paton pcw handout 20180430 · specific radiology examinations • chest x-ray (cxr) • abdominal...
TRANSCRIPT
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Common Radiology Studies in Pediatric Surgery
A Scenario Based Approach to Interpretation for the Pediatric Nurse and Provider
presented byElizabeth A. Paton, DNP, RN-BC, PNP-A, PPCNP-BC, CPEN, FAEN
Disclosure Information
I have no disclosures
Objectives
By the end of this presentation, the learner will be able to:1. Discuss a basic approach to interpreting common radiology
studies, including chest and abdominal X-rays, upper GIs, and CT scans.
2. Discuss key radiographic findings exhibited by patients with congenital abnormalities.
3. Recognize key abnormal radiological findings with acquired surgical diagnoses.
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Specific Radiology Examinations
• Chest X-ray (CXR)• Abdominal X-ray (KUB)• Computerized topography (CT)
o Chest o Abdomen
• Ultrasound• Upper gastrointestinal series (UGI)• Contrast enema• Esophagram
Chest X-rayQuality:
RotationInclusionPenetrationExpansion
Interpretation:AirwayBoneCardiacDiaphragmExtrathoracic tissuesFieldsGastric bubbleHilum and mediastinumInstrumentation
Abdominal X-ray
Interpretation:• Air• Bowel• Calcifications• Diaphragm• Everything else
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Normal Abdominal X-ray
Air?
Calcifications?
Diaphragm
Everything else
Flat Upright
Bowel
Axial- Abdominal WindowAxial- Lung WindowCoronalSagittal
Computerized Topography (CT) Abdomen
Ultrasound
May be used for diagnosis or evaluation of:• Masses• Appendicitis• Intussusception• Cholelithiasis/cholecystitis• Hypertrophic pyloric stenosis• Malrotation• Ovarian pathologies
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SMA/SMV to Evaluate for Malrotation
SMA= Superior Mesenteric Artery
SMV= Superior Mesenteric Vein
Esophagram
May be used for:• Evaluation for esophageal stricture• Integrity of anastomosis after TE fistula repair• Retained food bolus• Esophageal damage after caustic ingestion (e.g. battery)• Other congenital abnormalities
Esophagram
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Upper Gastrointestinal Series (UGI)
Used to evaluate for:• Duodenal atresia• Malrotation• Strictures or atresias of small bowel• Hypertrophic pyloric stenosis (not modality of choice)
Normal UGI
Normal UGI
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Contrast Enema
Used to evaluate for:• Hirschprung disease• Strictures or atresias of colon• Other reasons for delayed passage of meconium
Treatment for intussusceptionMay use:
• Air• Water soluble contrast• Barium
Normal Contrast Enema
PLACEMEN RADIOLOGICAL FINDINGS OF SPECIFIC SURGICAL DIAGNOSES
MEDICAL DEVICES
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Case Scenario 1
15 year old male presents with acute onset of left sided chest pain• History• PMHx• Vital Signs
o Temperature 37.0 ºCo Heart Rate 84 bpmo Respiratory Rate 36 bpmo Pulse Ox 95% room air
Case Progression
What are your differential diagnoses?• Costochondritis• Trauma• Pneumonia• Pneumothorax• Cardiac processWhat test(s) do you want to order?
Chest X-rayQuality:
RotationInclusionPenetrationExpansion
Interpretation:AirwayBoneCardiacDiaphragmExtrathoracic tissuesFieldsGastric bubbleHilum and mediastinumInstrumentation
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Pneumothorax
Pneumothorax
Case Progression
• What are your interventions?o Chest tube?o Oxygen?o Incentive spirometry?
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Pneumothorax
Case Progression
• What are your interventions?o Chest tube?o Oxygen?o Incentive spirometry?
Pneumothorax
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Chest Tube Placement
(Chest X-ray: Tubes- chest drains-position, 2017)
Case Scenario 2
18 month old female presents with an acute onset of difficulty swallowing
• History• PMHx• Vital Signs
o Temperature 37.0 ºCo Heart Rate 116 bpmo Respiratory Rate 32 bpmo Pulse Ox 99% room air
Esophageal Foreign Body
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Why obtain 2 view X-ray?
