paeds Flashcards
Images and discussion for paeds FRCR 2B
Bilious vomiting in a newborn is malrotation with mid- gut volvulus until proven otherwise.
Check for abnormal position and appearance of the DJJ and proximal small bowel on upper gastrointestinal series, which is the gold standard for diagnosis.
“Whirlpool sign” of twisted mesenteric vessels on sonography or CT indicates a midgut volvulus.
A double-bubble sign without distal bowel gas is diagnostic of duodenal atresia.
NB: Upper gastrointestinal series is not indicated unless distal gas is present (i.e., partial duodenal obstruction exists).
Distal gas requires further investigation to look for duodenal stenosis or web, malrotation with Ladd’s bands or volvulus, annular pancreas, or duplication cyst
Posterior urethral valve
Bullet-nosed dilatation of the posterior urethra and bilateral hydronephrosis in a male infant = posterior urethral valves.
This is the most common cause of bilateral hydronephrosis in a male infant.
Affected infants may present with pulmonary hypoplasia and cystic renal dysplasia and a history of maternal oligohydramnios.
Retroperitoneal neuroblastoma with skull metastases.
- IV contrast-enhanced CT images through the abdomen demonstrate a calcified right paraspinal mass; a large calcified retroperitoneal mass that crosses the midline, encasing the aorta and SMA; and left hydronephrosis.
- A delayed image from MIBG scan demonstrates increased uptake in the midabdomen corresponding to the retroperitoneal mass on CT. Head CT with IV contrast reveals a soft tissue mass, with an epicenter in the right temporal bone, associated with bone destruction and a sun- burst periosteal reaction.
- Normal results of MIBG do not exclude the diagnosis of neuroblastoma.
- A childhood suprarenal mass with calcification that crosses the midline and encases the mesenteric vasculature and/or invades the neural foramina is almost certainly a neuroblastoma.
Newborn with respiratory distress during feedings and failure to pass a nasogastric tube
- AP supine “babygram”; NG tube terminates in a gas-filled proximal esophagus. Bowel gas is present in the abdomen. The cardiac apex is in the right chest: dextrocardia, and there are vertebral anomalies in the upper thoracic and sacral spine.
- DIAGNOSIS: Esophageal atresia with tracheoesophageal fistula and vertebral and cardiac anomalies (VATER association)
- DISCUSSION: The VATER association :
- Vertebral and cardiovascular anomalies,
- Anorectal malformations,
- Tracheoesophageal fistula, and
- Renal and radial ray anomalies.
- What do you do next? Echocardiography and renal USS to screen for congenital heart disease and renal anomalies, most commonly patent ductus arteriosus, ventricular septal defect, and renal agenesis.
- Complications of esophageal atresia with tracheoesophageal fistula include aspiration pneumonia, postoperative leak and stricture, recurrent fistula, disordered esophageal motility, gastroesophageal reflux, congenital esophageal ste- nosis, and tracheomalacia.
- Always look for the VATER association in patients with esophageal atresia.
Newborn infant with acute decompensation
FINDINGS: Frontal supine radiograph of the chest and abdomen (Fig. 1.8.1) reveals a large oval-shaped lucency overlying the epigastrium. There is a verti- cal soft-tissue density running through the lucency.
DIAGNOSIS: Pneumoperitoneum
A 32-week-old, 1,500 g premature infant with abdominal distension, increased gastric residuals, and thrombocytopenia on day 6 of life
FINDINGS: AP supine film: diffuse gaseous distention of bowel, linear and crescentic areas of pneumatosis intestinalis (Fig. 1.10.2), and branching lucencies of portal venous gas. USS of the liver: echogenic foci bubbling through the liver.
DIAGNOSIS: Necrotizing enterocolitis
DISCUSSION: Necrotizing enterocolitis (NEC) most frequently affects premature infants or full-term infants with congenital heart disease.
- NEC occurs in premature infants or full-term infants with congenital heart disease.
- Plain-film findings : dilated bowel loops, pneumatosis, and portal venous gas.
- Pneumoperitoneum, ascites, or both indicate bowel perforation and the need for immediate surgery.
Full-term infant with progressive respiratory distress
FINDINGS: A series of CXR from day 1 to day 4 of life demonstrate initial opacification of the right upper lobe (Fig. 1.11.1), which subsequently becomes interstitial or reticular (Fig. 1.11.2) and finally hyperlucent (Fig. 1.11.3). Right-to-left mediastinal shift and progressive right middle and lower lobe collapse are also identified.
DIAGNOSIS: Congenital lobar emphysema of right upper lobe
- DISCUSSION: Mediastinal shift is the hallmark of “surgical” causes of neonatal respiratory distress. In most cases, CLE is associated with an intrinsic ball-valve obstruction in the affected bronchus. The result is progressive air trapping with mediastinal shift and compressive atelectasis of adjacent lobes. The initial opacification of the affected lobe results from impaired drainage of fetal lung fluid. The upper lobes and the right middle lobe are most frequently affected.
