a clinical question, and an assessment of any special patient considerations that increase or decrease risk. Second, an alternative study that does not use ionizing radiation can be selected. Third, less radiation can be used to create the images.
In a recent study, 26% of outpatient CT and magnetic resonance imaging (MRI) studies at a single academic medical center were not considered appropriate on the basis of evidence-based appropriateness criteria
Younger patients are at a substantially higher risk from radiation because they have more remaining years of life during which a radiation-induced cancer might develop
Hvordan kan man sammenligne medisinsk strålebruk opp mot vanlige hendelser i livet?
For you its about understanding what dosage means compared to a standard chest x-ray or yearly background radiation
When talking to parents the are shematics that show risk of likelyhood of different accidents.
Hvordan setter man risiko ved stråling (vba. f.eks.: medisinsk utstyr) i kontekst?
For å forklare til foreldre at denne testen er nødvendig
Radiation exposure compared with:
- natural background exposure
- flight hours in commercial air travel
- number of chest X-rays
- other radiation exposure situations.
Radiation risk presented as:
- quantitative estimates (e.g. 1 in 10 000 or 0.01%)
- qualitative estimate (e.g. low risk)
- comparison with the baseline risk level (e.g. an extra risk of 0.01% that adds to the average 40% baseline cancer incidence risk)
- Comparison with other risks faced in daily life (e.g. car driving).
A CT scan of the abdomen and pelvis, depending on the protocol, used may expose the patient to about 20 mSv of IR which, on average, increases the risk of fatal cancer by about 1 in 1000. However, this risk may be doubled in young patients, but halved in elderly patients. Remember, though, that the risk is cumulative if the patient undergoes repeated scans. This risk must be put into the clinical context and compared against other common risks. For example the risk of being killed on Western Australian roads in a ten year period is approximately 1 in 1000.
In summary, if the potential benefit of the scan outweighs the risk, then the scan is justified. If the patient needs a scan for treatment or management then they should not be put off having one.
Appropriate CT scans are good; inappropriate scans are bad.
Determining the most appropriate comparisons for a specific patient should be based on the particular situation, the unique risk perceptions of the patient and their parents or caregiver,
and the personal preferences and ability of the health professional. The message is not just about the facts, but also about how the facts are presented
When considering benefits and risks, there is an important risk that is quite often forgotten: the risk of not performing an exam that may result in missing a diagnosis and initiating treatment
too late to improve the medical outcome. The potential to improve a patient’s life expectancy due to early diagnosis and treatment must be considered in comparison to the magnitude of
the cancer risk and its latency compared to the age of the patient and other comorbidities
Patients and caregivers often personalize risks, even when scientists try to de-personalize them. This is especially common if the audience has a low understanding of radiation protection
concepts or statistics in general. For example, a “one-in-a-million” comparison to express cancer risk might be perceived as a low risk by the scientific community. However, patients, parents and caregivers may personalize risks and perceive that the “one” could be them or their loved one
Is this procedure dangerous? Are there any long-term effects or increased risk that we need to consider?:
- Imaging procedures provide very important information that allows health-care providers
to make informed decisions about your child’s care (even if the examination is
normal) and they can be lifesaving. Radiation risks for diagnostic imaging procedures are small. When an investigation is justified, the risk of not undergoing a radiation procedure is much greater than the radiation risk from the procedure itself. - It has been reported that there is an increased, albeit very low, risk of developing cancer in people exposed to low radiation doses.
- The chance that any child has of developing cancer over the course of her/his lifetime is more than 1 in 3 (i.e. in some countries it is around 40%). This natural chance of developing cancer may be very slightly increased by a radiation examination.
- Risks are in general higher at younger ages i.e. risks are higher in newborns, compared
to infants and older children.
What are the benefits versus risks?
- The benefits of medical imaging are extensive; for example, accurate diagnosis, precise guidance of therapy, monitoring of disease progression or remission and determining cure.
- Radiation risks from the low radiation doses used in diagnostic radiology procedures are generally small. The chance that anybody has of developing cancer over the course of her/his life is more than 1 in 3 (i.e. in some countries more than 40%). The low radiation doses used in diagnostic radiology procedures may increase this risk slightly.
At higher doses, such as those used for some very complex interventional procedures and for radiation therapy, tissue reactions such as redness may occur.
How much radiation will my child receive from a radiation imaging procedure?:
- It is important to keep children’s doses as low as reasonably achievable, particularly as children’s tissues are more radiosensitive and children have more time to develop late effects such as cancers.