Esophageal Foreign Body
Esophageal Foreign Body
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Bronchial Foreign Body
Case Scenario 3
9 year old female presents with 1 day history of abdominal pain• History• PMHx• Vital Signs
o Temperature 38.0 ºCo Heart Rate 92 bpmo Respiratory Rate 26 bpmo Pulse Ox 99% room air
Case Progression
What are your differential diagnoses?• Gastroenteritis• Constipation• Urinary Tract Infection• Ovarian pathology• AppendicitisWhat test(s) do you want to order?
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Appendicitis
Diagnostic Criteria:• Enlarged >6mm diameter• Wall thickening >2mm• Wall enhancement• Fat stranding• Appendicolith• Fluid filled
Appendicitis
Appendicitis
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Appendicitis
Case Scenario 4
5 week old male presents with vomiting• History• PMHx• Vital Signs
o Temperature 37.0 ºCo Heart Rate 144 bpmo Respiratory Rate 36 bpmo Pulse Ox 99% room air
Case Progression
What are your differential diagnoses?• Gastroesophageal reflux• Formula intolerance• Malrotation• Pyloric stenosisWhat test(s) do you want to order?
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Pyloric Stenosis
Diagnostic Criteria:• Muscle Thickness >3mm• Channel Length >14mm• Failure of channel to open and stomach contents to empty
Pyloric Stenosis
Pyloric Stenosis
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Case Progression
• What are your interventions?o Fluid resuscitationo NPOo Monitoring of electrolytes until corrected
§ CO2 <30, Chloride >100o Surgery- pyloromyotomy
Case Scenario 5
15 month old male presents with crampy, intermittent abdominal pain• History• PMHx• Vital Signs
o Temperature 37.0 ºCo Heart Rate 118 bpmo Respiratory Rate 36 bpmo Pulse Ox 99% room air
Case Progression
What are your differential diagnoses?• Gastroesophageal reflux• Gastroenteritis• Constipation• IntussusceptionWhat test(s) do you want to order?
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Intussusception
Intussusception
Intussusception
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Case Scenario 6
5 day old, 29 week preemie, presents with feeding intolerance and blood in stool
• History• PMHx• Vital Signs
o Temperature 37.2 ºCo Heart Rate 156 bpmo Respiratory Rate 36 bpmo Pulse Ox 97% room air
Case Progression
What are your differential diagnoses?• Milk protein intolerance• Anal fissure• Sepsis• Non-accidental trauma• Necrotizing Enterocolitis (NEC)What test(s) do you want to order?
Necrotizing Enterocolitis
Modified Bell Staging Criteria:
• IA: Signs of sepsis, abdominal distention, guaiac positive stools, KUB with normal gas pattern or mildly dilated loops of bowel
• IB: Same except bright blood from rectum
• IIA: Same except pneumatosis intestinalis noted on KUB
• IIB: Thrombocytopenia, abdominal tenderness, portal venous gas
• IIIA: Severely ill, acidotic, neutropenia, DIC, peritonitis, portal venous gas + ascites
• IIIB: Same as IIIA but KUB demonstrates pneumoperitoneum
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Necrotizing Enterocolitis
Pneumatosis
Necrotizing Enterocolitis
PLACEMENT OF MEDICAL DEVICESMEDICAL DEVICES
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Central Venous Line Placement
Superior Vena Cava
Right Atrium
Tip of CVL should be in the superior vena cava or at the cavo-atrial junction
(Chest X-ray: Tubes- CVL lines position, 2017)
Central Venous Line Placement
Central Venous Line Placement
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Central Venous Line Placement
Lines!!!!
ETT
NGT
UAC
Leadwire Leadwire
Temperature Probe
Nasogastric Tube Placement
Note position of side holes
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Post-Pyloric Tube
Weighted feeding tube
Nasojejunal Tube
Gastrostomy Tube Placement
Contrast within stomach
Contrast outside stomach
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CONGENITAL ABNORMALITIESMEDICAL DEVICES
Duodenal Atresia
Coiled Orogastric Tube (OGT)
Absence of distal bowel gas
What is your diagnosis?
