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radiology > Pediatric-chest, GI, GU > Flashcards

Pediatric-chest, GI, GU Flashcards

1
Q

croup-what, who, syx’s, orgm

A
  • acute laryngotracheobronchitis
  • 6 mo-3 yrs (avg 1 yr)
  • barky cough
  • parainfluenza
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2
Q

steeple sign

A

loss of normal shouldering/lateral convexities of subglottic trachea

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3
Q

epiglottis-who, orgm cause of death

A
  • 3.5 yrs (Recent spike in teenagers)
  • H influenza
  • death by asphyxiation from aryepiglottic folds (not epiglottis)
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4
Q

mcc acute upper airway obstruction in children

A

Croup

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5
Q

normal appearance of subglottic trachea

A
  • “shouldering”

- lateral/outward convexities

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6
Q

croup appearance on chest xray

A
  • narrowing subglottic trachea or overdistanded pharynx

- epiglottis & aryepiglottic folds normal

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7
Q

epiglottitis xray appearance

A

-thickening epiglottis (“thumb sign”) or aryepiglottic folds

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8
Q

omega epiglottis-fake out, how to distinguish

A
  • epiglottitis fake out caused by oblique imaging

- look at aryepiglottic folds

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9
Q

exudative tracheitis (bacterial tracheitis)-what, orgm, who, img

A
  • rare, deadly exudative infection of trachea
  • staph aureus
  • 6-10 yo
  • “linear soft tissue filling defect in airway”, irregular tracheal plaques
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10
Q

retropharyngeal cellulitis, abscess-what, causes, syx’s, who, app

A
  • pyogenic infection of retropharyngeal space usually following recent pharyngitis or URI
  • sudden onset fever, stiff neck, dysphagia, stridor
  • 6 mo-12 mo
  • massive retropharyngeal soft tissue thickening
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11
Q

normal soft tissue thickness btw pst pharynx and ant vertebral body

A
  • should not exceed AP diameter of cervical VBs

- ~ 6mm at C2, 22m at C6

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12
Q

pseudothickening RPS-who, when, how to distinguish

A
  • infants, short necks
  • neck not well extended
  • distinguish: true thickening=apex anterior convexity of ST, repeat with neck in full extension, gas in ST
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13
Q

subglottic hemangioma-what, where, ass

A
  • MC ST mass in trachea, MC subglottic
  • asymmetric narrowing trachea (left MC)
  • ass:
    • cutaneous hemangiomas 50%
    • PHACES syndromen 7%
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14
Q

PHACES

A
  • Posterior fossa (Dandy walker)
  • Hemangiomas
  • Arterial anomolies
  • Coarctation of aorta, cardiac defects
  • Eye abN
  • Subglottic hemangiomas/Sternal Cleft/Supraumbilical raphe
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15
Q

laryngeal cleft-aka, what, ass, img, dx

A

-aka laryngoesophgeal cleft
-communicating defect in pst wall of larynx and esophagus or anterior hypopharynx
- different cleft classifications
- ass malformations (usually GI, VACTER)
- fluoro: thin tract of contrast extending to larynx or trachea)
- dx=direct visualization/scope

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16
Q

aw papilloma-what, cause, app

A
  • lobulated mass(es) in airways & ass pulm nodules (solid & cavitated)
  • HPV (perinatal transmission)
  • usually mult: “papillomatosis” –> mult areas of atelectasis & air trapping (vs solitary carcinoid or FB)
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17
Q

adenoids

A
  • seen at 3-6 mo
  • full at 1-2 yrs
  • too big when encroach on airway
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18
Q

How often does meconium staining of amniotic fluid occ? What does it look like? Aspiration syndrome?

A

15%, 5%

-green stained amniotic fluid

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19
Q

group B Strep vs non GBS neonatal PNA

A
  • GBS= mc pna, low lung vol, 67% pl eff

- non GBS-hyperinflated, patchy & asymm perihilar densities, pl eff 75%

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20
Q

how often is meconium aspiration asss w/ PTX?

A

20-40%

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21
Q

when does TTN start, peak and resolve?

A

6 hrs, 24 hrs, 3 d

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22
Q

true or false: a normal plain film at 6 hrs excludes SDD

A

True

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23
Q

Increased risks of surfactant therapy

A
  • pulmonary hemorrhage

- PDA

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24
Q

GBS neonatal PNA-how, who, app

A
  • mc neonatal pna
  • from birth canal
  • (+) risk if premature
  • low lung vol, granular opacities, pl effusion 25%
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25
Q

“granular opacities”

A

GBS neonatal PNA (pl eff) & SDD (no pl eff)

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26
Q

persistent pulmonary HTN/persistent fetal circulation-what, 2˚ causes

A
  • persistence of high pressure in lungs

- 1 or 2˚ (hypoxia-from pna, meconium aspiration etc.)

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27
Q

“reduced thoracic circumference” on OB US

A

pulmonary hypoplasia

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28
Q

“fetal lung:head ratio <1” on OB US

A

pulmonary hypoplasia

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29
Q

CDH associations

A
  • cong heart dx
  • malrotation (ess 100%)
  • right sided -GBS
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30
Q

mortality rate in CDH related to…

A

degree of pulmonary hypoplasia

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31
Q

NG tube in CDH

A

curves into chest

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32
Q

true or false: bronchogenic cysts comm w/ aw

A

false

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33
Q

“recurrent PNA in same area”

A

intralobar sequestration

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34
Q

bronchopulmonary sequestration

A

extra lung that is NOT conn to aw or pulmonary arteries.