- There are many ways to lower dose and risk in paediatric imaging without compromising the diagnostic imaging data and image interpretation.
- Your child’s radiation dose will be adjusted based on the procedure and the detail of the images required for making the diagnosis, taking into account the size of your child. Smaller children need less radiation to make an acceptable image.
CT helps us save kids’ lives!
But when you image, radiation matters. (Children are more sensitive to radiation. What we do now lasts for their lifetime)
So, when you image, image gently! (More is usually not better. When CT is the right thing to do: One scan (single phase) is usually enough. Scan only the indicated area.)
Hvilke nevrologiske tilstander hos nyfødte og barn trenger man ofte å bruke bildediagnostikk til?
Hvordan graderer man hjerneblødninger til barn?
Nomenclature and grading of intracranial bleeding (Papile LA. 1978):
Grade 1 – Subependymal hemorrhage/germinal matrix hemorrhage (GMH)
Grade 2 – Intraventricular hemorrhage (IVH)
Grade 3 – IVH w/ ventricular dilatation (hydrocephalus)
Grade 4 – IVH +/- hydrocephalus + parenchymal bleeding/periventricular hemorrhagic infarction (PVHI)
Hvordan deler man inn kraniosynostose?
Hvilke etiologi har “klumper og humper” i nakken hos barn?
Hva er forskjellen mellom MR og UL når det gjelder disse tilfellene?
US cannot determine the exact nature of a soft tissue lesion (know limitations)
MRI has superior contrast resolution and can evaluate the deep extent of a lesion
Neck masses present as palpable lumps and bumps in children with acquired lesions more common than congenital ones. Assessment of the anatomical site of origin, signal, and contrast enhancement characteristics may help define the etiology of the lesions, eg, developmental, inflammatory, vascular, or neoplastic. The age of the patient along with detailed clinical history and physical exam findings are important element to narrow down the differential diagnosis. The correct final diagnosis is essential to guide treatment as well as the urgency of intervention.
Etiology on imaging can be
- cystic
- solid
Suspect malignancy
- pain
- size > 5 cm
Hva vises på disse bildene?
Lymphangiomas are cystic lesions, caused by maldevelopment of the lymphatic channels.
Hemangiomas are benign vascular neoplasms.
The majority occur in young children, with 90% in the head and neck region
They are the most common tumors of infancy.
60% of hemangiomas are seen in the head-neck regio.They usually appear in the first weeks after birth, show rapid growth, followed by spontaneous involution.
Other Vascular anomalies/malformations:
- venous
- lymphatic (cystic hygrom /lymphangioma)
- infantile hemangioma
- AVM (Arteriovenous malformations)
Vaskulære anomalier klassifiseres i dag på bakgrunn av histologi, klinikk og naturlig forløp.
Nomenklaturen hartidligere vært forvirrende. Følgende inndeling benyttes i dag:
Vaskulære tumores:
- Infantile hemangiomer (IH)
- Rapidly involuting congenital hemangiomas (RICH)
- Non-involuting congenital hemangiomas (NICH)
- Kaposiform hemangioendothelioma
- Tufted angioma
Vaskulære malformasjoner:
- Kapillære malformasjoner
- Venøse malformasjoner
- Lymfatisk malformasjoner
- Arteriovenøse malformasjoner
- Komplekse/kombinerte malformasjoner
Infantile hemangiomer (IH) er den vanligste formen for benign tumor hos spedbarn med en antatt insidens på 4–5%.
2 year old boy w/ one week history with lumps increasing in size below submandibular region. No fever. Normal biochemistry.
Hva viser bildene?
Ultrasound:
One patohologic lymph node in each submandibular region. The biggest on the left measuring 3 x 2 cm. Intranodular hypoeccoic lesions. Increased circulation w/ doppler US.
MRI (with iv. contrast):
Same findings. Increased vascularity and areas of necrosis/abscess formation.
Imaging of the rest of the body (from upper neck to lower abdomen) revealed no other pathology.
Hva viser bildene?
Ved hvilke pediatriske tilstander i thx. er det akt. med bildediagnostikk?
Hva viser bildene?
Retained fetal fluid or wet lung disease, presents in the neonate as mild respiratory distress.
The infant presents in respiratory distress, classically with grunting and nasal flaring, within the first six hours of life.
