US findings of melamine-related renal disorders in Hong Kong children

Background

The melamine-tainted milk incident has caused renal disorders in more than 290,000 children from mainland China since the start of the outbreak in 2008. Since then, more than 27,000 children in Hong Kong have undergone renal US screening.

Objective

To present and discuss the US features of melamine-related renal abnormalities in Hong Kong children.

Materials and methods

Between September 2008 and February 2009, 3,835 children attended the Department of Radiology of Princess Margaret Hospital for renal US examination. CT or plain abdominal radiography was performed in those with inconclusive findings. The US findings of detected melamine-related renal disorders were analysed.

Results

Echogenic foci in the kidneys were found in 22 children (0.6%). These were located in the renal pelvicalyceal system (in 12 children) and in the renal medulla (in 10 children). The echogenic foci measured 0.1–0.7 cm, with 6 children showing posterior acoustic shadowing, 14 showing comet-tail artefacts, and 2 showing echogenic dots.

Conclusion

The incidence of renal disorders amongst Hong Kong children exposed to melamine was lower than in their mainland China counterparts. The renal stones detected were also relatively small, with most demonstrating comet-tail artefacts instead of posterior acoustic shadowing.     

Imaging features of intravesical urachal cysts in children

Background

Urachal cysts, part of the spectrum of congenital urachal anomalies, are typically extrinsic to the urinary bladder.

Objective

The purpose of this study is to present the salient imaging features of a pediatric series of unusual intravesical urachal cysts that protrude into the bladder lumen.

Materials and methods

Five children with intravesical urachal cysts depicted on imaging studies were retrospectively identified during a 6-year period at a children’s hospital. The clinical charts and findings on ultrasound (US) and voiding cystourethrogram (VCUG) were reviewed.

Results

In all five children, US revealed a thin-walled ovoid cystic structure containing anechoic fluid or echogenic debris and residing along the midline of the anterosuperior aspect of the urinary bladder protruding into the bladder lumen. Histological examination of the partial cystectomy specimen from one child revealed a cystic urachal remnant with intestinal mucosal lining and reactive lymphoid hyperplasia. The cysts in the four other children were managed conservatively without operative intervention.

Conclusion

The purpose of this report is to expand the spectrum of urachal remnant anomalies to include these newly recognized intravesical urachal cysts, which are characterized on US by the presence of a thin-walled cyst along the midline anterosuperior aspect of the urinary bladder.     

Sonographic assessment of the retroperitoneal position of the third portion of the duodenum: an indicator of normal intestinal rotation

Background

The diagnosis of intestinal malrotation is based on an upper gastrointestinal contrast series (UGI), which is considered the imaging reference standard. It may however be challenging even for experienced paediatric radiologists.

Objective

The purpose of this study was to demonstrate the agreement between UGI and US in assessing the position of the third portion of the duodenum (D3) and to show that a retroperitoneal duodenum indicates normal forgut rotation.

Materials and methods

In a prospective study, US assessment of the duodenum and the superior mesenteric vessels was performed in consecutive children who were referred for clinically indicated UGI at a single institution.

Results

Eighty-five children, 5?months to 14?years old, were studied. In 82/85 (96%), both US and UGI suggested normal forgut rotation. In three children, US demonstrated a normal position of the D3 whereas UGI showed an abnormal position of the duodeno-jejunal junction.

Conclusion

US is a non-invasive, easily performed technique for excluding malrotation. UGI may be reserved for situations where US does not demonstrate a normal position of the D3.     

Application of a second-generation US contrast agent in infants and children—a European questionnaire-based survey

Background

No US contrast agent (US-CA) is currently licensed for use in children.

Objective

To survey the off-label use in children of a second-generation US-CA.

Materials and methods

Questionnaires were e-mailed to European paediatric radiologists, who were asked about their experience with the second-generation US-CA Sonovue? (Bracco, Milan, Italy). Number of examinations per indication and adverse effects were recorded. Examinations were categorised by intravenous or intracavitary use of US-CA.

