Miscellaneous Application in Paediatric Practice - HD

Overview

Okay. So, brief overview of what we are gonna see now. We've seen the most typical applications in children, which you will find easily in the literature. More and more we've seen trauma, we've seen focal liver lesions, and now a little bit more into what you can dare to do, and how the US can help you really in practical terms, many, many times in real acute clinical scenarios, we're gonna have a look at transcatheter uses of CUS and novel applications, which will include chest, biliary, bowel, PEIs, and in general, as a problem solving tool.

Transcatheter Procedure in Children

So briefly again, how do we perform transcatheter in children? We use one single drop of son of you diluted in, into 20 or 50 milliliters of saline. Again, here, the doses depend also on the cavity that you're gonna inject into. And if, obviously if you're looking for a tiny fistula, your doses will be slightly less diluted. Whereas if you're looking to a small abscess to a small cavity, then you can dilute a bit more, and you can evaluate intraperitoneal or intrathoracic ions, but also the biliary tree. And by using these, as you've heard yesterday as well, you can tell really easily, you can have more information about position of catheters, patency of the catheters, and also when a catheter is in the right position, you can have a quantitative idea of the amount of volume of fluid that's really effectively drained and you can diagnose possible fistulas communications between collections.

Literature Review

When you look at the literature at the moment, there isn't really much out there in terms of pediatric transcatheter use of cwe, but there is a fair bit on GI and biliary applications. This is a paper showing in intra liver intrahepatic injections of contrast within a drain liver abscess. You can get also all sorts of other types of examination transcatheter. This is a perianal fistula, and you can see how you can delineate really easily this fistula and possible ramifications. Again, in the literature, what you'll find mostly in terms of intra catheter use of CUS is probably about the visualization of the biliary tree. And there are a few papers out there outlining its usefulness in the biliary applications. This is a paper that was centered on liver transplant patients. And the injections through the T tube can easily demonstrate the anastomosis, the biliary anastomosis, and the patency of the anastomosis, and we can get pictures that are quite good quality compared to the your classic fluoroscopic image. And again, similarly, you can easily depict leakage of contrast through the T tube from a leaking anastomosis of the common bile duct.

Case Examples

Chest: Empyema in a Small Boy

But onto our cases. So this is a small boy who came to us with a classic history of pneumonia. One week of cough and high fever. He had, this was the presenting chest x-ray with a classic appearance of consolidation with an associated mnemonic fusion. And on the baseline ultrasound, which we will always perform for our chest pediatricians to insert a drain, you can see very easily the large area of consolidated lung with an associated effusion with strengths within it. So this classifies as an empaa. So the patient underwent drainage of the empaa, and which was initially quite successful. The problem is that a few days later, the child came back, really technique came back, meaning he was still in the hospital, but came back to our department really technique with reduced hair entry on the right hand side, you can see on the chest x-ray that was complete wipe out. So the obvious question here is, what's happening? Is this drain draining? Why is this fluid reaccumulating? What's going on? And we performed a baseline ultrasound scan. This is a transcos view. You can see the heart deeply, and again, you can see that the consolidation is still there. The is still there. If anything, it looks a bit worse when compared to the last scan. And therefore here, the classic question you've got the pediatrician on your side is, where is the drain? Is the drain draining? And you can understand how it may be quite difficult, first of all, because you are looking for an echogenic structure with something that it's quite echogenic in itself. And secondly, you're scanning a small child, which is screaming with the mom, not happy kicking. It's not the easiest task to find where the drain, the tip of the drain is. So we've started now injecting both iv, and you can see on this picture that we could delineate really easily the thickened, the enhancing pleura with the underlying consolidated lungs, which enhances avidly. And we could differentiate it really easily from the mnemonic. But again, the question remains. So the easiest way to find out was to inject a tiny bit of contrast down the drain, and not only we could see where the tip of the drain was, and it was indeed in the right place within the collection, but as the time went along, we realized very quickly that this drain was only draining a tiny lock of the collection of the empaa. And this was what we were left at the end of the scan, only this single lock was actually being drained, and therefore this would could easily explain why the patient wasn't getting any better. And this was quite useful because then the pediatrician could go ahead, inject some urokinase, and a few days late the next day, indeed, the patient came back and we repeated the scan to demonstrate that this time around the drain was indeed effectively draining the whole of the empyema. And the patient recovered really well. So you can see how it can be really useful, especially when you're stuck and you don't know, you don't really have an answer for the doctor who sent you the patient.

