(BQ) Part 2 book Pediatric ultrasound presents the following contents: Ultrasound of the chest, liver and bile system, spleen and pancreas, us of the gastrointestinal (GI) tract, ultrasound of the urogenital tract, small part and hip ultrasound.
6 Ultrasound of the Chest Michael Riccabona Contents 6.1 Requisites 6.1.1 Transducers 6.1.2 Positioning 6.1.3 Indications 6.1.4 How to Perform Chest US 6.2 Normal Findings 6.2.1 Chest Wall 6.2.2 Breast 6.2.3 Pleural Space 6.2.4 Diaphragm 6.2.5 Lung 6.2.6 Mediastinum 6.2.7 CDS 6.3 Pathology of Chest Wall 6.3.1 Aplasia, Variations of Ribs 6.3.2 Congenital Malformations 6.3.3 Traumatic Changes 6.3.4 Chest Wall Tumours 6.3.5 Breast 6.3.6 Role of US and Additional Imaging 6.4 Pathology of Pleural Space 6.4.1 Pleural Effusion 6.4.2 Empyema 6.4.3 Other Pleural Pathology 6.4.4 Role of Imaging 6.5 Pathology of Diaphragm 6.5.1 Diaphragmatic Hernia 6.5.2 Diaphragmatic Motion Disturbance 6.5.3 Role and Potential of Imaging 190 190 190 190 191 191 191 191 192 192 192 193 195 195 195 195 195 196 196 198 198 198 198 200 200 201 201 202 202 M Riccabona Division of Pediatric Radiology, Department of Radiology, University Hospital Graz, Auenbruggerplatz 3, Graz 8036, Austria e-mail: michael.riccabona@klinikum-graz.at M Riccabona, Pediatric Ultrasound, DOI 10.1007/978-3-642-39156-9_6, © Springer Berlin Heidelberg 2014 189 190 Ultrasound of the Chest 6.6 Lung Pathology 6.6.1 Pneumonia 6.6.2 Lung Abscess 6.6.3 Atelectasis 6.6.4 Respiratory Distress Syndrome (RDS)/Hyaline Membrane Syndrome 6.6.5 Sequestration 6.6.6 Congenital Cystic Adenomatoid Malformation (CCAM) 6.6.7 Cysts 6.6.8 Infarction 6.6.9 Tumours and Space-Occupying Lesions 6.7 Other Miscellaneous and Rare Applications 6.7.1 US for Interstitial Lung Disease 6.7.2 US for Pneumothorax 6.8 Additional Imaging 6.1 Requisites 6.1.1 Transducers 203 203 203 204 205 206 207 207 208 210 210 210 211 211 Chest Wall High-resolution linear arrays, plenty of US gel (stand-off pad sometimes helpful) Deeper Structures Sector and curved linear arrays – small surface helpful to properly insonate through intercostal space for sufficient penetration into deeper structures Frequency depends on age and depth of targeted structure 6.1.2 Positioning Depends on area of interest: prone, supine, decubitus • For jugular access extend head and neck, potentially put pillow below shoulders NOTE: For standardised assessment and measurement of pleural effusions standardised upright positioning (sitting) helpful – also improves comparability with chest radiographs 6.1.3 Indications • Pleural and pericardial effusions • Equivocal opacities on plain film – e.g tumour, malformation, cyst, pneumonia and effusion • Diaphragm and diaphragmatic motion 6.2 Normal Findings 191 • Pathology of chest wall (soft tissue, cartilage, breasts etc.) • Assessment of mediastinal structures – Particularly thymus, central vessels • Echocardiography addressed separately (see Chap 5) 6.1.4 How to Perform Chest US For large vessels: typical cardiologic planes • Jugular, parasternal and intercostal access For other chest areas: • Upper abdomen with transdiaphragmatic access through liver and spleen • Subxiphoid access • Jugular access • Intercostal access NOTE: In neonates and infants, ossification of chest wall is not completed – access through cartilaginous parts of sternum and ribs Documentation: Basic minimum documentation of all scanned areas is advisable, even if normal If lesion, image in longitudinal and axial sections: • Additional sections should be obtained if necessary and with pathology • Try to document all relevant structures with some neighbouring reference structure • Proper labelling, potentially using pictograms, is extremely helpful NOTE: Even if only chest US is requested, orienting overview of cardiac structures or potential effusion (and upper abdominal “sonoscope” – brief survey of particularly upper abdomen) is helpful Detailed course of investigation depends on individual query 6.2 Normal Findings 6.2.1 Chest Wall Below typical multilayer structures of skin and subcutaneous tissue, large chest and intercostal muscles seen Ribs seen as echogenic surfaces with shadowing in ossified parts, hypoechoic in cartilaginous aspects (see Fig 1.8): • Continuity of ribs/sternum easy to follow, subtle alterations depictable – helpful for diagnosis of fractures/fissures – to be differentiated from physiologic gaps such as additional ossification centres, syndesmoses or synchondroses Below chest wall: • Echogenic surface – reverberation echoes caused by air-filled lungs • In more medial position – cardiac and mediastinal structures 192 6.2.2 Ultrasound of the Chest Breast Breast appearance varies with age, depending on hormonal status: • Neonatally breast tissue seen, may appear large, eventually regresses • In (pre)puberty breast tissue increases, typical change in echotexture • Eventually typical adult breast US features NOTE: Some minimal breast tissue even in male neonates physiologic; thereafter no breast tissue should be seen at any stage of development in boys 6.2.3 Pleural Space Usually pleural space not accessible by US Visualisation of both pleural sheets only achieved by high-resolution linear arrays if some effusion present NOTE: The two pleural surfaces move independently from each other 6.2.4 Diaphragm Seen as un-/hypoechoic muscular structure – particularly at origin and insertion Majority of diaphragm usually only indirectly visible – by aerated lung surface: • Movement/shape of diaphragm assessed using this pseudosurface • With pleural effusion, even smaller parts of diaphragm visible • Documentation of diaphragmatic motion: M-Mode, video clip (Fig 6.1) 6.2.5 Lung Normal lung is aerated and only seen indirectly by surface (echogenic structure with reverberation echoes that change with respiration) • Parts beyond aerated lung surface not visualised NOTE: As soon as US can penetrate lung tissue, some pathology