Imaging of chronic inflammatory bowel disease with 18F-FDG PET in children and adolescents.

Standard for diagnosis of inflammatory bowel disease (IBD) is the endoscopy of the stomach and the intestine. Aim of this study was to determine the value of 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) in pediatric patients with mild to moderate IBD.We included 23 children and adolescents between 8 and 17 years (median 15 years, 13 boys, 10 girls) in this retrospective study in a routine clinical setting. Diagnoses were Crohn's disease in 19 and ulcerative colitis in 4 cases.3 children had a conventional FDG-PET, 20 patients a combined FDG-PET-computed tomography exam. All children had upper and lower intestinal endoscopy with biopsy and a Hydro-MRI exam to assess the jejunum and proximal ileum. The gastrointestinal tract was divided in 7 segments: Stomach plus duodenum, jejunum and proximal ileum, terminal ileum, cecum plus ascending colon, transverse colon, descending colon, and rectosigmoid.Superficial gastric lesions were missed, gastric ulcerations were detected. For the stomach, the sensitivity was 0.25, the specificity was 1.00, the positive predictive value was 1.00, for the lower intestine (terminal ileum and colon) the values were 0.74, 0.88, and 0.96; for the terminal ileum 0.89, 0.75 and 0.94, respectively.The sensitivity and specificity for of ileal and colonic lesions is high. FDG-PET has to be discussed as a tool for the determination of extent and degree of inflammation, especially in those parts of the small bowel that are not accessible to endoscopy. This has to be weighed against the additional radiation exposure administrated.

Standard value of ultrasound elastography using acoustic radiation force impulse imaging (ARFI) in healthy liver tissue of children and adolescents.

PURPOSE: Ultrasound elastography by acoustic radiation force impulse imaging (ARFI) is used in adults for non invasive measurement of liver stiffness, indicating liver diseases like fibrosis. To establish ARFI in children and adolescents we determined standard values of healthy liver tissue and analysed potentially influencing factors. MATERIALS AND METHODS: 132 patients between 0 and 17 years old were measured using ARFI. None of them had any liver disease or any other disease that could affect the liver secondarily. All patients had a normal ultrasound scan, a normal BMI and normal liver function tests. The mean value of all ARFI measurements was calculated and potentially influencing factors were analysed. RESULTS: The mean value of all ARFI elastography measurements was 1.16 m/sec (SD ±â€Š0.14 m/sec). Neither age (p = 0.533) nor depth of measurement (p = 0.066) had no significant influence on ARFI values, whereas a significant effect of gender was found with lower ARFI values in females (p = 0.025), however, there was no significant interaction between age groups (before or after puberty) and gender (p = 0.276). There was an interlobar difference with lower values in the right liver lobe compared to the left (p = 0.036) and with a significantly lower variance (p < 0.001). Consistend values were measured by different examiners (p = 0.108), however, the inter examiner variance deviated significantly (p < 0.001). CONCLUSION: ARFI elastography is a reliable method to measure liver stiffness in children and adolescents. In relation to studies which analyse liver diseases, the standard value of 1.16 m/sec (±â€Š0.14 m/sec) allows a differentiation of healthy versus pathological liver tissue.

Partial splenic embolization as an alternative to splenectomy in hypersplenism--single center experience in 16 years.

PROBLEM: In young patients with hypersplenism splenectomy implies a lifelong increased risk for post-splenectomy infection. Especially in children, whose immune system is not yet completely matured, the risk for some bacterial infection may increase after splenectomy because the spleen helps to defend against encapsulated bacteria like pneumococci, meningococci and haemophilus influenzae. We present partial splenic embolization as an alternative to surgical splenectomy. METHOD: Partial splenic embolization was performed in 17 patients from 1-31 years with hypersplenism of various etiologies and was achieved by selective catheterization of splenic arteries and injection of 150-355 µm polyvinyl alcohol particles (Ivalon (®)). After the intervention the patients received an intensified analgesic regimen and antibiotics to avoid concurrent infectious complications. RESULTS: Partial splenic embolization represented between 30-60% of the splenic volume and was followed in general by an immediate increase of all blood cells and symptoms of hypersplenism were reduced. In 2 patients the procedure was repeated because the result of the first embolization was insufficient in one patient and became necessary in another in the long run. Post-procedural side effects included fever, abdominal pain, ascites and pleural effusions. There were no acute infections in any patient. CONCLUSION: Our monoinstitutional experiences over 16 years offer, partial splenic embolization in patients with hypersplenism from miscellaneous reasons as a low-risk alternative to surgical splenectomy. The procedure can be repeated as necessary, but it is always a temporary palliation depending on the underlying disease which often leads to liver transplantation. Using intensive analgesia and antibiotics side effects were tolerable, and patients could be discharged after a few days.

