A prospective, longitudinal study of central venous catheter-related deep venous thrombosis in boys with hemophilia

BACKGROUND

Central venous catheters (CVCs) are often inserted into boys with hemophilia to secure venous access for factor prophylaxis and immune tolerance induction therapy. Complications associated with CVCs include catheter-related infections, local hemorrhage, and mechanical failure. Less frequently reported is CVC-related deep venous thrombosis (DVT). We conducted a prospective study to determine the frequency and outcome of this complication.

METHODS

All boys (n = 16) with congenital hemophilia A or B with a CVC in place who were registered in the pediatric comprehensive care program at the Hospital for Sick Children, Toronto, were included in the study. They were prospectively assessed by imaging studies and clinical examinations for CVC-related DVT at two time-points, 2 years apart. Each boy was evaluated for inherited hypercoagulability.

RESULTS

Eleven (69%) of the 16 boys had radiological evidence of DVT at the first evaluation and 13/16 (81%) at the second evaluation. In two boys there was improvement in the venogram findings at the second evaluation. None of the CVC-related DVTs completely resolved. Median age at the time of initial insertion of a CVC was 1.0 years (range 0.02-6.7 years). Median duration of CVC placement was 6.4 years (range 3.3-15.5 years). Only 4/13 boys with DVTs had clinical evidence of upper venous system obstruction. Only one boy, who did not develop a DVT, had a low protein C level.

CONCLUSIONS

CVC-related DVTs occur in the majority of boys with hemophilia who have CVCs inserted for a prolonged period of time. Annual screening with imaging is recommended for boys with CVCs in place for >/= 3 years. Consideration should be given to removing CVCs as soon as peripheral venous access is feasible.

Natural history of arterial and venous thrombosis in children treated with low molecular weight heparin: a longitudinal study by ultrasound

Low molecular weight heparin (LMWH) is efficacious in preventing recurrent thromboembolic events (TEs) in children. The efficacy of LMWH in resolving thrombus in children is, however, unknown and may differ from what has been observed in adults due to known differences in the hemostatic system. We reviewed the ultrasound (US) scanning reports of children treated with LMWH in order to determine the rate and predictors of thrombus resolution. Of 245 children consecutively treated for a non-cerebral TE with enoxaparin (Lovenox, Aventis Pharma Inc., QC, Canada) for at least 5 consecutive days, 190 (78%) had serial ultrasound available for analysis. The mean follow-up time was 7 months (median 3 months, range 3 days to 6.6 years). The rate of complete thrombus resolution was 101/190 (53%, 95% confidence interval 46.2-60.2%). On univariate analysis, arterial and non-occlusive thrombus had an increased rate of resolution when compared with venous and occlusive thrombus. Age at time of TE (neonates vs. non-neonates), location of TE, initial treatment (unfractionated heparin vs. LMWH) and dose of enoxaparin were not related to outcome. On multivariate analysis, type of vessel (vein vs. artery) and occlusion (occlusive vs. non-occlusive thrombus) independently predicted outcome. In children, the rate of complete thrombus resolution is similar to the rate in adults. The clinical significance of residual abnormal vessels, specifically to the occurrence of post-thrombotic syndrome and for the diagnosis of recurrence, needs to be explored in prospective studies.

Early treatment improves growth and biochemical and radiographic outcome in X-linked hypophosphatemic rickets

X-Linked hypophosphatemic rickets (XLH) is characterized by hypophosphatemia, rickets, and impaired growth. Despite oral phosphate and 1,25-dihydroxyvitamin D(3) treatment, many patients have suboptimal growth and bone healing. The aim of this study was to assess whether age at treatment onset impacts the outcome. Growth data, biochemistry, and radiographs of 19 well-controlled patients with XLH were analyzed retrospectively. Patients were divided into two groups based on the age at treatment onset (group 1, <1.0 yr; group 2, >or=1.0 yr). The median height z-score was higher in group 1 (n = 8) than in group 2 (n = 11) at treatment onset [-0.4 SD score (SDS) vs. -1.7 SDS; P = 0.001], at the end of the first treatment year (-0.7 SDS vs. -1.8 SDS; P = 0.009), throughout childhood (P > 0.05) and until predicted adult height (-0.2 SDS vs. -1.2 SDS; P = 0.06). The degree of hypophosphatemia was similar in both groups, but serum alkaline phosphatase remained higher in group 2 throughout childhood. Radiographic signs of rickets were more marked in group 2, but even patients with early treatment developed significant skeletal changes of rickets. These data suggest that treatment commenced in early infancy results in improved outcome in patients with XLH, but does not completely normalize skeletal development.

Correlation between radiographic transition zone and level of aganglionosis in Hirschsprung's disease: Implications for surgical approach

BACKGROUND/PURPOSE

The anticipated level of aganglionosis can influence the surgical approach to Hirschsprung's disease. The aim of this study was to determine the accuracy of the contrast enema in predicting this level.

METHODS

Over a 6-year period (1995 through 2000), 88 patients with Hirschsprung's disease underwent surgical correction. Preoperative contrast enema findings were available for 75 of these patients and were compared with operative and pathology reports. Data were analyzed by chi(2).

