Ebook Diagnostic pediatric ultrasound: Part 1

(BQ) Part 1 book Diagnostic pediatric ultrasound presents the following contents: Examining the child and creating a child friendly environment, physics and artifacts, neonatal cranial ultrasonography, spine, neck, mediastinum, pleura and thorax, peritoneal cavity and retroperitoneal space, liver and biliary system.

To access additional material or resources available with this e-book, please visit http://www.thieme.com/bonuscontent After completing a short form to verify your e-book purchase, you will be provided with the instructions and access codes necessary to retrieve any bonus content TPS 23 x 31 - | 11.05.15 - 17:20 TPS 23 x 31 - | 11.05.15 - 17:20 TPS 23 x 31 - | 11.05.15 - 17:20 Diagnostic Pediatric Ultrasound Dr Erik Beek, MD, PhD Consulting Radiologist Department of Radiology Wilhelmina Children's Hospital University Medical Center Utrecht Utrecht, The Netherlands Prof Rick R van Rijn, MD, PhD Professor Department of Radiology Emma Children's Hospital Academic Medical Center Amsterdam, The Netherlands Foreword by Alan Daneman, BSc, MBBCh, FRANZCR, FRCPC 2,025 illustrations Thieme Stuttgart • New York • Delhi • Rio de Janeiro TPS 23 x 31 - | 11.05.15 - 17:20 Library of Congress Cataloging-in-Publication Data Diagnostic pediatric ultrasound / [edited by] Erik Beek, Rick R van Rijn p ; cm Includes bibliographical references and index ISBN 978-3-13-169731-8 (hardback) – ISBN 978-3-13-169741-7 (eISBN) I Beek, Erik, editor II Rijn, Rick R van, editor [DNLM: Ultrasonography–methods Child Infant WN 208] RJ51.U45 618.92'007543–dc23 2015006968 © 2016 by Georg Thieme Verlag KG Important note: Medicine is an ever-changing science undergoing continual development Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book Nevertheless, this does not involve, imply, or express any guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications stated in the book Every user is requested to examine carefully the manufacturers’ leaflets accompanying each drug and to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the contraindications stated by the manufacturers differ from the statements made in the present book Such examination is particularly important with drugs that are either rarely used or have been newly released on the market Every dosage schedule or every form of application used is entirely at the user’s own risk and responsibility The authors and publishers request every user to report to the publishers any discrepancies or inaccuracies noticed If errors in this work are found after publication, errata will be posted at www.thieme.com on the product description page Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not always made in the text Therefore, the appearance of a name without designation as proprietary is not to be construed as a representation by the publisher that it is in the public domain Thieme Publishers Stuttgart Rüdigerstrasse 14, 70469 Stuttgart, Germany +49 [0]711 8931 421, customerservice@thieme.de Thieme Publishers New York 333 Seventh Avenue, New York, NY 10001 USA +1 800 782 3488, customerservice@thieme.com Thieme Publishers Delhi A-12, Second Floor, Sector-2, Noida-201301 Uttar Pradesh, India +91 120 45 566 00, customerservice@thieme.in Thieme Publishers Rio, Thieme Publicaỗừes Ltda Edifớcio Rodolpho de Paoli, 25 andar Av Nilo Peỗanha, 50 – Sala 2508 Rio de Janeiro 20020-906, Brasil +55 21 3172 2297 / +55 21 3172 1896 Cover design: Thieme Publishing Group Typesetting by Thomson Digital, India Printed in China by Everbest Printing Ltd ISBN 