Chest: Complex Pneumonia in a 2-Year-Old Girl

Another example of another small child, 2-year-old, typically the patient who get these complicated pneumonias are quite young. This was a little girl who came in with this chest x-ray showing a slightly more complex picture. You can see the air fluid levels and a very complex collection on ultrasound. The appearance is really heterogeneous and you can see partly consolidate lung. But again, here, there is another question, which is, is this all consolidated lung? Are we dealing with a necrotizing pneumonia versus a pneumonia with a collection? And ultimately, do we need to drain this or not? Obviously, if this was a necrotizing pneumonia, our chest pediatricians wouldn't go ahead and drain it because of the risk, the increased risk of developing a broncho pleural fistula. So it is a crucial question that you need to answer right away. And from the baseline ultrasound, we couldn't really tell. Yes, sometimes the color box may help if you see vessels going through these consolidated area that you know that you're dealing with in pneumonia. But again, this was not particularly helpful because there were areas that were non vascularized. So what was quite helpful was injecting some contrast. And after injection, you can see that there were bits of parenchyma that were enhancing as consolidated lung should do. However, bits in these consolidated lung, there were interspersed areas of non enhancing parenchyma. So we knew from this that we were dealing with a necrotizing pneumonia instead of an emina back in the day. Again, you need to get your clinicians on board and you need to convince them that what you're doing is for real. And so we performed a CT and that confirmed exactly the CUS picture. So we move on from performing cts in these patients, and we rely heavily on CUS these days.

Chest: Consolidation and Collection in Another Girl

This is another girl, similar example. Again, she came with these consolidation and monic collection, which was effectively drained, but sometimes you may have these other scenario where the drain has drained, it was effective, it has now stopped draining, and you want to know whether there is still some residual fluid to drain or whether you can just take the drain out. And this was the beam mode picture. Again, sometimes it may not be very helpful. Yes, you can see clearly that there are bronch grams. So you, most of what you're seeing, you can tell that it is a consolidation, but it is still unclear whether there is a little bit of fluid left. And this is easily resolved by injecting contrast iv. And you can see how you could follow these branching vessels all the way from the middle of the consolidation all the way to the periphery or the pleural edge. So all you were dealing with was actually consolidated lung and the patient could have a drain removed, and she did a full recovery follow up.

Biliary Scenarios

Another very useful application is in biliary scenarios and for the ization of the biliary tree. As Maria told you before, we have a big liver center. So this happened. This patient came in on a Saturday when I happened to be on call, and she came in with a high temperature and jaundice. We knew the patient had an ischemic angiopathy and she had already a biliary drain in C two. When I scanned her on the ultrasound suite, I saw that there were dilated ducts, as you can see here, and part of the drain I could depict easily. And it looked as if it wasn't dislodged. It looked to be within the village tree. But however, I couldn't explain why the ducts were still dilated. This is just to show you the degree of biliary dilatation and the pulse on doppler ultrasound indeed, to confirm that this was an ischemic angiopathy with collateral formation from the rule loop. So this is quite important because you are there with the little patient and you want to get an answer right away. Sometimes ultrasound lo may not be that helpful because you've seen the drain, you've seen it's in the biliary duct, but you don't know whether it's patent or not. So the patient is already on antibiotic cover. You can just inject down the drain. And what we saw was that the drain was visualized, but only partially with some gaps within it. And no biliary three whatsoever was visualized in this. So this was a blocked drain rather than dislodged. And not only we had the answer right away without need to move the patient to the fluoroscopy suit called the radiographer, called the registrar. We could just perform it there. And then we had the answer. And not only that, minutes later performing these, the drains started pouring by. So we had both diagnosis and therapeutic effect on this patient. And when she came back a few days later, the ducks were going down in inside, so it was really effective.

