Case report of a neonate presenting within 1 h of birth with right side scrotal swelling and a dusky skin discoloration thought clinically to be a hydrocele or testicular torsion. Ultrasound examination demonstrated bilateral hydroceles, more prominent on the right, scrotal oedema and a perinephric loculated fluid collection secondary to right adrenal hemorrhage. We review the ultrasound appearance of the normal and haemorrhagic neonatal adrenal and discuss the differential diagnosis of both neonatal adrenal lesions and scrotal swellings. The role and benefits of ultrasound in the primary diagnosis and management of neonatal adrenal hemorrhage is emphasized.

A 30-month-old male child presented to the Accident and Emergency Department with a 3 week history of limping and refusing to bear weight on the right leg. Over the last 6 months he had suffered from spells of diarrhoea and vomiting and had become increasingly pale and lethargic. On examination he was miserable and had a flexion deformity of the right hip. The abdomen was distended and a right sided mass was present. The previous medical history revealed no significant illness.

Magnetic resonance (MR) has an important role to play in the imaging of the paediatric chest, not least because of its zero ionizing radiation dose. Computerized tomography (CT) has been the preferred technique for cross-sectional imaging to date because of the ease of access, speed and superior spatial resolution. This article discusses the clinical situations where magnetic resonance may be used as the primary cross sectional imaging modality. The clinical indications and the complimentary roles of magnetic resonance and computerized tomography are discussed. The patient preparation, technical aspects, advantages and disadvantages of MR are documented.

Epithelioid haemangioendothelioma has not been previously described in a patient with congenital hemihypertrophy and diabetes mellitus. Hepatic nodules were incidentally discovered on a routine US examination searching for known associated abnormalities. Pulmonary nodules were present on chest X-ray and CT of the lungs. The diagnosis was confirmed by open biopsy of a hepatic nodule. Despite significant disease progression the patient remains symptom free.

AIM:To evaluate whether radiologists can accurately differentiate Wilms' tumours from other paediatric abdominal masses with renal involvement using modern imaging methods alone.METHODS:From February 1993 to June 1997, 23 patients presented to the Paediatric Oncology Service at The Royal Hospital for Sick Children, Edinburgh with an intra-abdominal mass which had renal involvement. Nine patients had Wilms' tumours, 12 had neuroblastomas, one patient had xanthogranulomatous pyelonephritis and there was a single case of a mesoblastic nephroma. In each case, two radiologists retrospectively reviewed the initial imaging examinations and independently reached a radiological diagnosis.RESULTS:The radiologists were concordant and reached the correct diagnosis in 20/23 cases (87%), unsure of the diagnosis in one case (4.3 %) and discordant in two cases (8.7 %). Radiologists should be aware that a mesoblastic nephroma can have identical imaging features to a Wilms' tumour. In most cases, ultrasound and a chest X-ray were sufficient to reach the correct diagnosis although computed tomography (CT) and magnetic resonance imaging were superior for demonstrating the relationship of the mass to the great vessels, retroperitoneum and spinal canal. Inferior vena cava invasion was strongly predictive of a Wilms' tumour. Displacement of the great vessels, extension of the mass across the mid-line, renal displacement and tumour calcification on CT were more suggestive of a neuroblastoma although these features were also seen in a significant number of patients with Wilms' tumours. Encasement of vessels by tumour, a paravertebral mass and spinal canal invasion were highly predictive of neuroblastoma.CONCLUSION:In this study, radiologists were accurate at diagnosing Wilms' tumours using modern imaging methods, however, care should be taken in children who are less than 1 year of age as a mesoblastic nephroma may have identical imaging characteristics.

Background. Two cases of pulmonary sequestration which regressed spontaneously are presented. Objective. To demonstrate the value of imaging studies in the diagnosis and follow-up of some forms of congenital masses of the lung in asymptomatic patients. Material and methods. We reviewed the clinical records and imaging studies of two asymptomatic children, one newborn and the other 3 months old, with thoracic masses which demonstrated variable degrees of spontaneous involution. Results. Abdominal ultrasound performed on the newborn with a palpable mass showed a triangular echogenic mass with a large central feeding vessel arising from the aorta. The mass had disappeared on follow-up US exam performed 6 years later. CT was performed in the 3-month-old patient with a persistent retrocardiac mass. A soft-tissue density mass in the left pulmonary base with a large feeding vessel arising from the aorta was visualised on contrast-enhanced CT. Five years later, a new CT scan showed significant shrinkage of the mass and no vessel. Conclusion. Radiological techniques such as real-time US with Doppler imaging and contrast-enhanced CT may establish the diagnosis of pulmonary sequestration by demonstrating the mass and its systemic vessel, thereby eliminating the need for more aggressive imaging procedures. Partial or total disappearance of these masses represents a further example of involutive pathology and suggests that not all cases of pulmonary sequestration should be surgically treated.