978-3-13169-731-8 Also available as an e-book: eISBN 978-3-13169-741-7 54321 This book, including all parts thereof, is legally protected by copyright Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage | 11.05.15 - 09:43 Contents Video Contents xi Foreword xv Preface xvii Contributors xix Abbreviations xxi Examining the Child and Creating a Child-Friendly Environment Anne Smets 1.1 Child-Friendly Staff 1.6 Examination 1.2 Appointment 1.7 How to Scan: Tips and Tricks 1.3 Appointment Letter 1.8 Private Room 1.4 Waiting Area 1.9 Communicating the Results 1.5 Examination Room Recommended Readings Physics and Artifacts 10 Rob Peters 2.1 Basic Principles of Ultrasound 10 2.4 Resolution 16 2.1.1 2.1.2 2.1.3 2.1.4 Ultrasonic Waves Wave Propagation in Homogeneous Media Wave Propagation in Inhomogeneous Media Doppler Echo 10 10 10 12 2.4.1 2.4.2 2.4.3 Axial Resolution Lateral Resolution Elevational Resolution 16 16 17 2.5 Artifacts in Sonography 17 2.2 Echoscopic Image Construction 13 2.2.1 2.2.2 2.2.3 2.2.4 2.2.5 Amplitude Mode Brightness Mode Motion Mode Color Doppler Power Doppler 13 13 14 14 15 2.5.1 2.5.2 Artifacts in 2D Ultrasound Artifacts in Doppler Ultrasound 17 18 2.6 Advances in Echoscopic Image Construction 19 2.3 Transducers 15 2.6.1 2.6.2 2.6.3 Compound Imaging Harmonic Imaging Elastography 19 19 19 2.3.1 Types of Transducers 15 2.7 Biological Effects and Safety 20 Neonatal Cranial Ultrasonography 22 Gerda Meijler, Linda de Vries, and Handan Güleryüz 3.1 Ultrasound Anatomy of the Neonatal Brain 3.2 Maturational Changes and Distinction between Physiologic and Pathologic Echogenic Areas in the Neonatal Brain White Matter Deep Gray Matter 3.2.1 3.2.2 3.3 Timing of Examinations 31 3.4 Measurements 36 26 3.4.1 3.4.2 Ventricular Measurements Measurements of Cerebral Structures 36 38 26 31 3.5 Preterm Infants: Pathology 39 22 v | 11.05.15 - 09:43 Contents Pathology Congenital Abnormalities Recommended Readings 70 78 94 3.6 Term Infants Spine 98 3.5.1 3.5.2 3.5.3 3.5.4 Germinal Matrix–Intraventricular Hemorrhage Post-hemorrhagic Ventricular Dilatation White Matter Injury Focal Infarction 39 52 60 64 70 3.6.1 3.6.2 Samuel Stafrace and Erik Beek 4.1 Embryology 98 4.4 Pathology 103 4.1.1 Ascensus Medullaris 99 4.2 Technique of Spinal Ultrasound 99 4.4.1 4.4.2 4.4.3 4.4.4 4.3 Normal Sonographic Anatomy 100 Non–Skin-Covered Back Masses: Open Lesions Skin-Covered Back Masses: Closed Lesions Occult/Closed Lesions without a Mass Sacral Dimple Recommended Readings 103 104 107 113 113 4.3.1 Normal Variants 102 Neck 116 Erik Beek 5.1 Normal Anatomy and Variants 116 5.2 Pathology 119 119 120 124 5.2.4 5.2.5 5.2.6 5.2.7 5.2.8 5.2.9 5.2.1 5.2.2 5.2.3 Vessels of the Neck Cystic Lesions Hemangiomas and Vascular Malformations Pilomatrixoma Solid Tumors Thyroid Gland Salivary Glands Thymus Miscellaneous Lesions Recommended Readings 127 127 137 138 143 145 151 Mediastinum 154 Ingmar Gassner and Gisela Schweigmann 6.1 Normal Anatomy and Variants 154 6.1.1 6.1.2 6.1.3 6.1.4 Thymus Trachea Esophagus Heart and Great Vessels 154 157 157 157 6.2 Pathology 6.2.1 Thymus Pleura and Thorax 6.2.2 6.2.3 6.2.4 6.2.5 Trachea Esophagus Congenital Vascular Anomalies Mediastinal Masses 159 159 163 170 6.3 157 Mediastinal Ultrasound in Intensive Care: Complications Associated with Central Venous Access 177 157 Recommended Readings 179 182 Joost van Schuppen and Rick R van Rijn vi 7.1 Indications for Ultrasonography 183 7.3 Pathology 186 7.2 Anatomy and Normal Variants 183 7.2.1 7.2.2 7.2.3 7.2.4 7.2.5 Thoracic Wall Pleura Lungs Breast Diaphragm 183 184 184 184 186 7.3.1 