Biomedical subjects
Publications and source records attributed to C J Sivit.
Niemann-Pick disease (NPD) is a metabolic disease in which cirrhosis is relatively common; however, there is no known association of NPD with hepatocellular carcinoma. We present a case of metastatic, multifocal hepatocellular carcinoma in a 4-year-old boy with NPD and onset of cirrhosis in infancy.
This study was designed to evaluate the sensitivity and specificity of abdominal ultrasonography as a diagnostic modality in a large series of children who presented with possible appendicitis. From August 1990 to July 1994, 452 children (203 boys, 249 girls) with an average age of 11 years (range, 1 to 20 years) underwent graded compression ultrasonography of the right lower quadrant of the abdomen for the evaluation of possible appendicitis. In the first 18 months of the study all patients with the possible diagnosis of appendicitis (group I; 180 patients) had abdominal ultrasonography after members of the surgical team evaluated and documented their findings in the medical record. In the second study period (30 months), abdominal ultrasonography was recommended only when the clinical diagnosis of acute appendicitis was equivocal (group II; 272 patients). Abdominal ultrasonography was performed using the graded compression technique with a 5.0-MHz linear array transducer. A positive ultrasound study for appendicitis was defined as the presence of an enlarged noncompressible appendix with an outer wall to outer wall diameter of greater than 6 mm, the presence of a complex mass, or the presence of an appendicolith. The sonographic data were correlated with surgical and pathological findings. Appendicitis was confirmed in 112 of the 452 cases. In 17 of these, the appendix was perforated. In the overall group of 452 children, abdominal ultrasonography had a sensitivity of 90%, specificity of 96%, and accuracy of 95%. There was no significant morbidity in the 11 patients with a false-negative study result. All 11 patients had an uncomplicated appendectomy. There were 11 false-positive results; 10 of these patients had a negative laparotomy result (negative laparatomy rate, 8.9%). For the two groups, the sensitivity and specificity of ultrasonography in the diagnosis of appendicitis were equivalent (group 1: 88% sensitivity, 96% specificity; group 2: 92% sensitivity, 97% specificity). On the basis of the high sensitivity and specificity rates, ultrasonography of the appendix can be a useful adjunct to standard examination in the diagnosis of acute appendicitis.
OBJECTIVE: The authors assessed the risks of nonoperative management of solid visceral injuries in children (age range, 4 months-14 years) who were consecutively admitted to a level I pediatric trauma center during a 6-year period ending in 1991. METHOD: One hundred seventy-nine children (5.0%) sustained injury to the liver or spleen. Nineteen children (11.2%) died. Of the 160 children who survived, 4 received emergency laparotomies; 156 underwent diagnostic computer tomography and were managed nonoperatively. The percentage of children who were successfully treated nonoperatively was 97.4%. Delayed diagnosis of enteric perforations occurred in two children. Fifty-three children (34.0%) received transfusions (mean volume 16.7 mL/kg); however, transfusion rates during the latter half of the study decreased from 50% to 19% in children with hepatic injuries, despite increasing grade of injury, and decreased from 57% to 23% in the splenic group with similar injury grade (p < 0.005, chi square test and Student's t test). CONCLUSION: Pediatric blunt hepatic and splenic trauma is associated with significant mortality. Nonoperative management based on physiologic parameters, rather than on computed tomography grading of organ injury, was highly successful, with few missed injuries and a low transfusion rate.
The peritoneal cavity and its specialized folds, the mesentery and omentum, are often involved in infectious, neoplastic, and traumatic conditions. Abnormalities in the development of these structures may also result in pathologic conditions. CT scans are often the modality of choice for evaluation of many of these entities. The following discussion reviews the normal anatomy and the CT features of disease processes that involve the peritoneal cavity, mesentery, and omentum in children. Identification and characterization of these pathologic conditions depend on knowledge of the normal appearance of the peritoneal cavity and its specialized folds and familiarity with the anatomic pathways for spread of disease.
