Ultrasound examination of neonatal hip dysplasia: Comparison of interobserver variation when classifying using Graf method and femoral head position.
Royal Hospital for Sick Children, Edinburgh
Background: Classification of neonatal hip dysplasia is often performed according to Graf, but interobserver variation compared with other methods is unknown.
Aim: To compare interobserver variation for Graf classification and femoral head position
Method: At a consensus meeting of the Scottish Hip screening Group meeting 12 experienced observers classified 25 anonymised static images by Graf type and femoral head position (normal, decentered or eccentric). Video of spontaneous instability and/or stress testing was presented where available.
Results: There was significantly greater agreement of observers using femoral head position than Graf type whether agreement was defined as unanimous (p<0.001), 11:1 (p<0.001), 10:2 p< 0.001) or 9:3 (p<0.001).
Conclusion: Graf classification results in greater inter-observer variation than assessment of femoral head position. Treatment decisions based on Graf classification are therefore less likely to be consistent than those based on femoral head position. It is suggested that treatment decisions should be performed on stability rather than Graf classification
When should treatment for Developmental Delay of the Neonatal Hip be commenced?
Jackson MR1, Wilkinson S2, Wilkinson AG1
Departments of Radiology1 and Physiotherapy2,
Royal Hospital for Sick Children, Edinburgh EH9 1LF
Background: There is controversy as to when treatment for DDH should be instituted. Some believe that many hips will improve spontaneously by 12 weeks of age, others that treatment is more effective if started early because more rapid bone growth allows better acetabular remodelling.
Aim: To establish the optimum time for commencement of treatment.
Method: All babies having a second ultrasound for suspected DDH over a 2.5 year period were identified from prospectively kept records. 167 babies that had follow-up of a pelvic radiograph at 1 year of age form the study population. The anonymised radiographs were assessed by an experienced paediatric radiologist
Results: 4% of untreated babies had an abnormal hip compared to 9% of those treated before 6 weeks of age. The rate of abnormality rose to 14%, 22%, 40% and 66% for babies treated after 6, 8, 10 and 12 weeks respectively.
Conclusion: The rate of residual abnormality rose rapidly for babies treated after 6 weeks of age, and commencement of treatment should not be delayed beyond 6 weeks in the hope of spontaneous improvement.
The value of axial sequenced in MRI assessment of childhood scoliosis
Joseph Jacoby and Joanna Fairhurst, Southampton General Hospital
Aims: To assess the benefit of axial sequences in the assessment of childhood scoliosis.
Introduction: The number of requests for MRI is rising rapidly and, coupled with limited scanner access, waiting times are increasing. Strategies to manage this problem include increasing capacity or patient throughput (e.g. faster sequences / fewer sequences). Increasing capacity is often not a practical option. Although the received wisdom is to perform axial sequences in scoliosis assessment, anecdotally we felt such sequences were non-contributory.
Methods: Scoliosis assessment scans for 2006 – 2009 were collated and divided into two groups – those demonstrating a scoliosis only, and those with a scoliosis and additional abnormalities (e.g. syrinx). Both groups were blindly re-reported using only the sagittal and coronal sequences. If reporters felt no additional abnormalities were demonstrated they were asked if further axial imaging was needed. If abnormalities were identified these were described.
Results: We will document:
• If reporters are confident to call a scan ‘normal’ (i.e. scoliosis only) without axial imaging.
• If abnormalities can be accurately characterized on only coronal and sagittal sequences.
Discussion: The study aims to test the hypothesis that axial sequences in the assessment of paediatric scoliosis are non-contributory. If this is shown to be the case scanning times may be reduced, which is of benefit to both the patient and the radiology service as a whole.
Preparation for allergic contrast media reactions: results of a national survey, review of the literature & suggested guidelines
Dr Richard Lindsay
Aim: To identify current practices within paediatric radiology in the UK, with regard to the use of prophylactic medication, prior to administering intravenous (IV) contrast medium (RCM). In addition, the pre-injection risk management strategies of the departments questioned was to be evaluated, and using consensus opinion, a protocol for managing patients identified as being at high risk for an adverse reaction to RCM was to be outlined.
