Sonographic Appearances of Common Gut Pathology in Paediatric Patients: Comparison with Plain Abdominal Radiography
|
|
- Tyler Nelson
- 5 years ago
- Views:
Transcription
1 3668 Radiographer Text 1/4/04 2:57 PM Page 11 The Radiographer vol. 51: Sonographic Appearances of Common Gut Pathology in Paediatric Patients: Comparison with Plain Abdominal Radiography Lino Piotto and Roger Gent ABSTRACT Even with the advent of more specialised imaging modalities such as fluoroscopic contrast examinations, CT and MRI, the plain abdominal radiograph remains the initial imaging modality in investigating the signs and symptoms of suspected gut pathology. However, ultrasound is playing an increasing part in the detection of gut pathology in paediatric patients. At our hospital, when plain abdominal radiography does not provide a diagnosis, ultrasound is commonly requested to rule out conditions that require urgent attention, such as intussusception, appendicitis and midgut malrotation and volvulus. After these conditions have been excluded however, the ultrasound examination can frequently lead to the diagnosis of several other conditions, including gastroenteritis, Crohn s disease, mesenteric lymphadenopathy and less commonly, duplication cysts, bezoas, and haemolytic uraemic syndrome. Although plain radiography of the abdomen may be suggestive of gut pathology, the additional information provided by sonography often provides a specific diagnosis, leading to better patient care. This paper is a presentation of ten case studies demonstrating the use of ultrasound to augment plain X-ray findings, in order to obtain a final diagnosis. Division of Medical Imaging Women s and Children s Hospital 72 King William Road North Adelaide South Australia 5006 Telephone: Fax: piottol@mail.wch.sa.gov.au INTRODUCTION For a long time now ultrasound has been used as the first examination for suspected hypertrophic pyloric stenosis. Yet there is still a widespread notion that ultrasound does not have a major diagnostic role in evaluating other gut pathology, a role traditionally undertaken by plain x-rays. The signs and symptoms of abdominal pathology are very non-specific. These include colicky abdominal pain, vomiting, diarrhoea, palpable abdominal mass, focal or generalised tenderness, blood and mucus per rectum and fever. Patients with abdominal pathology may present with one or more of these signs and symptoms, making a specific clinical diagnosis very difficult. By far the most common investigation for abdominal pain is the plain radiograph. These are often unhelpful, being normal in as many as one third of cases (unpublished data over a two year period from WCH). They may, however, show evidence of a soft tissue mass or small bowel obstruction. Both of these radiographic signs, although suggestive of the presence of intussusception or ileus, are non-specific. Ultrasound is valuable in the further assessment of these patients, and also in patients whose plain films are normal. The most common gut conditions encountered are appendicitis, intussusception and gastroenteritis. Less common conditions that can be diagnosed with ultrasound include mesenteric lymphadenopathy, midgut malrotation (with or without an associated volvulus) and Crohn s disease. Rarely, conditions such as duplication cysts, haemolytic uraemic syndrome, Henoch Schonlein Purpura, bezoars and malignancies are diagnosed from the ultrasound examination. INTUSSUSCEPTION Intussusception is one of the most common causes of abdominal emergency in early childhood. 1,2,3 In this condition, a segment of the bowel wall invaginates the lumen of the segment immediately distal to it. Intussusception occurs most commonly in the first two years of life, but is occasionally seen in older children and adults, associated with other conditions such as cystic fibrosis. It is thought that most cases arise as a result of hyperplasia of Peyer s patches, the lymphoid tissue of the intestinal wall. The resultant swelling of the intestinal wall is pushed distally by peristalsis, dragging the wall of the bowel with it, together with its attached mesentery. Compromise of venous drainage then results in marked oedema of the involved bowel wall. The commonest location is at the ileocaecal junction, where the ileum invaginates the large bowel this is termed an ileo-colic intussusception. Most commonly, the head of the intussusception is found in the ascending or transverse colon. In advanced cases however, the invagination can extend as far as the sigmoid colon, almost to the anus. The main clinical features are intermittent attacks of colic with drawing up of the legs and the passage of blood and mucus per rectum. These patients often appear very flat. A sausage shaped tumour may be palpable in the abdomen. Later, there may be vomiting due to intestinal obstruction. A review of patients with confirmed ileo-colic intussusception at our institution showed the plain radiographs were normal in 33 per cent of cases. In 57 per cent of cases, a soft tissue mass was apparent, while 19 per cent showed features of small bowel obstruction. On ultrasound examination, all intussusceptions display a concentric ring or doughnut sign, with marked oedema of the bowel wall. The diameter of the intussusception is typically 2.5cm or more. The Radiographer vol. 51, no. 1, April
2 3668 Radiographer Text 1/4/04 2:57 PM Page 12 SONOGRAPHIC APPEARANCES OF COMMON GUT PATHOLOGY IN PAEDIATRIC PATIENTS: COMPARISON WITH PLAIN ABDOMINAL RADIOGRAPHY Case 1 This six-month-old boy presented with intermittent vomiting. His supine abdominal radiograph showed a normal gas pattern throughout, with no evidence of a soft tissue mass (Figure 1a). Due to the clinical presentation of bilious vomiting, further investigation with a barium meal was performed to exclude a proximal small bowel obstruction. The barium study was normal. The subsequent ultrasound examination showed a well defined, rounded mass in the left iliac fossa (Figure 1b), with the concentric ring sign consistent with an ileo-colic intussusception. The intussusception was thought to be at the junction of the descending and sigmoid colons, subsequently confirmed with a barium enema. Figure 1a (far right): Normal supine abdominal radiograph in 6-month old male. Figure 1b (right): Transverse ultrasound image from the left iliac fossa, showing an intussusception, with arrow heads indicating the outer margin of the invaginated bowel. Case 2 A two-and-a-half-year-old boy with intermittent colicky abdominal pain for two days, associated with non-bilious vomiting. Plain radiography showed a rounded soft tissue mass to the right of the midline, possibly representing an intussusception. The bowel gas pattern was