The purpose of this report is to compare a computed tomography (CT) injury severity scale for hepatic and splenic injury with the following outcome measures: requirement for surgical hemostasis, requirement for blood transfusion and late complications. Sixty-nine children with isolated hepatic injury and 53 with isolated splenic injury were prospectively classified at CT according to extent of parenchymal involvement. Clinical records were reviewed to determine clinical outcome. Ninety-seven children (80%) were managed non-operatively without transfusion. One child with hepatic injury required surgical hemostasis, and 17 (25%) required transfusion of blood. Increasing severity of hepatic injury at CT was associated with progressively greater frequency of transfusion (P = 0.002 by chi 2-test). One child with splenic injury underwent surgery and eight (15%) required transfusion of blood. Splenic injury grade at CT did not correlate with frequency (P = 0.41 by chi 2-test) or amount (P = 0.35 by factorial analysis of variance) of transfusion. There was one late complication in the nonsurgical group. A majority of children with hepatic and splenic injury were managed non-operatively without requiring blood transfusion. The severity of injury by CT scan did not correlate with need for surgery. Increasing grade of hepatic injury at CT was associated with increasing frequency of blood transfusion. CT staging was not discriminatory in predicting transfusion requirement in splenic injury.
Over the past decade CT scanning has become generally accepted in North America as the diagnostic modality of choice for the evaluation of abdominal injury in children following blunt trauma [1-5]. Recently, there has been increasing interest in the use of sonography as the primary screening examination in this area. Initial studies utilizing sonography in the evaluation of trauma patients focused primarily on identifying hemoperitoneum in adults [6-8]. More recent studies have also attempted to evaluate the accuracy of sonography for the diagnosis of solid viscus injury [9-14]. Filiatraut and colleagues recently reported a long and successful experience using sonography for the investigation of blunt abdominal trauma in children [12]. Their work in this area should be applauded. However, whether widespread application of this modality can be successful remains uncertain. In the space below a critical evaluation of sonography and CT in the assessment of injured children is presented.
This report aims to provide a description of the spectrum of radiographic findings in children with AIDS and Pneumocystis carinii pneumonia (PCP). The chest radiographs of all children with perinatally transmitted HIV infection who had PCP were reviewed. Thirty-eight episodes of PCP were noted in 32 children. The age range was 2-17 months. The radiographic findings were characterized as to pattern, severity, presence of pulmonary air cyst, thoracic air leak, thoracic lymphadenopathy, and pleural effusion. The initial distribution of disease was as follows: diffuse (n = 20), patchy (n = 12), focal (n = 4), normal (n = 2). In nearly one-third of children parenchymal abnormalities were mild enough that most normal lung markings were visible. During the course of the illness pneumothorax was noted in eight cases, pulmonary air cyst in five, and pneumomediastinum in one. Pleural effusions were noted in three (5%) cases. Thoracic lymphadenopathy was not observed in any case. The authors concluded that the initial chest radiographic appearance of PCP in children with AIDS is variable. The initial chest radiograph may be normal. The distribution was patchy or focal in nearly one-half of all cases with parenchymal abnormalities. Pulmonary air cysts or thoracic air leaks were noted during the course of the illness in approximately one-third of all cases.
Clinical data and computed tomographic (CT) scans for 1,486 children evaluated after blunt abdominal trauma were reviewed to determine whether peritoneal fluid is a reliable indicator of the presence and severity of associated intraabdominal injury and the need for laparotomy. The CT scans were assessed for presence, location, and severity of intraabdominal injury, and amount of peritoneal fluid. Type of management (surgical or nonsurgical), indications for surgical management, overall hospital course, and clinical outcome were recorded at the time of discharge. Of the 326 children with abdominal injuries detected by CT, 121 (37%) had no associated peritoneal fluid collections. Eighteen (15%) of these children had injury to more than one abdominal organ. Splenic injuries by CT criteria were more severe in children with associated peritoneal fluid than in those with no associated fluid (P < .003). There were no significant differences in CT grading of liver and renal injuries among those with and without associated peritoneal fluid (P > .67). Two hundred fifty-nine (17%) of the 1,486 children had peritoneal fluid demonstrated by CT. Eighty percent of these children had concomitant intraabdominal injury. Associated injuries included solid organ injuries (in 68% of patients) hollow viscus or mesenteric injury (11%), isolated pelvic fracture (4%), and hypoperfusion syndrome (5%). Thirty-one patients (12%) had injury to more than one abdominal organ. Only 27 (11%) patients had small "unexplained" collections of peritoneal fluid in which no associated injury was detected through CT or clinical follow-up. The authors conclude that (1) solid organ injury is frequently present in the absence of peritoneal fluid, and (2) the identification of peritoneal fluid after blunt trauma should lead one to suspect that a specific intraabdominal injury is the cause of the fluid.
