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Prenatal hydrocolpos is characterized by fluid distension of the vagina. Hydrocolpos can be caused by multiple underlying etiologies and often demonstrates overlapping imaging features compared to other cystic abdominal and pelvic lesions. The purpose of the current pictorial essay is to provide a systematic prenatal magnetic resonance imaging (MRI) approach to differentiating the primary etiologies leading to hydrocolpos. After discussing the fundamental embryological processes involved in vaginal development, the current essay discusses the most common causes of hydrocolpos with their associated prenatal and postnatal imaging features. An approach to distinguishing the more common differential diagnoses is provided. Given the implications of parental counseling and postnatal management, this essay provides an important approach for narrowing differential diagnoses based on prenatal imaging.
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BACKGROUND. Despite evidence supporting the specificity of classic metaphyseal lesions (CML) for the diagnosis of child abuse, some medicolegal practitioners claim that CML result from rickets rather than trauma. OBJECTIVE. The purpose of this study was to evaluate radiologists' diagnostic performance in differentiating rickets and CML on radiographs. METHODS. This retrospective seven-center study included children younger than 2 years who underwent knee radiography from January 2007 to December 2018 and who had either rickets (25-hydroxyvitamin D level < 20 ng/mL and abnormal knee radiographs) or knee CML and a diagnosis of child abuse from a child abuse pediatrician. Additional injuries were identified through medical record review. Radiographs were cropped and zoomed to present similar depictions of the knee. Eight radiologists independently interpreted radiographs for diagnoses of rickets or CML, rated confidence levels, and recorded associated radiographic signs. RESULTS. Seventy children (27 girls, 43 boys) had rickets; 77 children (37 girls, 40 boys) had CML. Children with CML were younger than those with rickets (mean, 3.7 vs 14.2 months, p < .001; 89.6% vs 5.7% younger than 6 months; 3.9% vs 65.7% older than 1 year). All children with CML had injuries in addition to the knee CML identified at physical examination or other imaging examinations. Radiologists had almost perfect agreement for moderate- or high-confidence interpretations of rickets (κ = 0.92) and CML (κ = 0.89). Across radiologists, estimated sensitivity, specificity, and accuracy for CML for moderate- or high-confidence interpretations were 95.1%, 97.0%, and 96.0%. Accuracy was not significantly different between pediatric and nonpediatric radiologists (p = .20) or between less experienced and more experienced radiologists (p = .57). Loss of metaphyseal zone of provisional calcification, cupping, fraying, and physeal widening were more common in rickets than CML, being detected in less than 4% of children with CML. Corner fracture, bucket-handle fracture, subphyseal lucency, deformed corner, metaphyseal irregularity, and subperiosteal new bone formation were more common in CML than rickets, being detected in less than 4% of children with rickets. CONCLUSION. Radiologists had high interobserver agreement and high diagnostic performance for differentiating rickets and CML. Recognition that CML mostly occur in children younger than 6 months and are unusual in children older than 1 year may assist interpretation. CLINICAL IMPACT. Rickets and CML have distinct radiographic signs, and radiologists can reliably differentiate these two entities.
