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Today we are honored to welcome Dr. Barbara Pawley for a

1:32

lecture on the Fountain of Youth pediatric GU ultrasound.

1:36

Dr. Barbara Pawley completed her radiology residency

1:39

at University of Louisville, followed by a

1:41

pediatric fellowship at Kosair Children’s Hospital.

1:45

She’s the immediate past president of AAWR and

1:48

is currently Associate Professor of Emergency

1:51

Radiology as well as Fellowship Director of

1:54

Emergency Radiology at University of Kentucky.

1:57

At the end of the lecture, join Dr. Pawley

1:59

in a Q&A session where she will address

2:02

questions you may have on today’s topic.

2:04

Please remember to use the Q&A feature

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to submit your questions so we can get to

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as many as possible before our time is up.

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With that, we’re ready to begin our lecture.

2:14

46 00:02:14,415 --> 00:02:16,335 Dr. Pawley, please take it from here.

2:17

Hi, I’m Dr. Barbara Pawley, and I’m going to talk today about

2:21

pediatric genitourinary ultrasound, the Fountain of Youth.

2:27

So, thanks.

2:30

The slide.

2:32

Uh, we have different categories today that we’re going to

2:35

look at, and the first is developmental, and then infection.

2:41

Trauma, neoplasm, and some incidental findings.

2:47

Our goals today are to augment our existing

2:49

knowledge of pediatric GU pathology.

2:53

Make the diagnosis with ultrasound and

2:55

correlate with CT or MRI whenever possible.

2:59

I think that we can see things with ultrasound much

3:02

better if we’ve had some platform to put them on.

3:06

So seeing the CT and MRI, or even intraoperative

3:10

images, helps us to be able to see things

3:13

that we couldn’t see before with ultrasound.

3:17

So we’ll start with the developmental case.

3:20

This is a 13-year-old girl with worsening

3:23

right lower quadrant, dull, achy pain.

3:26

And, um, she’s had this for a couple

3:28

of days, and our first thoughts

3:32

would be a long differential, but starting with

3:35

appendicitis, and once that is excluded, then we

3:39

turn to some other things, usually looking at the

3:41

pelvis, and that’s what we did with this patient.

3:44

And you can see marked on this image that it

3:47

is the uterus, and a sagittal projection.

3:51

We are seeing some familiar appearance here.

3:54

This is the myometrium, and we can see that, instead of the

3:58

endometrial stripe, we’re seeing a fluid-filled endometrial

4:02

canal, and it is communicating with this large collection

4:07

of complex fluid down below it, and that is the vagina.

4:12

So we have the vagina communicating with

4:14

the endometrial canal, and additionally,

4:18

we can see in the left adnexa that

4:22

there is a tubular structure.

4:24

It’s marked there as the fallopian tube.

4:26

You might wonder, how do you know

4:28

that’s not a segment of bowel?

4:30

And the answer to that is that we don’t see peristalsis

4:33

there, so we are more convinced that it’s the fallopian tube,

4:39

and it’s also in close proximity to this ovoid structure.

4:43

That, uh, we think is the ovary,

4:46

and we have better proof of that.

4:48

As we look more carefully at both of those structures,

4:52

you can see that, um, this fallopian tube is

4:55

filled with fluid, and there are some characteristic

4:57

findings, these folds in the fallopian tube.

4:59

And, uh, ordinarily we don’t see the fallopian tube at all.

5:04

So, uh, only when we see it filled with

5:06

fluid can we see these features, and we

5:09

see them again on this transverse view.

5:12

And you can see those folds again.

5:14

And this time we can see the ovary in close proximity.

5:17

You can see the follicles along the margin,

5:20

so this is a little bit better view of that.

5:22

So what is going on with this patient?

5:26

Um, we have a CT to correlate with it.

5:29

It’s a beautiful example of the

5:30

similarity of CT and ultrasound.

5:34

We saw all of these things on our ultrasound,

5:38

but here they are on a CT as well.

5:41

You can see that myometrium there, the endometrial canal

5:44

with the fluid filling it, and this huge vagina. We can see

5:48

the extent of the vagina to better, uh, advantage on the CT.

5:52

And you can also see how there might be some compromise

5:55

to the ability to void, uh, because of the mass effect

5:59

from the huge vagina there, fluid-filled vagina.

6:03

So there may be difficulties voiding; there may

6:06

be difficulties in evacuation of stool as well.

6:10

Here is a CT. Um, you can see that, um.

6:16

Um, let’s see.

6:18

You can see that, uh, here on this image that,

6:23

uh, the uterus at the midline is, uh, very thick.

6:29

So there’s the myometrium and the endometrial canal.

6:33

And over to the left side.

6:35

And you can see this, uh, arrow pointing

6:38

to the very dilated fallopian tube.

6:40

So, um, that’s just the CT visualization of that.

6:45

And what does this patient have?

6:47

We can see that this patient has an imperforate hymen

6:52

causing hydrometrocolpos and bilateral hydrosalpinges.

6:56

This patient had a successful hymenotomy that

6:59

day and left, um, the hospital the next day.

7:02

So the presentation of this condition could be in the

7:06

neonatal time period with an abdominal mass, but more

7:10

commonly it presents in an adolescent, and they present

7:14

with abdominal pain or perhaps delayed onset of menses.

7:19

Associated conditions due to this mass effect can

7:22

be bladder outlet obstruction, as I pointed out,

7:25

as well as some hydronephrosis potentially

7:29

associated with that, or constipation, as I showed

7:34

that mass effect from the distended vagina.

7:37

And there can also be ascites because of the retrograde

7:41

drainage of fluid through the fallopian tubes.

7:44

We saw that the fallopian tube was distended with fluid,

7:49

and that can make its way out into the peritoneum.

7:53

The next case is our three-month-old female who came

7:56

to the emergency department with inguinal hernia.

