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Emergent Pediatric US: What We Should Know

Dr Lalitha.A.VMBBS, MD, DNB Paediatrics, FNB Paediatric Critical Care,(FACEE)

Associate Professor , Head of PICU and Ped ERSt John’s Medical College and Hospital,Blore


• Children are particularly at risk for the adverse effects of ionizing radiation, and even low-dose radiation is associated with a small but significant increase in lifetime risk of fatal cancer


Case 1• A 7-year-old female presents with low grade fever

abdominal pain.• Her Vitals are normal except temp of 38 degrees c

and per abdomen is tender and no guarding or rigidity.


Indications of bedside USG • Evaluation of

symptoms such asAbdominal painFlank painLow back painBlunt abdominal

traumaHematuriaUnexplained

hypotension

• Specific abdominal disease

Acute appendicitisUrinary retentionNephrolithiasisBiliary colicIntussception


Most common reasons • Three of the most common reasons for emergent

Ultrasoundsonography evaluation in the pediatric patient are

• Appendicitis, • Intussusception,• Hypertrophic pyloric stenosis (HPS)


Case 2• A previously healthy 2 year old child presents to

your emergency room with fever, lethargy, and acute abdominal pain , vomiting and diarrhea.

• Pt is unable to localize pain, but does exhibit rebound tenderness when you palpate the RLQ. Mom states that symptoms began 2 days ago.


Appendicitis

• Appendicitis is the most common condition requiring emergent surgery in childhood.

• Appendicitis occurs in all age groups but has a higher incidence in children between 5 and 15 years of age

• The classic presentation is onset of periumbilical pain that migrates to the right lower quadrant (RLQ) at McBurney’s point over a period of 12–24 hours, with associated anorexia, leukocytosis, and, oftentimes, low-grade fever


Appendicitis• Younger children cannot describe their symptoms,

and up to one-third have atypical clinical findings for appendicitis


Negative appendectomy rate• Historically, an acceptable

negative appendectomy rate (NAR) (ie, when a normal appendix is removed at surgery for clinically suspected appendicitis) has ranged from 15% to 25%

• Today, increased use of imaging has contributed to a much lower NAR -8.1%

• Krishnamoorthi R, Ramarajan N, Wang NE, et al. Effectiveness of a staged US and CT protocol for the diagnosis of pediatric appendicitis: reducing radiation exposure in the age of ALARA. Radiology 2011;259(1):231–239

Perforated Appendix


IA


Appendicitis

US image shows a normal appendix (arrowheads) as a tubular viscus less than 6 mm in diameter in the RLQ.

Appendicitis-US image shows an appendix (calipers) that measured 12 mm in diameter.


Normal

US image shows the distal blind-ending tip of the appendix (arrow) draped over the right iliac artery (ia)

US image shows echogenic periappendiceal fat (arrowheads), a finding that is sometimes referred to as a “hyperechoic halo” and indicates inflammation

Appendicits


US image shows the bulbous tip of a normal appendix (arrowheads) that measured 5 mm in diameter.

US image shows a dilated appendix (calipers) that contains an echogenic appendicolith (arrow) with associated posterior acoustic shadowing


Importance of USG• “Every US technologist and every radiology

resident should be taught how to perform appendiceal US and should achieve and maintain competence.”

Strouse PJ. Pediatric appendicitis: an argument for US. Radiology 2010;255(1):8–13.


• The most accurate US finding for acute appendicitis is an outer wall diameter greater than 6 mm under compression, with reported positive and negative predictive values of 98%

• Kessler N, Cyteval C, Gallix B, et al. Appendicitis: evaluation of sensitivity, specificity, and predictive values of US, Doppler US, and laboratory findings. Radiology 2004;230(2):472–478.


• Less sensitive and specific US findings for appendicitis include

hyperemia within the appendiceal wall echogenic inflamed periappendiceal fat, - on color

Doppler images the presence of an appendicolith


Case 3• A 8-month-old male presents with excessive

crying, passing of jelly stools and persistent vomiting. There is no history of fever. Baby is bottle fed, started on cerelac sine 15 days.


Intussusception• Intussusception is a condition that usually occurs

in children between 6 months and 2 years of age

• The “classic” clinical triad has been described as consisting of

(a) acute colicky abdominal pain, (b) “currant jelly” or frankly bloody stools (c) either a palpable abdominal mass or vomiting


Intussusception• .Radiograph shows a

large, round soft-tissue mass at the hepatic flexure, the classic finding of ileocolic intussusception.


USG • Ileocolic - right

subhepatic region • Short-axis US image

shows the target (donut) sign.

• Longitudinal US image shows the pseudo-kidney sign, which results when the intussusception is curved or is imaged obliquely.