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Maus-Tratos Infantis , Fraturas Ósseas , Raquitismo , Masculino , Feminino , Humanos , Criança , Lactente , Pré-Escolar , Estudos Retrospectivos , Raquitismo/diagnóstico por imagem , Radiografia , Osso e Ossos , Maus-Tratos Infantis/diagnóstico , Fraturas Ósseas/diagnóstico por imagem , RadiologistasRESUMO
BACKGROUND. Imaging findings represent key criteria for diagnosing chronic pancreatitis in children. Understanding radiologists' agreement for imaging findings is critical to standardizing and optimizing diagnostic criteria. OBJECTIVE. The purpose of this study is to evaluate the interobserver agreement among experienced pediatric radiologists for subjective, quantitative, and semiquantitative imaging findings of chronic pancreatitis in children. METHODS. In this retrospective study, CT or MRI examinations performed in children with chronic pancreatitis were submitted by six sites participating in the INSPPIRE (International Study Group of Pediatric Pancreatitis: In Search for a Cure) Consortium. One pediatric radiologist from each of the six sites reviewed examinations; three of the radiologists independently reviewed all CT examinations, and the other three radiologists independently reviewed all MRI examinations. Reviewers recorded 13 categoric imaging findings of chronic pancreatitis and measured pancreas thickness and pancreatic duct diameter. Agreement was assessed using kappa coefficients for the categoric variables and intraclass correlation coefficients (ICCs) for the continuous variables. RESULTS. A total of 76 CT and 80 MRI examinations performed in 110 children (65 girls and 45 boys; mean age, 11.3 ± 4.6 [SD] years) were reviewed. For CT, kappa coefficients for categoric findings ranged from -0.01 to 0.81, with relatively high kappa coefficients noted for parenchymal calcifications (κ = 0.81), main pancreatic duct dilatation (κ = 0.63), and atrophy (κ = 0.52). ICCs for parenchymal thickness measurements ranged from 0.57 in the pancreas head to 0.80 in the body and tail. The ICC for duct diameter was 0.85. For MRI, kappa coefficients for categoric findings ranged from -0.01 to 0.74, with relatively high kappa coefficients noted for main duct irregularity (κ = 0.74), side branch dilatation (κ = 0.70), number of dilated side branches (κ = 0.65), and main duct dilatation (κ = 0.64); kappa coefficient for atrophy was 0.52. ICCs for parenchymal thickness measurements ranged from 0.53 for the neck and body individually to 0.68 in the tail. ICC for duct diameter was 0.77. CONCLUSION. Interobserver agreement was fair to moderate for most CT and MRI findings of chronic pancreatitis in children. CLINICAL IMPACT. This study highlights challenges for the imaging diagnosis of pediatric chronic pancreatitis. Standardized and/or objective criteria are needed given the importance of imaging in diagnosis.
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Pancreatite Crônica , Adolescente , Atrofia , Criança , Dilatação Patológica , Feminino , Humanos , Imageamento por Ressonância Magnética/métodos , Masculino , Variações Dependentes do Observador , Pancreatite Crônica/diagnóstico por imagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios X/métodosRESUMO
The objective of this paper is to review common challenges when evaluating fractures in the setting of possible child abuse and approaches to navigate them. This paper reviews the variety of imaging modalities available for evaluating child abuse and the advantages/disadvantages of each. Additionally, the authors discuss management of equivocal fractures, including the impact of double-reading skeletal surveys. The complexity of dating the acuity of fractures in young children is discussed. Utilizing the knowledge of fracture type, fracture patterns and patient history, as well as in the setting of cardiopulmonary resuscitation, the authors provide methods for determining the likelihood of abuse.
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Maus-Tratos Infantis , Fraturas Ósseas , Criança , Maus-Tratos Infantis/diagnóstico , Pré-Escolar , Fraturas Ósseas/diagnóstico por imagem , Humanos , Lactente , Radiografia , Estudos RetrospectivosRESUMO
In this paper the authors review the normal imaging appearance of the fetal gastrointestinal tract and patterns of fetal gastrointestinal tract obstruction. The authors include a detailed summary from esophagus to the rectum, including the expected pattern of meconium and small-bowel contents at different gestational ages. Common fetal gastrointestinal tract obstructions are reviewed with accompanying case examples, emphasizing the role of the meconium and bowel-caliber patterns in establishing differential diagnoses. This review also includes imaging pitfalls, complications of gastrointestinal tract obstruction, and implications for patient care.