An inflammatory myofibroblastic tumor of the stomach as a rare cause of gastric outlet obstruction in an 8-month-old infant.

Inflammatory myofibroblastic tumors (IMT) are a rare entity. Localization in the stomach is extremely seldom and almost exclusively seen in children. Invasive growth of IMT may lead to irresectability or recurrence. In an 8-month-old girl presented with repetitive vomiting for several days. Complete surgical resection of a gastric IMT was possible.

[Trabecular bone mineral density measured by quantitative CT of the lumbar spine in children and adolescents: reference values and peak bone mass]. / Trabekuläre Knochendichte der Lendenwirbelsäule bei Kindern und Jugendlichen in der quantitativen CT: Referenzwerte und Peak Bone Mass.

PURPOSE: The aim of this study was to assess bone density values in the trabecular substance of the lumbar vertebral column in children and young adults in Germany from infancy to the age of peak bone mass. MATERIALS AND METHODS: We performed quantitative computed tomography (QCT) on the first lumbar vertebra in 28 children and adolescents without diseases that may influence bone metabolism (15 boys, 13 girls, mean ages 11 and 8 years, respectively). We also measured 17 healthy young adults (9 men, 8 women, mean ages 20 and 21 years). We used a Somatom Balance Scanner (Siemens, Erlangen) and the Siemens Osteo software. Scan parameters: Slice thickness 1 cm, 80 kV, 81 or 114 mAs. We measured the trabecular bone density and the area and height of the vertebra and calculated the volume and content of calcium hydroxyapatite (Ca-HA) in the trabecular substance of the first lumbar vertebra. RESULTS: Prepubertal boys had a mean bone density of 148.5 (median [med] 150.1, standard deviation [SD] 15.4) mg/Ca-HA per ml bone, and prepubertal girls had a mean density of 149.5 (med 150.8, SD 23.5) mg/ml. We did not observe a difference between prepubertal boys and girls. After puberty there was a significant difference (p < 0.001) between males and females: Mean density (male) 158.0, med 162.5, SD 24.0 mg/ml, mean density (female) 191.2, med 191.3, SD 17.7 mg/ml. The Ca-HA content in the trabecular bone of the first lumbar vertebra was 1.1 (med 1.1, SD 0.5) g for prepubertal boys and 1.1 (0.9, 0.4) g for prepubertal girls. For post-pubertal males, the mean Ca-HA content was 3.5 g, med 3.5, SD 0.5 g, and for post-pubertal females, the mean content was 2.8, med 2.7, SD 0.4 g. CONCLUSION: The normal trabecular bone mineral density is 150 mg/ml with a standard deviation of 20 mg/ml independent of age or gender until the beginning of puberty. Peak bone mass (bone mineral content) in the trabecular substance of the lumbar vertebral column is higher in males than in females, and peak bone density is higher in young female adults than in young male adults.

[Assessment of bone density in children and adolescents by quantitative CT of one lumbar vertebra only]. / Messung der Knochendichte bei Kindern und Jugendlichen mittels quantitativer CT an nur einem Lendenwirbelkörper.

