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.     

Schatzki ring in pediatric and young adult patients

Background

A Schatzki ring (SR) is an uncommon finding in children. Entities previously associated with an SR include gastroesophageal reflux (GER), hiatal hernia (HH) and eosinophilic esophagitis (EE).

Objective

The purpose of this study was to evaluate the overall incidence of SR and the frequency of the different entities associated with SR in the pediatric population.

Materials and methods

All radiology reports finalized between January 2000 and December 2009 were queried to identify patients with an SR. Each study identified through the search was reviewed to confirm the presence of a SR. The patient’s electronic medical record was then searched to identify all associated findings.

Results

A total of 18,668 upper gastrointestinal (GI) examinations or esophagrams were performed in 15,410 children and young adults during the study period. After reviewing the reports and images, 25 patients (0.2% of all patients) were confirmed to have a SR. Of these 24 patients (96%) had HH; 10/25 (40%) had EE, and 10/25 (40%) had GER.

Conclusion

SR is a rare diagnosis in children. Three entities are commonly associated with a ring: HH, EE and GER. Because of the relatively high incidence of EE, endoscopy and biopsy should be considered whenever a SR is identified in a child.     

Upper gastrointestinal bleeding in children: an 11-year retrospective endoscopic investigation

Background

Upper gastrointestinal bleeding (UGIB) may present as hematemesis, coffee-ground emesis, or melena requiring esophagogastroduodenoscopy (EGD) for diagnosis and/or therapy. Worldwide, differences exist for the etiology of UGIB reflecting geographical differences in common disease states. In the past 25 years, there have been improvements in endoscopic optics. This study was undertaken to determine: 1) if identifying a bleeding source in UGIB have improved with better endoscopic optics, 2) geographic differences in causes of UGIB, 3) differences in severity of UGIB based on clinical factors, and 4) the likelihood of fi nding a bleeding source based on symptom duration and time to endoscopy.

Methods

A retrospective chart review was made on children having EGD for evaluation of UGIB. Data collected included type, etiology, and degree of bleeding.

Results

Of 2569 diagnostic procedures, 167 (6.5%) were performed for UGIB. The most common presentation was hematemesis (73.4%). Melena was associated with lower hemoglobin levels and higher transfusion rates. A source of UGIB was found in 57.0%, no cause in 11.4% and a questionable cause in 29.7%. A source was found less commonly in children with a history of UGIB less than one month and in those undergoing endoscopy over 48 hours after a bleeding episode.

Conclusions

Improved endoscopic optics has not changed diagnostic ability for UGIB. Etiologic differences for UGIB in children from varying geographic areas are related to indication for endoscopy, patient selection, and co-morbid conditions. Duration of bleeding and time to endoscopy after a bleeding episode may help predict when endoscopy should be performed to determine a bleeding source.     

A novel diagnostic and treatment strategy for small intestinal lesions in children: hybrid treatment using transumbilical minimal incision surgery combined with double-balloon enteroscopy

Introduction

Double-balloon enteroscopy (DBE) is a useful and feasible modality for evaluating small intestinal lesions, even in children.

Methods

DBE makes it possible to perform biopsy, diagnosis, polypectomy and endoscopic therapies including hemostasis, tattooing and clipping of the small intestinal lesions. However, endoscopic procedures in the small intestines of children are more difficult than in adults, because the intestinal wall is thin and the lumen is narrow. A novel hybrid treatment was developed using DBE for small bowel lesions combined with transumbilical minimal incision surgery.

Conclusion

This hybrid treatment is safe, effective, provides excellent cosmetic results and can be used as an alternative for traditional open laparotomy or endoscopic surgery.     

Acoustic radiation force impulse (ARFI) elastography for the noninvasive diagnosis of liver fibrosis in children

Background

Acoustic radiation force impulse (ARFI) imaging) is correlated with histopathological findings using METAVIR and semiquantitative scoring system (SSS) criteria for liver fibrosis.

Objective

To compare acoustic radiation force impulse imaging with biopsy results in the evaluation of liver fibrosis in children.