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Anormalidades do Sistema Digestório , Diagnóstico Pré-Natal , Feminino , Idade Gestacional , Humanos , Recém-Nascido , Imageamento por Ressonância Magnética , Mecônio , GravidezRESUMO
BACKGROUND: Stages of healing for classic metaphyseal lesions (CMLs) are not well established. Follow-up skeletal surveys provide an opportunity to evaluate signs of healing CMLs. OBJECTIVE: To evaluate the sequence of CML healing phases by comparing initial and follow-up skeletal surveys in children with distal tibial CMLs on the initial survey. Findings could assist in child abuse investigations. MATERIALS AND METHODS: We identified all distal tibia CMLs with initial and follow-up skeletal surveys performed January 2009 through December 2018 at our institution. Two pediatric radiologists reviewed the surveys using Likert score from 1 (no CML) to 5 (definite CML). Only cases with score of 4 or 5 by both radiologists were selected for the study. The initial and 2-week follow-up skeletal surveys were reviewed in consensus for presence of the following signs: corner fracture, thin bucket handle fracture, thick bucket handle fracture, bucket handle fracture with endochondral bone filling the gap, subphyseal lucency, deformed corner, and subperiosteal new bone formation. We used the Kruskal-Wallis test to evaluate for significant difference in thickness among thin bucket handle fracture, thick bucket handle fracture, and bucket handle fracture with endochondral bone filling the gap. RESULTS: We included 26 children (12 girls) with age range 1-9.9 months who had a combined 34 distal tibia CMLs. Thin bucket handle fracture (n=13, 38.2%) was only seen on initial survey. On follow-up, six children had thick bucket handle fracture and four had bucket handle fracture with endochondral bone filling the gap. Fourteen thick bucket handle fractures (n=9) or bucket handle fractures with endochondral bone filling the gap (n=5) were noted on initial surveys; on follow-up, three (21.4%) had deformed corner, one (7.1%) had corner fracture, one (7.1%) had subphyseal lucency, and five (35.7%) were normal. None demonstrated thin bucket handle fracture on follow-up. Two of the nine (22.2%) thick bucket handle fractures became thicker, and 3/9 (33.3%) became bucket handle fractures with endochondral bone filling the gap. The metaphysis normalized in 8/34 (23.5%) CMLs on follow-up surveys. The thickness of thin bucket handle fracture was less than 1 mm (mean±standard deviation [SD] = 0.6±0.2 mm), which was significantly thinner (P<0.0001) compared with thick bucket handle fracture (1.7±0.5 mm) and bucket handle fracture with endochondral bone filling the gap (1.9±0.6 mm). CONCLUSION: The lack of thin bucket handle fractures on any follow-up skeletal surveys suggests this sign represents an acute phase of injury. The next phases of healing appear to be thick bucket handle fracture followed by bucket handle fracture with endochondral bone filling the gap. It is important to note that normalization of the metaphysis at 2-week follow-up does not exclude CML because this was seen in about one-fifth of cases.
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Maus-Tratos Infantis/diagnóstico , Radiografia/métodos , Fraturas da Tíbia/diagnóstico por imagem , Feminino , Seguimentos , Humanos , Lactente , Masculino , Estudos Retrospectivos , Tíbia/diagnóstico por imagem , Tíbia/lesõesRESUMO
BACKGROUND: Diagnosis of classic metaphyseal lesions (CMLs) in children suspected for child abuse can be challenging. Ultrasound (US) can potentially help diagnose CMLs. However, its accuracy is unknown. OBJECTIVE: To evaluate the accuracy of US in the diagnosis of CMLs using skeletal survey reports as the gold standard. MATERIALS AND METHODS: US of the metaphysis was performed in three patient groups age <1 year. Informed consent was obtained for patients scheduled for renal US (Group 1) and for patients scheduled for skeletal surveys for possible child abuse (Group 2). Targeted US was also performed in selected patients to evaluate for possible CML suspected on radiographs (Group 3). In Groups 1 and 2, US was performed of both distal femurs, and of either the right or left proximal and distal tibia. Two radiologists (Rad1 and Rad2) independently reviewed the US studies, blinded to history and other imaging. US sensitivity and specificity were calculated using the following gold standards: CML definitely seen on skeletal survey (positive), CML definitely not seen on skeletal survey or part of renal US group (negative). Cases where the skeletal survey was indeterminate for CML were excluded. Kappa statistics were used to evaluate interobserver variability. RESULTS: Two hundred forty-one metaphyseal sites were evaluated by US in 63 children (mean age: 5 months; 33 males); 34 had skeletal surveys and 29 had renal US. Kappa for the presence of CML was 0.70 with 95.7% agreement. US sensitivity was 55.0% and 63.2% and the specificity was 97.7% and 96.7% for Rad1 and Rad2, respectively. CONCLUSION: US has low sensitivity and high specificity in CML diagnosis. Thus, negative US does not exclude CML, but when the radiographs are equivocal, positive US can help substantiate the diagnosis.