7.3.2 7.3.3 7.3.4 7.3.5 Chest Wall Pleural Space Lungs Breast Diaphragm Recommended Readings 186 200 202 202 208 211 | 11.05.15 - 09:43 Contents Peritoneal Cavity and Retroperitoneal Space 214 Rick R van Rijn 8.1 Normal Anatomy 214 8.2 Pathology 215 215 219 221 8.2.4 8.2.5 8.2.6 8.2.7 8.2.8 8.2.1 8.2.2 8.2.3 Abdominal Vessels Lymphadenopathy Intraperitoneal Fluid Collections Peritonitis Pneumoperitoneum Peritoneal Tumors Retroperitoneal Tumors Cystic Congenital Anomalies Recommended Readings 225 229 229 234 238 243 Liver and Biliary System 246 Rick R van Rijn and RAJ Nievelstein 9.1 Normal Anatomy and Variants 246 9.2 Normal Measurements 249 9.2.1 9.2.2 9.2.3 Portal Venous Flow Hepatic Arterial Flow Hepatic Venous Flow 249 249 249 249 9.3.1 9.3.2 9.3.3 9.3.4 9.3.5 9.3.6 9.3.7 9.3 Pathology Congenital Anomalies Infection Acquired Biliary Pathology Trauma Tumors Pneumobilia Miscellaneous Conditions Recommended Readings 249 258 266 287 292 317 317 321 10 Spleen 324 Samuel Stafrace 10.1 Normal Anatomy and Variants 324 10.2 Pathology 332 10.1.1 10.1.2 10.1.3 10.1.4 10.1.5 10.1.6 10.1.7 Embryology Anatomical Considerations Technique and Normal Ultrasound Appearances Echogenicity and Changes in Echogenicity with Age Vascularity Normal Variants Normal Splenic Size 324 324 325 325 327 327 331 10.2.1 10.2.2 10.2.3 Abnormalities of Location and Number Abnormalities of Size Traumatic Injury of the Spleen 332 335 348 10.3 Acknowledgements 354 Recommended Readings 358 11 Pediatric Intestinal Ultrasonography 360 Simon Robben 11.1 Esophagus 360 11.6.1 Other Causes of Colitis 394 11.2 Gastroesophageal Junction 363 11.7 Rectum 397 11.3 Stomach 364 11.8 Anus 397 11.4 Small Bowel 367 11.9 Neonatal Bowel Obstruction 403 11.5 Appendix 387 11.10 Conclusion 412 11.6 Large Bowel 393 Recommended Readings 412 12 Pancreas 416 Maria Raissaki and Marina Vakaki 12.1 Examination Technique 416 12.3 Pathology 426 12.2 Normal Anatomy, Variants, and Pseudo-lesions 417 12.3.1 12.3.2 Developmental Anomalies Pancreatitis 426 428 vii | 11.05.15 - 09:43 Contents 12.3.3 12.3.4 Inherited Disorders Neoplasms 13 Kidneys 436 440 12.3.5 Recommended Readings Cystic Masses 444 449 452 Maria Beatrice Damasio, Ann Nystedt, Lil-Sofie Ording Muller, and Giorgio Pioggio 13.1 Normal Anatomy and Variants 452 13.8 Renovascular Disease 481 13.1.1 13.1.2 13.1.3 Kidneys Ureters Bladder 452 455 456 13.8.1 13.8.2 Renal Artery Stenosis Renal Vein Thrombosis 481 482 13.9 Parenchymal Nephropathy 485 13.2 Congenital Anomalies of the Kidney and the Urinary Tract 456 13.2.1 13.2.2 13.2.3 13.2.4 13.2.5 13.2.6 Renal Hypodysplasia Ureteropelvic Junction Stenosis Ureterovesical Junction Stenosis Ureterovesical Reflux Duplicate Collecting System Horseshoe Kidney 457 457 457 457 460 461 13.9.1 13.9.2 13.9.3 13.9.4 Glomerular Nephropathies Tubular Nephropathies Interstitial Nephropathies Vascular Nephropathies 487 487 488 489 13.10 Renal Trauma 490 13.10.1 Renal Trauma Grading 491 13.3 Urolithiasis and Nephrocalcinosis 464 13.11 Pediatric Renal Transplantation 491 13.4 Kidney Cysts and Cystic Nephropathies 467 491 491 13.5 Autosomal-Dominant Polycystic Kidney Disease 469 13.11.1 Early Postoperative Assessment 13.11.2 Differential Diagnosis of Early Graft Dysfunction 13.11.3 Differential Diagnosis of Long-Term Graft Dysfunction and Imaging Aspects 496 13.12 Bladder and Urethra 500 13.5.2 13.5.3 13.5.4 13.5.5 13.5.6 13.5.7 Autosomal-Recessive Polycystic Kidney Disease Nephronophthisis Glomerulocystic Disease Medullary Sponge Kidney Disease Multicystic Kidney Disease Simple Cysts Complicated Cysts 470 472 