Alexander A. Cacciarelli

Do all Children with an Acute Scrotum Require Exploration

A total of 77 consecutive children ranging in age from 1 day to 17 years was evaluated for an acute scrotum by a single examiner (E. J. K.). In 10 children a definite diagnosis of acute spermatic cord torsion was made based upon the history and physical examination. No imaging studies were performed and torsion was confirmed at surgery in 9 children. The diagnosis of testis torsion was not as clear-cut in the remaining 67 children and, therefore, a color Doppler ultrasound was performed before any surgical intervention. The study demonstrated normal or increased blood flow in 55 of these children and none proved to have testicular torsion, although other scrotal pathology requiring surgery was noted in 5 children. Twelve children did not demonstrate evidence of testicular blood flow on the color Doppler ultrasound and all had surgical confirmation of testis torsion. We conclude that in our experience the majority (71%) of children with an acute scrotum did not require immediate surgical exploration. Color Doppler ultrasound can reliably identify those children with an acute scrotum who require exploration and spare the majority needless surgery. Routine scrotal exploration is no longer necessary for all children with an acute scrotum.

The Sensitivity of Renal Scintigraphy and Sonography in Detecting Nonobstructive Acute Pyelonephritis

Recently it has been demonstrated that any child with proved acute pyelonephritis may be at risk for parenchymal scarring, whether or not reflux is present. Since cortical renal scintigraphy has been shown to detect accurately renal inflammation, we compared cortical scintigraphy with renal sonography in 46 children with documented acute pyelonephritis to determine which modality is best to detect patients at risk for renal injury. Cortical scintigraphy was abnormal in 36 children (78%) and renal ultrasonography was abnormal in 5 (11%). Reflux was demonstrated in only 20 cases (43%). We conclude that cortical scintigraphy is the preferred imaging technique for diagnosing renal inflammation, and it should be used routinely in every child with suspected acute pyelonephritis. A new imaging protocol is proposed.

Pediatric Urology: Management of Suspected Antenatal Torsion: What Is the Best Strategy?

Currently, management of the newborn with suspected antenatal torsion is somewhat controversial. Many surgeons recommend early surgical exploration within the first few days of life, primarily to avoid errors in diagnosis. However, since the surgical and general anesthetic risks at this age are increased, it might be preferable to defer an operation until risks to the patient are minimized. The optimal solution to this dilemma would be the ability to diagnose torsion and exclude other conditions noninvasively. We present a series of 12 patients 1 to 14 days old who presented with a scrotal mass secondary to suspected antenatal testis torsion. Color Doppler ultrasound in each case demonstrated abnormal testicular blood flow and architecture consistent with testis torsion. Eventual exploration of all 12 patients confirmed prenatal torsion. We conclude that scrotal ultrasound with color Doppler enhancement can accurately identify neonates with antenatal testis torsion and exclude other scrotal pathological conditions. If elected, surgery for torsion can then be deferred until the risks of anesthesia and surgery are improved.

Cholelithiasis in Infants with Down Syndrome Three Cases and Literature Review

Only four cases of cholelithiasis have been reported in patients with Down syndrome and none in Down syndrome infants. The cases of three Down syndrome infants (all males) with cholelithiasis are reported. Each exhibited different fetal complications, and in each, Down syndrome was diagnosed at birth. Gallstones apparently were congenital (a rarity) in one infant, since they were detected on the first day of life. Cholelithiasis was an incidental finding in another of the infants when, at 12 weeks old, he had renal ultrasonography because of a urinary tract infection. The third infant was 4 months old when sonographic studies revealed a gallstone. Despite the confirmation of cholelithiasis in all three infants, none has since had any signs or symptoms that suggest the need for intervention. Cholelithiasis is probably more common in Down syndrome infants than has been supposed, but whether Down syndrome infants with gastrointestinal (GI) malformations are more likely to have gallstones than are children with similar GI malformations but with normal karyotypes is unknown.