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Maus-Tratos Infantis/diagnóstico , Epífises/diagnóstico por imagem , Epífises/lesões , Fraturas Ósseas/diagnóstico por imagem , Ultrassonografia/métodos , Feminino , Humanos , Lactente , Masculino , Radiografia , Padrões de Referência , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE. The purpose of this study is to perform a statewide quality improvement process to improve compliance with the American College of Radiology (ACR) guidelines in performing skeletal surveys for suspected child abuse. SUBJECTS AND METHODS. We prospectively identified all outside hospital skeletal surveys for suspected child abuse in children younger than 3 years referred to our tertiary children's hospital in 2016-2017. We included a 3-month baseline and 21-month intervention period. The quality improvement process was based on sending educational material to all ACR member radiologists in the state and making telephone calls to radiology technologist team leaders whenever the surveys were not compliant, followed by e-mails with guidance on performing skeletal surveys. We documented the views obtained and compared them with the ACR guidelines. The percentage of compliance with each individual view was assessed with the chi-square test. The total number of compliant views per survey was evaluated with ANOVA. RESULTS. Two hundred twenty-seven patients (105 female) with a mean age of 0.8 year (SD, 0.67 year; range, 0.01-3 years) were evaluated. These 227 surveys (baseline, n = 27; postintervention, n = 200) were performed at 69 different outside hospitals. Compliance significantly (p = 0.006) improved from 25.9% (7/27) during baseline to 54.0% (108/200) after intervention. There was a nonsignificant trend of improved compliance between the first (51.9%; 41/79) and last 7-month (62.3%; 33/53) periods of intervention. Among individual views, only rib oblique views showed significantly (p = 0.02) improved compliance after the intervention, from 51.9% (14/27) to 73.5% (147/200). CONCLUSION. The compliance rate with ACR guidelines for skeletal surveys in suspected child abuse at outside general hospitals significantly increased after implementation of a quality improvement process.
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BACKGROUND: The classic metaphyseal lesion (CML) is highly specific for non-accidental trauma in infants. While the radiographic findings are well documented, there is little literature on the ultrasound (US) appearance. OBJECTIVE: To evaluate US findings in CMLs identified on radiographs. MATERIAL AND METHODS: This institutional review board-approved, retrospective evaluation of targeted US of CMLs was performed in selected groups of children from 2014 to 2017. Only CMLs confidently identified on radiography by a consensus of two radiologists were included. US images were obtained with a linear transducer, including longitudinal images at lateral, anterior, medial and posterior aspects. Two pediatric radiologists evaluated the US appearance, specifically the metaphyseal bone collar for thickness, deformity and fracture, as well as the sonographic zone of provisional calcification for irregularity and appearance of multiple lines. Radiography was the reference standard. RESULTS: Twenty-two patients (13 female; mean age: 4.2 months) were identified, with 39 CMLs in the tibia (n=22), femur (n=11), humerus (n=3), radius (n=2) and fibula (n=1). Thirty-three of the 39 CMLs (85%) were identified on US, while 6 (15%) were not seen (false negatives). Thirty of the 39 (77%) had metaphyseal bone collar thickening, 29 (74%) had collar deformity and 12 (31%) had visible fracture of the collar. At the sonographic zone of provisional calcification, 16/39 (41%) had irregularity and 5 (13%) had multiple lines visible. CONCLUSION: Identifying metaphyseal bone collar and zone of provisional calcification abnormalities is key to recognizing CMLs on US. While additional studies are necessary to evaluate the accuracy of US in the diagnosis of CMLs, our findings suggest US may have a potential role in either confirming or evaluating radiographically equivocal/occult CMLs.