8:00

And you can see on image A that this is a sort

8:04

of a midline, slightly left-of-midline image.

8:07

You can see the bladder partially filled with fluid,

8:10

and the green arrows show the defect in the pelvic wall.

8:15

And through that, there is some structure protruding,

8:18

which we cannot really distinguish on this image.

8:21

On image B in the top right corner,

8:24

we can see, uh, a familiar site.

8:27

The red arrow is pointing to the uterus

8:30

with a normal-looking endometrial stripe.

8:33

And then on either side, the yellow arrows

8:37

point to what we think are probably ovaries on

8:41

either side. We can see those ovaries better

8:44

and prove that they’re ovaries by the fact that

8:47

there are multiple follicles.

8:48

The asterisks are indicating where those follicles are.

8:52

The yellow arrows, again, point to the

8:53

ovaries on either side, so very, very

8:57

unusual finding in the emergency department.

9:00

We think that we’re going to see herniated bowel,

9:02

but instead we see the entire uterus and both

9:06

ovaries protruding through the hernia defect.

9:10

So this is an indirect inguinal hernia.

9:13

It’s one of the most common congenital abnormalities

9:16

in children, and in about 15 to 20% of female patients.

9:22

The hernia sac contains unilateral

9:25

ovaries, something we may not be aware of.

9:28

Maybe we don’t investigate the contents of

9:31

the hernia sac well enough, but containing the

9:33

whole uterus and both ovaries is quite rare.

9:36

Although I was quite astounded by this case,

9:39

the pediatric surgeons did not seem to be quite

9:43

as excited, so I would assume that they must

9:46

see similar findings more often than I do.

9:50

The theories on the mechanism of the

9:52

occurrence of this include the one herniated

9:55

ovary that can occur relatively commonly.

9:59

Um, that and the uterus and the other

10:02

ovary can herniate.

10:06

Into that sac because of internal

10:09

pressure from the child crying.

10:12

So, um, that’s the mechanism of it.

10:15

And then we move on to another case in this

10:18

category, which is a 17-year-old exchange

10:21

student who has not been in the US very long.

10:27

And has no prior medical care in this country.

10:31

So, um, we don’t have any previous

10:34

records or other information.

10:37

The patient presents with abdominal pain, and

10:39

it’s predominantly in the right upper quadrant.

10:42

So as we look at this patient with a right upper quadrant

10:44

ultrasound, that was our first line of evaluation.

10:48

We can see on image A that the liver parenchyma

10:52

is quite coarse and echogenic, and the white arrows

10:56

point to this tubular structure that, once we put

11:00

color on, we can see that this is the recanalized

11:04

paraumbilical vein, and that’s something we’re

11:07

not used to seeing in this 17-year-old at all.

11:11

We might see this in a patient with

11:13

cirrhosis, a little bit older person.

11:17

But this was a very unusual finding.

11:19

And as we move on to look at the liver parenchyma a

11:22

little bit more carefully on image C, you can see those

11:25

green arrows pointing to dilated, uh, hepatic ducts.

11:31

These, these, uh, uh, biliary ducts are very distended,

11:37

and, and, uh, we should not be able to see them at all.

11:40

So, um, the coarse echotexture

11:43

um, is very abnormal.

11:46

Then we go on to look at that a little more closely.

11:49

The yellow arrow points to that, those

11:51

ducts, to see how dilated they are.

11:54

Looking at image D, uh, you might be asking yourself why

11:59

is this in a talk about GU, and that is coming up.

12:03

Um, as with all right upper quadrant ultrasounds, we

12:07

look at the right, uh, the right kidney comes with that.

12:10

And so we had the opportunity to see the right kidney.

12:13

And as you can see there, it looks very coarse echogenic.

12:18

Um, we can see that there’s those cystic

12:21

tubular structures even in the kidney.

12:26

Those are the renal tubules, and this kidney was

12:30

quite large, measuring 15.1 centimeters in the sagittal

12:33

dimension, so that’s an extremely large kidney.

12:38

I asked the technologist to get the other kidney as well.

12:42

And it had the same appearance,

12:43

and it measured about the same.

12:46

So there it is a little closer up.

12:48

You can see those dilated renal tubules.

12:52

So, uh, this is just another look at that, uh,

12:55

right kidney, um, how coarse and echogenic it is.

12:59

This patient went on to get an MRI of

13:03

the, um, abdomen, and you can see that the

13:07

kidneys are very abnormal looking,

13:11

and they look cystic.

13:13

Uh, but not the typical kind of autosomal

13:16

dominant, uh, polycystic kidney disease that really

13:20

doesn’t present with so many, uh, uh, dilated

13:24

uh,

13:25

cysts until a little bit later in age.

13:27

So this patient is just a teenager, and, um, what he actually

13:32

has is autosomal recessive polycystic kidney disease.

13:36

And hence we see the dilatation of

13:39

the renal tubules, not the cortex.

13:43

So we also see that there are cystic

13:45

changes in the periphery of the liver.

13:48

And as I mentioned earlier, the, uh,

13:52

biliary ducts are dilated as well.

13:56

It almost has a Caroli disease kind of appearance.

13:59

And you may remember studying this disease, this

14:02

autosomal recessive polycystic kidney disease,

14:05

somewhere in your past as you studied for a core exam

14:08

or maybe as, um, uh, you study for an in-service exam.

14:13

And so what we see here is classic for that.

14:17

Usually the worse the kidney disease,

14:20

the less the liver disease, and vice versa.

14:23

This patient has quite a few findings in both,

14:27

so he is a very good example of, uh, the various

14:30

things that can be seen in this patient.

14:33

He mostly had right upper quadrant pain.

14:36

So his pain really wasn’t associated with

14:39

his kidney disease, but rather with his

14:41

liver disease. He had ascending cholangitis.