AIM: The aim of this study was to determine whether measuring the trabecular bone density in one lumbar vertebra (L) instead of three has an effect on the assessment of bone density in children. MATERIALS AND METHODS: Bone density was measured in 70 patients (38 male, 32 female), ages 1 to 22 years (mean age 12.4, median 13 years) using a Somatom Balance Scanner (Siemens). The trabecular bone density was measured (1-cm slice, 80 kV, 81 mAs) in L1 through L3. RESULTS: The mean bone density in the lumbar vertebrae was 139.9 mg/ml calcium-hydroxylapatite per ml bone in L1, 133.9 in L2, and 131.7 in L3, and the mean of all three vertebrae was 135.2 mg/ml. Measurements in L1 were 4.7 mg/ml (standard deviation [SD] 4.7 mg/ml) above the mean value of the three upper lumbar vertebrae. The density in L2 was 1.3 mg/ml below the mean (SD 3.1 mg/ml). On average, L3 was 3.5 mg/ml below the mean (SD 4.6 mg/ml). This minor systematic deviation in the measurement values for the individual vertebrae from the mean value was so low that there was no statistical evidence for a deviation from an ideal regression line. CONCLUSIONS: When using an adequate technique, especially accurate analysis of the topogram (scout view) and the tomogram, measurement of the bone density of one lumbar vertebra provides satisfactory information regarding the trabecular bone density in children, but the values differ in the three upper lumbar vertebrae. The bone density of L2 is close to the mean of the upper three vertebrae. In the case of pathologic values or a pathologic trabecular pattern, three vertebrae should be measured.

[Sonography of the optical nerve -- experience in 483 children]. / Die Sonographie des Nervus opticus -- Erfahrungen bei 483 Kindern.

INTRODUCTION: In case of increased intracranial pressure (IICP), the inflow of cerebrospinal fluid widens the space between the optic nerve (ON) itself and the surrounding dura mater leading to the sonographic appearance of increased diameter of the ON. The purpose of the study was to gain clinical experience in children and to determine (a) the mean values for patients without proven IICP and (b) pathologic values of those with proven IICP. MATERIALS AND METHODS: Ultrasound of the optic nerve was performed in 483 children with symptoms consistent with IICP, comprising 287 males and 196 females at an age ranging from 4 days to 24 years with a mean age of 7.5 + 5.1 years. The measured diameter of the ON of both eyes and the morphologic criteria concerning nerve sheath and papilla were evaluated retrospectively. RESULTS: Most of the investigated patients (n = 466) had no IICP as confirmed by neurological examination, EEG, sometimes CCT and/or MRI and clinical follow-up. The typical morphological findings in patients with normal intracranial pressure (ICP) were a clear and longitudinally extended demarcation of the ON with a well-delimited nerve sheath and without prominent papilla. The mean diameter of the ON in patients with normal ICP was 3.4 mm + 0.7 mm. In 17 patients with proven IICP, the mean diameter of the ON increased to 5.6 mm + 0.9 mm. Typically, the nerve sheath was indistinguishable from the hypoechoic ON, often but not invariably associated with a prominent papilla. In patients with IICP, the diameter of the ON alone matches the diameter of the ON plus nerve sheath in patients with normal ICP. CONCLUSION: IICP was detected with a high sensitivity by ultrasound using the diameter and the morphological criteria of an indistinguishable nerve sheath. A diameter of more than 4.5 mm is definitely pathologic and requires further investigation. Prominence of the papilla is an unreliable criterion for acute IICP.

Inflammatory reaction and capillary leak syndrome related to cardiopulmonary bypass in neonates undergoing cardiac operations.

