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THE PAEDIATRIC ABDOMEN 233 A B C D RT E F Figure 9.13 (A) Normal adrenal gland in a neonate, demonstrating the bulky, hypoechoic fetal cortex surrounding the thinner, hyperechoic medulla. (B) Left adrenal neuroblastoma. (C) Metastases were also present throughout the liver. (D) Confirmation of the left adrenal neuroblastoma and liver metastases on CT. (E) Adrenal haemorrhage in a neonate. (F) Same patient as in (E); 3 months later the haemorrhage has resolved and calcification has developed in the involuted adrenal gland.
234 ABDOMINAL ULTRASOUND Hypertrophic pyloric stenosis (HPS) HPS is a condition occurring in newborn infants commonly about 6 weeks of age when the pyloric muscle becomes hypertrophied and elongated, restricting the passage of gastric contents, causing projectile vomiting. Most infants with HPS are found to have a hypochloraemic alkalosis and, when seen in association with a palpable epigastric mass the size of an olive on test feeding, the diagnosis is clear without the need for ultrasonic imaging. However, ultrasound is very successful in demonstrating HPS in approximately 20% of infants in whom the pyloric olive cannot be palpated. 26,27 The baby should be positioned comfortably right side down and the stomach and pylorus identified usually just to the right of the midline in the low epigastric region. A small feed, of approximately 20– 30 ml of sugared water (preferable to milk as it does not contain echoes which may obscure vital detail), may be used to aid visualization of the gastric antrum if the stomach is empty. A nasogastric tube may also be used to administer clear fluid in a controlled way providing that the gastric position of the tube is confirmed prior to injection of the fluid. A small, highfrequency linear or curved linear transducer is best. The pylorus projects into gastric lumen and is outlined by the fluid. HPS can be confirmed by the demonstration of: ● ● ● Table 9.4 Wilms’ tumour Neuroblastoma Hepatoblastoma Hepatocellular carcinoma Rhabdomyosarcoma Leukaemia Lymphoma Paediatric abdominal malignancies thickened and elongated pyloric muscle increased but ineffective peristalsis failure of the pylorus to relax and open Various figures have been quoted for muscle thickness in hypertrophic pyloric stenosis ranging from 2.5 to 5 mm but 3 mm is most commonly accepted 28,29 (Table 9.5). It must be stressed that the examination is dynamic and measurements of muscle thickness must be interpreted in conjunction with the observations of gastric peristalsis and failure of the pylorus to relax normally. Sensitivity and specificity of 97% and 99% for the diagnosis of HPS have been reported in expert hands (Fig. 9.14). If clinical suspicion persists after a negative ultrasound, a repeat examination after 1 or 2 days may be performed to exclude an evolving pyloric stenosis. Intussusception Intussusception is the invagination of a segment of bowel into the lumen of the adjacent bowel. It is a common paediatric emergency, especially in younger children aged 3 months to 3 years, and tends to affect the ileocaecal region. The child presents with abdominal pain, sometimes with a palpable mass, vomiting or rectal bleeding. Intussusception can result in bowel necrosis and subsequently perforation requiring surgery. The ultrasound appearances of bowel within bowel are characteristic. In cross-section, the bowel assumes a ‘doughnut’ configuration, with concentric rings of bowel wall (Fig. 9.15). Dilated loops of fluid-filled obstructed bowel may be demonstrated proximal to the intussusception. The use of ultrasound to diagnose this condition is highly reliable, 30 reducing or eliminating the need for contrast radiology. An air enema is most commonly used to reduce the intussusception using inflation pressures of up to 120 mmHg. Hydrostatic reduction (that is, with water/saline) under fluoroscopic or ultrasound control is also an accepted treatment. 31 Table 9.5 Pyloric muscle dimensions Normal pylorus Pyloric length < 15 ≥ 16 (mm) Pyloric width < 11 ≥ 11 (mm) Muscle thickness < 2.5 ≥ 3 (mm) Hypertrophic pyloric stenosis
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Abdominal Ultrasound
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Abdominal Ultrasound How, Why and W
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v Contents Contributors Preface ix
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vii Contributors Rosemary Arthur FR
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ix Preface Ultrasound continues to
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ABBREVIATIONS xi MHA MHV MI MPV MRA
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Chapter 1 1 Optimizing the diagnost
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OPTIMIZING THE DIAGNOSTIC INFORMATI
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Chapter 2 17 The normal hepatobilia
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THE NORMAL HEPATOBILIARY SYSTEM 19
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Chapter 3 41 Pathology of the gallb
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PATHOLOGY OF THE GALLBLADDER AND BI
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Chapter 4 79 Pathology of the liver
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PATHOLOGY OF THE LIVER AND PORTAL V
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Chapter 5 121 The pancreas CHAPTER
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THE PANCREAS 123 the patient’s le
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THE PANCREAS 125 Acute pancreatitis
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THE PANCREAS 127 E F G Figure 5.3 c
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A C DISTANCE = 3.43 CM 5%. 13 Over
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THE PANCREAS 131 G H I Figure 5.5 c
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THE PANCREAS 133 head of pancreas.
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THE PANCREAS 135 pancreatic juice i
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Chapter 6 137 The spleen and lympha
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THE SPLEEN AND LYMPHATIC SYSTEM 139
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Chapter 7 153 The renal tract CHAPT
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THE RENAL TRACT 155 As with any oth
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THE RENAL TRACT 157 A B q 0 LRA AO
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THE RENAL TRACT 159 junctions of or
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THE RENAL TRACT 161 A B Figure 7.5
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THE RENAL TRACT 163 carcinomas, the
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THE RENAL TRACT 165 the vesicourete
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THE RENAL TRACT 167 Table 7.1 Sourc
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THE RENAL TRACT 169 A B Figure 7.13
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THE RENAL TRACT 171 Table 7.2 Diffe
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THE RENAL TRACT 173 Ultrasound stil
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THE RENAL TRACT 175 CT is useful fo
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THE RENAL TRACT 177 Xanthogranuloma
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THE RENAL TRACT 179 As with acute t
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THE RENAL TRACT 181 der with increa
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Page 294 and 295: INDEX 281 Intravenous urography (IV
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INDEX 283 Phrygian cap, 29 Pneumobi
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