14:45

So, um, this is just a really nice case of, uh,

14:49

to be able to see all the different findings in that.

14:52

And then we’ll move on to infection.

14:55

This is a 12-year-old who presents to the emergency

15:00

department with left scrotal pain and fever.

15:04

And you can see the first image on the left side

15:06

is a typical image that we get of the bilateral

15:09

testicles side by side, a comparison image.

15:11

And you can see here that the vascularity

15:14

of both testicles is very similar.

15:16

And so that helps us because, you know, we want to

15:18

know, is there hyperemia, or is there a lack of flow?

15:22

And seeing very similar flow is very helpful to us.

15:27

So then we noticed that there’s hyperemia, hyper

15:31

vascularity, more in the peripheral aspect of

15:34

the left side, and that is in the epididymis.

15:37

So this patient basically has epididymitis.

15:41

There’s inflammation of the spermatic cord as well,

15:45

panniculitis, and this patient was treated with an oral

15:50

antibiotic, as most of these types of cases are treated.

15:56

But with this patient, he came back a few days later, and

16:00

he still had pain, and we redid the ultrasound, and you can

16:03

see once again the right testicle looks pretty normal.

16:06

The left testicle is quite edematous.

16:08

We’re not seeing it all the way

16:10

here, a lot of edema around it.

16:12

This is that left testicle compared to the

16:14

normal uniform echotexture of the right.

16:17

It is quite hypoechoic.

16:20

It’s edematous, and it’s heterogeneous.

16:23

There’s a lot of edema around it, and putting color on

16:27

that, we can see that there’s hyperemia of the testicle.

16:30

Now, we didn’t see that before.

16:33

We did not see a large amount of vascularity

16:38

in that left testicle on the first study.

16:42

That is because this is taking the typical

16:44

pathway, the retrograde pathway of epididymal orchitis.

16:49

It’s a disease process that starts at the urethra

16:53

and involves the bladder, eventually makes its way

16:56

to the epididymis, and only later will it involve

16:59

the testicle itself, and then it becomes orchitis.

17:03

And we do see an asterisk there

17:05

that there is no vascularity there.

17:07

I will tell you more about that on the next slide.

17:10

So this patient, because he was doing very

17:13

poorly, he was treated with an IV antibiotic.

17:17

And, uh, he still did not really improve, and he was

17:22

reevaluated with ultrasound again a couple days later.

17:26

And again, you can see his normal right testicle.

17:29

Now his left testicle is showing some signs

17:33

of these white arrows demarcated area.

17:37

That is hypoechoic, pretty well circumscribed.

17:41

We put color on it.

17:42

We can see that there’s hypervascularity

17:45

all around that margin, but not within it.

17:48

Not in this area, but it’s all around.

17:51

And that is a typical look of advancing abscess formation.

17:57

So that’s what’s going on here.

17:59

That there was, um, infection

18:01

throughout that testicle, but now it’s

18:04

becoming walled off, creating an abscess.

18:07

Why no vascularity in the center?

18:10

Because this is just a collection of

18:12

purulent material. No blood flow into pus.

18:16

So, um, so we don’t have any blood flow there.

18:19

This patient went to the OR. Um, they

18:22

thought they might have to do an orchiectomy.

18:25

But, uh, they just drained it, and this patient, at least

18:28

at that time, did not have to undergo an orchiectomy.

18:32

So, um, this is the mediastinum testis,

18:36

and the infection is centered around that.

18:40

So that’s what’s, uh, going on at that point.

18:43

So this is epididymo-orchitis, and its cause in

18:47

prepubertal boys remains controversial.

18:51

Most cases of epididymitis in adults, um, are related to

18:56

a sexually transmitted disease, but not all of them.

19:00

The infection ascends from the bladder or

19:02

urethra, and it’s usually treated with a course of

19:06

antibiotics against the usual urinary pathogens.

19:10

But in this age patient, an STD is not the source of epi.

19:17

In prepubertal children, so rather

19:21

it is more often associated with constipation, and

19:25

straining leads to retrograde flow of urine.

19:28

So, um, when I think of, uh, epididymo-orchitis, I always wondered.

19:34

Why do these prepubertal children get this?

19:37

Uh, because we do see a fair number of them, and in

19:40

this patient, we were able to culture that, and it

19:44

was Pseudomonas aeruginosa, and, um, so, um, obviously

19:50

that is not a sexually transmitted disease.

19:52

So, um, just a nice example of

19:56

a different pathologic pathway.

19:59

So the next patient also has an infection.

20:03

Uh, had an infection, and this is a four-year-old

20:06

with fever, and you can appreciate on that

20:09

chest X-ray why he would be short of air.

20:11

And you can see the diffuse opacification, uh, the lung

20:15

parenchyma on the right side, and even some on the left.

20:19

And there was concern that there might be an empyema.

20:23

The patient got a CT, and, um, this was

20:27

necrotizing pneumonia, and there was, in fact,

20:32

the patient was diagnosed with strep sepsis.

20:38

So as part of this, uh, chest CT, we always

20:43

take the chest CT down to the level of the

20:45

kidneys, and that’s where the GU part comes in.

20:48

So as we do that, we see that the

20:52

kidneys marked with red arrows

20:54

have a striated nephrogram.

20:56

And so, at that appearance, I thought, wow, why does

21:00

this person have, uh, pyelonephritis or nephritis?

21:05

Um, and so as I reported that, uh, the

21:09

team started looking at the patient

21:12

for why he had nephritis, and they did

21:15

ultrasound of the kidneys and bladder.

21:18

And you can see here a very nice correlation of this striated

21:23

nephrogram on CT with a striated nephrogram on ultrasound.

21:28

So we have this

21:29

correlation, and, uh, it still leads us asking the question,

21:34

why does this patient have nephritis when he has no UTI?