- DDX from other surgical lesions of the lung in newborns (sequestration and cystic adenomatoid malformation) requires recognition of the characteristic location and temporal evolution of this abnormality.
- Infants with severe respiratory distress are treated by lobectomy, whereas functional assessment with ventilation–perfusion scanning and nonsurgical management may be indicated in less severely affected infants .
Aunt Minnie’s Pearls
- Progressive air trapping in the middle or either upper lobe in a newborn = congenital lobar emphysema.
- Although it will become hyperlucent within days, the affected lobe may initially be opacified owing to retained fetal lung fluid.
An 8-year-old female with history of recurrent right lung pneumonias that does not ever clear completely.
FINDINGS: Frontal radiograph of the chest (Fig. 1.12.1) reveals :
- heart to be shifted to the right,
- the right hemidiaphragm to be elevated, and
- the right heart border to be indistinct.
- There is a linear density pointing inferomedially in the right hemithorax to the medial right hemidiaphragm.
Coronal (Fig. 1.12.2) and 3D reconstructions of chest CT with IV contrast (Fig. 1.12.3) reveal a large vessel draining the right pulmonary veins into the inferior vena cava (IVC) just below the hemidiaphragm.
DIAGNOSIS: Scimitar syndrome
Aunt Minnie’s Pearls
Scimitar syndrome is characterized by anomalous right pulmonary venous drainage (the scimitar vein), right pulmonary hypoplasia, and dextroposition of the heart.
Full-term neonate with the classic obstructive triad of bilious vomiting, abdominal distention, and failure to pass meconium.
DIAGNOSIS: Meconium ileus
FINDINGS: AP supine (Fig. 1.13.1) view of the abdomen demonstrates numerous dilated loops of bowel. A contrast enema (Fig. 1.13.2) reveals a microcolon and numerous filling defects in the ileum (arrows).
DISCUSSION: Meconium ileus is the neonatal presentation of cystic fibrosis. Hydramnios and a family history of cystic fibrosis may be present. With simple meconium ileus, abnormally viscid meconium obstructs the ileum, and a water-soluble contrast enema with ileal reflux to the level of the dilated loops can relieve the impaction. This disorder is said to produce the smallest of all microcolons because the obstructing meconium causes the colon to be completely unused.
A similar diagnosis may be made in older children with cystic fibrosis where viscid stool obstructs the ileum and cecum. This disorder is known as meconium ileus equivalent.
Aunt Minnie’s Pearls
Meconium ileus / MICROCOLON is diagnostic of cystic fibrosis.
A water-soluble contrast enema is diagnostic and therapeutic in uncomplicated cases.
Newborn with abdominal distension
FINDINGS: AP supine radiograph of the abdomen (Fig. 1.14.1) reveals a collection of calcifications in the right lower quadrant and multiple dilated air-filled loops of bowel without definite gas in rectum, consistent with a distal bowel obstruction.
DIAGNOSIS: Meconium peritonitis
Aunt Minnie’s Pearl
Scattered or focal, punctuate peritoneal calcifications or a calcified pseudocyst in a newborn = shape in uterobowel perforation and meconium peritonitis.
FINDINGS: Metaphyseal cupping, fraying, and splaying are demonstrated on AP views of the wrist (Fig. 1.15.1) and knees (Fig. 1.15.2). Also apparent is loss of the zone of provisional calcification—seen radiographically as widening of the physes and loss of the epiphyseal and metaphyseal margins.
The visualized skeleton shows diffuse coarse demineralization. AP (Fig. 1.15.3) and lateral (Fig. 1.15.4) views of the chest reveal cupping and fraying of the costochondral junctions and proximal humeral metaphyses.
DIAGNOSIS: Rickets
DISCUSSION: Deficient mineralization of osteoid in children is known as rickets, whereas in adults the same pathologic process is osteomalacia.
Because rachitic changes are best visualized at the ends of the most rapidly growing bones, a rickets survey routinely includes views of the wrists and knees. In addition to the metaphyseal cupping and fraying and loss of the zone of provisional calcification producing widened physes, long bones may demonstrate bowing deformities as well. Cupping and fraying of the costochondral junctions, create palpable masses on the anterior chest wall likened to the beads of a rosary.
Aunt Minnie’s Pearls
- In rickets, the metaphyses are cupped, frayed, and splayed.
- Vitamin D deficiency causes poor osteoid mineraliza- tion and widening of the physes.
AP view of the pelvis (Fig. 1.16.1) shows :
- widening of the right proximal femoral physis,
- metaphyseal irregularity, and
- regional osteopenia.
- Lines drawn along the lateral femoral necks would intersect less femoral epiphysis on the right than on the left. The frog-leg lateral view (Fig. 1.16.2) reveals posterior and medial displacement of the epiphysis relative to the metaphysis, producing the classic ap- pearance of “ice cream falling off the cone.”
