Intestinal ultrasound in pediatrics. / Ecografía intestinal en pediatría.

Ultrasonography is the imaging technique of choice for studying the digestive tract in pediatric patients from the neonatal period to adolescence. Its dynamic character, absence of radiation, and scant preparation required make ultrasonography preferable to contrast-enhanced fluoroscopy, computed tomography, or magnetic resonance imaging. Technical advances in ultrasound, including high-resolution multifrequency probes, panoramic studies, color Doppler, Doppler with microvascularization, elastography, and contrast agents for use in children, have increased the sensitivity and specificity of this technique. Intestinal ultrasound is indicated for conditions with diverse etiologies and pathogenesis: congenital, infectious, inflammatory, tumor-related, and vascular. Knowledge of embryological development and the normal characteristics of the digestive tract help in identifying, recognizing, and interpreting the ultrasound findings of the different conditions in pediatric patients. This paper aims to show the indications for ultrasound studies of the digestive tract in children, the findings on these studies, and the management of the most common gastrointestinal conditions in pediatric patients.

Non-traumatic spleen disorders in children. Assessment by imaging. / El bazo pediátrico no traumático. Valoración por imagen.

The spleen is considered a "forgotten organ" by most radiologists and paediatricians despite being affected in many clinical paediatric situations. While it is the organ most often affected in paediatric abdominal trauma, non-traumatic spleen disorders are less well known. The spleen is well visualised by any imaging technique: ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI); the former is used most often in children. Using imaging techniques to determine the features of splenic anomalies, both congenital and acquired, enables a correct diagnostic approach, avoids unnecessary surgical procedures or biopsies, and helps the clinician to prescribe appropriate treatment. Our aim was to show the behaviour of the spleen in children using the different imaging techniques: its normal anatomy, the principal anatomical variants and the most common spleen disorder correlating with clinical symptoms, serology and histology.

Calyceal diverticula in children: imaging findings and presentations. / Divertículos caliciales en niños: hallazgos radiológicos y formas de presentación.

A calyceal diverticulum consists of a cystic eventration in the renal parenchyma that is lined with transitional cell epithelium with a narrow infundibular connection with the calyces or pelvis of the renal collector system; thus, the term pyelocalyceal diverticulum would be more accurate. Very rare in pediatric patients, calyceal diverticula can be symptomatic and require treatment. Calyceal diverticula are underdiagnosed because they can be mistaken for simple renal cysts on ultrasonography. To determine the approach to their follow-up and management, the diagnosis must be confirmed by excretory-phase computed tomography (CT) or magnetic resonance imaging (MRI). This article aims to show the different ways that calyceal diverticula can present in pediatric patients; it emphasizes the ultrasonographic findings that enable the lesion to be suspected and the definitive findings that confirm the diagnosis on CT and MRI. It also discusses the differential diagnosis with other cystic kidney lesions and their treatment.

Perinatal testicular torsion: ultrasound assessment and differential diagnosis. / Torsión testicular perinatal. Valoración ecográfica y diagnóstico diferencial.

Perinatal testicular torsion, defined as torsion occurring in the prenatal period or in the first month after birth, accounts for 10% of all cases of testicular torsion in pediatric patients. Most are extravaginal, and intravaginal torsion is rare. Its management is controversial, due to the low viability of the testis and the possibility of bilateral torsion. Ultrasonography is the method of choice to study testicular torsion. Combining B-mode and power Doppler imaging facilitates a fast reliable diagnosis. We review the ultrasonographic appearance of neonatal testicular torsion for each presentation, the differential diagnosis with other causes of increased scrotal volume in neonates, and its treatment.

Neonatal ovarian cysts: ultrasound assessment and differential diagnosis. / Quistes de ovario neonatales. Valoración ecográfica y diagnóstico diferencial.

