The radiologic picture of total colonic aganglionosis

The radiological findings pathognomonic of Hirschsprung's disease have been known for quite a long time. However, in addition to those diseases characterized by rectum or rectum-sigmoid aganglionosis (as in the classic form of Hirschsprung's disease), in pediatric pathology of surgical interest severe affections exist characterized by aganglionosis extending from the rectum to the entire colon, and exceptionally as far as the small bowel (ultra-long Hirschsprung's disease). The authors report on the results they obtained in radiological studies of 6 cases of total colonic aganglionosis by means of the current radiological procedures, i.e. plain abdominal films and barium enema. As for total colonic aganglionosis, no diagnostic radiological parameters have been assessed yet. The authors compare their results with those taken from international literature: microcolon with reflux into mega-ileum (2 out of 6 cases) appears to be the most suggestive X-ray finding for total colonic aganglionosis. Finally, the role is discussed of radiological studies in the diagnostic approach to total colonic aganglionosis. The authors conclude that, even though radiological investigations are indispensable, they are often not conclusive. Therefore, an accurate evaluation of the proximal extension of aganglionosis can be made only at surgery.     

CT evaluation of gastrointestinal tract perforation

The purpose of this study is to review the computed tomography (CT) appearance of gastrointestinal tract (GI) perforation. Forty-two patients with 10 cases of proximal GI perforation and 32 cases of distal GI perforation were evaluated based on the CT findings of extraluminal air (which was subdivided into the CT-falciform ligament sign crossing the midline and scattered pockets of air), bowel wall thickening (>8 mm in gastroduodenal wall, >3 mm in the small bowel wall, >6 mm in the caliber of the appendix and >5 mm in the colonic wall), associated abscess formation, ascites and adjacent fat stranding. The results were compared using Fisher's Exact Test. Detection of extraluminal air in the upright plain films and CT was analyzed by Z test. Our results showed that CT-falciform ligament sign was more frequent in the proximal GI perforation, while pockets of extraluminal air (excluding the cases accompanying CT-falciform ligament sign), bowel wall thickening and fat stranding were found in higher incidence in distal GI perforation (P<.05). CT detected extraluminal air in more cases than the upright plain films did (69% vs. 19%; Z=4.62>Z(0.01)=2.326). We concluded that CT is a good imaging tool to differentiate the various GI perforations.     

Adult Hirschsprung's disease

Two cases of adult Hirschsprung's disease are reported along with a review of 47 cases reported in the literature. Chronic constipation is present in almost all cases. The barium enema examination may suggest the diagnosis if an area of smooth narrowing with proximal dilatation is seen (83%), but biopsy proof of absence of ganglion cells is necessary. Fourteen per cent of patients had a dilated colon without a narrowed segment. Anal manometry is helpful if it demonstrates absence of normal anorectal inhibitory reflex. Total colonic aganglionosis in the adult has been reported, but is exceptionally unusual. The diagnosis of adult Hirschsprung's disease should be suspected in patients with a history of chronic constipation and appropriate radiographic findings.     

Nekrotisierende Enterokolitis (NEC) beim Neugeborenen

Necrotizing enterocolitis (NEC) is a disease of the premature neonate that requires early therapy, sometimes even surgery and therefore early diagnosis. In general, plain radiography of the abdomen and sonography are valuable imaging techniques for diagnosis of NEC. COURSE OF NEC: The disease starts with distension of small bowel loops. Furthermore the children develop pneumatosis in the bowel wall, which is a nonspecific pattern. If the NEC persists, the air passes into the portal vein system, causing a pneumoportogram. Finally, the disease can lead to perforation. In doubtful cases, the plain radiogram must be repeated within a period of 6 h. With sonography distension of the bowel, thickening of and pneumatosis in the bowel wall, the pneumoportogram and free intraperitoneal fluid can be easily depicted. The most common complications of NEC are intestinal stenosis and strictures that can lead to ileus. DIFFERENTIAL DIAGNOSIS: Focal perforation of ileum, volvulus and Hirschsprung's disease are some of the differential diagnoses.     