Materials and methods

Children with chronic liver disease and healthy children underwent acoustic radiation force impulse imaging liver measurements. ARFI gives a shear-wave velocity corresponding to tissue elasticity. In 39 children with liver disease, the values obtained were correlated with biopsy results. Receiver-operating characteristic (ROC) curves were used to determine the reliability of ARFI in estimating liver fibrosis in children.

Results

ARFI mean value was 1.12 in the healthy group and 1.99 in children with chronic liver disease. ROC curves show that an ARFI cutoff of 1.34 m/s is predictive of both METAVIR and SSS scores with a sensitivity of SSS >?2:0.85; METAVIR > F0:0.82. A cutoff of 2 m/s yielded a sensitivity of 100% to detect SSS > 4 or METAVIR > F2.

Conclusion

Acoustic radiation force impulse imaging is a reliable, noninvasive and rapid method to estimate moderate to severe liver fibrosis in children. It might prove useful to clinicians for fibrosis monitoring in children with liver disease and postpone the time of liver biopsy.     

Celiac Disease in Children with Moderate-to-Severe Iron-deficiency Anemia

Objective

To evaluate the proportion of children with moderate to severe iron-deficiency anemia who have associated celiac disease.

Methods

This cross-sectional analytical study was conducted among children aged 1 to 12 years of age with moderate-to-severe iron deficiency anemia and control children without anemia.Serum IgA-tissue trans-glutaminase levels were assessed in both cases and controls. All children with positive celiac serology underwent upper gastrointestinal endoscopy and duodenal biopsy; biopsy finding of Marsh grade 3 was considered positive for celiac disease.

Results

There were 152 anemic children and 152 controls with mean (SD) hemoglobinof 7.7 (1.8) and 12.2 (0.74) g/dL, respectively. 16 (10.5%) cases and 3 (2%) control patients had positive serology for celiac disease [OR (95% CI) 5.33 (1.52-18.67), P=0.007]. Six (3.9%) children with iron-deficiency anemia and none of the controls had biopsy features diagnostic of celiac disease.

Conclusion

In the Northern Indian tertiary-care hospital outpatient setting, Celiac disease was associated with 4% of children presenting with moderate-to-severe anemia.

     

Prevalence of Celiac Disease in Indian Children with Down Syndrome and its Clinical and Laboratory Predictors

Objective

To study the prevalence of celiac disease in Indian children with Down syndrome and evaluate its clinical and laboratory predictors.

Methods

Prevalence of celiac disease (CD) was assessed in 100 patients with Down syndrome (DS) attending pediatric genetic clinic at All India Institute of Medical Sciences,in a prospective observational study, based on the characteristic symptomatology, positive indirect immunofluorescence anti endomyseal antibody(anti EMA) test and duodenal histology based on adapted Marsh criteria. Clinical and laboratory features were compared in children having both CD and DS and those with DS alone.

Results

Anti EMA was positive in 7 out of 100 patients screened for CD; 6 in whom the duodenal biopsy could be done showed histopathological features consistent with celiac disease. Amongst various clinical features evaluated as possible risk factors; pallor reached statistical significance (OR?=?7.04 95%CI 1.08–45.7). In addition anemia (Hb <11 g%) was significantly associated with CD (p?=?0.06).

Conclusions

The present results showed a high prevalence of CD in DS children in a tertiary hospital in India and low hemoglobin to be an important risk factor. The authors recommend that all Indian children with Down syndrome, particularly those with anemia should be screened for celiac disease.     

Congenital duodenal obstruction in neonates: a decade’s experience from one center

Background

Congenital duodenal obstruction (CDO) is one of the most common anomalies in newborns, and accounting for nearly half of all cases of neonatal intestinal obstruction. This study aimed to review our single-center experience in managing congenital duodenal obstruction while evaluate the outcomes.

Methods

We conducted a retrospective analysis of the records of all neonates dianogsed with congenital duodenal obstruction admitted to our center between January 2003 and December 2012. We analyzed demographic criteria, clinical manifestations, associated anomalies, radiologic findings, surgical methods, postoperative complications, and final outcomes.

