Visualization of enlarged mesenteric lymph nodes at US examination. Clinical significance

Value of conventional ultrasound and shear‑wave elastography in the assessment of mesenteric lymphadenitis in a paediatric population

The present retrospective study was designed to explore the value of conventional ultrasound (US) and Virtual Touch Tissue Imaging and Quantification (VTIQ) in the assessment of mesenteric lymphadenitis (ML) in a paediatric population. A total of 103 patients with ML and 60 healthy paediatric patients were examined. VTIQ was performed to assess mesenteric lymph node (MLN) stiffness via shear-wave velocity (SWV). Univariate and multivariate logistic regression analyses were conducted to reveal independent variables for the identification of ML. The diagnostic performance of US, and US combined with VTIQ, were compared. All the quantitative VTIQ parameters (including the SWVMean, SWVMax and SWVMin) were significantly greater for MLNs in the control group than for MLNs in the ML group (all P<0.001). The SWV values in the control group were nearly 2-fold greater than that in the ML group. According to the multivariate logistic regression analysis, the longest diameter [odds ratio (OR)=6.042; P=0.046] was revealed to be the strongest independent predictor for ML, followed by the CRP level (OR=2.310; P<0.001) and the SWVMean (OR=0.106; P<0.001). According to the receiver operating characteristic analysis, the area under the curve (AUC) for US combined with VTIQ was 0.890 (95% CI: 0.831-0.949) with a greater sensitivity of 91.26% and a greater specificity of 86.67% than that for US alone (AUC: 0.798; 95% CI: 0.724-0.872; sensitivity: 79.61%; specificity: 80.00%). A significant negative correlation between increased VTIQ parameters and ML was observed. Utilizing VTIQ to assess MLN stiffness offers a non-invasive, convenient, reliable and reproducible approach for identifying mesenteric lymphadenopathy.

Abdominal and Thoracic Imaging Features in Children with MIS-C

(1) Background: Currently, multisystem inflammatory syndrome in children (MIS-C) is diagnosed based on clinical symptoms and laboratory findings of inflammation in the body. Once MIS-C is diagnosed, children will need to be followed over time. The imaging modalities most commonly used in the evaluation of patients with MIS-C include radiographs, ultrasound (US), and computed tomography (CT). Our study aims to summarise the literature data for the main gastrointestinal and pulmonary imaging features in children diagnosed with MIS-C and to share a single-centre experience. (2) Methods: We present the imaging findings in a cohort of 51 children diagnosed with MIS-C, admitted between December 2020 and February 2022. Imaging studies include chest and abdominal radiographs, thoracic, abdominal, and neck US and echocardiography (ECHO), and CT of the chest, abdomen, and pelvis. (3) Results: In accordance with the results in other studies, our observations show predominantly gastrointestinal involvement (GI) with ascites (33/51, 65%) and lymphadenopathy (19/51, 37%), ileitis or colitis (18/51, 35%), some cases of splenomegaly (9/51, 18%), hepatomegaly (8/51, 16%), and a few cases of renal enlargement (3/51, 6%) and gallbladder fossa oedema/wall thickening (2/51, 4%). Most common among the thoracic findings are posterior–basal consolidations (16/51, 31%), pleural effusion (14/51, 27%), and ground-glass opacities (12/51, 24%). We also register the significant involvement of the cardiovascular system with pericarditis (30/51, 58%), pericardial effusion (16/51, 31%), and myocarditis (6/51, 12%). (4) Conclusions: Radiologists should be aware of those imaging findings in order to take an important and active role not only in applying an accurate diagnosis, but also in the subsequent management of children with MIS-C. Radiological findings are not the primary diagnostic tool, but can assist in the evaluation of the affected systems and guide treatment.

Clinical and radiological findings for the new multisystem inflammatory syndrome in children associated with COVID-19

The World Health Organization defines the multisystem inflammatory syndrome in children (MIS-C) as a new syndrome reported in patients aged <19 years old who have a history of exposure to SARS-CoV-2. The onset of this syndrome is characterized by persistent fever that is associated with lethargy, abdominal pain, vomiting and/or diarrhea, and, less frequently, rash and conjunctivitis. The course and severity of the signs and symptoms vary; in some children, MIS-C worsens rapidly and can lead to hypotension, cariogenic shock, or even damage to multiple organs. The characteristic laboratory findings are elevated markers of inflammation and heart dysfunction. The most common radiological findings are cardiomegaly, pleural effusion, signs of heart failure, ascites, and inflammatory changes in the right iliac fossa. In the context of the current COVID-19 pandemic, radiologists need to know the clinical, laboratory, and radiological characteristics of this syndrome to ensure the correct diagnosis.