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Long Gap Esophageal Atresia
Long Gap Esophageal Atresia
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Coiled OGT
Presence of distal bowel gas
What is your diagnosis?
Esophageal Atresia with Distal Fistula (C)
Work Up for Midline Defects
• Esophageal Atresia +/- Tracheoesophageal Fistula• Imperforate Anus +/- Fistula• Omphalocele
Work Up for Midline Defects
• Physical Exam• Echocardiogram• Renal Ultrasound• Spinal Ultrasound +/- Delayed MRI• Skeletal Survey
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Imperforate Anus with Bucket Handle
Cross-table Lateral
Skeletal Survey
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Skeletal Survey
High Pressure Distal Colostogram
Malrotation
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Malrotation with Midgut Volvulus
Hirschsprung Disease
Hirschsprung Disease
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TRAUMA RADIOGRAPHSMEDICAL DEVICES
AAST Liver Trauma ClassificationGrade I:• Subcapsular hematoma <10% surface area, capsular tear <1cmGrade II:• Subcapsular hematoma 10-50% surface area, capsular tear 1-3 cmGrade III:• Subcapsular hematoma >50%, capsular tear >3cmGrade IV:• Parenchymal disruption 25-76% hepatic lobe or 1-3 segmentsGrade V: • Parenchymal disruption >75% hepatic lobe or >3 segmentsGrade VI:• Hepatic avulsion
(Khan, 2017)
Grade III Liver Laceration
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Grade IV Liver Laceration
Grade V Liver Laceration
MISCELLANEOUS ABNORMALITIESMEDICAL DEVICES
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Pectus Excavatum
Haller Index:243/72 = 3.37
Bezoar
Esophageal Stricture
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LET’S REVIEW SOME IMAGES….
Free Air
Free Air
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Pneumothorax
Central Venous Line Placement
Right Sided Congenital Diaphragmatic Hernia
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Portal Venous Gas and Pneumatosis
Appendicitis
Radiation Exposure
Radiation exposure may lead to:Increased cancer risk throughout lifetime
Pediatric considerationsChildren are more radiation sensitivePotential for radiation exposure over lifetime
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Radiation Exposure
Radiation exposure expressed as effective doseMillisievert (mSv)Considered whole body dose of radiation in relation to environmental exposureTypical environmental exposure is 3 mSv/year
Qualitative risk levelsNegligible- less than 2 days background exposureMinimal- more than 2 days, less than 1 month background exposureVery low- more than 1 month, less than 8 monthsLow- 8 months to 6 yearsModerate- more than 6 years
Radiation Exposure
Type of Exam Months of Annual Background Radiation2 view CXR 10 daysCT scan of abdomen and pelvis 3 yearsUpper GI 2 yearsCT chest 2 yearsCT head 8 months
Radiation Exposure
Helpful websites regarding guidelines for pediatrics:• American College of Radiology
• www.acr.org• Image Gently
• www.imagegently.org• The Society for Pediatric Radiology
• www.pedrad.org
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One last story…..
Special thanks to Tom Boulden, MD for his help and review
References
Chest X-ray: Tubes- chest drains-position. (n.d.). In Radiology Masterclass online. Retrieved from http://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_chest_drain
Chest X-ray:Tubes-CVL catheters-position. (n.d.). In Radiology Masterclass online. Retrieved from http://www.radiologymasterclass.co.uk/tutorials/chest/chest_tubes/chest_xray_central_line_anatomy
Khan, A.N. (2017). Liver trauma imaging. Medscape. Retrieved from https://emedicine.medscape.com/article/370508-overview
Murphy, A. & Hartley, L. (n.d.). Lines and tubes (chest radiograph). In Radiopaedia. Retrieved from https://radiopaedia.org/articles/lines-and-tubes-chest-radiograph