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13 Upper Abdominal US inNeonates, Infants andChildren: (Excluding the Kidneys)
329
• Stenosis, compression, distortion: congenital malformations (e.g. pre- or duode-
nal portal vein) or associated with spinal malformations. Using meticulous US
scanning technique and applying CDS (+ Ce-US?), most conditions can be rec-
ognised. Rarely stenosis of coeliac trunk and mesenteric artery also visible in
children (e.g. after vasculopathies).
• Superior mesenteric artery compression syndrome: difcult to diagnose (posi-
tioning manoeuvres).
• Assessment of functional changes: standardised examination conditions essen-
tial, however, large variation with signicant systemic inuence—few important
entities addressed in respective organ systems chapters (portal hypertension,
PDA, NEC, etc.).
13.8.2.2 Pelvic Congestion Syndrome
Rare in children—usually secondary to nutcracker anatomy of left renal vein or compression/occlusion (e.g. retroperitoneal tumour, renal vein thrombus in Wilms’ tumour).
• Enlarged pelvic vessels with inverted ow direction on CDS (e.g. draining from
cranial to caudal).
• Congestive changes of pelvic structures, particularly ovaries.
• Collateral circulation may be seen as irregular, tortuous, enlarged pelvic veins.
13.8.2.3 Mid-Aortic Syndrome
Abdominal aortic coarctation (small calibre) may affect longer segments or just
upper abdominal aorta.
US and CDS Findings
Depend on extent and involved vessels (i.e. coeliac trunk, SMA origin and renal
arteries):
• Causes stenosis with all respective grey scale and CDS/spectral Doppler nd-
ings: vessel tapering, increased velocity, distal poststenotic ow alterations, tur-
bulence, etc.
If one nds tapering of abdominal aorta, always assure that this is not second-
Note
ary to signicant steal phenomena (e.g. shunt ow by large renal AVM, by hepatic
haemangioendothelioma).
13.8.2.4 Retroaortic Left Renal Vein: Nutcracker Syndrome
See retrospective Chap. 10.
13.8.2.5 Compression by Superior Mesenteric Artery (Also Called
Nutcracker or SMA Syndrome)
Narrow angle between SMA and aorta—causing obstruction to duodenum with
respective symptoms.
Most commonly in very slim (female) patients (anorexia, after weight loss):
330
ab
M. Riccabona
• Only functional (US/uoroscopy) investigations in upright+lying position after
lling stomach and duodenum with uid can aid the diagnosis; the often
discussed low angle between SMA and aorta is uncertain in terms of diagnostic
cut-off values.
13.8.2.6 Arteriosclerotic Changes andAneurysms
Practically nonexistent in children.
Sometimes stenosis as well as aneurysmal ectasia may occur postoperatively
(transplant surgery) and in systemic vascular malformations/disease (e.g. Marfan
syndrome, Takayasu and with ADPKD Type II).
Distortion and compression of vessels can be found in numerous conditions such
as tumours, space-occupying enlargement of various organs, malposition of organs
(e.g. diaphragmatic hernia) and congenital malformations.
US ndings vary, respectively (if area accessible) (Fig.13.46); indirect signs
may be depictable downstream on CDS.
13.8.2.7 Embolic Thrombus toAbdominal Aorta
May occur after cardiac surgery/catheter angiography, as in cardiac malformations
with persisting right to left shunt allowing thrombosis (e.g. from umbilical lines) to
cross from right to left system.
US Findings
• Commonly rather echogenic thrombotic material disrupts anechoic lumen of
aorta with distal tapering due to restricted ow.
CDS Findings
CDS demonstrates ow restriction:
• Similar phenomena hold for emboli to renal/mesenteric arteries, but—due to
vessel size—these embolic entities can usually only be depicted in CDS by lack
Fig. 13.46 Aortic aneurysm after renal transplantation. (a) Grey scale and (b) CDS image of an
aneurysm (++) of abdominal aorta at surgical anastomosis of main transplant artery in an infant
after renal transplantation.