Gradually getting better at around 6-24 hours with rapid recovery by 48-72 hours.
Since the respiratory distress is mild, intubation is usually not required.
Usually full-term or slightly preterm.
Predisposing factor: C-section
Depicts a heart failure type pattern but key distinguishing features from congenital heart disease are a normal heart size and rapid resolution of the failure type pattern within days.
Radiography:
- Perihilar interstitial edema (fine lineary or reticular stripes) – “perihilar streakiness”
- Pleural effusions (usually small) at the base and fissures (“lappespalter”)
- Normal to slightly hyperinflation
- Normal chest radiograph by 48-72 hours postpartum
Treatment:
- Oxygen
- Maintenance of body temperature
- Improvement most often occurs in < 24 hrs
Hva er RDS?
Respiratory distress syndrome(RDS)is a relatively common condition resulting from insufficient production of surfactant that occurs in preterm neonates (< 37 weeks).
RDS is caused by pulmonary immaturity and surfactant deficiency, resulting in respiratory insufficiency from soon after birth.
As a result of the surfactant deficiency, the alveoli will not contain air and cause diffuse bilateral micro-atelectasis, in combination with fibrin and cellular debris due to alveolar damage, which leads to poor compliance of the lungs and prevents the newborn to expand the lungs properly.
Endogenous production of surfactant will begin at approximately 36 - 72 hours regardless of the gestational age of the patient. Therefore, the diagnosis of RDS is restricted to the first week of life.
Normal respiration during the first hours of life but then gradually develops mild respiratory distress which begins around 4-6 hours.
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Radiography:
- Decreases lung volume / low volumes (hypoinflation)
- Bilateral, relatively symmetric fine nodular/granular densities in the lungs
- Prominent central air bronchograms
- Bell-shaped thorax
- No pleural effusions
NB! Hyperinflation (in a non-ventilated patient) excludes the diagnosis.
X-ray ches is NOT required for diagnosis - Why take a picture?
The European guidelines for RDS from 2022 state the following: “There is now less emphasis on radiographic diagnosis and grading of RDS, such as “ground glass with air bronchograms.”
Definitions based on blood gas analyses are also redundant, as management has moved towards an approach of pre-emptive treatment with surfactant based on clinical assessment of work of breathing and inspired oxygen requirement to avoid worsening RDS”
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Presence of free air either in the chest or abdomen is a frequent complication of disease and therapy in the neonatal setting (secondary causes).
Unlike in adults where many/most pneumothorax have primary causes
On supine CXR and confirmed by decubitis CXR
“Air leak syndrome” (pneumothorax, pneumomediastinum, pneumopericardium, pulmonary interstitial emphysema/PIE, subcutaneous emphysema)
Pneumothorax is not uncommon in extremely premature infants with structurally immature lungs and lack ofsurfactant.
Risk of pneumothorax increases with lower gestational age, severity of RDS and is often associated withpositive pressure ventilation.
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Pneumomediastinum is the presence of extraluminal gas within the mediastinum.
Gas may originate from the lungs, trachea, central bronchi, oesophagus, peritoneal cavity and track from the mediastinum to the neck or abdomen.
Premature neonate. Air in the pericardial sac outlines the heart itself. This is an unfortunate complication of the need for mechanical ventilation in neonates with Respiratory Distress Syndrome. Can be self-limited and resolve spontaneously. If air accumulates faster than the pericardium can stretch, the heart will be squeezed by the increasing pressure and cardiac tamponade will result.
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Acute complication of ventilation treatment of RDS
Results from rupture of the alveoli with air accumulating in the peribronchial and perivascular spaces. PIE is recognized by linear lucencies radiating from the hilum
Neonatologist must maintain a balance between the ventilatory needs of the infant and the complications that can result from positive pressure ventilation.
The lung volumes on the daily neonatal CXR are used as a guide to determine the ventilator settings.
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Bronchopulmonary dysplasia (BPD) refers to late pathological lung changes that develop several weeks later in infants on prolonged ventilation
It occurs from a paradoxical combination of hypoxia and oxygen toxicity. There is initial capillary wall damage, interstitial fluid seepage and ensuing pulmonary oedema, which is followed by loss of ciliated epithelium and bronchiolar mucosal necrosis. Areas of both hyperexpansion and atelectasis are seen. This is followed by eosinophilic exudate and squamous metaplasia and may ultimately lead to interstitial fibrosis/fibro-proliferative bronchiolitis.
