DR NICKY WIESELTHALER RADIOLOGY CONSULTANT RED CROSS CHILDREN S HOSPITAL

Transcription

1 A CASE BASED APPROACH TO ULTRASOUND IN GIT DR NICKY WIESELTHALER RADIOLOGY CONSULTANT RED CROSS CHILDREN S HOSPITAL

2 Ultrasound= No Radiation!!! 1 CXR= 0.02 msv ( effective dose that calculates dose absorbed) 1 AXR= 0.8mSv 40 CXRs 1 CT Chest = 3-5mSv 250 CXRs 1 CT Abdomen = 10mSv 500 CXRs 1 CT head = 2mSv 100 CXRs 1 PET CT = 25mSv 1250 CXRs Courtesy of Dr Tracy Kilborn

3 Some Basics Know your machine WELL Settings and Probes- when to use what Size of patient versus body part Use your application experts! Descent history- what am I looking for? Why am I doing this? Starve patients 3-4 hours before Patient versus parent cooperation?? Use of sedation

4 Lets start with everyone s favourite topic.

5 JAUNDICE

6 Differential diagnosis of neonatal cholestatic liver disorders Structural Extrahepatic biliary atresia Choledochal cyst Caroli s syndrome Choledocholithiasis Alagille s syndrome Nonsyndromic bile duct paucity Undersized extrahepatic biliary system (biliary hypoplasia) Neonatal sclerosing cholangitis Infection Viral - Cytomegalovirus - Herpes simplex - Adenovirus - Enterovirus - Parvovirus B19 - Hepatitis B virus Bacterial infection (sepsis or remote from liver [eg, urinary tract infection]) Toxoplasmosis Syphilis Metabolic Alpha-1-antitrypsin deficiency Galactosemia Tyrosinemia Hereditary fructose intolerance Glycogen storage disease type IV Lipid storage disease - Niemann-Pick disease type A - Niemann-Pick disease type C - Gaucher s disease - Wolman s disease Mitochondrial enzymopathies (including fatty acid oxidation disorders) Peroxisomal disorders (eg, Zellweger syndrome) Bile acid synthesis disorders Progressive familial intrahepatic cholestasis syndromes - FIC-1 protein deficiency (PFIC 1) - Bile salt export pump deficiency (PFIC 2) - MDR3 protein deficiency (PFIC 3) North American Indian familial cholestasis Urea cycle defects Genetic Cystic fibrosis Trisomy 21 Trisomy 18 Neoplastic Neuroblastoma Hepatoblastoma Histiocytosis X Toxic Drug induced Total parenteral nutrition Endocrine Panhypopituitarism Hypothyroidism Immune Neonatal lupus erythematosus Vascular Budd-Chiari syndrome Congestive heart failure Hepatic hemagiomatosis Idiopathic Paediatr Child Health Vol 9 No 10 December 2004

7 Initial investigations for conjugated hyperbilirubinemia Blood Liver panel: aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, gamma-glutamyl transpeptidase, total bilirubin, conjugated bilirubin and albumin Coagulation studies (prothrombin time/international normalized ratio, partial thromboplastin time) Complete blood count and differential with smear Toxoplasmosis, other infections, rubella, Cytomegalovirus infection and herpes simplex (TORCH) serology Blood culture Hepatitis B surface antigen Glucose/serum lactate/serum amino acids/ammonia Thyroxine, thyroid-stimulating hormone Iron studies, ferritin Galactosemia screen Urine Reducing substances Organic acids Bacterial culture Urine Cytomegalovirus (positive result before four weeks of age is highly suggestive of congenital Cytomegalovirus) Imaging Abdominal ultrasound (evaluate for mass, choledochal cyst, small gallbladder, triangular cord sign)

8 Neonate with conjugated hyperbilirubinaemia

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10 ANATOMICAL FORMS OF BA- extent of fibrous obliteration of the EHBD is variable GB small or atretic GB small with irreg wall/contour and does not empty after feed GB normal / large and empties after feed

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12 Triangular Cord Triangular/Tubular echogenic cord of fibrous tissue in the porta hepatis Measured as >4mm thickness of the echogenic anterior wall of the R PV in longitudinal US High specificity for diagnosis of BA

13 4mnths old prolonged conjugated hyperbilirubinaemia

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15 Diagnosis of BA is made if you see a macrocyst or microcyst at porta without BD dilatation

16 GOLD STANDERD= intraoperative cholangiogram to diagnose BA

17 Diagnosis BA RULED OUT if there is bile duct dilatation

18 2month old conjugated hyperbilirubinemia and hepatomegaly?? Missed BA

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20 2 and half year old: RUQ pain and pale stools. No jaundice

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24 13 day old with conjugated hyperbilirubinemia

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26 18 mnths old: pallor and Splenomegaly No Hepatomegaly

27 Or could have presented with.hematemesis and oesophageal varices

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29 Normal liver

30 Sclerosing Cholangitis

31 CF with Steatosis

32 AI Hepatitis with Cirrhosis

33 MSK with congenital Hepatic Fibrosis

34 Failed Kasai

35 5mnth old twin with diarrhoea, vomiting, LOW and a mass

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38 17d old with a liver mass BUT AFP was normalising??

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40 Haemangioendothelioma VS Hepatoblastoma??

41 Arterial phase PV phase

42 Follow up 6 months later

43 12 years vomiting,abdo pain 1 week from EC tender RUQ

44 HYDATID

45 2y7m female with dysentery and vomiting, septic: RUQ tenderness.? Mass.

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48 3 yr old with tender distended abdomen and fever?mass in RUQ

49 image findings alone were inadequate in distinguishing pyogenic from amoebic liver abscesses. However, when the sonographic findings were coupled with clinical and laboratory data, a correct diagnosis was possible in 83 (86%) AJR Am J Roentgenol Sep;149(3):

50 4yr old referred from EC with pain, vomiting and deteriorating LFT s due to..

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54 10yr old boy with Thalassaemia on the hypertransfusion programme, presents with increasing jaundice, raised LFT s and abdo pain.

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56 Moving away from the Liver..

57 Take your pick LOW, fever, night sweats,abdo distension, positive TB contact, TBM, TB on CXR

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59 Points to remember re TB Nodes in abdo common Significant if >10mm in trv diameter If huge and multiple: diff diag = lymphoma HIV + sometimes both!! Check for splenic lesions with high res probe! Look for HIVAN

60 7 month old with red current jelly stool and abdominal cramping

61 INTUSSUSCEPTION- Length of history Free fluid Flow Assoc masses

62 6 weeks male projectile vomiting

63 HPS Find the GB 5, 10, 15mm

64 2yr old vomiting, abdo pain, leucopaenia,

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66 12yr fever and RIF pain. Previous UTI s

67 ILEITIS? TB or Chron s Dx

68 2yr old: Lymphoblastic Lymphoma on chemo

69 INFECTIVE COLITIS /TYPHLITIS

70 12 yrs old fell over bike handlebars 10 days ago. CT: grade 4 laceration pancreatic neck

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72 2yr old FTT, anaemia, abdo mass

73 Echogenic inner lining +hypoechoic rim = ENTERIC DUPLICATION CYST

74 Thank you