Axial torsion of Meckel's diverticulum presenting as a pelvic mass.

Meckel's diverticulum is the most common congenital gastrointestinal anomaly. Axial torsion of the diverticulum is rare and may produce nonspecific abdominal signs and symptoms. We describe a case of torsion of a Meckel's diverticulum that was noted as a pelvic mass on CT images.

Lamina muscularis propria thickness of renal pelvis predicts radiological outcome of surgical correction of ureteropelvic junction obstruction.

PURPOSE: We examine if there is a relationship between the histopathology of the renal pelvis and postoperative radiological findings in children with ureteropelvic junction obstruction. MATERIALS AND METHODS: The records of 220 patients who underwent pyeloplasty for isolated ureteropelvic junction obstruction between 1988 and 1996 were retrospectively reviewed, and 41 (42 kidneys) were identified who had adequate histological specimens and postoperative radiographic studies (ultrasonography and/or well tempered renogram) for examination. Histological features of the lamina muscularis propria from the renal pelvis were correlated with the radiographic outcome after pyeloplasty. RESULTS: Lamina muscularis propria thickness of the renal pelvis correlated significantly with radiological improvement. All kidneys with renal pelvic lamina muscularis propria thickness less than 250 microm. showed radiological improvement at 3 to 6 months postoperatively, those with thickness between 250 and 350 microm. had improvement at 9 months and those with lamina thickness greater than 350 microm. had a significantly worse outcome at all observation points. At 3 and 6 months postoperatively 16 of 30 (53%) and 23 of 34 (68%) children with radiological improvement had a mean lamina muscularis propria thickness of 252 +/- 131.5 microm. and 263 +/- 122.8 microm., respectively, while the remaining unimproved 14 and 12 patients had a mean thickness of 374 +/- 64.3 microm. (p <0.01) 372 +/- 66.1 microm. (p <0.05), respectively. CONCLUSIONS: The lamina muscularis propria thickness of the renal pelvic wall can provide insight to the expected time of postoperative improvement on radiological studies in children with ureteropelvic junction obstruction.

Two apparent suprarenal masses. Two cases in children: heterotaxy syndrome with spleen lying in suprarenal space and gastric duplication cyst lying in suprarenal space.

Two children had suprarenal masses detected when US was performed because of nonabdominal anomalies or lesions. Additional imaging was required in each to determine the nature of the masses: an ectopic (right-sided) spleen and a gastric duplication.

Pediatric voiding cystourethrography: a pictorial guide.

Voiding cystourethrography is commonly performed in children with prenatally diagnosed hydronephrosis, urinary tract infections, and voiding abnormalities. Voiding cystourethrography can be performed with many variations designed to optimize visualization of disease and minimize radiation exposure. The procedure should include assessment of the spine and pelvis; masses or opaque calculi; bladder capacity, contour, and emptying capability; presence and grade of reflux; and urethral appearance. Radiologists differ as to whether the patient should void prior to catheterization. Anteroposterior imaging of the bladder is performed during early filling; little or no imaging is necessary during intermediate filling. When bladder filling is complete, steep oblique images that are centered on the ureterovesical junction should be obtained. If reflux is observed, the ipsilateral renal fossa may be imaged prior to voiding. With a smaller than expected voiding volume, bladder refilling is recommended. Voiding around the catheter is also strongly recommended. In girls, one anteroposterior image of the urethra is usually sufficient; in boys, the entire urethra must be imaged. Steep oblique imaging is optimal. At the conclusion of voiding, each renal fossa should be imaged to detect reflux missed at fluoroscopy as well as other anomalies. Familiarity with these abnormalities and use of proper techniques will allow detection of most common pathologic conditions with very low radiation exposure.

Craniosynostosis 1998: concepts and controversies.

The diagnosis of craniosynostosis requires attention to radiologic technique, familiarity with the signs of closure at each suture, and correlation with the clinical setting. Misdiagnosis may result in unwarranted calvarial or craniofacial surgery or a delay of surgery, necessitating a more extensive procedure.

