Pneumatosis intestinalis and diarrhea in a child following renal transplantation.

Pneumatosis intestinalis is an uncommon finding beyond the neonatal period, but it has been reported in immunocompromized pediatric patients. The association of pneumatosis intestinalis in children following renal transplantation has to the best of our knowledge been only reported once in children. We describe a 4-year-old female who developed intermittent emesis, weight loss, and intermittently loose bloody stools after cadaveric renal transplantation at age 3.5 years. An abdominal x-ray demonstrated extensive pneumatosis in the colon. The infectious work-up was negative. Histologically, she had increased eosinophils throughout the lamina propria in the rectum. A glucose breath test was suggestive of small bowel bacterial overgrowth. She was treated with 10 days of metronidazole with resolution of the diarrhea and occult blood in stools. One month after the treatment she had radiologic resolution of her pneumatosis. Based on this report, pneumatosis intestinalis should be considered in the differential diagnosis of children after organ transplant suffering from diarrhea, abdominal pain, or blood in the stool.

Effect of cross-sectional imaging on negative appendectomy and perforation rates in children.

PURPOSE: To compare negative appendectomy and perforation rates in children who underwent ultrasonography (US), computed tomography (CT), or no imaging before urgent appendectomy. MATERIALS AND METHODS: All children who underwent urgent appendectomy during a 4(1/2)-year period were identified in a surgical billing database. Pathology reports were coded as negative or as showing acute inflammation or perforation. Imaging up to 14 days before appendectomy or abscess drainage was noted, and imaging-based diagnoses were compared with pathologic findings. Patient age and sex were recorded. RESULTS: Two hundred ninety-nine children, 176 (59%) male and 123 (41%) female (mean age, 10.4 years; age range, 1--21 years), underwent urgent appendectomy. One hundred twenty-six (42%) underwent no imaging, 121 (41%) underwent US with or without CT, and 52 (17%) underwent CT only; 44 (15%) underwent both US and CT. There were significantly higher rates of appendectomy with normal pathologic findings ("negative appendectomy") in patients who underwent no imaging (14% [18 of 126]) or US (17% [20 of 121]) versus the rates in those who underwent CT only (2% [one of 52]) (P =.02 and P =.007, respectively). The negative appendectomy rate was 7% in 96 patients who underwent CT with or without prior US. The perforation rates were not significantly different. CONCLUSION: As compared with children who underwent no preoperative imaging and those who underwent US, children who underwent CT had a significantly lower negative appendectomy rate, without a significantly higher perforation rate.

Unenhanced helical CT in the evaluation of the urinary tract in children and young adults following urinary tract reconstruction: comparison with sonography.

PURPOSE: To compare the accuracy of unenhanced, helical CT with sonography for the detection of complications of urinary tract reconstruction. MATERIALS AND METHODS: Forty-six kidneys in 24 patients were examined with CT and sonography. All scans were assessed for ease of renal visualization, presence of renal, ureteral, and bladder calculi, renal scars, hydronephrosis, and abdominal wall hernia. The results of both imaging modalities were independently reported. RESULTS: CT provided excellent visualization of all 46 kidneys, while sonography provided poor visualization of 8 kidneys (17%) (P < 0.001). CT detected calculi in 10 kidneys, 1 ureter, and 7 bladders. Sonography detected calculi in only 2 kidneys, and 2 bladders. Overall, CT detected significantly more calculi than US (18 vs 4, P = 0.01). CT detected scarring in 15 kidneys, while sonography detected scarring in 10. Hydronephrosis was detected in 6 kidneys by CT and in 8 kidneys by sonography. Three abdominal wall hernias were seen at CT that were not seen at sonography. CONCLUSION: CT is superior to sonography for the detection of urinary tract calculi and renal scarring. CT will demonstrate abdominal wall hernias that are unsuspected.

When appendicitis is suspected in children.

Acute appendicitis is the most common condition requiring emergent abdominal surgery in childhood. The clinical diagnosis of acute appendicitis is often not straightforward because approximately one-third of children with the condition have atypical clinical findings. The delayed diagnosis of this condition has serious consequences, including appendiceal perforation, abscess formation, peritonitis, sepsis, bowel obstruction, and death. Cross-sectional imaging with ultrasonography (US) and computed tomography (CT) have proved useful for the evaluation of suspected acute appendicitis. There has been a great deal of variability in the utilization of these modalities for such diagnosis in the pediatric population. The principal advantages of US are its lower cost, lack of ionizing radiation, and ability to assess vascularity through color Doppler techniques and to provide dynamic information through graded compression. The principal advantages of CT include less operator dependency than US, as reflected by a higher diagnostic accuracy, and enhanced delineation of disease extent in a perforated appendix.

Using helical CT to diagnosis acute appendicitis in children: spectrum of findings.

Helical CT in children shows an overlapping and wide spectrum of appearances of the normal and acutely inflamed appendix. The normal appendix may measure up to 10 mm in maximal diameter but should not have other CT signs of acute inflammation.

