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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5795_Библиотеки_им_академика_М_И_Перельмана.pdf
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M. Riccabona
US Findings
• Same as described in all other body compartments (see respective chapters).
• Typical signs for pathological lymph nodes: large (bigger than 1cm), spherical,
conglomerated, increased number of nodes, destructed/missing hilus (Fig.14.32).
Usually found along main mesenteric vessels.
• Massive pathologic lymph nodes and suspicious congurations or bulk needs
work-up (lymphoma? granulomatous disease? specic or atypical infection—
Yersinia, Tb? etc.).
• May also have abscesses, necroses and calcications.
• For retroperitoneal nodes, mainly focus on assessment along large vessels, again
using graded compression technique.
Note In oncology patients always consider potential lymphatic drainage path-
ways—perform focused search at most crucial stations (e.g. nodes at entry of ovarian vein to left renal vein after left ovarian tumour).
c
d
e
Fig. 14.32 Abdominal/mesenteric lymph nodes. (a, b) Reactively enlarged inammatory mesen-
teric lymph nodes (in gastroenteritis, EBV infection, etc.). (c, d) Hugely enlarged bulks of lymph
nodes in abdominal lymphoma, entire extent can only be conspicuously demonstrated using panoramic imaging (d). (e) Bulk of enlarged, anechoic unstructured abdominal lymph nodes in a girl
after renal transplantation consistent with post-transplant lymphoproliferative disease (PTLD)
14 US oftheGastrointestinal (GI) Tract
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14.2.9 Free Intraperitoneal Air
Can be seen sonographically as echogenic spots/bands with reverberation echoes,
typically on highest part of abdomen, below abdominal wall, above ascites, in front
of liver and outside of bowel. Can cause twinkling-like appearance on CDS
(Fig.14.33).
Note If too much transducer pressure applied, air pressed away and missed! Thus,
gentle investigation at highest point of abdomen (e.g. in front of liver) advised.
Depiction of free peritoneal air in constricted spaces more difcult.
Role of US
Free air can be seen, but more difcult to rule out. In suspicion actively search for it.
14.2.10 Free Intraperitoneal Fluid: Ascites
Dened as intraperitoneal uid of varying origin.
Simple (clear) or complicated (with echoes, sedimentations, septae) uid
between bowel lops, or located behind bladder, in Douglas/Morrison space and
around parenchymal organs (liver, spleen, kidney).
Note Site of uid does not necessarily correlate with organ of origin (e.g. in
trauma)—may be shifted by positioning, etc.
Causes: hypoproteinaemia, cardiac disease, portal hypertension, inammatory
and neoplastic disease, hypervolaemia, impaired lymphatic drainage, peritoneal dialysis, shunt, haemorrhage (e.g. trauma, postoperative, vascular rupture and coagulopathy), and also with gastroenteritis/systemic infection, third space phenomena, etc.
DDx Fluid from ruptured cyst, ruptured biliary structures (bilious ascites), exuda-
tive processes (e.g. pancreatitis), localised uid versus real cyst (ovarian, mesenteric, parenchymal organs, duplication cyst, cystic tumours, etc.), uid in constricted
compartments/abscess, etc.
Fig. 14.33 Free intraperitoneal air. Echogenic
lines under abdominal wall in front of the liver
with reverberation artefacts, consistent with free
intraperitoneal air after bowel perforation in this
neonate with NEC.Note some ascites (+ +) in
front of swollen kidney below liver margin
(sagittal right upper quadrant section)
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M. Riccabona
Some small amount of ascites may be physiologically present (e.g. after ovulation), postoperatively, etc.
Note In systemic conditions, simultaneous pleural effusion commonly present—
look for it.
US Findings
• Simple ascites, anechoic uid (Fig.14.34).
• Complicated ascites, oating echoes with more or less sedimentation, brin sep-
tae and clots.
