Intussusception is not an uncommon phenomenon in children and is one of the commoner causes of the acute abdomen between six months and five years of age. The vast majority of intussusceptions arise in the ileum and are either ileocolic or ileo-ileocolic. They are thought to occur because of hyperplasia of the lymphoid tissue in the ileum, possibly as a result of a viral infection [1, 2].

OBJECTIVEThe purpose of this study was to assess the safety of power injector use in peripheral IV injections for CT examinations of children by measuring the incidence of contrast extravasation and to review the management of extravasation as reported in the literature.SUBJECTS AND METHODSAt a tertiary pediatric center, we prospectively collected data on 557 children undergoing CT with IV contrast injection by power injector through a peripheral venous line. Data collected included age, weight, angiocatheter size, location of venous access, flow rate, total contrast volume, maximum injector pressure, and incidence of extravasation. Adverse effects such as emesis, sensation of warmth, hives, and allergies and anaphylaxis also were recorded.RESULTSThe patients' ages ranged from 13 days to 20 years (mean, 9.8 years). The size of angiocatheter most commonly used was 22 gauge (n = 443). The dorsum of the hand was the most common site of venous access (n = 373). The mean flow rate was 1.48 mL/s. When the patients were divided into groups on the basis of reaction or no reaction, statistical differences between the groups were found with respect to flow rate (p = 0.016) and pressure (p = 0.017) needed for injection. There were two episode of extravasation (0.3%), which were treated conservatively.CONCLUSIONThe use of power injectors through 18- to 24-gauge angiocatheters in children is safe when meticulous technique is used and personnel are appropriately trained. Our study showed a similar rate of extravasation as has been reported in other studies.

Objective To assess the value of spinal radiographs in determining the significance of reductions in bone mass or density in chronically ill children.Study design A pediatric scoring method for assessment of osteoporotic vertebral changes, developed on the basis of radiographs of 70 healthy controls and established adult scoring methods, was subsequently used to assess 32 pediatric patients with suspected secondary osteoporosis. Radiographic findings were correlated with bone mineral density (BMD), clinical data, and biochemistry.Results Thirty-two patients (median age 14.1 years) were included. Assessment of spinal radiographs with the developed scoring method found previously undiagnosed spinal compression deformities in 11 patients (34%) of whom 9 were asymptomatic and 8 had lumbar spine (size-corrected) MID measurements within +/- 2.0 SD of the age- and sex-specific norms. Fracture history and cumulative glucocorticoid (GC) dose did not differ between those with and without compression deformities.Conclusions Vertebral compression fractures can be documented in a significant number of chronically ill children and are poorly predicted by single BMD measurements and clinical history. Assessment of vertebral morphology is recommended as an additional tool in the diagnostic workup of pediatric osteoporosis.

OBJECTIVE. The sonographic double wall sign has been well described in the literature and is often the cornerstone in suggesting the diagnosis of an enteric duplication cyst. We report two cases with this sign that were erroneously diagnosed as enteric cysts and a third case without this sonographic feature that proved to be a duplication cyst. Histologic analysis of the specimens helps explain the cause of the sonographic pitfalls.CONCLUSION. The potential sonographic visualization of the split hypoechoic muscularis propria layer or identification of all five layers will increase the specificity in making the sonographic diagnosis of duplication cyst.

Three of 20 patients with juvenile osteoporosis were found to have a heterozygous mutation in the LRP5 gene. No mutations were found in the type I collagen genes. Mutations in the other family members with similar bone phenotype confirmed that LRP5 has a role in both juvenile and adult osteoporosis.

