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THE PAEDIATRIC ABDOMEN 239 E F G Figure 9.17 cont’d (E) Increased vascularity of inflamed appendix seen on colour flow Doppler imaging. (F) Walled off appendix abscess containing fluid and gas. (G) Complex inflammatory mass containing appendicolith. Ultrasound demonstrates a hypoechoic, thickened appendix, > 6 mm thick, with a blind end (Fig. 9.17). Occasionally an appendicolith, with strong acoustic shadowing, is present. The inflamed appendix is not compressible on gentle, graded compression with the transducer. This should be done very carefully, and released very slowly to avoid rebound tenderness. Ultrasound cannot reliably exclude appendicitis, especially if the appendix is retrocaecal. Perforation may not be easy to see with ultrasound, as fluid may disperse through the abdomen with decompression of the appendix itself. However, a frank periappendiceal fluid collection or abscess is easily demonstrable in a proportion of children and may, in some cases, be treated conservatively with antibiotics or drained percutaneously prior to surgery. The presence of free fluid, particularly if clear, in the abdomen is a non-specific finding and is not a reliable indicator of an acute abdomen. If echogenic fluid is seen, this is suggestive of intraperitoneal infection in the child with acute abdominal pain, but may be seen in other conditions, for example rupture of a haemorrhagic ovarian cyst. If ultrasound is equivocal, the clinicians may decide to observe the child but further imaging with CT scanning can be helpful in a few selective cases. Alternatively a laparoscopic examination may be performed where there is significant clinical concern 37 . Enteric duplication cysts These comparatively rare lesions present in infancy or early childhood with nausea, gastrointestinal bleeding, intestinal obstruction and, occasionally, a palpable mass. Most are intra-abdominal but oesophageal
240 ABDOMINAL ULTRASOUND A B Figure 9.18 (A) Duplication cyst with thickened wall adjacent to bowel. (B) Typical ‘double’ wall seen in enteric duplication cysts. Table 9.6 Abdominal fluid-filled masses in paediatrics—differential diagnoses Choledochal cyst Mesenteric cyst Duplication cyst Hepatic cyst Pancreatic pseudocyst Epidermoid cyst of the spleen Lymphangioma Ovarian cyst Encysted fluid associated with ventriculoperitoneal shunt tubing Renal cyst or renal dilatation Cystic renal tumour duplication cysts cause a thoracic lesion with respiratory symptoms. Multiple cysts may be present. The fluid-filled lesion may demonstrate a spectrum of ultrasonic appearances, from anechoic to References 1. McHugo JM, McKeown C, Brown MT et al. 1987 Ultrasound findings in children with cystic fibrosis. British Journal of Radiology 60: 137–141. 2. Williams SM, Goodman R, Thompson A, Mchugh K, Lindsell DRM. 2002 Ultrasound evaluation of liver hyperechoic, sometimes with gravity-dependent debris or blood. 38 The wall is well defined and a hyperechoic inner rim of mucosa may be identified in some cases of intestinal duplication (Fig. 9.18). The cyst is closely related to the adjacent bowel and this can be appreciated on real-time scanning as the bowel peristalses. CT and MRI rarely add anything to the ultrasound information. Contrast radiography may show an extrinsic defect but communication with the cyst is rare. There are many causes of intra-abdominal cystic masses in children. (Table 10.6). The main differential diagnosis in the infant girl is from an ovarian cyst as the ovary is generally an intra-abdominal organ at this age. Useful indicators of an ovarian origin can be detected on careful sonography, by detecting some residual ovarian tissue in the cyst wall, and the finding of a clearly seen multifollicular ovary on one side with absent visualization of a definite ovary on the other side. disease in cystic fibrosis as part of an annual assessment clinic: a 9-year review. Clinical Radiology 57: 365–370. 3. Wilson-Sharpe RC, Irving HC, Brown RC et al. 1984 Ultrasonography of the pancreas, liver and biliary
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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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THE RENAL TRACT 183 ● ● Morphol
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THE RENAL TRACT 185 ● ● hydrone
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THE RENAL TRACT 187 A Figure 7.27 A
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Page 210 and 211: THE RETROPERITONEUM AND GASTROINTES
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Page 268 and 269: INTERVENTIONAL AND OTHER TECHNIQUES
Page 288 and 289: 275 Bibliography and further readin
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Page 294 and 295: INDEX 281 Intravenous urography (IV
Page 296 and 297: INDEX 283 Phrygian cap, 29 Pneumobi
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