OBJECTIVE: To compare the incidence of and factors associated with vascular thrombosis after placement of heparin-bonded and standard femoral venous catheters. DESIGN: Prospective, masked, clinical study. SETTING: Multidisciplinary, tertiary, pediatric intensive care unit. PATIENTS: Consecutive cases (n = 50) of critically ill children admitted to a pediatric intensive care unit in whom either a heparin-bonded (n = 25) or a standard (n = 25) femoral venous catheter was placed. MEASUREMENTS AND MAIN RESULTS: Patients were examined by ultrasonography within 3 days of catheter insertion, weekly while the catheter was in place, and after catheter removal for evidence of vascular thrombosis. Data were collected prospectively regarding clinical evidence of catheter thrombosis, infusate composition, and positive blood culture results. Of 50 patients, 13 (26%) had thrombotic complications, 11 (44%) of the 25 patients in the standard-catheter group, in comparison with 2 (8%) of the 25 patients in the heparin-bonded catheter group (p = 0.004). In addition, there was a significantly higher incidence of positive blood culture results among patients in the standard-catheter group (24% vs 0%; p = 0.009). Positive catheter blood culture results were obtained in 38% of patients with thrombosis versus 3% without thrombosis (p = 0.001). Clinical evidence of thrombosis was found in 69% of patients with, versus 27% of patients without, ultrasound-proved thrombosis (p = 0.007). CONCLUSION: Heparin bonding of catheters is associated with significantly fewer thrombotic complications. A reduced incidence of positive catheter-related blood culture results may be associated with the absence of thrombosis.
Primary abnormalities of the peritoneum are rare in children. However, there is frequent secondary involvement of the peritoneal cavity and its specialized folds, the mesentery and omentum, in the presence of infectious, neoplastic, and traumatic conditions that originate at other sites in the abdomen or pelvis. Computed tomography (CT) is usually the modality of choice for evaluation of complex abdominal or pelvic pathologic conditions. Peritoneal cavity abnormalities include peritoneal fluid, pneumoperitoneum, and hemoperitoneum; peritoneal abscesses and peritonitis; metastases; and bladder or bowel rupture and solid organ injury. Mesenteric and omental abnormalities include an increase in or infiltration of mesenteric and omental fat; mesenteric lymphadenitis; mid-gut malrotation and bowel herniation; a variety of infections; metastases, lymphoma, and lymphangioma; and mesenteric injury. Knowledge of the spectrum of abnormalities that involve the mesentery, omentum, and peritoneal cavity and the characteristic CT appearances of these abnormalities is essential for improved diagnosis of these conditions.
PURPOSE: To assess if the initial grade of splenic injury depicted at computed tomography (CT) in children could help predict rate of healing. MATERIALS AND METHODS: Thirty-seven children with splenic injury graded at emergent CT were prospectively followed up with non-enhanced and contrast material-enhanced CT performed 2 weeks to 11 months after injury. RESULTS: In all 15 grade 1 and 2 splenic injuries, healing was seen at follow-up, including eight injuries that occurred in patients who underwent follow-up CT within 4 months. In 10 of 11 grade 3 splenic injuries, healing was seen within 6 months. In all 11 grade 4 injuries, residual lesions were seen within 4 months and healing took up to 11 months. Five of nine residual splenic injuries were more clearly visualized with contrast material enhancement. No splenic complications occurred. CONCLUSION: CT grade of splenic injury is related to rate of healing. Grade 1 and 2 injuries typically heal within 4 months, whereas grade 3 injuries take up to 6 months to heal and grade 4 injuries take up to 11 months.
