MRI-compatible audio/visual system: impact on pediatric sedation.

BACKGROUND: While sedation is necessary for much pediatric imaging, there are new alternatives that may help patients hold still without medication. OBJECTIVE: We examined the effect of an audio/visual system consisting of video goggles and earphones on the need for sedation during magnetic resonance imaging (MRI). MATERIALS AND METHODS: All MRI examinations from May 1999 to October 1999 performed after installation of the MRVision 2000 (Resonance Technology, Inc.) were compared to the same 6-month period in 1998. Imaging and sedation protocols remained constant. Data collected included: patient age, type of examination, use of intravenous contrast enhancement, and need for sedation. The average supply charge and nursing cost per sedated patient were calculated. RESULTS: The 955 patients from 1998 and 1,112 patients from 1999 were similar in demographics and examination distribution. There was an overall reduction in the percent of patients requiring sedation in the group using the video goggle system from 49 to 40% (P < 0.001). There was no significant change for 0-2 years (P = 0.805), but there was a reduction from 53 to 40% for age 3-10 years (P < 0.001) and 16 to 8% for those older than 10 years (P < 0.001). There was a 17% decrease in MRI room time for those patients whose examinations could be performed without sedation. Sedation costs per patient were $80 for nursing and $29 for supplies. CONCLUSION: The use of this video system reduced the number of children requiring sedation for MRI examination by 18%. In addition to reducing patient risk, this can potentially reduce cost.

Peripheral placement of apheresis catheters in children: feasibility, safety, and efficacy in the collection of blood stem cells--initial experience.

An 8-F 24-cm-long apheresis catheter was placed in the basilic vein with imaging-guided percutaneous technique in 15 children undergoing leukapheresis for collection of autologous peripheral blood stem cells. There were no immediate or long-term complications. This is a low-morbidity procedure requiring minimal sedation that results in successful collection of peripheral blood stem cells and allows flow rates comparable to those with surgically placed central catheters.

Partial splenic embolization in five children with hypersplenism: effects of reduced-volume embolization on efficacy and morbidity.

PURPOSE: To evaluate the effects of reducing the volume of spleen infarcted during partial splenic embolization (PSE) for treatment of hypersplenism in children. MATERIALS AND METHODS: Five children with hypersplenism underwent embolization of 30%-40% of the splenic volume. The results were compared with those of a previous study of 70%-80% PSE performed in 17 children. RESULTS: The hospital stay after the procedure was reduced from 16.0 days +/- 8.0 to 6.6 days +/- 5.6. The febrile period decreased from 15.0 days +/- 8.1 to 5.0 days +/- 6.6. The peak white blood cell count was 8,300/mm3 +/- 4,600 (8.3 x 10(9)/L +/- 4.6) versus 19,400/mm3 +/- 7,800 (19.4 x 10(9)/L +/- 7.8) in the earlier study. The peak platelet count was 153,000/mm3 +/- 65,000 (153 x 10(9)/L +/- 65) versus 636,000/mm3 +/- 406,000 (636 x 10(9)/L +/- 406). The platelet count after a mean follow-up of 14 months was 70,000/mm3 +/- 7,000 (70 x 10(9)/L +/- 7) versus 230,000/mm3 +/- 62,000 (230 x 10(9)/L +/- 62) after a mean follow-up of 45 months. The frequency of variceal hemorrhage decreased from 3.5 to 0.5 episodes per year. The frequency of epistaxis decreased from 30 to 15 episodes per month. CONCLUSION: Reduced-volume embolization decreased morbidity. All patients maintained a platelet count above baseline, and no patient required repeat embolization.

The use of papaverine in arterial sheaths to prevent loss of femoral artery pulse in pediatric cardiac catheterization.