We studied the inflammatory reaction related to cardiopulmonary bypass in 24 neonates (median age 6 days) undergoing the arterial switch operation for simple transposition of the great arteries, with respect to the development of postoperative capillary leak syndrome. Complement proteins, leukocyte count, tumor necrosis factor-alpha, and histamine levels were determined before, during, and after cardiopulmonary bypass. Additionally, protein movement from the intravascular into the extravascular space during cardiopulmonary bypass was assessed by the measurement of plasma concentrations of proteins with molecular weights ranging from 21,200 to 718,000. Capillary leak syndrome developed in 13 of the 24 neonates. Patients with capillary leak syndrome, as compared with those without, had preoperatively higher C5a levels (C5a, 3.0 +/- 0.6 microgram/L vs 0.9 +/- 0.2 microgram/L) (mean +/- standard error of the mean) (p < 0.05) and higher leukocyte counts (leukocytes, 17.9 +/- 2.1 X 10(3) cells/ml versus 11.7 +/- 0.8 X 10(3) cells/ml) (p < 0.05), suggesting in these neonates a preoperative inflammatory state. Preoperative clinical and operative data were identical in both patient groups. Before cardiopulmonary bypass, serum protein concentrations were similar in all patients. Ten minutes after institution of cardiopulmonary bypass, protein concentrations fell to significantly lower values in patients with capillary leak syndrome than in those without: albumin (19% +/- 1.5% vs 30% +/- 6% of the prebypass value, p < 0.05), immunoglobulin G (17% +/- 1.5% vs 29% +/- 5.5%, p < 0.001), and alpha 2-macroglobulin (15% +/- 1.2% vs 25% +/- 4%, p < 0.02). During cardiopulmonary bypass, albumin concentrations remained significantly lower in patients with capillary leak syndrome than in those without, whereas hematocrit values were similar in both groups. During cardiopulmonary bypass, patients with capillary leak syndrome also had lower concentrations of complement proteins C3 and C4 but not C1 inhibitor. C3d/C3 ratio and C5a levels were similar in both patient groups. In contrast, histamine liberation during cardiopulmonary bypass was significantly more pronounced in patients with capillary leak syndrome than in those without (725.2 +/- 396.7 pg/ml vs -54.1 +/- 58.4 pg/ml, p < 0.05). Tumor necrosis factor-alpha levels after protamine administration were also significantly higher in patients with capillary leak syndrome (38.1 +/- 10.0 pg/ml vs 15.3 +/- 3.4 pg/ml, p < 0.05). Leukocyte count during and after cardiopulmonary bypass was similar in both patient groups. This study demonstrates increased protein leakage as early as 10 minutes after initiation of.

[Sonographic detectability of narcotic drug containers in the gastrointestinal tract. Experimental research in the dog]. / Sonographische Nachweisbarkeit von Betäubungsmittelbehältnissen im Gastrointestinaltrakt. Experimentelle Untersuchung beim Hund.

A "body-pack" is a swallowed plastic or rubber container used by drug smugglers to carry drugs. We report our experience in diagnoses of such packs in vivo. We simulated the pack by stuffing a fingerstall of a latex handglove with a mixture of 10% barium powder and flour to render it radiopaque. Eight serial examinations were made. In each series, an adult Alsatian dog was fed upto 10 such "body-packs". The passage of these packs through the gastrointestinal tract was followed with ultrasound examinations made at 2, 24, and 48 hours postprandially. Immediately after each sonographic localisation of "body-pack" was made, an x-ray examination of the abdomen in this region was also carried out. Ultrasound correctly determined the position of the "body-pack" in 20 out of 24 examinations as compared to x-ray results. In 4 cases ultrasound could not confirm the location of the "pack".

[The renaissance of simultaneous tomography with the fluorescent-film storage system]. / Renaissance der Simultantomographie mit dem Speicherleuchtstoffoliensystem.

The handling, technical and exposure details of digital simultaneous tomography are explained, while particular emphasis is placed on image quality. Selected case reports demonstrate the application of this technique by using the digital storage fluorescent system (Fa. Siemens, Erlangen). Simultaneous tomography with storage fluorescent screens is particularly suitable to demonstrate or exclude osseous findings at the skull, the column and large joints.

[Development of a tissue-equivalent plastic block for the sonographic diagnosis of regions near to the skin]. / Entwicklung einer gewebeäquivalenten Kunststoffvorlaufstrecke für die sonographische Diagnostik hautnaher Bereiche.

A very soft and homogeneous plastic material has been developed from polyvinyl chloride with acoustic properties similar to those of human tissue. During an evaluation period of nine months, the material has proved excellent for the sonographic investigation of subcutaneous tissue, even at high frequencies. Significant advantages of the new material as compared with previously available substances depend on its stability, low sound attenuation and absence of reverberations. In order to achieve these desirable properties, twenty plasticisers of different type and concentration were used and the resulting compounds examined for their acoustic properties.

[Digital subtraction angiography with carbon dioxide using a new gas dosage system]. / Digitale Subtraktionsangiographie mit Kohlendioxid unter Verwendung eines neuen Gasdosiersystems.