Maternal exposure to prescription and non-prescription pharmaceuticals or drugs of abuse and risk of craniosynostosis.

BACKGROUND: The pre- and peri-natal drug exposures reported by women participating in a case-control study of children in Colorado were examined for association with infant craniosynostosis. METHODS: Mothers of case and control children underwent a standardized telephone interview and obstetric and newborn medical record review. The interview included questions on the use of prescription and non-prescription drugs, nutritional supplements, recreational and drugs of abuse. The mother's obstetric record was abstracted for information about pharmacologic agents taken before and during the antepartum period. RESULTS: There were no statistically significant risk ratios associating craniosynostosis with prenatal exposure to hydantoin, valproic acid, or cocaine. Mothers of four case children and one control child reported specific exposure to retinoic acid. There were no statistically significant increases in the odds ratio (OR) for any suture type among children exposed to hypoxigenic agents, sympathomimetic or parasympatholytic agents, or metal-containing agents. The OR was 1.87 (lower bound of the two-sided 95% test-based confidence interval (CI): 1.08) among children with sagittal/lambdoid suture synostosis who were exposed to nitrosatable drugs chlorpheniramine, chlordiazepoxide, and nitrofurantoin compared to controls. CONCLUSIONS: Certain nitrosatable drugs may be associated with increased risk of infant sagittal/lambdoid craniosynostosis. A possible mechanism related to ischaemia/reperfusion injury is suggested.

Pediatric uroradiology--1997.

The imaging of common pediatric urological problems is in evolution. Modifications of standard techniques such as substitution of cyclic voiding cystourethrography in the neonate and infants, introduction of newer modalities (Doppler ultrasound), and new nuclear renal agents (Tc-MAG3) have enhanced our ability to detect anomalies and abnormalities. In this brief article, some of the recent developments in imaging are reviewed and the ways in which these developments interface with traditional imaging studies are presented.

Surgery versus observation for managing obstructive grade 3 to 4 unilateral hydronephrosis: a report from the Society for Fetal Urology.

PURPOSE: The Society for Fetal Urology has undertaken the first multicenter prospective randomized study of high grade obstructive unilateral hydronephrosis to evaluate the natural history of untreated obstruction and compare it to the benefits of pyeloplasty. MATERIALS AND METHODS: Since 1991, infants with isolated unilateral Society for Fetal Urology grade 3 hydronephrosis and ipsilateral obstruction with greater than 40% differential renal function on well tempered renography were studied. Patients were randomly assigned to observation or pyeloplasty groups. Renal ultrasound and well tempered renography were performed biannually for 1 year and yearly thereafter. Crossover criteria for surgery included concurrent worsening of isotope washout and increasing grade of hydronephrosis or a greater than 10% point loss in percent differential renal function that was noted between studies. The end point of the study was the 3-year anniversary of randomization. RESULTS: A total of 32 infants from 10 centers were randomized equally to 2 groups. The starting grade of hydronephrosis and percent differential renal function were similar between the 2 groups. At 6 months and 1 year the grade of hydronephrosis was significantly reduced (p < 0.02) and well tempered renography was significantly more likely to demonstrate no obstruction (p < 0.03) in the surgical group compared with the observation group. The mean percent differential renal function remained stable and similar in both groups. Reduced hydronephrosis and resolution of obstruction in the surgery group persisted as a trend at the 2 and 3-year anniversaries. In the observation group 4 patients (25%) showed enough renal deterioration to qualify for crossover to surgery. CONCLUSIONS: Infant pyeloplasty significantly improved the grade of hydronephrosis and drainage pattern at 6 months and 1 year postoperatively, when compared with observation. Renal function stabilization was similar for either management approach. However, 25% of the patients satisfied objective criteria of status deterioration requiring pyeloplasty.

Diagnostic practice and the estimated prevalence of craniosynostosis in Colorado.