Clinical and radiological findings for the new multisystem inflammatory syndrome in children associated with COVID-19

El síndrome inflamatorio multisistémico pediátrico vinculado a la COVID-19 (SIM-PedS) es, según la Organización Mundial de la Salud, un nuevo síndrome descrito en pacientes menores de 19 años con historia previa de exposición a SARS-CoV-2. La presentación inicial de este síndrome se caracteriza por fiebre persistente que asocia debilidad, dolor abdominal, vómitos y/o diarrea. Menos frecuentemente los pacientes pueden presentar también erupción cutánea y conjuntivitis. El cuadro clínico tiene expresividad y evolución variables, por lo que algunos pacientes pediátricos afectados pueden empeorar rápidamente, desarrollando desde hipotensión y shock cardiogénico a daño multiorgánico. Los hallazgos analíticos característicos del síndrome consisten en elevación de marcadores inflamatorios y disfunción cardíaca. Los hallazgos radiológicos más frecuentes son cardiomegalia, derrame pleural, signos de insuficiencia cardíaca, ascitis y cambios inflamatorios en la fosa ilíaca derecha. En la pandemia actual por COVID-19 es necesario que el radiólogo conozca las características clínico-analíticas y radiológicas de este síndrome para realizar un correcto diagnóstico.

Identifying threshold sizes for enlarged abdominal lymph nodes in different age ranges from about 200,000 individual's data

The threshold size for enlarged abdominal lymph nodes (E-ALNs), a common pediatric disorder, has yet to be standardized. According to the maximum short-axis diameter, this study divided ALNs into Grade A (≥ 10 mm), Grade B (8–10 mm), Grade C (5–8 mm), and Grade D (< 5 mm, normal). To identify the threshold size for E-ALNs, the prevalence of each grade was compared between asymptomatic individuals and symptomatic (e.g., abdominal pain) individuals without other diseases (e.g., appendicitis) that could explain the symptoms for different ages using data from > 200,000 individuals. The results showed the following: (1) For ages 1–3 years, the recommended threshold size is 8 mm, as the differences in the prevalence between the two groups were nonsignificant for Grade C but significant (p < 0.05) for both Grades A and B. (2) For ages 3–14 years, the recommended threshold size is 5 mm, as the differences between the two groups were significant (p < 0.05) for Grades A, B, and C. (3) The prevalence of Grades A, B, and C was very low for ages 0–1 years and high for ages 1–6 years. (4) The prevalence for males was generally higher than that for females for Grades A and B.

Spectrum of Imaging Findings at Chest Radiography, US, CT, and MRI in Multisystem Inflammatory Syndrome in Children Associated with COVID-19

This case series examines the spectrum of imaging findings at chest radiography, US, CT, and MRI in 35 children admitted to a tertiary pediatric hospital in April and May 2020 with a post-coronavirus disease 2019 inflammatory condition known as multisystem inflammatory syndrome in children. The constellation of findings includes airway inflammation and rapid development of pulmonary edema on thoracic images, coronary artery aneurysms, and extensive right iliac fossa inflammatory changes on abdominal images. Awareness of this emerging condition and the expected multi-organ imaging findings will aid radiologists in the assessment of these complex cases.

Imaging findings of multisystem inflammatory syndrome in children associated with COVID-19

BACKGROUND

A hyperinflammatory immune-mediated shock syndrome has been recognised in children exposed to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19).

OBJECTIVE

To describe typical imaging findings in children with multisystem inflammatory syndrome associated with COVID-19.

MATERIALS AND METHODS

During the first wave of the COVID-19 pandemic, imaging studies and clinical data from children treated for multisystem inflammatory syndrome were collected from multiple centres. Standardised case templates including demographic, biochemical and imaging information were completed by participating centres and reviewed by paediatric radiologists and paediatricians.

