Biomedical subjects
Publications and source records attributed to G M Steiner.
The impenetrability of bone to ultrasound can be turned to advantage and the effects of bony lesions on the adjacent soft tissues can be analysed. Fractures, bone destruction, inflammation, distraction of bone and new bone formation can be diagnosed.
The rate of return to normal of the pylorus muscle in infantile hypertrophic pyloric stenosis was measured by ultrasound, using a simple pyloric volume calculation and a pyloric muscle index. The muscle hypertrophy took from two to 12 weeks to resolve.
Clinical symptoms in the infant differ from those in the adult in that they are most likely to have a congenital or developmental cause. These symptoms are discussed together with the history and imaging techniques most likely to reveal their cause in the gastrointestinal tract. (The genitourinary and respiratory tracts will be dealt with separately in future articles in this series.)
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Three cases of injury to the spleen in children are presented. The value of ultrasound in the diagnosis and monitoring of treatment of such splenic injuries is described, and the importance of free peritoneal fluid is stressed. Since splenectomy disturbs the immune mechanisms of the body, treatment should, if possible, be medical.
Measurements of pyloric length, diameter and muscle thickness were made from ultrasound images of 39 babies, 21 of whom were subsequently found at operation to have infantile hypertrophic pyloric stenosis. From these measurements, the volume of pyloric muscle in cm3 was estimated for each case and divided by the body weight in kilograms. The resulting pyloric muscle index proved to be a much more reliable guide to the diagnosis of pyloric stenosis than any of the individual measurements or the volume estimation alone.
Fifty per cent of the offspring of adults with the adult (dominant) form of polycystic kidney disease are carriers of the abnormal gene. Clinical symptoms and signs before adolescence are rare, but renal ultrasonography may detect evidence of cyst formation. Twenty two children, all offspring of parents with known adult polycystic kidney disease, have undergone renal ultrasonography. In six cases evidence of disease was detected without clinical manifestations at the ages of 1, 2, 5, 8, 13, and 14 years. There were no renal masses, hypertension, haematuria, or evidence of renal insufficiency. In four children from three sibships, whose families had no previous history of renal disease, bilateral renal masses were noted to be present at birth. In each case one parent was subsequently found to have adult polycystic kidney disease. At the ages of 1, 4, 6, and 20 years, while renal masses were still palpable, there was no evidence of renal insufficiency or hypertension in the younger children, while the oldest had mild renal failure. An analysis of the reported cases in childhood is suggestive of a bimodal distribution of enlarged kidneys, with a number of cases diagnosed at birth or soon after, followed by an increasing incidence during later childhood. Adult polycystic kidney disease presenting at birth may be qualitatively different from the disease detected by screening programmes of children at risk.
Current research shows that sigmoidoscopy or endoscopy together with a superficial mucosal biopsy taken with a fibreoptic-type instrument should not delay the subsequent performance of a barium enema. Rigid biopsy instruments are less controllable and may take 'deep', full-thickness bites when superficial biopsies are attempted. After such a biopsy, an enema should be delayed at least 7 days to allow re-epithelialisation. Neither of these two approaches is common practice as shown in our survey of British radiologists and clinicians. The radiologist should be responsible for performing the barium enema but the survey shows that there is a difference of opinion over who should be responsible for any complications arising from it. Close contact between the referring clinician and radiologist should be maintained at all times.
Aneurysm of the vein of Galen is a rare cause of hydrocephalus. It should be suspected clinically when there are dilated frontal veins, and/or an intra-cranial bruit. Nearly all cases present in infancy. CAT brain scans will demonstrate the vascular lesion and the degree of hydrocephalus. Arteriography is only thought to be necessary if ablative surgery is planned; embolisation treatment may be applicable. Four cases from the Sheffield Children's Hospital are reported in detail and the methods of diagnosis and possible treatment are discussed.
A simple coding system that codes the work done and diagnoses is described. It is economical and designed to withstand changes in staff.
Five cases presenting in late infancy and childhood with symptoms and signs referable to malrotation of the midgut are described. The condition may present with jaundice, malabsorption or the signs and symptoms of intestinal obstruction due to internal hernia or volvulus. It may also result in volvulus and gangrene of the midgut. A short root of the mesentery predisposing to this event will be seen on a barium meal and follow through examination and will warn of its impending occurrence.
Gastro-oesophageal reflux can lead to peptic oesophagitis and stricture formation. This is particularly true in infants in whom the condition should be suspected if the patient presents with vomiting, anaemia and failure to thrive. The anatomy of the oesophago-gastric junction is described. The inferior oesophageal sphincter is the main barrier to reflux, and marks the functional junction between oesophagus and stomach. It is under nervous and hormonal control. It is weak in the neonate who therefore frequently refluxes. An hiatus hernia can cause problems due to its bulk but the main problem of peptic oesophagitis is due to gastro-oesophageal reflux. The radiological examination should be carried out carefully with the patient swallowing in a prone position. The patient should be put in the Trendenlenberg position and compression applied to the abdomen. Reflux is intermittent and a negative examination should be repeated if the clinical findings suggest a diagnosis of peptic oesophagitis. Associated pyloric stenosis should always be excluded. Radiological examination of the gastro-oesophageal junction remains the quickest, simplest, and most convenient and safe technique as long as its limitations are appreciated.
Tantalum bronchography was performed on 22 left lungs obtained at necropsy. Seven were from patients dying in cor pulmonale as a result of chronic airways obstruction and 15 were from unselected necropsies. Of the latter group, nine had no evidence of respiratory disease and six had pathological changes of emphysema and bronchial mucous gland enlargement when the lungs were examined following formalin fixation. A range of changes in the bronchographic appearances from the normal to the groosly abnormal is illustrated. The main changes in severely diseases lungs were: irregularity of the bronchial walls, failure of the walls to taper towards the periphery, areas of narrowing and dilatation, and 'pooling' of tantalum at the ends of airways. A count was made of the numbers of small airway branches in the most distal 4 cm of the lung and also of the number of airways of less than 1 mm in diameter. Patients dying in cor pulmonale had a significantly reduced total number of patent small airways in the area measured and also fewer patent airways of less than 1 mm diameter compared to both the other groups. Histological study of four of the lungs in greater detail revealed that the reduction in small airways filling was the result of a combination of obliteration and obstruction of the lumen by pus. Tantalum bronchography provides a good indication of the state of the bronchial tree at the time of death, and the changes seen are the result of both acute and chronic disease processes.