RESULTS

The contrast enema showed a transition zone suggestive of Hirschsprung's disease in 67 of 75 patients (89%). In 59 of 67 (88%), the pathologic and radiographic transition zones were concordant. Seven of the 8 patients with discordant studies had total colonic (n = 5) or long-segment (n = 2) disease. Contrast enema correctly predicted the level of aganglionosis in 55 of 62 (89%) patients with rectosigmoid disease but only 4 of 13 (31%) of those with long-segment or total colonic disease (P <.01). Of the patients with a radiographic transition zone in the rectosigmoid, 54 of 60 (90%) had a matching level of aganglionosis.

CONCLUSIONS

In rectosigmoid Hirschsprung's disease, the location of the radiographic transition zone correlates accurately with the level of aganglionosis in 90% of cases. However, the small incidence of discordance between anticipated level of aganglionosis and operative findings should be recognized, particularly when planning a one-stage transanal pull-through.

Pediatric appendicitis in "real-time": the value of sonography in diagnosis and treatment

OBJECTIVES

To determine the accuracy of sonography in the diagnosis of clinically equivocal appendicitis, and to identify the factors leading to an inaccurate ultrasound diagnosis. The impact of sonographic findings on clinical management and outcome of children with appendicitis is examined.

METHODS

We performed a retrospective review of 317 children who attended the emergency department (ED) of a children's hospital for acute abdominal pain for which acute appendicitis was the main differential diagnosis. They had ultrasound because the diagnosis was uncertain clinically.

RESULTS

The positive predictive value of ultrasound for appendicitis was 0.92, and the negative predictive value was 0.88. The sensitivity and specificity could not be determined because there were 43 patients with equivocal ultrasound results. The pitfalls hindering the accuracy of ultrasound diagnosis included a high incidence of perforated appendicitis at presentation, the retrocecal appendix, and other technical factors such as abdominal guarding, excessive bowel gas, obesity, inadequate bladder filling, and the uncooperative patient. When ultrasound findings were combined with clinical judgment in clinical management, there were only five cases of non-therapeutic laparotomy and eight cases of delayed surgery due to missed diagnosis in our cohort.

CONCLUSIONS

Ultrasound is a useful for the evaluation of acute abdominal pain in children. However, in the setting of a pediatric hospital ED, the accuracy of ultrasound and its ability to improve early hospital triage may be reduced. Repeated clinical review is still essential and in selected cases, appendiceal CT scan may be required to guide therapeutic decision making.

Pitfalls in the sonographic diagnosis of juxtadiaphragmatic pulmonary sequestrations

BACKGROUND

Sonographic evaluation of juxtadiaphragmatic lesions is frequently the initial imaging modality of choice in the pediatric population. The increasing sophistication of sonographic and Doppler technologies has led to the suggestion in the literature that lesions suspected of being juxtadiaphragmatic pulmonary sequestrations can be confidently imaged by ultrasound examination alone.

OBJECTIVE

To present four cases which raise concern over the accuracy of sonographic examination of these lesions.

MATERIALS AND METHODS

We present four such lesions for which an initial erroneous diagnosis of pulmonary sequestration was suggested on an initial ultrasound examination.

CONCLUSION

The potential of a missed diagnosis of neuroblastoma has led us to propose that any lesion not demonstrating unequivocal sonographic findings of pulmonary sequestration should undergo further investigation and, if necessary, tissue sampling or excision.

Severe aortic thrombosis in the neonate--successful treatment with low-molecular-weight heparin: two case reports and review of the literature

Small- to moderate-sized aortic thrombi in the sick newborn are frequently demonstrated, however, severe aortic thrombosis is rarely encountered. We report two newborn infants presenting with signs of decreased lower limb perfusion shortly after birth. An occlusive infrarenal aortic thrombus was demonstrated in both infants by ultrasound. No predisposing condition for thrombosis could be found in the first infant; in the second, an umbilical arterial catheter was the likely cause. The infants were successfully treated with low-molecular-weight heparin. In both infants resolution of the thrombus was observed by ultrasound. No complications of treatment were encountered. The clinical spectrum of neonatal aortic thrombosis and treatment options are reviewed.

Fine-needle aspiration biopsy in the management of thyroid nodules in children and adolescents

We reviewed the utility of fine-needle aspiration biopsy (FNAB) in the management of thyroid nodules in 41 children and adolescents (35 girls; mean age, 13.3 years). Cytologic findings were benign in 30, malignant in 2, suspicious in 6, and insufficient in 3. The malignancy rate was 5%, with no false-negative results. Diagnostic accuracy for FNAB was 87% and inter-observer reliability was 88%. FNAB is safe and highly accurate in the evaluation of thyroid nodules in childhood.