Ovarian cysts are the most common abdominal cysts in female fetuses and newborn girls. Ultrasonography is the imaging technique of choice for diagnosing ovarian cysts because it makes it possible to differentiate them from other cystic lesions. Although most neonatal ovarian cysts regress in the first few months after birth, complications can occur during gestation or after birth. The manifestations of ovarian cysts on ultrasonography will depend on the complications. The management is controversial, although the current trend favors watchful waiting. We describe the different presentations of neonatal ovarian cysts with their complications and their patterns of findings on ultrasonography. We also discuss the differential diagnosis with other cystic abdominal lesions, and finally we discuss the therapeutic management of neonatal ovarian cysts.

Multicystic dysplastic kidney: Assessment of the need for renal scintigraphy and the safety of conservative treatment. / Displasia renal multiquística: evaluación de la necesidad de la gammagrafía renal y seguridad del tratamiento conservador.

OBJECTIVES: To assess the need for implementing renal scintigraphy in the diagnosis of the multicystic dysplastic kidney (MCDK) and the safety of its conservative treatment. MATERIAL AND METHODS: A retrospective study of patients with unilateral MCDK was conducted at our centre from January 2005 to August 2015. We calculated the positive predictive value (PPV) of ultrasonography, taking renal scintigraphy and pathology as the gold standard. We calculated a survival curve according to the Kaplan-Meier method to assess the annual probability of spontaneous resolution of the multicystic kidney. RESULTS: Fifty-six patients were identified, 48 (85.7%) of whom had a prenatal diagnosis. Thirty eight (67.9%) of the patients were males, and the left side was affected in 33 (58.9%) of the patients. We observed associated urological abnormalities in 22 (39.29%) patients, with vesicoureteral reflux the most common (8, 14.29%). Seven patients (12.5%) developed renal failure. Forty-nine (87.5%) patients developed compensatory contralateral renal hypertrophy. Of the 33 patients who underwent surgery, the pathology results confirmed the MCDK diagnosis in 32. Compared with scintigraphy and pathology, the PPV of ultrasonography was 100% and 97%, respectively. The rate of spontaneous involution was 5.4% at 3 months of life, 11.3% at 2 years and 38.4% at 5 years. CONCLUSIONS: In our experience, the conservative treatment of MCDK, until at least 5 years of age, is safe. Our data suggest that performing scintigraphy is not required for these patients, which means lower radiation exposure, as well as financial savings.

[Acoustic radiation force impulse imaging elastography is efficacious in detecting hepatic fibrosis in children]. / La elastografía mediante técnica Acoustic radiation force impulse es eficaz en la detección de fibrosis hepática en el niño.

OBJECTIVE: To evaluate the diagnostic performance of acoustic radiation force impulse imaging (ARFI) in detecting significant hepatic fibrosis in children. MATERIAL AND METHODS: Our hospital's ethics committee approved the study and all patients or their representatives provided informed written consent. We included 96 children (50 boys, 46 girls; mean age, 8 y). We also studied 16 volunteers without liver disease as controls and 80 patients with diseases that can lead to fibrosis and cirrhosis of the liver. The final sample included 31 patients with biopsies and the 16 controls. All patients underwent abdominal ultrasonography including Doppler imaging and elastography with ARFI. The ARFI value, expressed as velocity (m/s) of shear wave propagation through the tissue, was calculated by averaging 16 measurements in both liver lobes. We used one-way analysis of variance to compare means between groups; we set statistical significance at P<.05. We used Student's t-tests and chi-square tests for categorical data. RESULTS: The ARFI value in children with fibrosis ≥ F2 was higher (1.80±0.45m/s) than in controls and higher than in patients with F0-F1 (1.38±0.22m/s). The difference was significant (P<.001) for detecting F ≥ 2. Steatosis was not related with the ARFI value (Student's t-test, P>.84). Necroinflammatory activity was strongly associated with the ARFI value (Student's t-test, P<.01). Fibrosis and necroinflammatory activity were strongly associated with each other (chi-square test, P<.0001). CONCLUSION: The speed of shear wave propagation is significantly associated with the degree of hepatic fibrosis in children.

[Evaluation of carotid intima-media thickness in familial hypercholesterolemia in childhood]. / Evaluación del grosor del complejo íntima-media de la carótida en la hipercolesterolemia familiar durante la infancia.

