Sonographic diagnosis of hypertrophic pyloric stenosis.

In many pediatric centers, sonography has become the primary imaging method for the diagnosis of hypertrophic pyloric stenosis, but investigators have disagreed about which dimension of the gastric outlet is most useful and accurate. We analyzed 326 consecutive sonograms in 319 infants who presented with vomiting in order to further evaluate the sonographic criteria for the diagnosis of hypertrophic pyloric stenosis. Four observers retrospectively measured three parameters: (1) the thickness of the muscle in the wall of the gastric outlet, (2) the length of that muscle, and (3) the length of the pyloric channel. In the patients with hypertrophic pyloric stenosis, muscle thickness was 4.8 +/- 0.6 mm, muscle length was 2.1 +/- 0.3 cm, and channel length was 1.8 +/- 0.3 cm. In the patients without hypertrophic pyloric stenosis, muscle thickness was 1.8 +/- 0.4 mm, muscle length was 1.3 +/- 0.3 cm, and channel length was 1.1 +/- 0.3 cm. The mean measurement for each parameter was significantly larger in patients who had hypertrophic pyloric stenosis than in those who did not (p less than .01). However, histograms of the three parameters show significant overlap in the measurements of muscle length and channel length between the patients with and those without hypertrophic pyloric stenosis. The thickness of the muscle is the most discriminating and accurate criterion for hypertrophic pyloric stenosis.

Sonographic evaluation of abdominal lymphangiomas in children.

Sonography provided an accurate diagnosis in 10 preoperative studies and correctly showed the extent of the lesions in two postoperative examinations in a group of 12 children with surgically proven intraabdominal lymphangiomas. These masses typically contained anechoic fluid in one or more contiguous cystic loculations bounded by or containing one or more 1- to 2-mm thick septa. Thicker septa occurred in several cases with inflammation and/or accumulations of fatty tissue. Chylous or creamy fluid displayed fine diffuse echoes, whereas hemorrhage resulted in coarse echoes and/or solid masses. In two patients unusual renal involvement mimicked polycystic kidney disease. Typical sonographic appearances of lymphangioma may be radically altered by hemorrhage, inflammation, and unusual sites of involvement.

Atlantooccipital instability in Down syndrome.

Atlantooccipital instability is an uncommon and usually lethal result of major trauma. Nontraumatic cases of instability at this site are rare. We report the findings in two children with Down syndrome who have striking atlantooccipital subluxation demonstrated on flexion and extension radiographs. Since there is increasing radiologic evaluation of cervical spine stability in patients with Down syndrome who wish to participate in athletic activities, the status of the atlantooccipital joint needs careful assessment, especially after cervical fusion for C1-C2 instability.

Acute epiphyseal osteomyelitis in children.

Nine children over 20 months of age had acute osteomyelitis of the epiphysis of a long bone. The clinical features varied, but all of the patients had pain at the infected site and an elevated erythrocyte sedimentation rate. The distal femur was involved in seven cases, the proximal tibia in two, and the proximal humerus in one. In two patients there was a contiguous metaphyseal lesion, while the other seven patients (eight sites) had lesions limited to the epiphysis. Bone scintigraphy clearly identified the infected sites in all seven patients in whom it was performed, and allowed an early diagnosis in four cases. Radiographs showed a lytic lesion of the epiphysis that corresponded to the scintigraphic findings in all cases. The vascular supply to the epiphysis and the microscopic structure of the epiphyseal venous sinusoids provide locations that favor lodgement of blood-borne organisms. The epiphysis of the child should be recognized as another site of hematogenous osteomyelitis.

Abnormalities of the neonatal cerebral ventricles.

High-resolution ultrasonography allows accurate assessment of ventricular size and contour in the infant, so that conditions such as hydrocephalus, holoprosencephaly, and agenesis of the corpus callosum can be diagnosed. Ventricular shunt catheter placement can be guided, and some of the complications of cerebrospinal fluid shunt systems can be identified. Infection of the ventricular fluid causes striking findings, including increased echogenicity and septation within the lumen.

Arteriohepatic dysplasia: phenotypic features and family studies.

Arteriohepatic dysplasia (AHD) is a disorder characterized by intrahepatic cholestasis and peripheral pulmonary artery stenosis. We have reviewed the phenotypic features in the 56 previously reported cases and 7 persons from our institutions with AHD to summarize the type of cardiac, hepatic, facial, ocular and skeletal manifestations observed in this disorder. Family studies evaluating first-degree relatives of patients with AHD are compatible with an autosomal dominant mode of inheritance with reduced penetrance and variable expressivity.

Herpes simplex viral pneumonitis in childhood.