OBJECTIVE: The purpose of this study was to determine the utility of CT performed with maximal bladder distension in showing extravasation of IV contrast material as a means of detecting and localizing bladder rupture in children after blunt trauma. MATERIALS AND METHODS: Seven of 1500 consecutive children who had IV contrast-enhanced CT of the abdomen after blunt trauma had a rupture of the bladder proved at surgery (five patients) or by clinical and imaging findings (two patients). The scanning protocol in all patients included occlusion of the Foley catheter if present and a 5-min delay after IV injection of contrast material prior to scanning the pelvis. The CT scans of all 1500 children were prospectively evaluated for the presence and location of extravasated contrast material in the pelvis. RESULTS: Extravasated IV contrast material in the pelvis was noted in all seven children with bladder rupture (intraperitoneal in four, extraperitoneal in three) and two of 1493 children without bladder rupture (extraperitoneal in both). Both children with contrast material extravasation who did not have bladder rupture had a renal injury. The location of the rupture (intraperitoneal or extraperitoneal) could be determined from the distribution of extravasated contrast material in the pelvis seen on CT scans. CONCLUSION: The use of a scanning delay at CT prior to imaging the pelvis showed extravasation of IV contrast material in all seven children with bladder rupture. Intraperitoneal and extraperitoneal bladder rupture could be differentiated on the basis of the distribution of extravasated contrast material seen on CT scans.
OBJECTIVE: The purpose of our study was to evaluate the relationship of fluid between the splenic vein and the pancreas to fluid in the anterior pararenal space in children following blunt trauma and to assess the usefulness of detecting fluid separating the splenic vein and the pancreas in the CT diagnosis of pancreatic injury in children. MATERIALS AND METHODS: Twenty-five of 1725 consecutive children who underwent abdominal CT following blunt trauma had surgically or autopsy-proven pancreatic injury or clinical pancreatitis. An additional 29 children who underwent CT for evaluation of blunt trauma did not have pancreatic injury and were prospectively noted to have fluid in the anterior pararenal space. CT findings (visceral injury or intraperitoneal or extraperitoneal fluid) were recorded at the time of initial interpretation in all children. The CT scans of these 54 children were reviewed for the presence of fluid separating the splenic vein and the pancreas. RESULTS: Fluid separating the splenic vein and the pancreas was noted in 15 (60%) of 25 children with pancreatic injury and in 14 (48%) of 29 children who had fluid in the anterior pararenal space without pancreatic injury. In 14 of 15 children with pancreatic injury and fluid between the splenic vein and the pancreas, additional collections of peripancreatic fluid (anterior pararenal space or lesser sac) were also noted. In another four children with pancreatic injury, additional collections of peripancreatic fluid were noted in the absence of fluid between the splenic vein and the pancreas. CONCLUSION: Fluid separating the splenic vein and the pancreas on CT scans is a nonspecific finding usually associated with fluid in the anterior pararenal space. Although it may be seen in conjunction with pancreatic injury, it is rarely the only abnormal CT finding in such an injury.
Initial CT grading of renal injury was correlated with the frequency of complications and the time course of healing in 35 children. All renal contusions (grade 1, 8) and small parenchymal lacerations (grade 2, 8) healed without complications. All lacerations extending to the collecting system (grade 3, 9) resulted in mild to severe loss of renal function with progressive healing over 4 months. One of four segmental infarcts (grade 4A), and five of six vascular pedicle injuries (grade 4B) resulted in severe loss of renal function. Complications, including urinoma (2), sepsis (1), hydronephrosis (1), and persistent hypertension (2), were limited to grade 3 and 4 injuries. Our results suggest that mild renal injuries do not require follow-up imaging. Major renal lacerations and vascular pedicle injuries, however, often result in loss of renal function and should be followed up closely due to the risk of delayed complications. Follow-up examinations should continue for 3-4 months until healing is documented.
PURPOSE: To develop a clinical scoring scheme that can be used to predict the risk of abdominal injury in children after blunt trauma. MATERIALS AND METHODS: Presenting clinical features and outcomes, including the need for surgery, were reviewed for 793 children who underwent computed tomography (CT) after blunt abdominal trauma. These data were submitted to a logistic regression model to identify predictors for major abdominal injury. An abdominal injury score was developed on the basis of results of these analyses; higher scores denoted a progressively higher risk. RESULTS: The proportion of children with abdominal injury increased significantly with progressively higher scores (P = .0001). There was no significant difference between the predicted and actual frequency distributions of abdominal injury (P = .782). Patients were assigned to low-, intermediate-, and high-risk groups according to abdominal injury score, with a predicted probability of abdominal injury for each group of < or = 5%, 6%-15%, and > or = 16%, respectively. Frequency of major abdominal injury increased with higher scores, as did the need for laparotomy. CONCLUSION: The abdominal injury score shows promise as a useful tool for triage of children considered for emergency CT after blunt abdominal trauma.