INTRODUCTION: Familial hypercholesterolemia (FH) is characterized by exposure to severely elevated LDL-cholesterol from birth, which produces lipid deposits, which can be measured by means of intima-media thickness (IMT). SUBJECTS AND METHODS: The IMT and concentrations of cholesterol and its fractions, triglycerides, alipoproteins Apo-A1, Apo-B and endothelial risk factors (homocysteine and high sensitivity protein C ) were determined in 89 patients (44 males) from 2 to 19 years (9.54+/-3.91 years). IMT was measured by ultrasound using a 12MHz linear array transducer in both carotids to 1cm of the bulb. The IMT mean was compared with age, sex and analytical parameters using multiple regression analysis. RESULTS: The mean values were: IMT 0.334+/-0.088mm, total cholesterol 273.62+/-91.93mg/dl, LDL-cholesterol 204.21+/-86.16mg/dl, LDL/HDL 3.83+/-1.45, apoprotein A1 134.61+/-26.49mg/dl, apoprotein B 130.59+/-40.59mg/dl, homocysteine (median) 7.16mmol/dl, Protein C (median) 0.3mg/l. Using multiple regression analysis, only age was associated with IMT (P=0.049), a mean 0.005mm (95% CI: 0.000-0.010) being the annual increase: up to 12 years the increase in IMT was 0.002mm/year on (95% CI: -0.007-0,010) and then from that age it was 0.013mm/year (95% CI: -0.023-0.049). CONCLUSIONS: The measurement of the carotid IMT could become an objective parameter in the evaluation of the FH in childhood. In our study, it is only associated with age, the increase being most marked from 12 years onwards.

[Pleuropulmonary blastoma in children: imaging findings and clinical patterns]. / Blastoma pleuropulmonar en niños: manifestaciones clínicas y radiológicas.

PURPOSE: To describe the imaging findings, clinical presentation and follow up of pleuropulmonary blastoma (PPB) in children. MATERIALS AND METHODS: Authors present a retrospective review of three young children with pathologically proven PPB seen from 1992 to 2006 in a pediatric hospital. The imaging findings on simple views, CT and MRI are presented. RESULTS: The first patient showed two bilateral well-defined solid lung lesions on chest X-rays, with homogeneous low attenuation on CT. Patient is free of disease following chemotherapy and surgical treatment. The second patient displayed a right tension pneumothorax. After drainage, he presented on chest X-rays and CT an underlying multicystic lesion. Following chemotherapy and surgical treatment, he presented two pulmonary metastases, which were treated with chemotherapy and surgery. The patient is now free of disease. The third patient showed a complete opacification of the left hemithorax due to a massive pleural effusion; a pleuropulmonary solid mass was seen on US, CT and MRI. The disease progressed with mediastinal, orbital and abdominal metastasis. The patient eventually died. CONCLUSION: PPB is a rare chest tumor seen in young children that can present with diverse radiological findings, and sometimes can arise in congenital cystic lung lesions. CT is the gold standard technique both for diagnosis and follow-up of these tumors.

[Radiologic findings in non-Wilms' renal tumors in children]. / Hallazgos radiológicos de los tumores renales no-Wilms en la edad pediátrica.