21:39

They did not find a UTI; his urine was clean,

21:43

and so they did not treat him for a UTI.

21:46

So, um, just an investigation into that.

21:50

Uh, we can see that the striated nephrogram

21:53

is synonymous with renal infection.

21:57

Most nephritis comes from a UTI origin, so it’s

22:02

mostly that the patient has a bladder infection, and it

22:06

refluxes up to the kidney through the collecting system,

22:11

then ultimately to the renal parenchyma, and even

22:13

sometimes causing inflammation in the perinephric fat.

22:18

So that is the usual course of the infection.

22:21

But in our case, the patient did not have

22:24

any UTI, so there was no bladder infection.

22:27

How does he get nephritis?

22:29

It is because he has sepsis; he has a pathogen

22:33

that is delivered hematogenously directly to the cortex

22:37

of the kidneys, and it’s bilateral, of course.

22:41

So, um, so that’s how this patient ends up having nephritis

22:46

without a bladder infection, so.

22:50

Moving on to the next patient with an infection.

22:54

Uh, this is a 12-year-old, uh, morbidly obese patient.

22:59

And I add that information because it’s

23:01

very, uh, applicable to this patient’s case.

23:04

Um, the patient got this study at an

23:07

outside facility, and you can see that the

23:10

midline and the uterus looks pretty normal,

23:14

and the bladder looks normal as well.

23:16

It’s partially filled.

23:18

This patient was having pain, uh, in the pelvis,

23:21

so of course, uh, we would have to rule out

23:24

appendicitis first, but ultimately we arrived at

23:28

looking at the rest of the pelvic structures, and

23:30

you can see on the right and left side, very similar.

23:34

Uh, appearance.

23:35

This is a structure that we have seen already in this talk.

23:39

So, uh, you can see a tortuous tubular

23:42

structure, and we see them on both sides.

23:45

The pink asterisks mark the fallopian tubes, and

23:48

they’re filled with, um, complex, uh, fluid.

23:53

Uh, this is debris, and this is

23:55

compatible with a pyosalpinx.

23:59

So these fallopian tubes are very

24:01

distended, filled with infection.

24:04

And there’s bilateral tubo-ovarian abscess.

24:08

So, uh, the patient at the outside facility

24:11

uh, got a CT, and so it was a great opportunity

24:15

to see these same structures on CT.

24:18

And, uh, you can see the red arrow

24:20

on the far left, your left image.

24:24

This is, uh, inflammation that is all around

24:27

the inferior aspect of the liver margin.

24:30

There’s a trace amount of fluid there.

24:33

Down further in the pelvis, the red arrows

24:36

demarcate the very angry-looking bowel.

24:39

There’s a lot of inflammation surrounding it.

24:42

Here.

24:42

Make note of the very, uh, edematous loop of

24:46

bowel and the inflammation around it.

24:49

It contributes to the patient’s pain and symptoms.

24:52

And here in the low pelvis, you can see that

24:56

there’s like a mass of infection around these

25:00

fallopian tubes.

25:01

So this is both of them, the right and

25:04

the left, which we saw on ultrasound.

25:07

And, uh, there’s a lot of dilatation, and

25:11

they’re both fluid-filled, and this is all

25:14

infection and inflammation surrounding them.

25:17

And here on the sagittal view, you can

25:19

see the very similar appearance of the

25:22

fallopian tube that we saw on the ultrasound.

25:25

There it is.

25:27

Once again, originally you may think that this is

25:31

a segment of bowel, but without any peristalsis,

25:34

and given its position, then we turn our attention

25:37

to potentially the dilated fallopian tube.

25:41

So that is it on CT as well.

25:44

So, uh, the patient did not

25:46

actually progress to get better.

25:49

So eventually another CT was performed, and you can

25:53

see on this CT, the patient has a walled-off abscess.

25:57

This is not the only abscess the

25:59

patient had, um, but it’s, uh,

26:02

it’s, uh, good enough to be able to

26:05

give you the idea of what’s going on.

26:08

So she has multiple abscesses in the peritoneum.

26:12

You can see some fluid and inflammation around as well.

26:17

And so, of course, our first thought on this

26:19

patient was that this may be sexual abuse.

26:23

She’s only 12.

26:25

How else would a person get tubo-ovarian abscesses?

26:30

Um, so there was a lot of evaluation done, and also

26:35

this abscess was, uh, we did a culture of it, and it

26:40

grew out staph and E. coli, and these are not pathogens

26:43

that we see from sexually transmitted disease.

26:47

So.

26:48

Um, as you may recall, I told you this

26:51

patient was morbidly obese, and that was a very

26:55

important factor in her, uh, presentation.

26:58

She was not able to even walk down a hall.

27:03

She could not stand in the shower

27:05

long enough to take a shower.

27:07

So she just didn’t, and she had very poor hygiene.

27:10

She also struggled with issues of incontinence.

27:14

She wore a diaper to bed, and these factors

27:17

contributed to her situation of infection.

27:22

So, uh, this was not a sexually transmitted

27:24

disease, but rather, um, this was a result

27:28

of, uh, her, uh, hygiene situation.

27:32

And this is very typical of what you see

27:35

in Fitz-Hugh–Curtis syndrome, which is peri-

27:38

hepatitis inflammation associated with PID.

27:42

And so this patient had

27:45

an infection that originated at the level

27:50

of the vagina, made its way through the uterus,

27:52

out through the bilateral fallopian tubes, and

27:56

once it gets past the fallopian tubes, it’s

27:59

out in the peritoneum, so now it can surround the

28:04

ovaries, but it can also surround loops of bowel.

28:08

And this patient had inflammation

28:10

around the loops of bowel as well.

28:12

And around the liver margin, she did not, uh,

28:16

have, um, any, uh, around the dome of the liver.