472 472 472 473 473 13.12.1 13.12.2 13.12.3 13.12.4 13.12.5 13.12.6 13.12.7 Congenital Bladder Anomalies Urethral Anomalies Utricle Urachal Anomalies Calculi Infection Neoplasm 500 502 503 503 504 504 504 13.6 Renal Tumors 474 13.13 Contrast-Enhanced Cystosonography 506 13.6.1 13.6.2 Malignant Tumors Benign Tumors 474 478 Recommended Readings 509 13.7 Urinary Tract Infection 480 14 Adrenal Glands 512 13.5.1 Claire Gowdy and Annie Paterson viii 14.1 Embryology of the Adrenal Glands 512 14.2 Normal Anatomy 512 14.3 Normal Sonographic Appearance 512 14.4 Normal Variants 513 14.5 Pathology 514 14.5.1 Neonatal Adrenal Hemorrhage 514 14.5.2 Adrenal Hemorrhage in the Older Child 14.5.3 Adrenal Cysts 14.5.4 Adrenal Abscesses 14.5.5 Congenital Adrenal Hyperplasia 14.5.6 Adrenal Hyperplasia in Older Patients 14.5.7 Adrenal Hypoplasia 14.5.8 Medullary Tumors: Neurogenic Tumors 14.5.9 Medullary Tumors: Pheochromocytoma 14.5.10 Adrenal Cortical Tumors 514 514 517 517 518 518 519 520 520 | 11.05.15 - 18:13 Liver and Biliary System In most cases, fibrolamellar carcinoma presents with relatively few clinical findings The most common of these are malaise and weight loss A rare clinical presentation is gynecomastia as a result of conversion of androgens to estrogens by aromatases produced by the tumor On US imaging, a mostly heterogeneous solitary tumor is seen surrounded by normal liver parenchyma (▶ Fig 9.87) In a significant proportion of tumors, a central scar is noted, and differentiation from focal nodular hyperplasia is therefore of the utmost importance The tumor may show calcifications, most commonly in the region of the central scar Liver Metastases Fig 9.85 With the use of a high-frequency linear probe, the arterial supply of a hepatoblastoma is well visualized ( Video 9.85) (Courtesy of D Roebuck, Great Ormond Street Children’s Hospital, London, United Kingdom.) The two main tumors of childhood that metastasize to the liver are Wilms tumor (▶ Fig 9.88) and neuroblastoma (▶ Fig 9.89; ▶ Fig 9.90; Video 9.90) However, any other solid tumor can present with liver metastases, and differentiation among the various underlying malignancies based on imaging is not possible (▶ Fig 9.91, ▶ Fig 9.92, ▶ Fig 9.93) Fig 9.86a–d Seventeen-year-old boy with hepatocellular carcinoma a Ultrasound shows a homogeneous hypoechoic solid tumor in segment of the liver b Color Doppler shows displacement of the middle hepatic vein (arrow) The tumor does not invade the hepatic vein c On arterial-phase contrast-enhanced computed tomography, the lesion is hyperdense because of the arterial vascularization d Twenty minutes after the administration of Primovist, the lesion is well demarcated from the surrounding normal hepatic tissue 308 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.87a–e Seventeen-year-old boy presenting with weight loss a Ultrasound shows a large heterogeneous tumor in the right liver lobe b Small foci of calcification are spread throughout the tumor c Some large calcifications are visible d Noncontrast computed tomography shows a scar in the liver parenchyma overlying the tumor (arrow) Multiple calcifications are seen e On T2-weighted magnetic resonance imaging, the lesion has a heterogeneous, slightly increased signal intensity These imaging findings are suspicious of fibrolamellar carcinoma 309 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.88 Five-year-old girl with a recurrent Wilms tumor 1/2 years after the initial diagnosis Computed tomography shows multiple metastases in all liver segments (study performed at an outside