This study evaluated the efficacy of intraarterial papaverine infusion after pediatric cardiac catheterization in reducing the incidence of lost pulse. This study was conducted at a teaching pediatric hospital and was designed as a randomized, prospective, double-blind, placebo-controlled study. Patients were children 5 years old or less undergoing antegrade and retrograde heart catheterization. The intervention used was an intraarterial infusion of placebo or 1.5 mg/kg papaverine after catheterization. Bilateral femoral artery ultrasound study was performed pre- and postcatheterization, including two-dimensional, color, spectral, and pulsatility index analysis. Outcome measures included clinical loss of pulse, ultrasound findings, plus other clinical factors. Fifty-six patients participated in the study (28 per group). Six patients clinically lost the pulse in the catheterized arteries [four in the papaverine and two in the placebo groups (p > 0.64)]. Clinical loss of pulse correlated with diminished pulsatility index (p < 0.035). The use of papaverine did not prevent decreased pulse or pulsatility index (p > 0.79). Increased arterial time was the only clinical factor associated with lost pulse (p < 0.0004). Pulsatility index <3.34 correlated with loss of pulse in the catheterized artery. The results indicated that intraarterial papaverine infusion after femoral artery catheterization does not prevent loss of pulse in the catheterized artery, and decreased pulsatility index correlates with diminished pulse and represents a good noninvasive method of evaluating femoral artery patency and flow.

Esophageal foreign bodies: safety and efficacy of Foley catheter extraction of coins.

OBJECTIVE: Continued controversy over the role of fluoroscopically guided Foley catheter removal of esophageal foreign bodies has limited the use of this technique despite its significant economic advantages. We reviewed our experience for the safety, efficacy, and applicability of this technique with pediatric patients who had swallowed coins. MATERIALS AND METHODS: We retrospectively reviewed 10 years of experience with pediatric patients who had undergone fluoroscopically guided Foley catheter removal of coins. All the pediatric patients with a suspected esophageal foreign body were first evaluated by plain film radiography. Foley catheter extraction was attempted when a radiopaque coin was seen and the patient lacked signs of significant esophageal edema resulting in tracheal compromise. During the 10 years covered by our review, 14 pediatric radiologists with specific training in the Foley catheter technique were involved in such removals. A separate review (of consecutive pediatric patients who had a history of or symptoms suggesting ingestion of a foreign body) focused on the percentage of these patients in which the Foley catheter technique was used. RESULTS: Of the 337 coin extractions attempted using a Foley catheter, coin extraction was successful in 322 (96%) of 337 patients. No complications were encountered. Our focused review found 422 consecutive patients who had undergone radiography to rule out foreign bodies. A radiopaque object was found in 249 (59%) of 422 patients. Of these 249 objects, 208 (84%) were ingested coins. Of 208 coins, 123 (59%) were retained in the esophagus; of these 123 coins retained in the esophagus, 116 (94%) were amenable to fluoroscopically guided Foley catheter extraction. CONCLUSION: Fluoroscopically guided Foley catheter extraction of retained coins in pediatric patients who lack evidence of significant esophageal edema causing tracheal compromise is a safe and efficacious technique. It should be considered the technique of choice for such extractions.

Standard method of diagnosis versus use of a computer database in the evaluation of skeletal dysplasias.

OBJECTIVE: The objective of this study was to compare reference textbooks and the computer database, OSSUM, for accuracy and ease of use in the diagnosis of skeletal dysplasias. Materials and methods. Twenty cases of clinically and and radiologically established skeletal dysplasias were evaluated as unknowns by four pediatric radiologists. Readers 1 and 2 evaluated group A (10 cases) using reference texts and group B (10 cases) using OSSUM. Readers 3 and 4 evaluated group B using reference texts. The radiologists independently listed their roentgenographic findings, the top three diagnoses, confidence level, difficulty level, and time spent on each case. RESULTS: The correct diagnosis was made in 68% of both the reference text cases and the OSSUM cases. Difficulty level was significantly higher (3.5 vs 2.9, P = 0.0013) and confidence significantly lower (3.3 vs. 2.3, P = 0.0001) when using OSSUM. Average time spent on cases was 25 min with references and 30 min with OSSUM (P > 0.05). However, there was a decrease in both the time (38 min vs 23 min, P = 0.05) and the difficulty (3.9 vs 3.1, P = 0.001) between the first five and the last five cases. The composite of four readers correctly identified 90% of the skeletal dysplasias when the results of both methods were combined. CONCLUSIONS: In the ability to reach a correct diagnosis, no difference was detected between the OSSUM and reference texts methods. The increased time necessary, greater difficulty and decreased confidence levels with OSSUM are expected to improve with increasing program familiarity. Use of both textbooks and the database was complementary.

