3/30/18. Common Radiology Studies in Pediatric Surgery. Disclosure Information. Objectives

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1 Common Radiology Studies in Pediatric Surgery A Scenario Based Approach to Interpretation for the Pediatric Nurse and Provider presented by Elizabeth A. Paton, DNP, RN-BC, PNP-A, PPCNP-BC, CPEN, FAEN Disclosure Information I have no disclosures Objectives By the end of this presentation, the learner will be able to: 1. Discuss a basic approach to interpreting common radiology studies, including chest and abdominal X-rays, upper GIs, and CT scans. 2. Discuss key radiographic findings exhibited by patients with congenital abnormalities. 3. Recognize key abnormal radiological findings with acquired surgical diagnoses. 1

2 Specific Radiology Examinations Chest X-ray (CXR) Abdominal X-ray (KUB) Computerized topography (CT) o Chest o Abdomen Ultrasound Upper gastrointestinal series (UGI) Contrast enema Esophagram Chest X-ray Quality: Rotation Inclusion Penetration Expansion Interpretation: Airway Bone Cardiac Diaphragm Extrathoracic tissues Fields Gastric bubble Hilum and mediastinum Instrumentation Abdominal X-ray Interpretation: Air Bowel Calcifications Diaphragm Everything else 2

3 Normal Abdominal X-ray Air? Bowel Calcifications? Diaphragm Everything else Flat Upright Computerized Topography (CT) Abdomen Axial- Axial- Abdominal Coronal Sagittal Lung Window Ultrasound May be used for diagnosis or evaluation of: Masses Appendicitis Intussusception Cholelithiasis/cholecystitis Hypertrophic pyloric stenosis Malrotation Ovarian pathologies 3

4 SMA/SMV to Evaluate for Malrotation SMA= Superior Mesenteric Artery SMV= Superior Mesenteric Vein Esophagram May be used for: Evaluation for esophageal stricture Integrity of anastomosis after TE fistula repair Retained food bolus Esophageal damage after caustic ingestion (e.g. battery) Other congenital abnormalities Esophagram 4

5 Upper Gastrointestinal Series (UGI) Used to evaluate for: Duodenal atresia Malrotation Strictures or atresias of small bowel Hypertrophic pyloric stenosis (not modality of choice) Normal UGI Normal UGI 5

6 Contrast Enema Used to evaluate for: Hirschprung disease Strictures or atresias of colon Other reasons for delayed passage of meconium Treatment for intussusception May use: Air Water soluble contrast Barium Normal Contrast Enema PLACEMEN RADIOLOGICAL FINDINGS OF SPECIFIC SURGICAL DIAGNOSES MEDICAL DEVICES 6

7 Case Scenario 1 15 year old male presents with acute onset of left sided chest pain History PMHx Vital Signs o Temperature 37.0 ºC o Heart Rate 84 bpm o Respiratory Rate 36 bpm o Pulse Ox 95% room air Case Progression What are your differential diagnoses? Costochondritis Trauma Pneumonia Pneumothorax Cardiac process What test(s) do you want to order? Chest X-ray Quality: Rotation Inclusion Penetration Expansion Interpretation: Airway Bone Cardiac Diaphragm Extrathoracic tissues Fields Gastric bubble Hilum and mediastinum Instrumentation 7

8 3/30/18 Pneumothorax Pneumothorax Case Progression What are your interventions? o Chest tube? o Oxygen? o Incentive spirometry? 8

9 Pneumothorax Case Progression What are your interventions? o Chest tube? o Oxygen? o Incentive spirometry? Pneumothorax 9

10 Chest Tube Placement (Chest X-ray: Tubes- chest drains-position, 2017) Case Scenario 2 18 month old female presents with an acute onset of difficulty swallowing History PMHx Vital Signs o Temperature 37.0 ºC o o o Heart Rate 116 bpm Respiratory Rate 32 bpm Pulse Ox 99% room air Esophageal Foreign Body 10

11 Why obtain 2 view X-ray? Esophageal Foreign Body Esophageal Foreign Body 11

12 Bronchial Foreign Body Case Scenario 3 9 year old female presents with 1 day history of abdominal pain History PMHx Vital Signs o Temperature 38.0 ºC o Heart Rate 92 bpm o Respiratory Rate 26 bpm o Pulse Ox 99% room air Case Progression What are your differential diagnoses? Gastroenteritis Constipation Urinary Tract Infection Ovarian pathology Appendicitis What test(s) do you want to order? 12

13 Appendicitis Diagnostic Criteria: Enlarged >6mm diameter Wall thickening >2mm Wall enhancement Fat stranding Appendicolith Fluid filled Appendicitis Appendicitis 13

14 Appendicitis Case Scenario 4 5 week old male presents with vomiting History PMHx Vital Signs o Temperature 37.0 ºC o Heart Rate 144 bpm o Respiratory Rate 36 bpm o Pulse Ox 99% room air Case Progression What are your differential diagnoses? Gastroesophageal reflux Formula intolerance Malrotation Pyloric stenosis What test(s) do you want to order? 14

15 3/30/18 Pyloric Stenosis Diagnostic Criteria: Muscle Thickness >3mm Channel Length >14mm Failure of channel to open and stomach contents to empty Pyloric Stenosis Pyloric Stenosis 15

16 Case Progression What are your interventions? o o o o Fluid resuscitation NPO Monitoring of electrolytes until corrected CO2 <30, Chloride >100 Surgery- pyloromyotomy Case Scenario 5 15 month old male presents with crampy, intermittent abdominal pain History PMHx Vital Signs o Temperature 37.0 ºC o Heart Rate 118 bpm o Respiratory Rate 36 bpm o Pulse Ox 99% room air Case Progression What are your differential diagnoses? Gastroesophageal reflux Gastroenteritis Constipation Intussusception What test(s) do you want to order? 16

