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A Case Based Approach to Ultrasound in Git A CASE BASED APPROACH TO ULTRASOUND IN GIT DR NICKY WIESELTHALER RADIOLOGY CONSULTANT RED CROSS CHILDREN’S HOSPITAL Ultrasound= No Radiation!!! 1 CXR= 0.02 mSv ( effective dose that calculates dose absorbed) 1 AXR= 0.8mSv 40 CXRs 1 CT Chest = 3-5mSv 250 CXRs 1 CT Abdomen = 10mSv 500 CXRs 1 CT head = 2mSv 100 CXRs 1 PET CT = 25mSv 1250 CXRs Courtesy of Dr Tracy Kilborn Some Basics Know your machine…WELL Settings and Probes- when to use what Size of patient versus body part Use your application experts! Descent history- what am I looking for? Why am I doing this? Starve patients 3-4 hours before Patient versus parent cooperation ?? Use of sedation Lets start with everyone’s favourite topic…. JAUNDICE Differential diagnosis of neonatal cholestatic liver disorders Structural Extrahepatic biliary atresia Choledochal cyst Caroli’s syndrome Choledocholithiasis Alagille’s syndrome Nonsyndromic bile duct paucity Undersized extrahepatic biliary system (biliary hypoplasia) Neonatal sclerosing cholangitis Infection Viral - Cytomegalovirus - Herpes simplex - Adenovirus - Enterovirus - Parvovirus B19 - Hepatitis B virus Bacterial infection (sepsis or remote from liver [eg, urinary tract infection]) Genetic Toxoplasmosis Cystic fibrosis Syphilis Trisomy 21 Metabolic Trisomy 18 Alpha-1-antitrypsin deficiency Neoplastic Galactosemia Neuroblastoma Tyrosinemia Hepatoblastoma Hereditary fructose intolerance Histiocytosis X Glycogen storage disease type IV Toxic Lipid storage disease Drug induced - Niemann-Pick disease type A Total parenteral nutrition - Niemann-Pick disease type C Endocrine - Gaucher’s disease Panhypopituitarism - Wolman’s disease Hypothyroidism Mitochondrial enzymopathies (including fatty acid oxidation disorders) Immune Peroxisomal disorders (eg, Zellweger syndrome) Neonatal lupus erythematosus Bile acid synthesis disorders Vascular Progressive familial intrahepatic cholestasis syndromes Budd-Chiari syndrome - FIC-1 protein deficiency (PFIC 1) Congestive heart failure - Bile salt export pump deficiency (PFIC 2) Hepatic hemagiomatosis - MDR3 protein deficiency (PFIC 3) Idiopathic North American Indian familial cholestasis Urea cycle defects Paediatr Child Health Vol 9 No 10 December 2004 Initial investigations for conjugated hyperbilirubinemia Blood Liver panel: aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase, total bilirubin, conjugated bilirubin and albumin Coagulation studies (prothrombin time/international normalized ratio, partial thromboplastin time) Complete blood count and differential with smear Toxoplasmosis, other infections, rubella, Cytomegalovirus infection and herpes simplex (TORCH) serology Blood culture Hepatitis B surface antigen Glucose/serum lactate/serum amino acids/ammonia Thyroxine, thyroid-stimulating hormone Iron studies, ferritin Galactosemia screen Urine Reducing substances Organic acids Bacterial culture Urine Cytomegalovirus (positive result before four weeks of age is highly suggestive of congenital Cytomegalovirus) Imaging Abdominal ultrasound (evaluate for mass, choledochal cyst, small gallbladder, triangular cord sign) Neonate with conjugated hyperbilirubinaemia ANATOMICAL FORMS OF BA- extent of fibrous obliteration of the EHBD is variable GB small or GB small with GB normal / large atretic irreg and empties after wall/contour feed and does not empty after feed Triangular Cord Triangular/Tubular echogenic cord of fibrous tissue in the porta hepatis Measured as >4mm thickness of the echogenic anterior wall of the R PV in longitudinal US High specificity for diagnosis of BA 4mnths old – prolonged conjugated hyperbilirubinaemia Diagnosis of BA is made if you see a macrocyst or microcyst at porta without BD dilatation GOLD STANDERD= intraoperative cholangiogram to diagnose BA Diagnosis BA RULED OUT if there is bile duct dilatation 2month old conjugated hyperbilirubinemia and hepatomegaly ?? Missed BA 2 and half year old: RUQ pain and pale stools . No jaundice 13 day old with conjugated hyperbilirubinemia 18 mnths old: pallor and Splenomegaly No Hepatomegaly Or could have presented with ….hematemesis and oesophageal varices Normal liver Sclerosing Cholangitis CF with Steatosis AI Hepatitis with Cirrhosis MSK with congenital Hepatic Fibrosis Failed Kasai 5mnth old twin with diarrhoea, vomiting, LOW and a mass 17d old with a liver mass BUT AFP was normalising?? Haemangioendothelioma VS Hepatoblastoma?? Arterial phase PV phase Follow up 6 months later 12 years vomiting ,abdo pain 1 week from EC tender RUQ HYDATID 2y7m female with dysentery and vomiting, septic: RUQ tenderness. ? Mass. 3 yr old with tender distended abdomen and fever ?mass in RUQ ‘image findings alone were inadequate in distinguishing pyogenic from amoebic liver abscesses. However, when the sonographic findings were coupled with clinical and laboratory data, a correct diagnosis was possible in 83 (86%)’ AJR Am J Roentgenol. 1987 Sep;149(3):499-501 4yr old referred from EC with pain, vomiting and deteriorating LFT’s… due to….. 10yr old boy with Thalassaemia on the hypertransfusion programme, presents with increasing jaundice, raised LFT’s and abdo pain. Moving away from the Liver.. Take your pick…LOW, fever, night sweats ,abdo distension, positive TB contact, TBM, TB on CXR… Points to remember re TB Nodes in abdo common Significant if >10mm in trv diameter If huge and multiple: diff diag = lymphoma HIV + sometimes both!! Check for splenic lesions with high res probe! Look for HIVAN 7 month old with red current jelly stool and abdominal cramping INTUSSUSCEPTION- Length of history Free fluid Flow Assoc masses 6 weeks male projectile vomiting HPS Find the GB 5, 10, 15mm 2yr old vomiting, abdo pain, leucopaenia, 12yr fever and RIF pain. Previous UTI’s ILEITIS…? TB or Chron’s Dx 2yr old: Lymphoblastic Lymphoma on chemo INFECTIVE COLITIS /TYPHLITIS 12 yrs old fell over bike handlebars 10 days ago. CT: grade 4 laceration pancreatic neck 2yr old FTT, anaemia, abdo mass Echogenic inner lining +hypoechoic rim = ENTERIC DUPLICATION CYST Thank you.
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