Note Functioning ventriculoperitoneal shunt will cause ascites; often at least some
parts of abdominal shunts visualised. If loculated uid collections—always check
for potential obstruction to distal end of drain, within the pseudocyst collection + increasing hydrocephalus (Fig.14.35).
abc
Fig. 14.34 Simple (a, b) and complex (c) intraperitoneal ascites. (a, c) Sagittal section of lower
abdomen, empty bladder poorly distinguishable, the complex nature in (c) was due to haemorrhage
(+ +). (b) Axial view through full urinary bladder demonstrating retrovesical free peritoneal uid
Fig. 14.35 Peritoneal shunt with cyst. Cyst (a) around abdominal end of ventriculoperitoneal
shunt (b, arrow) causing shunt dysfunction/obstruction
14 US oftheGastrointestinal (GI) Tract
Fig. 14.36 Vascular problems. Huge vascular malformation of the bowel wall in the distal ileum
(+ …. +, extended view US) (a) with many thrombosed veins on CDS (b). Appearance of thrombosis on US—e.g. of iliac vessels: intraluminal thrombus nicely depictable on axial (c) and longitudinal section with CDS (d)
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Role of US
Very sensitive when screening entire abdomen, even for small amounts of uid.
Actively search in respective compartments (e.g. in FAST). May be used to guide
diagnostic puncture or drainage.
14.2.11 Mesenteric Vessels
Soma additional rare conditions such as stenosis or thrombosis exist even in childhood. Otherwise mesenteric vessels assed for other queries such as malrotation and
volvulus (see above), inammatory conditions (see above), as well as (vascular)
malformations (Fig.14.36a, b).
US Findings
Visibility depends on US access—may be obscured by bowel gas.
Graded compression may help—but may obscure particularly vein (compressed
and collapsed by transducer pressure).
Thrombosis appears as in other body compartments (see respective chapter)
(Fig.14.36c, d).
CDS helpful for depiction and assessment of vascularisation.
Duplex Doppler essential for assessing “perfusion” (see above).
Ultrasound oftheUrogenital Tract
inNeonates, Infants, andChildren
MichaelRiccabona
15.1 Requisites
15.1.1 Indications
Numerous indications—sometimes also used as screening method or for pacifying
parents. Typical queries: (Foetal) pelvicalyceal distention (PCD—used in Europe)
or urinary tract dilatation (UTD—used in USA), urinary tract infection (UTI), haematuria, failure to thrive, suspicion of VUR, obstructive uropathy, renal failure,
enuresis, micturition problems, urolithiasis, involvement in systemic or syndromic
disease, high blood pressure, trauma, tumour, nephritic and nephrotic syndrome,
renal transplantation, pre-/postoperatively, etc.
15
15.1.2 Preparation
Good (physiologic) hydration, sufciently lled bladder.
15.1.3 Transducers
Commonly (micro-)curved arrays with age-adapted frequency:
• Additionally/alternatively linear transducers, particularly for neonates and infants,
detailed analysis of renal parenchyma, perineal access, scrotum/penis/inguinal area.
• For deep vessels and initial overview, sector transducers can be used.
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_15
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M. Riccabona
15.1.4 Positioning
Usually supine for ank and ventral access (also for perineal US), additionally
prone with dorsal transducer position (paravertebral).
• Position changes also helpful for differentiating suspected sedimentations or
stones, as these move in dependent space with change of position (e.g. prone to
supine or decubitus) if intraluminal and not in papilla/xed to pelvic wall—pro-
vided sufcient distention of collecting system (Fig.15.1).
15.1.5 How toInvestigate
Always begin with bladder in longitudinal and axial sections:
• Include oblique section through ostia and distal ureters.
• Observe bladder neck.
• Bladder wall (thickness, conguration, trabeculation?), potential urachus remnants.
• Assess perivesicular space, potentially include perineal US (for urethra, best dur-
ing voiding).
• Post-void assessment (bladder/residual volume: use eq. L×W×H×correction
factor (Fig.15.2), correction factor varies based on shape of the bladder—spheric
conguration=0.5, rectangular conguration=1.0).
