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Hypertrophic Pyloric Stenosis

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Hypertrophic Pyloric Stenosis Imaging of Pediatric Abdominal Disease Mark S. Finkelstein DO, FAOCR Department of Medical Imaging What is our goal? . Familiarize pediatricians to a variety of common pediatric GI disorders . Outline a practical approach to imaging pediatric GI diseases . Review current methods & discuss current imaging techniques for the evaluation of pediatric GI disease What is the purpose of the plain film abdomen study? . Foundation of GI imaging . Distinguishes surgical vs. non-surgical disease . Considerations – AP supine: . Used to evaluate vague or chronic abdominal pain – Horizontal beam: . Used to demonstrate free intra-peritoneal air (erect,supine cross table lateral or decubitus) – Prone: . Useful for differentiating large from small bowel . Useful for excluding SBO Common Imaging Techniques . Fluoroscopy . Ultrasound . CT . Nuclear Medicine . MRI Fluoroscopy Technique . Fasting time: – Premature = 2-4 hours NPO – Infant < 2 1/2 yrs = 4 hours NPO – Children > 2 1/2 yrs = 6 hours NPO . Digital low dose fluoroscopy with small field size . Contrast medium: – Barium is best – Air – Other options: . Gastrograffin (GG) = High osmolality, water soluble warning: GG should only be used by qualified experienced pediatric radiologists . Metrizimide, Iohexol, Iopamidol, etc.= low osmolality, non-ionic water soluble Ultrasound Technique . Abdomen Prep (Complete/Limited) Fasting time: – Children < 5 yr. = 4 hours NPO – Children > 5 yr. = 8 hours NPO . Renal/Pelvic Prep – Infant < 1 yr. = Patient given formula, juice during exam – 1yr- 10yrs = Child must drink 12-16 oz clear fluid 1 -2 hrs prior to exam – > 11 yr. = Child must drink 24-32 oz clear fluid 1 -2 hrs prior to exam Children who are continent should not empty bladder 3 hrs prior to renal US exam CT Technique . Exam tailored to specific area or question . Spiral imaging technique . Minimal radiation . “Frush” Rainbow Protocol low kV, low mA . Intravenous non-ionic contrast delivered via power injector . Oral contrast not always necessary Nuclear Medicine . Provides physiologic information . Radionuclides – 99m Technetium - based – 111 Indium - rarely used – 123 Iodine - rarely used MRI . Particularly useful for IBD imaging – Limiting factors include peristaltic motion & limited spatial resolution . Excellent soft tissue/vascular discrimination . Usually requires sedation: – Nembutal IV: 2-6 mg/kg – Versed: max is 10 mg . Intranasal:0.2 mg/kg . PO: 0.4 mg/kg . IV: 0.1 mg/kg . Nursing and Recovery required Esophageal Atresia & Tracheoesophageal Fistula (EA & TEF) . Cause: – Failure of formation & separation of primitive foregut into respiratory & digestive tracts – Occurs during 3rd & 5th week of intrauterine life . Incidence: 1:2000 - 4000 livebirths Classification of EA & TEF . Atresia without fistula . Proximal fistula and distal atresia . Proximal and distal fistula . Proximal atresia and distal fistula . Fistula without atresia Symptoms of EA &TEF . Drooling . Respiratory distress/Cyanosis with feeds . Cough/choking with feed . Regurgitation of ingested fluids . Vomiting . Inability to pass NG tube . Retrotracheal air-filled pouch . Recurrent pneumonia Associates Anomalies with EA &TEF (ARTICLES) . Anal atresia (20%) . Renal (12%) . TE fistula . Intestinal atresia &/or malrotation . Cardiac (15- 39%) PDA, VSD . Limb anomalies (24%) radial hypoplasia, polydactyly . Esophageal atresia . Spinal anomalies EA without Distal Fistula No bowel gas! EA with Distal Fistula Bowel gas! “ H” Type Fistula Complications of EA & TEF repair . Esophageal stenosis . Esophagomediastinal fistula . GER . Esophageal diverticulum . Impaction of ingested material at anastomosis Proximal and Distal Atresia Pre-op: Proximal Post op: Discontinuity of & distal atresia with anastomotic site- marking cannula breakdown of anastomosis with leak above & below Interventional Radiology Repair Wire (arrow) from below Snare (arrow) from above Grasped and pulled together Once ends caught then wire pulled through & converted to silk suture Post-Interventional Care and Follow-up Post treatment Balloon Final result stenosis dilations one year later Complication: Food Impaction at Anastomosis Tx: IR Balloon Dilatation Esophageal Stricture & Stenosis . Etiologies – Esophageal Web: . 1-2 mm vertical length . Area of complete or incomplete narrowing – Rings: . 