Anastasia L. Hryhorczuk

Pediatric Abdominal Pain: Use of Imaging in the Emergency Department in the United States from 1999 to 2007

PURPOSE To evaluate use of imaging in children with acute abdominal pain who present to U.S. emergency departments (EDs). MATERIALS AND METHODS This study received expedited review by the institutional review board. The National Hospital Ambulatory Medical Care Survey is a government-administered yearly survey of EDs that is used to estimate ED care throughout the United States. This retrospective cohort study interrogated the database for the period from 1999 to 2007. Univariate regression analysis was performed, and a multivariate regression model was developed. RESULTS From 1999 to 2007, 16 900 000 pediatric ED visits were made for acute abdominal pain. Odds of undergoing computed tomography (CT) in this population increased during each year of the study period. No significant changes occurred in use of ultrasonography, number of patients admitted to the hospital, or number of patients with acute appendicitis. A multivariate model for CT use revealed increased odds of CT use in teens, white patients, the Midwest region, urban settings, patients with private insurance, and patients who were admitted or transferred. Odds of undergoing CT were significantly lower among patients who presented to a pediatric-focused emergency department (adjusted odds ratio, 0.72; 95% confidence interval: 0.58, 0.90). CONCLUSION The main findings of this study are that the rate of CT use in the evaluation of abdominal pain in children increased every year between 1999 and 2007 and that the use of CT was greater among children seen in adult-focused EDs. Factors affecting CT use include sex, race, age, insurance status, and geographic region.

Prevalence of Malignancy in Thyroid Nodules with an Initial Nondiagnostic Result After Ultrasound Guided Fine Needle Aspiration

The objective of this study was to determine the rate of malignancy in thyroid nodules with an initial nondiagnostic fine needle aspiration. From October 2001 to April 2007, biopsies were performed on 1344 thyroid nodules in our practice. Biopsies were performed on nodules using 25-27 gauge needles, ultrasound guidance and multiple passes using both suction and capillary action. We retrospectively reviewed the results of these biopsies as well as any further management of nodules that received nondiagnostic results (IRB HUM00006459). Following initial biopsy, 295/1344 (21.9%) of nodules received nondiagnostic pathologic results. Of this population, 39 nodules (13.1%) were lost to follow-up. Of the remaining 256 nodules that received a repeat FNA, surgical excision, or greater than 24 months of clinical and imaging follow-up, only five cancers were detected, representing only 2% of the population that received an initial nondiagnostic biopsy result. All of these cancers were papillary neoplasms. When rigorous, ultrasound-guided, fine needle aspiration of thyroid nodules is performed, a nondiagnostic histopathologic result should not be interpreted as suspicious for thyroid cancer. Given the low rate of malignancy in this population (2%), we suggest that clinical and imaging follow-up of these nodules, opposed to repeat sampling, is warranted.

Imaging Evaluation of Bowel Obstruction in Children: Updates in Imaging Techniques and Review of Imaging Findings

Bowel obstruction often represents an eventual endpoint that can arise from a wide variety of inciting etiologies in the pediatric population. In an acute setting, the radiologist’s goal is to first identify the presence of a bowel obstruction and subsequently recognize specific imaging features, which can guide clinicians to the underlying cause of the bowel obstruction and direct subsequent management. Although bowel obstruction in adults is predominantly due to adhesions (65%), incarcerated hernias (15%), or colonic neoplasm (13%), the causes of bowel obstructions in pediatric patients are more varied and often require different management. 1 This article reviews the role of currently available imaging modalities that can be used to assess a pediatric bowel obstruction, as well as the spectrum of characteristic imaging findings seen with bowel obstructions that may lead to the primary pathological process.

Accuracy of CT-guided percutaneous core needle biopsy for assessment of pediatric musculoskeletal lesions

BackgroundCT-guided percutaneous core needle biopsy has been shown in adults to be an effective diagnostic tool for a large number of musculoskeletal malignancies.ObjectiveTo characterize our experience with CT-guided percutaneous core needle biopsy of pediatric bone lesions and determine its utility in diagnosing pediatric osseous lesions, in a population where such lesions are commonly benign.Materials and methodsFrom 2000 to 2009, 61 children underwent 63 CT-guided percutaneous biopsies. Radiological, pathological and clinical records were reviewed.ResultsFourteen biopsies (22%) were performed on malignant lesions, while 49 biopsies (78%) were performed on benign lesions. Forty-nine of the 63 biopsies (78%) were adequate; these children underwent no further tissue sampling. Fourteen of the 63 biopsies (22%) were inadequate or non-conclusive. Of these patients, 12 underwent open biopsy. Retrospective analysis of percutaneous biopsies in these patients demonstrates that 9/12 provided clinically relevant information, and 4/12 patients received final diagnoses that confirmed initial core biopsy findings. No malignancies were diagnosed as benign on percutaneous biopsy. Overall, percutaneous core needle biopsy provided accurate diagnostic information in 84% (53/63) of biopsies.ConclusionOur results demonstrate that CT-guided percutaneous biopsy is safe and beneficial in children. This study supports the use of CT-guided percutaneous core needle biopsy for primary diagnosis of pediatric bone lesions.