must be expected (e.g atelectasis, consolidation, effusion, other non-aerated space-occupying process) Respiratory motion of lung surface used to differentiate normal aerated lung from pneumothorax, where no motion of reflecting surface/air space can be noted: • Also seen in air-filled bronchogenic cysts and severe obstructive hyperinflation • Documentation by video clip or M-Mode Basal parts of lungs best seen by transabdominal access: • Should be part of any standard abdominal US (as effusion, atelectasis and pneumonia may cause abdominal complains, particularly in young children) 6.2 Normal Findings a 193 b c Fig 6.1 Diaphragm and diaphragmatic motion: (a) Normal diaphragmatic respiratory motion on M-Mode – the echogenic border represents air-filled base of lung, not diaphragm itself, the inhomogeneous spots are minimal peripheral atelectatic areas (b) No diaphragmatic motion, conspicuously documented by M-Mode, after surgery and postoperative pleural effusion in diaphragmatic palsy (c) M-Mode under respirator therapy: M-Mode trace reflects effect of mechanical ventilation and not patients’ own respiratory motion 6.2.6 Mediastinum 6.2.6.1 Anterior Mediastinum/Thymus Mainly Thymus (Fig 6.2): • Physiologically large in neonates, then eventually regresses • Shape and size variable • Echogenicity: hypoechoic, mixed, with some septa (“dot-dash pattern”) • Behaviour of soft tissue: not compressing or displacing other structures, particularly vessels • Size of thymus difficult to assess, reliable age-related normal values not available • CDS: some internal vascularity Value of US: • Differentiate from other mediastinal or chest masses (unclear opacification on chest film) • Demonstrate normal echogenicity and behaviour in relation to surrounding structures of a large thymus • Additionally: ideal acoustic window to deeper structures NOTE: Large thymus at unusual age may point at diffuse infiltration or thymus hyperplasia; infiltration and tumours will cause increased stiffness and thus subsequent impression or displacement of surrounding structures or crossing vessels 6.2.6.2 Middle Mediastinum Contains – among others – large vessels, trachea, potential nodes may be visualised by US (Fig 6.3): • Particularly feasible in neonates and infants 194 a b c b d Ultrasound of the Chest Fig 6.2 Thymus: (a) Anterior mediastinum, axial section, linear transducer: Large neonatal thymus, serving as window to deeper structures such as the great vessels Note non-ossified sternum with central ossification centre (b) Sagittal section, anterior and middle mediastinum, linear transducer in trapezoid format, paramedian view: Large neonatal thymus Note anechoic non-ossified parts of ribs and large, uncompressed vessels; behind one can see a feeding tube in the oesophagus (c) Left anterior mediastinum, axial section, sector transducer: Enlarged thymus with inhomogeneous echogenicity in a child with Hodgkin lymphoma (d) Right anterior mediastinum, axial section, linear transducer in trapezoid format: US in mediastinitis, abscess-like pseudotumorous inflammatory lesions with nodular appearance in the mediastinum Fig 6.3 Middle mediastinum: vessels and lymph nodes Parasternal (jugular) sagittal view, sector transducer: thoracic aortic arch, supra-aortic vessels, two enlarged mediastinal lymph nodes (dotted circular lines) 6.3 Pathology of Chest Wall 195 • Large space-occupying lesions, tumours or lymph node enlargement visible • Anatomy of large vessels addressed with echocardiography 6.2.6.3 Posterior Mediastinum Difficult to visualise by US Usually anterior access supplemented by posterior paravertebral access Used for assessing tumours, particularly neuroblastoma 6.2.7 CDS Except for assessment of vessels, CDS not very useful in normal situation Indications for chest CDS for DDx in pathology mostly of the lung: e.g abscess or necrosis, tumour vascularisation, vascular malformations, suspected particularly peripheral pulmonary artery embolism (PAE, resemble triangular subpleural pneumonic areas without depictable vascularistion), etc 6.3 Pathology of Chest Wall 6.3.1 Aplasia, Variations of Ribs Quite common, cartilaginous part nicely assessed by US, wide range of rib anomalies: • 3DUS reconstructions improve understanding and visualisation (see Fig 1.34) • Plain film: US complements plain film 6.3.2 Congenital Malformations Vascular malformations (lymphangioma, haemangioma), other soft tissue masses – see below: • Reflect typical US appearance elsewhere (see Chaps 4, 8, and 11) 6.3.3 Traumatic Changes Fractures of ribs and sternum: see musculoskeletal US (Chap 11): • Particularly in cartilaginous parts and sternum – US may be superior to plain film, where these structures are difficult to assess if not significantly displaced NOTE: Follow entire structure in longitudinal and axial sections to detect any surface interruption/irregularity 196 a Ultrasound of the Chest b Fig 6.4 Chest wall lipoma: (a) Chest wall lipoma: well-defined subcutaneous mass (+ +), fat-like intermediate density echoes (b) Below lipoma mass, structures of chest wall can be appreciated: muscle and ossified ribs (shadowing) Often some reactive focal subperiosteal haematoma: • Without history, differentiation from osteomyelitis difficult • Particularly if bilateral, multiple, of different age – NAI should be considered Additional findings: • Complicated haemorrhagic pleural effusion, atelectasis • Haematoma: seen in all chest wall spaces, usually no indication for imaging – only in unclear cases, complicated course, suspicion of infection (DDx: seroma, etc.) 6.3.4 Chest Wall Tumours 6.3.4.1 Lymphangioma (veno-lymphatic vascular malformation) US finding: Multicystic space occupying lesions with echogenic septae • Spontaneous haemorrhages with fluid-fluid levels often present (see Fig 4.12) • CDS: potentially some vessels within septae 6.3.4.2 Lipoma US finding: Usually slightly inhomogeneous, echogenic mass, sharp