Is age associated with size of adult extrahepatic bile duct: sonographic study.

PURPOSE: To determine if the size of the extrahepatic bile duct increases with age in adults. MATERIALS AND METHODS: A total of 258 consecutive patients 18 years and older, without known biliary or pancreatic disease, who were fasting to undergo routine abdominal sonography were examined. The transverse and anteroposterior dimensions of the extrahepatic bile duct were measured proximally at the porta hepatis, at the middle above the head of the pancreas, and distally at the head of the pancreas. Simple linear regression of the average of these measurements against age tested the hypothesis of a slope of 1.0 mm per decade. RESULTS: The sample included a wide variety of ages: 55 years +/- 16 (mean +/- SD), with a range of 20-92 years, including 151 men and 107 women. One-tenth of the cohort were younger than 35 years old and one-tenth were older than 77 years old. The six measurements were proximal-transverse 3.5 mm +/- 1.0, proximal-anteroposterior 2.9 mm +/- 1.1, middle-transverse 3.9 mm +/- 1.2, middle-anteroposterior 3.4 mm +/- 1.2, distal-transverse 4.1 mm +/- 1.2, distal-anteroposterior 3.5 mm +/- 1.2. Least squares regression slope differed significantly from 0.1 mm per year (95% CI; -0.000703, +0.00110) and in fact contained zero. CONCLUSION: Findings were not able to help confirm an association between age and size of the extrahepatic bile duct in an asymptomatic adult population.

Work-up of urinary tract infection in infants and children.

Urinary tract infection (UTI) in infants and children demands rapid differentiation between upper UTI (pyelonephritis) and lower UTI (cystitis) for prompt treatment to be initiated so that renal damage is minimized. This pictorial review presents a wide gamut of structural and functional abnormalities of the urinary tract that may predispose infants and children to UTI, including vesicoureteral reflux, upper urinary tract obstruction (ureteropelvic junction obstruction), lower urinary tract obstruction (primary megaureter, ureterovesical junction obstruction, posterior urethral valve, ectopic ureterocele with or without associated duplex collecting system), neurogenic problems (dysfunctional voiding), calculi, and parenchymal scars. Sonography (ultrasound [US]) is the imaging modality of choice for assessment of renal size, growth (serial sonograms), texture, and blood flow. Other modalities used to work-up UTI in the pediatric patient include fluoroscopic voiding cystourethrogram, nuclear voiding cystourethrogram, and nuclear renal scintigraphy (NRS). Excretory urography is no longer recommended in the routine evaluation of childhood UTI because information regarding anatomy and function (qualitative and quantitative) can be better assessed with US and NRS, respectively. Computed tomography and magnetic resonance imaging are primarily reserved for complex cases in which a definitive diagnosis cannot be made with routine imaging. Algorithms for work-up of UTI in various pediatric age groups are presented.

US approach to jaundice in infants and children.

High-resolution real-time ultrasonography (US) serves as an important tool for differentiation of obstructive and nonobstructive causes of jaundice in infants and children, independent of liver function. Unconjugated hyperbilirubinemia occurs in approximately 60% of normal term infants and in 80% of preterm infants. Persistence of neonatal jaundice beyond 2 weeks of age demands US evaluation to differentiate between the three most common causes: hepatitis, biliary atresia, and choledochal cyst. In all three conditions, the hepatic echotexture is diffusely coarse and hyperechoic, but this appearance may be seen in a variety of hepatic inflammatory, obstructive, and metabolic processes. Thus, hepatic scintigraphy and at times percutaneous liver biopsy are necessary to narrow the differential diagnosis and to identify patients who require more invasive techniques (eg, intraoperative cholangiography). US is useful for demonstrating inspissated bile and biliary duct stones. In infants, stones are usually secondary to obstructive congenital anomalies of the biliary tract, total parenteral nutrition, furosemide treatment, phototherapy, dehydration, infection, hemolytic anemia, and short-gut syndrome, whereas in older children, stones are usually associated with sickle cell disease, bowel resection, hemolytic anemia, and choledochal cyst. Jaundice in infants and children may also be due to cirrhosis, benign strictures, and neoplastic processes.

The limitations of carotid sonography: interpretive and technology-related errors.

OBJECTIVE: This study compared carotid artery sonography with angiography to determine, in retrospect, which types of sonographic errors arose from incorrect interpretation of sonographic images and which errors could be ascribed to the limitations of sonographic imaging. MATERIALS AND METHODS: A review of all patients who underwent carotid artery sonography and angiography between 1993 and 1997 at our institution revealed 66 patients with complete sets of studies, yielding 132 examinations (right or left). Studies were not reinterpreted and angiography was considered to be the gold standard. Only stenoses of 60% or greater were included in our study. If the degree or location of stenosis differed on the two imaging studies, they were reviewed together to classify the type of sonographic error. RESULTS: We found complete agreement of sonography and angiography in 115 cases (87%) and discrepancies in 17 (13%). Thirteen of 17 sonographic errors were false-positive interpretations and three were false-negative interpretations. One was an error in location. Retrospective review showed seven interpretive errors. In all these cases, the color Doppler image better revealed the degree of stenosis. Other complicating factors included inconsistencies between absolute velocities, velocity ratios, and waveforms obtained while a patient was being treated with an intraaortic balloon pump. In the other 10 discrepancies, the sonographic interpretation was accurate. Seven of these cases were false-positive interpretations in patients with contralateral occlusions or stenoses. The other three cases in this group showed long segments of stenosis, ulcerations, or tortuous vessels on angiography. CONCLUSION: Our study suggests that increased accuracy can be achieved in the interpretation of carotid artery sonography by meticulous attention to the color image. When color Doppler sonography is technically limited by tortuosity or ulceration, or if significant contralateral disease is present, misinterpretation is more likely.