non-specific, with no suggestion of obstruction (Figure 2a). The ultrasound examination confirmed the presence of an intussusception in the ascending colon, corresponding to the position of the soft tissue mass seen in the radiograph (Figure 2b). Figure 2a (far right): Supine abdominal radiograph, showing a soft tissue mass (arrow heads) to the right of the midline. Figure 2b (right): Transverse ultrasound image over the soft tissue mass seen on the radiograph, showing an intussusception in the ascending colon. Case 3 This three-year-old boy presented with colicky abdominal pain and bilious vomiting. The abdominal radiograph demonstrated numerous fluid levels within moderately distended bowel loops, extending down to the pelvis. The appearances suggest a distal small bowel obstruction (Figure 3a). The ultrasound study revealed an ileocolic intussusception in the transverse colon (Figure 3b) and confirmed the presence of multiple dilated fluid-filled loops of small bowel, consistent with obstruction. A moderate amount of free fluid was also demonstrated in the peritoneal cavity. Several lymph nodes and some echogenic mesentery were visible within the intussusception. Figure 3b (right): Transverse ultrasound image of the transverse colon, showing an ileo-colic intussusception. The invaginating ileum and its associated mesentery are indicated by arrows, within the colon (arrow heads). 12 The Radiographer vol. 51, no. 1, April 2004
3 3668 Radiographer Text 1/4/04 2:57 PM Page 13 L. PIOTTO AND R. GENT Case 4 Not all intussusceptions are ileo-colic. Transient ileo-ileal intussusception is a common finding in abdominal sonography of paediatric patients, most often seen to the left of the midline. These are rarely symptomatic and resolve spontaneously. They do not cause any significant vascular compromise and therefore do not result in oedema of the bowel wall. Occasionally, two or even three separate segments of ileoileal intussusception may be present simultaneously. The sonographic appearance of an ileo-ileal intussusception is that of a localised expansion of a part of the ileum, with a concentric ring sign (Figure 4) corresponding to the invagination of the bowel. The diameter of these is invariably much less than that of an ileo-colic intussusception. Figure 4 (left): Transverse ultrasound image of an ileo-ileal intussusception (arrow heads) in the left flank of a 3-year old child. Figure 3a (above): Supine abdominal radiograph, showing multiple distended bowel loops. APPENDICITIS Appendicitis is another common abdominal emergency in childhood, and the most common condition requiring emergency surgery. 4 It is thought that most cases result from obstruction of the lumen of the appendix by faecal impaction or a faecolith, which then results in bacterial infection within the obstructed segment. In some cases, the appendix ruptures, resulting in a peri-appendiceal abscess easily demonstrable on ultrasound images. Clinically, patients with appendicitis have focal (rebound) tenderness over the appendix, with associated fever and leukocytosis. An inflamed appendix typically has a diameter of 6mm or more, is non-compressible, blind ending, hyperaemic and may be fluid-filled. When present, an appendicolith appears as a focus of increased echogenicity, not necessarily casting an acoustic shadow. The inflammatory reaction often results in increased echogenicity of the adjacent meso-appendix and omentum. It is also not uncommon to see a small amount of free fluid adjacent to the caecal pole. An inflamed appendix is more difficult to detect with ultrasound when in a retrocaecal position and when it is deep within the pelvis. Ultrasound is frequently useful when the clinical findings do not strongly support appendicitis. This can occur when the appendix is in a relatively high position, near the tip of the liver, or when there is negligible tenderness because the appendix is wrapped in a cushion of oedematous omentum. It is useful to initially concentrate on the region of maximum tenderness. Case 5 This 13-year-old boy presented with onset of severe right sided abdominal pain especially in the right flank. On his abdominal radiograph, apart from a prominent loop of small bowel in the right iliac fossa the radiographic appearances are non specific but raise the possibility of a localised ileus (Figure 5a). Suspicious of appendicitis, an ultrasound examination was performed which revealed a relatively long and swollen retrocaecal appendix (Figure 5b). The thick walled appendix also demonstrated noncompressibility, rather causing indentation of the posterior psoas when pressure was applied from the transducer (Figure 5c). Figure 5a (above): Supine abdominal radiograph suggestive of a localised ileus in the right iliac fossa. Figure 5b (left): Longitudinal ultrasound image in the right iliac fossa, showing a distended and inflamed appendix (arrow heads), lying anterior to the psoas muscle. The Radiographer vol. 51, no. 1, April
4 3668 Radiographer Text 1/4/04 2:57 PM Page 14 SONOGRAPHIC APPEARANCES OF COMMON GUT PATHOLOGY IN PAEDIATRIC PATIENTS: COMPARISON WITH PLAIN ABDOMINAL RADIOGRAPHY Figure 5c (left): Transverse ultrasound image of the inflamed appendix (arrow heads). With transducer pressure applied, the appendix is seen to be non-compressible as it indents the margin of the underlying psoas muscle (arrows). Figure 6a (below right): Supine abdominal radiograph showing a suspected calculus (arrow head) projected over the right edge of the lower sacrum. Figure 6b (below): Oblique pelvic radiograph demonstrating the calculus (arrows). Case 6 A nine-year-old boy with a two week history of fever and right iliac fossa pain was thought to have appendicitis. The A-P abdominal radiograph demonstrated a calcific density projected over the right edge of the lower sacrum (Figure 6a), but which was projected clear of the sacrum in the oblique view (Figure 6b). This was assumed to be an appendicolith. The A-P view showed a normal bowel gas pattern, with a mild scoliosis concave to the right. An ultrasound examination revealed a fluid collection in the pelvis behind the bladder, anterior to the rectum, and containing a small echogenic structure, likely to be the density visible on the radiographs (Figure 6c). The infected nature of the collection is apparent from the reactive oedema of the adjacent posterior bladder wall (Figure 6d). More superiorly was an inflammatory mass of bowel that showed hyperaemia on power Doppler images. A separate appendix could not be identified. MALROTATION Another condition that can present with these symptoms is malrotation of the intestine, resulting from failure of the gut to undergo its normal 270º anticlockwise rotation in the first