Breast US in children and adolescents

Ultrasonography (US) is of value in the evaluation and characterization of breast masses in children. Most masses represent either normal breast tissue, cysts, or fibroadenomas. Premature thelarche may be unilateral, and normal breast tissue is found at US. Cysts are commonly retroareolar; when they become infected, they appear sonographically as a complex mass. Fibroadenoma is the most frequent breast tumor in adolescent girls, and it is usually solitary, homogeneous, and hypoechoic. Malignant breast lesions are very rare in children; most are due to metastatic disease secondary to rhabdomyosarcoma, leukemia, lymphoma, and neuroblastoma, and their US appearance is nonspecific. Gynecomastia in boys can be mimicked by general obesity and pectoral hypertrophy; US is helpful in the diagnosis, especially when gynecomastia is asymmetric. Most breast lesions in children and adolescents are benign, and surgery should be avoided to prevent later deformity. US is the ideal imaging modality to evaluate breast lesions and may be used to guide a fine-needle aspiration biopsy. Color Doppler US evaluation is helpful; cysts are avascular, fibroadenomas may be avascular or hypovascular, and abscesses show peripheral increased flow. Bloody nipple discharge is more common in prepubertal patients, may occur in infants, and may be secondary to mammary ductal ectasia. Discharge commonly resolves spontaneously, and findings at US are frequently normal.

Carotid artery distensibility and cardiac function in adolescents with type 1 diabetes

OBJECTIVE

To determine the presence and correlates of early heart and blood vessel dysfunction in adolescents with type 1 diabetes mellitus (DM) of relatively short duration.

STUDY DESIGN

A total of 33 patients with DM (20 male, mean age 15.8 +/- 1.3 years, mean DM duration 9.3 +/- 3.9 years) and 16 healthy subjects in a nondiabetic control group (7 male, mean age 17.4 +/- 1.7 years) underwent (1) ultrasonography of the right carotid artery to assess distensibility, compliance, and intimal-medial thickness (IMT), (2) echocardiographic assessment of systolic and diastolic ventricular function, (3) lipid profile and hemoglobin A(1c), and (4) overnight timed urine collections for albumin excretion rate.

RESULTS

Ultrasonography showed significantly lower carotid artery distensibility in the DM group (38.5 +/- 8.2 x 10(-3) vs 46.5 +/- 11.7 x 10(-3)/kPa, P =.01) but no difference in compliance (14.0 +/- 3.4 x 10(-7) vs 15.8 +/- 2.9 x 10(-7)m(2)/kPa, P =.08) or IMT (0.061 +/- 0.013 vs 0.060 +/- 0.014 cm, P =.77). Left ventricular (LV) end-diastolic diameter, LV posterior wall thickness, end-systolic wall stress, shortening fraction, ejection fraction, LV mass, and diastolic function were similar in both groups. Total cholesterol, low density lipoprotein, high density lipoprotein, triglycerides, and blood pressure were also similar. The median albumin excretion rate was 4.8 microg/min in the DM group (range 1.1 to 19.2) and 3.0 microg/min in the control group (range 1.4 to 5.8) (P =.03). Hemoglobin A(1c) correlated inversely with both distensibility (r = -.43, P =.02) and compliance (r = -.39, P =.032).

CONCLUSIONS

This study indicates that early changes in macrovascular function, namely lower carotid artery distensibility, may precede abnormalities in cardiac function or in arterial IMT in adolescents with short duration type 1 DM. It also supports a relationship between hyperglycemia and carotid artery dysfunction.

The impact of imaging in the management of intussusception owing to pathologic lead points in children. A review of 43 cases

OBJECTIVE

To review the imaging appearances, management and outcome of a large number of children with intussusception owing to pathologic lead points (PLP) in an attempt to define the role of various imaging modalities in this clinical setting.

MATERIALS AND METHODS

Review of the records and imaging studies of 43 children with intussusception due to PLP diagnosed between 1986 and 1999.

RESULTS

The commonest PLP found were Meckel diverticulum, polyps, Henoch-Schonlein purpura and cystic fibrosis. PLP were depicted on sonography in 23 (66%) of 35 patients, on computed tomography in 5 (71%) of 7, on air enema in 3 (11%) of 28, and on barium enema in 6 (40%) of 15. Air enema successfully reduced 60% of the intussusceptions. Nine children had recurrent intussusceptions.

CONCLUSION

Sonography depicted two-thirds of PLP and provided a specific diagnosis in nearly one-third of our series. Our review does not provide sufficient data on how to continue the investigation of those patients in whom sonography does not depict a PLP but in whom there is a high index of suspicion for its presence. It remains a diagnostic challenge as to how to search for PLP in these patients, and other imaging modalities have to be requested according to each particular case.

Multiple unilateral renal cysts in two children

We report two children who presented with multiple renal cysts involving only one kidney and in whom there was no family history of renal disease and who did not have syndromes known to be associated with renal cystic disease. This unilateral involvement may represent a distinct entity, which has only been previously described in three cases; however, long-term follow-up will be needed to confirm this hypothesis. We illustrate the sonographic and computed tomographic findings, and the differential diagnosis is discussed.

Malignant peripheral nerve-sheath tumor arising in a previously irradiated neuroblastoma: report of 2 cases and a review of the literature

BACKGROUND

Only ten cases of the rare occurrence of a malignant peripheral nerve-sheath tumor (MPNST) arising in a ganglioneuroma either de novo or at a site of previous irradiation have been reported.