BACKGROUND: In the late 1980s, evidence of an epidemic of craniosynostosis in Colorado included reports of clusters from selected high-altitude communities and an investigation showing the high and rapidly rising rates of surgically corrected synostosis. Some evidence suggested that local diagnostic practice could account for the epidemic. OBJECTIVE: To determine the contributions of any excess rates of disease occurrence, surgery-based ascertainment, and diagnosis to the reported epidemic. DESIGN: Population-based birth prevalence study with diagnostic evaluation. SETTING: The Colorado Department of Health, April 15, 1986, to July 14, 1989. PATIENTS OR OTHER PARTICIPANTS: Children in the Craniosynostosis Registry or state birth record files. MAIN OUTCOME MEASURES: Birth prevalence was estimated from registry and birth record data; case classification by suture type and malformation patterns were determined by review of radiographs and medical records. RESULTS: The period birth prevalence of radiographically confirmed nonsyndromic synostosis was 14.1 per 10,000 live births. Of a total of 605 children, 307 (51%) had definite radiographic evidence of synostosis, for which the intrarater reliability was good (except for the coronal suture on plain films) and the interrater reliability was fair or good (except for the metopic suture on plain films). Between the first and third years, case reports fell from 347 to 103. CONCLUSIONS: Diagnostic criteria strongly influenced the rate of synostosis. The rate of radiographically confirmed synostosis was within the range of published estimates. Low diagnostic thresholds, which changed over time, created the semblance of a severe statewide epidemic and may have obscured excess rates of disease at high altitude.

Ureteral duplication and its complications.

Duplication of the ureters is a common anomaly and is frequently encountered by radiologists. Duplication may be either complete or incomplete and is often accompanied by various complications. Incomplete duplication is most often associated with ureteroureteral reflux or ureteropelvic junction obstruction of the lower pole of the kidney. Complete duplication is most often associated with vesicoureteral reflux, ectopic ureterocele, or ectopic ureteral insertion, all of which are more common in girls than in boys. Vesicoureteral reflux affects the lower pole and can be outgrown, as in nonduplicated systems. Ectopic ureterocele and ectopic ureteral insertion affect the upper pole. The ectopic ureterocele produces a filling defect of variable size in the bladder; it can be identified with contrast material studies or ultrasound. Ectopic ureters may function poorly, be difficult to detect, and cause enuresis in girls. A fourth complication, ureteropelvic junction obstruction, occurs only in the lower pole and is seen in more boys than girls. Anatomic variants or anomalies as well as suboptimal imaging techniques can either simulate or obscure duplication, making diagnosis difficult. However, familiarity with the embryology of duplication and an awareness of the potential pitfalls of excretory urography and voiding cystourethrography will foster an understanding of the varied appearances and associated complications of both incomplete and complete duplication.

Parental occupations as risk factors for craniosynostosis in offspring.

In a population-based case-control study, we examined relations between maternal and paternal occupations and the risk of infant craniosynostosis. Cases were 212 children born to Colorado residents and diagnosed during 1986-1989 with radiographically confirmed synostosis of unknown etiology. Controls were 291 children randomly selected from state birth records and frequency matched to cases on month and year of birth. Trained staff conducted telephone interviews of mothers of case and control children. Information was obtained about each job held by either parent during the pregnancy, and any job that the father held during the 3 months before the last menstrual period before conception. Jobs were coded using 1980 Census occupation and industry codes. We found no strong associations for maternal occupations. Of paternal occupations, two groups were associated with moderately increased odds ratios after adjustment for maternal smoking and altitude: agriculture and forestry (odds ratio = 2.3; 95% confidence interval = 1.0-5.2), and mechanics and repairmen (odds ratio = 2.7; 95% confidence interval = 1.2-6.1). For both, the odds ratios were higher for males.

Increased risk of craniosynostosis with higher antenatal maternal altitude.