Results

The study comprised 287 newborns (193 boys and 94 girls). Birth weight ranged from 950 g to 4850 g. Fifty-three patients were born prematurely between 28 and 36 weeks’ gestation. Malrotation was diagnosed in 174 patients, annular pancreas in 66, duodenal web in 55, duodenal atresia or stenosis in 9, preduodenal portal vein in 2, and congenital band compression in 1. Twenty patients had various combinations of these conditions. Presenting symptoms included bilious vomiting, dehydration, and weight loss. X-rays of the upper abdomen demonstrated the presence of a typical double-bubble sign or air-fluid levels in 68.64% of patients, and confirmatory upper and/or lower gastrointestinal contrast studies were obtained in 64.11%. Multiple associated abnormalities were observed in 50.52% of the patients. Various surgical approaches were used, including Ladd’s procedure, duodenoplasty, duodenoduodenostomy, duodenojejunostomy, or a combination of these. Seventeen patients died postoperatively and 14 required re-operation.

Conclusions

Congenital duodenal obstruction is a complex entity with various etiologies and often includes multiple concomitant disorders. Timely diagnosis and aggressive surgery are key to improving prognosis. Care should be taken to address all of the causes of duodenal obstruction and/or associated alimentary tract anomalies during surgery.     

The role of laparoscopy in the treatment of duodenal obstruction in term and preterm infants

Purpose

The aim of this study was to evaluate the role of laparoscopy in the surgical treatment of intrinsic and extrinsic duodenal lesions referring to the underlying cause of obstruction.

Methods

Retrospective chart review of all cases of duodenal obstructions undergoing surgery at our institution between April 2004 and March 2012.

Results

Twenty patients underwent surgery for duodenal obstruction (11 female, 9 male). Seven infants were born prematurely. Eleven infants had extrinsic, seven had intrinsic and two had a combination of intrinsic and extrinsic duodenal lesions. A laparoscopic procedure was initially started in 18 of 20 patients (90?%). Thirteen of the 18 infants (72?%) underwent various laparoscopic procedures: laparoscopic duodenoduodenostomy, resection of a duodenal membrane and the transsection of Ladd’s bands. In five patents, a conversion became necessary due to poor visualisation of the duodenum. In three patients (15?%) with extrinsic duodenal lesion a reoperation was necessary. Two of the 20 patients (10?%) were operated with an “open” approach to begin with.

Conclusion

Laparoscopy is feasible and safe in most cases. The few conversions were early in the series due to a lack of experience and necessitated by poor visualisation, most often caused by malrotation.     

Percutaneous drainage of intra-abdominal abscess in children with perforated appendicitis

Background

Because the surgical management of perforated appendicitis remains controversial, percutaneous catheter drainage (PCD) has gained favor for managing periappendiceal abscess in hemodynamically stable children.

Objective

To determine the safety and effectiveness of PCD in children with perforated appendicitis and to identify any variables of prognostic value.

Materials &; methods

We retrospectively evaluated clinical data and imaging features for 33 children undergoing PCD for periappendiceal abscess from October 2006 to February 2010. Those with preprocedural CT studies were assigned to one of three risk categories based on imaging features.

Results

Appendectomy was successfully postponed for all patients. Our technical success rate was 87.9%, with three recurrences (two requiring repeat drainage, one managed conservatively) and one possible complication (enterocutaneous fistula formation). Children with large and diffuse abscesses had a 50% rate of technical failure, which was significantly increased when compared to children with large but localized abscesses (P?Conclusion PCD can be effective for managing perforated appendicitis in children. Children with large and ill-defined abscess might be at increased risk for complication or recurrence.     

Correlation of 99mTc sucralfate scan and endoscopic grading in caustic oesophageal injury

Purpose

To determine a correlation between the 99mTc sucralfate scan and the endoscopy findings in children with caustic oesophageal injury.