Radiography:
- Ill-defined reticular markings with interspersed rounded lucent areas diffusely involving hyperinflated lungs
Can have relatively normal AP diameter on the lateral film
Presence of cardiomegaly may indicate the development of pulmonary hypertension
In chronic cases, the lateral film may show a much narrower AP diameter compared with the chest width on the frontal film
CT:
- Mosaic lung parenchymal pattern with areas of low attenuation and focal air trapping on expiratory HRCT (considered the most sensitive item to predict severity)
- Bronchial wall thickening (considered the most frequent finding)
- Small subpleural triangular/linear opacities
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Neonatal pneumonia can be a difficult clinical and radiographic diagnosis.
Neonatal pneumonia can present with either diffuse reticulonodular densities similar to respiratory distress syndrome or with patchy, asymmetric infiltrates with hyperaeration similar to meconium aspiration. The presence of a small pleural effusion is a useful distinguishing feature as it is a common finding in neonatal pneumonia (up to 2/3) and is uncommon in respiratory distress syndrome
Meconium aspiration
Mainly a clinical diagnosis
results in diffuse pulmonary disease and it is the most common cause of significant morbidity and mortality among full-term and post-term neonates.
Diagnosis is confirmed with visualization of meconium below the vocal cords
Thick tenacious properties of meconium, aspiration into the tracheobronchial tree will result in significant respiratory compromise and can be complicated by persistent pulmonary hypertension.
The child will usually be intubated and not infrequently extracorporeal membrane oxygenation is necessary. The mortality can approach 25% despite these supportive measures
Aspirated meconium results in complete obstruction of the bronchi, resulting in:
Coarse, diffuse bilateral patchy or more linear opacification which can present asymmetrical
atelectasis
compensatory hyperinflation of the remaining patent airways and overall the lungs
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Community acquired pediatric pulmonary infections are caused by a wide variety of organisms. They are most commonly viral in etiology and present in children less than 5 years old. Bacteria and mycoplasma become more common with increasing age.
CXR findings are diagnostic of pneumonia, but not specific as to the infecting organism. The most typical presentation is a lobar bronchopneumonia, which manifests on CXR as focal lobar consolidation with air bronchograms. The consolidation may have a round appearance, which can mimic a pulmonary mass.
Parapneumonisk effusjondefineres som pleuravæske assosiert med pneumoni. Tidlig i sykdomsforløpet erpleuravæsken vanligvis frittflytende (ukomplisert eller “enkel” effusjon) og steril.
Lokulært parapneumonisk effusjonrefererer til nedslag av fibrin som forårsaker septering og dannelse avlokulamenter i effusjonen som forhindrer fri flyt av væske. Lokulamenter detekteres vanligvis ved ultralyd.
Pleuraempyemdefineres som forekomst av bakterier ved mikroskopi og/eller åpenbart purulent pleuravæske.
Komplisert pneumonirefererer til pneumoni med hvilken som helst komplikasjon, herunder lokulært parapneumoniskeffusjon, empyem, pneumothoraks, nekrotiserende pneumoni, eller lungeabscess.
Billeddiagnostikk:Det anbefales røntgenthoraks med front og side bilde og thorakal ultralyd av alle med pneumoni ogeffusjon. Ut ifra disse undersøkelsene kan man si noe om i hvilken grad lungeparenkymet er affisert, effusjonensutbredelse og om det er tegn til organisering (lokulamenter). CT med kontrast tas ikke rutinemessig, men anbefalesved manglende respons på behandling og/eller mistanke om abscess, nekrotiserende pneumoni, kongenitt pulmonalluftveis malformasjon (CPAM) eller tumor.
Billeddiagnostikk:Rtg. thorax anbefales hos alle henviste barn med mistanke om pneumoni. Radiologiske infiltrater kan inndeles i
1) alveolære (”air space-filling” som for eksempel ved bronkopneumoni eller lobær pneumoni (ofte pneumokokk infeksjon),
2) nodulære/interstitielle (for eksempel ved mykoplasma infeksjon) eller
3) ringformede (for eksempel kaverne ved tbc).
Man kan dog ikke stille noen sikker etiologisk diagnose ut fra røntgenfunn.
Ved hvilke tilstander får man pleurale effusjoner?
Pleural effusions are common in bacterial pneumonias and should be easily recognized on the CXR.
Most pleural effusions are transudative parapneumonic effusions that will resolve with antibiotic treatment of the pneumonia.