Method: An online survey of paediatric radiology consultants representing all geographic regions of the UK was carried out. The questions asked included an assessment of the risk factors for adverse reactions to RCM, and how such reactions are anticipated and managed. The questionnaire asked about the perceived indications for, and the use of prophylactic medication prior to RCM administration.
Results: A response rate of 51% was achieved. The majority of respondents felt that a history of previous RCM reaction was an indication to administer prophylactic drugs prior to a further dose of RCM. No other risk factors were believed to require prophylactic medication.
Discussion: Using information obtained from the survey, a literature search was performed to assess the evidence available in support of each practice. A protocol was devised to identify children at risk of an adverse reaction to RCM, and guide the use of prophylactic medication in this group of patients.
Conclusions: The survey highlighted considerable variability in the risk assessment and management practices within paediatric radiology here in the UK. The derived protocol may guide radiologists’ management of children at risk for a RCM reaction.
A review of local dose-area product levels for paediatric
fluoroscopy in a tertiary referral centre. Are National Reference Doses falsely reassuring?
J Amarnath1, S J Mutch2, S Chakraborty1, K Platt1, K Park1
1. Department of Radiology, Children’s Hospital, Oxford
2. Department of Medical Physics & Clinical Engineering, Churchill Hospital, Oxford
Introduction: A retrospective study of dose-area product (DAP) values for fluoroscopic examinations was undertaken in a paediatric tertiary referral centre. The aim was to establish local diagnostic reference levels (DRLs) and to compare our results to current national reference doses (NRDs) and DRLs from another paediatric tertiary referral centre.
Method: 1732 examinations were performed in a dedicated paediatric fluoroscopy room over a period of 42 months. Data are presented for four of the most commonly performed examinations (1024) grouped according to the standard age of the patient.
Results: Our local DAPs were substantially lower for micturating cystourethrograms (four to tenfold lower) and upper gastrointestinal studies (13 to 25 fold lower) than the current NRDs published by the National Radiation Protection Board in 2002. The difference is likely to reflect technological advances in the equipment used and optimisation of both equipment performance and operator technique. The results obtained are comparable to those published by another paediatric tertiary referral centre in 2006.
Conclusion: It is important that practitioners carrying out paediatric fluoroscopy studies are aware that NRDs might not reflect current best practice. Regular review of local and national practice is essential to identify the DAP levels that are achievable.
Reporting and Communication in NAI (NonAccidental Injury) Imaging
Steve Morgan. ST4 Radiology Severn.
As a result of the Laming Inquiry in 20031, which investigated the death of Victoria
Climbe, the Royal College of Radiology, and the Royal College of Paediatrics and
Child Health published the ‘Standards for Radiological Investigations of Suspected
Non-accidental Injury’ (NAI) in March 20082.
The skeletal survey is often the primary radiological investigation in suspected NAI3,
and is a common investigation not just in Tertiary referral centres, but also in the
majority of NHS Trusts.
Additional imaging of the head and spine is also commonly required.
Reports therefore need to meet the new published standards of March 2008, being
properly structured, include a number of points, and be transmitted to and reviewed
It is also important to remember that they are often used as part of court
This audit explores the quality of current reports for skeletal surveys in the South
West of England, and head injury reporting at Bristol Childrens’ Hospital. In addition we have re-audited skeletal survey reporting at Bristol Childrens’.
The results, improvements, and ongoing deficiencies are discussed.
1 TSO. The Victoria Climbie Enquiry. Report of an Inquiry by Lord Laming. London: The
Stationary Office, 2003.
2 Standards for Radiological Investigations of Suspected Non-accidental Injury. The Royal
College of Radiologists and Royal College of Paediatrics and Child Health, March 2008.
3 Belfer RA, Klein BL, Orr L. Use of the skeletal survey in the evaluation of child maltreatment.
Am J Emerg Med 2001; 19 (2): 122-124.
4 The Royal College of Radiologists. Providing expert advice to the Court: advice to Members
and Fellows. London: The Royal College of Radiologists, 2005.