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Osso e Ossos/diagnóstico por imagem , Osso e Ossos/lesões , Maus-Tratos Infantis/diagnóstico , Ultrassonografia/métodos , Feminino , Humanos , Lactente , Masculino , Estudos RetrospectivosRESUMO
BACKGROUND: A hernia is due to a defect in the diaphragm. An eventration is due to a thinned diaphragm with no central muscle. Distinguishing right diaphragmatic hernia from eventration on chest radiographs can be challenging if no bowel loops are herniated above the diaphragm. Experience is limited with postnatal ultrasound (US) evaluation of diaphragmatic hernia or eventration. OBJECTIVE: To evaluate for specific US signs in the diagnosis of right diaphragmatic hernia and eventration. MATERIALS AND METHODS: We identified all patients (January 2007-December 2017) with right diaphragm US and surgery for eventration or hernia. We reviewed medical charts, and US images/reports for clinical presentation and diaphragm abnormalities. Surgical diagnosis was considered the reference standard. RESULTS: Seventeen children (mean age: 5 months) had US examination before surgery for hernia (n=9) or eventration (n=8). The most common presentation was respiratory distress. In the US reports, hernia was correctly diagnosed in all patients and three patients with eventration were misdiagnosed as hernia, yielding 100% sensitivity and 62.5% specificity. In a retrospective evaluation of the US studies, a combination of folding of a free muscle edge with a narrow angle waist had 100% specificity for hernia and was seen in 7/9 children with hernia. Combination of a broad angle waist and hypoechoic strip of diaphragmatic muscle covering the waist had 100% specificity for eventration and was demonstrated in 4/8 children with eventration. Five of 17 patients (31.6%) had no specific sign that differentiated hernia from eventration. CONCLUSION: On US, folding of the free edge of the diaphragm and a narrow angle waist are specific for hernia; a broad angle waist with muscle covering the elevated area is specific for eventration. Definitive differentiation between eventration and hernia may not be possible in about a third of patients.
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Eventração Diafragmática/diagnóstico por imagem , Eventração Diafragmática/cirurgia , Hérnias Diafragmáticas Congênitas/diagnóstico por imagem , Hérnias Diafragmáticas Congênitas/cirurgia , Ultrassonografia Doppler/métodos , Fatores Etários , Criança , Pré-Escolar , Estudos de Coortes , Diagnóstico Diferencial , Feminino , Seguimentos , Herniorrafia/métodos , Humanos , Lactente , Masculino , Cuidados Pré-Operatórios/métodos , Estudos Retrospectivos , Medição de Risco , Índice de Gravidade de Doença , Fatores SexuaisRESUMO
BACKGROUND: Fractures are the second most common finding in non-accidental trauma after cutaneous signs. Interpreting skeletal surveys could be challenging as some fractures are subtle and due to anatomical variations that can mimic injuries. OBJECTIVE: To determine the effect of a second read by a pediatric radiologist of skeletal surveys for suspected non-accidental trauma initially read at referring hospitals by general radiologists. MATERIALS AND METHODS: In 2016 and 2017, we identified all patients referred to our children's hospital with previous surveys performed and read at a community hospital by an outside radiologist. We excluded patients older than 3 years and studies performed at a children's hospital. The surveys were reviewed by a pediatric radiologist with the printed outside report available. Surveys with disagreement between outside read and pediatric radiologist read were reviewed by a second pediatric radiologist. A disagreement in the second read included only definite discrepant findings agreed upon by both pediatric radiologists. The Fisher exact test was performed to compare the ratio of discrepancies between readers in normal and abnormal surveys. RESULTS: Two hundred twenty-five surveys were performed (120 male) at 62 referring hospitals, with a mean patient age of 10.5 months (range: 5 days-3 years). The outside read identified fractures in 104/225 (46.2%) surveys. Thirty-seven of the 225 (16.4%) contained discrepancies in interpretation (n=111). Most of these disagreements (29/37, 78.4%) resulted in a significant change in the report. There was a significant (P<0.0001) difference between disagreement rate in outside read negative (4/111, 3.2%) and positive surveys (34/104, 31.7%). The second read identified additional fractures in 22/225 (9.8%) of the surveys and disagreed with first-read fractures in 17/256 (7.6%). Four of 19 (21.1%) classic metaphyseal lesions diagnosed by the outside read were normal variants; 18 classic metaphyseal lesions were missed by the outside read. CONCLUSIONS: This study supports second reads by pediatric radiologists of skeletal surveys for non-accidental trauma.