An empyema will result from spread of the infection into the pleural fluid
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Bronkitt
Bronchitis will manifest on the CXR as peribronchial thickening or “peribronchial cuffing“ (Norwegian: “perihilære, peribronkiale fortetninger”).
Viral infections do not have pleural effusions, however, these are relatively common in bacterial infections.
The CXR findings for viral infection are the same as that for asthma.
Ved hvilke abdominale lidelser bruker man bildediagnostikk?
Pediatri
Constipation is defined as infrequent or difficult evacuation of the feces. Typically dry hard fecal material is seen.
Obstipation is one step further than constipation and is characterized by the inability to pass the accumulation of dry hard feces. This can cause impaction of the entire length of the colon and lead to permanent damage if present for a substantial amount of time.
IBS = Idiopathic bowel syndrome
It is a “exclusion diagnosis”, which means we have to do clinical, biochemical and diagnostic testing to rule out other disorders and diseases.
The top two are medical conditions, the rest are surgical.
At least 3 differential diagnosis depend.
Neonatal ileus:
- Atresias/stenoses: In the duodenum (Down syndrome?), small intestine and large intestine/rectum. Accounts for 40% of all cases of neonatal ileus.
- Malrotation with duodenal obstruction (Ladd’s band) and possibly volvulus
- M. Hirschsprung: One of the most common causes of neonatal ileus; often delayed meconium passage, explosive emptying on exploration.
- Pancreas annulare (variant of duodenal atresia/stenosis)
- Intraluminal obstruction: Duodenal membrane, meconium ileus, meconium plug and cysts in the intestinal lumen.
- Intestinal duplication/duplication cyst
Meconium ileus:In 95% of cases associated with cystic fibrosis (CF) with pancreatic insufficiency (NB. CF is also associated with about 20% of allsmall bowel atresias!).
Hva er vanlige abd. tilstander hos hhv.:
- Nyfødte
- Nyfødte til 3 mnd.
- 3 mnd. til 3 år
- Skolebarn og oppover
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Coprostasis (faecaloma = hard faeces)
Colon transit time / CTT.
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Appendicitis is the obstruction of the appendiceal lumen resulting in distention of the appendix, superimposed infection, ischemia, and eventually perforation.
The incidence is 7-12% of the Western world population, occurring in all ages.
Symptoms include fever (56%), nausea and vomiting (40%), RLQ pain - McBurney sign (72%), and leukocytosis (88%).
In 20-30% of patients, however, the classic signs and symptoms are not present.
Perforation is a serious complication.
Surgical removal of the appendix is the treatment.
DD:
- Mesenteric lymphadenitis
- Ovarian torsion (girls)
- Acute IBD (Crohns, ulcerous colitis)
- +++
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Most swallowed foreign bodies, especially the round ones, pass through the entire gastrointestinal tract successfully, but some lodge in the esophagus, usually proximally at the thoracic inlet or at the level of the aortic arch.
The most common foreign body is a coin.
Batteries can cause mucosal damage.
The treatment is endoscopic removal or fluoroscopically guided removal.
Complications of chronic foreign bodies include traumatic tracheoesophageal fistula or an inflamed mass that compresses the trachea resulting in respiratory symptoms.
Some objects:
- Fish bones (don’t see)
- Coins
- Batteries
- Magnets !
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Esophageal atresia is the interruption of the tubular esophagus.
If there is bowel gas in the abdomen there must be an associated tracheoesophageal fistula, ~90% of cases of esophageal atresia.
Fistula is secondary to incomplete division of the trachea and esophagus during organogenesis.
Symptoms include drooling due to accumulation of pharyngeal secretions, regurgitation of ingested fluids.
Contrast collecting in proximal esophageal pouch. A contrast study of the pouch is rarely indicated. Air injected through the NG tube can be used as very safe, negative contrast agent
Atresia = absence or abnormal narrowing of an opening or passage in the body
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Most common cause of congenital duodenal obstruction. Failure of recannulation of the duodenum typically occurs in the region of the ampulla of Vater.
Acccounts for up to 40% of all intestinal atresias.
Associated disorders include Down syndrome (30%), malrotation (20%), heart disease (20%), renal anomalies, tracheoesophageal fistula, and the VACTERL anomalies.
Symptoms include bilious vomiting in the first day of life.