BACKGROUND: During the 1980s, the Colorado Department of Health received reports from several high-altitude communities of clusters of the malformation craniosynostosis. In a population-based, case-control study, we examined the association between overall and trimester-specific maternal antenatal altitude exposure and the occurrence of infant craniosynostosis. METHODS: We identified case children through a statewide registry and randomly sampled control children from birth records. By telephone interview, each mother provided data on the locations of all antenatal residences and places of employment as well as other factors. Staff mapped all locations and abstracted the corresponding altitudes. RESULTS: The odds ratio (OR) of any synostosis for a time-weighted mean antenatal altitude of > or = 2000 metres (high altitude) versus < 2000 metres (low altitude) was 1.4 (lower bound of the one-sided 95% test-based confidence interval (CI): 0.9). The OR was elevated in smokers but not in non-smokers. As compared to non-smokers, the OR of any synostosis for high-altitude smokers was 4.6 (lower bound of the 95% one-sided exact CI: 1.7). Particularly elevated were the corresponding OR of coronal (18.1, 4.4) and metopic synostosis (16.3, 2.8), and OR for high-altitude exposure during the second trimester (any synostosis: 6.4, 1.99; coronal: 28.6, 6.1; metopic: 26.7, 4.1). CONCLUSIONS: Antenatal maternal high-altitude exposure and smoking are associated with increased risk of infant craniosynostosis, perhaps through generation of intermittent hypoxaemia.

Complete duplication of the ureter with ureteropelvic junction obstruction of the lower pole of the kidney: imaging findings.

OBJECTIVE: The purpose of our study was to identify the radiographic signs that aid in the diagnosis of obstruction of the ureteropelvic junction of the lower pole (or moiety) of the kidney in children with complete duplication of the ureter and to describe the imaging appearance of this unusual cause of lower-pole hydronephrosis. MATERIALS AND METHODS: We reviewed the medical records and imaging studies of 16 children (11 boys and five girls) with complete ureteral duplication and ureteropelvic junction obstruction of the lower pole of the kidney over a 5-year period. standard criteria for determining urinary tract obstruction were used. RESULTS: Sonograms showed a lower-pole abnormality (hydronephrosis or cystic mass) in all 15 children who underwent sonography. Voiding cystourethrography, performed for all children, showed vesicoureteral reflux into the lower pole in addition to ureteropelvic junction obstruction in eight children (seven boys and one girl). For the other eight, the diagnosis of lower-pole ureteropelvic junction obstruction was made by excretory urography, at times complemented with diuretic renography or retrograde ureterography. CONCLUSION: Ureteropelvic junction obstruction of the lower pole of the kidney in children with complete duplication of the ureter should be a diagnostic consideration when there is dilatation of the lower moiety. Imaging changes parallel those of ureteropelvic junction obstruction in a nonduplicated system. This anomaly, unlike others seen in duplication, appears to be more common in boys than in girls.

Outcome of nonspecific hydronephrosis in the infant: a report from the Registry of the Society for Fetal Urology.

Since 1988 the Society for Fetal Urology has worked to evaluate if there is consensus on management of infants with nonspecific hydronephrosis. Initially, multicenter agreement on the criteria to grade hydronephrosis and method of diuretic renography were developed to promote similarities in how infant kidneys with nonspecific hydronephrosis were profiled for grade (0 to 4), per cent differential function by diuretic renography and drainage response by diuretic renography (obstructed, not obstructed or indeterminate). Between 1989 and 1992 a total of 33 pediatric urologists from 21 cities registered 464 cases (582 kidneys) of hydronephrosis. Of the cases 275 (59%) were managed by observation and 189 (41%) were treated surgically. The operated kidneys showed profiles (hydronephrosis grade 3 or greater and diuretic renography obstructed) that were significantly different from the profiles of observed kidneys (hydronephrosis grade 2 or less and diuretic renography no obstruction) (p < 0.001 each). Six months postoperatively the mean grade of hydronephrosis (1.8) and diuretic renography diagnosis (no obstruction) were significantly better than they were preoperatively (p < 0.001 each). In addition, postoperatively the mean grade of hydronephrosis, diuretic renography diagnosis and per cent differential function were similar to age matched observed kidneys. We conclude that when radiographic tests are done similarly, there is consensus in the management of infant hydronephrosis by surgery or observation.