Methods

This is an observational analytic study of children who had both 99mTc sucralfate scan and endoscopy after caustic substance ingestion at our institution in a period between January 2009 and September 2016. The oesophageal injury was classified into low grade and high grade according to the degree of adhesion on 99mTc sucralfate scan and modification of Zargar endoscopic grading.

Results

Out of a total of 197 children, 40 children were identified who had both investigations done on average 26 h post-injury. Low-grade adhesion on 99mTc sucralfate scan was found in 27 children (68%), and all had low-grade Zargar’s oesophageal injuries. None of these subsequently developed residual pathology. Thirteen had high-grade adhesion and five of these had high-grade injury on endoscopy. Three (23%) developed oesophageal strictures. Correlation of 99mTc sucralfate and endoscopic findings reached statistical significance with a p value of 0.0014. No morbidity was associated with either the scan or endoscopy.

Conclusions

We concluded that low-grade sucralfate scan finding has the potential to successfully eliminate the need for invasive endoscopy under general anaesthesia and thereby reducing procedure-related morbidity, hospitalization and associated costs. However, mandatory endoscopy is required in children with high-grade adhesion seen on 99mTc sucralfate scan. This requires confirmation using a larger prospective study.

     

Fetal gastrointestinal MRI: all that glitters in T1 is not necessarily colon

Background

It has been described that both the colon and distal ileum present with a physiological hypersignal on T1-weighted sequences during the second and third trimesters of pregnancy because of their protein-rich meconium content, it was unclear whether the normal characteristics that have been described on fetal MRI can be applied to gastrointestinal (GI) obstructions.

Objective

To analyse the localisation value of T1 hypersignal within dilated bowel loops in fetuses with gastrointestinal tract obstruction.

Materials and methods

A retrospective 4-year multicentre study analysing cases of fetal GI obstruction in which MRI demonstrated T1 hypersignal content in the dilated loops. Data collected included gestational age (GA) at diagnosis, bowel appearance on US, CFTR gene mutations and amniotic levels of gastrointestinal enzymes. The suggested prenatal diagnosis was eventually compared to postnatal imaging and surgery.

Results

Eleven patients were included. The median GA at US diagnosis was 23 weeks (range 13–32). In eight cases there was a single dilated loop, while several segments were affected in three. The median GA at MRI was 29 weeks (range 23–35). One case presented with cystic fibrosis mutations. Final prenatally suspected diagnoses were distal ileal atresia or colon in nine cases and proximal atresia in two. Postnatal findings were proximal jejunal atresia in nine cases and meconium ileus in two. In five cases the surgical findings demonstrated short bowel syndrome.

Conclusion

In cases of fetal occlusion, T1 hypersignal should not be considered as a sign of distal ileal or colonic occlusion. The obstruction may be proximal, implying a risk of small bowel syndrome, which requires adequate parental counselling.     

Utility of CT in the diagnosis and management of small-bowel obstruction in children

Background

CT is often used in the diagnosis and management of small-bowel obstruction in children.

Objective

To determine sensitivity of CT in delineating presence, site and cause of small-bowel obstruction in children.

Materials and methods

We retrospectively reviewed the CT scans of 47 children with surgically proven small-bowel obstruction. We noted any findings of obstruction and the site and cause of obstruction. Presence, absence or equivocal findings of bowel obstruction on abdominal radiographs performed prior to CT were also noted. We reviewed patient charts for clinical details and surgical findings, including bowel resection. Statistical analysis was performed using Fisher exact test to determine which CT findings might predict bowel resection.

Results

CT correctly diagnosed small-bowel obstruction in 43/47 (91.5%) cases. CT correctly indicated site of obstruction in 37/47 (78.7%) cases and cause of obstruction in 32/47 (68.1%) cases. Small-bowel feces sign was significantly associated with bowel resection at surgery (P?=?0.0091). No other CT finding was predictive of bowel resection. Out of 41 children who had abdominal radiographs before CT, 29 (70.7%) showed unequivocal obstruction, six (14.6%) showed equivocal findings and six (14.6%) were unremarkable.