RESULTS

We included 37 children (21 boys; median age 8.0 years). Polymerase chain reaction (PCR) testing was positive for SARS-CoV-2 in 15/37 (41%) children and immunoglobulins in 13/19 children (68%). Common clinical presentations were fever (100%), abdominal pain (68%), rash (54%), conjunctivitis (38%) and cough (32%). Thirty-three children (89%) showed laboratory or imaging findings of cardiac involvement. Thirty of the 37 children (81%) required admission to the intensive care unit, with good recovery in all cases. Chest radiographs demonstrated cardiomegaly in 54% and signs of pulmonary venous hypertension/congestion in 73%. The most common chest CT abnormalities were ground-glass and interstitial opacities (83%), airspace consolidation (58%), pleural effusion (58%) and bronchial wall thickening (42%). Echocardiography revealed impaired cardiac function in half of cases (51%) and coronary artery abnormalities in 14%. Cardiac MRI showed myocardial oedema in 58%, pericardial effusion in 42% and decreased left ventricular function in 25%. Twenty children required imaging for abdominal symptoms, the commonest abnormalities being free fluid (71%) and terminal ileum wall thickening (57%). Twelve children underwent brain imaging, showing abnormalities in two cases.

CONCLUSION

Children with multisystem inflammatory syndrome showed pulmonary, cardiac, abdominal and brain imaging findings, reflecting the multisystem inflammatory disease. Awareness of the imaging features of this disease is important for early diagnosis and treatment.

Clinical significance and sonographic evolution of enlarged abdominal lymph nodes in children

AIM

Paediatric evidence about the clinical implications of enlarged abdominal lymph nodes (EALN) is not univocal. The main purpose of our study was to evaluate the clinical significance and the morphological evolution of enlarged abdominal nodes in children with recurrent abdominal pain.

METHODS

All children with recurrent abdominal pain diagnosed with EALN were enrolled at the involved centres between September 2017 and June 2018. Number, size, localisation, shape and architecture of nodes were accurately recorded along with clinical and laboratory data at enrolment and after three and six months.

RESULTS

A total of 38 children were enrolled. After the six-month study period, 58% of them had lymph nodes reduced in size, 13% had unchanged lymph nodes, and 29% had lymph nodes increased in size. Overall, we observed a gradual, albeit slight reduction in the average size of enlarged nodes over the six-month period. The extent of size changes was not correlated with any clinical parameter.

CONCLUSION

Our data suggest that EALN are a non-specific finding, which is not worth a change in the diagnostic and therapeutic management of children with abdominal pain.

Utility of Point-of-care Ultrasound in Children With Pulmonary Tuberculosis

BACKGROUND

Point-of-care ultrasound (POCUS) detects extrapulmonary tuberculosis (EPTB) in HIV infected adults but has not been evaluated in children despite their higher risk of EPTB. This study's aims were to investigate feasibility of POCUS for EPTB in children, frequency of POCUS findings suggestive of EPTB and time to sonographic resolution of findings with treatment.

METHODS

This prospective South African cohort study enrolled children with suspected pulmonary tuberculosis (PTB). POCUS for pleural, pericardial or ascitic effusion, abdominal lymphadenopathy or splenic or hepatic microabscesses was performed and repeated at 1, 3 and 6 months of tuberculosis (TB) treatment. Prevalence of POCUS findings and their association with HIV infection was investigated in children with confirmed PTB (microbiologically proven), unconfirmed PTB (clinically diagnosed) or unlikely TB (respiratory disease that improved during follow-up without TB treatment).

RESULTS

Of 232 children [median age 37 months (interquartile range, 18-74)], 39 (17%) were HIV infected. Children with confirmed or unconfirmed PTB had a higher prevalence of POCUS findings than children with unlikely TB [18 of 58 (31%) and 36 of 119 (30%) vs. 8 of 55 (15%); P = 0.04 and P = 0.03, respectively]. Pleural effusion [n = 30 (13%)] or abdominal lymphadenopathy [n = 28 (12%)] were the most common findings; splenic microabscesses [n = 12 (5%)] were strongly associated with confirmed PTB. Children coinfected with HIV and TB were more likely than HIV-uninfected children with TB to have abdominal lymphadenopathy (37% vs. 10%; P < 0.001) or splenic microabscesses (23% vs. 3%; P < 0.001]. Most ultrasound findings were resolved by 3 months with appropriate TB treatment.

CONCLUSIONS

POCUS for EPTB in children with PTB is feasible. The high prevalence of findings suggests that POCUS can contribute to timely diagnosis of childhood TB and to monitoring treatment response.