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Maus-Tratos Infantis/diagnóstico , Erros de Diagnóstico/estatística & dados numéricos , Fraturas Ósseas/diagnóstico por imagem , Radiologistas/normas , Encaminhamento e Consulta , Pré-Escolar , Competência Clínica , Diagnóstico Diferencial , Feminino , Hospitais Pediátricos , Humanos , Lactente , Recém-Nascido , MasculinoRESUMO
There is an association between tracheal cartilaginous sleeve and syndromic craniosynostosis. We present a case of tracheal cartilaginous sleeve diagnosed by ultrasound (US) in a patient with Pfeiffer syndrome. The patient developed respiratory failure and was suspected at bronchoscopy to have tracheal cartilaginous sleeve. US performed before tracheostomy placement demonstrated continuous hypoechoic cartilage along the anterior surface of the trachea, confirming the diagnosis. Our report shows that US can make a definitive diagnosis of tracheal cartilaginous sleeve and raises the possibility of using US to screen for the condition in patients with syndromic craniosynostosis without the need for anesthesia or ionizing radiation.
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Acrocefalossindactilia/complicações , Traqueia/anormalidades , Traqueia/diagnóstico por imagem , Ultrassonografia/métodos , Broncoscopia , Diagnóstico Diferencial , Humanos , Lactente , Masculino , TraqueostomiaRESUMO
BACKGROUND: Ultrasound (US) is the first-line imaging modality to assess the morbidly adherent placenta, but sensitivity and specificity are lacking. OBJECTIVE: This investigation aims to improve diagnostic accuracy with a comprehensive score using clinical history, US, and magnetic resonance imaging (MRI). MATERIALS AND METHODS: We conducted a retrospective cohort study of pregnant women who received both transvaginal US and MRI with suspicion for morbidly adherent placenta between 2009 and 2016. US was scored with the following metrics: (i) previa, (ii) hypervascularity, (iii) loss of retroplacental clear space and (iv) lacunae. MRI was evaluated for (i) intraparenchymal vessels, (ii) abnormally dilated vessels, (iii) fibrin deposition, (iv) placental bulge and (v) bladder dome irregularity. Bayesian analysis was used to estimate the probability of morbidly adherent placenta for a given score. Diagnostic testing parameters were calculated. RESULTS: Among the 41 women with concerning imaging, histologically identified disease was confirmed in 16. The probability of morbidly adherent placenta increased with the score. At the highest US score, the probability of disease was 63.7%. With the highest MRI score, the probability of adherent placentation was 90.5%. Combining the US and MRI findings had a sensitivity of 56% and a specificity of 92%. CONCLUSION: A combined scoring system using MRI and US may accurately identify patients at risk for morbidity associated with morbidly adherent placenta.
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Imageamento por Ressonância Magnética , Placenta Prévia/diagnóstico por imagem , Placenta Retida/diagnóstico por imagem , Ultrassonografia Pré-Natal , Adulto , Teorema de Bayes , Feminino , Humanos , Gravidez , Estudos Retrospectivos , Sensibilidade e Especificidade , Índice de Gravidade de DoençaRESUMO
OBJECTIVE: The objective of this study is to evaluate whether coronal STIR MRI can be used as a screening test for nontraumatic acute hip pain in children. MATERIALS AND METHODS: From 2008 to 2012, we identified all patients younger than 18 years at our tertiary care facility who underwent pelvic MRI including coronal STIR for the following indications: acute hip pain, limping, or refusal to bear weight. Patients with a history of trauma were excluded. Each MR image was independently reviewed by four radiologists who were blinded to the clinical outcome. After first reviewing the coronal STIR images only, they then reviewed the full MRI studies in a random order different from that used for review of the coronal STIR images. The sensitivity and specificity of STIR-only images in identifying the presence of abnormality and specific diagnoses were calculated, with the full MRI study considered as the reference standard. Kappa values were calculated for STIR-only and full MRI studies. RESULTS: A total of 127 patients (67 female patients and 60 male patients; median age, 9 years; range, 5 months to 17 years) were identified. The most common abnormalities (calculated as the mean of frequency values noted by four readers) were hip effusion (52%; range, 46-58%), osteomyelitis (42%; range, 29-48%), and myositis (32%; range, 20-40%). For the detection of any abnormality, STIR-only images had a mean sensitivity of 95% and a mean specificity of 67%. For approximately one-third of STIR-only studies with true-positive results, additional abnormalities were found on full MRI studies. CONCLUSION: Coronal STIR imaging of the pelvis has high sensitivity (95%) in the detection of abnormalities associated with acute nontraumatic hip pain in children, but it often misses additional abnormalities.
