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Paton PCW Handout 20180430 · Specific Radiology Examinations • Chest X-ray (CXR) • Abdominal...
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3/30/18 1 Common Radiology Studies in Pediatric Surgery A Scenario Based Approach to Interpretation for the Pediatric Nurse and Provider presented by Elizabeth 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.
Transcript of Paton PCW Handout 20180430 · Specific Radiology Examinations • Chest X-ray (CXR) • Abdominal...
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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