trimester. Malrotation causes shortening of the root of the mesentery, predisposing the jejunum and ileum to twist around the narrow base. The twisting is referred to as a volvulus (of the midgut), and is a surgical emergency. The signs and symptoms of malrotation include bilious vomiting, abdominal pain and failure to thrive. Case 7 A two-day-old (38 week gestation) twin, vomiting, with large stomach residue and absence of bowel sounds was thought to have an intussusception. A supine radiograph revealed dilated bowel loops, most marked in the left upper quadrant. Bowel gas pattern in the right lower quadrant was normal, but showed some separation of the loops. In the clinical setting, meconium inspissation was thought Figure 6c (above left): Transverse ultrasound image showing a fluid collection (arrow heads) posterior to a distended bladder and containing a calculus (arrow). Figure 6d (above): Longitudinal ultrasound image showing an inflammatory mass of bowel, superior to the hypoechoic collection, with localised thickening (arrow heads) of the posterior bladder wall. The calculus is again visible within the inferior part of the collection. 14 The Radiographer vol. 51, no. 1, April 2004
5 3668 Radiographer Text 1/4/04 4:21 PM Page 15 L. PIOTTO AND R. GENT to be a possibility (Figure 7a). An ultrasound examination showed no intussusception, but did reveal reversal of the normal arrangement of the superior mesenteric vessels, with the SMV positioned on the patient s left of the SMA (Figure 7b). This is indicative of a midgut malrotation. Further scanning revealed the ultrasonic whirlpool sign, pathognomonic of a volvulus. 5 The whirlpool sign is elicited by moving the transducer cranially and caudally while scanning in the transverse plane. This movement demonstrates a corkscrew arrangement of the mesenteric vessels which simulates a whirlpool as the transducer is moved back and forth. A barium meal confirmed the ultrasonic diagnosis of midgut malrotation with associated volvulus. Figure 7a (far right): Supine abdominal radiograph showing some dilated bowel loops in the left upper quadrant. Figure 7b (right): Transverse ultrasound image in the mid abdomen showing reversal of the normal superior mesenteric artery/vein relationship. The artery (long arrow) is seen to lie to the patient s left of the vein (short arrow), anterior to the abdominal aorta (arrow heads). GASTROENTERITIS Patients with gastroenteritis, of viral or bacterial origin, may present with abdominal pain, bilious vomiting and diarrhoea. Ultrasound is not normally used to diagnose gastroenteritis. However, findings consistent with this condition are often found when the examination is being done to exclude the conditions that require intervention. Features of gastroenteritis on ultrasound images include multiple fluid-filled small bowel loops, often with slightly thickened walls and hyperperistalsis. Frequently, a fluid-distended colon is also apparent. Case 8 An 18-month-old girl presented with severe attacks of colic, thought to be due to intussusception. The erect abdominal radiograph demonstrated several air-fluid levels in the right iliac fossa, possibly representing a localised ileus due to an inflammatory process (Figure 8a). An abdominal ultrasound confirmed the presence of multiple fluid-filled loops of small bowel (Figure 8b), together with a distended and fluid-filled colon. In the absence of any other findings, these features are consistent with a diagnosis of gastroenteritis Figure 8a: Erect abdominal radiograph showing several air-fluid levels. Figure 8b: Longitudinal image of the right flank showing multiple fluid-filled loops of small bowel, consistent with gastroenteritis. CROHN S DISEASE Crohn s Disease is the most common inflammatory disease of the bowel, usually affecting the terminal ileum and proximal colon. Clinically, Crohn s disease affects children over the age of ten years, who may present with abdominal pain, diarrhoea, fever and weight loss. The disease appears as symmetrically thickened (greater than 5mm), hypoechoic, hypoperistaltic bowel wall. 6 Inflammatory bowel masses may also be seen in children with this condition, resulting in the formation of fistulae. Case 9 A 14-year-old boy with abdominal pain for a two week period. Plain radiography showed multiple prominent loops of small bowel that do not appear particularly dilated, but do demonstrate thickened mucosal folds. (Figure 9a). An ultrasound examination demonstrated thickened loops of bowel in both The Radiographer vol. 51, no. 1, April
6 3668 Radiographer Text 1/4/04 4:21 PM Page 16 SONOGRAPHIC APPEARANCES OF COMMON GUT PATHOLOGY IN PAEDIATRIC PATIENTS: COMPARISON WITH PLAIN ABDOMINAL RADIOGRAPHY iliac fossae, corresponding to areas of ileal wall thickening, subsequently proven to be due to Crohn s disease (Figure 9b). Figure 9a: Supine abdominal radiograph showing small bowel loops with thickened mucosal folds. Figure 9b: Transverse image of a loop of ileum, which has a thickened wall (outlined by arrow heads) due to Crohn s disease. MESENTERIC ADENITIS Mesenteric lymph node enlargement is commonly seen in patients presenting with acute abdominal pain. The enlarged nodes are most commonly identified in the root of the mesentery and are thought to represent a non-specific finding. 7 This appearance is commonly called mesenteric adenitis. This is essentially a benign condition, although it should be noted that node enlargement can also occur in response to a local inflammatory condition such as appendicitis or neoplastic infiltration. Case 10 A one-year-old boy presented with episodes of grunting and screaming, possibly due to intussusception. There was a normal gas pattern throughout small and large bowel on the plain radiograph. No abnormal loops or soft tissue masses were evident. The prominent gasfilled stomach is non-specific and probably represents swallowed air from crying Figure 10a: Normal supine abdominal radiograph. Figure 10b: Transverse ultrasound image from the mid abdomen, showing prominent lymph nodes (arrow heads). (Figure 10a). Ultrasound examination showed no evidence of an intussusception, but did show several enlarged lymph nodes on the right side, the largest measuring 15mm in length (Figure 10b). In the absence of other findings, the appearances are likely to represent mesenteric adenitis. CONCLUSION Ultrasound is very valuable in the investigation of paediatric patients with acute abdominal pain. With a careful scanning technique, ultrasound can quite often detect a range of gut pathology. Importantly, ultrasound has been very useful in the detection of those conditions that require urgent intervention such as intussusception, appendicitis and malrotation with volvulus. In our hospital, all cases of suspected intussusception have an ultrasound study before any treatment is instituted. In the event that the ultrasound examination does not reveal one of these conditions, it often provides an alternative diagnosis, which can then 16 The Radiographer vol. 51, no. 1, April 2004