OBJECTIVE: We reviewed the clinical features and CT evidence of active hemorrhage in children undergoing CT studies because of closed thoracoabdominal trauma. Our purpose was to evaluate the hypothesis that children with this CT finding have uniformly poor clinical outcomes. MATERIALS AND METHODS: The CT records of approximately 3000 children undergoing CT evaluation for trauma at four geographically distinct pediatric trauma centers were reviewed for the presence of active hemorrhage on CT scans. The location and severity of active hemorrhage, accompanying organ injury, initial clinical information, type of treatment (surgical or nonsurgical), and clinical outcome were recorded. RESULTS: Seven CT studies showing acute extravasation of intravascular contrast material in the abdomen (six) or chest (one) were identified. Hemorrhage was caused by severe solid organ injury in four children (three with hepatic injury and one with splenic injury) and by vascular injury to the internal iliac artery, segmental pulmonary artery, and descending colon in one child each. Every child with abdominal injuries had large collections of intraperitoneal fluid, and three children had abdominal CT signs of hypoperfusion. Although all patients were hemodynamically stable initially, four children became hypotensive during CT examination. Six children required surgical intervention because of ongoing blood loss, and two children died. CONCLUSION: Our results suggest that children with CT evidence of active hemorrhage have a different spectrum of injuries than that seen in adults. Despite the high rate of hemodynamic instability and need for urgent surgical intervention, most children with this CT finding survive.
OBJECTIVE: The purpose of this study was to determine the sensitivity and specificity of CT in diagnosing bowel rupture in children after blunt trauma and to compare CT findings in children with bowel rupture with those in children with the hypoperfusion complex. SUBJECTS AND METHODS: Twenty-one (1%) of 1488 children who had contrast-enhanced CT of the abdomen after blunt trauma had a bowel rupture subsequently verified at surgery or autopsy. Thirty-three additional children had a characteristic hypoperfusion complex at CT. The CT scans in all 1488 children were prospectively evaluated for the following findings: peritoneal fluid, extraluminal air, bowel wall enhancement, bowel wall thickening, and bowel dilatation. RESULTS: The most common CT findings in children with bowel rupture were peritoneal fluid (14, 67%) and bowel wall enhancement (13, 62%). One or more of the five studied CT findings were noted in 20 of the 21 children with bowel rupture and in 64 of the 1467 children without bowel rupture (sensitivity 95%, specificity 96%). Thirty-three children who had one or more of the CT findings and did not have bowel rupture had the hypoperfusion complex. CONCLUSION: Our results show that CT is accurate in the diagnosis of bowel rupture after blunt trauma in children. The most common findings are peritoneal fluid and bowel wall enhancement. CT findings in children with bowel rupture may overlap with those in children with the hypoperfusion complex.
Our purpose was to characterize the spectrum of hepatobiliary abnormalities on sonography in children with vertically transmitted HIV infection. Abdominal sonograms were performed on 41 children with HIV infection and correlated with clinical and histopathologic data. Hepatobiliary abnormalities were noted in 26 (63%) children. Hepatomegaly (n = 13) and abnormal hepatic echotexture (n = 13) were the most common abnormalities noted. Preexisting AIDS-related infections or neoplasms were noted significantly more frequently in children with hepatic or biliary abnormalities on sonography (18/26, 69%) than in children without abnormalities (5/15, 33%) (P = 0.0001). Most children with hepatobiliary abnormalities on sonography who underwent hepatic tissue sampling, however, did not have evidence of acute infection or neoplasia. Hepatobiliary abnormalities are frequently noted on sonography in children with HIV infection. Hepatomegaly and abnormal hepatic echotexture are the most frequent sonographic findings and are usually nonspecific.