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35
Q

intralobar bronchopulmonary sequestration-how common, who, cong ass, img, where

A
  • MC (75%)
  • adolescence
  • pulmonary venous drainage
  • no pleural cover–> recurrent inf (bacteria migrates in from pores of Kohn)
  • no ass cong anomolies
  • LLL pst segm (60%), RLL 40%
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36
Q

extra lobar bronchopulmonary sequestration-how common, present, ass

A
  • 25%, infancy
  • respiratory distress/cyanosis (rel to associated congenital anomalies)
  • ass w/ cong anomalies (extra for extra things)
  • pleural covering–> rarely infected
  • systemic venous drainage
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37
Q

Extralobar BPS associated congenital anomalies

A

extra for extra things:

  • CCAM
  • CDH
  • pulm hypoplasia (Can’t breath)
  • cong heart disease
  • vertebral anomalies (Cervical, not actually but fits the mnemonic.)
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38
Q

congenital lobar emphysema-mx

A

lobectomy

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39
Q

ccam-acronym

A

congenital cystic/pulmonary adenomatoid malformation

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40
Q

CCAM types

A

1) 1+ large cysts (2-10cm)-50%
2) numerous small, uniform size cysts-50%
3) solid appearing but microscopic cysts-10%
4) unlined cyst typically affecting single lobe, indist from type 1
0) acinar dysgenesis or dysplasia, represents global arrest of lung development, v rare

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41
Q

CCAM mx

A
  • 90% spon’t decrease during 3rd TM

- resect-risk of peluropulmonary blastoma, rhabdomyosarcoma

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42
Q

mass on 2nd TM US

A

pulmonary congenital malformation

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43
Q

normal 2nd TM US –> mass

A

1˚pulmonary tumor

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44
Q

pleuropulmonary blastoma (PPB)-what, where, img, types, ass

A
  • Rare malignant embryonal mesenchymal neoplasm of lung & pleura that arises during organ development
  • mc 2˚lung malignancy in children. Big fucking mass in chest of 1-2 yo
  • R-sided, pleural based, no chest wall invasion or Ca
  • types: cystic, mixed, solid
    • solid –> brain, bones
    • cystic < 1yo, benign
  • 10% multilocular cystic nephromas
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45
Q

PPB vs askin tumor or Ewing sarcoma of chest wall

A

PPB no chest wall/rib invasion

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46
Q

ideal termination of UA catheter

A

T8-10 or L3-L5

avoid renal arteries

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47
Q

what abdominal cong abN is a CI to UA catheter placement

A

omphalocele

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48
Q

UV catheter complications

A
  • clot in portal v–> lobar atrophy

- cystic liver mass ==> hematoma; sugg erosion into liver

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49
Q

classic img viral pna. what is special about RSV?

A
  • peribronchial edema
  • mucus/debris in aw –> hyperinfl & subsegm atel
  • RSV: segmental or lobar atel, esp RUL
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50
Q

round PNA-who, orgm, path, where, next step

A

-<8 yo
-S pneumonia
-path: don’t have goo collateral ventilation pathways
solitary
-pst lobes
-next step: follow up xray (no CT to exclude cancer)

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51
Q

lipoid pneumonia-classic hx, app, dx test of choice?

A
  • parents giving olive oil daily –> chronic fat aspiration
  • low attenuation in consolidated areas
  • dx=bronchoalveolar lavage?
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52
Q

Swyer James-which lung is abnormal?

A
  • post viral obliterative bronchiolitis –> affected lung smaller than normal/hyperexpanded lung.
  • cause of unilateral Lucent lung
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53
Q

pulmonary hypoplasia

A

lung tiny or incompletely developed-1˚ or 2˚

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54
Q

pulmonary papillomatosis-app, risk/compl, sim to what disease?

A
  • ST masses in aw & lungs/”multiple lung nodules w/ cavitation
  • 2˚ risk SCC
  • cysts & nodules = LCH + tracheal involvement
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55
Q

sickle cell/acute chest

A
  • kids > adults (2-4)
  • leading cause of death
  • rib infarct –> pain causes decreased inspiration –> atelectasis/ infection
  • pulmonary microvascular occlusion, infarct
  • img: opacities
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56
Q

findings of sickle cell in cheset

A
  • big heart
  • humeral head infarcts
  • h shaped vertebra
  • cholecystectomy clips
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57
Q

CF in the chest

A
  • apical predominant
  • mucous plugging –> bronchiectasis, hyperinflation, finger in glove
  • PAH
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58
Q

primary ciliary dyskinesia

A
  • ciliopathy-motile part doesn’t work
  • lower lobe predominant bronchiectasis
  • kartageners 50%
  • infertility (M); sub fertility (F)
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59
Q

why are men infertile in CF vs 1˚ ciliary dyskinesia

A
  • CF: vas deferences absent

- PCD: sperm don’t swim

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60
Q

mc mediastinal mass

A

thymus

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61
Q

sail sign vs spinnaker sail sign of thymus

A

sail sign=normal triangular shape of thymus in kids (esp large in <5 yo)
-spinnaker sail sgx-lifting of thymus in PMX

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62
Q

things that make you think thymus cancer

A
  • abN size for age (~15 yo)
  • heterog
  • Ca
  • compression aw/vasc
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63
Q

thymic rebound

A

thymus shrinks in acute stress (PNA, radiation, cry, burns)

  • recovery phase= return to size (sometimes larger); pet+!
  • grows but maintains N triangular morphology
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64
Q

mc abnormal mediastinal mass in children

A

lymphoma (~>10 yrs vs normal thymus)

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65
Q

lymphoma vs ALL/leukemia

A

indistinguishable on img (st mediastinal mass)

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66
Q

47 XXY

A

klinefelter’s syndrome

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67
Q

3 flavors of mediastinal GCT

A
  • teratoma-cystic, fat, Ca
  • seminoma-midline; bulky, lobulated
  • NSGCT- big & ugly; hemorrhage, necrosis; lung invasion
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68
Q

who’s at increased risk chest GCTs?

A

Klinefelter’s syndrome (300x risk)

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69
Q

middle mediastinal LAD causes

A
  • granulomatous (Tb or fungal) MC; lymphoma
  • mono (EBV 90%, CMV 10%)
  • 1˚ tb
  • histoplastmosis
  • coccidioidomycosis
  • lymphoma
  • sarcoid
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70
Q

what do pt’s with mono get after amoxicillin

A

rash

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71
Q

histoplasmosis-US region, chest imaging

A
  • MW, SE

- CXR: N (MC), hilar LAD

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72
Q

coccidioidomycosis-US region, chest img

A

-SW
-consolidation, nodules
hilar LAD

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73
Q

mediastinal lymphoma-which type

A

Hodgkins (4x MC than NHL)

-HL involves thymus 90%

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74
Q

pediatric chest sarcoid

A
  • rare, onset usually ~20s

- few case reports

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75
Q

mediastinal duplications cysts-

A
  • bronchogenic
  • enteric
  • neuroenteric
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76
Q

enteric mediastinal duplication cyst

A
  • abut esophagus, same attenuation, may comm (fluid/air)
  • distal R esophagus=2nd MC loc (ileum #1)
  • middle or pst mediastinum
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77
Q

bronchogenic mediastinal duplication cyst

A
  • abut trachea or bronchus, NO comm
  • fluid/mucous filled
  • subcarinal
  • middle mediastinum (70%), hila (30%)
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78
Q

pst mediastinal masses-peds

A
  • NB. GN, GB
  • Ewing Sarcoma
  • Askin Tumor (primitive neuroectodermal tumor of cw)
  • neuroenteric cyst
  • extramedullary hematopoiesis
  • round PNA
  • extralobar sequestration
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79
Q

neuroblastoma vs ganglioneuromas

A
  • GN: less aggressive, more cirdcumscribed, no Ca, older children
  • can’t differentiate based on imaging alone)
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80
Q

askin tumor (primitive neuroectodermal tumor of chest wall)-aka, features/img

A

part of Ewing sarcoma spectrum!