The hamartomatous polyposis syndromes: clinical and radiologic features.

Most radiologists are familiar with the clinical and radiologic features of the familial adenomatous polyposis syndromes [1]. The hamartomatous polyposis syndromes occur less frequently, however, and their radiologic and clinical manifestations are not as well known. This group of syndromes includes Peutz-Jeghers, multiple hamartoma, juvenile polyposis, Cronkhite-Canada, and Bannayan-Riley-Ruvalcaba. The predominant gastrointestinal lesion in these diseases is some form of hamartomatous polyp. The term hamartoma implies a nonneoplastic tumor or tumorlike condition composed of tissue elements normally present in the particular area [2]. In many of these syndromes, it is now recognized that hamartomatous polyps of the gastrointestinal tract coexist with adenomas and that adenomas may develop within hamartomatous polyps. Either situation may contribute to the frequent association of alimentary tract adenocarcinoma that occurs in most of these syndromes. Various types of benign mucocutaneous lesions are common and often lead to the correct diagnosis. Of greater importance is the frequent occurrence of other extraintestinal manifestations, including several forms of malignant disease. Because of this frequent association with both gastrointestinal and nongastrointestinal malignant tumors, early and accurate diagnosis of these syndromes is essential. Meticulously performed double contrast studies are the preferred radiologic procedures for the diagnosis of gastrointestinal polyps in all of these diseases.

Time versus density enhancement of liver, spleen, and great vessels following rapid intravenous infusion of perflubron emulsion.

RATIONALE AND OBJECTIVES: We studied hepatosplenic enhancement in rhesus monkeys for 5 hr after rapid administration of perflubron (perfluorooctyl bromide [PFOB]) in an attempt to determine a clinically useful imaging window. METHODS: Five rhesus monkeys were examined using perflubron emulsion, 90% w/v perfluorochemical administered intravenously at a dose of 1.5 ml/kg and rate of 0.5 ml/sec. Helical computed tomography examination of the abdomen was obtained prior to the contrast bolus and 5 min, 30 min, 1, 2, 3, 4, and 5 hr postcontrast. Mean density of liver, spleen, and aorta was measured at each time interval. RESULTS: Significant aortic enhancement of 53 +/- 7 Hounsfield units (HU) (p < .0001) and liver enhancement of 19 +/- 4 H (p < .0004) occurred after 5 min and did not change significantly (p > .05) over 5 hr. Splenic enhancement of 35 +/- 9 HU was significant at 5 min (p < .0001) and continued to increase for 5 hr. CONCLUSION: Enhancement of the liver, blood vessels, and spleen is rapid and persists for at least 5 hr, which suggests a wider temporal window for hepatosplenic imaging with perflubron than is currently available with iodinated contrast agents.

Perfluoroctyl bromide as a blood pool contrast agent for computed tomographic angiography.

RATIONALE AND OBJECTIVES: We determined whether perfluoroctyl bromide (perflubron) could be used as a computed tomography (CT) angiographic agent by studying vessel visibility (celiac artery, superior mesenteric artery [SMA], and renal arteries) with spiral CT and three-dimensional (3D) reconstructions. METHODS: Five rhesus monkeys were examined with a perflubron emulsion (90% [w/v] perfluorochemical; administered intravenously at a dose of 1.5 ml/kg and at a rate of 0.5 ml/sec. Spiral CT was performed immediately and at 5 hr after injection. Three dimensional images of the aorta at the level of the celiac artery, SMA, and renal arteries were reconstructed and blindly rated 0-4 (0 = not seen; 4 = excellent visualization) by two observers. RESULTS: All the vessels had the best ratings immediately after injection: celiac artery, 2.8 +/- 0.42; SMA, 2.7 +/- 0.48; left renal artery, 2.1 +/- 0.99; and right renal artery, 1.2 +/- 1.03. The ratings after the 5-hr delay were as follows: celiac artery, 1.3 +/- 1.34; SMA, 1.5 +/- 1.08; left renal artery, 1.5 +/- 0.97; and right renal artery, 1.2 +/- 0.79. CONCLUSIONS: Spiral CT angiography with a perflubron emulsion successfully demonstrated all vessels immediately and at 5 hr after contrast agent infusion. Further refinements of the dose, rate, and reconstruction technique are expected to increase vessel visibility over this wide imaging window.

