Pediatric abdominal radiographs ajr1
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Este documento presenta 10 casos clínicos pediátricos evaluados mediante radiografía de abdomen. Se resumen los principales hallazgos radiológicos de cada caso y se enfatizan puntos de enseñanza clave sobre la interpretación de imágenes abdominales en niños. El documento provee una guía para reconocer patrones anormales de gas intestinal, masas, neumatosis, neumoperitoneo, ascitis, calcificaciones, anomalías óseas y otras patologías comunes en la población pediátrica.
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Pediatric abdominal radiographs ajr1
- 1. María de la Luz Jiménez Camacho R2 IDT Grupo CT Scanner – INCICh Febrero, 2018 Sarah J. Menashe Ramesh S. Iyer Department of Radiology, Seattle Children’s Hospital. University of Washington
- 2. D. H. Lawrence «Los ojos no ven lo que la mente no sabe»
- 3. Objetivos ◈ Radiografías de abdomen son de ayuda de evaluación de anormalidades congénitas y patologías específicas en la población pediátrica ◈ Errores en la interpretación retrasa el diagnóstico, imágenes adiccionales innecesarias y exposición injustificada a la radiación.
- 4. Errores en radiología son multifactoriales ○ Percepción ○ Insuficiente caracterización ○ Falla en la comunicación
- 5. Abdomen pediátrico ◈ Causas de patología abdominal en población pediátrica difiere de los adultos ◈ Incapacidad del paciente de comunicar sus molestias El estudio inicial más solicitado radiografía abdominal
- 6. Patrón de gas intestinal ◈ Recién nacido (1er día). ○ Movimiento del aire hasta el sigmoides normalmente es de 8 – 9 horas. ◈ Distensión persistente de asas de intestino, distribución inusual de aire intestinal o presencia niveles hidroaéreos.
- 7. Caso 1
- 9. Masa abdominal ◈ Masa abdominal en el 1° año de vida suele ser benigna y de origen renal, hidronefrosis o por displasia renal multiquística. ◈ Tumor primario renal maligno más común en la infancia es el tumor de Wilms (1°) y neuroblastoma (2°). ○ Sarcoma renal de células claras. 4 – 5% de los tumores renales primarios en < 4 años. Alta agresividad y mortalidad.
- 10. Masa abdominal
- 11. Desplazamiento persistente de asas intestinales en múltiples proyecciones es sugestivo de masa intrabdominal Teaching point
- 12. Caso 2
- 14. Patrón de gas intestinal HERNIA INGUINAL ◈ Causas común de cirugía ◈ Niños prematuros riesgo de incarcelamiento ◈ Masculino 3:1 - 10:1 Inflamación escrotal o masa inguinal +/- obstrucción intestinal ◈ Asas con aire por debajo del ligamento inguinal.
- 15. Patrón de gas intestinal Tamaño de las asas intestinales depende de la edad del paciente ◈ Puntos de referencia óseos independientes de la edad del paciente ◈ Diámetro intestinal normal es menor que la altura combinada de los cuerpos vertebrales de L1 y L2, incluyendo el espacio intervertebral. ◈ Identificar las causas de obstrucción proximal o distal.
- 16. A A I I M M Patrón de gas intestinal ◈ Obstrucción intestinal en pacientes pediátricos son secundarios a múltiples causas: Adhesions Appendicitis Intussusception Inguinal hernia Malrotation with midgut volvulus Meckel diverticulum
- 17. Hernia inguinal
- 18. Hernias inginales son causas importantes de obstrucción intestinal en niños. La presencia de asas intestinales llenas de aire por debajo del canal inguinal, aún en ausencia de signos de obstrucción. Teaching point
- 19. Caso 3
- 21. Pneumatosis intestinal ◈ Presencia de gas dentro de la pared intestinal. ◈ Focal o difuso. ◈ Luscencia lineal, curvilínea o redonda ◈ Asociación mas frecuente es la enterocolitis necrotizante. ◈ Identificar localización, extensión y severidad; así como presencia de gas en la porta o neumoperitoneo. ◈ Tratamiento depende de la causa.
- 24. Gas extraluminal con patrón lineal o curvilíneo a lo largo de la pared abdominal es signo de neumatosis intestinal, el cual deberá correlacionarse clínicamente. Teaching point
- 25. Cavidad peritoneal • Espacio formado por el peritoneo visceral y parietal. • Acumulación de aire o líquido por múltiples causas.