margins (Fig 6.4) 6.3.4.3 Fibroma/Neurofibroma US finding: Usually sharp margin, hyperechoic or inhomogeneous 6.3.4.4 Other Tumours Rare; e.g rhabdomyosarcoma or Ewing sarcoma (Fig 6.5): • Sometimes difficult to differentiate from myositis ossificans, particularly Askin tumour US finding: No specific sonographic features 6.3.5 Breast Breast US: In childhood of limited importance Neonates: Transient physiologic swelling, cystic duct ectasia and cysts seen • Secondary infection with abscess formation and haematoma may occur (Fig 6.6a) 6.3 Pathology of Chest Wall 197 Fig 6.5 Chest wall tumour – Askin tumour/ Ewing sarcoma Extended field of view US demonstrates large chest wall tumour with calcified part (dorsal shadow) arising from partially destructed rib – i.e Ewing sarcoma a b c Fig 6.6 Breast US in childhood: (a) Neonatal breast abscess – huge collection with membrane and adjacent soft tissue reaction (hyperechoic, swelling) after neonatal mastitis; note plenty US gel to facilitate transducer coupling to tissue without interposing air (b) Impressive cystiform duct ectasia in a breast feed infant (c) Asymmetric prominent breast tissue at onset of pubarche in 11-year-old girl (Pre-)puberty cysts, tubular duct ectasia, fibroadenoma, inflammatory formations (Fig 6.6b): • Overall appearance varies with age and maturation (Fig 6.6c) • Most pathological entities not differ from typical US appearance in adults Additional application of breast US in childhood: Assessment of sexual maturation, documenting presence and size of breast tissue • In girls with suspected hormonal or genetic pathology • In boys with gynaecomastia – In some centres proof of significant breast tissue necessary for treatment decision NOTE: Breast carcinoma extremely rare in childhood CDS: Can be helpful for assessment of superficial tumours or vascular malformations and other pathology described in respective chapters 198 6.3.6 Ultrasound of the Chest Role of US and Additional Imaging US: Supplementary tool in clinically equivocal situation, follow-up Additional Investigations: • Suspicion of tumour – depending on oncology protocols – plain film, CT/MRI • Assessment of osseous structures: plain film, rarely CT • Mammography: rarely indicated, and only in/after puberty 6.4 Pathology of Pleural Space 6.4.1 Pleural Effusion Definition: Some fluid in between two pleural sheets of varying aetiology: • Cardiac, inflammation, trauma, tumour, etc • Most common pleural change, most common indication for chest US US findings: Simple pleural effusion: Unechoic fluid without septae (Fig 6.7) Complicated effusion: Fluid contains floating echoes, septae, complex nature (Fig 6.8): • Depends on haemorrhage, chronicity and recurrence, empyema, etc • Definite diagnosis of underlying entity not achievable by US NOTE: Quantification of pleural effusion limited If US used for follow-up (to determine increase or decrease of amount of fluid) – use standardised views and positioning: • Possibly in sitting or upright position • US aspect changes significantly with posture – with redistribution of fluid, depending on position 6.4.2 Empyema Definition and US findings: Complex effusion with multiple septae which may contain vessels (Fig 6.8b): • Some space-occupying component • May compress adjacent lung – often associated with or even caused by pneumonia, atelectasis and abscess (a)CDS: Peripheral and Septal Hyperaemia DDx: Any other complex fluid, most important entities: • Subphrenic/subpulmonic abscess, lung abscess (may exist concurrently) • Complex pericardial effusion • Haemorrhagic bronchogenic cyst • Complex echinococcal/hydatid cyst • Thoracic lymphangioma • Ventral meningocele (usually clear fluid, posterior mediastinum) • Duplication cyst 424 11 Small Part and Hip Ultrasound a b c Fig 11.22 Foreign body (a) Reverberation caused by a metallic foreign body (similar to needles for punctures) (b) Echogenic foreign body (wooden splinter causing acoustic shadowing) in the wrist Note inflammatory reaction of the oedematous and swollen surrounding soft tissue (c) Subcutaneous echogenic foreign body (+ +) without shadowing, but reverberations, consistent with glass splinter (foot) US Findings: Normal nerve – anechoic linear-tubular structure (more compressible than potentially adjacent vessels: for DDx – CDS, exhibit flow) • Detailed anatomic-topographic knowledge indispensable for identification 11.4 US for Peripheral Vessels Same rules apply for US of vascular pathology as in adults and in other body areas (see chapters abdomen and neck) Except for (syndromic) malformations and posttraumatic/postinterventional findings (e.g aneurysm), vessel disease is much rarer than in adults (no arteriosclerosis, rare thrombosis) (Fig 11.23) 11.5 US-Guided Interventions Many applications, increasing importance – details see Chap US ideal for guiding and monitoring procedure: 11.5 US-Guided Interventions 425 • Particularly in superficial structures and in children (radiation protection issues!) Typical Interventions/Indications • Biopsies (suspected tumours) • Aspiration and drainage (abscess, fluid collections) • Foreign body removal • Vascular access a c e b d f Fig 11.23 Vascular conditions (a) Tortuous large iliac vessels in a newborn with Klippel Trenaunay and large vascular malformations of the respective leg, with high shunt flow (b) CDS of the vessels reveals high velocity and turbulent flow (same patient as a) (c) Numerous large atypical vascular structures identified by CDS in the thickened and oedematous soft tissues of the respective leg (same patient as in a) (d, e) Venous thrombosis: no flow on aCDS (d, longitudinal section) within stiff, incompressible vein that exhibits stationary echoes within lumen (e, axial section) (f) Femoral artery aneurysm after vessel puncture, with colour jet and high flow velocities into the aneurysm 426 11 Small Part and Hip Ultrasound • Sclerotherapy (venous and lymphatic