Results

Out of 146 respondents, 88 stated that they did not perform contrast-enhanced US in children, but 36 of these (44%) would appreciate paediatric approval. Forty-five centres reported 5,079 examinations in children (age mean: 2.9?years; range: birth–18?years, M/F: 1/ 2.8). The majority (4,131 [81%] in 29 centres) were intravesical applications. The minority (948 [19%] in 30 centres) were intravenous applications. No adverse effects had been recorded from intravesical use. Six minor adverse effects (skin reaction, unusual taste, hyperventilation) had been recorded after five intravenous studies (0.52%).

Conclusion

Responses suggest a favourable safety profile of this second-generation US-CA in children. It also demonstrates a demand for such US-CA from paediatric radiologists.     

Ureteral polyps: an etiological factor of hydronephrosis in children that should not be ignored

To better define the demographics, urothelial distribution and typical gross anatomic and radiologic appearances of fibroepithelial polyps of the ureter in children. We reviewed 15 cases of fibroepithelial polyps of the ureter with hydronephrosis from the archives of our department. Data were collected from radiographic studies, gross anatomic pathology and pathology and radiology reports and categorized by age, sex, clinical presentation, lesion size and location. The mean patient age was 9.1 years, and 80% were male. All of them presented with hematuria and/or flank pain. The polyps were located in the upper ureter or ureteropelvic junction (UPJ) and pelvis. Of the polyps, 60% were multiple polyps or filiform, and 40% were single or bilobed and 1–6 cm in size. Only four cases showed typical filling defect on intravenous urography. In five cases, sonography showed a mildly echogenic structure extending into the ureter from the renal pelvis. Enhanced CT revealed soft tissue filling UPJ or/and proximal ureter in six cases, and hydroureter was found in one case by three-dimensional (3D) image. Fibroepithelial polyps were diagnosed in all cases by postoperative histological examination. Fibroepithelial polyps are the most common benign tumors of the ureter. Congenital factor may be associated with the origin of fibroepithelial polyps in children. The preoperative diagnosis of ureteral polyps is difficult. A history of flank pain, hematuria or both, other than abdominal mass, light-to-moderate hydronephrosis with soft-tissue in UPJ or upper ureter, shown by sonography and radiological examination, may help in the diagnosis of ureteral polyps in children. Ureteral polyps should be recognized as an important etiology for hydronephrosis in children.     

Doppler US measurement of the superior mesenteric artery blood flow in children and adolescents

Background

Blood flow volume in the superior mesenteric artery (SMA) measured by pulsed Doppler has been used in adults to evaluate Crohn disease but has not been utilized in children and adolescents.

Objective

To establish a cutoff point for normal SMA blood flow using pulsed Doppler US measurement in healthy children and adolescents.

Materials and methods

The study included healthy volunteers from an urban community, divided into two age groups, children (5–9?years) and adolescents (10–17?years). Anthropometric measurements included waist circumference and body surface area classified according to the z-score of body mass index. Heart rate, blood pressure, oxygen saturation and temperature were measured immediately before US evaluation.

Results

The average age of the 60 participants was 12.2?years. Of these, 21 (35%) were ages 5–9?years and 39 (65%) were ages 10–17?years; 21 (35%) were boys. Findings of the two examiners coincided for 58 of the 60 (96.7%) participants. SMA blood flow was significantly lower in the children (mean ± SD?=?556?±?122?ml/min) than in adolescents (mean ± SD 775?±?311?ml/min) (P?<?0.001). SMA blood flow showed statistically significant positive associations with body surface area.

Conclusion

We found that superior mesenteric artery blood flow is significantly lower in children than in adolescents and is associated with body surface area.     

Renal sonography with Doppler for detecting suspected pediatric renin-mediated hypertension – is it adequate?

Background

Renal Doppler US is used to evaluate suspected vascular causes of hypertension in children, despite mostly unknown diagnostic performance characteristics.