Sonographic Findings of Abdominal Tuberculosis in Children With Pulmonary Tuberculosis

Ultrasound reports of 102 children with microbiologically confirmed or clinically diagnosed pulmonary tuberculosis (TB) showed that 23 of 37 (64%) and 23 of 65 (36%) had TB suggestive abdominal lymphadenopathy, and 16 of 37 (44%) and 8 of 65 (13%) had splenic microabscesses, respectively. Splenic microabscesses were associated with HIV infection (P = 0.041). These data suggest that pulmonary TB is often complicated by abdominal TB in children.

Acute Nonspecific Mesenteric Lymphadenitis: More Than "No Need for Surgery"

Acute nonspecific, or primary, mesenteric lymphadenitis is a self-limiting inflammatory condition affecting the mesenteric lymph nodes, whose presentation mimics appendicitis or intussusception. It typically occurs in children, adolescents, and young adults. White blood count and C-reactive protein are of limited usefulness in distinguishing between patients with and without mesenteric lymphadenitis. Ultrasonography, the mainstay of diagnosis, discloses 3 or more mesenteric lymph nodes with a short-axis diameter of 8 mm or more without any identifiable underlying inflammatory process. Once the diagnosis is established, supportive care including hydration and pain medication is advised. Furthermore, it is crucial to reassure patients and families by explaining the condition and stating that affected patients recover completely without residuals within 2-4 weeks.

Sonography of Abdominal Pain in Children: Appendicitis and Its Common Mimics

Abdominal pain is very common in the pediatric population (<18 years of age). Sonography is a safe modality that can often differentiate the frequently encountered causes of abdominal pain in children. This pictorial essay will discuss the sonographic findings of acute appendicitis, including the imaging appearance of a perforated appendicitis. It will also present the sonographic features of the relatively common mimics of appendicitis, such as mesenteric adenitis/gastroenteritis, intussusception, Meckel diverticulum, and ovarian torsion.

Sonography of acute appendicitis and its mimics in children

The diagnosis of acute right lower quadrant pain in a pediatric population is challenging. Acute appendicitis is the most common cause of an acute surgical abdomen. The common mimics of acute appendicitis are acute gastrointestinal and gynecologic diseases. This article reviews the sonographic findings of the spectrum of common acute abdominal emergencies in children with a focus on imaging clues to a specific diagnosis. This awareness can impact on diagnostic accuracy and impact patient management.

The role of emergency ultrasound in the diagnosis of acute non-traumatic epigastric pain

The epigastrium is the site where pain coming from both abdominal and extra-abdominal organs is frequently referred. Although acute or chronic diseases of the stomach, duodenum, liver, pancreas and biliary tree are the most common causes of acute epigastric pain, several other entities, potentially more severe, should also be suspected and investigated. Clinical bedside ultrasonography (US) is actually the first-line imaging in acute epigastric pain patients presenting to the hospital Emergency Department (ED) because it is rapid, noninvasive, relatively inexpensive and focused, repeatable and reliable. Moreover, the systematic use of emergency US as a complement to routine management might save economic resources by avoiding further costs for complications and substantially reducing the time for making an accurate diagnosis. The purpose of this paper is to review the US spectrum of the most common diseases responsible for acute epigastric pain onset. We also propose a focused, well codified US protocol, that we call the "$ approach", based on our clinical experience and the current literature for acute non-traumatic epigastric pain evaluation in an emergency setting. Its systematic application by the emergency physician may reduce the wait for diagnosis and the over-usage of second-line radiological techniques, including computed tomography, as well as to increase the diagnostic accuracy with potential benefits for patient (safety), physician (efficacy) and the institution (efficiency).

Doppler sonography of the superior mesenteric artery in children with recurrent abdominal pain

PURPOSE

Abdominal pain is one of the most common conditions in childhood and adolescence. The aim of this study was to evaluate the superior mesenteric artery (SMA) Doppler findings in children with recurrent abdominal pain.

METHOD

Duplex Doppler sonographic measurements were performed in 20 patients with recurrent abdominal pain and in 34 controls.

RESULTS

The mean blood flow velocities, blood flow volume, and diameter of the SMA were significantly lower in patients with recurrent abdominal pain than in controls.

CONCLUSION

Insufficient development and/or vasoconstriction of the SMA vascular bed may be involved in recurrent abdominal pain, but further studies on larger groups are needed to test this hypothesis.