13 Upper Abdominal US inNeonates, Infants andChildren: (Excluding the Kidneys)
of ow and interruption of Doppler signals at site of thrombus (with respective
perfusion decits of affected organs).
331
13.8.2.8 Role ofUS
US—ideal initial investigation when complemented by CDS and spectral
analysis (sometimes ce-US). Complementary imaging: usually CT or MR
angiography.
Catheter angiography mostly used preoperatively or if therapeutic intervention
planned.
13.8.2.9 Complementing Imaging
• US+CDS (ce-US)—ideal initial investigation method.
• Diagnostically complementing: CTA/MRA.
• Catheter angiography: mostly used if therapeutic option planned for same
session.
13.8.3 Retroperitoneal Soft Tissues
13.8.3.1 Lymph Nodes
May be enlarged in inammatory (rare), but most commonly in malignant
disease.
Sometimes difcult to visualise—actively search areas adjacent/in between
abdominal aorta and IVC, e.g. in patients with ovarian or testicular tumours
(Fig.13.47a):
• Criteria resemble ndings in all other body compartments and in mesentery (see
respective entries).
13.8.3.2 Retroperitoneal Tumours
A number of conditions exist: retroperitoneal brosis (Ormond’s disease—
extremely rare in childhood), neuroblastoma/ganglioneuroma (see respective chapter), nerve sheath tumours and neurobroma (see respective chapter), rhabdomyoma,
teratoma, etc.
US ndings nonspecic and resemble aspects as described in principal locations
(see respective chapters):
• Sometimes meticulous US can help narrowing down DDx, e.g. spinal canal inva-
sion in neuroblastoma, destruction/inltration of vertebral body in sarcomatous
tumours, ureteral obstruction in retroperitoneal brosis and continuity with nerve
routes in nerve sheath tumours/schwannoma/neurobroma.
332
Fig. 13.47 Retroperitoneal masses. (a) Retroperitoneal lymph node metastasis/recurrence in a girl
after ovarian tumour at site of left ovarian vein junction with left renal vein. (b) Retroperitoneal
ganglioneuroma seen behind the bladder (axial section). (c) Neuroblastoma of left adrenal gland
region (actually originating from paravertebral plexus tissue) with invasion of the spinal neuroforamen, an obvious bridge of tissue to the neuroforamen (potentially entering the spinal canal) can be
seen in this slightly oblique axial section in the upper abdomen. (d) Retroperitoneal lymphatic
malformation in paramedian right upper abdomen (behind duodenum and liver) with multiple
cysts, some of them exhibit echoes as sign of haemorrhage
M. Riccabona
13.8.3.3 Abdominal Wall
Rarely focus of US in children.
Always use high-resolution linear transducers.
Imaging appearance same as in any other body area, US used as initial assessment tool.
US Findings
• Trauma: haematoma/seroma, muscle disruption—if large, dual image technique
or extended view US may improve documentation, demonstration and measure-
ments (Fig.13.48).
• Hernia and abdominal wall defects (postoperative, posttraumatic, etc.)—
see above.
13 Upper Abdominal US inNeonates, Infants andChildren: (Excluding the Kidneys)
Fig. 13.48 Abdominal wall seroma after huge
traumatic haematoma. Anechoic uid in the
abdominal wall with disrupted abdominal wall
structures/muscles after trauma
Fig. 13.49 Huge desmoid tumour of abdominal wall. (a) Split/dual image. (b) Extended eld
of view US
333
• Hypotrophic or displaced muscles (e.g. rectus diastasis, missing rectus muscle
and diffuse a-/hypoplasia in prune belly syndrome).
• Vascular malformation of abdominal wall vessels, or extending from neighbour-
ing areas.
• Abdominal wall tumours—unspecic ndings:
– For example, desmoids, neurobroma, rhabdomyoma, lipoma and (neuro-)
broma (Fig.13.49).
US oftheGastrointestinal (GI) Tract
MichaelRiccabona
14.1 Stomach
14.1.1 Requisites
Indications
Mostly vomiting (non-bilious), part of other abdominal US.