Imaging evaluation of suspected appendicitis in a pediatric population: effectiveness of sonography versus CT.

OBJECTIVE: The purpose of this study was to compare the diagnostic accuracy of graded compression sonography with that of helical CT for the diagnosis of appendicitis in a pediatric and young adult population. SUBJECTS AND METHODS: Between June 1996 and April 1999, 386 pediatric and young adult patients with suspected appendicitis were examined using sonography, CT, or both: 233 underwent sonography only, 71 underwent CT only, and 82 underwent sonography and CT. All sonograms and CT scans were prospectively interpreted as showing positive or negative findings for appendicitis by one of six pediatric radiologists. CT and sonographic findings were correlated with surgical and histopathologic findings or findings at clinical follow-up. RESULTS: Helical CT had a significantly higher sensitivity (95% versus 78%, p = 0.009) and accuracy (94% versus 89%, p = 0.05) than graded compression sonography for the diagnosis of appendicitis in children, adolescents, and young adults. The specificity of both techniques was 93%. Twenty of 82 patients who underwent both sonography and CT had discordance between the findings of the two examinations. The CT results were correct in a significantly greater number of patients with discordant examinations (17/20 patients [85%]). CONCLUSION: Helical CT has a significantly higher sensitivity and accuracy than graded compression sonography for the diagnosis of appendicitis in a pediatric and young adult population, particularly in children more than 10 years old.

Evaluation of suspected appendicitis in children and young adults: helical CT.

PURPOSE: To evaluate the accuracy of helical computed tomography (CT) for the diagnosis of appendicitis in children and to assess the utility of CT in establishing alternative diagnoses. MATERIALS AND METHODS: The medical records of 154 children (median age, 12 years; age range, 1-20 years) who were suspected to have appendicitis and who underwent CT were reviewed. The gastrointestinal tract was opacified in 151 of 154 patients: Only orally administered contrast material was used in 126 patients; only rectally administered contrast material, in 21 patients; and both oral and rectal contrast material, in four patients. CT findings were correlated with surgical and histopathologic findings or with clinical follow-up findings. RESULTS: Sixty-four CT scans were interpreted as positive for appendicitis and included 58 true-positive and six false-positive scans. Ninety scans were interpreted as negative and included 87 true-negative and three false-negative scans. CT had a sensitivity of 95% and a specificity of 94% for the diagnosis of appendicitis. In addition, in 32 (34%) of 93 patients without appendicitis, an alternative diagnosis was established on the basis of CT findings. CONCLUSION: Helical CT is useful in a pediatric population to diagnose or exclude appendicitis and to establish an alternative diagnosis.

Detection of active intraabdominal hemorrhage after blunt trauma: value of delayed CT scanning.

Active hemorrhage is a rare finding at CT following blunt abdominal trauma. The time interval between IV contrast administration and scanning the abdomen may impact on the ability to visualize active hemorrhage at CT. We report a case of active hemorrhage associated with splenic injury that was identified only at delayed CT scanning.

Acute hemoperitoneum in children: prevalence of low-attenuation fluid.

BACKGROUND: Recent evidence indicates that acute hemoperitoneum may have lower than expected attenuation values at CT. OBJECTIVE: To characterize the attenuation of acute hemoperitoneum at CT in children following blunt abdominal trauma and to assess the prevalence of low-attenuation fluid. MATERIALS AND METHODS: The CT scans of 19 consecutive children with isolated hepatic or splenic injury and associated peritoneal fluid were retrospectively analyzed. The attenuation value of peritoneal fluid was assessed in all peritoneal spaces. RESULTS: Fluid was noted in 53 peritoneal spaces (27 abdominal, 26 pelvic). Fluid attenuation ranged from 20 to 64 HU. The mean fluid attenuation in pelvic spaces (37.5 +/- 9.4 HU) was significantly lower than in abdominal spaces (444.9 +/- 10.2 HU) (P = 0.008). Fluid in 8/26 (31 %) pelvic spaces and 2/27 (7 %) abdominal spaces had attenuation values < or = 30 HU. Fluid surrounding the site of injury (perihepatic or perisplenic space) was significantly higher in attenuation than fluid at other sites (P < 0.001). There was no correlation between the mean attenuation value of peritoneal fluid in each patient and the admission hematocrit (r = -0.14, P = 0.55). CONCLUSIONS: There is great variability in the attenuation of acute hemoperitoneum. Blood in pelvic spaces has significantly lower attenuation than blood in abdominal spaces. Hemoperitoneum in the pelvis has values of < or = 30 HU in approximately one-third of spaces. The attenuation of acute hemoperitoneum does not correlate with hematocrit.

Prevalence and distribution of extraperitoneal hemorrhage associated with splenic injury in infants and children.