Ingestion of disc batteries by infants and small children is an increasing problem. Batteries that remain in the stomach can corrode and damage mucosa and/or produce poisoning. Between 1989 and 1992, 37 children who had swallowed a total of 46 disc batteries presented to the Royal Hospital for Sick Children, Edinburgh, and were referred for battery removal by use of an orogastric magnet under fluoroscopy. Thirty-nine batteries were removed successfully (without anesthesia) from 32 children, using a magnet attached to an orogastric tube. In three cases the battery had passed into the small bowel. In one case, magnet extraction failed, but the two batteries the child had ingested subsequently passed into the small bowel. In two cases the patients refused to swallow the tube. In one of these cases the battery was removed successfully by the magnet, with the patient under general anesthesia; in the other it passed spontaneously into the small bowel. The authors conclude that orogastric magnet removal is a minimally invasive, well-tolerated method of removing ingested disc batteries.

Neonatal adrenal haemorrhage with renal vein thrombosis, an almost exclusively left-sided phenomenon, may occasionally be bilateral in the presence of inferior vena cava thrombus but has only twice been reported as confined to the right side. These cases required a combination of ultrasound (USS), excretion urography, cystoscopy with retrograde pyelography, radioisotopes, and CT to diagnose this rare right-sided combination. We report a case of right adrenal haemorrhage causing right renal vein thrombosis accurately diagnosed using only duplex USS and radioisotopes. The potential complications of renal vein thrombosis and hypertension associated with adrenal haemorrhage requires accurate diagnosis and this paper emphasises the value of duplex USS.

Type I duplication of the rectum is a rare condition that in most reported cases does not occur in association with other congenital malformations. We describe three cases, two of which had duplications of other structures: the first had a functioning supernumerary pelvic kidney, the second a duplication of the bladder, urethra, and vagina; the third had no associated malformations but was unusual, because the duplication cyst lay anterior to the rectum, and unique in that the diagnosis of an intra-abdominal cyst was made by ultrasonic examination.

We present four unusual colonic complications of acute lymphoblastic leukaemia which occurred during the early induction period of chemotherapy. These included a transverse colitis, a haemorrhagic proctitis, a caeco-colic intussusception and an ileo-colic intussusception complicating typhlitis. Although complications are rare, they should be considered in the differential diagnosis of abdominal pain in children undergoing chemotherapy.

During the 12 year period, July 1980 to June 1992, 17 patients with blunt splenic trauma, aged 3.5 to 13.2 years (median 7.5), were treated. Ultrasound scanning was found to be valuable for diagnosis as well as follow-up of the healing of splenic injury. Eleven patients were observed on bed-rest without surgical intervention. The remaining six patients underwent exploratory laparotomy for suspected continuing intra-abdominal haemorrhage or because associated injuries rendered assessment of the possibility of intraabdominal bleeding unreliable. In each case the spleen was conserved. There was no mortality or late complication.

Between 1987 and 1992, 54 patients (32 male, 22 female) underwent 62 attempts at pneumatic reduction of intussusception. The mean age at presentation was 12.5 months (range 2.5 to 4 years 4 months). A retrospective review of all cases was performed to identify success rate and factors affecting it.Successful reduction was achieved in 46 cases (74%). One case was complicated by perforation and four cases (7%) by early recurrence. Patients with failed pneumatic reduction were more likely than those with successful reduction to have: (1) long duration of symptoms; (2) bleeding per rectum; (3) small bowel obstruction. Among the 16 cases of failed reduction, surgical findings were: five cases of ileo-ileo-colic intussusception, one with ileo-ileal, one with perforated ischaemic colon during air enema and one whose intussusception was found to be reduced at surgery. Three patients had lead points: Meckel's diverticula in two and a pinworm in one. Resection was required in three cases for non-viable bowel and in another two for the Meckel's diverticula.Pneumatic reduction of intussusception offers a high success rate with few complications. Performing an air enema earlier in the course of the disease may increase the chance of successful reduction.