Importance of sonographic detection of enlarged abdominal lymph nodes in children

OBJECTIVE

Abdominal lymph nodes are frequently visualized by sonography in the pediatric population. The term "mesenteric lymphadenitis" is frequently used in the radiologic literature to describe this finding, whereas in the pediatric literature, this term is reserved for specific inflammation of the lymph nodes. The purpose of this study was to compare by sonography the incidence of appearance of enlarged abdominal lymph nodes (EALNs) in healthy children compared with that in children with abdominal pain of various causes.

METHODS

In 200 patients referred for abdominal sonography for various indications, the presence of EALNs, their location, and size were registered. The patients were divided into 3 groups: those with abdominal pain due to an acute abdominal condition (group 1), those with abdominal pain without an acute abdominal condition (group 2), and asymptomatic patients (group 3).

RESULTS

Enlarged abdominal lymph nodes greater than 5 mm were detected in 83.3% of group 1 patients, 73.8% of group 2 patients, and 64% of group 3 patients. A significant statistical difference was found between patients with abdominal pain and asymptomatic children only for lymph nodes of 10 mm and larger (P = .0117). No statistically significant difference was seen in the presence of lymph node clusters between the patients with abdominal pain and asymptomatic children. There was a tendency of increased EALN occurrence with age, peaking at 10 years, with a decrease later.

CONCLUSIONS

Enlarged abdominal lymph nodes are frequently encountered in asymptomatic children and should not always be considered abnormal. Enlarged abdominal lymph nodes exceeding 10 mm in their shortest axis in children with abdominal pain may represent mesenteric lymphadenitis of various causes.

Mesenteric lymph nodes in children: what is normal?

BACKGROUND

Enlarged mesenteric lymph nodes (MLN) are frequently seen in children with abdominal pain and, in the absence of other disorders, have been attributed to primary mesenteric lymphadenitis.

OBJECTIVE

To evaluate the prevalence of enlarged MLN (short axis>or=5 mm) as detected by abdominal CT in children with a low likelihood for mesenteric lymphadenopathy.

MATERIALS AND METHODS

During a 14-month period, we identified all non-contrast abdominal CT examinations performed at a tertiary care pediatric hospital for evaluation of suspected or known renal stones. Two radiologists reviewed the examinations and recognized all enlarged MLN, measured the short-axis diameter, and noted the quadrant location.

RESULTS

Sixty-one children were identified who met entry criteria; mean age was 10.7 years (range 1.1-17.3 years). Enlarged MLN were found in 33 (54%) of the 61 children; the largest enlarged MLN was most frequently in the right lower quadrant (RLQ) (29 of 33, 88%). Seventeen of the 61 children (28%) had three or more enlarged MLN; all were in the RLQ. The largest short-axis diameter measured was 10 mm.

SUMMARY

MLN with a short-axis diameter of >5-10 mm are commonly found on abdominal CT examination of children with a low likelihood for mesenteric lymphadenopathy and should be considered a non-specific finding. A short-axis diameter of 8 mm might better define the upper limit of normal mesenteric lymph node size in children.

Enlarged mesenteric lymph nodes in asymptomatic children: the value of the finding in various imaging modalities

The purpose of this study was to determine the prevalence of enlarged mesenteric lymph nodes in asymptomatic children. We prospectively studied 189 consecutive asymptomatic children from the outpatients' nephrological clinics who were referred for abdominal ultrasound. For comparison, we retrospectively reviewed the abdominal CT studies of 99 children, performed following blunt abdominal trauma. The children of both groups were divided into four subgroups according to their ages. The size, the number and the morphology of mesenteric lymph nodes were assessed. On abdominal ultrasound, enlarged mesenteric lymph nodes were detected in 55 of 189 asymptomatic children (29.1%). The longitudinal diameter of the lymph nodes ranged between 5 mm and 19 mm. These lymph nodes were arranged in clusters (three to nine in number in a cluster). All the lymph nodes were oval-shaped, flattened, and without any discomfort following graded transducer compression. On abdominal CT, enlarged mesenteric lymph nodes were diagnosed in 28 of the 99 children (28.3%). These lymph nodes measured more than 5 mm and were arranged in clusters (three or more in number). In seven of these children associated minimal mural thickening of the terminal ileum was seen. The presence of enlarged mesenteric lymph nodes in asymptomatic children of all ages and in both sexes is a common, non-specific finding and should be evaluated only in the appropriated clinical context.

Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings

PURPOSE

To evaluate the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of ultrasonography (US), Doppler US, and laboratory findings in the diagnosis of appendicitis.