Should diffusion weighted imaging be routinely used in paediatric brain MR
N A Porter (BSc, MBBS, MRCS), M Kaleem (MBBS MRCPCH FRCR), K Hindle
(HDCR), S M Stivaros (BSc MBChB PhD FRCR)
Department of Radiology Royal Manchester Children’s Hospital (RMCH)
Diffusion weighted imaging (DWI) is a magnetic resonance (MR) sequence which
works by detecting signal changes related to the Brownian motion of interstitial water
molecules. It is a rapid sequence incurring a time burden of less than a minute per
patient brain scan. Due to the rapid acquisition time it is relatively immune to patient
movement artefact. In certain disease processes the additional findings of a DWI
sequence can significantly improve the sensitivity and specificity of the standard MR
neuroradiological assessment by providing unique and valuable diagnostic
information. For these reasons we introduced DWI to all our standard MR brain scans
in June 2009.
The aim of this presentation is to review the physiological and MRI basis for DWI
imaging. Additionally through illustrative cases we aim to highlight the uses and
findings in DWI which elucidate improved MR brain scan diagnostic capability.
Specifically we will discuss the use of DWI in cerebral abscess diagnosis and
differentiation from tumour, cerebral ischaemia (including hypoxic ischaemic
encephalopathy and non-accidental injury) and other disease processes such as
In conclusion we hope to show that DWI, a rapid sequence to perform, often provides
valuable additional diagnostic information. As a result we recommend that DWI
should be added to the routine MR brain assessment protocol in all paediatric centres.
Alice Oates*, Mike Reeves*, Martyn Paley*, Tom Farrell#, Robert Fraser#, Elspeth
*Department of Academic Radiology, University of Sheffield,UK
#Obstetrics and Gynaecology, Jessop Wing, Sheffield, UK
Background: Proton magnetic resonance spectroscopy (H-MRS) is used in clinical practise to detect various metabolites in the fetal, paediatric and adult brain. It is also able to detect lactate however the lactate peak is often obscured by a lipid peak reducing the clinical value of the technique.
Aims: This study aimed to discern the shortest echo time required to resolve a lactate peak without it being occluded by a lipid peak at a similar chemical shift, when the two substances are included in the same volume of interest.
Method: Phantoms of lactate and lipid solution were imaged at different TE values until the resulting spectra demonstrated the presence of lactate without contamination by lipid. One phantom had a lactate and oil solution that remained as two separate layers mimicking a fluid/ fat interface. The other phantom had a mixture of cream and lactate mimicking animal fat and lactate mixture in the same voxel.
Results: The lipid and lactate signals were shown to overlap at low TE (20ms). The lipid signal gradually decreases with a longer TE and has disappeared completely at a TE of 940 ms in the oil/lactate phantom and at 405 ms in the cream and lactate phantom.
Conclusion: MR spectroscopy for lactate is feasible on a 1.5T MR scanner however care must be taken in choosing the ideal parameters and in interpretation of the spectra.
AUDIT: Ultrasound as a tool in detecting the nature of cervical lymphadenopathy in children.
Charlotte Adams & Emily Ashworth
Introduction: Cervical lymphadenopathy is common within the paediatric population. Although usually representing benign illness, in a small proportion of cases, enlarged lymph nodes may be due to a sinister cause such as lymphoma. Ultrasound is the gold standard imaging technique for cervical lymphadenopathy and this audit investigates the accuracy of ultrasound in determining whether nodes are ‘normal’ or ‘abnormal’ in children with cervical lymphadenopathy in the Radiology Department of Bristol Royal Hospital for Children.
Methods: The audit team collated all neck ultrasound reports generated in the department over a period of approximately three years. 317 reports explicitly mentioned cervical lymphadenopathy and these were analysed to determine whether the impression given regarding the lymph nodes was suggestive of them being ‘normal’ or ‘abnormal’.
Combining the ultrasound list with information from the Pathology Department, 18 patients were identified who had undergone both a neck ultrasound and a cervical node biopsy within the time period. For these patients, their initial ultrasound impression was compared with the gold standard pathology result to see whether or not the nodes were correctly identified as ‘normal’ or ‘abnormal’ at ultrasound. An agreed standard of 90% correct identification rate was employed.