PATIENTS AND METHODS

We present two children who at the age of 19 months and 6 months were diagnosed with a cervicothoracic ganglioneuroblastoma and a retroperitoneal neuroblastoma, respectively. They both received radiation therapy as part of the treatment of their disease.

RESULTS

Following a 12-year interval, MPNST arose inside a benign ganglioneuroma in both patients. We illustrate the imaging findings in these two cases and review the cases reported in the literature to increase awareness of this association among radiologists.

Gastric perforation attributable to liquid nitrogen ingestion

Despite the widespread use of liquid nitrogen in medicine and industry, there are only a few reports of injuries associated with its use. We report a case of a 13-year-old boy who developed gastric perforation after liquid nitrogen ingestion. This is a previously unreported complication.

Spontaneous reduction of intussusception: clinical spectrum, management and outcome

BACKGROUND

To analyze the spectrum of clinical features, management and outcome of children with documented spontaneous reduction of intussusception (SROI).

MATERIALS AND METHODS

Review of records of 50 children (33 boys, 17 girls; age range 11 days-15 years; mean age 4 years) with documented SROI, in whom intussusception was initially diagnosed by sonography (US) in 44, air enema in 2, and computed tomography in 4, in the 6-year period 1992-1998.

RESULTS

Symptoms suggestive of intussusception were present in 21 (3 of whom had Henoch-Schönlein purpura and 4 had previous ileocolic intussusception reduced by air enema). Intussusception was an incidental finding in the other 29, in 28 of whom the finding was in the small bowel. Intussusception was limited to the small bowel in 43 and was ileocolic in 7. SROI was usually documented on US. Laparotomy performed in only 4 showed no evidence of intussusception or pathologic lead point. Outcome in all patients was favorable.

CONCLUSIONS

SROI may present in symptomatic or asymptomatic children and occurs more commonly than previously reported. These intussusceptions are usually short-segment, small-bowel intussusceptions with no recognizable lead point. In asymptomatic patients, conservative observation is warranted. Intervention should be dictated by the clinical findings in symptomatic patients.

Clinical utility of adrenal ultrasonography in the diagnosis of congenital adrenal hyperplasia

Rapid, accurate diagnosis of congenital adrenal hyperplasia (CAH) is essential in the neonate with ambiguous genitalia, life-threatening salt loss, or both. We aimed to determine the accuracy of adrenal ultrasonography in the diagnosis of CAH in a retrospective analysis of 52 children with ambiguous genitalia or salt-losing crises. Adrenal ultrasounds were interpreted as follows: "normal" if the adrenals were normal in size (adrenal limb width <4 mm), had a smooth surface, and a central echogenic stripe with a hypoechoic rim, and "abnormal" if they were increased in size (limb width >4 mm), had a lobulated or cerebriform surface, or showed abnormal echogenicity. Group 1 consisted of 25 neonates and infants with CAH; group 2, 19 children with conditions other than CAH; and group 3, 8 with treated CAH: 7 receiving replacement therapy and 1 whose mother received glucocorticoids during pregnancy. In all children in groups 2 and 3, adrenal ultrasounds were read as normal. In group 1 adrenal ultrasonography was normal in 2 (8%) and abnormal in 23 (92%). Thus adrenal ultrasonography has a sensitivity of 92% and a specificity of 100% for diagnosing CAH. Adrenal ultrasonography is a highly sensitive and specific adjunct in the diagnosis of CAH. The presence of enlarged, lobulated adrenals with stippled echogenicity is invariably associated with CAH.

A trial of growth hormone therapy in well-controlled hypophosphataemic rickets

OBJECTIVE

Conventional therapy of hypophosphataemic rickets (HR) with oral phosphate and calcitriol does not always result in normal linear growth. Recombinant human growth hormone (rhGH) offers theoretical advantages as an adjunctive therapy. We aimed to determine the effects of adjunctive rhGH therapy in children with well-controlled HR.

PATIENTS

In this report, 5 prepubertal children (aged 3.5-10.9 years) with well-controlled HR on conventional therapy were given adjunctive standard dose rhGH therapy for one year.

DESIGN AND MEASUREMENTS

Height, growth velocity, metabolic markers of calcium and phosphate metabolism, body composition, bone mineral density, wrist and knee X-rays, and renal sonography were assessed at regular intervals. Height and growth velocities were also calculated 12 months after ceasing rhGH therapy.

RESULTS

After 12 months therapy with rhGH, no significant biochemical or radiological benefits were observed. A significant increase in height SD score was observed (P = 0.023), but this was not associated with any increase in the growth velocity SD score and appears to have been due to catch-up growth caused by conventional therapy alone. When rhGH therapy was ceased, no significant decreases in mean height SD or growth velocity SD scores were observed.

CONCLUSIONS

In well-controlled hypophosphataemic rickets patients receiving conventional therapy, adjunctive therapy with standard dose rhGH offers no benefits in linear growth or rachitic disease markers.