Most prominent feature is the “double bubble” sign (dilated stomach and duodenal bulb) - dilated stomach and no gas distal to the proximal duodenum. Stated another way, there is no gas in the rest of the small or large bowel.
Treatment is surgery.
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Meconium ileus is caused by thick, tenacious meconium that adheres to the wall of the small bowel and causes obstruction most often at the level of the ileocecal valve in a neonate. Almost all patients with meconium ileus have cystic fibrosis; 10-15% of CF patients present with meconium ileus.
Complications include stenosis, volvulus, perforation, and meconium peritonitis (due to obstruction and ischemia from tenacious meconium).
It can be treated nonsurgically with water-soluble enemas to relieve the obstruction or be treated surgically.
Multiple dilated loops of bowel and an unused microcolon on barium enema.
Small bowel obstruction with dilated loops of bowel and soap bubble bowel gas pattern in the right lower quadrant.
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Hirchsprung Disease is most common cause of neonatal colonic obstruction, causes aganglionosis of the colon with absence of parasympathetic ganglia in mucosal and submucosal layers of colon.
Result of the failure of normal cranial-caudal migration of ganglion cells. The most common transition site is the rectosigmoid colon. Total colonic aganglionosis is rare.
Incidence is 1 in 5,000-8,000 live births, with a male to female ratio of 4-9 to 1.
May present with failure to pass meconium within the first 24 hours of life or later with constipation and paradoxical diarrhea (25%).
Overall ~75% of cases present within six weeks of birth 4, and over 90% of cases present within the first five years of life.
Full thickness rectal biopsy. The treatment is a surgical pull-through procedure
Normally, the rectum is larger than the colon. In Hirschsprung Disease, there is an abnormal rectosigmoid ratio with the rectum smaller than the sigmoid due to denervation hyperspasticity.
The transition zone is in the mid-descending colon.
Therefore, one see dilation of large and small bowel proximal to the “transition zone.”
The “Transition Zone” is the junction between the proximal normally innervated colon and the distal aganglionic segment. The normally innervated proximal colon becomes dilated.
X-ray and fluoroscopy
A carefully performed contrast enema is indispensable in both the diagnosis of Hirschsprung disease but also in assessing the length of involvement
anatomically divided into four types according to the length of the aganglionic segment
Ultrashort (2-4 cm internal anal sphincter only) / short segment (75%; rectal and sigmoid colon) / long segment (splenic flexture) / total colonic (rare)
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Necrotizing enterocolitis is the most common acquired gastrointestinal emergency of premature infants.
related to infection and ischemia, commonly affecting the ileum and acending colon. It usually presents during the first or second week of life with bloody stools (50%), explosive diarrhea, bilious emesis, mild respiratory distress, generalized sepsis, distention of the abdomen, and feeding difficulties
requires an immature gut and time for gut to become colonized in order to develop. These patients typically have been fed.
Typisk er premature barn som utvikler utspilt buk, fordøyer dårlig og har blod i avføringen i 2–3 ukers alder. Tilstanden kan raskt forverres med tegn på sepsis ogev. sirkulatorisk kollaps.
The treatment is bowel rest and antibiotics and surgery for bowel perforation.
Sensitive radiographic finding is pneumatosis, gas in the bowel wall.
Another sign is unchanged bowel gas pattern over several films indicating an ileus
Worrisome signs include gas in portal venous system and ascites. Infants can have an occult perforation without free intraperitoneal air in the setting of a gasless abdomen.
Følgende kriterier er anbefalt benyttet for å stille diagnosen NEC (2015): P77 Nekrotiserende enterokolitt (NEC)
Diagnostiske kriterier er enten A + B, eller C, se under.
A -En eller flere av følgende kliniske kriterier:
i) gallefarget aspirat eller oppkast,
ii) utspilt abdomen,
iii) makroskopisk/mikroskopisk (positiv hemofec) blod i avføringen
B - En eller flere av følgende radiologiske kriterier:
i) intramural luft,
ii) hepatobiliær luft,
iii) fri luft i peritoneum (perforasjon),
iv) local ileus («død tarmslynge»)
C- NEC påvist ved kirurgi
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Idiopathic thickening of gastric pyloric musculature which then results in progressive gastric outlet obstruction.
Its incidence is 3 in 1,000 live births, with a male to female ratio of 4-5:1.
Typically occurs between the first week to 3 months of age/typically 2-6th week.
There may be a positive family history.
Signs and symptoms include nonbilious, projectile vomiting and a palpable mass.