  • aka “Ewing sarcoma of cw”
  • displace rather than invade (exc when large)
  • heterogenous, enhancing solid parts, no Ca
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81
Q

neuroenteric cyst-where, features, ass

A

Cyst along neuraxis (usually intraspinal)

  • Most are intradural, extramedullary simple unilocular cysts ventral to spinal cord
  • lower cervical/thoracic region
  • well-demarcated, fluid att. no comm w/ csf
  • ± vertebral anomalies, other closed spinal dysraphisms
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82
Q

extra medullary hematopoiesis-who, app, ass

A

myeloproliferative disorders, bone marrow infiltration (including SCD)

  • BL, smooth sharply delineated ST paraspinal masses
    • HMG, SMG
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83
Q

mc posterior mediastinal mass in child <2 yo

A

neuroblastoma

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84
Q

what does better: thoracic or abdominal neuroblastoma

A

Thoracic

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85
Q

imaging pst mediastinal NB

A
  • pst mediastinal st mass, heterog + enh, Ca

- +/0 invasion ribs, VBs

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86
Q

spectrum ganglioneuromas

A
  • ganglioneuroma (most mature)
  • ganglioneuroblastoma (intermediate)
  • neuroblastoma (undifferentiated)
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87
Q

normal thymus vs lymphoma?

A

age: <10 yo n thymus, >10 yo lymphoma

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88
Q

anterior mediastinal masses-peds

A

-normal thymus
-lymphoma
thymic hyperplasia
GCT
lymphangioma

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89
Q

mediastinal lymphoma-img

A
  • usually >10 yo
  • ant or middle mediastinal mass
  • thymus, homogenous ST density, pericardial effusion, vascular/airway involvement
  • Ca uncommon if untreated
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90
Q

pst mediastinal masses-approach

A

<10 yo: malignant; NB
>10 you: benign:
-round mass: ganglioneuroma, NF
-cystic + spinal anomaly: neuroenteric cyst
-course bone trabecularion, hx anemia-EMH

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91
Q

big chest masses

A

Askin (PNET/Ewings)
Pleuopulmonary blastoma
*age

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92
Q

MC TE fistula

A

N type (85%)

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93
Q

esophageal atresias/fistulas-types to know

A
  • N type (85%)=blind ending esophagus w/ distal TE fistula
  • Esophageal atresia, no fistula (10%)
  • H type (1%)=no atresia, TE fistula; delayed diagnosis
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94
Q

TE fistulas w/ excessive air in stomach

A

N and H types

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95
Q

fake out for TE fistula

A

simple aspiration (look for laryngeal penetration)

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96
Q

what must be described prior to surgery in setting of EA/TE

A

right arch (4%)-changes approach

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97
Q

VACTERL

A 
3+ anomalies. Heart & kidney MC
Vertebral (37%)
Anal (63%)
Cardiac (77%)
TE (40%)
Renal (72%)
Limb (radial ray) (58%)
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98
Q

relationship btw limbs and kidneys in VACTERL

A
  • Both limbs involved –> both kidneys

- One limb involved –> one kidney

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99
Q

FB in trachea vs esophagus

A
  • esophagus flexible, accommodates FB-coin turned in any dir

- trachea rigid, forces coin to rotate into pst mem (skinny in AP dir)

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100
Q

FB, what to do: AA or AAA batteries

A
  • serial xray

- remove if in stomach >2d

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101
Q

FB, what to do: disc batteries

A
  • es-2 hrs

- stom-4 hrs

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102
Q

disc battery vs coin

A

disc=2 rings

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103
Q

FB, what to do: coin

A

remove if:

  • es 24 hrs
  • stom 28 d
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104
Q

FB, what to do: penny minted after 1982

A

remove from stomach

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105
Q

what makes pennies minted after 1982 special? what’s the problem?

A
  • contain zinc
  • problems:
      • stomach acid–> gastric ulceration
    • Zn toxicosis (if absorbed in great enough quality)–> pancreatic dysfunction, pancreatitis
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106
Q

FB, what to do: lead

A
  • remove immediately from stomach (gastric acid leads to immediate absorption)
  • distal passage must be confirmed
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107
Q

FB, what to do: sharp objects

A
  • esophagus-remove immediately
  • stomach-removed immediately
  • post pylorus=follow vs sx (if it does not perforated small bowel, it will be at IC valve)
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108
Q

classic ddx obstruction in older child-AIM

A
  • appendicitis; adhesions
  • inguinal hernia; intussuscpetion
  • midgut volvulus; meckels
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109
Q

vascular rings & slings

A
  • Pulmonary sling
  • double aortic arch
  • Innominate artery compression
  • aberrhant left subclavian + right arch
  • aberrhant right subclavian + L arch
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110
Q

only vascular ring/sling to go btw es & trachea?

A

pulmonary sling

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111
Q

what tracheal abnormality is pulmonary sling ass with?

A

tracheal stenosis

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112
Q

pulmonary sling is ass with many other cardiopulmonary & systemic anomalies. which ones?

A

hypoplastic right lung, horseshoe lung, TEF, imperforate anus, complete tracheal rings

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113
Q

pulmonary sling rx

A

surgical repositioning of artery (controversial)

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114
Q

dysphagia lusoria

A

trouble swallowing in setting of left arch with aberrant right subclavian

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115
Q

diverticulum of kommerell

A

pouch like aneurysmal dilation of proximal portion right subclavian artery

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116
Q

finding highly specific for duodenal atresia? when would you see it?

A
  • double bubble

- 3rd TM OB US, plain film or MRI

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117
Q

what is malrotation ass with?

