Imaging trends and radiation exposure in pediatric inflammatory bowel disease at an academic children's hospital.

OBJECTIVE: The purpose of this study was to retrospectively evaluate diagnostic imaging trends and radiation exposure in pediatric inflammatory bowel disease (IBD) at a U.S. academic children's hospital between 2001 and 2010. MATERIALS AND METHODS: Pediatric IBD patients within our health system during the 2001, 2006, and 2010 calendar years were identified. The number of abdominopelvic radiologic and endoscopic examinations (total and by modality) performed during each 1-year-period was recorded for each subject. Means were compared using the Wilcoxon rank sum test. The cumulative lifetime number of diagnostic examinations by modality and estimated effective radiation dose (using Monte Carlo simulation software and CT dose-length product values) was calculated for the 2010 IBD subject cohort. RESULTS: There was a 53% increase in the average number of abdominopelvic diagnostic examinations obtained per pediatric IBD patient comparing 2001 with 2010 (1.29 ± 2.19 vs 1.98 ± 3.46, p = 0.004). Abdominal radiography (p = 0.02), MRI (p < 0.0001), and esophagogastroduodenoscopy (EGD) (p = 0.01) showed significantly increased use. The increase in use of CT and ileocolonoscopy was not significant (p > 0.05). There was significantly reduced use of contrast enema, small-bowel follow-through (SBFT), and upper gastrointestinal (UGI) series (all, p < 0.0001). The average pediatric IBD patient seen in 2010 (mean age, 13.9 years) had undergone 1.08 CT, 0.82 MRI, 1.36 abdominal radiographic, 0.14 contrast enema, 0.52 SBFT, 0.54 UGI, 1.00 ileocolonoscopy, and 0.72 EGD examinations during his or her lifetime, with an average cumulative lifetime estimated effective radiation dose of 4.6 mSv. CONCLUSION: Although the number of yearly diagnostic examinations performed for pediatric IBD patients increased significantly between 2001 and 2010, the cumulative lifetime estimated effective radiation dose is relatively low in most of these patients.

Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception.

BACKGROUND: From the early 1980s onward, US has been considered a possible primary modality to assess patients for ileocolic intussusception. Since 2001, our institution has routinely used US to assess patients for ileocolic intussusception. OBJECTIVE: We analyzed 7 years of institutional experience to assess the value of US as a primary diagnostic test for intussusception. MATERIALS AND METHODS: This study was IRB-approved. From 1 January 2001 through 16 December 2007 814 US examinations for intussusception were performed in children aged 10 years and younger. Clinical records and radiological reports were reviewed for each patient, and cases were classified as true-positive, true-negative, false-positive, or false-negative. RESULTS: Of the 814 US examinations, 112 (13.8%) were interpreted as positive for intussusception, and of these, 96 were confirmed by enema, 1 was confirmed by surgery, and 15 (13.4%) were false-positive. Of the 814 examinations, 700 (85.9%) were interpreted as negative for intussusception, and of these, 698 (99.7%) were true-negative, and 2 were false-negative. Less than 1% of studies were nondiagnostic. The overall sensitivity of US for detecting intussusception was 97.9% and specificity was 97.8%. The positive predictive value of the test was 86.6% and the negative predictive value was 99.7%. CONCLUSION: US is a sensitive and specific test for detecting ileocolic intussusception and should be utilized as a first-line examination for assessment of possible pediatric intussusception.

Intramural and subserosal echogenic foci on US in large-bowel intussusceptions: prognostic indicator for reducibility?

BACKGROUND: In large-bowel intussusceptions, several US signs are known to indicate a lower likelihood of reducibility by enema. US can demonstrate echogenic dots or lines (foci) in the bowel wall, which might indicate an ischemic bowel. OBJECTIVE: To determine the presence of echogenic intramural and subserosal foci in large-bowel intussusceptions and to evaluate the degree of correlation with reducibility. MATERIALS AND METHODS: Between 2001 and 2008, 74 consecutive US examinations were retrospectively evaluated by two pediatric radiologists for intramural and subserosal echogenic foci, or trapped gas, in the intussusception. The degree of correlation between the sonographic findings and reducibility was evaluated. RESULTS: Of 73 intussusceptions examined by US, 56 (76%) were reducible and 17 (23%) were not reducible. Out of 10 intussusceptions with intramural gas, 11 with subserosal gas, and 14 with intramural and subserosal gas, 8 (80%), 6 (56%), 9 (64%), respectively, were not reducible. The presence of intramural gas or subserosal gas or both predicted a lower chance of reduction, but with regard to the effect of these findings together, intramural gas was the only significant predictor. CONCLUSION: Having intramural gas in large-bowel intussusception significantly decreases the chance of reduction.

Imaging of total colonic Hirschsprung disease.

BACKGROUND: Hirschsprung disease (HD) is a functional obstruction of the bowel caused by the absence of intrinsic enteric ganglion cells. The diagnosis of total colonic HD (TCHD) based on contrast enemas is difficult in newborns because radiological findings vary. OBJECTIVE: To evaluate the radiographic and contrast enema findings in patients with pathologically proven TCHD. MATERIALS AND METHODS: From 1966 to 2007, 17 records from a total of 31 patients with TCHD were retrospectively evaluated for diameter and shape of the colon, diameter of the small bowel, bowel wall contour, ileal reflux, abdominal calcifications, pneumoperitoneum, filling defects, transitional zones and rectosigmoid index. RESULTS: Three colonic patterns of TCHD were found: microcolon, question-mark-shape colon and normal caliber colon. Additional findings included spasmodic colon, ileal reflux, delayed evacuation and abdominal calcifications. Colonic transitional zones were found in eight patients with TCHD. CONCLUSION: The diagnosis of TCHD is difficult to establish by contrast enema studies. The length of the aganglionic small bowel and the age of the patient can influence the radiological findings in TCHD. The transitional zone and the rectosigmoid index can be false-positive in TCHD. The colon can appear normal. Consider TCHD if the contrast enema study is normal but the patient remains symptomatic and other causes of distal bowel obstruction have been excluded.