Patient Preparation
Optimal initially fasted + feeding tea/formula during investigation.
Positioning
14
• Commonly starts in supine position, positioning manoeuvres helpful (changing
to right/left/lateral decubitus).
• Sometimes posterior access may improve assessment, particularly of dorsal parts
or if gas impairs access.
Transducers
• Near eld (pylorus, ventral wall)—high-resolution linear (or curved array)
transducers.
• Deeper parts—curved linear arrays/sector transducers.
• Frequency depends on age and necessary penetration/depth.
M. Riccabona (*)
Department of Radiology, Division of Pediatric Radiology, Medical University Graz
and University Hospital Graz, Graz, Austria
e-mail: michael.riccabona@medunigraz.at
© Springer Nature Switzerland AG 2020
M. Riccabona (ed.), Pediatric Ultrasound,
https://doi.org/10.1007/978-3-030-47910-7_14
335
336
M. Riccabona
14.1.2 How toInvestigate
14.1.2.1 Access
Subxiphoid, median/upper left quadrant:
• For pylorus—upper right quadrant. Use left liver lobe as access.
• How to orient: try to localise either entrance or outlet in organo-axial section;
follow in organo-axial section before turning into longitudinal plane for outlet
(pylorus) or inlet (gastro-oesophageal junction).
• If fasted: assess residual volume (often best seen from transsplenic approach to
view greater curvature and posterior fundus).
Subsequently ll stomach with uid/formula—assess entire stomach including
all visible wall parts in two orthogonal planes:
• Assess peristalsis.
• Assess for reux or intermittent herniation towards thoracic space.
• Assess pylorus and its function (clearance of stomach contents into duode-
nal bulb).
Always observe paragastric area for potential changes (e.g. large veins at gastrooesophageal junction in portal hypertension with collaterals).
14.1.2.2 Functional Assessment ofBowel andStomach
Observation and documentation of peristalsis (M-mode, video clip).
Quantication of stomach content using ellipsoid equations (correct factor varies
with shape from 0.5in spherical shape to 1in more rectangular shape):
• Intermittent volume assessment allows estimation of gastric clearance (e.g. mea-
surements every 15 min for 1–1.5 h, depending on lling and clearance
dynamics).
Observe clearance to duodenum, potential reux into oesophagus.
CDS can be useful for documenting (direction of) gastro-oesophageal reux,
patency of pylorus and duodeno-gastric reux (Fig.14.1).
Fig. 14.1 CDS for documentation. CDS
demonstrates patency of pyloric canal after
feeding: red coded inux of stomach content into
duodenum (note colour map in left upper corner
of US image: red encodes direction away from
transducer, thus from stomach into duodenum).
Colour box angulated for better Doppler angle
14 US oftheGastrointestinal (GI) Tract
337
Remarks on Oesophagus Visualised at cervical part (see US of the neck), at
median part, provided sufcient mediastinal access (e.g. by large tumour); at distal
part, gastro-oesophageal junction (visible via paramedian left, slightly tilted sagittal
view), observe relation to aorta and diaphragmatic hiatus.
Note Typical structure dened by serosa, muscle and mucosa, as well as content
and wall thickness.
14.1.3 Normal Findings
Collapsed distal oesophagus and gastro-oesophageal junction should not measure
more than 7mm in infants.
Gastric wall has ve layers; wall thickness smaller than 3–4mm, depending on
lling and age.
Inner mucosa and echogenic layer thin. Contour of inner mucosa and gastric
folds can be visualised, if stomach sufciently lled with anechoic uid.
US appearance of stomach contents varies depending on kind of food and amount
of air (Fig.14.2a).
Pylorus/gastric outlet usually shows only slight thickening of wall in relation to
stomach wall. In infants muscle thickness should measure <3mm, length should be
<15mm and diameter <10mm (Fig.14.2b).
After feeding unhindered passage of stomach content into duodenum can be
observed (Fig.14.2c).
Note In preterms and newborns wall thickness physiologically less; length of
pyloric canal shorter. Pyloric length only assessable if stomach sufficiently
filled. Essential to observe function/gastric emptying and opening of
pyloric canal.
