Pediatric Gastrointestinal Emergencies - Ultrasound and Conventional Imaging

BACKGROUND:The abdominal pathology of newborns and infants, unlike adults, manifests itself most often in urgent conditions. This requires that a decision be taken in the shortest possible time, applying an appropriate or a combination of modalities. The higher radiation sensitivity of pediatric patients must be taken into consideration.LEARNING POINTS:Why ultrasound and conventional X-ray imaging?Tips about US and XR in childrenUS and XR diagnostic strength and significant findings in GIT emergencies (neonatal and infant group)MAIN BODY:The advantages and disadvantages of imaging modalities are discussed, according to pediatric age. The imaging of the most common units causing acute abdomen in pediatric patients is presented: necrotizing enterocolitis, congenital diaphragmatic hernia, proximal and distal GI obstruction, intussusception, pyloric stenosis, appendicitis, and mesenteric lymphadenopathy.CONCLUSION:We should know what condition to expect and how to search for it (age, clinical presentation, collaboration with pediatricians). Conventional radiology and ultrasound, especially in combination, may solve most of the problems in the pediatric abdomen. Perform XR and US with artistry to obtain the best diagnostic profit. Follow the ALARA/ALADA principle!Keywords: imaging, pediatric, acute abdomen, congenita

Sigmoid Volvulus Combined with Hiatus Hernia

INTRODUCTION: Sigmoid volvulus is the most common form of gastrointestinal volvulus. A case of sigmoid volvulus combined with hiatus hernia is presented.CASE PRESENTATION: An 81-year-old woman was admitted to the Surgery Department with a history of abdominal pain and distention for several days.The woman arrived from another hospital where chest and abdominal X-rays had been performed. They showed the presence of dilated bowels with some of the bowel loops situated above the right hemidiaphragm. This raised the suspicion of a diaphragmatic rupture. The patient had no history of trauma.On admission to our hospital, abdominal radiogram and computed tomography (CT) were performed. They revealed that the patient had sigmoid volvulus with dilation of the sigmoid colon and the typical `whirl sign` of the twisted sigmoid mesentery. A large hiatus hernia was also found. The entire stomach and a large part of the dilated sigmoid colon turned out to be herniated through the esophageal hiatus into the right hemithorax.The patient underwent surgical detorsion of the sigmoid colon and sigmoidopexy. It was decided that the hiatus hernia should be repaired at a second stage when the patient is stabilized.CONCLUSION: The dilated sigmoid colon in sigmoid volvulus may become herniated into the thoracic cavity when there is a preexisting hiatus hernia. Although a rare co-morbidity, this condition presents certain diagnostic difficulties. Abdominal X-ray and CT have proven to be valuable methods to establish the right diagnosis

Fistula as Complication of Advanced Rectal Cancer T3/T4, Grade G2, Diagnosed with Contrast-Enhanced Computed Tomography and Magnetic Resonance Imaging

INTRODUCTION: Patients with rectal cancer may suffer complications, such as rectal fistulas at various stages of diagnostics and treatment. Some present initially with complicated advanced disease. In other cases fistulas are developed after chemo-radiotherapy and/or surgery. The causes of these complications include malignant infiltration and inflammatory changes. Various imaging modalities are used to precisely diagnose the initial stage of the tumour, and to detect the complications of advanced cancer.CASE SERIES PRESENTATION: We present a case series of five patients with fistulas due to advanced rectal cancer. All five patients are with locally advanced cancer stage T3 and T4; with histological grade G2; all of them underwent contrast-enhanced computed tomography (CECT) and magnetic resonance imaging (MRI) of the pelvis for initial diagnosis and follow-up before and after treatment for fistula. All of them had adjuvant or neoadjuvant chemo-radiotherapy and only one of them underwent surgery. The complications were communication fistulas - rectovaginal, rectovesical, rectosacral and rectocutaneous fistulas and we will present one case of postoperative presacral abscess with fistula.CONCLUSION: Various imaging modalities are used for diagnostics, staging and planning of the treatment of rectal cancer. Both magnetic resonance and computed tomography are excellent imaging tools in the management of rectal neoplasia. The morphologic criteria for investigation/imaging of rectal cancer in the setting of advanced disease are: presence and contrast enhancement of tumour tissue, diameter and volume of cancer, infiltration and extent of tumour tissue and following complications with the most common being fistulas

Osmotic Demyelination Syndrome

INTRODUCTION: Osmotic demyelination syndrome is a state of acute demyelination due to rapid shifts in serum osmolality. The entity was formerly called central pontine myelinolysis, for the demyelination process most typically affects the central pontine white matter with sparing of the periphery. However, it can also affect the cerebral and cerebellar white matter, formerly called extrapontine myelinolysis. Predisposing conditions include alcoholism, rapid correction of hyponatremia, hypernatremia, liver failure, organ transplantation, extensive burns, malnutrition and hyperosmolar hyperglycemia.CASE PRESENTATION: A 39-year-old, obese woman was admitted to the Regional Hospital after sudden development of abdominal pain and vomiting. She was diagnosed with incarcerated paraumbilical hernia. An emergency laparotomy was performed with resection of approximately 1.5 m partially necrotic intestine. The patient had a previous history of 2 years with polydipsia and polyuria postpartum and was diagnosed with partial diabetes insipidus. For these complaints she received medical therapy, ceased in the early postoperative period. After the operation, the patient developed progressive impairment of consciousness and a rise of sodium levels, necessitating admission to the ICU. Acute toxic-metabolic encephalopathy was suspected and rapid correction of the serum sodium was performed. A day later the patient was transported to the ICU in our hospital. The serial computed tomography (CT) examinations revealed hypodensity of the corpus callosum and the central pons. MRI was contraindicated for the presence of surgical clips.CONCLUSION: Our patient had typical imaging findings of osmotic demyelination syndrome consisting of hypodensity in the central pontine region and in the corpus callosum