Nonocclusive small bowel infarction in familial dysautonomia syndrome

The authors report a case of a 14-year-old boy with familial dysautonomia (FD) in whom a small-bowel infarction developed during a dysautonomic crisis. Atypical features of the presentation included hypotension with prolonged fever and abdominal distension. The authors postulate that the bowel infarction was caused by prolonged hypoperfusion. It is recognized that the small bowel in normal subjects can adapt to periods of ischemia without irreversible injury. The authors speculate that the known abnormal systemic cardiovascular regulation in patients with FD may adversely affect splanchnic blood flow, which led to the catastrophic consequences in this case. This report draws attention to the risk of significant ischemic complications during a dysautonomic crisis, especially in the face of atypical features, and emphasizes the challenging cardiovascular management of such patients.

Malignancies in pediatric patients with ataxia telangiectasia

BACKGROUND

Patients with ataxia telangiectasia (AT), known to have an inherent increased susceptibility to the development of cancer, may present with malignancies that are unusual for the patient's age, are often difficult to diagnose clinically and radiographically and respond poorly to conventional therapy.

MATERIALS AND METHODS

We reviewed the clinical presentation and imaging studies of 12 AT patients who developed malignancies.

RESULTS

Eight of the twelve patients developed non-Hodgkin's lymphoma (CNS, thorax, bone), two developed Hodgkin's disease, and two were diagnosed with gastrointestinal mucinous adenocarcinoma.

CONCLUSION

The lymphomas were commonly extra nodal, and infiltrative rather than mass-like. The recognition of the tumors was often delayed due to confusion with the known infectious complications in AT patients.

Unsuccessful air-enema reduction of intussusception: is a second attempt worthwhile?

Pneumatic reduction of idiopathic intussusception is successful in about 80% of cases, while 60% of the failures are reduced at surgery without resection. To determine whether delayed, repeated attempts at enema reduction of failures would reduce the need for operation in selected cases, over a 2-year period (1994-1996 inclusive), 17 infants with idiopathic intussusception underwent delayed repeat enemas 2-19 h following the first failed attempt at reduction. Clinical parameters and radiologic findings were evaluated with respect to outcome. Ten intussusceptions were successfully reduced after the second attempt in 9 and after the fourth attempt in 1. Seven children underwent a laparotomy, 5 because of failure of progressive reduction at air enema (AE). Two were taken to surgery early in the series, 1 because of perforation during a second attempt and 1 while awaiting a third reduction attempt. The 10 successful reductions all showed progressive movement of the intussusceptum on each AE; the 2 who perforated failed to show progressive reduction on their second AE. Because of these cases, the remaining 5 were referred to surgery because of failure of progressive reduction of the intussusceptum on the second attempt. At laparotomy, of the 7 unsuccessful reductions, 4 required resection and 3 had difficult manual reduction. The presence of vomiting, a mass, and/or bloody stools were not predictors of outcome. Failures had higher body temperatures (38.1 +/- 0.3 vs 37.4 +/- 0.1 degrees C, P = 0.07), heart rates (153.7 +/- 8 vs 136.9 +/- 2.1 min, P = 0.03), and longer duration of symptoms (36.8 +/- 4 vs 21.3 +/- 3.6 h; P = 0.01) than successes. Delayed repeat AEs may be safe and effective in selected cases of idiopathic intussusception, but should be considered only if significant movement of the intussusceptum is noted at each attempt. The ideal time for repeat AE reduction prior to surgery is not established, but 2-4 h appears appropriate. Pyrexia, tachycardia, and duration of symptoms greater than 36 h are relative contraindications to this course of management.

Observer reliability in grading nephrocalcinosis on ultrasound examinations in children

BACKGROUND

Nephrocalcinosis is often associated with a variety of hypercalcemic conditions. Diagnostic ultrasound is often used for assessing nephrocalcinosis in children, but its reliability has not been proven.

OBJECTIVE

To determine the reliability of expert interpretation of sonographic films with a grading scale of severity for nephrocalcinosis.

MATERIALS AND METHODS

Fifty-eight ultrasonographic films of 30 children with Williams syndrome and other conditions know to be associated with nephrocalcinosis were assessed. We used a blinded randomized design to assess intra- and interobserver reliability.

RESULTS

Grades I, II, and III nephrocalcinosis were noted in 13 %, 19 %, and 27 % of the examinations, respectively. The weighted kappa coefficient was 0.80 (standard error 0.12; 95 % confidence interval 0.68-0.92) for intraobserver agreement and 0.76 (standard error 0.13; 95 % confidence interval 0.63 to 0.89) for interobserver agreement. Reliability in assessing change from one examination to the next, with independently graded films, was fair with an unweighted kappa coefficient of 0.68 (95 % confidence interval 0.38-0.96) and 0.51 (95 % confidence interval 0.21-0.80) for intra- and interobserver reliability, respectively.

CONCLUSION

The severity of nephrocalcinosis can be reliably interpreted with an ultrasonography grading scale.

Neonatal adrenal congestion: a sonographic-pathologic correlation

We reviewed the clinical, sonographic and pathologic findings in eight neonates in whom diffuse enlargement and abnormal echogenicity of the adrenal glands was documented sonographically. Four of the patients suffered from perinatal asphyxia and two others required mechanical ventilation for other reasons. Six patients died and one suffers from severe development delay, cerebral palsy and failure to thrive. Sonographically, the glands were enlarged, their surface was smooth and there was loss of the central echogenic stripe. Diffuse sinusoidal congestion was found histologically in all five in whom autopsies were performed. These sonographic findings represent part of the spectrum of adrenal changes in neonatal asphyxia and other causes of perinatal stress, and may be associated with poor outcome because of other sequelae of asphyxia.