The value of CT in detecting bowel perforation in children after blunt abdominal trauma

In this era of conservative management for most infants and children with blunt abdominal trauma, there is a concern that the diagnosis of bowel perforation may be missed or delayed. To determine the sensitivity of CT in the detection of perforated viscus in this population, we reviewed the CT examinations of 547 consecutive children who had had blunt abdominal trauma. Of six patients (1%) with documented bowel perforation, four (67%) had free intraperitoneal air detected preoperatively by CT. The remaining two cases had secondary signs of bowel thickening and unexplained peritoneal fluid. Free intraperitoneal air was not a specific indicator for bowel perforation. Of nine patients in whom CT studies showed pneumoperitoneum, only four (44%) had a ruptured bowel. The remaining five patients had pneumoperitoneum from sources other than bowel perforation including pneumomediastinum, bladder perforation, and previous peritoneal lavage. This experience shows that the CT finding of pneumoperitoneum is useful, although not specific for the detection of bowel perforation in children with blunt abdominal trauma. When free air is not present, secondary signs of bowel wall thickening and unexplained peritoneal fluid suggest a bowel perforation.     

Colonic perforation at CT colonography: assessment of risk in a multicenter large cohort

PURPOSE: To assess retrospectively the incidence, clinical features, and treatment of colonic perforation at computed tomographic (CT) colonography in a large multicenter cohort. MATERIALS AND METHODS: The study was performed in accordance with the institutional ethics committees' requirements of a retrospective review in each of the participating centers, and no informed consent was required. A review of all patients who underwent CT colonography between January 2001 and December 2004 in 11 medical centers representing more than 95% of studies performed in a single country was performed to determine the rate of colorectal perforation. Data about patient demographics and patient- and procedure-related risk were recorded. Information about the location of the perforation, its likely mechanism, and treatment was collected. Analysis included calculation of rates of colonic perforation and surgical treatment and of 95% confidence intervals. RESULTS: A total of 11 870 CT colonographic studies were performed in 6837 (57.6%) men and 5033 (42.4%) women (mean age, 59.9 years; range, 38-90 years) with seven cases of colorectal perforation, yielding a risk rate of 0.059% (one of 1696 studies; 95% confidence interval: one of 974, 971 of 6537). The mean age of the patients with perforation was 77.8 years. Six (84%) of seven cases of perforation occurred in symptomatic patients at high risk for colorectal neoplasia, and one (16%) occurred in an asymptomatic average-risk patient. All studies were performed after insufflation of room air. Six (84%) cases of perforation occurred in patients in whom a rectal tube was inserted, and in five of them, a balloon was inflated. Five (71%) cases of perforation occurred in the sigmoid colon; and two (29%), in the rectum. Four (57%) patients (one in 2968 patients; 95% confidence interval: 1.5 in 10 000, 14.7 in 10 000) required surgical treatment. Possible factors that contributed to perforation were left inguinal hernia containing colon (n = 4), severe diverticulosis (n = 3), and obstructive carcinoma (n = 1). CONCLUSION: Perforation of the colon and rectum is a rare complication of CT colonography. Older age and underlying concomitant colonic disease were present in patients with perforation.     

A large lipoma of the descending colon: A rare case report

Colon lipoma is a rare benign disease in the gastrointestinal tract with an incidence rate of approximately 0.035%-4.4%. The disease is often asymptomatic, so it is frequently discovered incidentally through endoscopy, computed tomography , or autopsy. When the tumor is over 2 cm in size, symptoms such as abdominal pain, bowel disorders, and bowel obstruction are common. Surgery is considered the mainstay of treatment for colonic lipomas. Furthermore, surgical (rather than endoscopic) resection is preferred for lipomas >2 cm to avoid complications such as bleeding and perforation. We report on a 61-year-old female patient who was diagnosed with a 4-cm descending colonic fat tumor detected by endoscopy and computed tomography and confirmed by pathology.     

Upper abdominal trauma: pitfalls in CT diagnosis

Medical records and computed tomographic (CT) scans of 83 patients with upper abdominal trauma were retrospectively reviewed to determine errors in diagnosis using CT. Patients with possible pancreatic injury, small bowel perforation, or injury to an occult malignancy represented the most difficult diagnostic cases. A false-positive diagnosis of pancreatic injury occurred in seven of 77 patients (9%) and represented the most frequent error in the series. In three patients with subsequently surgically proved small bowel perforation, one duodenal and two proximal jejunal, the injuries were not correctly diagnosed on CT scans. In retrospect, positive CT findings were present in the case of duodenal rupture. Additionally, in two patients, duodenal rupture was suspected based on CT findings of extraluminal gas and fluid near the duodenum, but both cases were proved normal at surgery. The series included three patients with trauma involving unsuspected tumors in the liver, kidney, and stomach.     