malformations) US-guided reposition (e.g epiphysiolysis) Preparation • Proper preparation essential for success • Initial assessment, informed consent, discussion with clinician, laboratory assessment, time out • Sterile handling, analgesia and sedation, patient positioning • Adequate transducers with sterile covers and potentially needle guide: – Needle guides less frequently used/cumbersome in small and superficial structures – Freehand technique is usually preferred • Proper instruments readily available (needles of various sizes and length, catheters, medications, fixation devices, haemostat, etc.): – For biopsies: specimen-handling needs, microscope in intervention room, pathology support • Monitor and document procedure • Post-procedural check and follow-up Practical Tips • Use highest-frequency transducer that allows visualisation of target lesion • Set focal zone at target • Reduce near-field echoes to improve needle visualisation • Align transducer with long axis of needle to visualise entire needle path • Try to maintain flat angle for needle path, as parallel as possible to transducer surface – needle poorly/not depicted if passes parallel to US beam • Scan with nondominant hand; keep in contact with the patient Index A Abdominal/mesenteric abscess, 282 Abernethy malformation, 233 Abscess formation, 150–151 aCDS See Amplitude-coded colour Doppler sonography (aCDS) Acoustic cavitation, 17 Acute (infective) endocarditis, 184–185 Acute myocarditis, 184 Acute pyelonephritis (aPN)/interstitial nephritis, 345 Adrenal glands haemorrhage, 366–367 inflammatory condition, 367 normal findings, 365, 366 tumours adrenal adenoma, 367 adrenal cysts, 367 carcinoma, 200, 369–370 ganglioneuroma, 367, 369 neuroblastoma, 368–369 phaeochromocytoma, 369 Aerobilia, 248 A-(amplitude) mode, 9–10 Amplitude-coded colour Doppler sonography (aCDS), 31–32 Anencephaly, 92 Angiomyolipoma, 242 Angiosarcoma, 244 Annular pancreas, 270 α1-Antitrypsin deficiency, 229 Aortic aneurysm, 280 Aortic coarctation (CoA), 178, 179 Aplasia, 195 Appendicitis, 313–315 Arnold Chiari malformation, 92–93 Artefacts See also Colour Doppler sonography (CDS) anisotropy, 15 beam width artefact/increment or slice thickness, 14 bowing artefacts, 11 marginal shadowing, 12–13 mirror image artefact, 14, 15 noise, 12 posterior enhancement, 13 refraction artefact, 15 reverberation enhancement, 14 shadowing, 15 side loop artefact, 12 Arteriosclerosis, 158 Arteriovenous fistula (AVF), 350 Arthritis capsular thickening, 407 hip osteoarthritis, 408 joint fluid/effusion, 407–408 Asplenia, 260 Atelectasis, 204–205 Atresia, 7–8 Atrial septal defect (ASD), 173, 174 Atrioventricular septal defects (AVSD), 173–174 B B-(brightness) mode, 10 Biliary tract and gall bladder aerobilia, 248 cholestasis and jaundice, 252 cholestatic changes/inspissated bile/gall stone, 248–249 congenital conditions and normal variants choledochal cyst, 247–248 hypo-/aplasia, 246–247 intrahepatic gall bladder, 245 M Riccabona, Pediatric Ultrasound, DOI 10.1007/978-3-642-39156-9, © Springer Berlin Heidelberg 2014 427 428 Biliary tract and gall bladder (cont.) CT/MRI, 253 ERCP/MRCP, 253 general findings, 245 malformations, 252 metabolic disease, 253 postoperative conditions, 253 scintigraphy, 253 sclerosing cholangitis, 249 thickened gall bladder wall, 251 trauma, 253 tumour-like conditions cholangiocellular tumours granular cell tumour, 252 polyps, 251 US-guided biopsy, 253 Biologic effects, diagnostic US mechanical effects, 17 risks actual indices, 19 guidelines and recommendations, 18 mechanical index, 18 specific risk, 17–18 thermal index, 18 thermal effects, 16 Bowel acquired obstructive pathology hernia, 307–308 intussusception, 308–309 meconium ileus, 306–307 sigma and midgut-volvulus, 307 tumours, 310 assessment of, 302 congenital anomalies atresia, 301–302 duplication/diverticula, 304–305 Hirschsprung disease/neuronal intestinal dysplasia, 304 malrotation, 302–303 Meckel diverticulum, 305–306 volvulus, 303–304 indications, inflammatory appendicitis, 313–315 colitis, 317–318 Crohn disease, 315–317 gastroenteritis, 312–313 maldigestion and malabsorption syndrome, 318 NEC, 310–312 trauma, 319 patient preparation and position, 298–299 transducers, 298–299 ultrasound findings, 300 Index Brain ultrasound additional imaging catheter angiography, 124 CT, 123 fundoscopy, 124 MRI, 124 plain film, 123 cerebral calcifications, 122 cerebral cysts, 98–100 cerebral haemorrhage (see Cerebral haemorrhage) hydrocephalus (see Hydrocephalus) inflammation postnatal, 106–107 prenatal intrauterine infections and residuals, 105–106 ischemic encephalopathy in brain hypoxia, 104–105 focal hypoxemia and ischemia, 102–104 global/diffuse brain oedema, 101–102 periventricular leukencephalomalacia (PVL), 100–101 migration and gyration alterations and disturbances colpocephaly, 94 holoprosencephaly, 96–97 hydranencephaly, 97 lissencephaly, 94–95 macro/polygyria, 94–95 megalencephaly, 94–95 pachygyria, 94–95 schizencephaly, 95–96 neural tube defects anencephaly, 92 Arnold Chiari malformation, 92–93 corpus callosum malformations, 93 Dandy-Walker malformations, 93 lipoma, 94 normal findings CDS (see Colour Doppler sonography (CDS)) cisterna magna, 89 mastoid access with sector transducer, 83 periventricular echogenicities (see Periventricular echogenicities) transfontanellar access, 80 vascular variations, 89, 91 ventricular asymmetry, 87 ventriculomegaly, 89 phakomatoses, 98 requisites indications for, brain US, 79 morphometry and documentation, 81–82 Index patient positioning, 79 transfontanellar access, 80 transtemporal access, 78 transtemporal, transcranial, mastoid access, 80 skull fracture, 123 haematoma, 122 space-occupying lesions and tumours, 123 tumours and space-occupying lesions, 119–121 Budd-Chiari syndrome, 233 C Cardiac tumours, 186 Cardiomyopathies, 184 Cartilaginous epiphysis, 408 Cavitation, 17 CCAM See Congenital cystic adematoid malformation (CCAM) CDS See