Primary intrathoracic rhabdomyosarcoma is a rare tumour in childhood. Three cases are presented and the radiological findings and clinical course are reviewed. The radiological manifestations are varied but a rapidly growing soft tissue mass with compression of adjacent structures is the most common. A rare association with an underlying congenital pulmonary cyst is described. The prognosis is worse than for rhabdomyosarcoma at other sites, with a predisposition for cerebral metastases.

An 11-year-old girl with duodenal and jejunal strictures considered to be inaccessible for surgery was successfully treated using balloon dilatation under fluoroscopic control via a duodenostomy. This is the first reported paediatric case of small bowel stricture dilatation using a balloon catheter, and it is also the first report of the small bowel being approached for balloon dilatation through a duodenostomy. This case demonstrates another use for balloon dilatation which appears to be a relatively safe and effective form of treatment for short, subacute strictures involving the gastro-intestinal tract.

Duplex Doppler sonography and direct intracranial pressure (ICP) measurement were performed on 18 patients with infantile hydrocephalus. ICP was measured through a frontal reservoir or ventricular tap using a nondisplacement pressure transducer. The Pourcelot Resistive Index, RI=(peak systolic-end diastoli)/peak systolic velocity was obtained from pulsed-wave Doppler measurements of blood flow velocity in the anterior (ACA) and/or the middle cerebral (MCA) arteries. There was a statistically significant positive correlation between ICP and RIs in the MCA and ACA. Paired RI measurements in 7 patients with raised ICP decreased significantly from a mean of 0.90 pre-tap to 0.75 post-tap. Our results suggest that the RI provides a reliable measure of cerebrovascular resistance in hydrocephalus. Duplex Doppler ultrasonography thus is a useful noninvasive means of monitoring cerebrohaemodynamic change with simultaneous imaging of ventricular size in infantile hydrocephalus.

Seven cases of neonatal pulmonary sequestration are reviewed which illustrate the varied clinical presentations and radiological findings. In four patients, real time ultrasound scanning was used to image the chest and the features are described. In three cases, the systemic supplying artery was demonstrated by duplex Doppler scanning and further invasive investigations were avoided; after a chest radiograph, this should be the examination of choice in the investigation of a neonate with a possible pulmonary sequestration.

To reassess the plain abdominal X ray (AXR) in the initial investigation of childhood urinary tract infection, radiologists from four paediatric units prospectively collected data on the yield from the AXR in 683 children. Five children had renal calculi. All were detected on ultrasound, but one was not visible on the initial AXR. Four spinal abnormalities were identified, none of which prompted any action by the clinician involved. While the costs, in both financial and radiation risk terms, may be small, the benefit of the AXR appears equally small. Where expert paediatric ultrasonography is available we would recommend that the AXR be reserved for patients with haematuria, loin pain, family history of calculus disease, or where further urinary tract infection occurs despite a normal ultrasound scan.

Pulsed Doppler ultrasound was used to assess the renal artery in patients with multicystic kidney. In 7 out of 7 patients there was marked abnormality of the waveform. Doppler ultrasound may be a useful complementary diagnostic method in patients suspected of having a multicystic dysplastic kidney.

A 3-month-old boy presented with a short history progressive respiratory distress and stridor. A chest radiograph showed mediastinal shift to the right. A high-kV radiograph showed apparent complete occlusion of the right main bronchus (RMB) about 1 cm from the carina. At bronchoscopy the RMB was thought to be compressed an extrinsic mass. Adequate ventilation was impossible. Blood gases showed respiratory acidosis. A thoracotomy failed reveal any mass compressing the RMB. Repeat bronchoscopy confirmed a “pit-like” RMB orifice and an inflamed and narrowed left main bronchus (LMB). A brief cardiac arrest followed bronchoscopy. He was successfully resuscitated with adrenaline instilled into the endotracheal tube. Post-operatively, ventilation pressures of 60/15 were required to maintain slight chest movement and acceptable blood gases. He was treated with nebulized adrenaline, ribavirin, steroids and antibiotics. He gradually improved and was extubated after 11 days.