Recurrent tumor after resection of hepatic metastases from colorectal carcinoma: location and time of discovery as determined by CT.

OBJECTIVE: Despite studies showing increased survival rates for patients after surgical resection of hepatic metastases, recurrences occur in 75% of treated patients. The purpose of this study was to determine the location and time of discovery of recurrent tumor on CT scans after resection of hepatic metastases from colorectal carcinoma. MATERIALS AND METHODS: In a 6-year period, 32 patients (16 men and 16 women) who had undergone partial hepatic resection for colorectal metastases had follow-up CT at our institution. A total of 125 CT examinations of the chest and abdomen were retrospectively reviewed for the presence and location of recurrent disease. Recurrence was either confirmed by biopsy (n = 12) or presumed on the basis of growth of new lesions (n = 17). RESULTS: With a mean follow-up of 22 months (range, 1-60 months), recurrence was found at 29 sites in 25 patients. Thirteen sites were hepatic, and 16 were extrahepatic. Three patients had both hepatic and pulmonary disease. Recurrence within the liver was away from surgical margins in 11 (85%) of 13 patients at 14 +/- 7 months and adjacent to a surgical margin in the remaining two patients (15%) at 17 +/- 1 months. Extrahepatic recurrences were discovered in the lung in 11 (69%) of 16 patients at 21 +/- 12 months; in an adrenal gland in two patients (13%) at 19 +/- 5 months; in lymph nodes of the porta hepatis in one patient (6%) at 11 months; at the primary colonic anastomosis in one patient (6%) at 3 months; and in a retroperitoneal lymph node in the remaining patient (6%) at 12 months. CONCLUSION: Surgery was effective in treating the preoperatively detected hepatic metastases. Only two of 25 patients had recurrence related to a hepatic surgical margin. Most recurrences occur more than 1 year after surgery, most often in lung or liver away from surgical margins, and they probably represent small metastases undetectable with current preoperative or intraoperative techniques.

Characterization of swallowing and defecation in Parkinson's disease.

UNLABELLED: Despite the high prevalence of Parkinson's disease, the pathophysiology of its gastrointestinal symptoms remains poorly understood. OBJECTIVES: to evaluate swallowing and defecatory function in patients with Parkinson's disease and age- and sex-matched controls and to correlate objective findings with subjective symptoms. METHODS: The following studies were performed on 13 patients with Parkinson's disease and seven controls: extrapyramidal function assessment, gastrointestinal symptom survey, videoesophagram, colon transit study, defecography, and anorectal manometry. RESULTS: Abnormal salivation (frequency, %, control vs. Parkinson's disease: 14 vs. 77, p < 0.05), dysphagia (14 vs. 77, p < 0.05), constipation (14 vs. 31, p < 0.05), and defecatory dysfunction (29 vs. 77, p < 0.05) were more common among Parkinsonian patients. However, videoesophagographic abnormalities were equally common in both groups. Colon transit time was significantly prolonged in the Parkinson's disease group. Altered puborectalis function was noted on defecography in 31% of Parkinson's disease subjects, but in none of the controls (p < 0.05). Anorectal manometry identified several abnormalities in the Parkinson's disease group, which included decreased basal anal sphincter pressures, prominent phasic fluctuations on squeeze, and a hyper-contractile external sphincter response to the rectosphincteric reflex. Many patients exhibited both slow transit and manometric abnormalities, and symptoms were poor predictors of test results. CONCLUSION: In this group of patients with mild to moderate Parkinson's disease, videoesophagographic abnormalities were not confined to the patients with Parkinson's disease. Studies of colonic and anorectal function, in contrast, identified a number of abnormalities. Therefore, colonic and anorectal dysfunction appears to be an early gastrointestinal manifestation of Parkinson's disease, and may represent the direct involvement of the gut by this disease process.