Objective

To evaluate renal Doppler US for detecting vascular causes of hypertension in children with high clinical suspicion of aortic or renal artery narrowing.

Materials and methods

We identified pediatric renal Doppler US examinations performed for hypertension between January 1995 and June 2010 at our institution. We excluded children without follow-up angiography (CT-, MR-, or catheter-based). Two pediatric radiologists reviewed imaging studies and documented relevant findings. Intrarenal spectral Doppler resistive index measurement <0.5 or tardus parvus waveform constituted a positive examination.

Results

Thirty-five boys and 13 girls underwent renal Doppler US and confirmatory imaging (mean age? =? 9.0 years). Nineteen US examinations were truly negative, two were falsely negative, 18 were truly positive (16 involved narrowing of the aorta or main renal artery) and nine were falsely positive. Sonography had a sensitivity and specificity of 90% and 68%, respectively, for detecting a vascular cause of hypertension.

Conclusion

Renal Doppler sonography reliably detects renin-mediated hypertension caused by aortic or main renal artery narrowing in children. More studies are needed to determine its ability to detect intrarenal and accessory renal artery stenoses.     

Melamine-induced urinary calculi in infants—sonographic manifestations and outcomes 1 year after exposure

Background

In 2008, the melamine-tainted-milk incident started with reports of increased incidence of urolithiasis in infants in China. Affected children were screened for urolithiasis.

Objective

The purpose of this study was to analyze sonographic characterization of infant melamine-induced urolithiasis.

Materials and methods

Transabdominal US examination was done in 603 infants with melamine-induced calculi. The imaging characteristics of calculi and hydronephrosis were analyzed. Follow-up US imaging was performed.

Results

Comet-tail sign was seen behind the calculus of <4 mm. Calculi of ≥4 mm were found in 299 inpatients with clear posterior border and with or without light shadowing. Solitary and multiple stones had similar incidence. Incidence of calculi in the inferior renal calyx was the highest (55.2%) in inpatients. Calculus size in inpatients age 2–3 years was smaller than that of children younger than 2 years old (P?<?0.05). Inpatients age 2–3 years had the highest incidence rate (48.0%) of hydronephrosis.

Conclusion

Calculi of <4 mm manifested as hyperechoic foci near the renal papillae, while calculi of ≥4 mm usually manifested as echogenic foci with visible inferior edge in the renal calyx. Hydronephrosis was a common imaging finding in inpatients ages 2–3 years.     

Ultrasound and colour Doppler in infantile subglottic haemangioma

Background

Subglottic haemangioma causes progressive and life-threatening stridor, typically manifesting at age 2?C3?months. Standard diagnosis is by laryngoscopy. Larynx sonography is rarely used but allows assessment of the presence and extension of a mass that impinges on the subglottic airway. The additional use of colour Doppler enables demonstration of the vascular nature of such masses.

Objective

To compare US and endoscopic findings in infants with subglottic haemangioma and to evaluate accuracy of US and colour Doppler imaging in this diagnosis.

Materials and methods

We report eight infants with subglottic haemangioma seen in our institution over the last decade. They presented with laryngeal stridor and were all investigated with both US and endoscopy. Six infants underwent colour Doppler sonography.

Results

US and endoscopic findings showed excellent anatomical correlation in lateral subglottic haemangioma. Colour Doppler imaging was deemed helpful in four infants.

Conclusion

Larynx sonography with complementary colour Doppler imaging was non-invasive and helpful in the diagnosis of subglottic haemangioma.     

Dynamic US study in the evaluation of infants with vertical or oblique talus deformities

Background

Congenital vertical talus (CVT) is a rare foot deformity that is sometimes difficult to differentiate from oblique talus (OT) by physical examination and foot radiography.

Objective

The purpose of this study was to summarize our experience with US in evaluation of CVT and OT deformities.