Results: Of the 317 neck ultrasound reports mentioning cervical lymphadenopathy, 75.4% gave the impression of ‘normal’ nodes, 23.3% ‘abnormal’ nodes and 1.3% ‘indeterminate’. 28.2% of patients with an abnormal ultrasound underwent biopsy. Of the patients who had undergone both cervical ultrasound and node biopsy within the time period (n=18), in 72.2% of cases the nodes were correctly identified as being due to ‘normal/infective’ or ‘abnormal’ by ultrasound (sensitivity 85%; specificity 40%).This did not meet the agreed 90% standard. However, 100% of the malignant cases were correctly identified as being abnormal at ultrasound.
Conclusion: Ultrasound can correctly identify almost three-quarters of cases of cervical ymphadenopathy in children as being due to a ‘normal’ or ‘abnormal’ cause. Further research and a re-audit are necessary to ascertain the true accuracy of ultrasound imaging for cervical lymphadenopathy in the paediatric population.
Follow up chest x-ray (CXR) in simple community acquired pneumonia audit.
S.Chawla (SPR Radiology Mersey Deanery),M.Tawil (Consultant Paediatric Radiologist)
Department of Radiology, Alder Hey Children’s Hospital, Liverpool, United Kingdom.
Background: Respiratory disease forms a large proportion of paediatric admissions to Alder Hey Hospital. The CXR is considered as the ‘golden’ tool for confirmation of pneumonia. In the paediatric population, it is common to provide a follow up clinical examination and repeat CXR to see if the pneumonia has resolved. The aim of this audit was to determine if we are complying with radiographic follow-up guidelines set by the British Thoracic Society?
Method: This was a retrospective audit review of all patients at our institution from July 09 – January 10. All patients over the age of 2 referred from Accident & Emergency and the community with radiological evidence of lung collapse, consolidation or round pneumonia were included. Patients with asthma or chronic lung disease were excluded. A simple proforma was used to collect the data and five main questions were answered including;
· CXR follow up or not.
· Follow up clinically or radiologically indicated.
· Follow up documented in the report.
· The time frame for follow-up.
· If follow up was documented by the radiologist and was it carried out by the clinical team.
Results: Over the study period 947 CXRs were reviewed of which 38 demonstrated chest abnormalities (male=23 and female 15) in accordance with our inclusion criteria.
CXR follow up was carried out in 45%, yet only in 11% of cases were radiologically and clinically indicated.
In those followed up, CXR was only normal in those taken after at least 6 weeks (82.3%).
CXR follow up only indicated and beneficial in a small proportion of children (11%).
Conclusion: Our audit demonstrates that a routine repeat CXR is not necessary in children with community-acquired pneumonia who are asymptomatic.
The overall frequency of complicated pneumonia is increasing and repeat CXR should be taken if poor response to treatment (clinically indicated).
National audit of the use of ultrasound imaging to guide paediatric chest
Wallis, A, Mortimer, A, Thyagarajan, M.
Purpose: Following the BTS guidelines for the management of pleural infection in children , we performed an audit of current practice in UK Paediatric Radiology Departments regarding the use of ultrasound to guide chest drain insertion for pleural infection in children. Prior to the publication of these guidelines there was little consensus regarding the management of pleural infections in children. The guidelines are evidence based and demonstrate best practice. We set out to determine the national compliance to these guidelines, identifying whether they are recognised and being adhered to.
Methods: The audit was conducted in the form of a web-based questionnaire e-mailed to members of The British Society of Paediatric Radiologists who were either general radiologists with an interest in paediatric imaging or paediatric radiologists. The audit was approved by our local clinical audit department.
Results: 53 consultant radiologists completed the questionnaire. 22 (42.3%) were general radiologists with an interest in paediatric imaging and 30 (57.7%)were paediatric radiologists. 40 (76.9%) were previously aware of the guidelines, 12 (23.1%) were not. The guidelines state that ultrasound must be used to confirm the presence of a pleural fluid collection and should be used to guide drain placement. 31 (60.8%) used ultrasound to mark a site for chest drain insertion by paediatricians, 10 (19.6%) used ultrasound guided insertion of drain as standard rather than marking the site. 2 (4.2%) stated that the paediatricians use ultrasound themselves to guide placement.