Conclusion

CT is highly sensitive in diagnosing small-bowel obstruction in children and is helpful in determining the presence of small-bowel obstruction in many clinically suspected cases with equivocal or normal plain radiographs. CT also helps to determine the site and cause of the obstruction with good sensitivity.     

Tracheobronchial calcifications in children

Background

Tracheobronchial calcifications are considered a rare radiologic finding in children. Our clinical experience indicates that this finding is not infrequently seen among children with prosthetic heart valves who have been treated with warfarin sodium.

Objective

We hypothesized that calcifications of the tracheobronchial tree are more common than previously reported in this patient population.

Materials and methods

We reviewed the medical records and imaging studies of children who underwent cardiac valve replacement at our institution to estimate the prevalence.

Results

Tracheobronchial calcifications were identified on chest radiographs in 6 out of 17 children (35%), indicating that this imaging finding might be frequently overlooked.

Conclusion

All children positive for tracheobronchial calcifications had been anticoagulated with warfarin sodium between the time of surgery and development of positive imaging findings. Our findings suggest that tracheobronchial calcifications are not uncommon in children treated with warfarin. Further investigation is necessary to determine wether there is a cause–effect relationship in these children.     

Imaging features of pancreatic tumors in children: 13-year experience at a pediatric tertiary hospital

Background

Pancreatic tumors are rare in children, resulting in limited information regarding their frequency and imaging appearances.

Objective

To review all pancreatic tumors seen in children over a decade at a large tertiary pediatric institution and to describe multimodality imaging findings.

Materials and methods

We conducted a retrospective review of imaging studies performed in children with pancreatic tumors between January 2000 and December 2012, analyzing imaging features on available US, CT and MR examinations. We reviewed patient charts for clinical features, management and final diagnosis.

Results

We included 23 children in this study. Of these, 12 had solid and papillary epithelial neoplasms (SPEN), 3 had neuroendocrine tumors, 3 had lymphoma, and 1 each had hemangioendothelioma, benign congenital cysts with adipose tissue, dendritic cell sarcoma, metastatic rhabdomyosarcoma, and lipoma. All children with SPEN were teenage girls. SPEN showed characteristic imaging features including well-defined margins with surrounding capsule, solid-cystic components and hemorrhage.

Conclusion

Pancreatic tumors are uncommon in children. SPEN is the most common tumor and is seen predominantly in teenage girls and shows characteristic imaging features.     

Duodenal pathologies in children: a single-center experience

Objective

Several studies have been performed concerning pathologies of the stomach and esophagus in the pediatric age group. However, there have been very few studies of duodenal pathologies in children. The authors aimed to examine the clinical, endoscopic, and histopathological characteristics, as well as the etiology of duodenal pathologies in children.

Glossopexie als Therapie der ersten Wahl bei hochgradiger Glossoptosis

Background

Glossoptosis is a dangerous but often overlooked cause of upper airway obstruction in infants. An operation may be necessary in serious cases. Two operative methods are available: tracheostomy and glossopexy. Tracheostomy guarantees a definite solution for the airway obstruction, but is known to have a considerable morbidity and mortality risk. In contrast, the effectiveness of glossopexy is often judged to be uncertain. We present our experience with glossopexy procedures and discuss the prerequisites for successful therapy.

Method and patients

Between 1997 and 2002 we conducted five glossopexy procedures in infants with glossoptosis. In all patients a standardized airway endoscopy under spontaneous respiration was conducted before operation. For glossopexy a modification of the technique by Randall was used.

Results

In all patients airway obstruction disappeared directly after operation. No intra- or postoperative complications and no delays in swallowing or speech development were observed.

Discussion

We therefore recommend glossopexy as the treatment of first choice for patients with severe true glossoptosis.     