Parenteral nutrition-associated cholestasis in neonates: multivariate analysis of the potential protective effect of taurine.

BACKGROUND: Neonates receiving parenteral nutrition (PN) are at risk for PN-associated cholestasis (PNAC); however, no preventive factors for PNAC have been clearly identified. Despite reports suggesting that taurine may prevent PNAC in neonates, such an effect of taurine has not yet been definitively demonstrated. We determined whether taurine supplementation reduces the incidence of PNAC in premature or critically ill neonates. METHODS: This study was part of a prospective, randomized, multi-institutional trial designed to assess cholecystokinin vs placebo as a potential preventive therapy of PNAC. Taurine supplementation of PN varied between institutions. The presence or absence of taurine in PN was analyzed by multivariate analysis, with a primary outcome measure of serum conjugated bilirubin (CB) as a measure of PNAC. RESULTS: Taurine reduced PNAC in premature infants (estimated maximum CB [95% confidence interval] 0.50 mg/dL [-0.17 to 1.18] for those receiving taurine, vs 3.45 mg/dL [1.79-5.11] for neonates not receiving taurine, approaching significance, p = .07). Taurine significantly reduced PNAC in infants with necrotizing enterocolitis (NEC; estimated maximum CB 4.04 mg/dL [2.85-5.23], NEC infants receiving taurine, vs 8.29 mg/dL [5.61-10.96], NEC infants not receiving taurine, p < .01). There were too few neonates with surgical anomalies to evaluate the effect of taurine in this group. CONCLUSIONS: Within specific subgroups of neonatal patients, taurine supplementation does offer a very significant degree of protection against PNAC. Patients with NEC or severe prematurity are most likely to benefit substantially from taurine supplementation.

Use of cholecystokinin-octapeptide for the prevention of parenteral nutrition-associated cholestasis.

OBJECTIVE: To determine whether cholecystokinin-octapeptide (CCK-OP) would prevent or ameliorate parenteral nutrition-associated cholestasis (PNAC) among high-risk neonates treated with total parenteral nutrition. STUDY DESIGN: This was a multicenter, double-blind, randomized, controlled trial conducted between 1996 and 2001. PATIENTS: Neonates at risk for the development of PNAC included very low birth weight neonates and those with major surgical conditions involving the gastrointestinal tract. SETTING: Tertiary care hospitals. INTERVENTION: Patients were randomized to receive CCK-OP (0.04 mug/kg per dose, twice daily) or placebo. Eligible infants were all <30 days of age. Patients were enrolled within 2 weeks after birth or within 7 days after surgery. OUTCOME MEASURES: The primary outcome measure was conjugated bilirubin (CB) levels, which were measured weekly. Secondary outcome measures included incidence of sepsis, times to achieve 50% and 100% of energy intake through the enteral route, number of ICU and hospital days, mortality rate, and incidences of biliary sludge and cholelithiasis. RESULTS: A total of 243 neonates were enrolled in the study. CCK-OP administration did not significantly affect CB levels (1.76 +/- 3.14 and 1.93 +/- 3.31 mg/dL for CCK-OP and placebo groups, respectively; mean +/- SD). Secondary outcome measures also were not significantly affected by the study drug. CONCLUSIONS: Use of CCK-OP failed to reduce significantly the incidence of PNAC or levels of CB. CCK-OP had no effect on other secondary measures and should not be recommended for the prevention of PNAC.

Congenital short-gut syndrome.

A case of congenital short gut is reported in a 4-month-old boy presenting with failure to thrive. Upper gastrointestinal examination (UGI) with small bowel follow-through (SBFT) demonstrated dilation of the duodenum and jejunum, with rapid transit to rectum. On barium enema (BE), rapid transit of barium was noted to the dilated proximal small bowel seen on UGI/SBFT. Neither study delineated the ileocecal region, and the overall length of bowel appeared short. The diagnosis of congenital short gut was confirmed at surgery. Congenital short-gut syndrome is a rare entity. The diagnosis can be suggested by imaging, but is usually confirmed operatively.

The effect of screening sonography on the positive rate of enemas for intussusception.

BACKGROUND: The referring physicians at our institution used the enema as a diagnostic test in children with suspected intussusception. OBJECTIVE: To determine the change in rate of positive enema findings performed for suspected intussusception with the intervention of screening ultrasound (US). MATERIALS AND METHODS: Since October 1995, 224 children (mean age 2.2 years) with suspected intussusception were referred for enema examination. In January 2001, US was introduced as a screening test for intussusception. Enemas were performed for all children with positive US findings and were offered for those with negative US findings if clinical suspicion persisted. RESULTS: Before 2001, 184 children underwent enema with intussusception documented in 40 (22%). Since January 2001, 40 children have been seen with suspected intussusception (12/40 positive or 30%). Two directly underwent enema (1/2 positive); 38 children underwent US. In 12 of 38 children, the US finding was positive, and an intussusception was found at enema examination in 11 of 12. In 26 cases, the US finding was negative. Seven of the 26 children with a negative sonogram finding had an enema, which was also negative. Nineteen enemas were canceled. With a screening US, the positive rate for enemas is now 58% (11/19). We know of no case of intussusception missed at US. CONCLUSION: Screening US has decreased unnecessary enemas for clinically suspected intussusception, increasing positive findings from 22% to 58%. This has in turn reduced children's exposure to radiation.