Patterns of recurrence of intussusception in children: a 17-year review

PURPOSE

Patterns of recurrence of intussusception (INT) were reviewed to determine whether changes in management have affected the rate and patterns of recurrence as well as long-term outcome in children with multiple (i. e., 2 or more) recurrences.

MATERIALS AND METHODS

Review was done of 763 children with 876 intussusceptions, including (1) recurrence rate, (2) patterns of recurrence (number of and interval between recurrences), (3) reducibility, (4) pathologic lead points (PLP), (5) operative findings and (6) long-term follow-up in those with multiple recurrences.

RESULTS

Above features (1)-(6) were the same in those managed with barium enema (1979-1985) and those managed with air enema (1985-1996). Overall recurrence rate was 9 %; 11 % with barium enema and 8 % with air enema. Sixty-nine patients had 113 recurrences: 47/69 (68 %) and 1 recurrence and 22/69 (32 %) had multiple recurrences. Multiple recurrences presented as isolated episodes or in clusters up to 8 years. Reducibility was 100 % for initial INT and 95 % for recurrent episodes; there were no perforations. Surgery, in 4 with irreducible recurrence, revealed no PLP. PLP were present in 5 (8 %): 2 (4 %) with 1 recurrence and 3 (14 %) with multiple recurrences. No pattern of recurrence was predictive for PLP. Long-term follow-up (up to 15 years) available in 11 with multiple recurrences revealed a favourable outcome.

CONCLUSIONS

Rates and patterns of recurrence did not change with altered management. Because of the high reduction rate of recurrences, lack of perforation and favourable long-term follow-up, we recommend radiological reduction for recurrent INT. Multiple recurrences are not a contraindication. A careful search for PLP is mandatory. Surgery should be reserved for irreducible recurrences or for demonstrated PLP.

The value of sonography, CT and air enema for detection of complicated Meckel diverticulum in children with nonspecific clinical presentation

BACKGROUND

Complicated Meckel diverticulum (MD) in children does not always present with painless rectal bleeding and its presentation can then produce a difficult diagnostic dilemma. In this clinical setting, sonography (US), CT or even air enema may be the first modality chosen to evaluate these children rather than the radionuclide Meckel scan (RNMS).

PURPOSE

To assess the value of US, CT and air enema for detection of complicated MD.

MATERIALS AND METHODS

Review of clinical, imaging, surgical and pathological findings in 64 children (55 males, 9 females) aged 4 days -14 years (mean = 3.7 years) with MD seen during an 8-year period, 1990-1997.

RESULTS

(a) In 33 patients with rectal bleeding, MD was detected on RNMS in 32. Ten of these 32 had other imaging studies, all of which were negative. (b) The other 31 patients, with varied clinical presentations, did not undergo RNMS. In these 31 and the 1 with a negative RNMS, 14 (44 %) had imaging features highly suggestive for the diagnosis of MD on US in all 14, on CT in 1, and on air enema in 3. The radiological spectrum of the inflamed, hemorrhagic MD is illustrated.

CONCLUSION

The inflamed, hemorrhagic and the inverted, intussuscepted MD have a spectrum of features recognizable on US, CT and air enema. Some of these appearances are specific, others are not. Knowledge of and recognition of these features will facilitate detection of complicated MD in larger numbers of children presenting with symptoms other than the classic history of painless rectal bleeding and also in those with normal RNMS.

Asymmetric medullary nephrocalcinosis in two children

Medullary nephrocalcinosis (MNC) is usually a bilateral process with symmetric involvement of both kidneys. Asymmetric medullary nephrocalcinosis has been previously reported in the literature, but has not been well illustrated or explained. We report the sonographic findings in two pediatric patients with hypercalcemia. In both patients an unrelated unilateral renal abnormality, (renal vein thrombosis in one and obstructive hydronephrosis in the other) prevented the development of MNC in the affected kidney, probably by decreasing the glomerular filtration rate and/or altering the renal tubular function.

Colo-colic intussusception associated with pneumatosis cystoides intestinalis

This paper describes pneumatosis cystoides intestinalis in association with colo-colic intussusception in a young teenager. The intussusception was easily reduced at barium enema. The recognition of the characteristic filling defects in the barium column facilitates a correct diagnosis. This association has only been reported previously in six adults.

Congenital thymic cysts in children--mostly misdiagnosed

BACKGROUND/PURPOSE

Thymic cysts are rare lesions of the neck and mediastinum that are difficult to diagnose. Often considered inconsequential, these lesions can frequently be symptomatic. In this report the authors contrast their experience with that of the literature.

METHODS

From 1984 through 1997, the authors encountered 14 patients with this lesion. All cysts were completely excised. Patients that had an acquired cyst of the thymus were excluded from this series.

