Prenatal diagnosis of intestinal nonrotation using magnetic resonance imaging: Is it possible?

BACKGROUND: Malrotation of the bowel refers to any variation in the rotation and fixation of the gastrointestinal tract during the first trimester and is most commonly detected postnatally. Nonrotation of the bowel and incomplete rotation of the bowel are subtypes of malrotation. OBJECTIVE: To determine if the nonrotation subtype of malrotation of the bowel can be detected on prenatal magnetic resonance imaging (MRI). MATERIALS AND METHODS: Cases from 2012 to 2018 with nonrotation of the bowel without obstruction confirmed by imaging, surgery and/or autopsy were compared to prenatal imaging. Prenatal imaging was retrospectively reviewed to determine if prenatal diagnosis of malrotation could be made. Exclusion criteria included diaphragmatic hernia, omphalocele and gastroschisis. RESULTS: Ten cases of nonrotation diagnosed postnatally by upper gastrointestinal series (upper GI)/small bowel follow-through (SBFT) or autopsy had prenatal MRI. Prenatal MR studies were performed for assessment of heterotaxy syndrome with congenital heart disease (6/10), congenital heart disease with additional anomalies (suspected VACTERL [vertebral, anorectal, cardiac, tracheoesophageal, renal, limb] and suspected lung agenesis, ventriculomegaly) (3/10) and skeletal dysplasia (1/10). Eight upper GI/SBFT cases demonstrated nonrotation of the bowel without obstruction with the small bowel completely on one side of the abdomen contralateral to the stomach and the colon ipsilateral to the stomach; four cases were confirmed by surgery. The small bowel in one upper GI/SBFT case was unilateral contralateral to the stomach with a meandering colon. One case had nonrotation diagnosed at autopsy. There were no cases of postnatal midgut volvulus. Retrospective review of the 10 cases had prenatal MRI performed between 23 and 37 weeks of gestation. The coronal plane was the most optimal plane to assess the position of the stomach, small bowel and colon in relationship to each other. The small bowel was best assessed on T2-weighted images while the colon was best assessed on T1-weighted images. A nonrotated position of the small bowel was present in all 10 fetal MRI cases mirroring postnatal findings, with the small bowel contralateral to the stomach in 9/10 cases and ipsilateral to the stomach (in the right abdomen) in 1/10 cases. The colon was visualized by prenatal MRI in 9/10 cases, with 1 case limited due to a lack of T1-weighted imaging. A nonrotated position of the colon contralateral to the small bowel was present in 7/9 cases. In 2/9 cases, the colon was wandering, positioned on both sides of the midline. Colonic position in all nine cases matched postnatal findings. No cases presented with prenatal bowel obstruction. CONCLUSION: Detection of nonrotation of the bowel is possible on prenatal MRI.

Renal Tumors of Childhood: Radiologic-Pathologic Correlation Part 2. The 2nd Decade: From the Radiologic Pathology Archives.

Malignant renal tumors account for 7% of childhood cancers, and Wilms tumors are by far the most common-but not in older children and adolescents. Among individuals in the latter half of their 2nd decade of life, renal cell carcinoma (RCC) is more common than Wilms tumor. The histopathologic spectrum of RCCs in children differs from that in adults. The most common subtype of RCC in children and adolescents is Xp11.2 translocation RCC, which is distinguished by hyperattenuation at nonenhanced computed tomography, a defined capsule, and associated retroperitoneal lymphadenopathy. Papillary RCC is the second most common histologic subtype. It enhances less intensely compared with the adjacent renal parenchyma and has a propensity for calcification. Clear cell RCC is seen in patients with von Hippel-Lindau disease and is distinguished by its relatively hypervascular nature. Medullary carcinoma affects adolescents with the sickle cell trait and is characterized by an infiltrative growth pattern and extensive metastasis at presentation. Angiomyolipoma is seen in children with tuberous sclerosis complex and is often multifocal and hypervascular, with macroscopic fat. Metanephric tumors are central, circumscribed, and typically calcified. Lymphoma usually manifests as multifocal masses, but it may involve a solitary mass or infiltrative pattern. Extensive adenopathy and involvement of the gastrointestinal tract or other organs also may be seen. Primitive neuroectodermal tumor is an aggressive neoplasm that is typically quite large at diagnosis. Knowledge of the clinical, biologic, and histopathologic features of renal tumors in older children and adolescents and their effects on the imaging appearance can help the radiologist offer a useful preoperative differential diagnosis.

Frequency of skeletal injuries in children with inflicted burns.