7 3668 Radiographer Text 1/4/04 2:57 PM Page 17 L. PIOTTO AND R. GENT allow appropriate treatment. These examinations sometimes require considerable time and patience, particularly if the child is uncooperative or in pain. Analgesia prior to the ultrasound examination is very advantageous. REFERENCES 1. Lim, H.K., Bae, S.H., Seo, G.S., Yoon, G.S. Assessment of reducibility of ileocolic intussusception in children: usefulness of color doppler sonography. Radiology 1994; 191: Woo, S.K., Kim,J.S., Paik, T.W., Choi, S.O. Childhood intussusception: US-guided hydrostatic reduction. Radiology 1992; 182: Shiels, W.E. Editorial Childhood Intussusception: Management Perspectives in J Pediatr Gastroenterol Nutr 1995; 21: Siegel, M.J. 2002, Pediatric Sonography, Lippincott Williams & Wilkins, Philadelphia, USA. 5. Pracros, J.P., Sann, L., Genin, G. et al. Ultrasound diagnosis of midgut volvulus: the whirlpool sign. Pediatr Radiol 1992; 22: Siegel, M.J., Friedland, J.A., Hildebolt, C.F. Bowel Wall Thickening in Children: Differentiation with US. Radiology 1997; 203: Sivit, C.J., Newman, K.D., Chandra, R.S. Visualization of enlarged mesenteric lymph nodes at US examination. Pediatr Radiol 1993; 23: Peer Reviewed Submitted: October 2003 Accepted: February 2004 The Radiographer vol. 51, no. 1, April
Abdominal Pain in Pediatric Patients Image Gently
Abdominal Pain in Pediatric Patients Image Gently Susan D. John, M.D. Baptist Health Emergency Radiology 2017 Disclosure I have no financial relationships with a commercial entity producing healthcarerelated
More informationSummary and conclusions
Summary and conclusions 7 Chapter 7 68 Summary and conclusions Chapter 1 provides a general introduction to this thesis focused on the use of ultrasound (US) in children with abdominal problems. The literature
More informationInteresting 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
More informationFHS Appendicitis US Protocol
FHS Appendicitis US Protocol Reviewed By: Shireen Khan, MD; Sarah Farley, MD; Anna Ellermeier, MD Last Reviewed: May 2018 Contact: (866) 761-4200 **NOTE for all examinations: 1. If documenting possible
More informationIntroduction and Definitions
Bowel obstruction Introduction and Definitions Accounts for 5% of all acute surgical admissions Patients are often extremely ill requiring prompt assessment, resuscitation and intensive monitoring Obstruction
More informationACUTE ABDOMEN IN OLDER CHILDREN. Carlos J. Sivit M.D.
ACUTE ABDOMEN IN OLDER CHILDREN Carlos J. Sivit M.D. ACUTE ABDOMEN Clinical condition characterized by severe abdominal pain developing over several hours ACUTE ABDOMINAL PAIN Common childhood complaint
More informationPlain abdomen The standard films are supine & erect AP views (alternative to erect, lateral decubitus film is used in ill patients).
Plain abdomen The standard films are supine & erect AP views (alternative to erect, lateral decubitus film is used in ill patients). The stomach can be readily identified by its location, gastric rugae
More informationMedical application of transabdominal ultrasound in gastrointestinal diseases
Medical application of transabdominal ultrasound in gastrointestinal diseases Hsiu-Po Wang Department of Emergency Medicine National Taiwan University Hospital Real-time ultrasound has become a standard
More informationVomiting in children: The good coordination between radiologists and pediatricians is the key to success
Vomiting in children: The good coordination between radiologists and pediatricians is the key to success C. Santos Montón 1, M. T. Garzon Guiteria 2, A. Hortal Benito-Sendín 1, K. El Karzazi 1, P. Sanchez
More informationRole of radiology and imaging in the daignosis of acute abdominal conditions
Role of radiology and imaging in the daignosis of acute abdominal conditions Miah MAY Introduction In our day to day practice we have to face many of the acute abdominal conditions. As we know acute abdomen
More informationThe jejunum and the Ileum. Prof. Oluwadiya KS
The jejunum and the Ileum Prof. Oluwadiya KS www.oluwadiya.siteled.com Introduction Introduction The small intestine (SI) comprises of the duodenum, jejunum and the ileum The jejunum is the second part
More informationEmergent Pediatric Ultrasound. Katharine Dennis, RDMS/RVT Tiffany Schultz, RDMS UNC Health Care Dept of General Ultrasound
Emergent Pediatric Ultrasound Katharine Dennis, RDMS/RVT Tiffany Schultz, RDMS UNC Health Care Dept of General Ultrasound Introduction Learning Objectives Review common pediatric emergent ultrasound exams
More informationAnatomy of the Large Intestine
Large intestine Anatomy of the Large Intestine 2 Large Intestine Extends from ileocecal valve to anus Length = 1.5-2.5m = 5 feet Regions Cecum = 2.5-3 inch Appendix= 3-5 inch Colon Ascending= 5 inch Transverse=
More informationGood morning! July 24, 2014
Good morning! July 24, 2014 Prep #1 A 2-year-old boy presents to your office with a 2-day history of swelling of the right eye. He has been otherwise well. There are scattered insect bites on his body,
More informationHirschprung s. Meconium plug R/S >1 R/S <1
NEONATAL ABDOMINAL EMERGENCIES LOW OBSTRUCTION HIGH OBSTRUCTION INTESTINAL OBSTRUCTION High obstruction - proximal to mid-ileumileum Few dilated, air filled bowel loops Complete obstruction diagnosed by
More informationIntestinal Obstruction Clinical Presentation & Causes
Intestinal Obstruction Clinical Presentation & Causes V Chidambaram-Nathan Consultant Transplant and General Surgeon Sheffield Kidney Institute Northern General Hospital Intestinal Obstruction One of the
More informationAdult Intussusception
Bahrain Medical Bulletin, Vol. 27, No. 3, September 2005 Adult Intussusception Suhair Alsaad, MBCHB, CABS, FRCSI* Mariam Al-Muftah, MBCHB** Objectives: Adult intussusception is a rare entity. We present
More informationCase Whirlpool sign in midgut volvulus
Case 11454 Whirlpool sign in midgut volvulus Emad El-din Althamer 1, Shagufta Jabeen 2, Nada Al-Assaf 1, Akram Jawad 1, Muhammad Hassan 1, Muhammad Fatani 1, Rumayan Al-Rumyan 1, A Aziz Mosabihi 1, Ahmeduddin
More informationSIMPLE GUIDE FOR SONOLOGICAL EVALUATION OF APPENDICITIS
SIMPLE GUIDE FOR SONOLOGICAL EVALUATION OF APPENDICITIS A Case Study by Dr. Avni K P Skandhan, India (Consultant Radio Diagnosis, Malabar Institute of Medical Science, Malappuram, Kerala) Email: avniskandhan@gmail.com
More informationNeonatal intestinal obstruction: how to make etiological diagnosis?