28:20

So we didn’t see these violaceous strings, which are

28:22

a result of infection there and, uh, adhesions.

28:26

So, um, that’s a very good example of

28:29

Fitz-Hugh–Curtis and how it progresses.

28:32

This is a companion case, a 16-year-old who

28:36

presented to the ER with left pelvic pain, and

28:39

she got an ultrasound first, and you can see

28:42

that she has a structure that you might think is

28:45

the ovary, but there were other findings around it.

28:49

And this ovary area measured five and a half

28:54

centimeters, and that is very large for an ovary.

28:58

Um, usually they are about two to three cm,

29:03

um, but not five and a half in an

29:07

otherwise normal young teenager.

29:09

So this, um, was an abnormal finding along

29:13

with other findings of inflammation.

29:16

So she went on to get a CT.

29:18

And so there’s a very nice correlation.

29:21

Uh, this turned out to be a tubo-

29:22

ovarian abscess, which you can see here.

29:26

And there is the very dilated fallopian tube

29:29

with the surrounding infection and inflammation.

29:32

The right adnexal area does not

29:35

look the same, not quite as far progressed.

29:38

And as I mentioned earlier, there’s

29:39

a lot of inflammation to the bowel.

29:41

There’s that thickened bowel wall

29:43

we saw on the other patient as well. On coronal image,

29:47

you just see this, um, tubo-

29:50

ovarian abscess in another plane.

29:53

So, um, the patient and the parents, uh, confirmed

29:57

the patient was not sexually active at all, and

30:01

there was a lot of evaluation of this patient,

30:04

and eventually it was determined that it

30:06

was probably from a tampon left in too long

30:09

or a hygiene issue.

30:11

And so, uh, the takeaway point for this is that

30:14

we’ve seen two cases of, um, tubo-ovarian abscess,

30:19

or PID, that was not sexually transmitted disease.

30:24

I don’t know about you, but generally when

30:28

I see, um, PID, I think sexually transmitted,

30:33

um, but I just want to show you that there are

30:35

other methods of having that same diagnosis.

30:39

And then moving on to trauma.

30:41

We have this young patient, six years old, a

30:43

female who came to the emergency department,

30:47

and she had been in an all-terrain vehicle accident

30:50

and thrown forward against the handlebars.

30:54

You can see on these multiple images that

30:57

we did the exam that typically, uh, is

31:00

done for very young patients, children.

31:03

They don’t start out with a CT for their trauma.

31:05

They start out with an ultrasound,

31:07

and we ultrasound all four quadrants.

31:11

And then we ultrasound the heart area, and

31:14

we’re looking for, um, solid organ injury.

31:19

Uh, so when we see all this fluid that you see

31:22

around the liver margin and in the right lower

31:25

quadrant and bilateral sides of the pelvis, then

31:29

we start worrying about a solid organ injury.

31:33

So that warrants a CT.

31:36

So she went on to get a CT.

31:39

And starting with the fact that, um, on her,

31:44

uh, reconstructed T-spine images, you can see

31:47

that she has had a flexion injury.

31:51

You can see the compression of the superior, uh, margin

31:56

of the thoracic vertebrae, loss of vertebral height.

32:00

This confirms her mechanism of injury, and you can see here

32:05

that she has quite a bit of fluid in her abdomen and pelvis.

32:10

She might have had a full bladder when she had this

32:12

accident because we see the typical injury to the dome

32:16

of the bladder that you see here with the yellow arrow.

32:19

This is, um, the injury to the dome of the

32:22

bladder where, uh, all the fluid from the

32:25

bladder is escaping into the nearby, uh, area.

32:30

And in this case, when it’s the dome of the

32:32

bladder that’s injured, it’s usually a peritoneal,

32:35

intraperitoneal rupture of the bladder.

32:39

And so the fluid

32:41

flows around all these loops of bowel,

32:44

and that is confirmation that it is a

32:46

peritoneal rupture, not an extraperitoneal.

32:50

So, um, here you can see that the, uh, contrast

32:56

was instilled in the bladder through this

32:59

wound-tip catheter, and you can see that there’s some air,

33:02

and the contrast is just coming out into the peritoneum.

33:07

This is the peritoneal reflection.

33:09

So this patient had to go to the OR because that is

33:12

how the, uh, intraperitoneal bladder rupture is treated

33:16

intraoperatively.

33:19

That’s in contrast to this patient who came

33:21

to our ER after a motor vehicle accident,

33:26

and he probably didn’t have a full bladder.

33:29

His injury is to the anterior margin of the bladder,

33:33

and the contrast is escaping into the space anterior to that.

33:38

It’s more of a confined space and usually into

33:41

the space of Retzius as a potential space, and that’s

33:45

why on a plain radiograph, it will stay kind of

33:49

in close proximity instead of flowing all around.

33:53

It, uh, can just collect there,

33:55

and it gives that flame shape.

33:58

And so that is the classic appearance.

34:00

And, um, so, uh, it can also flow into the retroperitoneum,

34:06

but, uh, this one seems to be mostly collecting anteriorly.

34:10

Not completely, but here you can see it actually,

34:14

uh, collecting in that, um, anterior space.

34:18

And so the patient was treated as typical

34:21

treatment for an extraperitoneal bladder rupture.

34:25

And that is by placing a catheter in the

34:27

bladder, decompressing the bladder, keeping

34:30

it decompressed, and allowing it to heal.

34:32

So the patient was sent home with the bladder catheter, and

34:36

he returned, uh, several days later,

34:39

nine days later, he came back.

34:42

He had urosepsis, and here you can see his bladder.

34:46

The, um, the injury did not heal.

34:48

And he has this large collection of fluid with,

34:51

uh, gas locules throughout it and an air-fluid level.

34:55

Uh, some enhancement of that,

34:57

uh,

34:58

collection.

34:59

So this patient required a percutaneous drain.