Colour Doppler sonography (CDS) Cellulitis, 418 Cerebral haemorrhage CDS role, 118 in infants and older children, 118–119 in preterm babies, 114–116 in term infants, 116–118 Cervical cyst, 146, 147 Cervical ectopic thymus, 148 Chest ultrasound breast mammography, 198 normal findings, 191 pathology, 197 CDS, normal findings of, 195 chest wall aplasia, variations of ribs, 195 congential malformations, 195 fibroma/neurofibroma, 196 lipoma, 196 lymphangioma, 196 normal findings, 191 plain film, CT/MRI, 198 rhabdomyosarcoma/Ewing sarcoma, 196, 197 traumatic changes, 195–196 diaphragm diaphragmatic hernia, 201–202 diaphragmatic motion disturbance, 202 imaging role and value, 200–201 normal findings, 191–195 429 indications, 190–191 lung additional imaging, 211, 212 atelectasis, 204–205 congenital cystic adenomatoid malformation, 207 cysts, 208 infarction, 208–209 lung abscess, 203, 204 normal findings, 191–195 pneumonia, 203 respiratory distress syndrome/hyaline membrane syndrome, 205 sequestration, 206–207 tumours and space-occupying lesions, 200 mediastinum anterior mediastinum/thymus, 193 middle mediastinum, 193–195 plain film, CT, 198 posterior mediastinum, 195 patient positioning, 190 performance, 191 pleural space empyema, 198, 199 imaging role and value, 200–201 normal findings, 192 pleural effusion, 198, 199 pleural thickening, 199 tumours, 200 US transducers, 190 Choledochal cyst, 247–248 Chronic pancreatitis, 272 Cirrhotic liver, 227–228 Cisterna magna, 89 Colour Doppler sonography (CDS) application and restriction, 31 artefacts aliasing, 34, 35 angle correction, 35 filtering artefacts, 35 gain-induced errors, 35 motion artefact, 35 sample volume artefact, 34 scaling problem, 35 spectral broadening, 34 twinkling artefact, 36 arterial flow velocities, 85–86 equipment setting and transducer handling, 37 in neonates, 86 older neonates and infants, 86 in preterms, 87 principle, 30–31 430 Colour Doppler sonography (CDS) (cont.) transfontanellar, 84, 85 transtemporal, 84, 86 venous system, 84–86 Congenital cystic adematoid malformation (CCAM), 206, 207 Congenital heart defect atrial septal defect, 173–174 atrioventricular septal defects, 173–175 cor triatriatum, 184 double outlet right ventricle, 183 Ebstein anomaly, 183–184 patent ductus arteriosus of Botalli, 176–177 persistent truncus arteriosus, 177 total anomalous pulmonary venous return, 181–182 transposition of great arteries, 181–182 univentricular heart, 183 ventricular septal defect, 174–175 Congenital hiatal hernia, 292 Congential malformations, 195 Contrast-enhanced US approach, 43–44 basics, 42–43 contrast-enhanced voiding urosonography basics, 44–45 restriction, 46 technique, 44–45 future development, 51 intravenous ce-US, 47–50 sono-genitography, 46–47 sonographic pyelography, 46–47 Contrast enhanced voiding urosonography (ce-VUS), 44–47 benefits and limitations, 66–67 bladder and ureter, 66 diagnosis, 66 indications, 64 male urethra, 67 renal appearance, 67 Contusion, 236 Corpus callosum malformations, 93 Crohn disease, 315–317 Cross-beam imaging See Sono-CT Cystic dysplasia, 380–381 Cystic fibrosis, 229 Cystic hygroma, 156 Cystic kidneys acquired cystic kidney disease, 334 complicated cyst(s), 332 inherited/congenital cystic disease, 332–334 Index multicystic dysplastic kidney, 333 multiple cysts, 332 simple cyst, 332 Cysts, lung, 208 D Dandy-Walker malformations, 93 Dermoid cyst, 146 Developmental hip dysplasia (DDH) Graf classification decentered hip, 405, 406 immaturity, 405 luxated hip, 406 normal hip, 404–405 Harcke classification, 407 Diaphragmatic hernia, 201, 202 Diaphragmatic motion disturbance, 202 Dilating (congestive) cardiomyopathy, 184 Doppler sonography, 11 amplitude-coded colour Doppler sonography, 31–32 colour-coded/colour Doppler sonography (see Colour Doppler sonography) continuous wave Doppler (CW), 28, 29 Doppler phenomenon, 27–28 duplex-Doppler sonography, 29–30 flow-sensitive US technique, 32–33 interpretation, 37–38 limitations, 37 parameters and measurements, 33–34 pulsed wave Doppler (PW), 28–29 Double outlet right ventricle (DORV), 183 Duplication cyst, 146–147 E Embryonal cell sarcoma, 244 Empyema, 198–199 Epiphysiolysis, 408–409 Extended field of view US, 39–40 Eye and orbit ultrasound normal findings, 124–125 pathology foreign bodies, 125 papilla congestion, 124 retinal displacement, 125 tumours, 126 F Fasciitis, 418, 419 Fatty liver/steatosis, 225–226 Index Female genital ultrasound congenital malformations cystic change, 390 ovarian malformations, 391 uterine duplication, 389, 391 vaginal aplasia, 390 vaginal atresia, 389 vaginal fistula, 389–390 vaginal septum and duplications, 388 genital tumours and space-occupying lesions cysts, 392–393 ovarian childhood tumours, 393 rhabdomyosarcoma, 393 teratoma, 392–393 indications, 385 inflammatory conditions, 391–392 investigation procedures, 386 normal findings developmental stages, 386, 387 neonatal cystic ovary, 387, 388 sonogenitography, 388 ovarian torsion, 394–395 pregnancy, 395 requisites, 386 transducers, 386 traumatic changes, 394 Fibroma/neurofibroma, 196 Focal foveolar hyperplasia, Focal nodular hyperplasia (FNH), 241–242 Four-dimensional US (4DUS) See also Three-dimensional US (3DUS) benefits, 55, 56 physics and technique, 50–51 restriction, 56 Fracture calcification, 412 in reparative phases, 412 skull, 122 subperiosteal haematoma, 413 G Gastritis, Gastroenteritis, 13 Gastrointestinal (GI) tract bowel (see Bowel) stomach (see Stomach) Gastro-oesophageal reflux (GOER), 292–294 Glomerulonephritis, 347–348 Glycogen storage disease, 229 GOER See Gastro-oesophageal reflux (GOER) Granulomatous disease, 146, 147, 225 431 H Haemangioma, 148–149, 239–241 Haematoma, 151–152 Haemolytic uremic syndrome (HUS), 354 Haemorrhagic pancreatitis, 271–272 Haemosiderosis, 229–230 Harmonic imaging (HI), 39, 40 Hepatic adenoma, 242 Hepatic leiomyosarcoma, 244 Hepatic sarcomas, 244 Hepatoblastoma, 242–243 Hepatocellular carcinoma, 