A
  • heterodoxy syndromes
  • omphalocele
  • of note: SMA to right of SMV
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118
Q

FP malrotation on upper GI

A

distal bowel obstruction displacing duodenum (bc of ligamentous laxity)

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119
Q

corkscrew duodenum

A

midgut volvulus

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120
Q

Next step: non-bilious vs bilious vomiting

A
  • US (pyloric stenosis)

- upper GI (midgut volvulus until proven otherwise)

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121
Q

Ladd’s bands

A

fibrous stalk of peritoneal tissues that fixes cecum to abdominal wall –> obstruction duodenum (intermittent episodes)

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122
Q

partial vs complete duodenal obstruction

A
  • complete= midgut volvulus, duodenal atresia

- partial=ladd band, annular pancreas, duodenal web, stenosis

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123
Q

pre-duodenal portal vein-what, ass

A

anatomic variant, PV sit ant to D2

-duo obstr 50%, but ISN’T the cause (ass w/ other things…ladds bands, annular pancreas, etc)

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124
Q

Borchardt Triad

A

Gastric volvulus

1) inability to pass NGT
2) severe epigastric pain
3) retching w/o vomiting

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125
Q

When does hypertrophic pyloric stenosis occur?

A

specifically 2-12 wks (ie: not at birth and not >3mo)

-peak-3-6wks

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126
Q

primary differential pyloric stenosis

A

pyorospasm (will relax during exam)

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127
Q

MC patient pitfall during exam for pyloric stenosis that creates FN?

A

gastric overdistention –> displacement antrum & pylorus –> FN

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128
Q

pylori stenosis FP

A

off axis measurement

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129
Q

“paradoxical aciduria”

A

pyloric stenosis

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130
Q

Organoaxial vs mesenteroaxial age diff

A

Organo=Old

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131
Q

duodenal atresia association

A
  • DS (30%)
  • other intestinal atresia
  • biliary abN
  • cong heart dx
  • VACTER
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132
Q

How do we know that double bubble is not an acute obstruction caused by a midgut volvulus, which is, a surgical emergency?

A

Dilatation of the duodenal bulb is seen only with chronic causes of obstruction. Not enough time for the bulb to become dilated in acute obstruction, such as with midgut volvulus

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133
Q

duodenal atresia vs stenosis

A
  • atresia=occlusion, stenosis=fixed narrowing

- With duodenal stenosis, the double bubble is seen in association with the presence of distal bowel gas

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134
Q

duodenal web-what, where, ass, img

A
  • partial canalization (not total like atresia)
  • distal to ampulla
  • ass: DS, malrot
  • pin sized hole;
  • wind sock deformity-older kids where web-like diaph stretched
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135
Q

small left colon- aka, what, mx

A
  • meconium plug
  • Functional colonic obstr,
  • self limited, relieved by contrast enema
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136
Q

What is small left colon ass and NOT ass with

A
  • NOT ass w/ CF

- mothers with DM or Mg sulfate for eclampsia

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137
Q

Hirschsprung dx-who

A

boys (4:1)

DS

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138
Q

HD dx imaging

A
  • recto-sigmoid ration <1

- saw tooth (bowel spasm)

139
Q

HD presentation

A
  • no BM > 48-72 hrs
  • forceful passage meconium after rectal exam
  • nec bowel s/p 1 mo
140
Q

total colonic aganglionosis

A

rare variant of HS mimicking microcolon

*can involve TI

141
Q

calcified mass in mid abd

A
  • meconium peritonitis. Sterile peritoneal rxn to in-utero bowel perforation ( w/ bowel atresia or MI
  • perforation seals
142
Q

imperforate or ectopic anus-range, ass

A
  • anal atresia –> arrest of colon as it descends through pubrectalis sling
  • fistula to GU tract
  • ass=VACTERL, tethered cord-need screening US
143
Q

MCC bowel obstruction peds > 4yo

A

appendicitis

144
Q

mcc obstruction in boy 1mo-1yr

A

indirect ing hernia

145
Q

when does intuss present?

A

3mo-3 yr, no lead points

146
Q

when does intuss matter?

A

> 2.5 cm

-SB-SB <2 and spon’t reduce

147
Q

intuss img

A

target sign

pseudo kidney

148
Q

suspected lead points for intuss

A

HSP, MD, enteric cysts

149
Q

CI enema reduction

A
  • free air
  • peritonitis
  • septic/hypovolemic shock
150
Q

Intuss success rate, recurrence timeframe, risk perforation (what to do?)

A
  • succ: 80-90% (reduced with HSP)
  • recurr 72 hrs
  • 0.5% perforation –> needle decompression. *air causes less peritonitis than barium”
151
Q

Meckel’s diverticiulum

A

congenital diverticulum of distal ileum, persistent piece of omphalomesenteric duct

152
Q

MD rule of 2’s

A
  • 2% population
  • 2 types of heterotypic mucosa (gastric, pancreatic)
  • 2 ft of IC valve
153
Q

complications MD

A
  • diverticulitis
  • bleed (30%)
  • intuss (seen w/ inverted diverticulum)
  • obstruction
154
Q

pentology of cantrell

A

1) omphalocele
2) ectopic cordis (abN location of heart)
3) diaphgragmatic defect
4) pericardial defect or sternal cleft
5) cardiovascular malformation

155
Q

right sided extra-abdominal evisceration of neonatal bowel and sometimes stomach/liver through paraumbilical wall defect

A

gastroschisis

156
Q

gastroschisis ass

A

intestinal atresia

157
Q

gastroschisis maternal labs

A

AFP+ (higher than omphalocele)

158
Q

complication gastroschisis repair

159
Q

omphalocele ass

A

Trisomy 18 MC chrom
cardiac (50%)
syndromes-Klinefelter, BW, Turners, Pentalogy of Cantrell

160
Q

probably causes gastroschisis vs omphalocele

A
  • gastroschisis-environmental (ass w/ bowel atresia)

- genetic-ass w/ various other syndromes

161
Q

enteric duplication cysts-what, compl, ass

A
  • development anomalies (failures to canalize), can comm with lumen (but usually don’t)
  • can obstr, perf
  • ass: vertebral anomalies (30%)
162
Q

cyst w/ gut signature

A

enteric duplication cyst

163
Q

cyst w/o gut signature

A

omental cyst (lymphangioma=MC)

164
Q

necrotizing enterocolitis-path

A

immature bowel mucosa –> translocation bacteria –> ischemia & inf

165
Q

who gets NEC

A
  • premature (90% w/I 1st 10 days)
  • LBW (<1500 g)
  • cardiac-can be FT
  • perinatal asphyxia
  • Hirschsprung kids that go home and come back
166
Q

NEC findings

A
  • pneumatosis (most definitive), PV gas (2nd most)
  • focally dil bowel (RLQ)
  • featureless small bowel w/ separation
  • unchanging bowel gas pattern, ie: several plane films w/ bowel gas pattern unchanged.
167
Q

where does NEC mostly occur?