Neonatal intestinal obstruction: how to make etiological diagnosis? Poster No.: C-1414 Congress: ECR 2013 Type: Educational Exhibit Authors: W. Mnari, M. Zguidi, A. Zrig, M. Maatouk, B. Hmida, R. Salem,
More informationThe Gastrointestinal Tract
CHAPTER 10 The Gastrointestinal Tract INTRODUCTION Although sonography may not always be the modality of choice for the detection of all gastrointestinal abnormalities, it does provide a noninvasive, nonionizing
More informationPictorial review of bowel ultrasound: Common and unsuspected pathologies
Pictorial review of bowel ultrasound: Common and unsuspected pathologies Poster No.: C-1668 Congress: ECR 2013 Type: Educational Exhibit Authors: A. Law, A. Ali, G. Hutchison; Bolton/UK Keywords: Ultrasound-Colour
More informationDevelopment of pancreas and Small Intestine. ANATOMY DEPARTMENT DR.SANAA AL-AlSHAARAWY DR.ESSAM Eldin Salama
Development of pancreas and Small Intestine ANATOMY DEPARTMENT DR.SANAA AL-AlSHAARAWY DR.ESSAM Eldin Salama OBJECTIVES At the end of the lecture, the students should be able to : Describe the development
More informationThe Role of Ultrasound in the Assessment of Inflammatory Bowel Disease
The Role of Ultrasound in the Assessment of Inflammatory Bowel Disease Dr. Richard A. Beable Consultant Gastrointestinal Radiologist Queen Alexandra Hospital Portsmouth Hospitals NHS Trust Topics for Discussion
More informationNeonatal intestinal obstruction: how to make etiological diagnosis?
Neonatal intestinal obstruction: how to make etiological diagnosis? Poster No.: C-1414 Congress: ECR 2013 Type: Educational Exhibit Authors: W. MNARI, M. Zguidi, A. Zrig, M. MAATOUK, B. Hmida, R. Salem,
More informationMidgut. Over its entire length the midgut is supplied by the superior mesenteric artery
Gi Embryology 3 Midgut the midgut is suspended from the dorsal abdominal wall by a short mesentery and communicates with the yolk sac by way of the vitelline duct or yolk stalk Over its entire length the
More informationPathology of Intestinal Obstruction. Dr. M. Madhavan, MBBS., MD., MIAC, Professor of Pathology Saveetha Medical College
Pathology of Intestinal Obstruction Dr. M. Madhavan, MBBS., MD., MIAC, Professor of Pathology Saveetha Medical College Pathology of Intestinal Obstruction Objectives list the causes of intestinal obstruction
More informationAdult Intussusception: A Complication of Metastatic Melanoma or Primary Malignancy?
January 2013 Adult Intussusception: A Complication of Metastatic Melanoma or Primary Malignancy? Johanna Sheu, Harvard Medical School Year III 1 Agenda Menu of tests Definition/anatomy/classification Pediatrics
More informationHome FAQ Archives ABP Topics NeoReviews.org My Bookmarks CME Information Help. Print this Page Add to my Bookmarks Page 3 of 10
Welcome Kristin Ingstrup [ Logout ] SEARCH Home FAQ Archives ABP Topics NeoReviews.org My Bookmarks CME Information Help Overview Editorial Board My Learning Plan January February March May June July August
More informationA novel plain abdominal radiograph sign to diagnose malrotation with volvulus
A novel plain abdominal radiograph sign to diagnose malrotation with volvulus Nataraja RM 1, Mahomed AA 1* 1. Department of Paediatric Surgery, Royal Alexandra Hospital for Sick Children, Brighton,UK *
More informationASSESSING THE PLAIN ABDOMINAL RADIOGRAPH M A A M E F O S U A A M P O F O
ASSESSING THE PLAIN ABDOMINAL RADIOGRAPH M A A M E F O S U A A M P O F O Introduction The abdomen (less formally called the belly, stomach, is that part of the body between the thorax (chest) and pelvis,
More informationPelvic Pain? Cause Beyond the Ovary
Pelvic Pain? Cause Beyond the Ovary Catherine Kirkpatrick Consultant Sonographer United Lincolnshire Hospitals Trust Aims Consider not all pelvic pain is ovary or uterus related Explore some non gynae
More informationUS in non-traumatic acute abdomen. Lalita, M.D. Radiologist Department of radiology Faculty of Medicine ChiangMai university
US in non-traumatic acute abdomen Lalita, M.D. Radiologist Department of radiology Faculty of Medicine ChiangMai university Sagittal Orientation Transverse (Axial) Orientation Coronal Orientation Intercostal
More informationPaediatric surgical emergencies. Mani Thyagarajan BWCH
Paediatric surgical emergencies Mani Thyagarajan BWCH General points Always discuss Call consultant for help ASAP CT scan is a bad modality in paediatrics Ultrasound? Intussusception? Renal colic? UTI
More informationSWISS SOCIETY OF NEONATOLOGY. Prenatal diagnosis and postnatal management of meconium pseudocysts
SWISS SOCIETY OF NEONATOLOGY Prenatal diagnosis and postnatal management of meconium pseudocysts September 2007 2 Burch E, Caduff JH, Hodel M, Berger TM, Neonatal and Pediatric Intensive Care Unit (BE,
More informationSonographycally guided hydrostatic reduction of childhood intussusception
Sonographycally guided hydrostatic reduction of childhood intussusception Dubravka Vidmar, Alenka Višnar Perovič Clinical Radiology Institute, University Clinical Centre Ljubljana, Slovenia Background.