Treatment usually includes surgery. Associated abnormalities include esophageal atresia, tracheoesophageal fistula, renal abnormalities, Turner’s Syndrome, trisomy 18, and rubella.
Radiology
«Single bubble
Ultrasound is the modality of choice in the right clinical setting because of its advantages over a barium meal are that it directly visualises the pyloric muscle and does not use ionising radiation.
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Intussusception (invaginasjon) occurs when one segment of bowel is pulled into itself or a neighboring loop of bowel by peristalsis. It is also known as bowel telescoping into itself. For example, the terminal ileum could invaginate into the colon. Idiopathic incidences may be seen following viral illness with hypertophy of Peyer’s patches in the terminal ileum. Age of presentation is usually 3 months to 24 months. Pathologic intussusception is associated with a lead point such as a tumor, inspissated feces (cystic fibrosis) or lymphoma, often in older child greater than age 2. Symptoms include crampy abdominal pain, bloody stools, and vomiting. Treatment is fluoroscopically guided reduction with air or fluid enema or surgery if unreducible. At our institution an air enema is first performed followed by surgery if this method is unsuccessful.
Intussusception can occur essentially anywhere.In F, no such distribution is present as in the vast majority of cases a lead point lesion is present (not in children 90% cases), and thus the location will depend on the location of that lesion.In children there is a strong predilection for the ileocolic region
US / CT / fluoroscopy.
Hvordan behandler man invaginasjon?
Treatment depening on time
conservative = nasogastric drainage, IV fluids and possibly AB.
Fluoroscopy
Air or barium (ultrasound ?)
Recurrence up to 30%
Surgery
signs of = peritonitis or schock, long lasting, failed fluoro
reducible or irreducible (resection)
Væsketerapi (NaCl eller Ringer) startes umiddelbart før ytterligere diagnostiske og terapeutiske tiltak dersom barnet er moderat til alvorlig dehydrert.
Kirurg varsles når diagnosen er stilt og for diskusjon rundt valg av behandlingsmetode.
Radiologisk behandling er kontraindisert ved funn av peritonitt, fri luft, sepsis og/eller sjokk.
Reponering (med luft/væske) er smertefullt. Gi smertestillende (f.eks. morfin 0,05 mg/kg langsomt i.v. 10 til 15 min før reponering. Dosen kan gjentas ved behov). Det kan også bli behov for sedasjon med midazolam. Barnet overvåkes med pulsoksymeter under radiologiske reponering. Ha med maske-bag for ventilasjon ved evt. apné.
Reponering kan gjøres med vanlig rtg. colon (vannløselig kontrast). Dette vil løse de fleste ileokoliske og kolokoliske invaginater (75–90%), og representerer diagnostikk og behandling i ett. Ultralydveiledet reponering med luft eller saltvann er alternative metoder som kan benyttes, avhengig av radiologens erfaring.
Ved reponering bør barnet ligge i mageleie og luft- eller væsketrykk økes gradvis til maksimalt 120 mm Hg eller 150 cm hevehøyde (perforasjonsfare ~1 %). Vellykket behandling gir umiddelbar klinisk bedring, men kan også vurderes med ny ultralyd undersøkelse. Tilbakefall sees hos ca. 10% og kan reponeres med samme metode (vær oppmerksom på mulig ledepunkt). Tilstander med samtidig invaginasjon på flere nivåer forekommer, og bør mistenkes dersom ikke barnet blir bedre etter behandling.
Kirurgisk behandling: Ved kontraindikasjon for radiologisk behandling og hvis reponering av invaginatet ikke lykkes etter flere forsøk.
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Malrotation is the failure of the normal embryonic rotation of the bowel, which results in suspension of the small bowel on a narrrow vascular pedicle. The duodenal-jejunal junction does not reach its expected location to the left of the spine at the level of the duodenal bulb.
Malposition of the cecum may result in its location in the left side of the abdomen.
Complications include obstruction and midgut volvulus.
Most present at early age with bilious vomiting, but symptoms can occur at any age. Midgut volvulus is a surgical emergency, because it can lead to bowel necrosis.
Barium meal demonstrates a cork-screw proximal jejunum, with the DJ-flexure never reaching the left side of the abdomen, or ascending to L1
Når forekommer malrotasjonsvolvolus?
DJ loop anterior to SMA and transverse colon posterior to SMA = causing compression of colon by SMA (obstruction)
A midgut volvulus of malrotated bowel can potentially occur at any age but in approximately 75% of cases is within a month of birth, most within the first week, and 90% within 1 year.
