Factors associated with diagnostic ultrasound for midgut volvulus and relevance of the non-diagnostic examination.

BACKGROUND: Few reports explore the frequency and factors associated with diagnostic ultrasound (US) for midgut volvulus. OBJECTIVE: To evaluate predictive factors for diagnostic US for midgut volvulus and clinical outcomes of patients with non-diagnostic US. MATERIALS AND METHODS: This retrospective study included infants imaged for midgut volvulus with US. Exams were rated as diagnostic (midgut volvulus present or absent) or non-diagnostic by a pediatric radiologist, and in cases of disagreement with the original report, an additional pediatric radiologist was the tie-breaker. For each exam, the following were recorded: age, weight, respiratory support, exam indication, sonographer experience, and gaseous dilated bowel loops on radiography. Logistic regression models with "stepwise" variable selection were used to investigate the association of diagnostic US for midgut volvulus with each of the independent variables. RESULTS: One hundred nineteen patients were imaged. US was diagnostic in 74% (88/119) of patients. In subsets of patients presenting with bilious emesis or age <28 days, US was diagnostic in 92% (22/24) and 90% (53/59), respectively. Logistic regression suggested that symptom type (bilious vs other) was the best predictor of diagnostic US (type 3 P=0.02). Out of 26 patients with available radiographs, US was diagnostic in 92% (12/13) of patients without bowel dilation on radiographs compared to 62% (8/13) of patients with bowel dilation (P=0.16). Weight, respiratory support, and sonographer experience did not differ between groups. Two sick neonates, ages 2 days and 30 days, in whom the primary clinical concern was dropping hematocrit and sepsis, respectively, had non-diagnostic ultrasounds in the setting of bowel dilation on radiography. Both were found to have midgut volvulus at surgery and both expired. CONCLUSION: US was most frequently diagnostic in patients with bilious emesis or age less than 28 days. Non-diagnostic US for midgut volvulus must prompt a predetermined follow-up strategy, such as an additional imaging study (e.g., upper GI series), particularly in a sick child, as non-diagnostic US may miss midgut volvulus.

Congenital lung lesions: a radiographic pattern approach.

Congenital lung malformations represent a spectrum of abnormalities that can overlap in imaging appearance and frequently coexist in the same child. Imaging diagnosis in the neonatal period can be challenging; however, the recognition of several archetypal radiographic patterns can aid in narrowing the differential diagnosis. Major radiographic archetypes include (1) hyperlucent lung, (2) pulmonary cysts, (3) focal opacity and (4) normal radiograph. Here we review the multimodality imaging appearances of the most commonly seen congenital lung malformations, categorized by their primary imaging archetypes. Along with the congenital lung malformations, we present several important imaging mimickers.

Sporadic Burkitt Lymphoma Presenting with Middle Cranial Fossa Masses with Sphenoid Bony Invasion and Acute Pancreatitis in a Child.

Acute pancreatitis in children is usually due to infection, trauma, or anatomical abnormalities and is rarely due to obstruction from malignancy. Sporadic Burkitt lymphoma (BL) is an aggressive non-Hodgkin B-cell lymphoma that usually involves the bowel or pelvis, with isolated cases presenting as acute pancreatitis. We report a case of BL in a 12-year-old male presenting as acute pancreatitis with obstructive jaundice and a right middle cranial fossa mass invading the sphenoid bone. The common bile duct in this case was dilated to 21 mm in diameter on abdominal ultrasound and to 26 mm on magnetic resonance cholangiopancreatography (MRCP), significantly greater than any value reported in the literature for BL. Given the rapidly progressing nature of BL, we emphasize the importance of recognizing heterogeneous presentations of this disease to improve patient survival. We also conclude that it is important to consider malignancy in a child with acute pancreatitis, particularly in the presence of obstructive jaundice or multisystem involvement. Other Presentations. This case report has no prior publications apart from the abstract being accepted to the 2020 SIOP (International Society of Pediatric Oncology) meeting and 2020 ASPHO conference (canceled due to the COVID-19 pandemic) and subsequently published as an abstract only in Pediatric Blood and Cancer. We have also presented the abstract as a poster presentation at our institution's (NYU Langone Hospital-Long Island, previously known as NYU Winthrop) annual research day conference in 2020.