Background/Purpose: The anticipated level of aganglionosis can influence the surgical approach to Hirschsprung's disease. The aim of this study was to determine the accuracy of the contrast enema in predicting this level.Methods: Over a 6-year period (1995 through 2000), 88 patients with Hirschsprung's disease underwent surgical correction. Preoperative contrast enema findings were available for 75 of these patients and were compared with operative and pathology reports. Data were analyzed by chi(2).Results: The contrast enema showed a transition zone suggestive of Hirschsprung's disease in 67 of 75 patients (89%). In 59 of 67 (88%), the pathologic and radiographic transition zones were concordant. Seven of the 8 patients with discordant studies had total colonic (n = 5) or long-segment (n = 2) disease. Contrast enema correctly predicted the level of aganglionosis in 55 of 62 (89%) patients with rectosigmoid disease but only 4 of 13 (31%) of those with long-segment or total colonic disease (P < .01). Of the patients with a radiographic transition zone in the rectosigmoid, 54 of 60 (90%) had a matching level of aganglionosis.Conclusions: In rectosigmoid Hirschsprung's disease, the location of the radiographic transition zone correlates accurately with the level of aganglionosis in 90% of cases. However, the small incidence of discordance between anticipated level of aganglionosis and operative findings should be recognized, particularly when planning a one-stage transanal pull-through.

X-Linked hypophosphatemic rickets (XLH) is characterized by hypophosphatemia, rickets, and impaired growth. Despite oral phosphate and 1,25-dihydroxyvitamin D(3) treatment, many patients have suboptimal growth and bone healing. The aim of this study was to assess whether age at treatment onset impacts the outcome. Growth data, biochemistry, and radiographs of 19 well-controlled patients with XLH were analyzed retrospectively. Patients were divided into two groups based on the age at treatment onset (group 1, <1.0 yr; group 2, >or=1.0 yr). The median height z-score was higher in group 1 (n = 8) than in group 2 (n = 11) at treatment onset [-0.4 SD score (SDS) vs. -1.7 SDS; P = 0.001], at the end of the first treatment year (-0.7 SDS vs. -1.8 SDS; P = 0.009), throughout childhood (P > 0.05) and until predicted adult height (-0.2 SDS vs. -1.2 SDS; P = 0.06). The degree of hypophosphatemia was similar in both groups, but serum alkaline phosphatase remained higher in group 2 throughout childhood. Radiographic signs of rickets were more marked in group 2, but even patients with early treatment developed significant skeletal changes of rickets. These data suggest that treatment commenced in early infancy results in improved outcome in patients with XLH, but does not completely normalize skeletal development.

We reviewed the utility of fine-needle aspiration biopsy (FNAB) in the management of thyroid nodules in 41 children and adolescents (35 girls; mean age, 13.3 years). Cytologic findings were benign in 30, malignant in 2, suspicious in 6, and insufficient in 3. The malignancy rate was 5%, with no false-negative results. Diagnostic accuracy for FNAB was 87% and inter-observer reliability was 88%. FNAB is safe and highly accurate in the evaluation of thyroid nodules in childhood.

Despite the widespread use of liquid nitrogen in medicine and industry, there are only a few reports of injuries associated with its use. We report a case of a 13-year-old boy who developed gastric perforation after liquid nitrogen ingestion. This is a previously unreported complication.

Objective. To review the imaging appearances, management and outcome of a large number of children with intussusception owing to pathologic lead points (PLP) in an attempt to define the role of various imaging modalities in this clinical setting.Materials and methods. Review of the records and imaging studies of 43 children with intussusception due to PLP diagnosed between 1986 and 1999.Results. The commonest PLP found were Meckel diverticulum, polyps, Henoch-Schönlein purpura and cystic fibrosis. PLP were depicted on sonography in 23 (66 %) of 35 patients, on computed tomography in 5 (71 %) of 7, on air enema in 3 (11 %) of 28, and on barium enema in 6 (40 %) of 15. Air enema successfully reduced 60 % of the intussusceptions. Nine children had recurrent intussusceptions.Conclusion. Sonography depicted two-thirds of PLP and provided a specific diagnosis in nearly one-third of our series. Our review does not provide sufficient data on how to continue the investigation of those patients in whom sonography does not depict a PLP but in whom there is a high index of suspicion for its presence. It remains a diagnostic challenge as to how to search for PLP in these patients, and other imaging modalities have to be requested according to each particular case.

