Sosamma Methratta

An implemented MRI program to eliminate radiation from the evaluation of pediatric appendicitis

BACKGROUND Recent efforts have been directed at reducing ionizing radiation delivered by CT scans to children in the evaluation of appendicitis. MRI has emerged as an alternative diagnostic modality. The clinical outcomes associated with MRI in this setting are not well-described. METHODS Review of a 30-month institutional experience with MRI as the primary diagnostic evaluation for suspected appendicitis (n=510). No intravenous contrast, oral contrast, or sedation was administered. Radiologic and clinical outcomes were abstracted. RESULTS MRI diagnostic characteristics were: sensitivity 96.8% (95% CI: 92.1%-99.1%), specificity 97.4% (95% CI: 95.3-98.7), positive predictive value 92.4% (95% CI: 86.5-96.3), and negative predictive value 98.9% (95% CI: 97.3%-99.7%). Radiologic time parameters included: median time from request to scan, 71 minutes (IQR: 51-102), imaging duration, 11 minutes (IQR: 8-17), and request to interpretation, 2.0 hours (IQR: 1.6-2.6). Clinical time parameters included: median time from initial assessment to admit order, 4.1 hours (IQR: 3.1-5.1), assessment to antibiotic administration 4.7 hours (IQR: 3.9-6.7), and assessment to operating room 9.1 hours (IQR: 5.8-12.7). Median length of stay was 1.2 days (range: 0.2-19.5). CONCLUSION Given the diagnostic accuracy and favorable clinical outcomes, without the potential risks of ionizing radiation, MRI may supplant the role of CT scans in pediatric appendicitis imaging.

Gossypiboma treated by colonoscopy.

Gossypibomas are an unusual postoperative complication and are reluctantly reported in the literature. In the past, the patient would require a laparotomy. More recently, they have been treated laparoscopically and percutaneously by interventional radiology. This is the first case report of a gossypiboma treated with colonoscopy. This may represent an addition treatment option for this complication.

Morel-Lavallée lesion of the thigh: characteristic findings on US

A 12-year-old boy presented for evaluation 3 weeks after an ATV accident. Although no traumatic injury was initially noted, he developed progressive left thigh swelling and blisters 2 weeks after the injury. US identified a collection in the subcutaneous tissues with hyperechoic material (arrowheads) along the wall (Fig. 1). Serous collections were drained at surgery; cultures were negative. Because of continued drainage of lymphatic-appearing fluid, the child was treated with Sotradechol foam injection and doxycycline twice, with improvement. The Morel-Lavallee lesion is an internal degloving type of injury with separation of the hypodermis from the underlying deep fascia. This results in disruption of the vascular and lymphatic plexus and a cavity is created, filling with blood, lymph, liquefied fat and necrotic debris [1]. US demonstrates a collection in the subcutaneous region with hyperechoic nodules corresponding to remnants of fat. If there is history of shear injury to the soft tissue with chronic recurrent fluid collection and imaging features of subcutaneous collection with fat lobules along the wall, the diagnosis of Morel-Lavallee lesion should be suspected. Treatment options include serial aspiration and, if unsuccessful, sclerodesis. Early identification is important, as delay can increase incidence of infection-related morbidity.

Alternative diagnoses at paediatric appendicitis MRI

As the utilization of MRI in the assessment for paediatric appendicitis increases in clinical practice, it is important to recognize alternative diagnoses as the cause of abdominal pain. The purpose of this review is to share our institutions experience using MRI in the evaluation of 510 paediatric patients presenting with suspected appendicitis over a 30 month interval (July 2011 to December 2013). An alternative diagnosis was documented in 98/510 (19.2%) patients; adnexal pathology (6.3%, n = 32), enteritis-colitis (6.3%, n = 32), and mesenteric adenitis (2.2%, n = 11) comprised the majority of cases. These common entities and other less frequent illustrative cases obtained during our overall institutional experience with MRI for suspected appendicitis are reviewed.

An unusual case of neonatal peritoneal calcifications associated with hydrometrocolpos.

Abstract. Neonatal peritoneal calcifications usually suggest a diagnosis of meconium peritonitis, but in this case, a premature baby girl, peritoneal calcifications were caused by hydrometrocolpos secondary to imperforate hymen, a rare association. The patient presented with respiratory distress and ascites and demonstrated abdominal calcifications on plain film. Other radiographic work-up revealed hydrometrocolpos without evidence of gastrointestinal tract obstruction. The patient was diagnosed and treated for imperforate hymen; she was recovered fully.