Ovarian neoplasms of childhood.

Ovarian neoplasms are rare in children. Although usually asymptomatic, they sometimes present with abdominal pain, abdominal distension or palpable mass. The distribution of neoplasms in the pediatric population is different from in adults; benign mature cystic teratoma is the most common ovarian tumor in children. Radiologists should be familiar with the variable sonographic, CT and MRI findings of ovarian neoplasms. Although the less frequently encountered ovarian malignancies cannot be reliably distinguished by imaging alone, it does play an important role in workup. This review discusses the imaging and relevant clinical manifestations of the more commonly encountered pediatric ovarian neoplasms.

Acute Urinary Retention Caused by an Ovarian Teratoma-A Unique Pediatric Presentation and Review.

BACKGROUND: Acute urinary retention (AUR) is a rare diagnosis both in pediatric and adult female populations, especially when compared to adult males. AUR occurs in women at a rate of 7 in 100,000 per year in a 1:13 female to male ratio. Multiple studies have shown that within the pediatric population AUR is far less common in females and is caused by different pathologies than AUR in adult women. CASE REPORT: We report the case of an 11 year-old prepubescent female who presented to the emergency department with acute urinary retention found to be caused by a mature cystic ovarian teratoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case is unique in that it describes an ovarian mass leading to AUR which has not previously been described in the pediatric literature. We will review the causes of AUR in the pediatric female population and compare these to the causes of AUR in other populations.

The efficacy of digital fluoroscopic image capture in the evaluation of vesicoureteral reflux in children.

BACKGROUND: In accordance with ALARA, minimizing radiation exposure associated with voiding cystourethrograms (VCUG) is of critical importance. Advances in fluoroscopic technology might help achieve this goal. OBJECTIVE: To determine the efficacy of fluoroscopic image capture compared to conventional digital radiographic spot (DRS) images in voiding cystourethrograms (VCUG) for the evaluation of vesicoureteral reflux (VUR) in children. MATERIALS AND METHODS: The study was a retrospective review of 65 VCUG examinations (130 kidney/ureter units). Each examination consisted of fluoroscopically captured spot (FCS) images and the corresponding DRS images. Each set of images was evaluated by three pediatric radiologists for the diagnosis of VUR for a total of 390 kidney/ureter units reviewed. Using the DRS image set as the reference standard, the efficacy of the FCS images for diagnosing reflux was determined. RESULTS: The diagnostic accuracy of the FCS images in terms of the binary characterization of reflux as negative or positive was 97.2% (379/390). The sensitivity of the FCS images was 92.6% (88/95); the specificity of the FCS images was 98.6% (291/295). CONCLUSION: Fluoroscopically captured images are adequate in documenting absence of VUR on VCUG examinations, obviating the need for radiographic spot images and resulting in reduction in radiation exposure.

Laparoscopic neo-os creation in an adolescent with uterus didelphys and obstructed hemivagina.

Uterus didelphys is a rare congenital anomaly with a well-documented association with obstructed hemivagina and ipsilateral renal agenesis. Treatment of this anomaly includes drainage of hematocolopos and excision of the vaginal septum, which has traditionally used a scalpel or scissors, often with hymenotomy. Recently, a less invasive approach using hysteroscopic resection has been reported, allowing improved visualization with preservation of the hymenal ring. In this article, we present an alternative minimally invasive approach using a combination of laparoscopy and vaginoscopy in the case of a 10-year-old girl. This approach allows for treatment in cases wherein vaginoscopy provides inadequate visualization with the advantage of enabling full evaluation for associated complications affecting future fertility including endometriosis, pelvic infection, and pelvic adhesions.