A

right colon/terminal ileum

168
Q

what is only parameter ass w/ decreased NEC

A

maternal breast milk

169
Q

what do you ask yourself in determining NEC vs feces?

A

first-did the kid eat?

secondly- is it moving?

170
Q

how often is pancreas involved in CF?

171
Q

dorsal pancreatic agenesis-what, ass

A
  • dorsal bud does not form –> absent tail –> DM (most beta cells are in tail)
  • ass w/ polysplenia
172
Q

peds pancreatic mass: age 1, 6, 15

A

pancreatoblastoma, adenoCA, SPEN (solid & papillary epithelial neoplasm)

173
Q

mc pediatric pancreatic solid tumor

A

Solid and papillary epithelial neoplasm (SPEN)

  • female adolescent (asian or black)
  • rx-surgical (good outcome)
174
Q

pediatric liver tumors ages 0-3 yrs

A
  • infantile hepatic hemangioma
  • hepatoblastoma
  • mesenchymal hamartoma
175
Q

infantile hepatic hemangioma-ass findings, syndromes, labs

A
  • liver mass + CMG (high output CHF)
  • aorta above hepatic branches enlarged relative to aorta below celiac via differential flow
  • +skin hemangiomas 50%
  • endothelial GF+
  • kasabach-merritt Syndrome (platelet eater)
  • spon’t involute w/o therapy mo’s-yrs, prog Ca+

Hemangioma: Benign endothelial neoplasm of neonates/infants in soft tissues or viscera (especially liver)

  • Not hemangioendothelioma (more aggressive tumor)
  • Not cavernous hemangioma (venous malformation)
Congenital hemangioma (CH): Found in perinatal period, does not proliferate beyond birth; stains GLUT1 negative
Rapidly involuting subtype more common in liver than noninvoluting

Infantile hemangioma (IH): Develops in 1st few weeks of life with characteristic proliferating & involuting phases; stains GLUT1 positive

176
Q

hepatoblastoma-app, labs, ass, RF

A

-well circumscribed solitary RIGHT sided mass, Ca 50%, +/- ext into PV, HV, IVC
-AFP+
bHCG–> precocious puberty
-ass: hemi-HTr, *Wilms, BWd
-RF: prematurity

177
Q

mc 1˚liver tumor of childhood <5yo

A

hepatoblastoma

178
Q

mesenchymal hamartoma

A
  • Cystic. Large portal v branch feeds tumor. solid comp mildly enh
  • AFP-
  • ø Ca
179
Q

pediatric liver tumors > 5yrs

A
  • HCC
  • fibrolamellar
  • undifferentiated embryonal sarcoma
  • young children/teens: hepatic adenoma, hemangioma, FNH, angiosarcoma
180
Q

2nd mc liver cancer in kids

181
Q

undifferentiated embryonal sarcoma-what, app

A
  • pissed off cousin of mesenchymal hamartoma, ie: cystic but much more aggressive
  • hypodense +sept & fibrous pseudocapsule
  • known to rupture
182
Q

pediatric liver tumors w/ elevated AFP

A
  • hepatoblastoma

- HCC

183
Q

what liver tumors would you expect at any age?

A

-mets (Wilms, NB)

184
Q

fetal HMG

A
  • congenital syphilis

- transient abN myelopoiesis (TAM)

185
Q

congenital syphilis- findings, when, earliest and last orgn

A
  • prenatal US >20wks: HMG + enlarged placenta

- liver earliest and last

186
Q

transient abN myelopoiesis (TAM)-what, who, mx

A

preleukemic syndrome in DS

  • advanced maternal age
  • 80% self-resolve; 20% –> myeloid leukemia
187
Q

hereditary hemorrhagic telangiectasia (osler-weber-rendu) in liver

A
  • mult AVMs
  • dilated hepatic a
  • cirrhosis
188
Q

prolonged newborn jaundice (>2wks)

A

1) neonatal hepatitis

2) biliary atresia

189
Q

mx biliary atresia

A

Kasai procedure (bf 3 mo)

190
Q

biliary atresia-findings, ass, test of choice, mx

A
  • absent extra hepatic biliary ducts –> proliferation intrhepatic
  • +/- absent gb (normal GB supports neonatal hep)
  • triangle cord sgx
  • nuc medicine IDA = test of choice
  • ass-polysplenia, trisomy 18
  • mx
    • bx-exclude alagille
    • kasai procedure (bf 3 mo)
191
Q

alagille syndrome

A
  • congenital genetic multisystem disorder. Infants typically present with symptoms relating to the liver where it is one of the most common causes of hereditary cholestasis.
  • hereditary cholestasis (from paucity intrahepatic bd’s)
  • peripheral pulmonary stenosis
192
Q

what is the purpose of liver bx in biliary atresia?

A

exclude alagille syndrome

193
Q

triangle cord sign

A

triangular echogenic structure near portal v in biliary atresia
-possibly CBD remnant?

194
Q

peds + gs

A

sickle cell

195
Q

situs solitus

A

normal: left gastric bubble, larger part of liver on right, minor fissure on R

196
Q

situs inversus totalis-what, findings, ass

A

total mirror image transposition of abdominal and thoracic contents

  • gastric bubble on right
  • large liver on left
  • left minor fissure
  • inverted bronchial pattern
  • ass: 1˚ciliary dyskinesia
197
Q

situs ambiguus

A

“heterotaxy”, ie: L or R isomerism

198
Q

changes of spleen in sickle cell

A

-enlarge progressively –> auto infarct & shrink (1st decade) (painless)

199
Q

what can happen if sickle cell spleen remains enlarged? Hx?

A

1) acute splenic sequestration crisis-hogs blood; 2nd mcc death SCC
- hx=abd pain, hypotension and SMG
2) abscess
3) infarct

200
Q

how does spleen infarct look on us?