Another example of a small boy who had undergone a left lateral segment liver transplant, he had developed an asmo stricture at the at the biliary rule loop connection. And he had an internal external drain in situ. He presented this time with a leak at the skin entry and a very high output from the skin entry. So the question was, where is the drain? Is it dis large? Same thing again. So when we scanned him with the ultrasound, we could see very easily that the drain was in the biliary tree, but we couldn't really tell where the tip of the drain was. And by injecting a few drops down the drain, we could see that the drain was probably too, it was indeed across the stricture. So it was doing partially its job. However, all we were feeling was the rule loop, as you can see here. And there was no visualization of the intre pathic duct. So following these CS, we could bring the patient to the fluoroscopy suit and just manipulate the drain by withdrawing a little bit to just obtain better drainage of the intrahepatic duct through the holes. And this did the trick really easily, and the patient stopped leaking.

Inflammatory Bowel Disease

Maria showed you already an example, another possible application in pediatrics is inflammatory bowel disease. Typically you can see findings of IPD on normal ultrasound B mod ultrasound, and you've got the support of raised inflammatory markers, so you know what you're dealing with. But sometimes it can be useful to tell whether or not there is active inflammation going on. This is a patient who had these large lymph nodes in the right IAC fossa, and we could see a thickened loop of small bowel in the right iac fossa by injecting contrast. We could tell that there was avid enhancement of the walls and identified the involved segment and is correlated quite nicely with the MRI that he performed later on.

Scrotal Disease

Oh, I'm not gonna dwell on scrotal disease because Dean has presented this really nicely this morning. And again, this is a situation with which you shouldn't really find yourself into the classic situation of adolescent presenting to the emergency department with swelling of the scrotum shouldn't really come through your suite. It's quite a minefield. You should just go straight to theater. But this is what happened. The had sent the patient to us, so he was with us. We saw the scrotum was enlarged. The testis was really heterogeneous, and by injecting a little bit of contrast, we could tell that the testicle was completely gone. There was no announcement whatsoever. And this was a missed torsion.

Pancreatic Mass

A couple of cases where we found CUS being quite helpful in terms of helping us resolving a difficult clinical scenario. This was a adolescent girl referred from another hospital with this CT of a pancreatic mass, incidentally found on an abdominal scan. She had mildly elevated amylase, and we saw, we repeated, we performed a first line ultrasound examination, and we confirmed the presence of this mass. I think I was lucky enough to call these solid what actually turned out to be a solid pseudo papillary tumor of the pancreas, which was confirmed on the MRI in terms of typical findings of a fibrous scar with some hemorrhage on the T one weighted images. But however, you still need tissue diagnosis. The tumor had enhancement of the ws, but we couldn't really tell from the MRI where the solid beats of the mass were sitting. And the patient on the went an endoscopic ultrasound with FNA and biopsy. However, they could not obtain any tissue. So we were really stuck. We knew from the imaging that that was the likely diagnosis, but we needed tissue. So what was really helpful here was performing a CUS at the time of the trans cutaneous biopsy. And we could identified really easily what the solid component of this tumor was and therefore guide our biopsy, which was eventually performed on the CT guidance. And we could aim at the beat that were enhancing on the CUS performed in the city suit. So again, you can see how it can be really helpful in these scenarios when you are a bit stuck.

Splenic Lesion

Again, another situation when it can be helpful. This was a 13-year-old girl with a long standing abdominal pain of a non curse. She had a an MRE, which showed colitis. And as you always, as it always happens, you find these incidental findings on the MRI, this one had, tiny splenic clump that looked at a little bit different than the rest of the splenic parenchyma. But the surgeons got really excited when they looked back and they saw these at on exploratory laparotomy. So the easiest thing in this case was to do an ultrasound scan, which wasn't really helpful. But when we injected contrast, we could see that this bit of the spleen was enhancing exactly in the same way as the spleen. And importantly, on the late phase, there was no wash out. So we could send away the patients parents are happy and the clinicians are happy.

Conclusion

So in conclusion, you can be quite imaginative. You can use these on adoc basis to resolve quite a few situations in which you may find yourself a little bit stuck with these patients. And you can do these easily at the bedside without the need for Mr. CT fluoroscopy. And you can be very versatile in the uses of CUS, not only you can use it as a transcatheter aid to evaluate your collections as we've seen, it can be quite useful in the lung, for example, in terms of IV use. And it can really assist the normal gray scale ultrasound pictures when it's needed. So the bottom line message from this talk is think outside the box. You can use it a little bit everywhere, both IV and intracavitary. So just use your imagination.