The relationship between alpha angle and resistive index of the femoral epiphysis in the normal and abnormal infant hip.

BACKGROUND: The arterial vascularity of the hip has been investigated in normal infants using duplex Doppler sonography. This study addressed the differences in hip vascularity in infants with respect to gender and acetabular morphology. OBJECTIVE: To determine whether there is a relationship between the resistive index of the vessels of the femoral chondroepiphysis and the alpha angle in normal infant hips and in those with developmental dysplasia of the hip. MATERIALS AND METHODS: We studied 76 hips (38 patients) with gray-scale and power Doppler US. The patients were referred because of a possible abnormal clinical hip examination or had risk factors for developmental dysplasia of the hip. The infants ranged in age from 1 day to 6 weeks. There were 13 boys and 25 girls. Gray-scale images were initially performed in the coronal and transverse planes to evaluate acetabular morphology, alpha angle and position of the femoral chondroepiphysis relative to the acetabulum. The hips were then examined with power Doppler US, in both sagittal and transverse planes, to identify arterial vessels within the femoral epiphysis. Resistive indices were then recorded from the spectral analysis in each vessel identified. Each examination was performed by one of five pediatric radiologists. Mixed model regression was used to assess the relationship between resistive index and alpha angle, age and gender. RESULTS: Of the 76 hips, 34 had an alpha angle of 60 degrees or greater and were classified as normal, 26 had an alpha angle between 50 degrees and 59 degrees and were classified as immature, and 13 had an alpha angle of less than 50 degrees and were either subluxed or dislocated at the time of examination. At least two vessels were documented in each femoral epiphysis except in three hips, in which no vessels could be documented because of technical factors. There was a statistically significant linear relationship between the alpha angle and resistive index, such that the resistive index tended to rise with increasing alpha angle (P=0.0022). In addition, female infants had a significantly higher average resistive index than the average resistive index in male infants with the same alpha angle (P=0.0005). CONCLUSION: There is a direct linear relationship between alpha angle and resistive index in the infant hip. Female infants have a higher average resistive index than male infants. We believe that these results might serve as a model for predicting an infant hip at risk of ischemia. In addition, the fact that lower resistive indices of the femoral epiphysis are associated with acetabular dysplasia might help explain the documented low incidence of avascular necrosis in untreated hip dysplasia.

Metanephric adenoma in an 8-year-old child: case report and review of the literature.

Metanephric adenoma (MA) is a renal tumor that is rarely found in children. We present a case of MA that was incidentally discovered in an 8-year-old child on computed tomography. We also review the literature regarding this lesion in the pediatric population. There are certain imaging features of MA that may suggest the diagnosis preoperatively. Metanephric adenoma is often hyperechoic on sonography, hyperdense on noncontrast computed tomography scans, and of low signal intensity on T1- and T2-weighted magnetic resonance images. Nephron sparring surgery has been performed in several cases. However, the distinction of MA from other metanephric lesions as well as from Wilms' tumor and papillary renal cell carcinoma may not be readily apparent at the time of surgery.

Idiopathic intraparenchymal hematoma of the liver in a neonate.

Hepatic hematomas in newborn infants are not frequently detected clinically, but are often found at perinatal autopsies. These hematomas of the liver are usually subcapsular in location. A variety of etiologies for such hematomas has been implicated, such as trauma, sepsis, and coagulopathies. We present a neonate who presented with jaundice and abdominal distention. Initial imaging studies revealed a large intraparenchymal lesion of the liver, which was at first thought to be suspicious for neoplasm; however, MRI showed the lesion to be hemorrhagic and follow-up sonographic studies showed total resolution of this lesion, compatible with hematoma. The intraparenchymal location and the idiopathic nature of this lesion distinguish this case from others previously reported.