Background . To analyze the spectrum of clinical features, management and outcome of children with documented spontaneous reduction of intussusception (SROI). Materials and methods. Review of records of 50 children (33 boys, 17 girls; age range 11 days–15 years; mean age 4 years) with documented SROI, in whom intussusception was initially diagnosed by sonography (US) in 44, air enema in 2, and computed tomography in 4, in the 6-year period 1992–1998. Results . Symptoms suggestive of intussusception were present in 21 (3 of whom had Henoch-Schönlein purpura and 4 had previous ileocolic intussusception reduced by air enema). Intussusception was an incidental finding in the other 29, in 28 of whom the finding was in the small bowel. Intussusception was limited to the small bowel in 43 and was ileocolic in 7. SROI was usually documented on US. Laparotomy performed in only 4 showed no evidence of intussusception or pathologic lead point. Outcome in all patients was favorable. Conclusions . SROI may present in symptomatic or asymptomatic children and occurs more commonly than previously reported. These intussusceptions are usually short-segment, small-bowel intussusceptions with no recognizable lead point. In asymptomatic patients, conservative observation is warranted. Intervention should be dictated by the clinical findings in symptomatic patients.

Objective: To determine the presence and correlates of early heart and blood vessel dysfunction in adolescents with type 1 diabetes mellitus (DM) of relatively short duration. Study design: A total of 33 patients with DM (20 male, mean age 15.8 ± 1.3 years, mean DM duration 9.3 ± 3.9 years) and 16 healthy subjects in a nondiabetic control group (7 male, mean age 17.4 ± 1.7 years) underwent (1) ultrasonography of the right carotid artery to assess distensibility, compliance, and intimal-medial thickness (IMT), (2) echocardiographic assessment of systolic and diastolic ventricular function, (3) lipid profile and hemoglobin A1c, and (4) overnight timed urine collections for albumin excretion rate. Results: Ultrasonography showed significantly lower carotid artery distensibility in the DM group (38.5 ± 8.2 × 10-3 vs 46.5 ± 11.7 × 10-3/kPa, P =.01) but no difference in compliance (14.0 ± 3.4 × 10-7 vs 15.8 ± 2.9 × 10-7m2/kPa, P =.08) or IMT (0.061 ± 0.013 vs 0.060 ± 0.014 cm, P =.77). Left ventricular (LV) end-diastolic diameter, LV posterior wall thickness, end-systolic wall stress, shortening fraction, ejection fraction, LV mass, and diastolic function were similar in both groups. Total cholesterol, low density lipoprotein, high density lipoprotein, triglycerides, and blood pressure were also similar. The median albumin excretion rate was 4.8 μg/min in the DM group (range 1.1 to 19.2) and 3.0 μg/min in the control group (range 1.4 to 5.8) (P =.03). Hemoglobin A1c correlated inversely with both distensibility (r = –.43, P =.02) and compliance (r = –.39, P =.032). Conclusions: This study indicates that early changes in macrovascular function, namely lower carotid artery distensibility, may precede abnormalities in cardiac function or in arterial IMT in adolescents with short duration type 1 DM. It also supports a relationship between hyperglycemia and carotid artery dysfunction. (J Pediatr 2000;137:465-9)

We report two children who presented with multiple renal cysts involving only one kidney and in whom there was no family history of renal disease and who did not have syndromes known to be associated with renal cystic disease. This unilateral involvement may represent a distinct entity, which has only been previously described in three cases; however, long-term follow-up will be needed to confirm this hypothesis. We illustrate the sonographic and computed tomographic findings, and the differential diagnosis is discussed.