Pediatric Musculoskeletal Ultrasound: Practical Imaging Approach

OBJECTIVE The purpose of this article is to review some of the common indications for pediatric musculoskeletal ultrasound examination, with emphasis given to imaging technique, normal anatomy, and the spectrum of pathologic findings seen in the pediatric population. CONCLUSION Ultrasound is an essential first-line tool in pediatric musculoskeletal imaging. It aids in determining which patients may benefit from further imaging, including radiography, CT, and MRI.

Esophageal Abnormalities in Pediatric Patients

W519 may initially raise suspicion for esophageal atresia and tracheoesophageal fistula (Fig. 2A). The visualization of a dilated pharyngeal pouch on fetal MRI is an additional finding compatible with esophageal atresia (Fig. 2B). Nevertheless, a prenatal diagnosis of esophageal atresia with or without tracheoesophageal fistula can be made in less than 10% of patients. More commonly, affected patients are only identified at birth, when they present with respiratory distress, difficulty feeding, and inability to control secretions. If attempts are made to pass an enteric catheter, the catheter tip may not reach the stomach. Radiographs may show a tip in a characteristic position, projecting over the distal portion of the esophageal pouch (Fig. 3). Attention to the visualized osseous structures is important because patients with VACTERL associations may have evidence of spinal segmentation anomalies (Fig. 4). Patients with typical esophageal atresia often are sent for operative repair on the first day of life, without undergoing preoperative fluoroscopic studies, CT, or MRI. Prone esophagraphy should be avoided because it can result in aspiration. Gentle injection of air into the proximal pouch can be performed to illustrate pouch length. Preoperative echocardiography, however, may be of benefit, to determine the location of the aortic arch and enable the surgeon to choose the appropriate thoracotomy site, which is on the side opposite that of the aortic arch. A minority (about 25%) of patients with esophageal atresia have the long gap variety, which is defined as a greater than 2.5 cm separation between the distal and proximal esophageal segments, which cannot be approximated without tension. In these patients, initial placement of a gastrostomy tube is essential to provide nutritional support. Because primary repair of the esophagus is not feasible in these cases, a staged approach Esophageal Abnormalities in Pediatric Patients

Pediatric Abdominal Organ Transplantation: Current Indications, Techniques, and Imaging Findings.

The anatomy, normal postoperative radiological appearance, and imaging features of common postoperative complications of pediatric abdominal transplants are reviewed, including renal, liver, and intestinal transplants. Doppler ultrasound is the mainstay of imaging after transplantation. Computed tomography (CT) and CT angiography, MR imaging and magnetic resonance (MR) angiography, MR cholangiopancreatography, conventional angiography, and nuclear medicine imaging may be used for problem-solving in pediatric transplant patients. Accurate and timely radiological diagnosis of transplant complications facilitates appropriate treatment and minimizes morbidity and mortality.

Bowel Obstructions in Older Children

W1 cosa within the diverticulum or inflammation. Bowel obstruction due to a Meckel diverticulum presents in either of two typical patterns: First, a distal ileal obstruction can occur secondary to bowel torsion around an omphalomesenteric band (Fig. 1). Second, obstruction can be due to intussusception of a Meckel diverticulum (Fig. 2). In addition, Meckel diverticulum varies in size and can be incidentally seen on CT when very large. It may mimic a single enlarged bowel loop. Notably, patients with intussuscepting Meckel diverticula are usually older than patients with idiopathic intussusception. In both cases, surgical resection of the Meckel diverticulum is essential for definitive treatment.

Anaplastic large cell lymphoma of the esophagus in a pediatric patient

We report a 3-year-old boy who initially presented with abdominal pain and was subsequently found to have an esophageal perforation. The child did not respond to conservative management, and subsequent lymphadenopathy led to a lymph node biopsy demonstrating an anaplastic lymphoma kinase (ALK)+ anaplastic large cell lymphoma. Esophageal perforation and thickening is most commonly seen in children with a history of esophageal intervention or foreign body/caustic ingestion. Esophageal involvement in children with non-Hodgkin lymphoma (NHL) has not, to our knowledge, been reported in the literature. This case illustrates an unusual presentation of pediatric NHL.

Spectrum of Syndromic Disorders Associated with Pediatric Tumors: Evolving Role of Practical Imaging Assessment

Although pediatric tumors are largely sporadic in cause, continued advancements in science have elucidated a growing body of tumors that are associated with syndromes. Early identification of these syndromic disorders associated with developing tumors can alter the course of disease and potentially save lives. Medical imaging has a pivotal role in screening surveillance, diagnosis, and management of these tumors. Understanding characteristic manifestations of these syndromes is important to optimize image utilization. This article discusses clinically important syndromes associated with pediatric tumors with brief overview of the background, genetics, and clinical features. Diagnosis, imaging, management, and treatment are also reviewed.