35:03

So, um, comparing these, we have the extra-

35:06

peritoneal bladder rupture that is generally

35:08

treated with catheterization to allow healing

35:12

to the bladder as the bladder is decompressed.

35:15

The intraperitoneal bladder rupture is treated with surgery.

35:21

These people go to the OR because the large absorption of

35:24

urine leads to electrolyte and metabolic abnormalities.

35:28

So just the two different pathways that, uh, are

35:32

taken for the different types of bladder injury.

35:35

And we move on to look at a tumor case.

35:38

Uh, this is a 14-year-old male with hematuria

35:41

for a few weeks, and recently he developed dysuria,

35:44

so he presents to the ER like so many people do.

35:49

And, uh, as any child presenting with macro-

35:53

hematuria, we want to ask the history. Has there been trauma?

35:57

And in our patient, no urinary tract infection,

36:01

because sometimes they can become hemorrhagic.

36:04

Um, but he hasn’t had that.

36:06

Um, and personal or family history of nephrolithiasis.

36:12

Sometimes the movement of the, um, renal

36:16

stone through the ureter can cause bleeding.

36:18

So, um, what we want to ask next is the

36:20

652 00:36:22,185 --> 00:36:25,125 hematuria, tea-colored or pink or red?

36:25

If it’s tea-colored, we think something

36:27

farther away from the bladder.

36:29

So we’re thinking glomerulonephritis because it

36:33

is the most common cause of hematuria in a child.

36:38

But if it’s pink or red, then we think

36:40

something down at the bladder or close to it.

36:43

And, um, that’s, uh, what this patient had.

36:47

So, um.

36:49

We went on to do an ultrasound of the

36:51

kidneys and the bladder, and the kidneys were

36:54

totally normal, so I’m not showing them.

36:56

But the bladder, uh, looked like this, and we could see

36:59

the transverse and the sagittal view of the bladder.

37:02

And there was this echogenic focus along

37:04

the posterior aspect of the bladder.

37:07

And it’s somewhat irregular.

37:09

This patient has had hematuria, so.

37:13

You could maybe think this might be a thrombus, um, as

37:17

anybody might think in a patient who is having bleeding.

37:20

So, um, we then, uh, astutely,

37:24

the technologist, uh, put color.

37:27

You can see the usage of color is very helpful.

37:30

In this case, the blood flow into that

37:33

area is not compatible with a thrombus.

37:36

We didn’t see blood flowing into pus, and

37:38

we don’t see blood flow into thrombus.

37:42

But since we see blood flow into this

37:44

area, it is a concerning finding.

37:47

So now we are.

37:48

Um, and we must go to investigate this more fully.

37:52

And the patient got a CT, and so we

37:55

can see a nice correlation here.

37:57

This looks very sinister.

37:59

It looks like a bad sign.

38:01

These are the fronds, uh, extending from this.

38:04

It has a single stalk, and in fact it is very sinister.

38:09

It has turned out to be

38:11

a transitional cell carcinoma in a 14-year-old male.

38:17

So very unusual.

38:19

Did not expect to see this in the ER.

38:22

Um, so the takeaway there is that you want to

38:26

see if you see blood flow into a structure.

38:29

It’s not something inert like a thrombus.

38:32

And then a couple of incidental cases.

38:35

This is a 16-year-old male with right scrotal

38:38

pain that began at 5:00 AM, and now it has

38:41

been present for three and a half hours.

38:42

And he says no trauma.

38:44

He has just a small hydrocele on that right side.

38:48

And, uh, here you can see that the comparison image of

38:51

the testicles shows pretty symmetric flow of vascularity.

38:55

So, um, things are looking pretty good there.

38:58

I mean, we’re thinking about, because he has

39:01

no trauma.

39:02

I mean, no trauma, but a sudden onset of scrotal pain.

39:07

You have to think it could be a torsion,

39:10

but it doesn’t look that way on this image.

39:13

The patient then got, uh, the typical images to look for the

39:16

vascular flow, and we can see the submitted images include

39:20

a normal arterial waveform and a normal venous waveform.

39:24

So at first glance, this looks like a pretty normal study

39:27

and doesn’t explain the patient’s pain, but if you look

39:31

in the area of the spermatic cord, you can see this whirlpool

39:36

kind of appearance of the vascularity that is concerning.

39:41

So we have normal right arterial flow, but

39:46

as we, uh, interrogated, uh, the technologist a

39:49

little more about this since there was concern.

39:53

Um, I asked her, is there, uh, a lot of venous flow

39:58

there, or did you have trouble getting a venous waveform?

40:01

And she said, no, that was the only venous

40:03

waveform she could get throughout the testicle.

40:06

But, uh, she did not declare that on her tech sheets.

40:09

So, uh, that was, uh, unfortunate.

40:12

But, um, nevertheless, uh, you can see on this

40:16

ultrasound, um, this, uh, whirlpool kind of

40:20

appearance of the, uh, of the spermatic cord.

40:24

There it is.

40:25

And

40:27

the patient went to surgery.

40:30

So the patient was found to have right testicular torsion

40:32

with twisting of the spermatic cord, uh, by 360 degrees.

40:36

That was on the op report.

40:38

And the testicle appeared dusky at first, but

40:40

as it was detorsed, uh, it became more viable-

40:44

looking, and the patient escaped an orchiectomy,

40:47

which is a great thing for this patient.

40:49

So, um.

40:52

Is testicular torsion.

40:54

If we looked at this rapidly, um, and didn’t

40:57

investigate any further, uh, we might have

41:00

thought that, uh, this patient had a normal exam.

41:04

But, um, the important thing is to be aware

41:06

of the difficulty to find the venous flow,

41:09

which is much more affected by torsion than arterial flow,

41:13

because the venous structures are just more pliable

41:17

and easy to crimp as they tors, and it’s very, very

41:21

important to look for the torsion of the spermatic cord.