Transient acute renal failure in the neonate

We have observed a transient renal insufficiency in newborns associated with ultrasonographic finding of hyperechoic renal pyramids. This condition rapidly resolves, coinciding with both normalization of the renal ultrasound and the occurrence of significant proteinuria. Others have recognized a similar state of oliguria and cylindruria associated with a prolonged nephrogram on intravenous urography in newborns. There is evidence to suggest that hyaline cast deposition within the collecting tubules may account for these imaging abnormalities. The precise events surrounding the protein deposition are unknown, and it may be either the cause or the result from the transient renal dysfunction. Our 2 cases add to the evidence that there is a distinct entity of acute renal dysfunction, with identifying characteristics, in neonates associated with a good prognosis and rapid resolution.

Clinical and imaging features of rhabdoid tumor of the kidney

Rhabdoid tumor of the kidney (RTK) is a rare, highly malignant neoplasm of childhood. The clinical profile of this neoplasm differs from that of Wilms’ tumor. We present two cases of RTK. In both our cases, large bulky masses with poorly defined margins and calcifications were demonstrated. The clinical and imaging findings are compared with other childhood renal neoplasms.

Unusual complication of peripherally inserted central venous catheter placement: the left pericardiophrenic vein

Received: 10 October 2002 Revised: 14 April 2003 Accepted: 11 August 2003 Published online: 7 November 2003 Springer-Verlag 2003 Understanding the venous anatomy of the thorax facilitates interpretation of catheter position (Fig. 1). In Fig. 1, the two brachiocephalic veins can be seen uniting to form the superior vena cava to the right of the heart. The left brachiocephalic vein, which drains the arm via the subclavian, also receives multiple smaller branches. These include the left first intercostal vein, superior intercostal vein, pericardiophrenic vein, internal thoracic (internal mammary) vein, persistent left superior vena cava, and the left thymic vein. The left pericardiophrenic vein, formed from the venous branches draining the superior aspect of the diaphragm and the pericardium, runs parallel to the left cardiac border and drains into the floor of the left brachiocephalic vein, approximately opposite the left internal jugular vein. It is this position that most likely allows a catheter from the internal jugular on

Cardiothoracic Ratio in Newborns with Severe Intrauterine Growth Retardation

tional heart disease. The radiographs were taken in the NICU with the infant in a supine position. The radiographs were reviewed by a single radiologist who was unaware of the infants’ clinical status or growth data. The CT ratio was determined by dividing the largest width of the cardiac silhouette by the largest internal width of the bony thorax. Statistical analyses were performed using the Fischer’s exact test for categorical data and Student’s t-test for continuous data.

Pediatric Urology: Management of Suspected Antenatal Torsion

Currently, management of the newborn with suspected antenatal torsion is somewhat controversial. Many surgeons recommend early surgical exploration within the first few days of life, primarily to avoid errors in diagnosis. However, since the surgical and general anesthetic risks at this age are increased, it might be preferable to defer an operation until risks to the patient are minimized. The optimal solution to this dilemma would be the ability to diagnose torsion and exclude other conditions noninvasively. We present a series of 12 patients 1 to 14 days old who presented with a scrotal mass secondary to suspected antenatal testis torsion. Color Doppler ultrasound in each case demonstrated abnormal testicular blood flow and architecture consistent with testis torsion. Eventual exploration of all 12 patients confirmed prenatal torsion. We conclude that scrotal ultrasound with color Doppler enhancement can accurately identify neonates with antenatal testis torsion and exclude other scrotal pathological conditions. If elected, surgery for torsion can then be deferred until the risks of anesthesia and surgery are improved.

The Incidental Detection of Gallium-67 Citrate in a Urinoma Following a Right Pyeloplasty: A Case Report

An abnormal accumulation of radionuclide was identified within the right juxtadiaphragmatic and juxtahepatic spaces during gallium-67 citrate scintigraphy in a post-pyeloplasty patient. Its mode of presentation, the recent pyeloplasty and the known biologic distribution of gallium suggested that it represented gallium-67 concentration within a postoperatively created urinoma. Diagnosis was confirmed by excretory urography and laparotomy.