MATERIALS AND METHODS

A total of 125 consecutive patients suspected of having appendicitis were prospectively included for US appendiceal (diameter enlarged to 6 mm or greater, intraluminal fluid, lack of compressibility) and periappendiceal (periileal inflammatory changes, cecal wall thickening, periileal lymph nodes, peritoneal fluid) evaluation, Doppler US evaluation (appendiceal wall signal), and laboratory assessment (leukocytosis, C-reactive protein [CRP]). Definite diagnoses were established at surgery in 61 patients, at endoscopy with biopsy in two patients, and at clinical follow-up in 62 patients.

RESULTS

The prevalence of appendicitis was 46%. The appendix was identified with US in 86% of the patients, which included 96% of patients with and 72% of patients without appendicitis. The most accurate appendiceal finding for appendicitis was a diameter of 6 mm or larger, with a sensitivity, specificity, NPV, and PPV of 98%. The lack of visualization of the appendix with US had an NPV of 90%. The most accurate periappendiceal finding of appendicitis was the presence of inflammatory fat changes, with an NPV of 91% and a PPV of 76%, whereas other findings had both NPV and PPV less than 65%. An increase in both white blood cell (WBC) count and CRP level had a PPV of 71%, whereas combined normal WBC count and CRP value had an NPV of 84%.

CONCLUSION

A threshold 6-mm diameter of the appendix under compression is the most accurate US finding for appendicitis and has high NPV and PPV.

Diagnostic value of ultrasonography in differentiating enteritis from intestinal neoplasia in dogs

One hundred and fifty dogs with histopathologically confirmed intestinal disease were evaluated retrospectively. Sixty-one dogs had enteritis and 89 dogs had intestinal neoplasia. Ultrasonographic findings including the thickness and distribution of the intestinal lesion, the integrity of intestinal wall layering, regional lymph node thickness, the location of the intestinal segment involved, and regional motility were evaluated. Dogs with intestinal tumor had wall thickness (1.5 cm) significantly greater than dogs with NSE lesions (0.6 cm; p < 0.001). Ninety-nine percent of dogs with intestinal tumor had loss of wall layering while 88% of dogs with NSE had normal or altered wall layering (p < 0.001). Dogs with NSE were significantly more likely to have diffuse lesion (72%) than dogs with intestinal tumor (2%; p < 0.001). Lymph node median thickness in 24/61 dogs with NSE was 1.00 cm. The median thickness of the lymph nodes in 56/89 dogs with intestinal tumors was 1.9 cm. A multivariate analysis showed that loss of wall layering alone was an excellent predictive factor in differentiating intestinal tumor from NSE. In our population, dogs with loss of intestinal wall layering were 50.9 times more likely to have a tumor than enteritis.

Mesenteric lymphadenopathy in children examined by US for chronic and/or recurrent abdominal pain

BACKGROUND

Children with recurrent abdominal pain often undergo US to confirm or exclude organic disease.

OBJECTIVE

To assess the prevalence of mesenteric lymphadenopathy on US in these children.

MATERIALS AND METHODS

We prospectively studied 189 children with recurrent abdominal pain with US of the abdomen, using graded compression. The results were compared with 73 children in a control group. The children in both groups were divided into three age groups. The size, number, morphology and location of mesenteric lymph nodes were noted, as well as additional findings. Pediatricians followed the patients from 3 months to 1 year, and a repeat US study was done in 30 children.

RESULTS

Mesenteric lymphadenopathy was present in 116 of 189 children (61.4%), with the greatest prevalence in boys in the younger age groups. The location of the nodes was mainly in the right lower quadrant. In the control group, 7 of 73 children had mesenteric lymphadenopathy, a significantly lower prevalence than in the study group ( P<0.001). Additional findings, apart from lymphadenopathy, were present in 27 (14.2%) of the 189 children in the study group, and in 5 (6.8%) of the 73 children in the control group.

CONCLUSION

Mesenteric lymphadenopathy is a common, and often the only abnormal, finding on US in children with recurrent abdominal pain.

Sonographic detection of lymph nodes in the intussusception of infants and young children: clinical evaluation and hydrostatic reduction

OBJECTIVE

Our aim was to assess the sonographic appearance of enlarged lymph nodes in the intussusception in infants and young children and to investigate whether the enlarged lymph nodes affect the hydrostatic reduction rate of intussusception.