We report two cases of herpes simplex pneumonia in children. One patient had Down syndrome, and the other was immunosuppressed by cancer therapy. Both had interstitial pneumonitis with nonspecific physical, radiographic, and laboratory findings, and both died. The diagnosis of herpes simplex pneumonia was made by isolation of herpes simplex virus from autopsy lung cultures as well as by demonstration of antigen in the tissue with an immunoperoxidase procedure. Inasmuch as herpes simplex pneumonia is a potentially treatable infection, early virologic studies are recommended in immunocompromised children with progressive pneumonitis of undetermined cause.

Congenital hydrocephalus due to prenatal intracranial hemorrhage.

A 3,400-g female neonate with a large head, widened sutures, and full fontanels at the time of her delivery by cesarean section is described. Imaging with ultrasound and computed tomography at 24 and 36 hours of age showed findings typical of hydrocephalus caused by intraventricular hemorrhage occurring several days or more prior to birth. There was no direct evidence of any predisposing vascular lesion or coagulopathy. Such a phenomenon has not been previously reported.

Echographic demonstration of extracerebral fluid collections with the lateral technique.

The authors describe the technique of real-time sector scanning in the coronal plane through the side of the head to visualize the opposite cerebral convexity. This lateral technique utilizes the temporal squama and/or coronal suture as windows, and often requires the use of a 3.0-MHz transducer. Several cases illustrate extracerebral fluid or echogenic blood collections in which the lateral technique added useful information not shown by standard imaging through the anterior fontanelle. Four of the fluid collections were not visible with standard imaging techniques. The lateral technique appears to be a useful addition to the cranial echogram.

Family studies in tuberous sclerosis. evaluation of apparently unaffected parents.

A family study was conducted to evaluate the apparently unaffected parents of 13 patients with tuberous sclerosis. None of the parents had a personal or family history suggesting the diagnosis of tuberous sclerosis. All 26 parents were examined according to a protocol that entailed medical history, physical examination (including Wood's lamp examination of the skin), funduscopic examination through a dilated pupil, roentgenograms of the hands, feet, and skull, renal ultrasound studies, and cranial computed tomography (CT). In these 13 families, three fathers and one mother had previously undiagnosed tuberous sclerosis. Three of the four had skin changes, three had calcifications shown by CT, and one had renal cysts. These data demonstrate the importance of detailed examination of all parents of patients with tuberous sclerosis before recurrence-risk counseling is given.

Muscle thickness in hypertrophic pyloric stenosis: sonographic determination.

Abdominal sonography was performed in 169 infants with vomiting. The hypertrophied circular muscle of the pylorus and distal antrum could be seen as a thick, hypoechoic cylinder in all cases of hypertrophic pyloric stenosis. The thickness of each wall of this cylinder was 4 mm or more in 86 of 93 patients subsequently shown to have hypertrophic pyloric stenosis at surgery. None of the patients without stenosis displayed this finding on sonography. Although technically demanding, sonographic imaging with a high-frequency system (7 MHz or more) can be an accurate initial examination for hypertrophic phyloric stenosis.

Ultrasound in the diagnosis of hypertrophic pyloric stenosis.

Abdominal B-scan ultrasound imaging was performed on 35 infants who presented with vomiting. A thick hypoechoic ring was visualized in 21 of the 23 patients found at surgery to have hypertrophic pyloric stenosis. The ring was shown to represent the hypertrophied circular muscle of the pylorus. Each side of the ring measured 4 mm or more in thickness in the positive studies. None of the patients without hypertrophic pyloric stenosis showed this finding, although thinner hypoechoic rings were often seen, representing parasagittal sections of distal antral muscle.

Gastroesophageal reflux in children: radionuclide gastroesophagography.

Sixty-five symptomatic infants and children underwent radionuclide gastroesophagography, acid reflux testing, and barium esophagography with water-siphon testing to evaluate the clinical efficacy of the scintigraphic technique in detecting gastroesophageal reflux. After ingesting 99mTc sulfur colloid in fruit juice, patients rested beneath the gamma camera for 30-60 min while esophageal activity was monitored continuously. By using the acid reflux test as a standard of comparison, the sensitivity of radionuclide gastroesophagography was 75%. Because of its physiologic nature, low radiation exposure, and convenience, radionuclide gastroesophagography warrants further evaluation as a screening test for gastroesophageal reflux.

Endotracheal foreign bodies. Difficulties in diagnosis.

The diagnosis of foreign body aspiration into the lower airway depends primarily on the radiographic demonstration of partial bronchial obstruction causing localized air trapping or atelectasis, present in 95 per cent of the cases. Endotracheal foreign bodies may often be visualized directly on high kilovoltage radiographs of the airway of the airway or by fluoroscopy. In three of the four cases presented in this report, radiologic evaluation was normal, but endotracheal foreign bodies were subsequently demonstrated endoscopically. Foreign objects may remain in the trachea for prolonged periods of time, causing persistent coughing, wheezing, or stridor. When there is a clear history or strong suspicion of foreign body aspiration in a patient with persistent symptoms, bronchoscopy should be used for diagnosis and treatment.