Materials and methods

We identified all children (2005–2011) younger than 6 months who underwent dynamic focused US of the foot at our tertiary-care facility to evaluate clinically equivocal cases of CVT. Diagnostic criteria for CVT were persistent talonavicular dislocation on forced plantar flexion of the foot. OT was diagnosed based on reduction of the talonavicular dislocation on forced plantar flexion. Medical and imaging charts were reviewed for diagnosis on US and plain radiographs (when available) and for underlying neuromuscular disorders, treatment and outcome on follow-up.

Results

Ten patients (eight boys and two girls, mean age 33 days) were evaluated by US for CVT. Radiographs of the foot were obtained in only two children and were non-diagnostic. Thirteen feet were evaluated by US. Diagnosis of CVT was confirmed by surgery in seven children, three of whom had bilateral CVT. Diagnosis of OT in three children was supported by response to casting treatment.

Conclusion

Dynamic US can reliably distinguish between CVT and OT deformities.     

Seasonal and day of the week variations of perforated appendicitis in US children

Purpose

The present study aimed to determine whether children with perforated appendicitis were more likely to present during specific days of the week or seasons of the year.

Methods

After obtaining IRB exemption, a retrospective, population-based study of patients <18 with ICD9 codes of acute (540.9) or perforated (540.0, 540.1) appendicitis in the Kids’ Inpatient Database (KID) was performed. Univariate and multivariate analyses were performed analyzing patient and hospital factors.

Results

A total of 31,457 children were identified with acute appendicitis, of whom 10,524 (33.5%) were perforated. Mondays [odds ratio (OR): 1.16; 95% Confidence Interval (CI): 1.05?1.28] were significant for increased likelihood as day of presentation with perforation in US children more than any other day of the week. In seasonal analysis, fall (OR: 1.12; 95% CI: 1.04?1.21) and winter (OR: 1.11; 95% CI: 1.03?1.20) were at higher odds for perforation at presentation. Patients with Medicaid (OR: 1.22; 95% CI: 1.03?1.43) and those uninsured (OR: 1.50; 95% CI: 1.16?1.93) were more likely to present with perforation.

Conclusion

Perforated appendicitis was more likely to present on Mondays in US children. Although appendicitis is most common in summer months, rates of perforated appendicitis were highest in fall and winter.     

The impact of early sonographic evaluation on hospital admissions of children with suspected acute appendicitis

Purpose

Early ultrasound (US) evaluation of children with abdominal pain and suspected acute appendicitis (AA) is an important diagnostic tool. Since 2007, US has become part of routine emergency room (ER) work-up performed for suspected pediatric AA in our hospital.

Methods

We retrospectively compared hospital admissions from 2007 to 2008 with those from 2005 to 2006, when most ultrasounds were done after admission to Pediatric Surgery for observation.

Results

During the study (2005?C2008), 6,511 children came to the ER with acute abdominal pain. Although pediatric ER sonography increased from 28.1% (865/3,079) in 2005?C2006 to 51.7% (1,775/3,432) in 2007?C2008 (p?<?0.0001), hospitalizations decreased from 33 to 30.1% (p?=?0.011). Concurrently, ER US for AA increased from 20.8% (639/2,440) to 38.9% (1,336/2,096) (p?<?0.0001), admissions for suspected AA decreased from 51.8% (331/639) to 42% (561/1,336) (p?<?0.0001).

Conclusions

Sonography led to a significant decline in admissions and better selection of patients who required surgery for AA. Recurrent ER referrals for the same complaint within 2?weeks was very low (2.9%) with no difference between the two study periods (p?=?1); none had AA. These findings encourage us to continue early US in children with suspected AA. This effective tool decreases unnecessary hospital stays, investigative procedures, and surgery, while reducing costs.     

Laparoscopy versus ultrasonography for the evaluation of Mullerian structures in children with complex disorders of sex development

Purpose

The diagnosis of children with disorders of sex development (DSD) requires a karyotype, different biochemical and radiological investigations in the context of a multidisciplinary team. The aim of this study was to compare the diagnostic accuracy of laparoscopy (L) versus ultrasonography (US) in the assessment of children with complex DSD.