OBJECTIVE: The purpose of this study was to evaluate the prevalence and distribution of associated extraperitoneal hemorrhage in infants and children with splenic injury. CONCLUSION: Splenic injury occasionally resulted in extraperitoneal hemorrhage that tracked into the anterior pararenal space. Extraperitoneal hemorrhage always occurred in association with intraperitoneal hemorrhage. In addition, blood tracking into the anterior pararenal space after splenic injury dissected the splenic vein and pancreas in two (25%) of eight patients.

Selective management of pediatric pancreatic injuries.

BACKGROUND: Despite trauma being the most common cause of pediatric pancreatitis, the diagnosis and management is often difficult. METHODS: The hospital course, diagnostic and surgical procedures, and complications for all children with traumatic pancreatitis evaluated at a Regional Level I Trauma Center were reviewed retrospectively. RESULTS: Twelve of 3,500 children (0.35%, mean age, 8.7 +/- 1.2 years) were reviewed. Intraoperative diagnosis was made in three after penetrating trauma. Nine children sustained blunt pancreatic trauma (BPT) with serial radiographic imaging confirming the diagnosis in seven. Serial serum amylase levels, when performed, were normal in two and elevated in six, but did not predict injury severity or need for further intervention. Endoscopic retrograde cholangiopancreatography was performed in three children and indicated the need for surgical intervention in two and prevented planned laparotomy in one. Two children underwent computed tomography-guided fluid drainage. Pseudocysts developed in five children. Mortality rate from penetrating injuries was 66% with no deaths from BPT. CONCLUSIONS: A combination of serial radiographic, laboratory, and ERCP findings will improve the diagnosis and management of BPT. Penetrating or main ductal injuries require surgical intervention, and fluid collections may require drainage, but, otherwise, most BPT can be managed nonoperatively with minimal morbidity and mortality.

Hepatic arterial pseudoaneurysm: a rare complication of blunt abdominal trauma in children.

We report a child who developed a hepatic artery pseudoaneurysm following blunt hepatic injury. This is a rare complication of hepatic trauma in children. The imaging evaluation and clinical management of hepatic artery pseudoaneurysms are presented.

Pediatric hepatic trauma: does clinical course support intensive care unit stay?

PURPOSE: The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care. METHODS: A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed. RESULTS: Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications. CONCLUSIONS: Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.

Blunt abdominal trauma in children: impact of CT on operative and nonoperative management.

OBJECTIVE: The purpose of this study was to evaluate the impact of CT on operative management of children examined after blunt abdominal trauma. SUBJECTS AND METHODS: Fifteen-hundred consecutive children who sustained blunt abdominal trauma were prospectively examined with CT. CT findings and the decision for operative or nonoperative management were recorded prospectively. In the children who underwent laparotomy, indications for operative intervention as determined by the attending trauma surgeon and surgical findings were also recorded. RESULTS: Three hundred eighty-eight (26%) of the CT scans had abnormal findings: solid viscus injury, 286; other CT abnormality, 102. Twenty (7%) of 286 children with a solid viscus injury and 25 (83%) of 30 children with a hollow viscus injury underwent therapeutic laparotomy. Abnormalities seen on CT were noted in all 20 children with solid viscus injury and 24 of 25 children with hollow viscus injury who underwent therapeutic laparotomy. The decision for laparotomy was based on CT findings in five (25%) of 20 children with solid viscus injury and 17 (68%) of 25 children with hollow viscus injury. Eleven hundred twelve children (74%) had normal findings on CT. Only one of these children later required laparotomy. CONCLUSION: CT rarely influenced the decision for operative intervention in children who sustained blunt abdominal trauma. CT findings affected the decision for operative intervention in most children with hollow viscus injury; however, CT findings affected such a decision in only a small subset of children with solid viscus injury. Normal abdominal CT findings strongly predicted a lack of subsequent deterioration requiring operative intervention.

Pancreatic emergencies.

Sonography and CT scan remain the examinations of choice for evaluating pancreatic diseases. This article addresses the clinical and imaging features of the two most important pancreatic emergencies: (1) pancreatitis and (2) trauma. The rationale for selecting sonography or CT scan is also addressed.

Gastrointestinal emergencies in older infants and children.

Gastrointestinal tract emergencies in older infants include traumatic and nontraumatic conditions. The imaging evaluation of these conditions strongly affects diagnosis and management. This article provides a clinical overview and reviews the rationale for imaging and important imaging features of these gastrointestinal tract emergencies.

Imaging children with acute right lower quadrant pain.

In summary, sonography is the primary modality for evaluating children with acute right lower quadrant pain. Sonography is particularly useful in the evaluation of children with suspected appendicitis in whom the clinical findings are equivocal, and in the evaluation of female children with suspected pelvic pathology. Findings at sonography should not supersede clinical judgement in patients who are believed to be at high clinical risk of having appendicitis on the basis of clinical signs and symptoms. Abdominal radiographs are helpful primarily if small bowel obstruction or perforation is suspected; CT is useful for evaluating complications of appendicitis and evaluating the postoperative patient.