RESULTS

Of the 14 patients ranging in age from 2 weeks to 16 years, seven patients had cervical masses, five had mediastinal masses, and two children had both sites involved. Seven children were symptomatic with wheezing and upper respiratory infection, with cough and fever being the most common clinical features. Investigations included chest radiograph, contrast esophagram, sonography (US) and computerized tomography (CT). Displacement of vital mediastinal or neck structures was observed in eight patients. Only two patients received correct diagnosis before surgery. Successful and complete excision of all cysts was achieved. The cysts were benign and ranged in size from 2 to 22 cm in diameter.

CONCLUSION

Often forgotten, thymic cysts are rare benign lesions that should be considered in the differential diagnosis of cervical and mediastinal masses in children.

Periventricular band of increased echogenicity: edema or calcification?

This paper illustrates the cases of two infants with an identical appearance of a periventricular band (PVB) of increased echogenicity on cranial sonography, shown on CT to be due to edema in one and calcification in the other. Such a PVB due to edema has not been reported previously, and its similarity to calcification on sonography is emphasized.

Non-operative management of traumatic pancreatic pseudocysts associated with pancreatic duct laceration in children

Objective. To assess the successful non-operative management in traumatic pancreatic pseudocysts (TPP) associated with duct laceration in children. Surgical therapy (cystogastrostomy or distal pancreatectomy with splenic salvage) has been classically considered the treatment of choice for those pseudocysts. Materials and methods. This report presents the clinical and imaging findings in two children with TPP and pancreatic duct disruption observed either on endoscopic retrograde cholangiopancreatography or injection via catheter drainage. Results. Both children responded to long-term cyst drainage. Conclusion. Although the experience is limited, the authors suggest that pancreatic injury associated with duct laceration can respond to non-operative management.

Disappearing suprarenal masses in fetuses and infants

This paper presents 12 infants (9 boys, 3 girls) in whom the diagnosis of a suprarenal mass (10 left, 2 bilateral) was made on antenatal sonography. All were otherwise healthy neonates who were born at term after a normal pregnancy, labor and delivery. The masses ranged from 1 to 3.5 cm in diameter on initial scans at gestational ages of 19-35 weeks. Eleven masses were hyperechoic and 4 of these contained small, well-defined cysts. The 12th was hypoechoic. Follow-up sonography showed complete disappearance of the mass antenatally in 1 case and postnatally by 4-6 months in 5 cases; there was marked diminution in the size of the mass by 2 months of age in 4 infants, by 4 months in 1 case and by 15 months in 1 case. Eleven were managed nonoperatively. Laparotomy (after disappearance of the mass) in the 12th case revealed only some fibrous tissue. The 11 echogenic masses resemble previously reported imaging findings in infants with histologically proven intra-abdominal sequestrated lung. Conservative management with careful sonographic follow-up should, therefore, be considered in otherwise healthy fetuses or neonates with these imaging findings. We are less certain what the hypoechoic mass represented.

The appearance of inverted Meckel diverticulum with intussusception on air enema

This paper presents the appearances of inverted Meckel diverticulum with an irreducible intussusception on air enema in four children. The inverted Meckel diverticulum appeared as a bulbous (3) or triangular (1) filling defect in the air column projecting off the distal end of the soft tissue mass of the irreducible intussusceptum. The bulbous defect appears to be highly suggestive, and may be specific, for inverted Meckel diverticulum. Earlier recognition of the presence of the Meckel diverticulum as the lead point of the intussusception could have changed the management in two of the children.

The diagnosis of malrotation during air enema procedure

This paper describes the correct diagnosis of cecal malposition, suggesting midgut malrotation, during air enema examination in seven patients. It is possible to diagnose cecal malposition by air enema, even in the presence of a reducible intussusception.

Abdominal calcification in cystic fibrosis with meconium ileus: radiologic-pathologic correlation

BACKGROUND

There is confusion in the radiological literature as to the site of abdominal calcification in cystic fibrosis (CF) with meconium ileus (MI) in neonates.

PURPOSE

To correlate the site of radiographic abdominal calcification with histologic and operative findings.

MATERIALS AND METHODS

A review of clinical, radiographic, surgical and histologic data in 58 neonates with CF and MI.

RESULTS

Abdominal calcification was identified in 15 (26 %) neonates: on an abdominal radiograph in 8 (13 %), at laparotomy in 3 and histologically in 10 (37 %) of the 27 resected specimens. The radiographic pattern of calcification varied from small specks in three cases to small, better-defined areas in two. In the other three patients, the calcification was more extensive and curvilinear. Histologically, calcification was found to be intramural in ten resected specimens, of which two also had intraluminal and one serosal calcification. The more extensive, curvilinear calcification identified radiographically correlated with histologically proven dystrophic intramural calcification. The less marked flecks or discrete areas of radiographic calcification may represent intramural, serosal or intraluminal calcification.

CONCLUSION

Intramural calcification is common microscopically in CF with MI. Extensive radiographic calcification in these patients is more likely to represent intramural rather than serosal or intraluminal calcification.