Colonic transit studies with 99mTc-rhenium sulfide colloid in live rats. A preliminary study

Abnormal colonic motility is associated with clinical relevant conditions such as irritable bowel syndrome or constipation. Accurate assessment of colonic transit in an animal model would be useful in studying these conditions and screen potential drug candidates. The aim of this study was to assess if scintigraphic analyses could reliably evaluate total and segmental colonic transit as a measure of colonic motility of a non-absorbable radiotracer in rats. Normal Lewis rats (250-300 g) were given oral technetium-99m-rhenium sulfide colloid (15-20 MBq; 0.5 mL; n=4) followed by a rinse with water for injection (1.0 mL). Rats were fed and hydrated ad libitum. After 30 min, each rat was contained inside an 'imaging' tube then placed on a g-camera collimator. Whole body 5 min static images were acquired every 30 min up to 9 h, and then finally at 25 hours. Region of interest analyses were applied to the caecum/proximal colon, sigmoidal loop and distal colon/rectum. The tracer entered into the colon at approximately 4 hours, and the rats remained static to permit 'live' imaging. At 4 hours the % whole body activity was: 51% caecum/proximal colon, 39% sigmoidal loop, 6% distal colon/rectum; at 8 hours, 30% caecum/proximal colon, 13% sigmoidal loop, 7% distal colon/rectum. In the whole colon there was < or =1% of total activity present at 25 hours, and the half clearance time was determined as 4.0 hours. These results suggest this is a reliable technique of measuring regional colonic transit as a measure of colonic motility in normal rats. This methodology might be well suited to screen potential motility effects of drug candidates.     

Chest radiographs in the evaluation of the febrile infant

Chest radiographs are often considered an essential part of the workup of the febrile infant. Anteroposterior and lateral radiographs of the chest are frequently obtained in this group of patients, irrespective of respiratory tract symptoms and/or signs. A total of 226 children (less than or equal to 2 years old) with and without signs and symptoms of lower respiratory tract infections were examined to assess the yield of chest radiographs. The radiograph was considered positive only if a focal parenchymal infiltrate was present. Hyperinflation or bronchial thickening was not included as a positive finding because these children usually do not receive antibiotics despite the fact that viral illness or reactive airway disease may be present. In a retrospective study of 105 infants, confidence intervals for yield were established for children with (95% Cl = 12%, 32%) and without (95% Cl = 0%, 14%) symptoms or signs of lower respiratory tract infection. In a prospective study of 121 infants without chest symptoms or signs, confidence levels for positive yield were better defined (95% Cl = 0%, 3%). The data suggest that obtaining chest radiographs to look for parenchymal infiltrates treatable with antibiotics in infants less than 2 years old is necessary only in those infants who have clinical evidence of lower respiratory tract illness.     

The left lateral view in the plain-film assessment of abdominal distension.

Since the left lateral position facilitates the entry of air into the rectosigmoid, it has been employed in the plain-film evaluation of patients with abdominal distension. The value of this view is illustrated by examples of patients with (a) colonic ileus due to imipramine hydrochloride (Tofranil) or chlorpromazine, (b) partial mechanical obstruction due to diverticulitis, (c) involvement of the rectum by Hirschsprung's disease, and (d) sequential evaluation of a patient with clindamycin colitis. This simple maneuver is recommended for (a) evaluation of patients with plain-film evidence of low colonic obstruction, (b) problems of differential diagnosis between bowel obstruction and ileus, and (c) evaluation of patients with conditions affecting the rectosigmoid.     