- 26. Caso 4
- 28. Neumoperitoneo ◈ Amplia variedad de causas (iatrogénicas, cirugía reciente, perforación de víscera hueca) ◈ Hallazgos radiológicos sutiles ◈ Radiografía de abdomen en decúbito supino la acumulación de aire será debajo del tendón central del diafragma y el espacio subfrénico medial, difíciles de visualizar
- 29. Neumoperitoneo ◈ Alta sospecha clínica. ◈ Proyecciones complementarias en bipedestación y decúbito lateral izquierdo ○ Sensibilidad 85% y 96% ◈ Detección de 1-2 mL de aire libre.
- 30. NEUMOPERITONEO
- 31. Neumoperitoneo
- 32. Regla del pulgar, la atenuación de tejidos blandos del hígado deberá ser homogénea. La presencia de interfaces centrales que delimiten estructuras centrales deberán considerarse como neumoperitoneo. Teaching point
- 33. Caso 5
- 35. Ascitis Acumulación anormal de líquido en la cavidad peritoneal tiene múltiples causas en niños ◈ Signos específicos, pero con sensibilidad variable. ○ Radioopacidad abdominal generalizada ○ Centralización de las asas intestinales
- 36. Ascitis Signo de Hellmer. Desplazamiento medial del borde lateral hepático. Signo con mayor sensibilidad y especificidad.
- 38. La ascitis puede manifestarse radiológicamente por la centralización de las asas intestinales e incremento de la densidad abdominal. Teaching point
- 39. Calcificaciones • Pueden ser hallazgos incidentales en adultos, sin embargo eso no pasa con los niños • Calcificaciones anormales son importantes en bebés y niños • Amplia variedad de causas
- 40. Caso 6
- 41. Calcificaciones
- 42. Calcificaciones • Localización y morfología • Edad • Síntomas Permiten identificar la causa y diagnósticos diferenciales Neonato con calcificaciones difusas intraperitoneales son sugestivas de peritonitis meconial. Calcificación triangular en el área adrenal, hemorragia suprarrenal. Calcificaciones proyectadas en el riñón, trayectos ureterales o vejiga en niños mayores son sugestivos de litiasis
- 43. Neuroblastoma Primera consideración de calcificaciones retroperitoneales asociadas a masa de tejidos blandos ◈ Elevación del hemidiafragma o desplazamiento del riñón ipsilateral ◈ Origen del sistema nervioso simpatico ◈ Sitio más común es abdominal ◈ Calcificaciones 60% 50% < 2 años 90% < 8 años
- 44. Calcificaciones
- 45. Cuando la apariencia radiográfica sugiere calcificaciones abdominales, hay amplia cantidad de diagnósticos diferenciales por lo cual se deberá de tener en cuenta el contexto clínico. Teaching point
- 46. Caso 7
- 47. Calcificaciones
- 48. Cateterismo de la vena umbilical ◈ Lesión vascular o parenquimatosa ◈ Localización en la línea media de la pared abdominal anterior, se extiende superior y posteriormente a través del receso umbilical hacia la vena porta izquierda, ductus venoso y la VCI. ◈ Adecuada localización es en la porción supradiafragmática de la VCI o AD.
- 49. Cateterismo de la vena umbilical ◈ Complicaciones: hematoma subcapsular, absceso o colecciones líquidas hepáticas, necrosis parenquimatosa, laceración hepática y fístula veno-biliar. ◈ Trombosis es la complicación que ocurre cuando el catéter se posiciona adecuadamente.
- 50. Calcificaciones
- 51. Calcificaciones abdominales son frecuentemente asociadas con patología en la edad pediátrica y requiere investigación; por lo cual presencia y localización debe ser documentada Teaching point
- 52. Huesos • Radiografías de abdomen no se adquieren para la evaluación ósea (costillas, columna vertebral y pelvis), pero debe ser parte de una evaluación integral. • Anormalidades congénitas y del desarrollo; así como neoplasias óseas o infección.