243 Hernia, 10–11 High-resolution US (HR-US), 39 Hip joint arthritis and inflammation, 407 ephysiolysis, 408–409 normal findings, 411, 412 Perthes disease, 409 US requisites and technique, 410, 411 Hip ultrasound bones, joints, tendons arthritis, 407 cysts, 417 foreign bodies, 422, 424 fracture, 410 indications, 410–411 inflammation, 417–420 joint effusion, 413–414 neoplasia (see Neoplasia) normal findings, 411, 412 peripheral nerves, 422–424 transducers, 410 trauma, 415–417 DDH (see Developmental hip dysplasia) device presets, 398 epiphysiolysis, 408 Graf technique coronal selection, lateral assessment, 399 documentation, 400 dynamic assessment, 399 normal anatomy, 402–404 pathology, 404–407 guidelines, 424–425 Harcke technique, 400, 401 indications, 398 Morin-Terjesen technique anatomy, 402 degree of lateralisation assessment, 401 pathology, 404–407 in older children, 403–404 patient positioning, 398 432 Hip ultrasound (cont.) Rosendahl modification anatomy, 402, 403 objective, 400 transducers, 398 US-guided interventions, 424–426 Hirschsprung disease, HPS See Hypertrophic pyloric stenosis (HPS) Hyaline membrane syndrome, 205 Hydrocele, 378–379 Hydrocephalus causes of, 108 CDS role, 110–111 Doppler in, 111 epidural/subdural differentiation, 109–110 extracranial partition, 112 shunt, 112 task of US, 108 US appearance aqueductal stenosis, 109, 110 dilated extra-axial CSF space, 108 fourth ventricle obstruction, 109, 110 Hydronephrosis (HN), 335 Hyperplastic gastric mucosa, Hypertrophic cardiomyopathy, 184 Hypertrophic obstructive cardiomyopathy, 185 Hypertrophic pyloric stenosis (HPS), 3–4 Hypodysplastic kidney, 331 I Image compounding, 39 Image documentation, 25–26 Infarction, lung, 208–210 Intracardiac thrombi, 186 Intrahepatic gas, 238–239 K Kawasaki disease, 185 Kidney ultrasound adrenal glands (see Adrenal glands) biopsy after VUR treatment, 361 balloon dilatation, 363 drainage/nephrostomy, 360–361 extracorporeal lithotripsy (ESWL), 363 findings after pyeloplasty, 362–363 post-biopsy, 360 pre-interventional, 359 prone position, 360 inflammatory renal parenchyma acute pyelonephritis (aPN)/interstitial nephritis, 345 Index glomerulonephritis/nephrotic syndrome, 347–348 necrosis and abscess formation, 345, 346 pyelitis, 344, 345 scarring, 346 tuberculosis, 346 xanthogranulomatous pyelonephritis, 347 normal findings, 324–330 normal variants bladder anomalies, 330 cross-fused dystopia, 330 duplex, 328, 329 ectopic, 328, 329 horseshoe kidney, 330 renal agenesis, 329 retro-aortal left renal vein, 328 parenchymal appearance, 325–327 parenchymal disease HUS, 354 nephrotic syndrome, 354 scars, cirrhotic kidney, 354–355 pathology cystic renal disease (see Cystic kidneys) dysplasia/hypoplasia, 330–331 hydronephrosis (HN), 335 posterior urethral valve (PUV), 339–340 secondary obstruction, 343–344 UPJO, 335–338 uretero-vesical junction obstruction (UVJO)/obstructive megaureter (POM/MU), 338–339 vesico-ureteric reflux (VUR), 339, 341 renal failure, 375 renal/urinary tract trauma, 355–357 transplantation normal findings, 363, 364 pathologic findings, 364–365 tumours benign, 357 malignant, 357–359 pre/semimalignant, 357 urinary bladder (see Urinary bladder ultrasound) vascular conditions AVF, 350 infarction, 350–351 neprocalcinosis, 352–353 renal artery stenosis, 348–350 renal vein thrombosis, 351–352 urolithiasis, 353–354 Index L Laceration, 234 Lipoma, 196 Liver abscess, 223–225 Liver calcifications, 238 Liver congestion, 226–227 Liver fibrosis, 227 Liver haematoma, 235 Liver ultrasound Abernethy malformation, 233 biliary tract and gall bladder (see Biliary tract and gall bladder) congenital changes and normal variance butterfly/midline liver, 222 hypoplasia/atrophy, 222 situs inversus, 222 Doppler findings hepatic artery (HA), 219–220 hepatic veins (HV), 219, 220 portal vein (PV), 219, 221 hepatic vein thrombosis/occlusion/ stenosis, 233 inflammatory conditions granulomatous disease, 225 hepatitis, 223 liver abscess, 223–225 normal findings, 216–222 gall bladder, 218, 219 hepatic artery (HA), 218 hepatic veins (HV), 217 hepato-choledochal duct, 218–219 intrahepatic bile ducts, 219 ligaments, 217 portal vein (PV), 217–218 size, 216 parenchymal liver disease cirrhotic liver, 227–228 hepatopathy, 225–227 liver fibrosis, 227 in systemic disease, 229–230 portal hypertension, 230–231 portal vein and hepatic artery stenosis, 232 portosystemic shunts, 234 requisites and investigation course of investigation, 215 fasting, 214 standard liver measurements, 216 supine position, 214 transducers, 214–215 space occupying liver lesions, 237–245 angiomyolipoma, 242 complicated cysts, 237–238 focal nodular hyperplasia (FNH), 241–242 433 haemangioma, 239–241 hepatic adenoma, 242 hepatic sarcomas, 244 hepatoblastoma, 242–243 hepatocellular carcinoma, 243 intrahepatic gas, 238–239 liver calcifications, 238 mesenchymal hamartoma, 241 metastasis, 244 proliferative disorders, 244 simple cysts, 237, 238 standard liver measurements, 215, 216 transplantation complications, 255 donor US, 254 intraoperative, 254 postoperative assessment, 254 recipient evaluation, 254 trauma (see Trauma) ultrasound transplantation, 254–255 vascular malformations, 232 Lung abscess, 203, 204 Lung sequestration, 206–207 Lymphangioma, 196 Lymphatic malformation, 148–149, 281–282 M Male genital ultrasound normal findings, 378 orchitis/ependymitis, 381–383 pathologic findings cystic dysplasia, 380–381 ependidymal cysts, 381 hydrocele, 378, 380 microlithiasis, 381, 382 spermatocele, 381 testicular and paratesticular cysts, 381 undescended testes, 379 varicocele, 379–380 penile, 378 prostate/seminal vesicle, 377 scintigraphy and MRI, 385 scortum/testis, 377 scrotal trauma, 383 testicular tumours, 384–385 torsion inguinal hernia, 384 testicular and hydatid torsion, 384 torsion of appendages, 384 Malrotation, 302 Meconium ileus, 306–307 Menetrier disease, 296 Mesenchymal hamartoma, 241 434 Mesenchymal tumours, 149 