BACKGROUND: It is estimated that inflicted burn injuries in physically abused children occur with a prevalence of approximately 6-20%. Identification of burns of a nonaccidental nature is oftentimes difficult. Underlying skeletal injuries in abusive environments are often overshadowed by the acute burn injury. OBJECTIVE: We assessed the prevalence of inflicted burns and the frequency of associated skeletal injuries in a population from a large children's hospital. MATERIALS AND METHODS: From a database of nearly 3,000 children who were assessed for possible abuse from 1997 to 2012, we identified 142 children with burn injuries. We included only those who had undergone skeletal surveys as part of the diagnostic workup. The final diagnosis, based on the burn, was categorized as nonaccidental, accidental or indeterminate by a child abuse pediatrician. We excluded children with no skeletal survey (n = 18), children in whom the final diagnosis could not be found (n = 6), and other conditions misdiagnosed as burn (n = 6). The resulting cohort consisted of 112 children. RESULTS: Of the 112 children with burns, 54 were girls and 58 boys with ages ranging from 1 month to 110 months, mean age of 15 months. Forty-five (40%) were determined to be nonaccidental, 36 (32%) were indeterminate and 31 (28%) accidental. The most common causative mechanism was scalding and the most common location was the perineum and lower extremity in all three diagnostic categories. Skeletal surveys were positive for fractures in 15/45 (33%) of the nonaccidental group; 2/36 (6%) in the indeterminate group, and 0/29 (0%) in the accidental group. Fractures in the nonaccidental group included healing rib fractures in seven, classic metaphyseal lesions in three, healing shaft fractures in six, skull fracture in one and clavicle fracture in two children. Fractures in the indeterminate group included shaft fractures in two, one of which was healing. CONCLUSION: Intentional burns in children appear to be more common than previously known, occurring in 40% of the children in our series, a greater percentage than has been reported in the literature. In addition, nearly one-third of these children with inflicted burns had associated skeletal injuries, most commonly healing rib fractures. Thus young children with concern for nonaccidental burns should undergo a skeletal survey.

Infantile Adenomyomatosis of the Gallbladder in a 3-Month-Old.

Adenomyomatosis of the gallbladder is an acquired condition of the gallbladder with epithelial, mucosal, and muscular hypertrophy. The result is usually gallbladder wall thickening with associated diverticula known as Rokitansky-Aschoff's sinuses. These mucosal invaginations of the gallbladder wall may extend beyond the muscular layer. The condition is typically asymptomatic and is predominantly diagnosed in adults between 50 and 60 years of age, usually with concomitant cholelithiasis, motility disorders, or chronic inflammation. Few cases within the literature have been described in the pediatric population and even fewer within this subset have been diagnosed in infants. We describe a case of a 3-month-old male with failure to thrive, persistent nonbilious, nonbloody emesis, and elevated transaminases with ultrasound evidence of gallbladder adenomyomatosis. The patient was managed with outpatient laboratory monitoring and follow-up imaging.

An unusual cause of postpartum abdominal pain: case report.

Abdominal pain is a common presenting complaint in the Emergency Department. It extends to all populations regardless of age, sex, or socioeconomic status. After gathering a history and examining the patient, most Emergency Physicians form a differential diagnosis and initiate an appropriate work-up. However, in the postpartum woman, additional causes must be considered and treated accordingly, knowing that there are consequences for both mother and child. We present a case of a postpartum woman presenting with right-sided abdominal pain, the cause of which, although atypical, has potential for significant morbidity and mortality if it goes undiscovered.

Imaging of the Pediatric Urinary System.

Recent advances in pediatric urinary tract imaging include development of alternative imaging methods without use of ionizing radiation; evolving understanding of the relationship of urinary tract infection, vesicoureteral reflux, and renal scarring, including the important role of dysfunctional voiding; development of a consensus nomenclature and risk-based classification for fetal and antenatal urinary tract dilation; advances in the understanding of sporadic and inherited renal cystic disease; and a proposed modification of the Bosniak criteria for distinguishing complex renal cysts from cystic renal tumors in children.

Achondroplasia in the Premature Infant: An Elusive Diagnosis in the Neonatal Intensive Care Unit.

Achondroplasia is a difficult prenatal diagnosis to make before the late second and third trimester. We describe two cases where an infant was born prematurely with no overt signs of achondroplasia. Despite multiple chest and abdominal radiographs during the neonatal course, the diagnosis was not made until term equivalent age was reached. We retrospectively reviewed these two cases to highlight the elusive findings of achondroplasia in the premature infant.

Prenatal Imaging of the Gastrointestinal Tract with Postnatal Imaging Correlation.

Prenatal detection of a wide variety of anomalies and masses of the gastrointestinal tract is now possible. Prenatal imaging with ultrasonography and in selected cases magnetic resonance imaging provides invaluable information to the referring obstetrician, the maternal fetal medicine specialist, the neonatologist and pediatrician who will care for the child after birth, the surgeons and pediatric specialists who will repair or manage a prenatally detected anomaly, and of course to the parents, allowing them to prepare psychologically and financially for the specific interventions that may be needed for their child. Additional screening for associated anomalies can take place, route of delivery can be decided, and arrangements for delivery in an appropriate setting can be made. Prenatal detection also allows for consideration for pregnancy termination. This article will give a broad overview of anomalies of the gastrointestinal tract that can be detected prenatally and their imaging appearance postnatally.

A case of bronchobiliary fistula in the setting of adult polycystic kidney and liver disease, with a review of the literature.

A case of bronchobiliary fistula (BBF) was demonstrated in the setting of polycystic kidney and liver disease (PCKLD) by hepatobiliary scintigraphy. High-resolution noncontrast computed tomography through the liver showed a polycystic liver. A calcified cyst adjacent to the dome of the liver appeared to have a fistulous connection with the lung on coronal reconstructions. Hepatobiliary scan confirmed the fistulous connection. In a review of the literature, BBF has been associated with hydatid cyst disease, trauma, postsurgical states, and malignancy. As demonstrated by this case, BBF is difficult to diagnose and requires a high clinical index of suspicion. Hepatobiliary scintigraphy is the imaging modality of choice to confirm BBF, and PCKLD should be added to the list of antecedent etiologies.