A

hypoechoic + bright bands

201
Q

heterotaxia syndromes

A

Right vs left sided

202
Q

Right sided heterotaxia syndrome/Right isomerism

A
  • 2 left pleural fissures
  • asplenia
  • more cardiac malform
  • reversed aorta/ivc
203
Q

Left sided heterotaxia syndrome/left isomerism-findings, ass

A
  • Absent minor fissures (1 right fissure)
  • polysplenia
  • fewer cardiac malform
  • azygos con’t of IVC
  • ass: biliary atresia (10%)
204
Q

renal agenesis 2 flavors & ass

A

1) BL absence- Potter sequence

2) UL abscence-reproductive

205
Q

how will they demonstrated UL renal agenesis on prenatal US?

A

absent renal artery in view of aorta OR oligohydramnios

206
Q

UL renal agenesis associations

A
  • 70% F-unicornuate uterus or rudimentary horn

- 20% M-absent epididymis, IL vd + IL seminal vesicle cyst.

207
Q

potter sequence:

A

insult (?ace inh)–> renal agenesis –> oligohydramnios –> pulm hypoplasia

208
Q

lying down adrenal or “pancake adrenal” sgx

A

elongated adrenal in renal agenesis (vs surgical absence)

209
Q

MC kidney fusion anomaly

A

horseshoe kidney (hung up by IMA)

210
Q

horseshoe kidney complications

A

1) prox to VB–> injury

2) poor drainage-stones, inf, CA (chr inflamm) (Wilms, TCC, renal carcinoid)

211
Q

classic horseshoe kidney association

A

turner’s syndrome

212
Q

crossed fused renal ectopia-what, which side MC, compl

A
  • one kidney crosses midline & fuses with other. Each maintains orthotropic ureteral orifice.
  • ectopic kidney is inf
  • L>R
  • compl: stones, inf, hydro (50%)
213
Q

how will exam show crossed fused renal ectopia

A

-2 axial CT slices-1 at top without kidney, 1 at bladder with 2 opacified ureters

214
Q

MC congenital anomaly of GU tract in neonates

A

congenital UPJ obstruction

215
Q

congenital UPJ obstruction-how often BL, mech, app, rx, role of radiologist, classic history

A
  • 80% intrinsic defect in circular m bundle of renal pelvis
  • hx: teenager with flank pain after drinking lots of fluids
  • hydro w/o hydroureter, BL 20%
  • look for vessels crossing UPJ (changes mx)
  • rx- pyeloplasty
216
Q

Whitaker test

A

urodynamics study + antegrade pyelogram

217
Q

ARPKD liver involvement -what’s involved, how is it diff from AD, compl

A
  • abN bd and congenital hepatic fibrosis (vs cysts in AD)
  • inverse rel btw liver & kidney inv
  • portal HTN –> death (usually MCC death)
218
Q

ARPKD img

A
  • smoothly enlarged, diffusely echogenic
  • loss of corticomedullary differentiation
  • cysts=tumular, spare cortex
  • +/- in utero øurine in bladder
219
Q

ARPKD compls

A
  • htn
  • renal fx
  • portal htn –> death
220
Q

neonatal renal v thrombosis- path, app/pres

A
  • maternal diabetes, sepsis, dehydration; peripheral –> hilar
  • L>R
  • acute=renal enlargement
  • chronic=atrophy
221
Q

neonatal renal artery thrombosis-cause, pres

A

UA catheters

-severe HTN

222
Q

prune belly (eagle barrett syndrome)-who, what, app

A
  • males shaped like a pear
  • triad:
    1) ø abd wall m
    2) hydroureteronephrosis
    3) cryptorchidism
223
Q

congenital (primary) megaureter

A
  • wastebasket term for enlarged ureter intrinsic to ureter (ie: not 2/2 distal obstr)
  • 3 causes:
    1) distal adynamic segm
    2) reflux at UVJ
    3) idiopathic
224
Q

congenital/1˚ megaureter vs obstruction

A

obstruction: collecting system dilated

225
Q

retrocaval (circumcaval) ureter- what, classic six’s, syx’s

A
  • anomaly of IVC. Proximal ureter courses pst to IVC, emerges to right of aorta and ant to R iliac vessels
  • reverse J or fishhook ureter
  • asyx (MC), obstruction, recurrent UTI
226
Q

Weigert Meyer Rule

A

upper pole inserts inf and medially

227
Q

kidney size duplicated system

228
Q

compl duplicated system in F

A

incontinence (ureter may insert below sphincter into vagina

229
Q

ureterocele-path, classic sign, ass

A
  • cystic dilation intravesicular ureter 2/2 obstruction at ureteral orifice
  • “cobra head sign”-on IVP or US
  • ass: upper pole moiety in dupl system
230
Q

ectopic ureter-insertion and syx

A
  • F: usually distal to external sphincter in vestibule

- M: usually above external sphincter –> asyx

231
Q

mcc ureteral obstruction in male infants

A

pst urethral valve

232
Q

org of pst urethral valve fold

A

wolfian duct

233
Q

pre-natal US classic triad Pst urethral valve

A
  • hydronephrosis
  • bladder dilation
  • oligiohydramnios
234
Q

“key hole”

A

-appearance of bladder on fetal MR in pst urethral valve

235
Q

pst urethral valve img

A
  • VCUG-abrupt caliber change, dilated pst urethra, normal ant urethra
  • fetal MR- hydro + key hold
  • prenatal US: hydro, bladder dilation, oligiohydramnios
236
Q

“peri-renal fluid collection”

A

2/2 forniceal rupture

  • non spec, seen with any obstructive path
  • ?classically pst urethral valve
237
Q

non-obstructive causes of hydro in baby boys

A
  • VUR
  • 1˚ megaureter
  • prune belly
238
Q

obstructive causes of hydro in baby boys

A
  • PUV
  • UPJ Obstr
  • ureteral ectopia
239
Q

next step: hydro on routine prenatal screen:

A

repeat US once born

  • most go away
  • if persistent…
    1) VCUG (GS),
    2) MAG3 (function & drainage),
    3) MR urography (function, structure; sedation required.
240
Q

mcc palpable renal mass in childhood

241
Q

Vascular complication PUV

242
Q

grading VUR

A

1) ureter
2) ureter + non dilated CS (calyces still pointy)
3) ureter + mild dil (calyces blunted)
4) ureter + mod dil
5) tortuous

243
Q

hutch diverticulum-what, dx, rx

A
  • congenital muscular defect at or just above UVJ. Congenital bladder diverticula, seen at the vesicoureteric junction, in the absence of posterior urethral valves or neurogenic bladder. They are thought to result from a weakness in the detrusor muscle anterolateral to the ureteral orifice.
  • dx: VCUG>US. Dynamic (voiding)
  • rx-VUR
244
Q

allantois

A

umbilical attachment to bladder

245
Q

Complication of urachal remnant

A

infection (MC)

-adenoCA 90%

246
Q

spectrum urachal remnant anomalies

A

patent, vesiculourachal diverticulum, urachal cyst, umbilical urachal sinus

247
Q

bladder exstrophy-what, img (classic sign), compl

A
  • herniation urinary bladder through hole in ant infra-umbilical abd wall
  • “manta ray sign”-unfused pubic bones
  • compl: adenoCa
248
Q

cloacal malformation

A

GU & GI drain into common opening

-F

249
Q

cloacal malformations and urachal anomolies: F or M?