Mesenteric cystic formation, 281 Mesenteric lymph nodes, 282, 284 Microgastria, 292 Micturition urosonography, 44 Mid-aortic syndrome, 279 (T) M-mode (time-motion-mode), 9–10 Myositis, 418 N NEC See Necrotizing enterocolitis (NEC) Neck ultrasound cervical soft tissues abscess formation, 150, 151 malformations, 146 normal findings, 144 traumatic changes, 151–152 tumours, 148–150 cervical vessels arteriosclerosis, 158 dissection, 158 examination, 139–140 normal findings, 144–145 stenosis, 158–159 thrombosis and occlusion, 161 vascular anomalies, 159–160 glands examination, 138 salivary gland (parotid, submandibular and sublingual glands) (see Salivary gland) thyroid gland (see Thyroid gland) intervention, 140 lymph nodes enlarged nodes, 146 examination, 138 inflammation, 146 normal findings, 140–141 patient positioning and handling, 138 transducer, 138 Necrosis, 345, 347 Necrotising pancreatitis See Haemorrhagic pancreatitis Necrotizing enterocolitis (NEC), 310–311 Neoplasia bone tumours, 420 cartilaginous tumours, 421 echogenic foreign body, 424 haemangioma/vascular malformation, 422 lymphoma/metastasis, 422 osteosarcoma, 422 ultrasound appearance, 421 Index Nephrotic syndrome See Glomerulonephritis Neprocalcinosis, 352–353 Neuroblastoma, neuroma, neurofibroma and nerve sheath tumours, 150 Neuronal intestinal dysplasia, 304 Nutcracker syndrome, 280 O Oedematous pancreatitis, 271, 272 Osteomyelitis, 420 P Paediatric echocardiography acquired paediatric heart disease acute (infective) endocarditis, 184 acute myocarditis, 184 cardiac tumours, 186 cardiomyopathies, 184 intracardiac thrombi, 186 Kawasaki disease, 185 pericarditis/pericardial effusion, 185 apical views, 167–169 catherisation and angiography, 186–187 clinical queries, 187 congenital heart defect (see Congenital heart defect) functional parameter LV systolic function, 171 systolic function, 171 TAPSE, 171 left ventricular outflow obstruction aortic coarctation, 178, 179 aortic valve stenosis, 177, 178 interrupted aortic arch, 178 subaortic stenosis, 177 supravalvular aortic stenosis, 178 MRI and CT, 187 normal values, 172–173 orientating examination, 187 parasternal views parasternal long axis view, 166–167 parasternal short axis view, 167 patient positioning, 165 right ventricular outflow obstruction isolated pulmonary valve stenosis, 179 subvalvular pulmonary stenosis, 179 supravalvular pulmonary stenosis, 179 TOF and pulmonary atresia, 180–181 sedation, 165 standardised examination, 166 Index standard planes, 165–166 standard US technique, 165 subcostal views sagittal subcostal view, 169 subcostal four-chamber view, 169, 170 suprasternal view, 169–170 techniques contrast enhanced US, 172 Doppler sonography, 171 M (motion)-mode echocardiography, 170–171 three-dimensional (3D) echocardiography, 172 tissue Doppler imaging, 172 transesophageal echocardiography, 172 transducers, 165 trauma and emergency, 188 Paediatric ultrasound See also Paediatric echocardiography device handling, 21–22 measurement organ size, 24–25 remarks, 23–24 transducer handling, 23 patient positioning, 20–21 requisites environmental requisites, 19 indications, 19 specific needs, 20 three-dimensional US (see Threedimensional US (3DUS)) transducer abdominal US, 23 chest US, 22–23 neurosonography, 22 small part US, 22 Pancreas divisum, 270 Pancreas ultrasound indication, 268 investigation course, 268–269 normal findings, 269–270 pancreatitis chronic, 272 haemorrhagic/necrotising, 271 oedematous/reactive pancreatitis, 271 requisites, 268 space-occupying lesions CT, 275 cysts/pseudocysts, 274 ERCP, 275 scintigraphy/PET, 275 tumours, 274–275 435 trauma, 272–274 variations and malformations annular pancreas, 270 pancreas divisum, 270 Patent ductus arteriosus (PDA), 176–177 Pelvic congestion syndrome, 278–279 Pericarditis/pericardial effusion, 185, 186 Periventricular echogenicities embryologic cavities, 87, 90 in preterm infants, 87, 89 Persistent truncus arteriosus, 177 Perthes disease, 409 Pleural effusion, 198, 199 Pleural thickening, 199 Pneumonia, 203 Polysplenia syndrome, 261 Pulmonary atresia (PA), 180–181 Pulsed wave Doppler (PW) imaging, 28–29 Pyelitis, 344, 345 Pyloric atresia, 292 R RDS See Respiratory distress syndrome (RDS) Reactive pancreatitis See Oedematous pancreatitis Renal artery stenosis, 348–349 Renal infarction, 350–351 Renal vein thrombosis, 351–352 Report diagnosis, 26 issue, 26 nomenclature, 27 predefined reports, 27 Respiratory distress syndrome (RDS), 205–206 Restrictive cardiomyopathy, 184 Retroperitoneal tumours, 287 Retroperitoneum ultrasound abdominal vessels investigation, 276 patient positioning, 276 transducers, 276 US findings, 276, 278 variants and malformations, 277–278 abdominal wall, 288 free intraperitoneal air, 283, 284 free intraperitoneal fluid, ascites, 283–284 mesentery abscesses, 282–283 cyst, 281–282 lymphatic malformation, 282 436 Retroperitoneum ultrasound (cont.) lymph nodes, 283, 284 mesenteric (peritoneal) masses, 281–282 twisted appendices epiploica, 283 soft tissues lymph nodes, 287 tumours, 287–288 vascular pathology arteriosclerotic changes and aneurysms, 280 complementing imaging, 281 embolic thrombus, 280–281 mid-aortic syndrome, 279 nutcracker/SMA syndrome, 280 pelvic congestion syndrome, 278–279 thrombosis/occlusion, 278 US role, 281 Rhabdomyosarcoma, 150, 196, 197, 244, 393 S Salivary gland calcifications/sialolithiasis, 156 cysts, 156 inflammation, 155–156 normal findings, 143, 144 tumours, 156 SMA syndrome See Nutcracker syndrome Sono-CT, 39 Sonoelastography, 41–42 Spinal canal ultrasound additional imaging, 135–136 disc pathology, 135 indications, 127 inflammatory changes, 135 normal findings, 128–130 osteomyelitis, 135 paravertebral structures, 135 pathologic findings dermal sinus tract, 133 diastematomyelia, 133 dural lipoma, 131, 132 dysraphism, 130–132 filum termiale, 132, 134 hydromyelia, 132 periosteal/subperiosteal changes, 135 requisites, 127 transducers and technique, 