Methods

We retrospectively examined the theatre database searching for children with DSD who underwent laparoscopic surgery from 1999 to 2011. The medical and radiological records were reviewed.

Results

Eighteen patients were identified. Age at diagnosis ranged from birth to 14?years (mean 2.5?years). There were seven patients with 46XY dysgenetic testicular DSD (4 mosaic Turner, 3 mixed gonadal dysgenesis), seven patients with 46XY non-dysgenetic testicular DSD (4 persistent Mullerian duct syndrome, 2 complete androgen insensitivity syndrome, one unknown), two patients with ovotesticular DSD, one patient with 46XX DSD (congenital adrenal hyperplasia) and one patient with 46XY DSD complete sex reversal. Fifteen underwent ultrasonography prior to laparoscopy. Both modalities identified Mullerian structures in seven (47?%) patients, in one (7?%) patient US and L confirmed the absence of Mullerian structures, while in six (40?%) patients there was discordance, with US failing to visualize pelvic Mullerian structures. In the last patient with 46XY non-dysgenetic testicular DSD, the rectum was thought to be a dilated uterus on ultrasonography.

Conclusions

Pelvic ultrasonography failed to identify Mullerian structures in 40?% of patients with complex DSD. On the contrary, laparoscopy allowed excellent visualization of pelvic structures and gonads in children with complex DSD.     

Radiographic signs of open median sternotomy in neonates and infants

Background

Leaving the median sternotomy wound open following cardiac surgery is employed to avoid cardiovascular compression. Horizontal struts can be used. Radiologists interpreting portable radiographs might be unaware of the open median sternotomy (OMS).

Objective

To describe the frequency of radiographic signs of OMS and to increase awareness among radiologists to prevent misdiagnosis of pneumothorax and pneumomediastinum.

Materials and methods

Radiographs of 41 infants (17 girls/24 boys) with OMS were studied (age range 2?days to 8?months, mean 33?days). Central lucency and sternal edges were noted. Interclavicular distances before and after sternotomy were compared.

Results

Central lucency was seen in 25/41 (61%) children. Sternal struts were apparent in 27 (66%). In 14 without struts, central lucency was present in 8 (57%). In 27 children with struts, central lucency was present in 17 (63%) and absent in 10 (37%). Split sternal centers were identified in 6/41 (15%). The mean interclavicular distance was 23.5?mm (SD?=?4.39) before sternotomy and 38.2?mm (SD?=?7.0?mm) after sternotomy (P?Conclusion OMS has characteristic signs in the majority of cases. Recognition of these findings is useful and can prevent misinterpretation.     

Color Doppler US of normal cerebral venous sinuses in neonates: a comparison with MR venography

Background

Color Doppler US (CDUS) has been used for evaluation of cerebral venous sinuses in neonates. However, there is very limited information available regarding the appearance of superficial and deep normal cerebral venous sinuses using CDUS and the specificity of the technique to rule out disease.

Objective

To determine the specificity, inter-modality and inter-reader agreement of color Doppler US (CDUS). To evaluate normal cerebral venous sinuses in neonates in comparison to MR venography (MRV).

Materials and methods

Newborns undergoing a clinically indicated brain MRI were prospectively evaluated. All underwent a dedicated CDUS of the cerebral venous sinuses within 10?h (mean, 3.5?h, range, and 2–7.6?h) of the MRI study using a standard protocol.

Results

Fifty consecutive neonates participated in the study (30 males [60%]; 25–41?weeks old; mean, 37?weeks). The mean time interval between the date of birth and the CDUS study was 19.1?days. No cases showed evidence of thrombosis. Overall agreement for US reading was 97% (range, 82–100%), for MRV reading, 99% (range, 96–100%) and for intermodality, 100% (range, 96–100%). Excellent US-MRI agreement was noted for superior sagittal sinus, cerebral veins, straight sinus, torcular Herophili, sigmoid sinus, superior jugular veins (94–98%) and transverse sinuses (82–86%). In 10 cases (20%), MRV showed flow gaps whereas normal flow was demonstrated with US. Visualization of the inferior sagittal sinus was limited with both imaging techniques.