OBJECTIVES: To analyze the radiologic findings of non-Wilms' renal tumors in children. MATERIAL AND METHODS: This is a retrospective study of 26 patients with histologically confirmed non-Wilms' renal tumors. The following variables were evaluated on radiological studies: location, size, margins, necrosis, hemorrhage, calcifications, subcapsular hematoma, adenopathies, and metastases. Age and clinical presentation were also analyzed. RESULTS: We found 11 mesoblastic nephromas (predominantly solid masses, ill-defined margins, necrosis, hemorrhage, and peritumoral collections; mean patient age, 15 years old); 7 multilocular cystic nephromas (multicystic masses, thickened septa, well-defined margins, capsule, and partial involvement of the kidney; patient age range: 5 to 12 months); 4 renal carcinomas (one with dense calcifications, one mass in the pyelocaliceal system, one with infiltration of the excretory tract, one solid infiltrating mass, retroperitoneal adenopathies, and one metastasis; age range: 2 to 15 years); one clear cell sarcoma (circumscribed solid mass with necrosis and retrocaval adenopathy in a two-year-old boy); one rhabdoid tumor (hypodense mass, ill-defined margins, retroperitoneal adenopathy, vesical clots, and synchronous intracranial tumor, in a six-month-old boy); one intrarenal neuroblastoma (infiltrating solid mass, necrosis, retroperitoneal adenopathy, and bone marrow infiltration in an eight-year-old boy); and one angiomyolipoma (tumor in the upper pole, extrarenal growth, hypoenhancing, and two fatty lesions in the contralateral kidney, in a ten-year-old patient with tuberous sclerosis). CONCLUSIONS: Radiology, together with clinical and epidemiological data, enables the diagnostic work-up of pediatric renal tumors. Histological diagnosis remains indispensable.

[Diagnostic imaging of piriform sinus fistulas]. / Estudio mediante técnicas de imagen de las fístulas del seno piriforme.

OBJECTIVES: To establish the usefulness of ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and barium contrast swallow studies in the diagnosis of piriform sinus fistulas (PSF). MATERIAL AND METHODS: We reviewed the clinical histories and imaging studies of four pediatric patients diagnosed with PSF. Cervical ultrasound was the first imaging study performed in all cases. Three patients subsequently underwent intravenous contrast-enhanced CT examination and one underwent MRI. Barium contrast swallow studies were performed in all patients at a later time. All cases were confirmed at surgery. RESULTS: Ultrasound enabled the lesions to be located on the left side and showed the existence of heterogeneous collections in and around the thyroid glands in all four patients. Posterior CT and MRI studies determined the exact size of the abscessed lesions. Barium contrast swallow studies demonstrated the existence of the PSF in all four cases. CONCLUSIONS: The presence of a recurrent inflammatory process and acute suppurating thyroiditis located on the left side should raise suspicions of PSF. Both CT and MRI are useful in the study of PSF; however, in our experience, ultrasound examination is the technique of choice for initial evaluation and follow-up. After the acute process, barium swallow studies continue to be the main method for diagnosing the trajectory of the fistulous tract.

[Biliary atresia: Retrospective clinical study]. / Atresia de vías biliares: estudio clínico retrospectivo.

OBJECTIVE: To gain further insight into the natural history of patients with biliary atresia. PATIENTS AND METHODS: We performed a retrospective, cross-sectional, descriptive, case series study. All patients with biliary atresia attended at the Pediatric Gastrointestinal and Hepatology Unit of La Fe Children's Hospital in Valencia (Spain) from January 1990 to December 2000 were included. RESULTS: Of 16 children followed-up, eight are currently stable, six have undergone liver transplantation and two died. The mean age at diagnosis was 47.5 days. The most frequent clinical manifestation was jaundice (87.5%) and the most common biochemical finding was raised gamma-glutamyltransferase (3-4 times its standard value), which appeared in 100 % of the patients. Abdominal ultrasonography was diagnostic in 85.7% of the patients. Nuclear scintiscan (DISIDA) showed a sensitivity of 100%. Portoenterostomy with intraoperative liver biopsy was performed in all patients. Patient age at surgery was a predictor of long-term outcome, with more favorable results in patients aged less than 65 days of life. CONCLUSIONS: Biliary atresia should be suspected as soon as possible, since early surgical treatment is the only therapeutic measure that can improve outcome.

Varus deformity of the distal end of the femur secondary to a focal fibrous lesion.

Severe unilateral varus deformity of the distal end of the femur secondary to a focal fibrous lesion is reported. It is a malformative process rare at this level, this being the first report of it in the radiological literature. The conventional radiograph is pathognomonic and CT is useful in the confirmation of the fibrous tissue. Osteotomy is indicated only if the deformity progresses or the angle of varus is severe.