Ultrasound of: Appendicitis Intussusception Pyloric Stenosis
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1 Ultrasound of: Appendicitis Intussusception Pyloric Stenosis Andrew Phelps MD Assistant Professor Pediatric Radiology UCSF Benioff Children s Hospital
2 No Disclosures
3 Take Home Message Appendicitis occurs at any age. Intussusception and Pyloric Stenosis have specific age ranges.
4 Outline 1) Appendicitis 2) Intussusception 3) Pyloric Stenosis
5 Outline 1) Appendicitis 2) Intussusception 3) Pyloric Stenosis
6 Appendicitis Age Range Any!
7 Scanning Technique
8 10 minutes to find Appendix
9 Start anterior to the iliac vessels. Most often this is where you will find the appendix.
10 Look from All Directions
11 Normal Appendix
12 Normal Appendix mobile tubular blind-ending no peristalsis < 6 mm diameter
13 Normal Appendix Donut Train Tracks Stool Free Fluid
14 Appendix Fakeouts
15 Ileum Mimicking Appendix Look for bumpy folds.
16 Ureter Mimicking Appendix Sagittal Transverse
17 Ovarian Vein Mimicking Appendix
18 Appendicitis
19 Appendicitis 11 mm, focally tender
20 Appendicitis Color flow sometimes helpful.
21 Appendicitis Look for inflamed echogenic fat.
22 Outline 1) Appendicitis 2) Intussusception 3) Pyloric Stenosis
23 Intussusception Age Range 4 months 4 years > 4 years: Worry about tumor.
24 Intussusception Technique
25 5 minutes to find intussusception Start in RLQ. Scan all 4 quadrants.
26 Normal Bowel
27 Normal Spine
28 Normal Psoas Muscles
29 Normal Small Bowel Marbelized mucosa
30 Normal Terminal Ileum AIR/ STOOL
31 Normal Ileocecal Valve resembles pylorus
32 Normal Ascending Colon Speckles from stool/gas.
33 Intussusception
34 2 year old with colicky pain.
35 Intussusception
36 7 year old, VPS, emesis.
37 Intussusception in 7 year old from lymphoma!
38 Small Bowel Small Bowel Intuss. Presumed clinically insignificant.
39 2yo abdominal pain. Central Abd
40 Inverted Meckel s Small Bowel Intussusception Small Bowel Obstruction
41 Intussusception Fakeouts
42 Normal Ileocecal Valve IC valve normally herniates slightly into cecum
43 Inflamed Ileocecal Valve Sagittal Transverse A real intussusception wouldn t be this short.
44 Ileum Edema after Intussusception Reduction
45 Colitis Mimicking Intussusception No Compression With Compression
46 Outline 1) Appendicitis 2) Intussusception 3) Pyloric Stenosis
47 Pylorus Stenosis Age Range 3 weeks 6 months
48 Pylorus Scanning Technique
49 Use liver as window to pylorus. Place patient right-side down if need to get gas out of the way.
50 Normal Pylorus
51 Normal Pylorus Muscular layer is hypoechoic. Py St Du
52 Normal Pylorus Gas in duodenal bulb confirms correct location. Du Py
53 Pyloric Stenosis
54 Pyloric Stenosis Pyloric Stenosis Normal Pylorus 4 mm thickness, 16 mm length 3 weeks 6 months
55 Pyloric Stenosis Longitudinal Transverse
56 Pyloric Stenosis Fakeouts
57 Incorrect Measurements
58 Incorrect Measurements 7 x 15 mm 3 mm
59 Correct Measurements 7 x 15 mm 3 mm
60 To exclude pylorospasm, wait for emptying.
61 Outline 1) Appendicitis 2) Intussusception 3) Pyloric Stenosis
62 Take Home Message Appendicitis: any age Intussusception: 4 mo 4 years Pyloric Stenosis: 3 wk 6 mo
63 Questions
64 Question 1 What is the appendix diameter cutoff for appendicitis? a. >5 mm b. >6 mm c. >7 mm d. >8 mm
65 Question 1 What is the appendix diameter cutoff for appendicitis? a. >5 mm b. >6 mm c. >7 mm d. >8 mm Ref: Trout AT, Sanchez R, Ladino-Torres MF, Pai DR, Strouse PJ. A critical evaluation of US for the diagnosis of pediatric acute appendicitis in a real-life setting: how can we improve the diagnostic value of sonography? Pediatr Radiol Jul;42(7):813-23
66 Question 2 What do you need to worry about in a 10 year old with intussusception? a. abuse b. infection c. inflammatory bowel disease d. tumor
67 Question 2 What do you need to worry about in a 10 year old with intussusception? a. abuse b. infection c. inflammatory bowel disease d. tumor Ref: Zhang Y, Dong Q, Li SX, Ren WD, Shi B, Bai YZ, Zhang SC, Zheng LQ. Clinical and Ultrasonographic Features of Secondary Intussusception in Children. Eur Radiol Apr 5
68 Thank you!
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