PURPOSE: The clinical evaluation of digital subtraction angiography with carbon dioxide using a newly developed low-tech CO2 dosage and injection system. METHOD AND PATIENTS: The hand-held system (CO2 angio set) consists of a dosage chamber in connection with a special stopcock to apportion the gas. By optimising injection volume and pressure steady gas flow characteristics are approximated. A safety design prevents unintentional gas injection. CO2 arteriographies were performed on 185 patients. Main indications were renal insufficiency and a history of adverse reactions to iodinated contrast media. In patients with femoral cannula access, catheterless reflux angiography was performed. RESULTS: The injection system provided complete and coherent visualisation of the abdominal aorta, visceral, pelvic, and lower limb arteries via catheter (71 cases) or via femoral cannula using reflux technique (114 cases). Stenoses, occlusions, and collaterals were assessable. Employing the gas reflux over the aortic bifurcation bilateral run-off studies up to the calf trifurcation were performed via unilateral femoral cannula. Use of a dedicated stacking software improved image quality of distal femoral, popliteal and calf arteries. CONCLUSION: The CO2 management system allows adequate imaging of the arteries below the diaphragm. Ease and safety of use and low costs are advantageous.

[Catheterization of the nasolacrimal duct]. / Sondierung des Ductus nasolacrimalis.

A technique is described for passing a guide wire through the lacrimal duct into the nose following catheterisation of the duct. The wire is passed into the pharynx, a 7 F feeding tube is passed through the nose into the pharynx and these are then pulled out of the mouth with a Magill forceps. The tip of the feeding tube is then cut off and the guide wire introduced into a side hole of the catheter. By removing the catheter, the tip of the guide wire is pulled along and can be removed from the nose.

[Extensive acute pulmonary embolism: fragmentation treatment with a rotatable pigtail catheter]. / Ausgedehnte akute Lungenembolie: Fragmentations-behandlung mit dem Pigtail-Rotationskatheter.

A 58-year-old patient with extensive pulmonary embolism complicated by cardiogenic shock and contraindications to thrombolysis was treated by mechanical embolus fragmentation using a rotatable pigtail catheter system. Considerable recanalization of the left pulmonary arteries was rapidly achieved with relative ease of instrumentation. Subsequently, the hemodynamic condition stabilized.

Esophageal foreign bodies: removal of the new euro coins with a magnet tube.

AIM OF THIS STUDY: We use a magnet tube to extract esophageal coins. It is smaller than the Foley balloon catheter and easier to handle than a forceps. We present the magnet tube maneuver and investigate whether the new euro coins can be removed with a magnet. METHOD: We take radiographs of coins and measure the adhesive force of the magnet and compare with the 10 Pfennig German coin which we most often removed successfully from the esophagus. RESULTS: The 1, 2, and 5 euro cent pieces are magnetic and can possibly be removed with a magnet tube. The non-magnetic pieces can be identified based on the rim and size. DISCUSSION: When an esophageal foreign body is not round and smooth like a coin, the fluoroscopic guided procedure becomes more risky with respect to mucosal injury. When a large object is stuck in the esophagus for more than 24 hours, an endoscopy must be considered to rule out any severe damage to the esophageal wall.

[Solid-pseudopapillary tumors in childhood]. / Solid-pseudopapillärer Pankreastumor im Kindesalter, Ein Bericht über 5 Fälle, Germany.

We report on fife female patients with solid pseudopapillary tumors of the pancreas. The tumors are extremely rare in children. They occur mainly in adolescent and young adult females. The tumors are neoplasms of low malignancy with infrequent metastases, for instance, in the liver or the peritoneum. Although the tumors had reached a large diameter, all of them underwent complete tumor resection. After that the patients have a very good prognosis. Thus, so it is important to distinguish solid-pseudopapillary tumors from other tumors of the pancreas.

[A false negative bone scintigram in a biparietal skull fracture in a case of a Battered Child Syndrome]. / Falsch-negatives Skelett-Szintigramm bei einer biparietalen Schädelfraktur beim "Battered Child"-Syndrom.

The case of a small girl is reported who after a head injury showed radiologically two fractures of the skull whereas the bone scintigram done eight days later with 99mTc-DPD was normal. The possible reasons for this discrepancy are discussed.

[Dupuytren's disease in children - case report and literature review]. / Morbus Dupuytren im Kindesalter - Fallbericht und Literaturrecherche.

Dupuytren's disease in childhood and adolescence is extremely rare. As in adults most patients are male. We report on a girl at the age of 7 years with a cord in the palm.