Paediatric endoscopy by adult gastroenterologists in Ile-Ife,Nigeria: A viable option to increase the access to paediatric endoscopy in low resource countries

Background:

Paediatric endoscopy performed by adult gastroenterologists is a service delivery model that increases the access of children to endoscopy in countries where paediatric gastroenterologists with endoscopy skills are scarce. However, studies on the usefulness of this model in Nigeria and Sub-Saharan Africa are scarce. We aimed to evaluate the indications, procedures, diagnostic yield and safety of paediatric endoscopy performed by adult gastroenterologists in a Nigerian tertiary health facility.

Materials and Methods:

It was a retrospective study that evaluated the records of paediatric (≤18 years old) endoscopies carried out in the endoscopy suite of Obafemi Awolowo University Teaching Hospital Complex Ile-Ife, Nigeria from January 2007 to December 2014.

Results:

A total of 63 procedures were successfully completed in children of whom 4 were repeat procedures which were excluded. Thus, 59 endoscopies performed on children were analysed. Most (49; 83.1%) of these procedures on the children were diagnostic with oesophagogastroduodenoscopy being the commonest (43; 72.9%). Epigastric pain (22; 37.3%), haematemesis (17; 28.8%) and dysphagia (9; 15.3%) were the predominant indication for upper gastrointestinal (GI) endoscopy while haematochezia (9; 15.3%) and rectal protrusion (2; 3.4%) were the indications for colonoscopy. Injection sclerotherapy (3; 5.1%) and variceal banding (2; 3.4%) were the therapeutic upper GI endoscopic procedures conducted while polypectomies were performed during colonoscopy in 5 children (8.5%). Abnormal endoscopy findings were observed in 53 out of the 59 children making the positive diagnostic yield to be 89.8%. No complication, either from the procedure or anaesthesia was observed.

Conclusion:

Paediatric endoscopy performed by adult gastroenterologists is useful, feasible and safe. It is being encouraged as a viable option to fill the gap created by dearth of skilled paediatric gastroenterologists.Key words: Endoscopy, gastroenterology, gastrointestinal, Ile-Ife, Nigeria, paediatrics     

Melanotic neuroectodermal tumour of infancy: CT and MR findings

Background

Melanotic neuroectodermal tumour of infancy (MNTI) is a rare neoplasm of neural crest origin.

Objective

To describe three further cases of MNTI, with emphasis on CT and MRI findings.

Materials and methods

Data for children with histologically confirmed MNTI following biopsy or surgery were retrieved. Three children with available imaging at the time of diagnosis were included in the study.

Results

All three children had primary tumour in the head and neck region: one in the maxilla, one in the occipital bone (extra-axial but with intracranial extension) and one with an unusual tumour growing exophytically from the subcutaneous tissues adjacent to the occipital bone. All tumours were iso/hypointense both on T1- and T2-weighted MRI, and showed marked contrast enhancement in their non-ossified components. CT allowed identification of bone destruction and remodelling.

Conclusion

Our findings are consistent with previously reported cases of MNTI regarding age at presentation and location in the head and neck region. Our MR findings did not demonstrate the typical pattern of T1-shortening expected from melanin deposition.     

Long-term outcome of inflammatory bowel disease—Unclassified in children

Objectives

To document the frequency at diagnosis and evolution over time of inflammatory bowel disease-unclassified in children.

Methods

Analysis of case records (2004–2011) of patients diagnosed with inflammatory bowel disease-unclassified following uppergastrointestinal endoscopy, ileocolonoscopy and small bowel imaging. Any subsequent diagnostic reclassification by 2016 was recorded.

Results

344 children diagnosed as inflammatory bowel disease: 58% Crohn’s disease, 34.5% ulcerative colitis, and 7.5% (n=26) inflammatory bowel disease-unclassified. 25/26 inflammatory bowel disease-unclassified patients were followed for 4.5–11.5 years. 17 of these patients needed endoscopic reevaluation leading to changed diagnosis in ten (Crohn’s disease 7, ulcerative colitis 3).

Conclusion

7.5% (25/344) of inflammatory bowel disease children had inflammatory bowel disease-unclassified at diagnosis; 10 (40%) evolved into Crohn’s disease or ulcerative colitis.