Large adrenal cysts in teenage girls: diagnosis and management

Large adrenal cysts usually occur in the fifth and sixth decades of a patient's life but are rare in the first two decades. This paper presents the clinical, cross-sectional imaging, surgical, pathological and follow-up data of three teenage girls with large adrenal cysts. Two had vague upper abdominal pain and, in the other, the cyst was found incidentally. The cysts were surgically removed in two patients, while in the third, follow-up imaging has shown no change in the cyst over a 4-year period, suggesting that conservative management is a reasonable option.

An unusual position of the gallbladder following nephrectomy for large neoplasms

The cases of two children are presented in whom the gallbladder was found to lie in an unusual position in the ipsilateral renal fossa following nephrectomy for large neoplasms. This postoperative visceral position must be recognized, as the appearance on cross-sectional imaging can mimic postoperative fluid collections at the resection site or tumor recurrence.

Sonographic appearances of inverted Meckel diverticulum with intussusception

This study illustrates the sonographic findings of inverted Meckel diverticulum acting as a lead point of an intussusception in five patients. In four patients, the inverted diverticulum was seen as a segment of blind-ending, thick-walled bowel projecting for a variable distance from the apex of the intussusceptum. The larger diverticula had a characteristic bulbous shape. The central serosal surface of the inverted diverticulum was filled with fluid in one patient, with fluid and fat in another, and with echogenic fat only in the other two. The presence of fat was confirmed by CT in one patient. The features illustrated in these four patients appear to be specific. In the fifth patient, the sonogram revealed a nonspecific echogenic mass at the apex of the intussusceptum. Recognition of these features on sonography may obviate the need for further investigation.

Nodular hyperplasia in treated congenital goitrous hypothyroidism

Two patients with congenital goitrous hypothyroidism, treated since birth, are described. Each developed progressive nodular thyroid enlargement in adolescence, possibly related to ongoing thyroid stimulation due to slight and transient elevations of thyroid stimulating hormone (TSH) levels. The incidence and degree of persistent thyroid enlargement in these patients has not been well documented. If present in a significant number of patients despite appropriate L-thyroxine replacement, our therapeutic aims in congenital goitrous hypothyroidism may need to be modified to achieve TSH suppression, rather than normalization.

Intussusception. Issues and controversies related to diagnosis and reduction

Diagnosis and management of intussusception remain controversial. The authors discuss the evolution of changes and advances in practice and procedures. They advocate sonographic diagnosis and air enema reduction; the abdominal radiograph is reserved for children with clinical evidence of peritonitis and suspected perforation, if clinical findings are unusual, or if the sonographic examination is equivocal.

Intussusception: ability of fluoroscopic images obtained during air enemas to depict lead points and other abnormalities

PURPOSE

To evaluate the ability of fluoroscopic images obtained during air enemas to depict or exclude lead points of intussusceptions and other abnormalities that require surgical treatment in the absence of intussusception.

MATERIALS AND METHODS

The clinical, radiologic, surgical, and pathologic findings were reviewed in 14 patients with lead points or other lesions.

RESULTS

Fluoroscopic images failed to depict a lead point in 10 patients. The air enema easily reduced intussusceptions with benign lead points in seven patients. Fluoroscopic images depicted pathologic lead points in two patients and were normal in two patients with intussusception. Fluoroscopic images failed to depict an abnormality that required surgery in the absence of intussusception in two patients.

CONCLUSION

Successful reduction of an intussusception does not always rule out a lead point. Other imaging studies, the patient's condition, and laparotomy may also be necessary to diagnose and treat lead points and other lesions.

Bochdalek's hernia completely reduced by spontaneous ipsilateral tension pneumothorax

This report describes a premature (29 weeks gestation) infant with a left Bochdalek's diaphragmatic hernia, in whom the development of a spontaneous ipsilateral tension pneumothorax caused complete reduction of the hernia into the abdomen. In the presence of a tension pneumothorax, a diaphragmatic hernia may be masked on a chest radiograph and therefore difficult to diagnose.

Perforation during attempted intussusception reduction in children--a comparison of perforation with barium and air

This paper compares the effects on patients of perforation with barium and with air during attempted intussusception reduction by reviewing the clinical, radiological, surgical and pathological findings and sequelae in seven children who received barium and seven who received air. In both groups perforation occurred in infants under 6 months of age (with one exception) with a long duration of symptoms. All patients with barium enema required resection of bowel whereas only four with air enema required resection. Anesthetic times were longer in those patients with barium perforation in whom the intussusception did not move and there was a large leak. The patients with perforation due to air had a shorter hospital stay with decreased morbidity compared to those with perforation due to barium. Perforation occurred through areas of transmural necrosis in a minority of patients in each group. Perforations through normal bowel and shear injury (with air enema) indicate that increased pressure during the examination is an important factor in some patients. Because perforation with air is so much easier to deal with surgically and the children do better clinically, there is a tendency for some to consider perforation with air an inconsequential situation. However, a potential rare complication with this technique is tension pneumoperitoneum. Keeping this in mind, we continue to use air as the contrast of choice because the procedure in our hands is a safe, quicker and easier technique and we have achieved a substantial improvement in reduction rates. Overall reported perforation rates with air enema compare favourably with those due to barium enema.(ABSTRACT TRUNCATED AT 250 WORDS)