More informationJMSCR Vol 3 Issue 11 Page November 2015
www.jmscr.igmpublication.org Impact Factor 3.79 Index Copernicus Value: 5.88 ISSN (e)-2347-176x ISSN (p) 2455-0450 DOI: http://dx.doi.org/10.18535/jmscr/v3i11.52 Ultrasonographic Evaluation of Acute Abdomen
More informationPitfalls in the CT diagnosis of appendicitis
The British Journal of Radiology, 77 (2004), 792 799 DOI: 10.1259/bjr/95663370 E 2004 The British Institute of Radiology Pictorial review Pitfalls in the CT diagnosis of appendicitis 1 C D LEVINE, 2 O
More informationAPPENDICITIS AND ITS APPEARANCES ON CT
APPENDICITIS AND ITS APPEARANCES ON CT APPENDICITIS Results from acute inflammation of the appendix. Most common abdominal surgical emergencies. Diagnosis usually clinical based on physical exam and lab
More informationGastrointestinal Tract. Anatomy of GI Tract. Anatomy of GI Tract. (Effective February 2007) (1%-5%)
Gastrointestinal Tract (Effective February 2007) (1%-5%) Anatomy of GI Tract Esophagus bulls-eye or target EG junction seen on sagittal scan posterior to left lobe of liver and anterior to aorta Anatomy
More informationUltrasound of: Appendicitis Intussusception Pyloric Stenosis
Ultrasound of: Appendicitis Intussusception Pyloric Stenosis Andrew Phelps MD Assistant Professor Pediatric Radiology UCSF Benioff Children s Hospital No Disclosures Take Home Message Appendicitis occurs
More informationMy Patient Has Abdominal Pain PoCUS of the Biliary Tract and the Urinary Tract
My Patient Has Abdominal Pain PoCUS of the Biliary Tract and the Urinary Tract Objectives PoCUS for Biliary Disease PoCUS for Renal Colic PoCUS for Urinary Retention Biliary Disease A patient presents
More informationMohamed EL-hemaly Gastro- intestinal surgical center, Mansoura University.
Mohamed EL-hemaly Gastro- intestinal surgical center, Mansoura University. Chronic transmural inflammatory process of the bowel & affects any part of the gastro -intestinal tract from the mouth to the
More informationGuidelines, Policies and Statements D5 Statement on Abdominal Scanning
Guidelines, Policies and Statements D5 Statement on Abdominal Scanning Disclaimer and Copyright The ASUM Standards of Practice Board have made every effort to ensure that this Guideline/Policy/Statement
More informationAbdominal ultrasound:
Abdominal ultrasound: Non-traumatic acute abdomen Wittanee Na-ChiangMai, MD Department of Radiology ChiangMai University 26/04/2017 Contents Technique of examination Normal anatomy Emergency conditions
More informationThe abdominal Esophagus, Stomach and the Duodenum. Prof. Oluwadiya KS
The abdominal Esophagus, Stomach and the Duodenum Prof. Oluwadiya KS www.oluwadiya.com Viscera of the abdomen Abdominal esophagus: Terminal part of the esophagus The stomach Intestines: Small and Large
More informationUNDERSTANDING X-RAYS: ABDOMINAL IMAGING THE ABDOMEN
UNDERSTANDING X-RAYS: ABDOMINAL IMAGING THE ABDOMEN Radiology Enterprises radiologyenterprises@gmail.com www.radiologyenterprises.com STOMACH AND SMALL BOWEL STOMACH AND SMALL BOWEL Swallowed air is a
More informationBowel Obstructions in Older Children
Residents Section Pattern of the Month Hryhorczuk et al. owel Obstructions in Older Children Residents Section Pattern of the Month Residents inradiology nastasia Hryhorczuk 1 Edward Y. Lee 1,2 Ronald
More informationExploring Anatomy: the Human Abdomen
Exploring Anatomy: the Human Abdomen PERITONEUM AND PERITONEAL CAVITY PERITONEUM The peritoneum is a thin serous membrane that lines the abdominal cavity and covers, in variable amounts, the viscera within
More informationThe peritoneum. Prof. Oluwadiya KS, MBBS, FMCS(Orthop) Website:
The peritoneum Prof. Oluwadiya KS, MBBS, FMCS(Orthop) Website: http://oluwadiya.com The peritoneum Serous membrane that lines the abdominopelvic cavity and invests the viscera The largest serous membrane
More informationCecal Volvulus: Case Presentation and Review of CT Findings
August 2011 Cecal Volvulus: Case Presentation and Review of CT Findings Omar Pardesi, Harvard Medical School Year III Our Patient LD: History & Physical HPI: 28 y.o. female presents with diffuse abdominal
More informationEmergency MDCT in case of right lower quadrant pain
Emergency MDCT in case of right lower quadrant pain Poster No.: C-0563 Congress: ECR 2015 Type: Educational Exhibit Authors: M. Lisitskaya, V. Sinitsyn; Moscow/RU Keywords: Abdomen, Emergency, Gastrointestinal
More informationDr. Zahiri. In the name of God
Dr. Zahiri In the name of God small intestine = small bowel is the part of the gastrointestinal tract Boundaries: Pylorus Ileosecal junction Function: digestion and absorption of food It receives bile
More informationListed below are some of the words that you might come across concerning diseases and conditions of the bowels.
Listed below are some of the words that you might come across concerning diseases and conditions of the bowels. Abscess A localised collection of pus in a cavity that is formed by the decay of diseased
More informationRadiology of the abdomen Lecture -1-
Radiology of the abdomen Lecture -1- Objectives To know radiology modalities used in abdomen imaging mainly GI tract. To know advantages and disadvantages of each modality. To know indications and contraindications
More informationDuodenum retroperitoneal
Duodenum retroperitoneal C shaped Initial region out of stomach into small intestine RETROperitoneal viscus Superior 1 st part duodenal cap ; moves upwards and backwards to lie on the R crura medial to
More informationIntraperitoneal cysts in infancy and childhood An overview and sonographic differentiation
Intraperitoneal cysts in infancy and childhood An overview and sonographic differentiation M. Mearadji International Foundation for Pediatric Imaging Aid Rotterdam, The Netherlands Intraperitoneal cysts
More informationLab Monitor Images Dissection of the Abdominal Vasculature + Lower Digestive System
Lab Monitor Images Dissection of the Abdominal Vasculature + Lower Digestive System Stomach & Duodenum Frontal (AP) View Nasogastric tube 2 1 3 4 Stomach Pylorus Duodenum 1 Duodenum 2 Duodenum 3 Duodenum
More informationGeneral Data. 王 X 村 78 y/o 男性
General Data 王 X 村 78 y/o 男性 Chief Complaint Vomiting twice this early morning Fever up to 38.9ºC was noted Present Illness (1) Old CVA with left side weakness for more than 10 years and with bed ridden
More informationInfantile Hypertrophic Pyloric Stenosis
A Sonographic walk-through: Infantile Hypertrophic Pyloric Stenosis Tara K. Cielma, RDMS, RDCS, RVT, RT(S) Anjum N. Bandarkar, MD, Adebunmi O. Adeyiga, MD, Diagnostic Imaging and Radiology, Children s
More informationDevelopment of the Digestive System. W.S. O The University of Hong Kong
Development of the Digestive System W.S. O The University of Hong Kong Plan for the GI system Then GI system in the abdomen first develops as a tube suspended by dorsal and ventral mesenteries. Blood
More informationEmbryology of the Midgut and Hind gut
Embryology of the Midgut and Hind gut Prof. Abdulameer Al-Nuaimi E-mail: a.al-nuaimi@sheffield.ac.uk E-mail: abdulameerh@yahoo.com Abdominal organs www.google.co.uk/search? Development of Duodenum The
More informationGastrointestinal Pathology. August 2007
Gastrointestinal Pathology August 2007 Case 1 Dysphagia and halitosis Case 1 Dilatation of the oesophagus with a smooth narrowing of its lower end. The large volume of contained fluid indicates delayed
More informationPediatric Surgical Emergencies Veronica Victorian, PA-C
Pediatric Surgical Emergencies Veronica Victorian, PA-C Texas Children s Hospital Division of Pediatric General Surgery Assistant Professor, Baylor College of Medicine Objectives 1. Define Pediatric Surgical
More informationAbdominal Assessment
Abdominal Assessment Mary Marian, MS,RD,CSO University of AZ, Tucson, AZ Neha Parekh, MS,RD,LD,CNSC Cleveland Clinic, Cleveland, OH Objectives: 1. Outline the steps in performing an abdominal examination.
