ACUTE ABDOMEN IN OLDER CHILDREN. Carlos J. Sivit M.D.

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1 ACUTE ABDOMEN IN OLDER CHILDREN Carlos J. Sivit M.D.

2 ACUTE ABDOMEN Clinical condition characterized by severe abdominal pain developing over several hours

3 ACUTE ABDOMINAL PAIN Common childhood complaint 4-5% office / ER visits Frequent associated symptoms fever, emesis, anorexia, sore throat Majority w/self limited disease uri, om, pharyngitis,, viral syndrome, gastroenteritis, constipation

4 ROLE OF IMAGING 1 o in patients w/confusing signs & symptoms or when surgery considered Diagnosing 1 o abnormality Characterizing disease extent Establishing alternative diagnosis

5 INTUSSUSCEPTION ACUTE APPENDICITIS SEGMENTAL OMENTAL INFARCTION MESENTERIC LYMPHADENOPATHY

6 INTUSSUSCEPTION

7 INTUSSUSCEPTION Most common early childhood emergency Peak incidence 5-9 mos 95% idiopathic (3( 3 mo - 3 yr) Most common type ileocolic

8 INTUSSUSCEPTION Pathologic lead points <3 mos or >3 yrs Enteric duplication Meckels diverticulum Intramural hematoma - Polyp - Lymphoma - CF

9 INTUSSUSCEPTION RADIOGRAPHY Low sensitivity & specificity Include supine & upright views Scrutinize for mass, sbo,, free air Cecal / t.i. visualization excludes ileocolic

10 INTUSSUSCEPTION US Primary exam for screening High sensitivity & specificity Graded compression technique

11 US FINDINGS PREDICTIVE OF REDUCTION Flow on Color Doppler Absence of trapped fluid Thin external hypoechoic rim

12 INTUSSUSCEPTION IMAGING INTERVENTION Fluoroscopic reduction Water soluble contrast, air, barium US guided reduction Tap water

13 INTUSSUSCEPTION ADVANTAGES OF AIR Decreased fluoroscopy times Less peritoneal contamination w/ perforation

14 INTUSSUSCEPTION ADVANTAGES OF LIQUID Proven track record Better contrast resolution Earlier visualization of perforation

15 INTUSSUSCEPTION Fluoroscopic reduction Immobilization Tight anal seal Contrast flow into distal ileum & disappearance of soft tissue mass 1% perforation rate

16 APPENDICITIS

17 APPENDICITIS Most common surgical emergency Difficult clinical diagnosis Many nonsurgical conditions mimic Classic constellation of periumbilical pain migrating to rlq,, n/v & fever in <1/3

18 CURRENT STATUS Great variability in utilization Limited consensus on best way US 1 o technique late 80 s-mid 90 s CT becoming 1 o modality

19 APPENDICITIS ADVANTAGES OF US Lower exam cost No preparation required Lack of ionizing radiation Accurately delineates adnexal disease

20 APPENDICITIS ADVANTAGES OF CT Higher diagnostic accuracy High accuracy in diagnosing perforated appendicitis Enhanced delineation of disease extent in perforated appendicitis Associated with improved outcomes

21 APPENDICITIS CT TECHNIQUE Targeted exam vs entire abdomen-pelvis No gi contrast vs oral vs rectal contrast No IV contrast vs IV contrast Multiplanar reformation ALARA

22 RECTAL CONTRAST Differentiate bowel from appendix Delineates cecal wall thickening Opacifies normal appendix

23 IV CONTRAST Easier identification of appendix Wall enhancement in appendicitis Abscess detection Alternative diagnoses

24 MULTIPLANAR REFORMATION Single breath hold scan of entire abdomen & pelvis at 1-22 mm collimation Similar spatial resolution for multiplanar reformations Provides increased confidence in diagnosis

25 APPENDICITIS CT FINDINGS - Enlarged appendix - Wall enhancement - Appendicolith - Cecal apical changes - Inflammatory rlq changes

26 ENLARGED APPENDIX Overlap between normal & abnormal < 6 mm normal 7-99 mm indeterminate > 9 mm - abnormal Increasing importance of other findings with indeterminate diameter May only involve distal appendix

27 DISTAL APPENDICITIS 10-15% of cases Inflammation more pronounced/localized distal end

28 CECAL APICAL THICKENING

29 ARROWHEAD SIGN Triangular shaped contrast collection 2 o cecal apical thickening

30 INFLAMMATORY CHANGES Periappendiceal fat stranding Thickening lateral conal fascia Ileocecal lymphadenopathy Thickening of contiguous structures

31 APPENDICOLITH Present in ~1/3 Within lumen, phlegmon or abscess Increased likelihood of perforation Lacks specificity

32 PERFORATED APPENDICITIS Focal fluid Phlegmon Appendiceal wall defect Extraluminal appendicolith Peritonitis

33 PERITONITIS Serious complication Early rupture prior to adhesion development More common in young Free fluid Enhancement/thickenin g along peritoneal reflections

34 ALARA Increased radiosensitivity & larger window for expressing damage Age/size specific protocols Low tube currents: ma Low kvp: : kvp Avoid repeat scanning

35 SEGMENTAL OMENTAL INFARCT

36 SEGMENTAL OMENTAL INFARCT 1 o form: anomaly of venous drainage involving right lateral segment Venous kinking 2 o patient position or post- prandial congestion may contribute 2 o form: hypercoagulable states, trauma, vasculitis

37 SEGMENTAL OMENTAL INFARCT Ovoid or cake like right-sided mass Anterolateral peritoneal cavity Mass effect on adjacent organs Complications include abscess & peritonitis

38 MESENTERIC LYMPHADENOPATHY

39 MESENTERIC LYMPHADENOPATHY Nodes located along ileal & jejunal arteries & SMV in folds of small bowel mesentery Extend from LUQ obliquely down to RLQ Most frequently noted in RLQ Oval shape Homogenous attenuation/echotexture echotexture

40 MESENTERIC LYMPHADENOPATHY Nonspecific finding Associated w/ variety of conditions Most commonly infectious or inflammatory May be associated w/appendicitis Mesenteric lymphadenitis is clinical syndrome associated w/acute abdomen

41 ACUTE ABDOMEN IN OLDER CHILDREN

Interesting Pediatric ultrasound cases. Presented by: Falguni Patel (RDMS, RVT)

Interesting Pediatric ultrasound cases Presented by: Falguni Patel (RDMS, RVT) Role of ultrasound to rule out Appendicitis Overview: Ultrasound is relatively inexpensive, safe and quick solution to rule