hospital; ultrasound not available for review) Fig 9.89a,b Six-month-old girl with neuroblastoma and liver metastases a Note the discrete hypoechoic lesion b T1-weighted magnetic resonance imaging after gadolinium shows enhancement of the liver metastasis (arrow) The primary tumor is in a left paravertebral location (open arrow) 310 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.90a,b Eleven-month-old boy with massive retroperitoneal neuroblastoma (see also ▶ Fig 8.42) a Ultrasound shows multiple discrete hypoechoic lesions b T2-weighted magnetic resonance imaging shows multiple lesions in all liver sections The primary tumor is in a retrocrural (arrow), retroperitoneal location and extends into the pelvis ( Video 9.90) In general, liver metastases appear on US as discrete hypoechoic lesions, but this is not always the case Neuroblastoma metastases can show calcifications (▶ Fig 9.94), and they can also present as a single large heterogeneous lesion that can be mistaken for a primary liver tumor Although leukemia is not, in the strictest sense, a metastatic disease, it can also involve the liver In the majority of cases, the liver shows a homogeneous, often slightly hyperechoic, parenchyma with clear hepatomegaly (▶ Fig 9.95) However, focal hypoechoic lesions can also been seen in these patients (▶ Fig 9.96) Malignant Tumors of the Gallbladder and Biliary Tract Fig 9.91 Ultrasound of an 18-year-old boy shows numerous diffusely distributed calcified lesions This boy had a history of medullary thyroid gland carcinoma Pathologic examination revealed that these lesions represented metastatic disease Malignant tumors of the gallbladder and biliary tract in children are very rare Although rhabdomyosarcoma (approximately 20% of all cases of which are encountered outside the head and neck region, genitourinary tract, or extremities) is the most common tumor of the biliary tree, it accounts for only approximately 0.04% of all childhood tumors The most common presenting symptom is jaundice and abdominal pain On US, a solid lesion is seen in the liver hilum, and in most cases dilatation of the intrahepatic bile duct is present at diagnosis MR imaging, including MRCP, is mandatory for presurgical evalVideo 9.98) Although rare, uation (▶ Fig 9.97; ▶ Fig 9.98; peritoneal metastases occur 311 | 11.05.15 - 18:13 Fig 9.92a,b Six-year-old boy with Ewing sarcoma a Ultrasound shows a large, partially calcified lesion in the right liver lobe b Contrast-enhanced computed tomography shows a partly necrotic liver metastasis (arrow) 312 Fig 9.93a–c Three-month-old boy with multiple locations of myofibroma a Ultrasound (US) of the liver with a high-frequency linear probe shows several circumscribed hypoechoic lesions b US shows a circumscribed hypoechoic subcapsular lesion in the right liver lobe (between the markers) c Coronal STIR (short T1 inversion recovery)–weighted magnetic resonance imaging shows the geographic distribution of the lesions | 11.05.15 - 18:13 Liver and Biliary System Fig 9.94a,b One-year-old girl with neuroblastoma arising from the right adrenal gland a Ultrasound shows the primary tumor (asterisk) and a relatively well-demarcated liver metastasis (arrow) b In the same patient, the liver shows diffuse metastatic disease Scattered microcalcifications are seen within the metastases Fig 9.95a,b Five-year-old girl with acute lymphoblastic leukemia a Ultrasound shows an enlarged liver without focal parenchymal changes b The liver has a homogeneous parenchyma 313 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.96a,b One-month-old