More informationAlways keep it in the differential
Acute Appendicitis Lissa C. Sakata and Lindsey Perea 2 Always keep it in the differential Learning Objectives 1. The learner should be able to describe the etiology of acute appendicitis. 2. The learner
More informationA Comparative Ultrasound and Plain Abdominal X-Ray: Evaluation of Non-Classical Clinical Cases of Appendicitis
A Comparative Ultrasound and Plain Abdominal X-Ray: Evaluation of Non-Classical Clinical Cases of Appendicitis Dorothy Makanjuola, FRCR; Qasim Al-Qasabi, FRCS; Tajuddin Malabarey, FRCR From the Departments
More informationA rare case of intestinal obstruction due to internal hernia. Dr. Jayanth 3 rd year PG Dept. Of General Surgery
A rare case of intestinal obstruction due to internal hernia Dr. Jayanth 3 rd year PG Dept. Of General Surgery One of the common cause of acute abdomen May lead to high morbidity and mortality if not treated
More informationCaeco-colic Intussusception Simulating an Appendicular Mass
Article ID: WMC003206 ISSN 2046-1690 Caeco-colic Intussusception Simulating an Appendicular Mass Corresponding Author: Dr. Matthew O Adelekan, Surgeon, North manchester General Hospital - United Kingdom
More informationVolvulus of the Gastrointestinal Tract: x-ray and CT imaging
Volvulus of the Gastrointestinal Tract: x-ray and CT imaging Poster No.: C-0076 Congress: ECR 2013 Type: Educational Exhibit Authors: E. Papadaki, S. Paschalidou, S. GIANNOU ; Rethymno, CR/ 1 2 2 3 1 3
More informationGI Tract Lynn Ta Jennifer Zhang July 6, 2006 GI TRACT. 1) Other Names: Gastrointestinal tract Digestive tract Alimentary tract
GI Tract Lynn Ta Jennifer Zhang July 6, 2006 GI TRACT 1) Other Names: Gastrointestinal tract Digestive tract Alimentary tract 2) Definition/Location: Digestion and absorption are the primary functions
More informationQuestion 1 History. Likely Diagnosis Differential. Further Investigation or Management. Requires Paediatric Surgical referral for laparotomy
Question 1 Male newborn spilling green tinged vomit day 1 of life Imaging Abdominal X-Rays performed on 03/05/2012 Upper and lower gastrointestinal contrast studies performed on 03/05/2012 Abdominal X-Rays
More informationIMAGING GUIDELINES - COLORECTAL CANCER
IMAGING GUIDELINES - COLORECTAL CANCER DIAGNOSIS The majority of colorectal cancers are diagnosed on colonoscopy, with some being diagnosed on Ba enema, ultrasound or CT. STAGING CT chest, abdomen and
More informationOriginal Research Article
Original Research Article Role of (Non Gynaecological Causes) Kaleem Ahmad 1, Rishav Kumar Jain 2, Ashok Yadav 3, Shilpa Vahikar 4 1 Associate Professor, Department of Radiodiagnosis, 2 Professor, Department
More informationCT abdomen and pelvis
CT abdomen and pelvis General indications: Assessment of vague abdominal symptoms (pain, colics,distenstion,...) Varifecation of a lesion discovered by other diagnostic modalities as US, barium,ivp, Staging
More informationAbdominal Ultrasound. Diane Hallinen, MD. Bloodroot
Abdominal Ultrasound Diane Hallinen, MD Bloodroot Abdominal Ultrasound Vasculature Hepatobiliary Spleen Kidney Bladder Bowel Where to put the probe? Vasculature We are going to talk about Celiac Trunk
More informationANATOMY OF THE SMALL & LARGE INTESTINES. Semester 1, 2011 A. Mwakikunga
ANATOMY OF THE SMALL & LARGE INTESTINES Semester 1, 2011 A. Mwakikunga LEARNING OBJECTIVES 1. List the parts and anatomical regions of the small and large intestines 2. State anatomical relations of the
More informationDevelopment of the Digestive System. W.S. O School of Biomedical Sciences, University of Hong Kong.
Development of the Digestive System W.S. O School of Biomedical Sciences, University of Hong Kong. Organization of the GI tract: Foregut (abdominal part) supplied by coeliac trunk; derivatives include
More informationAnatomy of the SMALL INTESTINE. Dr. Noman Ullah Wazir PMC
Anatomy of the SMALL INTESTINE Dr. Noman Ullah Wazir PMC SMALL INTESTINE The small intestine, consists of the duodenum, jejunum, and illium. It extends from the pylorus to the ileocecal junction were the
More informationObjectives. Pediatric Mortality. Another belly pain. Gastroenteritis. Spewing & Pooing Child 4/18/16
Gastro-tastrophies A Review of Pediatric GI Emergencies Objectives Discuss common presentations of Pediatric Abdominal Pain complaints Discuss work up and physical exam findings Discuss care, management
More informationCLINICAL VIGNETTE 2016; 2:1
CLINICAL VIGNETTE 2016; 2:1 Editor-in-Chief: Olufemi E. Idowu. Neurological surgery Division, Department of Surgery, LASUCOM/LASUTH, Ikeja, Lagos, Nigeria. MANAGEMENT OF APPENDICITIS Ibrahim NA, Njokanma
More informationThe appendix is a small, tube-like structure attached to the first part of the large intestine, also called the colon. The appendix.
