Pediatric Hepatobiliary, Pancreatic & Splenic US

Transcription

1 Pediatric Hepatobiliary, Pancreatic & Splenic US Susan J. Back, MD Department of Radiology, The Children s Hospital of Philadelphia

2 No Disclosures

3 Objectives Normal Abnormal: cases and US advances

4 Objectives Normal Abnormal: cases and US advances

5 Hepatobiliary Ultrasound Size Echotexture Duct dilation Gallbladder Calculi

6 Hepatobiliary: Normal Liver Size Term 307 children 5 days to 16 years Genders equal Height best correlate

7 Hepatobiliary: Normal Liver Size Term 307 children 5 days to 16 years Genders equal Height best correlate Preterm 498 infants wk GA Girls smaller Weight best correlate

8 Hepatobiliary: Normal Gallbladder Mean length Mean Diameter Birth 1y: 2.5 cm 1 cm y: 6 cm 2 cm Wall thickness < 3 mm Radiology 1982; 144:

9 Hepatobiliary: Normal CHD Common hepatic duct little variation with age Always < 4 mm Radiology 1982; 144:

10 Hepatobiliary: Echotexture Homogeneous No sound attenuation deep lobe Portal vein/duct wall interfaces

11 Hepatobiliary: Echotexture Homogeneous No sound attenuation deep lobe Portal vein/duct wall interfaces Echogenicity > right kidney

12 Spleen Ultrasound Shape: cleft, lobules Location: wandering Radiographics 1999; 19: Number: polysplenia or asplenia Size: splenomegaly or atrophy

13 Spleen Ultrasound Lesions Solitary Multiple Diffuse Radiographics 1999; 19:

14 Spleen: Normal Size Term 512 children 1 day to 17 years Genders equal Height best correlate* *Others weight best AJR 1991; 157: AJR 1993; 160:

15 Spleen: Normal Size Term 512 children 1 day to 17 years Genders equal Height best correlate Preterm 498 infants wk GA Girls smaller Weight best correlate

16 Spleen Echotexture Homogeneous Echogenicity > liver Echogenicity >> left kidney Convex surface smooth Concave surface nodular

17 Pancreas Ultrasound Size Echotexture Duct dilation Fluid collection

18 Pancreas US Technique Sonographic window Ultrasound Clin 2013;8: Left hepatic lobe Left kidney or spleen Stomach with water ingestion

19 Pancreas: Normal Size Ultrasound Clin 2013; 8:

20 Pancreas: Normal Duct Size Mean / mm J Ultrasound Med 2000; 19:

21 J Ultrasound Med 2000; 19: Pediatr Radiol 1990; 20: Pancreas: Echotexture 1 day old Echogenicity > liver Newborn hyperechoic Preterm > term Smooth or slightly lobulated 7 month old

22 Objectives Normal Abnormal: cases and US advances

23 Inherited and Congenital Fibropolycystic Disease Biliary Atresia Hyperinsulinism Cystic Fibrosis Sickle cell disease

24 3 yo girl with progressive abdominal distension, thrombocytopenia 10.2 cm (95%) Size: large Echotexture: coarse Duct dilation: variable

25 Congenital Hepatic Fibrosis (CHF) 10.2 cm (95%) Size: large Echotexture: coarse Duct dilation: variable Duct Size Fibropolycystic disease Small Medium Large CHF, biliary hamartoma ADPLD Choledochal cyst, Caroli disease Fibrous enlargement of bile ducts and portal tracts Ducts are present, not paucity

26 Congenital Hepatic Fibrosis (CHF) 10.2 cm (95%) Size: large Echotexture: coarse Duct dilation: variable Additional Cirrhotic morphology Portal hypertension Splenomegaly 11.4 cm

27 Congenital Hepatic Fibrosis (CHF) 10.2 cm (95%) Size: large Echotexture: coarse Duct dilation: variable Mean 2.58 m/s Elastography: quantify stiffness/fibrosis

28 4 week old girl with conjugated hyperbilirubinemia

29 Biliary atresia Gallbladder Triangular cord Triangular cord sign (TCS) Absent CBD Abnormal GB (small) No GB change with feed

30 Biliary atresia Meta-analysis 23 studies US in BA Gallbladder US Sign Sensitivity Specificity Triangular cord GB abnormal 0.85 ( ) 0.92( ) TCS 0.74 ( ) 0.97 ( ) Triangular cord sign (TCS) Absent CBD Abnormal GB (small) No GB change with feed GB abn +TCS 0.95 ( ) 0.89 ( ) AJR 2016: 206:W73-82

31 Biliary atresia Triangular cord Triangular cord sign (TCS) Absent CBD Abnormal GB (small) No GB change with feed Images at 1, 4, 6.5 hours no bowel activity, GB not visualized

32 Biliary atresia Gallbladder Triangular cord Triangular cord sign (TCS) Absent CBD Abnormal GB (small) No GB change with feed Additional Enlarged Elastography: hepatic BA artery vs other (HA) liver disease Increased ratio HA to portal vein Pediatr Radiol (2015) 45:

33 1 month old girl hyperinsulinemic hypoglycemia 18F-DOPA PET/CT

34 Congenital Hyperinsulinism 18F-DOPA PET/CT Hyperfunctioning β cells Focal or diffuse Unregulated release of insulin

35 Congenital Hyperinsulinism sagittal Focal can be difficult to find in OR Intraoperative US assistance Hypoechoic Variable homogeneity

36 Congenital Hyperinsulinism 15 MHz 50 MHz sagittal Focal can be difficult to find in OR Intraoperative US assistance Hypoechoic Variable homogeneity 4.2 x 4.2 mm 0.3 mm duct

37 12 yo boy with Cystic Fibrosis

38 Cystic Fibrosis liver disease Echotexture: Hyperechoic, homogeneous Additional Heterogeneous Cirrhotic morphology Portal hypertension

39 Cystic Fibrosis Liver Disease Network (CFLD NET) Prediction by US Risk of Hepatic Cirrhosis (PUSH) 719 children, 3-12 yo No known cirrhosis J Pediatr 2015; 167:

40 Cystic Fibrosis Liver Disease Network (CFLD NET) Prediction by US Risk of Hepatic Cirrhosis (PUSH) 719 children, 3-12 yo No known cirrhosis US detected: 3.3% cirrhosis 8.9% heterogeneous J Pediatr 2015; 167:

41 Cystic Fibrosis liver disease Focal biliary cirrhosis ARFI elastography Radiol med 2012; 117:

42 Cystic Fibrosis- Pancreas Size: normal or atrophy Echotexture: increased Calcifications, cysts, cystosis

43 Cystic Fibrosis- Pancreas ARFI Elastography Softer in pancreatic insufficiency Insufficiency 0.88 m/s No insufficiency 1.07 m/s Normal 1.22 m/s * Size: normal or atrophy Echotexture: increased Calcifications, cysts, cystosis J Cystic Fibrosis 2013;12: *Eur J Radiol 2011;80:e226 30

44 8 yo boy Hb SS and abdominal pain

45 8 yo boy Hb SS and abdominal pain Number: present, one Size: small Echotexture: increased Lesions: multiple Previously autosplenectomy by 5y Transfusion & Hydroxyurea Splenomegaly Echogenic parenchyma Nodules Hemosiderosis Regenerative nodules Extramedullary hematopoiesis J Pediatr : J Ultrasound Med 2016; 35:

46 8 yo boy Hb SS and abdominal pain Number: present, one Size: small Echotexture: increased Lesions: multiple Additional Absent Heterogeneous echotexture Calcification Abscess

47 Summary Normal Abnormal: cases and US advances