- 53. Caso 8
- 54. Huesos
- 55. Dolor óseo ◈ Común en la población pediátrica ◈ De causa benigna ◈ Causas habituales son trauma e infección; así como neoplasia. ◈ Síntomas confusos ◈ Hallazgos por imagen se complementan con historia clínica, examen físico y laboratorios para llegar al diagnóstico. Evaluación integral de las estructuras óseas
- 56. Neoplasias óseas primarias de la infancia 1° Sarcoma de Ewing 2° Osteosarcoma ◈ Síntomas variables dependiendo de la localización. ◈ DDx de lesiones líticas agresivas son: osteosarcoma, infección e histiocitosis de células de Langerhans
- 57. Sarcoma de Ewing
- 58. Estructuras óseas deberán evaluarse de manera sistemática en las radiografías abdominales ya que se pueden encontrar una amplia variedad de hallazgos óseos Teaching point
- 59. Caso 9
- 60. Huesos
- 61. Displasia del desarrollo de la cadera Espectro de anormalidades del crecimiento y desarrollo de la cadera • Incluye cabeza femoral, acetábulo o ambos. • Displasia, subluxación o franca dislocación • Causas congénita (primaria) o del desarrollo (teratológica) • Factores predisponentes: presentación de nalgas, mujeres, oligohidroamnios, primogénito y AHF
- 62. Displasia del desarrollo de la cadera ◈ Historia clínica y examen físico evaluación inicial ◈ Escrutinio universal con ultrasonido < 6 m. Evaluación en debe realizarse en el 1er año de vida cuando hay FR o EF sugestiva (ACR 2009) ◈ Osificación de las cabezas femorales 4 – 6 meses ◈ Asimetría en tamaño y posición de las cabezas femorales deberá ser evaluada
- 63. Evaluación de la cadera en radiografías de abdomen es importante, principalmente en pacientes jóvenes que no caminan en los que la subluxación puede no ser evidente clinicamente Teaching point
- 64. Caso 10
- 65. Huesos
- 66. Agenesia sacra Constipación funcional o constipación sin causa conocida afecta 3% de la población pediátrica ◈ 40% se presenta 1° año de vida ◈ Agenesia sacra, es la ausencia congenita de todo o parte del sacro ○ Diabetes materna (aislada) ○ Asociación con VACTERL y OEIS ○ Autosómica dominante (severo) incluye ausencia completa de sacro o hemisacro, masa presacra y malformación anorectal
- 67. Agenesia sacra Síndrome de Currarino, ◈ Agenesia sacra parcial asociada con una masa presacra y una malformación anorrectal ◈ «Sacro en simitarra° ○ Preservación del 1° segmento sacro ◈ US <4 meses muestran ausencia o anormalidad del centro de osificación sacos y masa quística 5 segmentos sacros osificados presentes al nacimiento en un RN a término Id por Rx
- 68. Huesos
- 69. Cuando un niño es enviado para una radiografía de abdomen por constipación deberá evaluarse la integridad sacra. Teaching point
Notas del editor
- Escritor inglés. Nacio 1930. Su literatura expone una extensa reflexión acerca de los efectos deshumanizadores de la modernidad y la industrialización,2 y abordó cuestiones relacionadas con la salud emocional, la vitalidad, la espontaneidad, la sexualidad humana y el instinto.
- Fig. 1—2-year-old girl with 4- to 5-month history of intermittent fevers and one-week history of abdominal distention. A, Initial abdominal radiograph obtained at outside institution missed focal paucity of bowel gas (arrows) with medial displacement of bowel loops in left upper abdomen. Subtle calcifications in this region were difficult to visualize. Subsequent ultrasound examination (not shown) revealed left-sided abdominal mass.
- Fig. 1—2-year-old girl with 4- to 5-month history of intermittent fevers and one-week history of abdominal distention. A, Initial abdominal radiograph obtained at outside institution missed focal paucity of bowel gas (arrows) with medial displacement of bowel loops in left upper abdomen. Subtle calcifications in this region were difficult to visualize. Subsequent ultrasound examination (not shown) revealed left-sided abdominal mass. B, Contrast-enhanced CT obtained for staging shows large multilobulated mass (arrows) with linear calcifications in left renal fossa. Mass invaded left kidney and completely replaced left renal parenchyma. Pathologic analysis revealed clear cell sarcoma of kidney.
- Fig. 2—4-week-old boy (born prematurely at 27 weeks of gestation) who had history of heart block requiring pacemaker and of respiratory failure. Patient presented with increased fussiness. A, Abdominal radiograph shows right inguinal hernia containing gas-filled bowel loops (arrows), which initially was not reported. Pacemaker is also seen.
- Adhesiones Apendicitis Intususcepción Hernia inginal Malrotación intestinal con vólvulus Divertículo de Meckel
- Fig 4—6-week-old boy with tetralogy of Fallot after placement of Blalock-Taussig shunt with increased irritability that raised clinical concern for possible pneumatosis related to necrotizing enterocolitis, given recent cardiac surgery. A, Abdominal radiograph obtained with patient in supine position shows unusual low position of weighted tip of enteric tube projected over sacrum at S2, thought to reflect duodenal distortion related to enteric tube presence. Lucency (arrows) in right upper quadrant representing pneumoperitoneum was not described.