Abdominal lymphangioma in a preterm infant.

A newborn infant, noted on prenatal ultrasonography to have a huge, multiseptated cystic intraabdominal mass, had severe respiratory failure at birth because of a massively distended abdomen. Acute treatment included removal of 1.7 L of serous fluid, aggressive respiratory support, and numerous diagnostic studies. Definitive therapy was excision of the cyst by laparoscopy. Pathologic examination showed cystic lymphangioma.

Benign cystitis in children mimicking rhabdomyosarcoma.

Seventeen (13 male, 4 female) patients, aged 13 months to 13 years, with benign cystitis had imaging findings that mimicked those of rhabdomyosarcoma. Our experience indicates that in the child with hematuria, dysuria, and frequency plus cystographic or sonographic demonstration of a bladder with reduced capacity and circumferential wall thickening or sonographic findings of isoechoic bladder wall thickening (focal, multifocal or circumferential distribution), intact mucosa, and bullous lesions should strongly suggest inflammation and not malignancy. When an inflammatory lesion is suspected, follow-up imaging should be performed in 2 weeks, which if normal will preclude biopsy.

Ultrasonographic features of gastrointestinal duplications.

The variable sonographic appearance of duplication cysts is presented. Eighteen sonograms from 14 patients, aged 1 day to 8 years, were reviewed over an 8 year period. Water and other aqueous contrast agents were used in six patients as part of the sonographic evaluation. All lesions were confirmed by surgery. All but two patients were symptomatic. Twenty-four cysts were detected, ranging in size from 1.7 to 15.5 cm. The duplication cysts revealed a spectrum of sonographic findings (cystic to solid appearing masses). The mass characteristics, including the "muscular rim sign," and internal debris or hemorrhage, were demonstrated. Multiple unsuspected cysts (3 of 14 or 20%) and complications such as perforation were readily seen with ultrasonography. Serial sonograms demonstrated the changing morphology of two cysts. Other unsuspected intra-abdominal and pelvic pathologic conditions, including pyloric stenosis and ovarian cysts, were identified. Identification of the muscular rim sign is the most reliable indication of a duplication cyst. Multiple masses as well as possible accompanying anomalies in the abdomen and pelvis are readily evaluated with sonography. Lesions are easily followed with serial studies if there is no surgical intervention.

Correlative imaging of pelvic soft tissue sarcomas in children.

The authors retrospectively reviewed 15 cases of pelvic soft tissue sarcoma treated at the Children's Hospital of Philadelphia during a recent 6-year period. These patients were treated before the availability of magnetic resonance imaging. The authors compared ultrasonography, computed tomography, and excretory urography/voiding cystourethrography for establishing the diagnosis and following the progression/regression of the disease. Results were correlated with clinical, surgical, and pathologic findings. Although computed tomography and ultrasonography were both capable of characterizing the size and texture of the lesion, computed tomography was superior in defining disease arising from the pelvic sidewall. Both techniques effectively identified residual mass at the tumor site, but neither could differentiate active tumor from inactive tumor, posttherapy inflammation, or fibrosis. Excretory urography/voiding cystourethrography provided no information that could not be gleaned from either ultrasonography or computed tomography.

Urethral stones: US for identification in boys with hematuria and dysuria.

There are multiple causes for hematuria in infants and children. When hematuria is accompanied by dysuria, however, one should focus attention on the lower urinary tract. Although ultrasound (US) is a well-established method for assessing the kidneys and bladder, little attention has been focused on its use for evaluating urethral abnormalities, since voiding cystourethrography or retrograde urethrography usually is used. In the cases of two young boys, sonography aided in the identification of clinically unsuspected urethral stones. US evaluation of the urethra is now included as an integral part of urinary tract sonography in male patients with hematuria accompanied by dysuria.

Sonography of the elbow in infants and children.

High-resolution real-time sonography of the musculoskeletal system of infants and young children is being used with increasing frequency, in part because of the inability of plain film radiography to visualize unossified cartilage. Real-time sonography now plays an important role in the evaluation of infantile hip dysplasia, as well as in the identification and aspiration of joint effusion. The purpose of this essay is to illustrate clinical situations in which sonography of the elbow is helpful.

The predictive value of ultrasonography in evaluation of infants with posterior urethral valves.

Between 1981 and 1989, 28 infants less than 6 months old with posterior urethral valves underwent ultrasound evaluation as part of the initial evaluation at our hospital. The single ultrasound feature that correlated with subsequent renal function was the status of corticomedullary differentiation. The presence of corticomedullary junctions in at least 1 kidney in 17 infants was always associated with a serum creatinine level of 0.8 mg./dl. or less in long-term followup. Of 11 patients with absent corticomedullary differentiation 7 had eventual creatinine levels of greater than 0.8 mg./dl. with 5 of them suffering clinically significant renal insufficiency. An association between vesicoureteral reflux and absent corticomedullary junctions was also found.