Conclusion

Excellent reading agreement was noted for US, MRV and intermodality. CDUS is highly specific to rule out cerebral venous thrombosis in neonates and holds potential for clinical application as part of clinical-laboratory-imaging algorithms of pre/post-test probabilities of disease.     

Contrast-enhanced sonography of malignant pediatric abdominal and pelvic solid tumors: preliminary safety and feasibility data

Background

Little information exists regarding pediatric contrast-enhanced US.

Objective

To assess the safety and feasibility of contrast-enhanced US of pediatric abdominal and pelvic tumors.

Materials and methods

This prospective study included eight boys and five girls (mean age, 10.8?years) with abdominal or pelvic tumors. Cohorts of three subjects underwent US with perflutren contrast agent at escalating dose levels. Neurological and funduscopic examination, electrocardiography and continuous pulse oximetry were performed before and after contrast administration. Three radiologists independently scored six imaging parameters on pre- and postcontrast sonography. Inter-reviewer agreement was measured by the Kappa statistic.

Results

No neurological, retinal, electrocardiographical or pulse oximetry changes were attributable to the contrast agent. Two subjects reported minor, transient symptoms. Postcontrast US parameter scores improved slightly in 8 of 12 subjects. Postcontrast ultrasound inter-reviewer agreement improved slightly for detection of tumor margins (precontrast = 0.20, postcontrast = 0.26), local tumor invasion (precontrast = -0.01, postcontrast = 0.10) and adenopathy (precontrast = 0.35, postcontrast = 0.44).

Conclusions

Although our sample size is small, perflutren contrast agents appear to be safe and well tolerated in children. Contrast-enhanced sonography of pediatric abdominal and pelvic tumors is feasible, but larger studies are needed to define their safety and efficacy in children.     

Renal Doppler evaluation in the child with hypertension: a reasonable screening discriminator?

Background

Hypertension is diagnosed in 1–5% of children, and 5–10% of those hypertensive children have renovascular disease. The gold standard for a diagnosis of renal artery stenosis is arteriography, and Doppler ultrasound (Doppler US) continues to be advocated as a useful screening test.

Objective

The purpose of this study was to determine the utility of Doppler US in children as a screening tool and to better define clinical features of children in whom arteriography should be performed.

Materials and methods

This retrospective study evaluated the imaging and clinical parameters for all children who had a renal US with Doppler followed by a diagnostic arteriogram for the evaluation of hypertension during a 12-year period at a tertiary children’s hospital. Sixty-two children were included. We evaluated each child’s clinical parameters and placed each child into one of three categories of hypertension: mild, moderate or severe.

Results

Eleven of 17 kidneys with proven renal artery stenosis were detected with Doppler US (sensitivity 64%). Six children with renal artery stenosis were missed by Doppler US, four of whom had segmental artery lesions. Of the children with positive renal artery stenosis on arteriography, all but three (79%) were classified as having moderate to severe hypertension.

Conclusion

Doppler US is a useful screening examination when evaluating children with hypertension, detecting renal artery stenosis in most affected children. The clinical risk classifications are helpful in guiding which children should proceed with arteriography regardless of the Doppler US results.     

Effectiveness and safety of ultrasound-guided percutaneous liver biopsy in children

Background

Percutaneous liver biopsy (PLB) is an important procedure in the diagnosis and follow-up of paediatric liver disease. Its purpose is to obtain tissue for histopathological observation, in our case, with ultrasound (US) guidance.

Objective

To evaluate the effectiveness and safety of US-guided PLB in children.