Conclusions: There is a good level of national adherence to the guidelines. The exact role of ultrasound varied depending on the size of the hospital, as many District General Hospitals will transfer patients to tertiary centres if a pleural effusion is confirmed on ultrasound. The results highlight that just under 25% of those who replied were unaware of the guidance and we hope to further educate clinicians and radiologists regarding the best practice of management of pleural infections in children.
 BTS guidelines for the management of pleural infection in children. I M Balfour-Lynn, E Abrahamson, G Cohen,
J Hartley, S King, D Parikh, D Spencer, A H Thomson,D Urquhart, on behalf of the Paediatric Pleural Diseases
Subcommittee of the BTS Standards of Care Committee. Thorax 2005;60(Suppl I):i1–i21. doi:
Barium Follow Through for Paediatric inflammatory bowel disease:
Histopathological and enteroscopical correlation.
Amonkar SJ1, Kaleem M2, Saha B3, Akobeng AK4.
1 Consultant Radiologist with Paediatric sub-speciality interest, North Manchester
General Hospital (NMGH).
2 Consultant Paediatric Radiologist, Royal Manchester Children’s Hospital (RMCH).
3 Gastrointestinal SHO, RMCH
4 Consultant Paediatric Gastroenterologist, RMCH
Aim: Barium follow through has been the mainstay radiological investigation for paediatric inflammatory bowel disease for decades, with alternatives such as MR and capsule enterography appearing recently and only in limited centres. We wanted to compare the positive radiological findings with endoscopy/colonoscopy and the gold standard,histopathology, to see if it is still a worthwhile investigation.
Method: A 5 year retrospective analysis of paediatric barium follow through studies performed at RMCH between November 2002 and November 2007 was undertaken, along with histopathological, enteroscopy and clinical data where available.
Results: 582 follow through exams were performed. Of these, 71 of these were radiologically equivocal or positive for inflammatory bowel disease on 70 different patients. Males were slightly more represented (59%) than females, with an overall mean age of 11.4 years at time of study. Of the 70 cases, 58 cases had histopathological specimens for comparison. Overall, a positive radiological study correlated with a positive pathological specimen in 57% of cases. Clinical notes (and hence endoscopy findings) were available for 46 cases. Here, radiology and endoscopy were both positive in 52%, and interestingly, endoscopy and pathology were only agreeingly positive in 46% of cases. Overall, total agreement with positive radiology, endoscopy and histology was seen in only 43% of cases where comparison was possible.
Comment: Whilst barium follow through has till recently been the main radiological investigation for inflammatory bowel disease, with 57 % positive correlation , we believe we should be replacing it with MR enterography, which negates the radiation dose and gives further extraluminal information.
Dynamic MRI in evaluation of Children with Rectal Prolapse:
A single centre review
Miss Alison Campbell MRCS Research Registrar
Mr Harry Ward, MS, FRCS Consultant Paediatric Surgeon
Mr Niall Power Consultant Radiologist
The Royal London Hospital Whitechapel E1B 1BB
Introduction: Rectal prolapse is most commonly seen in women over the age of 60. In paediatric practice rectal prolapse is seen in infancy. It is managed conservatively by either the family general practitioner or the paediatrician. Paediatric surgical involvement is reserved for extreme and refractory cases. A multitude of operations are described in the literature. However no one operation deals adequately with all 3 components of the problem. In recent adult literature the role of dynamic magnetic resonance imaging (dMRI) has been described. We describe our experience of managing rectal prolapse in the paediatric population requiring surgical intervention. We particularly looked at the important role of dynamic MRI in assessing the patient preoperatively.
Methods: We performed a retrospective case note review of all children surgically treated with rectalprolapse between 2002 and 2010 at our institution. Data were gathered regarding age at presentation, underlying conditions, timing and findings of dMRI (specifically descent of rectum from pubococcygeal line on straining), timing and type of surgery, outcomes and follow up.