Multi-detector CT-colonography in inflammatory bowel disease: prospective analysis of CT-findings to high-resolution video colonoscopy

AIM: Prospective analysis of multi-detector CT-colonography (MDCTC) in patients with inflammatory bowel disease (IBD) compared to high-resolution video-endoscopy (HRVC). MATERIALS AND METHODS: Twenty-one patients (mean age 49.6 years) with Crohn's disease or ulcerative colitis underwent MDCTC (Somatom Volume Zoom, Siemens, Erlangen; 1mm collimation, Pitch 8, 100 mAs, 120 kVp). HRVC was performed within 2 h after MDCTC. MDCTC was analyzed by two blinded readers. MDCTC-findings including bowel wall alterations and extraintestinal changes were compared to results of HRVC. RESULTS: Over-all-sensitivity was 100% for endoluminal lesions with correct diagnosis of two cancers. Acute and chronic IBD were correctly identified by MDCTC in 63.6%, and 100%, respectively, with a specificity of 75%, and 100%. Sensitivity, specificity, positive and negative predictive values of MDCTC for diagnosis of acute and chronic disease were best for chronic disease. Sensitivity was worst for acute ulcerative colitis and specificity was worst for acute Crohn's disease. Haustral loss was seen only in ulcerative colitis. Pseudopolyps and fistulae were findings exclusive to Crohn's disease. Particularly extraintestinal findings as increased vascularization and local lymphadenopathy correlated well with endoscopic definition of acute disease. Because of the possibly more vulnerable colonic wall in acute inflammatory bowel disease, the air inflation for MDCTC should be performed most carefully to avoid any risk of colonic perforation. CONCLUSION: MDCTC may help to distinguish between patients with acute and chronic IBD. Especially extraintestinal complications, tumorous as well as pseudo-tumorous lesions can be detected with high sensitivity and specificity.     

Evaluation of the gasless abdomen in the newborn and young infant with metrizamide

The finding of a gasless abdomen on the abdominal radiograph of an infant over 12 hr old is usually abnormal and may reflect a serious pathologic disorder. Accurate diagnosis is important to plan appropriate therapy. A careful review of the clinical history and the plain chest and abdominal radiographs will often permit an accurate diagnosis to be made. In cases where the diagnosis remains in doubt, contrast studies of the bowel with metrizamide have proved helpful. This report presents six infants with gasless abdomens of unknown cause. In each case, a metrizamide contrast study of the bowel was helpful in providing an accurate diagnosis.     

Non-obstructive colonic dilation: radiologic findings in 50 patients following colonoscopic treatment

Fifty patients with acute onset of colonic dilatation without mechanical obstruction were evaluated before and after colonoscopic decompression. Colonic dilatation, as demonstrated radiographically, was segmental or consistent with mechanical obstruction in 33 (66%). Signs of impending cecal perforation were seen in five (10%) and these patients had colonoscopic decompression, tube cecostomy, or both. Following colonic decompression, cecal diameter may remain unchanged for two to four days, despite decreased abdominal girth and even shortening of the colon radiographically. Improvement in pain, distention, tenderness, fever and leukocytosis may precede radiographic improvement. The radiologist must recognize this entity, look for signs of impending perforation and signs of bowel shortening, with or without decompression after treatment. Barium studies of the colon should be avoided since they can hamper the endoscopic diagnosis and treatment of colonic dilatation.     

Microcolon of prematurity: a form of functional obstruction

Six premature infants (birth weights 920-1320 g) developed marked abdominal distension after birth, and contrast enema examination showed a microcolon. Four of the six were born to mothers with toxemia who received magnesium sulfate. Bilious emesis was absent in all six, despite marked distension and failure to pass meconium. None of the patients had aganglionosis or cystic fibrosis; five of six were followed without surgery and recovered spontaneously. The sixth had perforation 8 hr after contrast enema and required bowel diversion; this infant also survived. This appears to be an equivalent form in small premature infants of the "small-left-colon syndrome" seen in term infants. Surgery should be reserved for complications; it is not necessarily indicated by the finding of a microcolon in such patients.     

256-MSCT对先天性心脏病婴儿心脏成像的冠状动脉检出情况

目的探讨256-MSCT对复杂性先天性心脏病婴儿(1岁内)心脏成像时的冠状动脉检出情况。方法从789例行256-MSCT检查的<1岁的患儿中随机抽取100例,评价冠状动脉节段的成像情况(按10个节段计算),包括检出的节段数目及血管清晰度。结果总节段检出率为51.7%,左主干(LM)及右冠状动脉(RCA)近段检出率分别为96%和99%,左前降支(LAD)、左回旋支(LCX)、RCA各支血管的节段检出率分别为53.33%、33.67%、53.33%。左、右冠状动脉近段血管清晰度评分(4分/3分/2分/1分)分别为LM(62例/22例/12例/4例)和RCA(56例/20例/17例/7例)。患儿平均接受的有效剂量为(0.898±0.282)mSv。结论 256-MSCT对复杂性先天性心脏病婴儿(1岁内)心脏成像时的冠状动脉检出情况较为满意,尤其对左、右冠状动脉近段检出率很高,且血管清晰度明显提高,能够满足临床诊断需求。     