41:24

And the next patient was not so lucky.

41:27

This is a 23-month-old who had scrotal swelling.

41:33

And they thought maybe the patient had an inguinal hernia.

41:36

So, uh, the patient came in, and we see this

41:38

left testicle in the area of concern, and

41:42

it looks maybe a little bit heterogeneous.

41:45

Uh, there is definitely inflammation around it.

41:47

And, um.

41:49

You can see that they used power Doppler

41:51

to get, uh, some flow in this testicle, and

41:56

there’s a lot of flow around it in the epididymis.

42:01

And, uh, ultimately they, with using power Doppler,

42:04

were able to get this arterial waveform,

42:07

and you can see the inflammation around that

42:10

testicle and in the epididymis, and you can see that

42:14

there’s inflammation up at this spermatic cord

42:17

and a lot of hypervascularity around that.

42:21

So the way this was, uh, evaluated was

42:24

that it was thought to be epididymitis

42:26

causing inflammation of this spermatic cord,

42:28

panniculitis, and power Doppler showed

42:31

a single focus of vascular flow, which

42:34

redirected the impression away from torsion.

42:37

So, um.

42:39

So then this patient was sent home on an antibiotic because

42:43

they thought he had epididymitis, and he came back 24 hours

42:47

later, at which point I saw this patient, and, uh, you can

42:51

see that there’s a lot of inflammation around the left

42:53

hemiscrotum. The left testicle, the left epididymis, they’re all

42:57

edematous, heterogeneous, maybe a little worse than yesterday.

43:02

Uh, they did manage to give me an arterial waveform there.

43:06

There’s the cursor.

43:09

Um, and then in the left, uh,

43:13

spermatic cord region,

43:14

we can see this area that looks sort of circular.

43:19

I didn’t like it.

43:20

Um, but I did look back.

43:22

I have to say that I looked back at the previous exam

43:24

on the previous day, and when I saw this, I just did not like it

43:29

for this patient because the testicle looked so bad.

43:33

And this looks like the, you know, the

43:35

flow toward the probe and the flow away.

43:38

It’s kind of the yin and the yang,

43:39

it’s making its circle there.

43:42

I called GU.

43:43

I said, please take this patient to the OR.

43:46

And they did.

43:47

And this patient had a necrotic

43:51

left testicle.

43:52

And, um, so, um, that was, um, a sad case because, uh,

43:58

there was not enough attention given to the spermatic cord.

44:01

Um, so that’s my takeaway for that.

44:04

Um, I don’t want to leave the females out on the torsion.

44:09

Uh, this is a 12-year-old female with, um, acute onset of

44:14

nausea and vomiting and pain, and she had an ultrasound.

44:18

You can see her right ovary is very, uh, abnormal looking.

44:22

The follicles are seen along the margin.

44:26

Um, it’s an echogenic test of, uh, sorry, ovary.

44:30

And, um, here on this image is the clincher.

44:34

Um, this ovary measures

44:37

eight centimeters by 5.4 centimeters.

44:41

So, uh, we could not find her left ovary.

44:45

And so even though we couldn’t find

44:46

it, we know that this is very abnormal.

44:50

It’s just way too big.

44:52

And, uh, the follicles along

44:54

the margin and the echotexture.

44:57

Possibly a tiny bit of fluid.

44:59

There are all consistent with ovarian torsion.

45:02

It’s a very classic look for it, and this patient went

45:05

to the OR, and sure enough, that was ovarian torsion.

45:08

So just nice to show a comparison of ovarian

45:11

torsion as well as testicular torsion.

45:15

So our take-home points are indirect.

45:17

Inguinal hernia is one of the most common

45:19

congenital abnormalities in children, about

45:22

a fifth to a sixth of the female patients.

45:24

The hernia sac contains its lateral ovary.

45:28

Something I just wasn’t aware of before I saw this case.

45:31

Adult epididymitis is a result of STD quite

45:35

frequently, not always, but quite frequently.

45:38

It stems from the urethra.

45:39

In prepubertal children, epididymitis, uh,

45:43

is not from STD, but more from constipation.

45:47

Straining leads to retrograde flow of urine, and

45:51

nephritis is mostly from reflux, from infection,

45:54

from the bladder to the collecting system.

45:56

But with sepsis, the infection can be

45:59

introduced hematogenously into the kidneys without a UTI.

46:04

Pelvic inflammatory disease is not

46:06

always sexually transmitted disease.

46:08

I know I think that immediately, but, uh, here you

46:11

can see that it can be related to hygiene.

46:16

Intraperitoneal bladder rupture is treated

46:18

surgically due to electrolyte imbalance, and extra-

46:21

peritoneal with a catheter, which usually works,

46:24

but not in the one patient I showed you.

46:27

And then distinguish thrombus

46:28

from mass with color Doppler.

46:30

Uh, if we had stopped thinking, uh, just with

46:33

thinking that was thrombus from the hematuria, then

46:36

we would’ve really missed an important finding.

46:39

And the whirlpool sign of the spermatic cord is

46:41

the most definitive evidence of testicular torsion.

46:45

And that concludes, uh, these are my

46:48

references, and I'm grateful for them.

46:51

And, uh, that's the end of my presentation.

46:55

So, um, now I am going to see

46:59

if we can answer some questions.

47:03

So, uh, let's see.

47:06

Um, and I'll just ask, uh.

47:11

If, uh, Ashley has anything to tell me,

47:13

or I'll just read some of these off.

47:15

For the kidney size, you use age as sole evaluation

47:19

of enlargement, um, uh, for the kidney size.

47:24

Well, it is very good to make that kind

47:27

of evaluation, um, when people are, um.

47:32

When you have a pediatric patient and you are

47:35

being evaluated for a pediatric condition, I

47:39

would say that you would want to refer to the

47:42

charts to, um, sort of give guidance to that.