Results: Ten patients (2 female) were identified. Median age at presentation was 11 years 1 month (range 8 – 15 years). Mean follow up was 3.4 years (range 1-5). Six had underlying gastrointestinal problems: constipation (4), post diarrhoeal illness (1) and eosiniophilic duodenitis (1). All patients had a dMRI performed. Nine out of 10 patients had a preoperative dMRI. Mean rectal prolapse from PC line on straining during dMRI was 2.86cm (range 1 – 4cm). Arbitrarily severe was defined as >3cm, moderate as 2-3cm, and mild as <2cm. Seven were defined as severe, 2 mild (1 did not strain in scanner), 1 had no dMRI pre first procedure. Ten patients had a total of 20 procedures. The average number of procedures was 2 (range 1-3). Submucosal injections (6), Trans‐abdominal rectopexies (6), posterior saggital rectopexy(1), delormes (5) and express procedures (2).
Of those undergoing delormes; preoperative dMRI findings were: severe (3) all required further surgery post delormes, mild (2) one has had no further problems post delormes, 1 did not strain in scanner (therefore findings may not be representative) he now needs repeat surgery. Six patients underwent transabdominal rectopexy. In those for whom this was first procedure (3): 2 had severe prolapse on dMRI, 1 had moderate prolapse. Three patients underwent transabdominal rectopexy as 2nd/3rd procedure all had severe prolapse on dMRI. The outcome for the patients undergoing transabdominal rectopexy (6) varied. Four had a good outcome, 1 had an express procedure at a later date, 1 patient currently has a rectal ulcer.
Conclusion: The combination of anatomical and functional information by dynamic MRI demonstrates why no one operation will deal completely with the problem of rectal prolapse. The information obtained on dMRI is an invaluable part of the pre – operative assessment. Dynamic MRI demonstrates pathophysiology of rectal prolapse and indicates type of surgery required. However, compliance with procedure in a child may be difficult.
Imaging of surgical complications following paediatric liver transplantation.
H Woodley1, T Humphrey1, C Smith2, R Prasad2
Department of Paediatric Radiology1 and Hepatobiliary Surgery2, Leeds Teaching
Aim: Surgical complications of orthotopic paediatric liver transplantation (OLT) are common. All children undergoing OLT at our institution are monitored post operatively with ultrasound and doppler imaging (DUS). Imaging is performed on days 1,2,3,5 and 7, at 1 month, 3 months and yearly unless otherwise clinically indicated. The aim of this review is to document the surgical complications of OLT detected by DUS.
Methods: A retrospective analysis of all OLT at our institution using case note analysis, results server and electronic image resources. Children with less than 3 months follow up were excluded.
Results: 123 children underwent 137 transplants over 10 years. Acute surgical complications correctly detected by DUS were; 8 hepatic artery stenoses, 7 hepatic artery thromboses, 3 biliary strictures, 2 portal vein thromboses and 1 hepatic vein stenosis. 8 examinations incorrectly predicted hepatic artery abnormality although only 1 of these children progressed to angiography. 5 examinations incorrectly predicted portal venous abnormality.
All except 1 complication in week 1 was detected by protocol ultrasound examination. 9 out of 37 USS performed between day 7 and 28 demonstrated significant abnormality. Longterm complications detected were; 13 biliary strictures, 11 portal vein stenoses, 5 hepatic vein stenoses, 4 hepatic artery stenoses, 1 hepatic artery thrombosis, 1 hepatic artery aneurysm, 2 portal vein thromboses and 1 splenic vein thrombosis. Long term complications occurred despite normal early ultrasound examinations.
Conclusion: Complications in paediatric OLT are common and accurately detected by DUS. The current post transplant imaging protocol in our institution identifies complications but deviation from the protocol is justified if there is clinical concern.
Pneumatic intussusception reduction, our experience
N Rao, N Broderick, K Halliday, J Somers
AIM: To compare our pneumatic intussusception reduction rate with the BSPR target and identify reasons for failed reduction.
METHOD: We retrospectively reviewed 39 patients admitted with intussusception to our tertiary centre from January 2006 – August 2010 inclusive. We identified patients and their radiology reports on our Radiology System Database. We also reviewed the clinical case notes for the clinical and surgical findings. 30 out of the 39 patients proceeded to a pneumatic reduction, 16 cases had a successful reduction. There were 2 cases that had a pneumoperitoeum post reduction. No other complications were identified????