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Artralgia/diagnóstico por imagem , Articulação do Quadril/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Adolescente , Criança , Pré-Escolar , Diagnóstico Diferencial , Feminino , Humanos , Lactente , MasculinoRESUMO
BACKGROUND: Colonic volvulus is rare in children and associated with colonic dysmotility. Diagnosis of colonic volvulus on radiographs in these patients can be challenging. The purpose of the study was to identify the accuracy of abdominal radiographs and findings suggestive of colonic volvulus. MATERIALS AND METHODS: A retrospective (2003- 2014) study of all children with colonic volvulus proven surgically or endoscopically reviewed their medical charts for underlying disease and clinical presentation as well as their original radiograph reports. Two pediatric radiologists (reader 1 and reader 2) independently reviewed the radiographs. The kappa test was used to evaluate interobserver variability. RESULTS: There were 19 cases of colonic volvulus in 18 patients (11 males) a mean age 14 years. Cecal volvulus was the most common finding at 14/19 cases (74%). Sixteen of 18 (89%) patients had neurological impairment and 10 of 18 (56%) had intestinal dysmotility. The most common presentation was abdominal distension (14/19 [74%]) and pain (11/19 [58%]). Colonic volvulus was diagnosed in only 7/16 (44%) of the abdominal radiographs. The specific finding of a coffee-bean sign was retrospectively observed only by reader 2 in two cases. Absence of rectal gas and focal colonic loop dilation were the most common findings by the readers (average 73.5% and 87%, respectively) with Kappa values of 0.3 and 0.38, respectively. CONCLUSION: Diagnosis of colonic volvulus in children can be challenging. Radiologists should be alerted to the possibility of colonic volvulus when there is focal colonic loop distention or absent rectal gas.
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Doenças do Colo/diagnóstico por imagem , Volvo Intestinal/diagnóstico por imagem , Radiografia Abdominal/métodos , Adolescente , Adulto , Criança , Colo/diagnóstico por imagem , Feminino , Humanos , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Adulto JovemRESUMO
BACKGROUND: Missing a fracture in a child on skeletal surveys for suspected non-accidental trauma can have devastating results. Double-read has the potential to improve fracture detection. However the yield of double-read is unknown. OBJECTIVE: To determine the advantage of double-read versus single-read of radiographic skeletal surveys for suspected non-accidental trauma. MATERIALS AND METHODS: The study was performed in two phases. In the first phase (April 2013 to September 2013), double-read was performed for all skeletal surveys obtained during weekday working hours. Because we had no new double-read findings in studies initially read as negative, we conducted a second phase (January 2014 to March 2014). In the second phase we limited double-reads to skeletal surveys found positive on the first read. At the end of this period, we retrospectively performed double-read for all initially negative skeletal surveys. We excluded follow-up skeletal surveys. The difference in discrepancy (new fracture or false diagnosis of a fracture) ratio between negative and positive skeletal surveys was evaluated using the Fisher exact test, and change in discrepancy ratio between the first and second study phases was evaluated using the stratified Cochran-Mantel-Haenszel test. RESULTS: Overall in the two phases, 178 skeletal surveys were performed in 178 children (67 girls) with mean age of 9 months (range 3 days to 3.7 years). Double-read found 16 discrepancies in 8/178 (4.5%) skeletal surveys. Seven of these studies showed additional fractures (n=15). In one study, an initial read of a skull fracture was read as a variant on the second read. There was a significant (P=0.01) difference between rate of disagreement in negative skeletal surveys (1/104, 1.0%) and positive skeletal surveys (7/74, 9.5%). No significant change in disagreement rate was demonstrated between the two phases of the study (P=0.59). CONCLUSION: Double-read of skeletal survey for suspected non-accidental trauma found false-negative fractures in a few cases and rarely found false-positive diagnosis of a fracture. Double-read uncommonly found discrepancies in an initially normal skeletal survey. Limiting double-read to initially positive studies improves the yield of the double-read.