A

urachal: M 2x > F
cloacal: only F

250
Q

neurogenic bladder ass

A

spinal dysraphism: tethered cord, sacral agenesis, etc.

251
Q

pediatric renal masses: neonate, ~4yo, teen

A
  • neonate: nephroblastomatosis, mesoblastic nephroma
  • ~4: Wilms, Wilms variant, lymphoma, multilocular cystic nephroma
  • teen: lymphoma, rcc
252
Q

“solid renal tumor of infancy”-you can be born with it

A

mesoblastic nephroma

253
Q

nephroblastic rests

A

leftover embryologic renal tissue

254
Q

“solid renal tumor of childhood”-never born with it

255
Q

renal + brain tumor in infancy

256
Q

multilocular cystic nephroma app

A
  • big cysts that don’t communicate

- septal enhancement

257
Q

what can’t you distinguish multi cystic nephroma from?

A

cystic wilms-must resect

258
Q

solid renal tumor of adolescence

259
Q

“Michael Jackson tumor”

A

multi cystic nephroma

260
Q

What is the MC RCC subtype?-img, classic hx

A

“translocation Carcinoma RCC”

  • dense solid, enh & expansile growth
  • hx prior cytotoxic crx
261
Q

RCC subtype: sickle cell trait

A

medullary subtype

262
Q

RCC subtype: VHL

A

Clear cell subtype, often BL

263
Q

necrosis in nephroblastomatosis should make you think…

264
Q

how often do you US screen nephroblastomatosis?

A

q3 mo until 7-8 yo

265
Q

mesoblastic nephroma: underlying path, MC age, where in kidney, img ass

A
  • fetal hamartoma
  • 80% first mo
  • renal sinus
  • antenatal US: +/- polyhydramnios
266
Q

multi cystic dyspastic kidney

A
  • multiple tiny cysts form in utero. Macro cysts on img.
  • no functioning renal tissue
  • CL renal tract aN 50% (mc UPJ obstr)
267
Q

syndromes ass with wilms

A
  • beckwith-wiedemann (overgrowth)
  • Sotos (overgrowth)
  • WAGR
  • Drash
268
Q

Beckwith-Wiedemann

A
  • macroglossia (MC)
  • omphalocele
  • hepatoblastoma
  • wilms
  • hemiHTr
  • Cardiac
  • big orgns
269
Q

Sotos syndrome

A

macrocephaly
Retarded
Ugly face

270
Q

WAGR

A

wilms
aniridia
genital
growth retardation

271
Q

Drash

A

wilms
pseudohermaphroditism
progresive glomerulonephritis

272
Q

synchronous bilateral Wilms

A

BL in 5-10%

273
Q

wilms age range

A
  • avg 3 yo
  • all before 10 yo
  • never before 2mo
274
Q

should you bx wilms?

A

no-seeding of tract –> upstage

275
Q

wilm’s variants

A

clear cell–> bones (lytic)

rhabdoid- brain tumors

276
Q

multilocular cystic nephroma

A
  • noncommunicating fluid filled located surround by thick fibrous capsule
  • by definition, no solid comp or necrosis
  • bimodal
  • “protrudes into renal sinus”
277
Q

renal rumor that “protrudes into renal sinus”

A

multilocular cystic nephroma

278
Q

2nd mc renal malignancy of childhood

A

RCC (MC translocation carcinoma)

279
Q

RCC (MC translocation carcinoma)

A
  • hx: prior cytotoxic crx
  • denser than cortex on non-con CT
  • solid, enh, expansile growth
280
Q

RCC vs WIlms

A

RCC smaller, older color, more likely to Ca

281
Q

renal lymphoma

A

never 1˚

BL expansile masses

282
Q

initial imaging bladder masses

A

US w/ full bladder

283
Q

MC pediatric tumor of bladder

A

rhabdomyosarcoma (cause obstr)

284
Q

Rhabdomyosarcoma botryoid subtype img app

A

“bunch of grapes”-multiple round masses grouped together,

285
Q

rhabdomyosarcoma locations

A
  • H/N (orbit, NP)=MC

- 20% bladder, prostate

286
Q

how often is RMS met at pres?

287
Q

RMS bimodal peak

A

2-4yo, 15-17yo

288
Q

RMS non-botryoid subtype img app

A

big nodular ugly horrible nightmare

289
Q

mc extratesticular mass in young men

290
Q

MC extra-cranial solid childhood malignancy

A

neuroblastoma

291
Q

neuroblastoma locations

A

adrenal 35%,
RP 30%,
pst mediastinum 20%,
neck 5%

292
Q

NB age range

A

<2yo (can be born with it)

-95% <10 yo

293
Q

what upstages NB?

A

stage 3:

  • crossing midline
  • CL positive nodes
294
Q

NB better prognostic factors

A
  • <1yo
  • thoracic primary
  • stage 4S
295
Q

stage 4S high yield:-who, met locs, prog?

A

<1 yo

  • mets confined to skin, liver, BMARROW (not cortical bone!) (lytic)
  • excellent prognosis
296
Q

NB ass

A

NF1, HSD, DiGeorge BW

*most are sporadic

297
Q

opsomyoclonus

A
  • dancing eyes & feet

- PNS ass w/ NB

298
Q

best nuc medicine scan for NB?

299
Q

NB labs

A

urine catecholamines+ (95%)

300
Q

NB vs Wilms

A
  • NB <2yo, poorly marginated, Ca 90%, encases vess, bone met

- Wilms: ~4 yo, well marginated, Ca <10%, invade vess, no bone met (prefer lungs)

301
Q

neonatal adrenal hemorrhage cause and ass

A
  • birth trauma, stress

- ass: scrotal hemorrhage

302
Q

adrenal hemorrhage vs NB. First step.