Defecatory function in Parkinson's disease: response to apomorphine.

We evaluated the effects of the dopaminergic agent apomorphine on defecation and anorectal function in patients with Parkinson's disease (PD). A gastrointestinal symptom survey, extrapyramidal assessment, defecating proctogram, and anorectal manometric study were performed in 8 subjects with PD. Basal studies showing abnormalities were repeated following apomorphine administration. Prior defecographic abnormalities were normalized following apomorphine injection in 1 of 3 subjects and significant improvements in manometric parameters were observed in all 5 subjects who underwent repeat anorectal manometry. We conclude that apomorphine can correct anorectal dysfunction in PD, and that these abnormalities may be a consequence of dopamine deficiency secondary to the PD process. These findings may also have therapeutic implications.

CT during arterial portography: diagnostic pitfalls.

Computed tomography (CT) during arterial portography (CTAP) is an important technique for evaluating the liver before hepatic tumor resection. With this technique, most tumors are of low attenuation compared with that of enhancing parenchyma. At times, low-attenuation lesions are encountered that represent perfusion abnormalities rather than tumor deposits. These perfusion abnormalities can be categorized as (a) those resulting from improper technique; (b) those extending from hilum to capsule (straight-line sign), with or without an obstructing mass; (c) perihilar and periligamentous abnormalities; (d) subcapsular defects (linear or wedge shaped); and (e) those seen with cirrhosis or regenerating nodules. Adjuvant use of delayed CT, magnetic resonance imaging, and intraoperative ultrasound aids in characterization of these nontumorous defects, thereby improving specificity. The authors conclude that when potential candidates are evaluated for hepatic tumor resection, knowledge of the existence of the various diagnostic pitfalls of CTAP and their imaging characteristics is imperative to avoid inadvertent false results.

Inflammatory fibroid polyps of the gastrointestinal tract: radiologic evaluation.

Inflammatory fibroid polyps (IFPs) are uncommon lesions of the gastrointestinal tract. Only scattered case reports have appeared in the radiology literature. The authors reviewed the cases of 33 patients (20 women and 13 men; average age, 45 years) to determine if these polyps had any distinctive diagnostic radiologic features. The IFPs were located in the stomach (n = 16), small bowel (n = 13), and colon (n = 4). The lesions originated in the submucosa and were composed of fibroblasts, inflammatory cells, and a network of blood vessels. Gastric IFPs were most often located in the antrum and were usually ulcerated. Most of the patients presented with clinical evidence of gastrointestinal blood loss. Small bowel polyps were usually located in the ileum, and patients were typically older women with intestinal obstruction due to intussusception. Most of the lesions appeared as large, intramural masses at radiologic examination. Some of the lesions were pedunculated, and all were solitary. There were no distinctive features to differentiate IFPs from other mural or intraluminal lesions of the gastrointestinal tract.

Peutz-Jeghers syndrome.

The Peutz-Jeghers polyp is an unusual type of hamartomatous polyp; its characteristic feature is a smooth muscle core arising from the muscularis mucosae and extending into the polyp. Peutz-Jeghers polyps vary in size and shape; are found in the stomach, small bowel, and colon; and are usually multiple. Peutz-Jeghers syndrome is an inherited condition that often remains undiagnosed until after the polyps are identified, despite mucocutaneous pigmented lesions on the lips and mouth of children or young adults. In the past, standard therapy involved removal of the polyps that produced intussusception, but now endoscopic removal of all polyps is recommended. The polyps are not premalignant, but a definite association exists between Peutz-Jeghers syndrome and gastrointestinal carcinoma. Evidence shows that the syndrome is associated with an increased risk of extraintestinal malignancy, especially carcinomas of the pancreas, breast, and reproductive organs.