- Fig 4—6-week-old boy with tetralogy of Fallot after placement of Blalock-Taussig shunt with increased irritability that raised clinical concern for possible pneumatosis related to necrotizing enterocolitis, given recent cardiac surgery. A, Abdominal radiograph obtained with patient in supine position shows unusual low position of weighted tip of enteric tube projected over sacrum at S2, thought to reflect duodenal distortion related to enteric tube presence. Lucency (arrows) in right upper quadrant representing pneumoperitoneum was not described. B and C, Subsequent cross-table lateral (B) and left lateral decubitus (C) abdominal radiographs were obtained a few hours after radiograph shown in A, in setting of increased abdominal distention and fever after enteric tube removal. Images show increased pneumoperitoneum (arrows, B) with interval development of portal venous gas (arrowheads, B and C). Trace subcutaneous gas was also noted along anterior abdominal wall.
- Fig. 5—11-year-old girl with abdominal distention and lethargy occurring 1 month after total colectomy was performed for ulcerative colitis. A, Abdominal radiograph obtained with patient in supine position shows large-volume ascites with bulging flanks (arrowheads), diffuse ground-glass appearance within abdomen, and paucity of bowel gas with centralization of gas-filled bowel loops, which initially were missed. Hellmer sign is present, with medial displacement of lateral edge of liver (arrows). Fig. 6—13-year-old girl with history of constipation and suprapubic pain. A, Abdominal radiograph obtained with patient in supine position shows paucity of bowel gas with centralization of bowel loops. Prominent bulging of flanks (arrowheads) with medial displacement of liver edge (Hellmer sign) (arrows) is also shown. Findings were suggestive of large-volume ascites, and ultrasound examination was performed (not shown), which confirmed this finding and also showed multiple abdominal and pelvic soft-tissue masses. B, Coronal contrast-enhanced CT image of abdomen and pelvis shows multiple heterogeneous soft tissue masses (arrows), consistent with peritoneal implants, in lower abdomen and pelvis as well as along diaphragm bilaterally. Large-volume ascites were again shown. Pathologic findings revealed desmoplastic small round-cell tumor.
- Fig. 5—11-year-old girl with abdominal distention and lethargy occurring 1 month after total colectomy was performed for ulcerative colitis. A, Abdominal radiograph obtained with patient in supine position shows large-volume ascites with bulging flanks (arrowheads), diffuse ground-glass appearance within abdomen, and paucity of bowel gas with centralization of gas-filled bowel loops, which initially were missed. Hellmer sign is present, with medial displacement of lateral edge of liver (arrows). B, Follow-up CT image confirmed radiographic findings. Intraoperative evaluation revealed more than 5 L of chylous ascites. Fig. 6—13-year-old girl with history of constipation and suprapubic pain. A, Abdominal radiograph obtained with patient in supine position shows paucity of bowel gas with centralization of bowel loops. Prominent bulging of flanks (arrowheads) with medial displacement of liver edge (Hellmer sign) (arrows) is also shown. Findings were suggestive of large-volume ascites, and ultrasound examination was performed (not shown), which confirmed this finding and also showed multiple abdominal and pelvic soft-tissue masses. B, Coronal contrast-enhanced CT image of abdomen and pelvis shows multiple heterogeneous soft tissue masses (arrows), consistent with peritoneal implants, in lower abdomen and pelvis as well as along diaphragm bilaterally. Large-volume ascites were again shown. Pathologic findings revealed desmoplastic small round-cell tumor.
- Fig. 7—2-year-old boy who presented with vomiting. A, Lateral abdominal radiograph obtained as part of abdominal series shows multiple distended bowel loops suggestive of partial obstruction, which resulted from large ileocolic intussusception subsequently diagnosed on abdominal ultrasound. However, small retroperitoneal calcification projecting anterior to T12 vertebral body (arrow) was difficult to identify prospectively. B, Patient presented 2 years later with right lower quadrant pain and constipation. Abdominal radiograph obtained with patient in supine position shows large ovoid well defined left upper quadrant density (arrow) concerning for calcified mass. Abdominal ultrasound exaination (not shown) confirmed presence of large left retroperitoneal mass, which was pathologically proven to be neuroblastoma. C, Large calcified components (arrows) of left retroperitoneal mass centered in region of left adrenal gland were seen on contrast-enhanced CT obtained for staging.
- Fig. 6—13-year-old girl with history of constipation and suprapubic pain. A, Abdominal radiograph obtained with patient in supine position shows paucity of bowel gas with centralization of bowel loops. Prominent bulging of flanks (arrowheads) with medial displacement of liver edge (Hellmer sign) (arrows) is also shown. Findings were suggestive of large-volume ascites, and ultrasound examination was performed (not shown), which confirmed this finding and also showed multiple abdominal and pelvic soft-tissue masses. B, Coronal contrast-enhanced CT image of abdomen and pelvis shows multiple heterogeneous soft tissue masses (arrows), consistent with peritoneal implants, in lower abdomen and pelvis as well as along diaphragm bilaterally. Large-volume ascites were again shown. Pathologic findings revealed desmoplastic small round-cell tumor.