girl with infantile acute lymphoblastic leukemia a The liver is enlarged; exact measurement not possible on ultrasound (normal upper limit is 9.0 cm) b Multiple focal hypoechoic lesions are seen throughout the liver (arrow) 314 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.97a–f Eight-year-old boy with abdominal pain and jaundice a Abdominal ultrasound (US) shows a large, hypoechoic, slightly heterogeneous tumor in the liver hilum b The tumor extends to the level of the pancreas There are some dilated intrahepatic bile ducts (arrow) c Dilated bile ducts are visible; note the “tram tracking” or “double barrel” sign (arrow) d T2weighted MRI shows the tumor, with high signal intensity, situated within the liver hilum The dilated intrahepatic bile ducts are shown (arrow) e Because of jaundice, endoscopic retrograde cholangiopancreatography (ERCP) was performed; a narrow and irregular common bile duct is visible Intrahepatic bile duct dilatation, mainly in the right liver lobe, is clearly visible f US after stent placement The stent is clearly visible (arrow) In cases of suspected stent obstruction or dislocation, US is the first imaging method of choice The imaging findings are characteristic for rhabdomyosarcoma of the biliary tract 315 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.98a–e Two-year-old boy, transferred from an outside hospital, with a history of failure to thrive, weight loss, and jaundice In the referring hospital, a mass in the liver hilum was seen a Abdominal ultrasound shows a hypoechoic tumor in the liver hilum b Sagittal view shows an elongated aspect of the tumor c The common bile duct is dilated (arrow) and obstructed by the tumor d Color Doppler imaging is useful in demonstrating dilated intrahepatic bile ducts e Coronal T2-weighted magnetic resonance imaging shows the extent of the tumor with a close relation to the portal vein (arrow), dilatation of the gallbladder (asterisk), and dilatation of the intrahepatic bile ducts (open arrow) The imaging findings are characteristic for rhabdomyosarcoma of the biliary tract ( Video 9.98) 316 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.99a–c a One-month-old premature neonate with necrotizing enterocolitis, plain abdominal radiograph shows intestinal pneumatosis b US shows air in the portal system The ring down artefact is visible c US shows air in the portal system, note the linear distribution (arrow) Video 9.99 US shows air in the portal system 9.3.6 Pneumobilia 9.3.7 Miscellaneous Conditions Pneumobilia is the presence of air in the biliary tree, and it should be distinguished from portal venous air On imaging, the air, like portal venous air, appears as small hyperechoic foci in the liver However, in pneumobilia the air does not move and is seen mainly in the periphery of the liver In children, pneumobilia may develop after ERCP (▶ Fig 9.99), in association with incompetence of the sphincter of Oddi, and after biliary–enteric anastomoses (▶ Fig 9.100) Portal Venous Air With the increasing quality of US systems, the detection of portal venous air is no longer limited to severely ill children In neonates, the clinically most important and severe cause of portal air is Bell stage IIb or higher necrotizing enterocolitis Videos 9.99 and (▶ Fig 9.101, ▶ Fig 9.102, ▶ Fig 9.103; 9.101) However, portal venous air can also be encountered 317 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.100a,b a One-month-old premature neonate with necrotizing enterocolitis, plain abdominal radiograph shows intestinal pneumatosis and air in the portal venous