5-10mm vertical length . Area of complete or incomplete narrowing – Strictures . >10 mm vertical length Causes of Esophageal Stricture (LETTERS MC) . Lye ingestion . Esophagitis (reflux) . Tumor . Tubes (prolonged NG intubation) . Epidermolysis bullosa . Radiation . Surgery/Scleroderma . Moniliasis . Congenital Common Foreign Bodies & Chemical Ingestion . Alkaline Agents . Acids . Phenols . Silver Nitrate . Batteries: Injuries are more extensive and have poorer outcomes if battery is a lithium “ flat coin” battery. Maximum damage is inflicted within 2 to 2.5 hours after the ingestion. Coins Attempted Suicide via Lye Ingestion Initial CXR 6hrs. later Pulmonary edema Post Lye Ingestion Stricture Colon Interposition: End stage treatment secondary to prior Lye Ingestion StrictureInitial Barium 6Swallow weeks later Intrinsic causes for Intestinal Obstruction . Antral Web . Duodenal Web . Duodenal Stenosis . Duodenal Atresia . Annular Pancreas Antral Web (Antral mucosal diaphragm) Presentation: . Age: 3mos. - 80 yrs. Located 1.5 cm from pylorus . Symptomatic if opening < 1 cm . 2 - 3 mm thick symmetric antral band perpendicular to long axis of stomach Association: . gastric ulcer (30-50%) Classic x-ray appearance . “double bulb” antrum in profile . concentric/eccentric orifice . normal gastric peristalsis at site of lesion Antral Web Duodenal Atresia, Stenosis & Web . Cause: Failure of duodenal canalization or recanalization during 3rd-6th or 6th-11th week gestation . Incidence: 1:10,000 livebirths . Frequency: M = F . Clinical presentation: – Prematurity – Polyhydramnios – Bilious emesis in first hours of life Duodenal Atresia, Stenosis & Web . Associations: . Trisomy 21 (Down’s syndrome): – 30%Coexisting congenital heart disease – VATER Syndrome . Location – Atresia/Stenosis occur in region of Ampula of Vater . (80% just distal to ampulla) – Concurrent annular pancreas found in 20% of cases of duodenal atresia/stenosis Duodenal Atresia Note: Hepatopancreatic duct anomaly can permit air to move distal to the obstruction in duodenal atresia. Courtesy of www.adhb.co.nz Duodenal Web (duodenal diverticulum) Duodenal Web Courtesy of Dept of Surgery: Brown Medical School http://bms.brown.edu Annular Pancreas . Most common anomaly of pancreas . Cause: Abnormal ring or collar of pancreatic tissue that encircles the duodenum secondary to abnormal migration of the ventral pancreas (head & uncinate) . Location: – 2nd portion duodenum (85%) – 1st/3rd portion of duodenum (15%) . Age of discovery: 50% childhood, 50% adulthood Annular Pancreas . Symptoms: . Abdominal pain (70%), . Nausea & vomiting (60%), . Jaundice (50%), . Hematemesis (10%) . Satiety . Feeding difficulties . X-Ray findings: . Polyhydramnios . Enlarged head of pancreas . “Double bubble” sign . Treatment: Surgical bypass Annular Pancreas Diagram courtesy of www.henryfordhealth.org CT Annular Pancreas Extrinsic causes for Intestinal Obstruction . Hypertrophic Pyloric Stenosis . Malrotation . Volvulus . Gastrointestinal duplications . Intestinal Atresia . Intestinal Hematoma Hypertrophic Pyloric Stenosis . Cause: Idiopathic hypertrophy and hyperplasia of circular muscle fibers of pylorus . Incidence: 3:1000; M:F=4-5:1 . Inherited as a dominant polygenic trait . Increased incidence in firstborn boys . Age of onset: 2-8 weeks of life . Symptoms: – Non-bilious projectile vomiting (15-20%) – Palpable olive (80%) by experienced surgeon, false positive rate (14%) – Nasogastric aspirate >10ml NPO 4 hrs (92%sensitive, 86% specific) Hypertrophic pyloric stenosis: volumetric measurement of nasogastric aspirate to determine the imaging modality. M S Finkelstein, G A Mandell and K V Tarbell. December 1990 Radiology, 177, 759-761. HPS . Radiographic Findings: . UGI (95% sensitive) – elongated pyloric channel – “double track” sign – “string” sign – “Twining recess” = “diamond “ sign – “Pyloric teat” sign – “Antral beak” sign – “Kirklin” sign”= “mushroom” sign = indentation of base of duodenal bulb – “caterpillar “ sign = Gastric hyperperistalsis – Gastric Atony UGI findings of HPS HPS . Ultrasound Findings: – “Target” sign= hypoechoic ring around echogenic mucosa – “Cervix” sign = indentation of muscle mass on fluid filled antrum – “Antral nipple” sign = redundant pyloric mucosa protruding into antrum – Pyloric length>14 mm – Pyloric muscle thickness >4mm – Pyloric diameter >13mm US findings of HPS Channel length = 1.53cm Muscle thickness = 0.45cm Normal Bowel Fixation Ligament of Treitz (LOT) a. Left of midline b. Approx. halfway between greater & lesser curvature of stomach c. At level of duodenal cap Norma l Mesentery: a. Fan-like mesentery from LOT to cecum Malrotation . Definition: General term for any abnormal variation in intestinal rotation . Malposition of intestine does not unto itself cause problems... however this condition is frequently accompanied by malfixation… which can lead to fibrous bands (Ladd’s bands) and subsequent obstruction or intestinal volvulus Malrotation Ladd’s bands originate from malpositioned Abnormal small bowel mesenteric cecum. Causing transverse compression of attachment: duodenum and mechanical obstruction * Short pedicle increases risk for volvulus Malrotation without Volvulus Courtesy of www.emedicine.com
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