Secondhand tobacco exposure is associated with nonalcoholic fatty liver disease in children

BACKGROUND Nonalcoholic fatty liver disease (NAFLD) is the leading cause of liver disease in children in the United States, and prevalence rates are rising. Smoking is associated with NAFLD, but the association of secondhand smoke exposure with NAFLD is unknown. AIMS To investigate the association of secondhand tobacco exposure with NAFLD in children. METHODS We surveyed parents/guardians of 304 children aged 3-12 years who had received an abdominal ultrasound at Penn State Hershey Medical Center. The survey addressed demographics, medical history, secondhand tobacco exposure, activity level, screen viewing time and other environmental exposures. A pediatric radiologist and sonographer reviewed the ultrasounds to grade the presence of bight liver compatible with NAFLD. We conducted logistic regression analysis to assess the association of secondhand tobacco exposure and NAFLD. RESULTS 54% of eligible potential participants responded to the survey. Fatty liver was present in 3% of the children. Increasing child age was associated with increased odds of NAFLD (OR 1.63 95% CI 1.1, 2.4). Reported child obesity was associated with increased odds of NAFLD (OR 44.5 95% CI 5.3, 371.7). The rate of NAFLD was higher in the smoke exposed group (6.7% vs. 1.7%). For every extra pack per day smoked at home, the odds of a child having NAFLD increased 1.8 times (AOR 1.8, 95% CI 1.2, 2.8), and any exposure increased a childs odds of NAFLD four-fold (AOR 4.0, 95% CI 1.02, 15.8). CONCLUSION We found an association of secondhand smoke exposure and NAFLD in children. This may represent an area for future prevention efforts.

MRI for clinically suspected pediatric appendicitis: case interpretation

As utilization of MRI for clinically suspected pediatric appendicitis becomes more common, there will be increased focus on case interpretation. The purpose of this pictorial essay is to share our institution’s case interpretation experience. MRI findings of appendicitis include appendicoliths, tip appendicitis, intraluminal fluid–debris level, pitfalls of size measurements, and complications including abscesses. The normal appendix and inguinal appendix are also discussed.

Reduction of radiation exposure in pediatric patients with trauma: cephalic stabilization improves adequacy of lateral cervical spine radiographs

INTRODUCTION Plain radiographs continue to play a role in cervical spine clearance. Inadequate radiographs commonly necessitate repeat x-rays or computed tomography imaging (10 × radiation dose). We have used the technique of cephalic stabilization (CS) to improve the results of plain radiographs. Cephalic stabilization lateral radiographs are obtained, with one assistant applying traction to the arms while another placing fingers in the patients ears and stabilizing the head. This study tests the hypothesis that CS improves visualization of the cervicothoracic junction during lateral cervical spine radiographs. METHODS A 2-year review of institutional pediatric trauma registry identified 46 patients with CS, matched 1:3 with controls. Randomized lateral radiographs were evaluated independently by 2 pediatric radiologists to determine adequate visualization of the craniocervical and cervicothoracic junctions. Reviewers were blinded to CS through image cropping. RESULTS The proportion of adequate visualization of the cervicothoracic junction was 0.85 for cases with stabilization and 0.60 for controls. Odds of obtaining adequate visualization with stabilization are 3.8 times those without stabilization (P = .001) and were even greater for patients younger than 13 years. CONCLUSIONS Cephalic stabilization improves visualization of the cervicothoracic junction in lateral cervical spine radiographs and can reduce radiation exposure in patients who would otherwise require further imaging.

Fecal Impaction Causing Pelvic Venous Compression and Edema.

Chronic constipation is a common condition which may result in fecal impaction. A 13-year-old male with chronic constipation and encopresis presented with fecal impaction for three weeks. The impaction caused abdominal pain, distension, encopresis, and decreased oral intake. He was found in severe distress with non-pitting edema of his feet and ankles along with perineal edema. The pedal edema worsened after receiving a fluid bolus, so concern arose for venous compression or a thrombus. A Duplex Ultrasound demonstrated changes in the venous waveforms of the bilateral external iliac and common femoral veins without thrombosis. Manual disimpaction and polyethylene glycol 3350 with electrolytes resolved the pedal and perineal edema. Four months later, he had soft bowel movements without recurrence of the edema. A repeat Duplex Ultrasound was normal. We present a child in whom severe fecal impaction caused pelvic venous compression resulting in bilateral pedal and perineal edema.

The Depression Index: an objective measure of the severity of pectus excavatum based on vertebral diameter, a morphometric correlate to patient size

BACKGROUND/PURPOSE In patients with Pectus Excavatum (PEX), the proposed Depression Index (DI) is derived from the absolute measurement of sternal depression using the transverse vertebral body diameter as a surrogate for height. The previously described objective and useful Pectus Index (PI) and Correction Index (CI), utilize thoracic diameters and do not always reflect the severity of the deformity as observed by clinicians. METHODS Data for age, weight, height and vertebral diameter of T9, 10 and 11 were collected on 60 patients, with normal skeletons, undergoing CT scanning. The DI, PI and CI were calculated from CT scans on 76 patients with PEX. Indices were also compared to subjective rankings of the deformity from visual inspection of photographs by 5 clinicians. RESULTS All parameters of age, weight and height correlated with the vertebral diameter. The DI correlated with the severity of the PEX deformity as also measured by the PI and the CI. There was a better correlation of the observed deformity severity to the DI than the PI or CI. CONCLUSION There is a strong correlation between transverse vertebral size and patient height. The DI is an objective measurement of the severity of a PEX deformity that is independent of the thoracic diameters.