MATERIALS AND METHODS

This retrospective case control study included a total of 65 children with intussusception, consisting of two groups: a study group of 28 patients with lymph nodes detected in intussusception and a reference group of 37 patients of similar age without lymph nodes in intussusception. The selection criterion for the study group was the presence of a minimum of two lymph nodes, of which at least one had a long axis of 11 mm or greater. The intussusception patterns, target or doughnut-like, and the presence of trapped fluid in the intussusception were also evaluated. Clinical records were reviewed for associated disease. The reducibility of both study and reference groups was assessed and correlated with all the sonographic features mentioned.

RESULTS

Twenty-two of the 28 patients in the study group and none in the reference group had a recent or a current history of gastroenteritis. The overall hydrostatic reduction rate was 46.4% in patients with enlarged lymph nodes in the intussusception and 81.1% (p < 0.005) in patients without enlarged lymph nodes in the intussusception. Larger rather than numerous lymph nodes significantly affected the reducibility rate. Most of the reference group patients had a hydrostatic reduction at first attempt, whereas a second attempt at hydrostatic reduction was required in most of the study group patients.

CONCLUSION

Enlarged lymph nodes in the intussusception are mainly found in patients with a current or recent history of gastroenteritis and decrease the overall hydrostatic reduction rate.

Sensitivity and specificity of the individual CT signs of appendicitis: experience with 200 helical appendiceal CT examinations

PURPOSE

Our goal was to determine the sensitivity, specificity, and diagnostic value of individual signs at helical appendiceal CT.

METHOD

Two hundred helical appendiceal CT scans (100 appendicitis and 100 normal appendix cases) were interpreted for individual signs of appendicitis. Scan findings were correlated with appendectomy or clinical follow-up results.

RESULTS

Individual CT signs identified and their sensitivity and specificity, respectively, included fat stranding (100%, 80%), enlarged (> 6 mm) unopacified appendix (93%, 100%), focal cecal apical thickening (69%, 100%), adenopathy (62%, 66%), appendolith(s) (44%, 100%), arrowhead sign (23%, 100%), paracolic gutter fluid (18%, 86%), abscess (11%, 100%), cecal bar (10%, 100%), extraluminal air (8%, 97%), phlegmon (7%, 99%), ileal (3%, 86%) or sigmoid (3%, 95%) wall thickening, and diffuse cecal wall thickening (0%, 91%).

CONCLUSION

Individual appendiceal CT signs of appendicitis vary in sensitivity, specificity, and thus diagnostic value. An enlarged appendix with periappendiceal fat stranding occurs in 93% of appendicitis CT cases. Less common but specific signs [cecal apical changes, appendolith(s) are usually present in the remaining appendicitis cases. Some signs seen with appendicitis (adenopathy, fat stranding, adjacent bowel wall thickening, fluid) can also be noted with alternative conditions, and in these cases normal appendix identification is the key to excluding appendicitis.

Imaging children with acute right lower quadrant pain

In summary, sonography is the primary modality for evaluating children with acute right lower quadrant pain. Sonography is particularly useful in the evaluation of children with suspected appendicitis in whom the clinical findings are equivocal, and in the evaluation of female children with suspected pelvic pathology. Findings at sonography should not supersede clinical judgement in patients who are believed to be at high clinical risk of having appendicitis on the basis of clinical signs and symptoms. Abdominal radiographs are helpful primarily if small bowel obstruction or perforation is suspected; CT is useful for evaluating complications of appendicitis and evaluating the postoperative patient.

Ultrasound in the differential diagnosis of appendicitis

The purpose of this study was to determine the accuracy of sonography in detecting diseases other than appendicitis in the clinical setting of suspected appendicitis. Six hundred and nine patients were evaluated using graded compression ultrasound (US). A broad spectrum of diseases was suggested in the group of patients who eventually turned out not to have appendicitis (n = 426), including gastrointestinal (154), gynaecological (32), biliary (11), urological (8), and miscellaneous (5) abnormalities. However, out of these there were three cases of incorrect sonographic diagnoses with serious sequelae. Appendicitis coincidental with another disease capable in itself of explaining the patients' symptoms was confirmed in seven out of 10 patients where sonographically suggested; in six patients out of this group only the suggested alternative condition was held responsible for the symptoms while the inflamed appendix was overlooked. US is of considerable value in establishing alternative diagnoses in patients with equivocal signs of appendicitis. However, one should always consider the possibility of co-existing appendicitis in patients where US has revealed another condition which could be held in itself responsible for the patient's symptoms.