Material and methods

A retrospective study over a period of 12?years, from January 1999 until December 2010, with a selection of US-guided PLB performed in children with focal liver lesions or diffuse hepatic disease and liver transplant (LT). A 16-gauge automatic needle was used and a maximum of three fragments of liver were collected. Contraindications were: bile duct dilatation (>3?mm) INR?>?1.5 (reference range, 0.9 -- 1.2) and platelet count <50,000 (reference range, 150,000 -- 450,000). Analysis focused on complications and final diagnosis.

Results

A total of 513 biopsies were performed, 379 (73.9%) in children who had undergone orthotopic LT, 117 (22.8%) in children with liver disease of unknown cause and 17 (3.3%) in children with focal hepatic lesions. Histological diagnosis was obtained in 509 of 513 (99.3%) biopsies performed. Minor complications were registered in 38 patients (7.4%) and major complications occurred in 5 patients (1%). None needed a surgical intervention.

Conclusion

US-guided PLB in children is a safe and efficient method to achieve a specific diagnosis in liver disease.     

Relapse surveillance in AFP-positive hepatoblastoma: re-evaluating the role of imaging

Background

Children with hepatoblastoma routinely undergo repetitive surveillance imaging, with CT scans for several years after therapy, increasing the risk of radiation-induced cancer.

Objective

The purpose of this study was to determine the utility of surveillance CT scans compared to serum alpha-fetoprotein (AFP) levels for the detection of hepatoblastoma relapse.

Materials and methods

This was a retrospective study of all children diagnosed with AFP-positive hepatoblastoma from 2001 to 2011 at a single institution.

Results

Twenty-six children with hepatoblastoma were identified, with a mean age at diagnosis of 2 years 4 months (range 3 months to 11 years). Mean AFP level at diagnosis was 132,732 ng/ml (range 172.8–572,613 ng/ml). Five of the 26 children had hepatoblastoma relapse. A total of 105 imaging exams were performed following completion of therapy; 88 (84%) CT, 8 (8%) MRI, 5 (5%) US and 4 (4%) FDG PET/CT exams. A total of 288 alpha-fetoprotein levels were drawn, with a mean of 11 per child. The AFP level was elevated in all recurrences and no relapses were detected by imaging before AFP elevation. Two false-positive AFP levels and 15 false-positive imaging exams were detected. AFP elevation was found to be significantly more specific than PET/CT and CT imaging at detecting relapse.

Conclusion

We recommend using serial serum AFP levels as the preferred method of surveillance in children with AFP-positive hepatoblastoma, reserving imaging for the early postoperative period, for children at high risk of relapse, and for determination of the anatomical site of clinically suspected recurrence. Given the small size of this preliminary study, validation in a larger patient population is warranted.     

Utility of sonographic assessment of the position of the third part of the duodenum using water instillation in intestinal malrotation: a single-center retrospective audit

Background

Intestinal malrotation and particularly volvulus are potentially devastating conditions. Upper gastrointestinal (UGI) contrast studies have been considered the gold standard for diagnosis. However the use of ultrasonography (US) has been increasingly described. We describe a method for delineating the duodenal anatomy with US as a means to exclude malrotation.

Objective

To report our experience using US to assess intestinal rotation.

Materials and methods

We conducted a retrospective audit of US scans performed at a tertiary referral centre to exclude malrotation for paediatric surgery between 2008 and 2011.

Results

One hundred thirty-nine infants were included, of whom 114 had a normal US scan. Of the 114, nine had subsequent upper gastrointestinal contrast studies that confirmed the initial results; there were no false-negatives. There were abnormal US scans in four infants associated with midgut volvulus and malrotation; there were no false-positives. The other 21 US scans were equivocal, and 11 of these had a confirmatory UGI contrast study; only one required surgery to correct malrotation.

Conclusion

US has been a safe and effective tool in the assessment of intestinal rotation at our institution. The main advantages of US imaging are its lack of ionising radiation and its rapid and accurate diagnosis of volvulus.