Fig. 14.2 Normal stomach and pylorus. (a) Fluid-lled stomach, adjacent spleen. (b) Normal
pylorus (+ +) while stomach empty. Wall narrow, though pylorus appears long. Wall layers, particularly prominent echogenic mucosal inner layer, nicely appreciated. (c) Open normal pylorus
after feeding tea—unhindered passage of anechoic uid from stomach into duodenum
338
M. Riccabona
14.1.4 Normal Variants
Not reliably assessable by US.
14.1.5 Malformations
14.1.5.1 Microgastria
Small content, easier to visualise on foetal scans than postnatally.
14.1.5.2 Pyloric Atresia
Rare condition, usually diagnosed prenatally.
Difcult to differentiate from high-grade pyloric stenosis and gastric webs.
14.1.5.3 Congenital Hiatal Hernia
Variant from diaphragmatic hernia (see respective chapter), can be depicted by US
if large.
Tip Fill stomach and observe dynamically.
14.1.6 Pathologic Findings
14.1.6.1 Gastro-Oesophageal Reflux (GOER)
Definition
Reux of stomach contents to oesophagus—small amounts of intermittent regurgitation physiologic in rst 3months of life. To be distinguished from intermittent
regurgitation during swallowing which may be physiologic.
Grading
Mild, intermediate and severe (Table14.1).
Criteria
Frequency, duration, dilatation of distal oesophagus and oesophageal clearance.
Provocation
Drinking (water siphon test), left decubitus position with slight pressure on abdomen with transducer, similar to uoroscopy.
US Findings
Regurgitation of uid from stomach into oesophagus with variable widening of the
gastric inlet (Fig.14.3a, b). Details depend on kind of food, stomach and gastric
wall thickness + severity of GOER.Assess number and duration of reux episodes,
grade of dilatation of distal oesophagus, oesophageal clearance and wall thickness.
Observe for potential intermittent herniation of gastric parts to thoracic cavity in
cd
14 US oftheGastrointestinal (GI) Tract
Table 14.1 Grading of gastro-oesophageal reux (GOER) in infants
Grade
No reux Thin Prompt clearance into
Up to four reux
episodes
More than four
reux episodes
Numerous reux
episodes
Continuous
reux
US criteria of grading GOER in infants, based on correlation to pH-metry
Oesophagus Function
stomach, during swallowing no
reux after feeding
No dilatation Prompt clearance after GOER Physiological
Mild dilatation Slightly delayed clearance
Signicant dilatation Signicant delay Intermittent
Constantly open
gastro-oesophageal
junction
after GOER
Yo-yo phenomenon of stomach
content to distal oesophagus
ab
339
Diagnosis
Normal
GOER
Mild GOER
GOER
Severe GOER/
hiatal hernia
Fig. 14.3 Gastro-oesophageal reux (GOER). (a) Parasagittal paramedian view in upper abdo-
men: GOER of air mixed stomach content into distal oesophagus without dilatation (+ +), normal
wall of hiatal structures. NOTE: Similar images seen during feeding (then normal direction of food
going into stomach/not inverse as in GOER). (b) Same section as in (a): stomach lled with uid—
regurgitation into slightly dilated distal oesophagus, normal wall of hiatal structures. (c) Axial
median section, upper abdomen, transducer tilted cranially: (pseudo-)tumourous structure (+ +)
with thick wall and inhomogeneous echoes at gastro-oesophageal junction. (d) Same patient and
same US section as in (c): after feeding tea “tumour” lls with uid and air conrming hiatal hernia with parts of stomach herniated into chest
intermittent sliding hiatal hernia, particularly after lling stomach (Fig.14.4c, d).
Document GOER—best achieved by video clips or CDS (documents direction of
ow) using adapted settings.
Note Use standard meal, avoid ingredients that cause or provoke GOER.
Role of US
In infancy good correlation with pH monitoring and uoroscopy. The older the
child, the poorer US performs.
Evaluation of oesophagus and its mucosa for secondary inammation not
possible.