Recognition and prevention of barium enema complications.

The barium enema is a safe and accurate diagnostic study of the colon but, in rare cases, complications may result. Many of these can be prevented by proper equipment and careful attention to technique. When a complication does occur, prompt recognition and management is vital in decreasing morbidity and mortality. Perforation of the bowel is the most frequent serious complication, occurring in approximately 0.02% to 0.04% of patients. Rarely the colon may burst due to excessive transmural pressure alone. However, a colon weakened by iatrogenic trauma or disease is more likely to perforate during an enema than is a normal healthy bowel. Injury to the rectal mucosa or anal canal due to the enema tip or retention balloon is probably the most common traumatic cause of barium enema perforation. Inflation of a retention balloon within a stricture, neoplasm, inflamed rectum, or colostomy stoma is particularly hazardous. Recent deep biopsy or polypectomy with electrocautery makes the bowel more vulnerable to rupture. The tensile strength of the bowel wall is impaired in elderly patients, patients receiving long-term steroid therapy, and in disease states including neoplasm, diverticulitis, inflammatory bowel disease, and ischemia. Intraperitoneal perforation leads to a severe, acute peritonitis with intravascular volume depletion. The ensuing shock may be rapidly fatal. Prompt fluid replacement and laparotomy are essential. If the patient survives the initial shock and sepsis, later complications caused by dense intraperitoneal adhesions may develop. Extraperitoneal perforation is usually less catastrophic but may result in pain, sepsis, cellulitis, abscess, rectal stricture, or fistula. Intramural extravasation often forms a persistent submucosal barium granuloma which may ulcerate or be mistaken for a neoplasm. The most dramatic complication of barium enema is venous intravasation of barium. Fortunately, this is quite rare as it may be immediately lethal. Most cases have been attributed to trauma from the enema tip or retention balloon, mucosal inflammation, or misplacement of the tip in the vagina. Bacteremia has been found in as many as 23% of patients following barium enema and, in rare cases, may cause symptomatic septicemia. Other less common complications include barium impaction, water intoxication, allergic reactions, and cardiac arrhythmias. Preparatory laxatives and cleansing enemas have been implicated in some instances of dehydration, rectal trauma, water intoxication, and perforation. Careful review of the indications for examination, previous radiographs, and clinical history will identify many of the patients at greater risk for complications so that appropriate precautions may be observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Extracolonic manifestations of the familial adenomatous polyposis syndromes.

The classic prototypes of the gastrointestinal polyposis syndromes are familial polyposis coli and Gardner syndrome. Extracolonic manifestations have been described in both diseases, and the distinction between them has become less clear. In fact, some authorities have suggested that familial polyposis coli and Gardner syndrome may represent a spectrum of the same disease. In both conditions, extracolonic expressions are the rule rather than the exception, and familiarity with them is essential for accurate diagnosis and correct patient management. In this pictorial essay, we discuss familial polyposis coli and Gardner syndrome together under the heading familial adenomatous polyposis syndromes. The colonic characteristics of these syndromes will be reviewed briefly, followed by examples of the most common extracolonic manifestations.

Development of squamous cell carcinoma of the esophagus after endoscopic variceal sclerotherapy.

We describe the case of a 45-yr-old white male with portal hypertension and presumed Laennec's cirrhosis who developed squamous cell carcinoma of the esophagus 8 months after completion of a course of endoscopic variceal sclerotherapy. The epidemiology and natural history of esophageal cancer and their relationship to our patient are analyzed. This report emphasizes that squamous cell carcinoma of the esophagus should be considered in the differential diagnosis of postsclerotherapy dysphagia. Further studies will be required to determine whether or not esophageal variceal sclerotherapy is associated coincidently or causally with the development of squamous cell carcinoma of the esophagus in patients at increased risk for this condition.