17 Intussusception Intussusception Intussusception 17

18 Case Scenario 6 5 day old, 29 week preemie, presents with feeding intolerance and blood in stool History PMHx Vital Signs o Temperature 37.2 ºC o o o Heart Rate 156 bpm Respiratory Rate 36 bpm Pulse Ox 97% room air Case Progression What are your differential diagnoses? Milk protein intolerance Anal fissure Sepsis Non-accidental trauma Necrotizing Enterocolitis (NEC) What test(s) do you want to order? Necrotizing Enterocolitis Modified Bell Staging Criteria: IA: Signs of sepsis, abdominal distention, guaiac positive stools, KUB with normal gas pattern or mildly dilated loops of bowel IB: Same except bright blood from rectum IIA: Same except pneumatosis intestinalis noted on KUB IIB: Thrombocytopenia, abdominal tenderness, portal venous gas IIIA: Severely ill, acidotic, neutropenia, DIC, peritonitis, portal venous gas + ascites IIIB: Same as IIIA but KUB demonstrates pneumoperitoneum 18

19 Necrotizing Enterocolitis Pneumatosis Necrotizing Enterocolitis PLACEMENT OF MEDICAL DEVICES MEDICAL DEVICES 19

20 3/30/18 Central Venous Line Placement Superior Vena Cava Right Atrium (Chest X-ray: Tubes- CVL lines position, 2017) Tip of CVL should be in the superior vena cava or at the cavo-atrial junction Central Venous Line Placement Central Venous Line Placement 20

21 Central Venous Line Placement Lines!!!! ETT Leadwire Leadwire NGT UAC Temperature Probe Nasogastric Tube Placement Note position of side holes 21

22 Post-Pyloric Tube Weighted feeding tube Nasojejunal Tube Gastrostomy Tube Placement Contrast within stomach Contrast outside stomach 22

23 CONGENITAL ABNORMALITIES MEDICAL DEVICES Duodenal Atresia What is your diagnosis? Coiled Orogastric Tube (OGT) Absence of distal bowel gas 23

24 Long Gap Esophageal Atresia Long Gap Esophageal Atresia 24

25 Esophageal Atresia with Distal Fistula (C) What is your diagnosis? Coiled OGT Presence of distal bowel gas Work Up for Midline Defects Esophageal Atresia +/- Tracheoesophageal Fistula Imperforate Anus +/- Fistula Omphalocele Work Up for Midline Defects Physical Exam Echocardiogram Renal Ultrasound Spinal Ultrasound +/- Delayed MRI Skeletal Survey 25

26 Imperforate Anus with Bucket Handle Cross-table Lateral Skeletal Survey 26

27 Skeletal Survey High Pressure Distal Colostogram Malrotation 27

28 Malrotation with Midgut Volvulus Hirschsprung Disease Hirschsprung Disease 28

29 TRAUMA RADIOGRAPHS MEDICAL DEVICES AAST Liver Trauma Classification Grade I: Subcapsular hematoma <10% surface area, capsular tear <1cm Grade II: Subcapsular hematoma 10-50% surface area, capsular tear 1-3 cm Grade III: Subcapsular hematoma >50%, capsular tear >3cm Grade IV: Parenchymal disruption 25-76% hepatic lobe or 1-3 segments Grade V: Parenchymal disruption >75% hepatic lobe or >3 segments Grade VI: Hepatic avulsion (Khan, 2017) Grade III Liver Laceration 29

30 Grade IV Liver Laceration Grade V Liver Laceration MISCELLANEOUS ABNORMALITIES MEDICAL DEVICES 30

31 Pectus Excavatum Haller Index: 243/72 = 3.37 Bezoar Esophageal Stricture 31

32 LET S REVIEW SOME IMAGES. Free Air Free Air 32

33 Pneumothorax Central Venous Line Placement Right Sided Congenital Diaphragmatic Hernia 33

34 Portal Venous Gas and Pneumatosis Appendicitis Radiation Exposure Radiation exposure may lead to: Increased cancer risk throughout lifetime Pediatric considerations Children are more radiation sensitive Potential for radiation exposure over lifetime 34

35 Radiation Exposure Radiation exposure expressed as effective dose Millisievert (msv) Considered whole body dose of radiation in relation to environmental exposure Typical environmental exposure is 3 msv/year Qualitative risk levels Negligible- less than 2 days background exposure Minimal- more than 2 days, less than 1 month background exposure Very low- more than 1 month, less than 8 months Low- 8 months to 6 years Moderate- more than 6 years Radiation Exposure Type of Exam Months of Annual Background Radiation 2 view CXR 10 days CT scan of abdomen and pelvis 3 years Upper GI 2 years CT chest 2 years CT head 8 months Radiation Exposure Helpful websites regarding guidelines for pediatrics: American College of Radiology Image Gently The Society for Pediatric Radiology 35

36 One last story.. Special thanks to Tom Boulden, MD for his help and review References Chest X-ray: Tubes- chest drains-position. (n.d.). In Radiology Masterclass online. Retrieved from _xray_chest_drain Chest X-ray:Tubes-CVL catheters-position. (n.d.). In Radiology Masterclass online. Retrieved from _xray_central_line_anatomy Khan, A.N. (2017). Liver trauma imaging. Medscape. Retrieved from Murphy, A. & Hartley, L. (n.d.). Lines and tubes (chest radiograph). In Radiopaedia. Retrieved from 36