A
  • hem: anechoic, T2(-), avascular
  • NB: hyper echoic, T2(+), hypervascular
  • first step: f/u US
303
Q

mcc adrenal insufficiency in kids?

A

congenital adrenal hyperplasia 2/2 21 alpha hydroxyls deficiency

304
Q

CAH img

A

cerebriform adrenals

305
Q

hydrometrocolpos-what, causes, pres, app, ass

A
  • obstructed vagina does not drain uterus
  • causes-imperforate hymen (MC), vaginal stenosis, lower vaginal atresia, cervical stenosis
  • pres: infancy-mass or teenage-delayed menarche
  • expanded, fluid/blood-filled vaginal cavity w/ distention of uterus
  • ass: uterus didelphys (75% have transverse vaginal septum)
306
Q

ovarian torsion peds vs adult

A
  • adult-mass

- peds: normal excessive mobility. “fluid-debris levels within displaced follicles”

307
Q

suspect ovarian torsion if…

A

-ovary 3x size CL

+ fluid-debris levels in displaced follicles

308
Q

ovarian pediatric masses

A
  • 2/3 dermoid/teratomas-MC

- 1/3 cancer (75% germ cell tumor)

309
Q

mcc idiopathic scrotal edema

310
Q

pathology hydrocele

A

patent processus vaginalis

311
Q

pediatric acute scrotal pain: 3 considerations

A

1) testicular appendage torsion
2) testicular torsion
3) epididymo-orchitis (isolated orchitis is rare)

312
Q

age range epididymitis

A

<2 yo, > 6yo

313
Q

causes of orchitis

A
  • nearly always progress from epididymitis

- isolated=mumps

314
Q

testicular appendage

A

vestigial remnant of mesonephric duct

315
Q

blue dot sign

A

physical exam sign in testicular appendage torsion. (testicle looks like blue dot)

316
Q

best indicator testicular appendage torsion?

317
Q

bell clapper deformity

A

failure of tunica vaginalis and testis to connect

318
Q

histologic breakdown of testicular cancer (adult & peds)

A 
germ cell 90%
   -seminoma 40%
   -non-seminoma 60%- Teratoma, YS, Mixed GC (chorioCA)
Non GC (10%)
   Leydig
   Sertoli
319
Q

Germ cell tumors seen in 1st decade of life

A

YS (heterogeneous appearance) & teratoma

320
Q

teratomas M vs F

A

aggressive in men

321
Q

sertoli cell tumors ass

A

subtype associated with peutz-jeghers syndrome

322
Q

testicular calcifications and CA

A

small=seminoma

big=GCT

323
Q

mc tumor of fetus or infant

A

sacrococcygeal teratoma

324
Q

sacrococcygeal teratoma compl

A
  • benign (80%); older infant pres=higher malignant pot

- large size –> ME on GI system, hip dislocation, n compression–> incontinent

325
Q

sacrococcygeal location

A
  • external to pelvis (47%)
  • internal to pelvis (9%)
  • mixed (dumbbell)-34%
326
Q

what’s associated with high sacrococcygeal recurrence rate

A

incomplete resection of coccyx

327
Q

sacrococcygeal classification. Which is ass w/ highest malignancy rate?

A

type 1- totally extra pelvic
type 2-barely pelvic but not abd
type 3- some abd
type 4-totally abd. Highest mal.

328
Q

testicular tumors/masses to consider

A
  • Germ cell tumors-teratoma, YS. Others (embryonal, chorio, seminomatous, mixed) more rare in peds
  • Epidermoid
  • Choriocarcinoma
  • Lymphoma/leukemia
  • adrenal rests
  • abscess
  • infarct
329
Q

pediatric abdominal calcification

A
  • meconium peritonitis
  • neo-NB, teratoma, HB
  • adrenal hemorrhage
  • RUQ: gs, HB, hepatic torch (CMV, toxo)
330
Q

hepatic infantile hemangioma/hemangioendothelioma vs other hemangiomas

A

It’s a highflow vascular neoplasm. “hemangioma” otherwise is venous malformation

331
Q

hepatic infantile hemangioma vs hemangioendothelioma

A
  • both: benign high flow vasc neo’s. CHF

- diffs: HE can metastasize

332
Q

hepatic infantile hemangioma- ass, mx

A
  • Kasabach-Merrit syndrome & GLUT-1

- b-blockers, sx if CHF

333
Q

pro ass with infantile hemangioms

334
Q

img hepatic infantile hemangioma

A

focal, MF, diffuse.

  • vascular
  • T2+
  • enh peripherally w/ delayed fill in
  • Ca, central necrosis, hemorrhage
335
Q

clear cell sarcoma

A

“bone loving tumor”

-uncommon renal cancer with propensity to metastasize to bone

336
Q

pediatric renal met

337
Q

congenital lobar overinflation/hyperinflation/emphysema-moa

A

one way valve

338
Q

renal tubular ectasia-aka

A

ARPKD. Newborn BL kidney enlargement, echogenicity, reversal/loss of normal CM diff (ie: medulla hyperecho) via dilated ectatic tubules

339
Q

newborn kidney appearance on ultrasound

A

The US appearance of the kidneys in neonates and infants up to 6 months of age is distinctive and differs significantly from that in older children and adults. The renal cortex in neonates has echogenicity equal to or greater than that of the liver and spleen, whereas in older children and adults, the cortex is hypoechoic relative to those organs. The echogenicity of neonatal renal cortex is due to the relative concentration, as well as the increased cellular volume, of glomeruli. The medullary pyramids appear prominent and hypoechoic because of a relatively lower cortical volume (,Fig 1). By the time a child is 6 months old, the echogenicity of the renal parenchyma assumes an adult pattern. In addition, the intense echogenicity due to fat in the renal sinuses of older patients is relatively scant or absent in the newborn infant (,4).

340
Q

acute scrotum-order of frequency

A

EO
appendage torsion
testicular torsion-most serious/needs tromp dx

341
Q

aniridia

A

absent iris

342
Q

pleuroblastoma cystic vs solid types

A
  • solid –> brain, bones

- cystic < 1yo, benign

343
Q

pulmonary agenesis vs aplasia vs hypoplasia

A

Agenesis: Absent lung, pulmonary artery, & bronchus

Aplasia: Absent lung & pulmonary artery with rudimentary blind-ending bronchus

Hypoplasia: Hypoplastic lung, pulmonary artery, & bronchus

radiology (31 decks)

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