Intussusception. Short-axis US image (a) and an annotated version (b) demonstrate what are believed to be the typical components of an intussusception. The intussuscipiens (receiving loop) contains the infolded intussusceptum (donor loop), which has two components: a central entering limb of bowel (E) and an edematous returning limb (R). The attached mesentery (m) is dragged between the twolimbs.


Intussusception• In a recent study in which a large proportion of

examinations were interpreted by radiology residents and general emergency radiologists working overnight and weekend shifts,

• US had a sensitivity of 97.9%, a specificity of 97.8%, and a negative predictive value of 99.7% for intussusception

Hryhorczuk AL, Strouse PJ. Validation of US as a first-line diagnostic test for assessment of pediatric ileocolic intussusception. Pediatr Radiol 2009;39 (10):1075–1079


Rx of Intussusception• nonsurgical reduction with an air or hydrostatic

enema • Several factors have been reported to decrease the

chances of successful enema reduction, long duration of symptoms (>48 hours), significant dehydration, radiographic evidence of small bowel obstruction, patient age less than 3 months or greater than 5

years


Factors that can affect the reducibility of intussusception

• Color Doppler image shows vascular flow within an intussusception, a finding that indicates viable bowel.


Factors that can affect the reducibility of intussusception

• US image shows trapped fluid (arrow) within an intussusception


Mimics of ileocolic intussusception• Ruptured appendicitis

in a 7-year-old girl with RLQ pain. Sagittal US images show a 2-cm mass with alternating echogenic and hypoechoic rings—the target sign


• Appendicitis• 2-15 yrs• 6-10mm

• Intussception• 6 months to 2 years• >4–5 cm


Case 4• 35 days old male child presents with history of

persistent vomiting-nonbilious , since 1week.There is history of not gaining weight.

• o/e-looks healthy but mild dehydration, CVS,RS- normal ,PA-mass in epigastrium

Hypertrophic Pyloric Stenosis


Hypertrophic Pyloric Stenosis

• HPS is seen in two to five of every 1,000 births• familial predisposition, • 95% - 3rd and 12th weeks of life, with peak

presentation during the 4th week of life.• Nonbilious vomiting• PA palpation of an olive-shaped mass in the

epigastrium representing the thickened pylorus.


HPS• HPS in a 4-week-old male

infant who presented with vomiting.

• Left lateral decubitus radiograph demonstrates a large area of increased density in the left upper quadrant representing a fluid-filled, massively distended stomach


USG in HPS• US is now widely accepted as the first-line option

because it can be performed rapidly and is highly accurate, with a sensitivity and specificity approaching 100% in experienced hands

Hernanz-Schulman M, Berch BR, Neblett WW. Imaging of infantile hypertrophic pyloric stenosis (IHPS). In: Medina LS, Applegate KE, Blackmore CC, eds. Evidence-based imaging in pediatrics: improving the quality of imaging in patient care. New York, NY: Springer, 2009; 447–457


Normal HPS

Transverse US image shows the free flow of liquid (arrow) from the gastric antrum into the duodenum through a normal pyloric channel.

US image helps confirm apathologically thickened (calipers, A) and elongated(calipers, B) pyloric channelconsistent with HPS


USG in HPS• Short-axis US image

demonstrates the target sign of HPS, created by a thickened hypoechoic pyloric muscle (*) surrounding echogenic redundant mucosa.


USG in HPS• Long-axis US image of the

pylorus • Cervix sign due to its

resemblance to the uterine cervix.


Conclusions • US is an important tool in the evaluation of

pediatric abdominal conditions such as appendicitis, intussusception, and HPS.

• The lack of ionizing radiation makes US either an ideal screening modality or the test of choice in these patients

• With practice, one can quickly learn how to diagnosis or exclude each condition with confidence.


"Red Flag Signs" for Acute Abdominal Pain in Children

Signs Bilious vomiting Signs History of intra abdominal surgery Signs Features of peritonitis Signs Blood in stool Signs Blood in vomitus Signs Features of Intestinal obstruction Signs Abdominal distension


Remember:• The goal of treating acute abdominal pain is

ensuring that life threatening surgical causes are ‐quickly diagnosed and treated!


THANK YOU


For Further details, visit www.indusem.org/indusem2016Other Attractions: 21st October 2016: PRE CONFERENCE WORKSHOPS: 1.Pediatric emergency ultrasonography workshop (full day) by John Gullet &Team, USA at St John’s Hospital, Bangalore2. Pediatric Trauma Workshop at Indira Gandhi Institute Of Child Health 22nd October 2016: First Consensus Meeting on Triage of Critically ill Child in Emergency Department at Auditorium, St John’s

Hospital, Bangalore

Pediatric Emergency Conclave

ORGANISING CHAIRPERSON: Dr. SANTOSH SOANS ORGANISING SECRETARY: Dr. LALITHA A V Ph:9448467673

acute abdomen dr.lalitha

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