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Maus-Tratos Infantis/diagnóstico , Erros de Diagnóstico/prevenção & controle , Fraturas Ósseas/diagnóstico por imagem , Radiografia/métodos , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
BACKGROUND: There is growing literature on the use of ultrasound (US) for evaluation of Crohn disease in adults, but few studies have been conducted on children. Several studies demonstrated high accuracy of US in the diagnosis of Crohn disease. Using US as the primary screening imaging modality for Crohn disease can reduce health care costs, the need for sedation and ionizing radiation exposure. OBJECTIVE: The aim of our study is to determine if US can be used for screening evaluation of pediatric Crohn disease. MATERIALS AND METHODS: A prospective cohort study of pediatric patients undergoing MR enterography (MRE) for suspected or known history of Crohn disease was performed, with gray-scale and Doppler US of the terminal ileum done immediately before or after MRE. US images were interpreted by two radiologists (Reader 1 and Reader 2) not involved in image acquisition, in blinded and randomized fashion. US findings of Crohn disease including bowel wall thickening, wall stratification, increased vascularity on Doppler, lymphadenopathy, fat infiltration and extraintestinal complications were evaluated. MRE findings of terminal ileitis were considered the reference standard. Demographic data, body mass index (BMI), symptoms, and laboratory, endoscopic and histopathological data were obtained from electronic medical records. RESULTS: Forty-one patients (mean age: 13.7 years: 4.6-18.9 years) were evaluated. Mean BMI was 21.2 (range: 13-40.2); 10 patients (24.3%) were either overweight or obese. Final diagnoses were Crohn disease (n=24), ulcerative colitis (n=4) and normal/non-inflammatory bowel disease-related diagnoses (n=13). US demonstrated sensitivity of 67% and 78% and specificity of 78% and 83%, by Reader 1 and Reader 2, respectively. MRE sensitivity and specificity were 75% and 100%, respectively, compared to final clinicopathological diagnosis. Interobserver agreement between Reader 1 and Reader 2 was good (0.6< kappa <0.8). CONCLUSION: In screening for Crohn disease in children, US has limited sensitivity for detecting terminal ileitis.
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Doença de Crohn/diagnóstico por imagem , Ultrassonografia/métodos , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Prospectivos , Sensibilidade e EspecificidadeAssuntos
Aspartato-Amônia Ligase/deficiência , Feto/diagnóstico por imagem , Microcefalia/diagnóstico , Adulto , Aspartato-Amônia Ligase/genética , Pré-Escolar , Diagnóstico , Feminino , Humanos , Indiana , Deficiência Intelectual/diagnóstico , Deficiência Intelectual/genética , Deficiência Intelectual/patologia , Imageamento por Ressonância Magnética , Masculino , Microcefalia/genética , Microcefalia/patologia , Paridade , Gravidez , Segundo Trimestre da GravidezRESUMO
OBJECTIVE: The purpose of our study was to determine whether adding oblique bilateral rib radiography to the skeletal survey for child abuse significantly increases detection of the number of rib fractures. MATERIALS AND METHODS: We identified all patients under 2 years old who underwent a skeletal survey for suspected child abuse from January 2003 through July 2011 and who had at least one rib fracture. These patients were age-matched with control subjects without fractures. Two randomized radiographic series of the ribs were performed, one containing two views (anteroposterior and lateral) and another with four views (added right and left oblique). Three fellowship-trained radiologists (two in pediatrics and one in trauma) blinded to original reports independently evaluated the series using a Likert scale of 1 (no fracture) to 5 (definite fracture). We analyzed the following: sensitivity and specificity of the two-view series for detection of any rib fracture and for location (using the four-view series as the reference standard), interobserver variability, and confidence level. RESULTS: We identified 212 patients (106 with one or more fractures and 106 without). The sensitivity and specificity of the two-view series were 81% and 91%, respectively. Sensitivity and specificity for detection of posterior rib fractures were 74% and 92%, respectively. There was good agreement between observers for detection of rib fractures in both series (average kappa values of 0.70 and 0.78 for two-views and four-views, respectively). Confidence significantly increased for four-views. CONCLUSION: Adding bilateral oblique rib radiographs to the skeletal survey results in increased rib fracture detection and increased confidence of readers.