Slipped capital femoral epiphysis (SCFE)- salter Harris I
FINDINGS: AP chest and abdomen film (Fig. 1.18.1) shows marked left-to-right shift of the heart, me- diastinum, and support apparatus. The left side of the chest contains multiple tubular radiolucencies (arrows), and the abdomen is gasless.
DIAGNOSIS: Congenital diaphragmatic hernia, Bochdalek type
The left chest can be white out: NGT- Air as contrast: Bowel can be fluid filled
if chest xray: ask for AXR to look at paucity of bowel gas.
AP CXR , AXR: an endotracheal tube and enteric tube to be in appropriate position. The apex of the cardiothymic silhouette is on the right. The stom- ach is noted to be on the left. There is a soft-tissue mass overlying the mid abdomen with indistinct superior margins and sharply defined inferior and lateral margins. The mass appears to contain bowel gas. An umbilical clip is noted at the inferior extent of the mass. The bowel gas pattern is not distended, and there is no evidence of free intraperitoneal air.
DIAGNOSIS: Omphalocele
maternal serum AFP usu elevated, it is most commonly diagnosed by prenatal ultrasound.
cardiac and VATER
AP chest and abdomen radiograph (Fig. 1.20.1) reveals an umbilical venous catheter with the tip overlying the right atrium and an enteric tube in the stomach. There is paucity of bowel gas in nondistended loops overlying the midabdo- men. There is no evidence of free intraperitoneal air. There are well-circumscribed fingerlike masses over- lying the right lower quadrant and pelvis.
DIAGNOSIS: Gastroschisis
A 6-week-old full-term infant with constipation
AP scout (Fig. 1.21.1) and overhead (Fig. 1.21.2) views from a limited-contrast enema demonstrate an air-filled and dilated sigmoid colon on the scout radiograph. Contrast enema reveals a transition from a relatively narrow rectum to dilated sigmoid and descending colon.
DIAGNOSIS: Hirschsprung disease
FINDINGS: AP film of the pelvis (Fig. 1.27.1) demonstrates progressively decreasing lumbar interpediculate distances, short and squared ilia, narrowed sacrosciatic notches, and horizontal acetabular roofs. AP view of the lower extremities (Fig. 1.27.2) demonstrates short, thick long bones with focal enlargement of the metaphyses. Lateral view of the lumbar spine (Fig. 1.27.3) demonstrates the vertebra to have short pedicles, decreased vertebral body height, and a bullet shape at the thoracolumbar junction. T2-weighted MR image of the cervical spinal cord (Fig. 1.27.4) shows stenosis at the foramen magnum, constricting the spinal canal and focal high signal in the adjacent cervical spinal cord.
DIAGNOSIS: Achondroplasia
HISTORY: A 2-year-old with bowed lower extremities
FINDINGS: AP views of the right (Fig. 1.30.1) and left (Fig. 1.30.2) tibias show beaking, fragmentation, and depression of the medial tibial metaphyses. Hy- poplasia and medial sloping of the proximal tibial epiphyses are also evident.
DIAGNOSIS: Blount disease (infantile tibia vara)
Radiographs are useful to differentiate the various causes of bowed legs, such as physiologic bowing, rickets, Blount disease, posttraumatic physeal arrest, and focal fibrocartilaginous dysplasia.
FINDINGS: AP radiograph of the pelvis with hips in neutral position (Fig. 1.31.1) reveals lateral and superior displacement of the left femur, increased angulation of the left acetabular roof, and delayed ossification of the left femoral head.
DIAGNOSIS: Developmental dysplasia of the hip (DDH)
RF: FH, breech presentation, F>M,
FINDINGS: Lateral radiograph of the skull (Fig. 1.36.1) reveals an elongated skull. Frontal radiograph (Fig. 1.36.2) reveals narrowing and sharpening of the sagittal suture and a sclerotic ridge of bone at the expected location of the sagittal suture.
DIAGNOSIS: Scaphocephaly or dolichocephaly secondary to premature sagittal craniosynostosis
FINDINGS: AP radiograph of the spine (Fig. 1.37.1) reveals a splaying of the posterior elements of the lumbar spine consistent with a spinal dysraphism. Lateral view of the skull (Fig. 1.37.2) reveals calvarial fenestrations or lacunae primarily in the parietal bones.
DIAGNOSIS: Luckenschadel or lacunar skull
A 2-year-old with head trauma
Lateral view of the skull at the time of the trauma (Fig. 1.38.1) reveals a diastatic linear parietal skull fracture; 2 months later (Fig. 1.38.2), there is a larger radiolucent defect with relatively smooth and sclerotic edges in the parietal bone.
DIAGNOSIS: Leptomeningeal cyst
A leptomeningeal cyst or “growing fracture” is an uncommon late complication of a skull fracture. Instead of healing, the fracture “grows”
Aunt Minnie’s Pearls
Leptomeningeal cyst is characterized by a progres- sively widening smooth-edged calvarial defect with overlying pulsatile soft-tissue mass in a patient with prior history of skull fracture.