Assess both kidneys from ventral, lateral, and dorsal in longitudinal and cross
sections:
• Evaluate entire organ; document any abnormalities in two planes.
Fig. 15.1 Dependent position of sludge oating in a somewhat dilated collecting system: US
image taken in supine (a) and prone (b) position showing the gravity dependent redistribution of
oating material forming a sedimentation level (arrow)—thus not xed to papilla or within distal
medulla, but moving within collecting system
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
377
dard measurements for volume calculation. Correction factor varies with bladder shape.
Additionally bladder wall thickness may be an indicator for bladder pathology (>2mm in full,
>4mm in empty bladder), L length, W width, D depth. (b) Longitudinal (extended view technique
is helpful in large-size bladders for proper measurement); (c, d) axial section—with axial measurements (callipers) for volume assessment; calculation depends on bladder shape that denes the
correct correction factor: in spheric-ellipsoid shape factor=0.5 (c), in a rectangular shape it is 1
(d). Note additionally thickened and trabeculated bladder wall. (e, f) Open bladder neck in axial (e)
and sagittal (f) view—a potential sign for bladder instability or other functional disturbance. (g)
Ureteric inow jet–best seen on CDS: note the asymmetry in this example
• Assess: shape, size, position, contour, parenchymal echogenicity, and cortico-
medullary differentiation, collecting system dilatation (if enlarged, measured in
axial plane) and thickening of pelvic wall and peripelvic fat/brotic tissue.
• Calculate renal volume (L×W×H×0.53).
• Assess vascular anatomy (CDS) (e.g. accessory renal artery); follow vessels to ori-
gin or drainage (e.g. retro-aortal left renal vein). Add spectral analysis if indicated
from main as well as intrarenal vessels (from upper, middle, and lower segment).
• aCDS is applied for peripheral vasculature (e.g. focal perfusion defects?).
378
M. Riccabona
Note Physiologic difference in colour intensity between highly vascularised cortex
and less vascularised medullae. Compare both sides in relation to perirenal
structures.
• Always assess perirenal space (adrenal gland).
• Try to assess pelvi-ureteric junction (open? obstructed by vessel? kinking?…);
follow ureter downwards, if dilated.
• Assess collecting system after voiding (changes in dilatation?).
• Consider CEUS for lesion characterisation (e.g. complicated cyst) or equivocal
ndings on baseline US/(a)CDS (e.g. suspected perfusion defects, traumatic
lesions …).
CDS Document ureteric jet into bladder (symmetric? position of ostium?), vascu-
lar anatomy extrarenally as well as main intrarenal arteries (proper scale setting not
to miss aliasing and turbulences at sites of possible stenosis or AVF…). Assess for
possible twinkling (calcications and sedimentations) (Fig.15.2f),
• New sensitive (a)CDS techniques (such as SMI) even better depict jets and
“swirls”.
15.1.5.1 Diuretic US
Used for assessment in dilated urinary tracts/distended pelvicalyceal system: standardised diuretic stress induced by medication (e.g. furosemide, dose=1mg/kg, up
to 20mg) given orally or IV (acts faster). Repeat assessment of kidney till ndings
(dilatation of collecting system, Doppler ow spectra) have returned to baseline—
delayed or missing normalisation of ow patterns after diuretic stress indicates signicant obstruction.
15.1.6 Contrast-Enhanced Voiding Urosonography (ce-VUS)
Denition
ce-VUS=sonographic test for vesico-ureteric reux (VUR).
Has become a standard procedure for VUR evaluation since UCA approved for
paediatric use. Is reliable, no radiation, can be performed at bedside (see also chapter on contrast-enhanced ultrasound). Short description outlined here, too.
How To Do After assuring sterile urine and initial US assessment performed, urethral catheter placed (or suprapubic puncture) and bladder emptied:
• Then bladder gradually lled by drip infusion (infusion height <40cm above
bladder level—physiologic lling pressure):
– Potential antibiotics added (or antibiotic prophylaxis).