Increased risk of craniosynostosis with maternal cigarette smoking during pregnancy.

We analyzed data from a population-based case control study to determine whether maternal prenatal smoking or alcohol drinking might increase the risk of craniosynostosis. Between 1986 and 1989, the Colorado Craniosynostosis Registry ascertained 233 children whose diagnoses were confirmed by an independent radiologist. Of the 212 (91%) cases who participated 86 had lambdoid, 69 had sagittal, 25 had coronal, 18 had metopic, and 14 had multiple suture synostosis. Random sampling of birth certificate records yielded 367 eligible controls, of whom 291 (79%) participated. Study staff interviewed case and control mothers between 1989 and 1991 for prenatal smoking and alcohol drinking. We used Mantel-Haenszel and polychotomous logistic regression techniques to estimate the relative odds of craniosynostosis for smoking and drinking in all cases and in relevant case subgroups. Smoking was associated with a relative odds of craniosynostosis of 1.7 (95% confidence interval, 1.2-2.6). For smoking of more than one pack per day, the relative odds were 3.5 (1.5-8.4) for all types of synostosis combined, and 5.6 (2.1-15.3) for coronal synostosis. No strong or significant association was noted for drinking. Maternal prenatal smoking may increase the risk of craniosynostosis in this population.

Abnormalities of the bladder in children: imaging findings.

Radiologic evaluation of the genitourinary tract in infants and children frequently focuses on the kidneys. The bladder may be imaged in a cursory or perfunctory manner or not at all. Unfortunately, this practice contributes to errors in diagnosis of renal abnormalities both prenatally and throughout childhood. For example, a "renal cyst" diagnosed prenatally really might be the obstructed upper pole of a duplex kidney; scanning the bladder is necessary to detect the dilated distal ureter or ureterocele below. Similarly, the bladder might have a congenital anomaly when the kidneys are normal. The appearance of many common and a few uncommon bladder anomalies in children are described in this article. Some normal variants and acquired problems, such as tumors and neurogenic bladder, are discussed and illustrated because these can cause problems in diagnosis. Changes in the appearance of the bladder produced by surgery to correct vesicoureteral reflux are also presented.

Periosteal reaction of the ribs in neonates treated with extracorporeal membrane oxygenation: prevalence and association with soft-tissue swelling.

OBJECTIVE: The objectives of the study were to determine the prevalence of periosteal reaction of the ribs in infants treated with extracorporeal membrane oxygenation and to evaluate its association with soft-tissue swelling. MATERIALS AND METHODS: The chest radiographs of 100 consecutive neonates treated with extracorporeal membrane oxygenation were evaluated to determine the maximal soft-tissue swelling during therapy and whether periosteal reaction of the ribs developed. The length of extracorporeal membrane oxygenation and the time elapsed before periosteal reaction developed were recorded. The medical records of those with periosteal reaction were reviewed to determine known causes of this condition. The records of a control group of 11 neonates were evaluated in the same manner. RESULTS: Periosteal reaction of the ribs developed in 13 (21%) of the 61 neonates who had less than 11 mm of soft-tissue swelling. In 69% of those with periosteal reaction, the finding first was seen 21-32 days after birth. In the control group, periosteal reaction developed in only one, a neonate who had vibrator chest physiotherapy. CONCLUSION: Periosteal reaction of the ribs in patients treated with extracorporeal membrane oxygenation is associated with soft-tissue swelling greater than 11 mm. The periosteal reaction appears to be a self-limiting and benign process.

Peritoneal fluid in children with intussusception: its sonographic detection and relationship to successful reduction.

A retrospective review of the abdominal/pelvic ultrasound (US) examinations in 21 consecutive children with intussusception proven on barium enema was performed to determine what is the incidence of US detected peritoneal fluid in this population and to see if the rate of reduction was different in this subset. Twelve of the 21 children (57%) had free fluid demonstrated with US. Eight of these 12 (67%) had successful reduction. Six of the nine children (67%) without free fluid were also successfully reduced.