HomeRadiologyVol. 217, No. 3 PreviousNext Diagnosis PleaseCase 29: Gastric Trichobezoar and Subphrenic AbscessBenjamin Z. Koplewitz, Alan Daneman, Scott Fields, Raphael Udassin, Sigmund H. EinBenjamin Z. Koplewitz, Alan Daneman, Scott Fields, Raphael Udassin, Sigmund H. EinAuthor Affiliations1From the Departments of Radiology (B.Z.K., S.F.) and Pediatric Surgery (R.U.), Hadassah Medical Center, PO Box 12000, Jerusalem 91120, Israel, and the Hebrew University, Jerusalem, Israel; and the Department of Diagnostic Imaging (B.Z.K., A.D.) and the Division of General Surgery (S.H.E.), the Hospital for Sick Children, Toronto, Ontario, Canada, and the University of Toronto. Received May 12, 1999; revision requested June 10; revision received June 30; accepted July 22. Address correspondence to B.Z.K. (e-mail: [email protected]).Benjamin Z. KoplewitzAlan DanemanScott FieldsRaphael UdassinSigmund H. 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Crossref, Medline, Google ScholarArticle HistoryPublished in print: Dec 2000 FiguresReferencesRelatedDetailsCited ByLarge gastric trichobezoar causing failure to thrive and iron deficiency anaemia in an adolescent girl: a case report emphasising the imaging findings and review of the literatureDuncanLyons2019 | BJR|case reports, Vol. 5, No. 2Gastric perforation secondary to a trichobezoar: A case report and review of the literatureGayatriMalhotra-Gupta, CourtneyJanowski, RichardSidlow2017 | Journal of Pediatric Surgery Case Reports, Vol. 26Trichobezoar Presenting With Chief Complaints of Chest Pain, Weight Loss, and Gastrointestinal BleedingMatthewRamirez, RahulPathak, CynthiaWebber, David J.McLario2011 | Pediatric Emergency Care, Vol. 27, No. 4Trichotillomania ± trichobezoar: revisitedVNSehgal, GSrivastava26 May 2006 | Journal of the European Academy of Dermatology and Venereology, Vol. 20, No. 8Trichobézoard géant chez l'enfant. 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Pneumatic reduction of idiopathic intussusception is successful in about 80% of cases, while 60% of the failures are reduced at surgery without resection. To determine whether delayed, repeated attempts at enema reduction of failures would reduce the need for operation in selected cases, over a 2-year period (1994-1996 inclusive), 17 infants with idiopathic intussusception underwent delayed repeat enemas 2-19 h following the first failed attempt at reduction. Clinical parameters and radiologic findings were evaluated with respect to outcome. Ten intussusceptions were successfully reduced after the second attempt in 9 and after the fourth attempt in 1. Seven children underwent a laparotomy, 5 because of failure of progressive reduction at air enema (AE). Two were taken to surgery early in the series, 1 because of perforation during a second attempt and 1 while awaiting a third reduction attempt. The 10 successful reductions all showed progressive movement of the intussusceptum on each AE; the 2 who perforated failed to show progressive reduction on their second AE. Because of these cases, the remaining 5 were referred to surgery because of failure of progressive reduction of the intussusceptum on the second attempt. At laparotomy, of the 7 unsuccessful reductions, 4 required resection and 3 had difficult manual reduction. The presence of vomiting, a mass, and/or bloody stools were not predictors of outcome. Failures had higher body temperatures (38.1 +/- 0.3 vs 37.4 +/- 0.1 degrees C, P = 0.07), heart rates (153.7 +/- 8 vs 136.9 +/- 2.1 min, P = 0.03), and longer duration of symptoms (36.8 +/- 4 vs 21.3 +/- 3.6 h; P = 0.01) than successes. Delayed repeat AEs may be safe and effective in selected cases of idiopathic intussusception, but should be considered only if significant movement of the intussusceptum is noted at each attempt. The ideal time for repeat AE reduction prior to surgery is not established, but 2-4 h appears appropriate. Pyrexia, tachycardia, and duration of symptoms greater than 36 h are relative contraindications to this course of management.