system (arrow) b US shows air in the portal system Fig 9.101 Two-month-old neonate with a complex cardiac congenital anomaly and necrotizing enterocolitis Ultrasonography of the upper abdomen shows branching echogenic foci in the periphery of the liver parenchyma (arrow), consistent with air bubbles in the portal vein Video 9.101 Movie shows motion of air bubbles in the branches portal vein branches 318 | 11.05.15 - 18:13 Fig 9.102a–c a Female premature with antenatal CMV infection, a routine abdominal US on the NICU ward was requested by the attending neonatologist The liver shows a normal parenchyma b During the US exam the NICU nurse flushed the venous umbilical line On US of the liver iatrogenic portal air was directly seen c Intravascular air, as a result of retrograde flow during flushing, is even visible within the spleen Fig 9.103a,b a Seven-year-old male with primary sclerosing cholangitis An ERCP with stent placement was performed b Abdominal US performed after the ERCP shows pneumobilia (arrow) 319 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.104a,b a Nine-year-old girl, year after hemi-hepatectomy for hepatoblastoma A hepatico-jejunostomy is present and air is visible within the biliary tract This should be an expected finding b Color Doppler shows that the air is indeed within the biliary tree and not within the portal venous system Fig 9.105a,b Three-week-old boy On antenatal ultrasound (US), hepatic calcification was detected a Postnatal US (sagittal view) confirms the presence of three discrete liver calcifications (between the calipers) Further work-up revealed no abnormalities b On this image of the intrahepatic calcifications, the acoustic shadow (arrow) is better appreciated 320 | 11.05.15 - 18:13 Liver and Biliary System Fig 9.106a,b One-day-old neonate, a On plain abdominal radiography, discrete calcifications over the liver region are noted (arrow) b Ultrasound shows parenchymal calcifications (arrow) and calcifications on the surface of the liver (open arrow) Further work-up revealed no abnormalities after placement of an umbilical venous line (▶ Fig 9.102) and in gastroenteritis, and it has been described as an incidental finding in pyloric hypertrophy It can be also be encountered in older children with neutropenic enterocolitis On US, portal venous air is detected as small, hyperechoic moving foci, with a ring-down artifact, within the portal venous system On Doppler US, sharp spikes in the spectral pattern are seen and heard Tips from the Pro ● After stent placement in the biliary tract, the absence of air within the biliary tract is a sign of potential stent obstruction Neonatal Liver Calcifications In the neonate, liver calcifications can be a rare chance finding that is more often encountered on antenatal than on postpartum US (▶ Fig 9.105 and ▶ Fig 9.106) If neonatal liver calcification is encountered, the child should be evaluated for congenital malformations, chromosomal anomalies, and congenital viral infections (including rubella, toxoplasmosis, and herpes simplex) If these causes are excluded, the outcome in general is good There are no set guidelines for routine follow-up imaging Recommended Readings Akata D, Akhan O Liver manifestations of cystic fibrosis Eur J Radiol 2007; 61: 11– 17 Behr GG, Johnson CM Vascular Anomalies: Hemangiomas and Beyond–Part FastFlow Lesions AJR 2013; 200: 414–422 Behr GG, Johnson CM Vascular anomalies: hemangiomas and beyond—Part 2, Slowflow lesions AJR Am J Roentgenol 2013; 200: 423–436 Bronshtein M, Blazer S Prenatal diagnosis of liver calcifications