127 trauma, 134 tumours, 134–135 Spleen ultrasound indications, 258 investigation course, 258–259 Index malformations, 260–261 normal anatomy, 259–260 normal variants, 260 patient positioning, 258 requisites, 258 space-occupying lesions abscess, 266–267 cysts, 265–266 tumours, 267 splenic infarction, 264–265 splenomegaly, 261, 262 trauma, 261–264 Splenic infarction, 264–265 Splenic lobulations, 260 Splenomegaly, 261, 262 Splenunculus (accessory spleen), 260 Stomach assessment of, 293 bezoars and foreign bodies, 296 bowel, functional assessment, 290–291 duplication cysts, 296–297 eosinophilic gastr(oenter)itis, 296 focal foveolar hyperplasia, 297 gastric perforation, 296 gastritis/ulcers, 295 GOER, 292–293 granulomatous disease, 296 HPS, 293–295 hyperplastic gastric mucosa, 296 indications, 289 inflammatory pseudotumour, 297 malformation, 292 malignant masses, 297 Menetrier disease, 296 myofibroma and polyps, 297 patient preparation and position, 289 teratoma, 297 transducers, 290 ultrasound appearance of, 291, 297 Synovitis See Tendinitis-tendovaginitis T Tendinitis-tendovaginitis, 419–420 Teratoma, 5, 150 Tetralogy of Fallot (TOF), 180–181 Three-dimensional US (3DUS) benefits, 55, 56 paediatric 3DUS cardiac US, 54, 55 female genitalia, 54 future development, 57 kidney, 51–53 Index musculoskeleton, 54 neonatal neurosonography, 51 small part imaging, 54–55 urinary bladder, 53–54 physics and technique, 50–51 restriction, 56 Thrombosis and occlusion, 161, 278 Thymic cyst, 148 Thyroid gland adenoma/carcinoma, 155 amyloid goitre, 155 cystic changes, 152 hypothyroidism, 153 inflammation, 155–156 malformation, 152, 153 nodular goitre, 154–155 normal findings, 140–143 Tissue heating, 16 Total anomalous pulmonary venous return (TAPVR), 181–182 Transposition of great arteries (TGA), 181, 182 Trauma cervical soft tissues, 151–152 chest wall, 196 female genitals, 393 kidney ultrasound, 355–357 liver contusion, 236 haematoma, 235 haemobilia, 236 herniation, 236 injury grading system, 234 laceration, 234 liver infarction, 236 pancreatic injury grading, 273 laceration, 274 scrotal, 383 spleen injury grading system, 234 haematoma, 263 posttraumatic AVF, 264 urinary bladder, 376 urinary tract, 356, 357 Tricuspid annular plane systolic excursion (TAPSE), 171 Tuberculosis, 347 Tumours adrenal adenoma, 367 adrenal cysts, 367 bladder tumours, 372–373 carcinoma, 200, 369 cardiac tumours, 186 437 cholangiocellular tumours, 251–252 cysts, 392 ganglioneuroma, 366, 369 granular cell tumour, 252 lung, 210 neuroblastoma, 368–369 ovarian childhood tumours, 392, 393 phaeochromocytoma, 369 pleural space, 200 polyps, 251 retroperitoneum, 287–288 rhabdomyosarcoma, 393 salivary gland, 156 spinal canal, 134 teratoma, 392–393 testicular tumours, 384–385 Twisted appendices epiploica, 283 Tyrosinaemia, 229 U Ulcers, 295 Ultrasound (US) device amplification, cooling device with filters, emission, gel bottle warming device and transducer stands, input/output options, keypad and monitor, printer/CD player, reception, signal processing frame rate/persistence, gain, post-processing, preprocessing, sound energy, 5–6 time gain compensation (TGC), transducer curved linear array, intracavitary probes, linear array transducers, matrix 1.5-/2-dimensional array, 8–9 sector transducers, 7–8 transmission, Ultrasound guided interventions biopsy after procedure, 70 liver, 69 procedure, 69–71 renal, 69, 71 splenic, 70 438 uploaded by [stormrg] Ultrasound guided interventions (cont.) ce-VUS benefits and limitations, 66 bladder and ureter, 64, 66 diagnosis, 66 indications, 64 male urethra, 67 renal apperance, 67 drainage/puncture needle/tube size, 72 schematic drawing, 72 Seldinger technique, 72 Trocar technique, 71 foreign body removal, 75 intracavitary contrast application, 67 intravenous ce-US, 68, 69 lumbar puncture, 74–75 precaution/preparation, 60 requisites, 60 US genitography, 64 US-guided filling structures diagnostic sonographic enema, 61, 62 physiologic cavities, 61 therapeutic sonographic enema, 62–64 vascular access, 73, 74 Ultrasound (US) waves absorption, acoustic impedance, definition, deflection, focus, impedance change, propagation and modulation, reflection, resolution, 3–4 Undescended testes, 379 Univentricular heart (UVH), 183 Ureteropelvic junction obstruction (UPJO), 335–338 Urinary bladder ultrasound normal findings, 324–325 paravesical changes, 376 pathologic findings atypical shape, 371–372 bladder tumours, 372–373 Index calcification, 373 inflammation, 375–376 infravesical obstruction, 375 megaureter, 375 persisting urachus, 373–374 polyps, 372 traumatic changes, 376 ureterocele, 373, 374 vesico-ureteric reflux, 376 requisites, 370 transducers, 370 Urogenital tract ultrasound female genitals (see Female genital ultrasound) indications, 322 investigations diuretic, 323 longitudinal and axial sections, 323 kidney (see Kidney ultrasound) male genitals (see Male genital ultrasound) patient positioning, 323 patient preparation, 322 transducers, 322 Urolithiasis, 353 US texture analysis, 41 V Varicocele, 379–380 Veno-occlusive disease (VOD), 233 Ventricular asymmetry, 87, 89 Ventriculomegaly, 89 Vesico-ureteric reflux (VUR), 339–343 VOD See Veno-occlusive disease (VOD) Volvulus, 303–304 W Wandering spleen, 261 Wilson disease, 229 X Xanthogranulomatous pyelonephritis, 347 ... Space-Occupying Liver Lesions 21 4 21 4 21 4 21 4 21 5 21 5 21 6 21 6 21 7 21 7 21 7 21 8 21 8 21 8 21 9 21 9 22 0 22 2 22 2 22 3 22 5 23 0 23 4 23 7 M Riccabona Division of Pediatric Radiology, Department of Radiology, University... Disease 6.7 .2 US for Pneumothorax 6.8 Additional Imaging 6.1 Requisites 6.1.1 Transducers 20 3 20 3 20 3 20 4 20 5 20 6 20 7 20 7 20 8 21 0 21 0 21 0 21 1 21 1 Chest Wall High-resolution... Complications 7.1 Requisites and Investigation 7.1.1 Preparation 24 5 24 5 24 5 24 8 25 1 25 2 25 3 25 3 25 4 25 4 25 4 25 4 25 5 Fasting helpful for sufficient filling of gall bladder and bile duct