Neonate is entirely normal for a period before suddenly presenting with bilious vomiting. If the volvulus does not spontaneously reduce, then the venous obstruction created by the superior mesenteric vein wrapped around the superior mesenteric artery results in venous obstruction and gradual onset of ischaemia and eventual necrosis. As this occurs, the abdomen becomes swollen as fluid accumulates in the lumen of the bowel, and becomes tender. Eventually peritonitis and shock become established.
Abnormal bowel:
- dilated duodenum proximal to obstruction
- thickened wall of small bowel distal to obstruction
- dilated fluid-filled loops of small bowel
Når bruker man bildediagnostikk ved muskell- og skjelettsykdommer hos barn?
For tumores (either arising from the bones or soft tissues) there will be a need for doing all of the radiology modalities (esp. X-ray + CT + MRI).
Hva er DDH, og hvilken modalitet brukes?
Bildediagnostikk pediatri
Developmental Dysplasia of the hip (DDH), also known as congenital hip dislocation, is recurrent subluxation or dislocation of the hip secondary to acetabular dysplasia, abnormal ligamentous laxity, or both. The acetabular dysplasia yields an increased acetabular angle and a shallow acetabular fossa. Early diagnosis of DDH is important because chronic dislocation of the femoral head can lead to growth deformity of the acetabular fossa.
More prevalent in females than males (9:1).
Clinical findings of DDH include a shortened leg with decreased range of abduction when flexed, asymmetry of the gluteal folds, and positive “clicks” with dislocation (Barlow maneuver) and relocation (Ortolani maneuver).
Ultrasound is the study of choice at most centers when clinical suspicion of DDH is present. It allows the hip to be evaluated for both abnormal mobility and dysmorphic acetabular features.
Plain film radiography has a very limited role in evaluation of DDH in children under 6 months of age due to the lack of ossification of the femoral head. In particular, radiographs are unreliable in children 6-12 months of age because of a lack of skeletal ossification. When radiography is used, AP views are most helpful as frogleg views are likely to reduce a subluxed or dislocated hip.
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In the pediatric population, septic arthritis most commonly occurs from infectious extension from the adjacent metaphysis. Bacterial organisms (Staphylococcus aureus > Group A Streptococci) are the most common etiologic agents of septic arthritis. Most cases are monocular and involve large joints (hip > knee).
Radiographic findings of septic arthritis include asymmetric widening of the hip joint spaces by > 2mm (the distance is measured between the teardrop of the acetabulum and the medial cortex of the femoral metaphysis. Other findings include displacement or obliteration of the fat pads surrounding the hip (obturator internus, iliopsoas and gluteus). Unfortunately, these findings are not sensitive for the presence of a joint effusion. A normal appearing plain film by no means excludes the diagnosis of septic arthritis
Toxic Synovitis is a diagnosis of exclusion. It occurs most commonly in children under the age of 10 who present with no limping and no pain on palpation. These patients have a positive joint effusion that is negative for organisms on aspiration and that resolves with rest. The effusion is likely due to a viral infection.
Legg-Calvé-Perthes disease = idiopathic avascular necrosis. Age 5-8 years.
Hva kjennetegner frakturer hos barn?
Children respond differently than adults to trauma:
- immature bone with open growth plates and cartilaginous epiphyses
- tough periosteum with incomplete mineralization of underlying bone which results in greater elasticity and a greater propensity to deform prior to breaking
- As a result, complete fractures are far less common in children, whereas bending, bowing and partial fractures are much more common
- Are far less likely to sustain ligamentous damage as a result of trauma than are adults
Most commonly encountered locations for pediatric fractures include the wrist and elbow
Hvordan kan man klassifisere frakturer hos barn?
Hva er avulsjonsfrakturer?
Up to one-third of all pediatric fractures involving the long bones will involve the physis. These fractures carry added significance because involvement of the “growth plate” may lead to arrested development of the affected limb. The more severe the injury, the higher the likelihood of requiring surgery with internal fixation.
Avulsion fractures occur most commonly in adolescent athletes as a result of abnormal stress placed on the tendinous attachments of muscles. Prior to fusion of the ossification centers, the growing apophysis is more likely to become injured than the adjoined tendons. The most common sites of avulsion occur in the pelvis where the muscles with the greatest strength are attached.