47:47

But in the ER, um, this, this is, um, even

47:52

though this is a young patient, 17, um.

47:55

The enlargement, you really don't have to

47:58

look at a, a chart for that age patient.

48:01

Um, this age patient is pretty much

48:04

an adult size, and we know adult sizes.

48:08

Um, when you get up to 15 centimeters and you have

48:12

an abnormal look, uh, we know that's enlarged.

48:15

But yes, I have definitely, in my pediatric practice,

48:19

used charts to look at sizes to get an idea.

48:22

So I would say it's good to do that.

48:25

And, uh, cortical width, uh, on renal ultrasound.

48:31

Um, correct way to measure cortical width.

48:35

Um, I would say.

48:38

Uh, you would, uh, just make sure that you have

48:41

your ultrasound probe in the correct, uh, position.

48:45

And you might take a couple of different images and,

48:50

uh, see what the measurements are, and you should

48:54

get measurements that are very close to each other.

48:57

Uh, and then ultimately you'll be able

48:59

to, um, get probably a median of those.

49:05

Uh.

49:06

Those measurements.

49:07

So, um, in, in these cases, the exact measurement

49:13

of the, uh, kidney was not as critical as

49:17

it may be in some other, uh, instances.

49:21

So, uh, uh, role for indirect radionuclide

49:26

cystography and evaluation of VU reflux.

49:29

Um.

49:30

This is actually not the thrust of my talk, but,

49:33

um, I do know that, um, we don't like to do the,

49:39

uh, fluoroscopy evaluations like we used to.

49:43

Um, so, um, a radionuclide study can be useful, I would say.

49:52

Um, the, uh.

49:55

That if you have a patient who has significant

49:59

factors like multiple infections, UTI infections,

50:04

you have an ultrasound that demonstrates that there's

50:07

abnormalities in the dilatation of the collecting

50:10

system and ureters that, um, getting to the bottom

50:14

of that with looking at a, uh, VUR reflux evaluation

50:18

is very important, and I think it would justify

50:22

doing that either by fluoroscopy or radionuclide.

50:26

Either way, I would either one, and then, uh.

50:32

Distinguish between intraperitoneal and extraperitoneal fluid.

50:36

In the case of bladder rupture, uh, as I mentioned,

50:40

um, it is, uh, best to, uh, if you see the fluid

50:45

flowing around the loops of bowel, then you can be

50:50

sure that you are in the peritoneum. The loops of bowel

50:54

are, you don't see those in the extraperitoneum.

50:57

So that is a very good way.

51:00

And the other way is just like if you're trying

51:02

to inject, uh, into a patient, say through a

51:06

tube, and it, it extravasates into soft tissue.

51:09

Uh, that's the same kind of thing that you see,

51:12

uh, in an extraperitoneal bladder rupture.

51:15

It just stays confined.

51:18

Um, and that's a, a very good way to be able

51:21

to tell that when it stays confined, you get

51:23

that flame shape and, uh, instead of flowing.

51:27

So that's the best way.

51:29

And, uh, how common is TOA syndrome in patients with PID?

51:33

Um, not, not very common, and honestly, as I have

51:39

looked, uh, now I'm not in the field of GYN, so I may

51:45

not see all the cases that they see, but I can tell

51:47

you lots about cases in the emergency department,

51:51

which a lot of them will come through.

51:54

Um, that, uh, I have not really seen,

51:58

uh, other cases of Fitz-Hugh–Curtis syndrome.

52:01

So it's, it's not very common, but often talked about.

52:06

How do, um, let's see, the liver to avoid Riedel lobe, um, uh,

52:14

well, I. Uh, I think it's kind of a gestalt of looking

52:21

at the configuration of the liver in all three planes.

52:25

Uh, your coronal, your sagittal, your axial, and, um, and

52:30

you should be able to get a good idea whether that's a Riedel

52:33

lobe, um, and, and not it, if it, if it is a Riedel lobe.

52:38

So, uh, in fact, the importance of knowing if you have

52:42

hepatomegaly is probably going to hinge more on whether you

52:45

have, uh, caudate enlargement and left lobe enlargement.

52:50

That's usually the cases that you see it in.

52:53

So that's going to be a big help to you to evaluate

52:57

those, the relative hypertrophy of the left lobe.

53:01

Renal cause, you suspect extrarenal causes in case

53:05

the primary renal changes as initial presentation

53:10

imaging, uh, when you suspect,

53:16

I'm not sure I understand that.

53:18

Um, but, um, uh, there's, can we find any relation

53:24

between ectopic testicular and indirect hernia?

53:30

Um, relationship, not that I'm aware of.

53:35

So I'm sorry.

53:37

I can't really help you with that particular question.

53:39

Um, uh, so, uh, no open questions.

53:46

Alright.

53:47

Um, I thank everyone for joining me, and, um, I had, uh,

53:54

uh, I'm very glad that I got to share this information,

53:58

so thank you.

53:58

967 00:54:00,105 --> 00:54:01,725 Dr. Pawley, thank you so much for your

54:01

lecture today, and thanks for everybody

54:04

for participating in our noon conference.

54:07

And a special thanks to our co-sponsor, A A

54:09

WR. You can access the recording of today's

54:13

conference and all our previous noon conferences

54:15

by creating a free MRI online account.

54:19

Be sure to join us next Thursday, January 19th,

54:22

at PM Eastern for a lecture by Dr. Marcelo de

54:26

Abreu on spine degeneration and inflammation.

54:29

Our next A A WR co-sponsored lecture is January 26th,

54:34

with who will give a talk on breast advocacy updates.

54:38

You can register for these lectures@mrnline.com and follow

54:42

us on social media for updates on future noon conferences.

54:46

Thanks again, and have a great day.