FINDINGS: Our overall reduction rate was 53% which is below the BSPR goal target of >65-70%, but above the minimal target of 50%. The complication rate was 7% (2/30).
TREATMENT PATTERNS OF INTUSSUSCEPTION IN INFANCY: A NATIONAL,
Aim of the Study: To examine the clinical presentation, management and outcomes of intussusception ininfancy - the first national study on this condition, which remains one of the commonestcauses of intestinal obstruction in children.
Methods: Prospective, active surveillance of intussusception was carried out from 1 March 2008 to 31 March 2009. We collected data on intussusception presenting in the first year of life – both from paediatric surgeons and paediatricians. Patient data on socio-demographic characteristics were also collected via the study questionnaire completed by clinicians.
Main Results: 258 confirmed cases were identified in our national cohort. Two-thirds (65%) were boysand the median age was 6 months (interquartile range=4.2-8.5 months). Non-bilious vomiting was the commonest presentation (79%) followed by abdominal pain (75%), lethargy (71%) and rectal bleeding (56%). Amongst investigations, 137 (53%) cases had abdominal x-ray, which showed an intussusception in 32/137 (23%) cases. Abdominal ultrasound was used for diagnosis in 243 (94%) patients and had a sensitivity of 98% (237/243 patients detected).
Enema reduction was the first line of treatment for a majority of cases (238/258, 92%). Air enema was the commonest type of reduction performed (235/238 cases). The success rate of air enema reduction was 61% (143/235 patients). 112 of 258 cases (43%) required surgery, which included 92 infants following an unsuccessful air enema reduction. The median hospital stay was 72 hours (interquartile range=24-96 hours). Majority (237/257, 92.2%) of patients recovered fully, 19 (7.4%) had post-operativesequelae and there was one death (0.4%).
Conclusion: Abdominal ultrasound was the most sensitive investigation. Enema reduction was effective in under two-thirds of infants, which does not meet the national target of >65-70% successful reduction rate; a significant proportion required surgery. This study may be used as an indicator to improve performance variation in quality for paediatric surgeons and radiologists.
BSPR 2010 Poster Presentation Abstracts
Title: Prostatic utricle: Review of literature and multimodality imaging
Authors: Manubolu S; Broderick N
Purpose / Aim: The purpose of this exhibit is to review the literature and imaging appearances of the Prostatic Utricle: A rare paediatric diagnosis.
Methodology: Authors present a pictorial review of the multimodality imaging appearances of prostatic utricle from their patient group. Knowledge based on extensive literature search combined with authors experience has emphasized various aspects of prostatic utricle from embryology to management.
Summary: Prostatic utricle is a rare diagnosis in paediatric radiology. Familiarity with the multimodality imaging appearances of this diagnosis is vital in every day paediatric radiology practice. Knowledge of its anatomy and differential diagnosis is crucial as this is completely treatable entity when correctly diagnosed.
MRI vs Endoscopy in Paediatric IBD
P. Borg, T. Win, Sheffield Children’s Hospital
Aim & Background
To assess diagnostic accuracy of MRI in paediatric patients with suspected Inflammatory Bowel Disease; compared to endoscopic findings (gold standard) in patients at Sheffield Children’s Hospital.
Literature suggests MRI compared with endoscopy had a diagnostic accuracy of 90% indicating a good degree of concordance1.
13 patients who were investigated over a 12 month period between Oct ’08 and Nov ’09 with small bowel MRI for inflammatory bowel disease were identified using PACS software.
MRI small bowel technique used:
• Oral contrast (Kleanprep) 800mls
• Oral contrast is divided into 3 portions (e.g. 200ml 1 hour before scan, 200ml 30 minutes before scan, 200 mls on MRI table)
• IV Buscopan
(over 12 years old 20mg)
(Under 12 years old 0.3-0.6mg/kg)
• T2 FIESTA CORONAL
• T1 and T2 AXIAL breath hold
• Heavy T2 MRCP sequences
• T1 3D VOLUME fatsat pre and post contrast
• Sagittal T2 for ileo-caecal valve
Endoscopic findings were collected from patient’s clinical notes. The radiological findings were compared to endoscopic findings (gold standard) and the diagnostic accuracy of MRI was calculated.