- Fig. 7—2-year-old boy who presented with vomiting. A, Lateral abdominal radiograph obtained as part of abdominal series shows multiple distended bowel loops suggestive of partial obstruction, which resulted from large ileocolic intussusception subsequently diagnosed on abdominal ultrasound. However, small retroperitoneal calcification projecting anterior to T12 vertebral body (arrow) was difficult to identify prospectively. B, Patient presented 2 years later with right lower quadrant pain and constipation. Abdominal radiograph obtained with patient in supine position shows large ovoid well defined left upper quadrant density (arrow) concerning for calcified mass. Abdominal ultrasound exaination (not shown) confirmed presence of large left retroperitoneal mass, which was pathologically proven to be neuroblastoma. C, Large calcified components (arrows) of left retroperitoneal mass centered in region of left adrenal gland were seen on contrast-enhanced CT obtained for staging.
- Fig. 8—11-day-old boy with history of repaired congenital diaphragmatic hernia. A, Chest radiograph shows irregular ill-defined calcification (arrow) in upper abdomen to right of L1 vertebral body, which initially was not detected.
- Fig. 8—11-day-old boy with history of repaired congenital diaphragmatic hernia. A, Chest radiograph shows irregular ill-defined calcification (arrow) in upper abdomen to right of L1 vertebral body, which initially was not detected. B, Color Doppler ultrasound image of liver and proximal portal veins shows complete occlusion of left portal vein with calcified shadowing thrombus. In retrospect, patient had umbilical venous catheter in first days of life, which was presumed cause of thrombosis.
- Fig. 9—12-year-old girl with intermittent right-sided flank pain for 3 months. A, Abdominal radiograph shows subtle lytic lesion (arrow) involving right L3 pedicle, which initially was missed on radiographs obtained at outside institution.
- Fig. 9—12-year-old girl with intermittent right-sided flank pain for 3 months. A, Abdominal radiograph shows subtle lytic lesion (arrow) involving right L3 pedicle, which initially was missed on radiographs obtained at outside institution. B, Axial contrast-enhanced T1-weighted MR image for continued pain shows enhancing bony lesion (arrow) with small adjacent soft-tissue component involving right aspect of L3 vertebral body that extends into right L3 pedicle. Pathologic examination showed Ewing sarcoma. Horseshoe kidney was incidentally noted.
- Fig. 10—14-week-old boy born prematurely who had undergone bowel resection for necrotizing enterocolitis. Abdominal radiograph obtained with patient in supine position shows physiologic periosteal reaction along bilateral femoral shafts. Bilateral hip subluxation was not identified prospectively. Surgical clips were present in right lower quadrant at site of bowel resection. Ultrasound examination performed 1 week later (not shown) showed bilateral hip dysplasia (right hip affected more than left hip), as evidenced by abnormally low alpha angles (< 60°) and deficient acetabular coverage (< 50%).
- Fig. 11—6-month-old boy with constipation since birth. A, Frontal abdominal radiograph shows right hemisacral agenesis with crescent-shaped defect (arrows) consistent with scimitar sacrum, which was not identified on initial interpretation. B, Spinal T2-weighted MR image obtained because of concern for tethered cord shows low-lying cord with conus at L4 level. Multiloculated cystic presacral lesion (arrowheads) was seen originating from caudal aspect of thecal sac and herniating through right sacral defect (arrow), with imaging features suggesting meningocele. Mass caused significant anterior displacement of rectosigmoid colon. Distal cord syringohydromyelia was also noted. C, Subsequently obtained 3D reformatted CT image of sacrum better shows hemisacral agenesis (arrows).
- Síndrome de Currarino
- Fig. 11—6-month-old boy with constipation since birth. A, Frontal abdominal radiograph shows right hemisacral agenesis with crescent-shaped defect (arrows) consistent with scimitar sacrum, which was not identified on initial interpretation. B, Spinal T2-weighted MR image obtained because of concern for tethered cord shows low-lying cord with conus at L4 level. Multiloculated cystic presacral lesion (arrowheads) was seen originating from caudal aspect of thecal sac and herniating through right sacral defect (arrow), with imaging features suggesting meningocele. Mass caused significant anterior displacement of rectosigmoid colon. Distal cord syringohydromyelia was also noted. C, Subsequently obtained 3D reformatted CT image of sacrum better shows hemisacral agenesis (arrows).