15 Ultrasound oftheUrogenital Tract inNeonates, Infants, andChildren
379
• Alternating scanning of retrovesical space+bladder as well as both kidneys dur-
ing lling:
– Drip infusion may be used as manometer to see moments of increased bladder
pressure during lling—may indicate unstable bladder, helps to depict
moments of high pressure VUR.
• Fractional instillation of UCA (at present mostly Sonovue®/Lumason®, Bracco/
Italy), concentration = 0.1–1.0 (−3.0%)% of actual bladder lling volume,
depending on transducer and equipment (Fig.15.3).
– Company recommendation (Lumason/SonoVue) 1mL/lling.
– Alternatively mix solution of saline with 0.1–1.0% UCA in plastic container,
and use this for drip infusion as specied above.
• Ongoing alternating assessment of bladder, retrovesical space/distal ureter, and
both kidneys.
• Note: In rst years of life, cyclic lling (three cycles) recommended.
• Scanning continued when bladder is lled (urge or spontaneous voiding).
• Assess urethra by perineal US (during voiding, possibly use dedicated cycle/last
cycle with catheter removal):
• After voiding, check kidneys for potential reuxed UCA within collecting sys-
tem, CM drainage dynamics, and bladder for residual urine/diverticulae.
ab
cde
Fig. 15.3 ce-VUS: bladder and ureter. (a) Filling of the bladder with saline drip infusion
(30–40 cm H
instilled—bladder lumen gets distended with echogenic material. Note the echoic CM-lled distal
right ureter behind the bladder, only clearly detectable by the contrast image. (c) Single contrast
image: echogenic contrast in a megaureter in dilating VUR (V°). (d) Single contrast image: contrast reux into narrow distal ureter, with gapping and pathologically shaped UVJ. (e) Voiding on
ce-VUS (transvesical sagittal access in an infant): only proximal urethra (++) seen from abdominal sagittal approach/view
0 pressure) via catheter. (b) Dual image technique (left—contrast image): UCA
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Fig. 15.4 Male urethra during voiding on ce-VUS. (a) Neonatal male urethra during voiding,
perineal access: voiding attempt before catheterisation, no UCA; only the urine works as physiologic CM—outlining the proximal urethra to the level of the pelvic oor. (b, c) Two images of male
neonatal urethra during voiding on ce-VUS; note the dynamic changes of the shape of the proximal
urethra and the better visualisation using the coloured contrast image—particularly helpful if the
room cannot be properly darkened such as in bedside examinations (e.g. in NICU)
M. Riccabona
• At last cycle, catheter withdrawn for proper view of unobstructed urethra on
perineal US (Fig.15.4)—unless same catheter used for complementing focused
uoroscopic VCUG.
– Consider stepwise catheter withdrawl with still running UCA-infusion, to
gradually assess urethra—not to miss, e.g. ectopically inserting reuxing ureters or more subtle urethral pathology.
Note Urethra only assessable if viewed during voiding.
Tip If VCUG is planned always perform ce-VUS rst (ionidated CM is heavier
and thus may obscure VUR on ce-VUS if done after conventional VCUG).
15.2 Normal Findings
15.2.1 Bladder
Well-lled bladder has smooth contour and muscular wall, not >2–4 mm thick
(depends less on age than on lling):
• Ostium at latero-cranial end of bladder trigone as well as distal ureters often seen
physiologically in well-lled bladder and good-hydrated children.
• Assess bladder volume (see above and respective chapter). Simple equation
often used to dene normal range: volume (mL)=[age (in years)+2]×30.
• Bladder neck closed unless there is an urge to void; after voiding bladder neck
should be closed. Open bladder neck, thickened bladder wall, irregular inner
contour with trabeculation and pseudo-diverticulae, high bladder tension, or
atypical contour may raise suspicion of neurogenic bladder/functional
disturbance.