Out of 13 patients who had a bowel MRI, 11 also had an endoscopy (OGD/Colonoscopy).
2 patients had no endoscopy and therefore findings could not be compared.
The average patient age was 14.6 years (range 9-16).There were 8 males and 5 females.
None of the 13 patients developed any serious side effects from the MRI investigation.
9 out of 11 (81%) had endoscopic findings which were concordant with MRI findings (of these 5 had active disease and 3 were normal). 2 out of 11 (19 %) had endoscopic findings which were different to MRI findings (1 reported disease on MRI and normal colonoscopy, 1 reported normal on MRI, but ulcers on colonoscopy).
The diagnostic accuracy of MRI in this series was 81%.
• MRI small bowel is a new technique in paediatric inflammatory bowel disease.
• Only 11 patients included in our study.
• Diagnostic accuracy is 81%, no radiation and is a less invasive procedure than endoscopy.
• Should MRI small bowel replace small bowel follow through?
MRI is a valuable tool for surveillance and monitoring effects of treatment in inflammatory bowel disease in combination with clinical signs and markers of inflammation.
1. Bowel magnetic resonance imaging of pediatric patients with oral mannitol MRI compared to endoscopy and intestinal ultrasound. Borthne AS, Abdelnoor M, Rugtveit J, Perminow G, Reiseter T, Kløw NE Eur Radiol. 2006 Aug;16(8):1870.
Paediatric breast masses- a retrospective review and pictorial presentation of our experience.
Findlay J, Landes C, Alder Hey Children’s Hospital.
Aim: To present the results and the sonographic findings of a 3 year retrospective review of all paediatric breast ultrasound performed at Alder Hey Children’s Hospital.
Also to present a pictorial review of our interesting cases and other less common pathological conditions.
Background: This review was performed to answer the question: Should paediatric breast ultrasound be performed in an adult breast unit rather than in a paediatric hospital?
Methods: 108 paediatric patients aged 11 days to 18 years were identified using our centricity system. The imaging and results were analysed
Results: 78 females, 30 males with a wide range of conditions were identified. These were grouped into age categories and our findings are presented schematically, with the interesting imaging presented.
The majority of the scans occurred during the pubescent period and were a result of normal variation in breast development or gynaecomastia in boys. Pathological masses included cystic lymphatic malformation, haemangioma, retroareolar cysts, abscess, galactoceles, fibroadenoma and early onset thelarche. No cases of malignancy or metastases were identified.
Conclusion: Paediatric breast ultrasound is an appropriate investigation and can be safely performed in the paediatric setting. Adult breast pathology is rare in the paediatric population and when identified should be referred to an adult hospital for further management.
49, XXXXY has a distinctive radiological phenotype
Amaka Offiah1, Christine M Hall2, Sarah F Smithson3
1. Department of Paediatric Radiology, Sheffield Children’s Hospital, Sheffield, UK
2. Formerly Department of Paediatric Radiology, Great Ormond Street Hospital for Children, London,
3. Department of Clinical Genetics, St Michael’s Hospital, Bristol, UK
We describe the clinical and radiological findings in 3 patients with the abnormal chromosome complement of 49, XXXXY. The patients were identified from retrospective review of radiological images from the Bristol Skeletal Dysplasia Registry. Available clinical information, cytogenetic data and radiographs were analysed and some common themes emerged.
All 3 patients had severe learning difficulties and were of short stature. Additional clinical findings, (not consistent in all 3), included dysmorphic facial features, kyphoscoliosis, coloboma, hypogonadism and diabetes mellitus.
The radiological findings were similar in the patients and are briefly summarised in Table 1.
Table 1: Radiological Findings in 3 Patients with the 49, XXXXY Chromosome Complement
Narrow bell-shaped thorax
Relatively long clavicles
Dislocated radial heads / elbows
Short terminal phalanges of the hands
Flexion deformities / subluxation small joints of hands / feet
Mild epiphyseal dysplasia
We illustrate the skeletal findings associated with 49, XXXXY in these patients and compare these with published cases. There are some striking features which have not previously been described. Investigation of other patients with this chromosome abnormality (and patients with 49 XXXXX) will be interesting to further delineate this apparently distinct radiological phenotype.