The appendix is a small, tube-like structure attached to the first part of the large intestine, also called the colon. The appendix is located in the lower right portion of the abdomen. It has no known
More informationPneumatic Reduction of Intussusception Using Equipment Readily Available in the Hospital
ORIGINAL ARTICLE Pneumatic Reduction of Intussusception Using Equipment Readily Available in the Hospital M A Zulfiqar, MMed*, M Noryati, MMed**, A H Hamzaini, MMed*, C R Thambidorai, FRACS*** *Department
More informationAbdominal radiology 腹部放射線學
Abdominal radiology 腹部放射線學 台北醫學大學 - 市立萬芳醫院 留偉順 laowilson@hotmail.com The Normal Abdominal Series Chest Supine abdomen Erect abdomen Left lateral decubitus abdomen Learning objectives Understanding normal
More informationTHE ORAL CAVITY
THE ORAL CAVITY WALL OF ABDOMEN (ANTERIOR) The paraumbilical vein drains into the portal vein and then through the liver. This is an important clinical connection. THE ABDOMINAL VISCERA The small
More informationTHE INS AND OUTS OF HERNIAS WHERE TO START? WHAT IS A HERNIA? CLINICAL INDICATIONS THE INGUINAL CANAL THE CLINICAL QUESTION 18/09/2018
THE INS AND OUTS OF HERNIAS Cassandra Harrison BA/BSc, MMRU, AMS WHERE TO START? The Clinical Question Essential anatomy Inguinal hernia Scanning technique Variations WHAT IS A HERNIA? CLINICAL INDICATIONS
More information... Inflammatory disorder of the colon that occurs as a complication of antibiotic treatment.
Definition Inflammatory disorder of the colon that occurs as a complication of antibiotic treatment. " Epidemiology Humans represent the main reservoir of Clostridium difficile, which is not part of the
More informationDR JAIKISHOR JOTHIRAJ MD POST GRADUATE DEPT OF RADIODIAGNOSIS
DR JAIKISHOR JOTHIRAJ MD POST GRADUATE DEPT OF RADIODIAGNOSIS YASHODAMMAL 70 YRS OD LADY had C/o diffuse lower abdominal pain 20 days h/o blood in stools 4 days h/o vomiting 2 days h/o burning micturation
More informationBushra Arafa Zayed & Hanan Jamal. - Dana AF
- 10 - Bushra Arafa Zayed & Hanan Jamal - Dana AF - Mohammad Al Muhtaseb Notes: This sheet was written in the same order as the slides, and everything in the slides is mentioned in this sheet. Pictures
More informationSonographic Whirlpool Sign in Ovarian Torsion
Technical dvance Sonographic Whirlpool Sign in Ovarian Torsion S. oopathy Vijayaraghavan, MD, DMRD Objective. To describe an additional maneuver during sonography for ovarian torsion and to assess its
More informationPEDIATRIC EMERGENCY DEPARTMENT CLINICAL GUIDELINE: GI SURGICAL EMERGENCIES: VOMITING
GI SURGICAL EMERGENCIES: VOMITING PYLORIC STENOSIS Population: Infants: onset between 2-5 weeks of age 1 in 250 births Male: female ratio 4:1 Familial incidence History: No vomiting in the first few weeks
More informationAbdomen and Pelvis CT (1) By the end of the lecture students should be able to:
RAD 451 Abdomen and Pelvis CT (1) By the end of the lecture students should be able to: State the common indications for Abdomen and pelvis CT exams Identify possible contra indications for Abdomen and
More informationCLINICAL PRESENTATION AND RADIOLOGY QUIZ QUESTION
Donald L. Renfrew, MD Radiology Associates of the Fox Valley, 333 N. Commercial Street, Suite 100, Neenah, WI 54956 6/23/2012 Radiology Quiz of the Week # 78 Page 1 CLINICAL PRESENTATION AND RADIOLOGY
More informationPediatric Bowel Obstruction
Pediatric Bowel Obstruction Matt Zerden, Harvard Medical School III Patient 1 16 year old presents with severe, episodic abdominal pain, nausea and vomiting. Questionable abdominal mass in RLQ Previous
More informationPediatric abdominal emergencies In the first year of life
Common Pediatric abdominal emergencies In the first year of life Kristian Stien Thomassen Section of Pediatric Radiology Dept. of Radiology and Nuclear Medicine Oslo University Hospital Understand the
More informationDissection Lab Manuals: Required Content
Dissection Lab Manuals: Required Content 1. Introduction a. Basic terminology (directions) b. External features of the cat c. Adaptations to predatory niche d. How to skin a cat e. How to make the incisions
More informationRadiology of GI system diseases
GI Cycle - Lecture 12 436 Teams Radiology of GI system diseases Objectives 1. 2. 3. To know common GIT Pathologies presentation. To understand step wise approach in requesting GIT Radiology Investigations.
More informationIntussusception on Small Bowel Examinations in Children
299 Alan Daneman1 Bernard J. Reilly1 MemI de Silva2 Patrick OIutola1 Received December 1 8, 1 981 ; accepted after revision April 1 9, 1982. Department of Radiology, Hospital for Sick Children, 555 University
More informationImaging Children with Acute Abdominal Pain -- Role/Protocols of US, CT, MR
Imaging Children with Acute Abdominal Pain -- Role/Protocols of US, CT, MR Kimberly E. Applegate, MD, MS Emory University Financial disclosures: AIM (American Imaging Management) radiation protection advisory
More informationADENOMYOSIS CHRONIC PELVIC PAIN IN WOMEN IMAGING CHRONIC PELVIC PAIN IN WOMEN CHRONIC PELVIC PAIN IN WOMEN ADENOMYOSIS: PATHOLOGY ADENOMYOSIS
CHRONIC PELVIC PAIN IN WOMEN IMAGING CHRONIC PELVIC PAIN IN WOMEN MOSTAFA ATRI, MD Dipl. Epid. UNIVERSITY OF TORONTO Non-menstrual pain of 6 months Prevalence 15%: 18-50 years of age 10-40% of gynecology
More information