Obstet Gynecol 1995; 86: 739–743 Görg C, Riera-Knorrenschild J, Dietrich J Pictorial review: Colour Doppler ultrasound flow patterns in the portal venous system Br J Radiol 2002; 75: 919–929 Catalano OA, Singh AH, Uppot RN, Hahn PF, Ferrone CR, Sahani DV Vascular and biliary variants in the liver: implications for liver surgery Radiographics 2008; 28: 359–378 Chaudry G, Navarro OM, Levine DS, Oudjhane K Abdominal manifestations of cystic fibrosis in children Pediatr Radiol 2006; 36: 233–240 Chavhan GB, Parra DA, Mann A, Navarro OM Normal Doppler spectral waveforms of major pediatric vessels: specific patterns Radiographics 2008; 28: 691–706 Colombo C Liver disease in cystic fibrosis Curr Opin Pulm Med 2007; 13: 529–536 De Bruyne R, Van Biervliet S, Vande Velde S, Van Winckel M Clinical practice: neonatal cholestasis Eur J Pediatr 2011; 170: 279–284 Ferri PM, Ferreira AR, Fagundes ED, Liu SM, Roquete ML, Penna FJ Portal vein thrombosis in children and adolescents: 20 years experience of a pediatric hepatology reference center Arq Gastroenterol 2012; 49: 69–76 Fletcher BD, Magill HL Wheel-within-a-wheel patterns in hepatosplenic infections Radiology 1988; 169: 578–579 Franchi-Abella S, Branchereau S, Lambert V et al Complications of congenital portosystemic shunts in children: therapeutic options and outcomes J Pediatr Gastroenterol Nutr 2010; 51: 322–330 Goyal N, Jain N, Rachapalli V, Cochlin DL, Robinson M Non-invasive evaluation of liver cirrhosis using ultrasound Clin Radiol 2009; 64: 1056–1066 Horton JD, San Miguel FL, Membreno F et al Budd–Chiari syndrome: illustrated review of current management Liver Int 2008; 28: 455–466 Humphrey TM, Stringer MD Biliary atresia: US diagnosis Radiology 2007; 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108: 82–91 321 | 11.05.15 - 18:13 Liver and Biliary System Mortelé KJ, Segatto E, Ros PR The infected liver: radiologic-pathologic correlation Radiographics 2004; 24: 937–955 Nievelstein RA, Robben SG, Blickman JG Hepatobiliary and pancreatic imaging in children-techniques and an overview of non-neoplastic disease entities Pediatr Radiol 2011; 41: 55–75 Roebuck DJ, Aronson D, Clapuyt P et al International Childrhood Liver Tumor Strategy Group 2005 PRETEXT: a revised staging system for primary malignant liver tumours of childhood developed by the SIOPEL group Pediatr Radiol 2007; 37: 123–132, quiz 249–250 Roebuck DJ, Yang WT, Lam WW, Stanley P Hepatobiliary rhabdomyosarcoma in children: diagnostic radiology Pediatr Radiol 1998; 28: 101–108 322 Rozel C, Garel L, Rypens F et al Imaging of biliary disorders in children Pediatr Radiol 2011; 41: 208–220 Schneider BL Portal hypertension in liver disease in children In: Suchy FJ, Sokol RJ, Balistreri WF, eds Shannon A, Alkhouri N, Carter-Kent C et al Ultrasonographic quantitative estimation of hepatic steatosis in children With NAFLD J Pediatr Gastroenterol Nutr 2011; 53: 190–195 Sola JE, Cheung MC, Yang R et al Pediatric FAST and elevated liver transaminases: An effective screening tool in blunt abdominal trauma J Surg Res 2009; 157: 103–107 ... TPS 23 x 31 - | 11 .05 .15 - 17 :20 TPS 23 x 31 - | 11 .05 .15 - 17 :20 TPS 23 x 31 - | 11 .05 .15 - 17 :20 Diagnostic Pediatric Ultrasound Dr Erik Beek, MD, PhD Consulting Radiologist Department of... Variants 324 10 .2 Pathology 332 10 .1. 1 10 .1. 2 10 .1. 3 10 .1. 4 10 .1. 5 10 .1. 6 10 .1. 7 Embryology Anatomical Considerations ... Complicated Cysts 470 472 472 472 472 473 473 13 .12 .1 13 .12 .2 13 .12 .3 13 .12 .4 13 .12 .5 13 .12 .6 13 .12 .7 Congenital Bladder Anomalies Urethral Anomalies