Giant colonic diverticulum

Five patients with giant colonic diverticulum (GCD) are reported. Three of them had complications of the GCD including free perforation with pneumoperitoneum and peritonitis and an instance of carcinoma arising in a GCD. The preoperative diagnosis of GCD is made radiographically with findings of a large, smoothly marginated, round or oval, homogenous radiolucency in the abdomen that is in close apposition to the colon on barium enema examination. Barium enters the GCD in 60% of the cases. Most GCDs are considered to be pseudodiverticula; however, an occasional case may have all layers of bowel in the wall of the diverticulum and is believed to represent a true diverticulum or a communicating partial colonic duplication.     

新生儿及小婴儿巨结肠经肛门改良Soave根治术的应用

目的：介绍经肛门改良加Soave巨结肠根治术的方法，观察术后临床疗效。方法：先天性巨结肠患儿12例，手术年龄17—90d，体重3．1—7．0kg。手术于肛门齿状线上5—10mm环形切开直肠粘膜．下拖并向上分离直肠粘膜约20—25mm，此处切断直肠肌鞘，分离直肠，将病变肠管由肛门拖出切除，近端结肠切缘于直肠粘膜齿状线上切缘吻合。结果：平均手术时间87min，术后次日开始进食，患儿恢复良好，平均出院时间为8．6d。近期随访效果良好。结论：经肛门改Soave巨结肠根治手术打击小，术后患儿恢复快，此法治疗新生儿及小婴儿巨结肠是安全可行的。     

Abdominal echography in colonic diseases

In the past few years, several studies have assessed the visualization of digestive diseases by ultrasound, but its clinical accuracy has been rarely defined. Thus we evaluated the contribution of sonographic examination as an initial diagnostic mean in the detection of colonic lesion. During a period of thirty six months (June 85-June 88) when we performed a standard sonographic abdominal examination, we utilized ultrasound to look for thickening or other modifications of the large bowel wall, if the clinical findings suggested a colonic disease. In these conditions we performed 453 US examinations. In our study, 363 cases were considered to be negative and the controls demonstrated colonic wall lesions in 24 cases. Thus the sensitivity was one of 77%. The sonographic examination was positive in 90 cases with 6 false positives. Thus our specificity reached 98.2% and the accuracy achieved was 93.3%. Thus sonographic examination appears to be a rapid, non invasive, mobile, mean of examining the abdominal cavity and also the large bowel in all patients. If this examination is negative, a colonic disease is possible since sensitivity is 77%. On the other hand, if the examination is positive, a colonic disease is very probable, since specificity reached 98.2%. The accuracy of US Colonic examination is 93.3% and with using abdominal plain film, theses percentages may be improved.     

Sudden unexpected infant deaths associated with car seats

The purpose of this study was to investigate the frequency, circumstances, demographics, and causes of death of infants dying while seated in car safety seats. A retrospective review of a pediatric autopsy database at a specialist center over a 16-year period was undertaken to identify any infant deaths (aged <1 year), in whom death occurred while seated in a car safety seat. Fourteen car seat-associated deaths were identified from a total of 1,465 coronial infant autopsies (0.96 %). Four involved infants were being appropriately transported in the car seat, all of whom had a medical underlying cause of death (one infection and three congenital heart disease). The majority (10 cases; 70 %) occurred while car seats were being inappropriately used, outside of the car, including as an alternative to a cot or high-chair. Five of these infants died of explained causes, but four deaths remained unexplained after autopsy, and in one no cause of death was available. There were no cases of previously healthy infants dying unexpectedly in a car seat when it was being used appropriately, and in this series there were no cases of traumatic death associated with car seats, either during road traffic accidents, or from falling or being suspended from a car seat. Infant deaths in car seats are rare. These data support the recommendation that car seats be used only for transport and not as alternatives for cots or high-chairs. More research is required to investigate the effect of travel in car seats on infants with underlying conditions. There appears to be no increased risk of unexpected deaths of healthy infants transported appropriately in car seats.