Intussusception: Ultrasound

A longitudinal US image shows a "pseudokidney" sign of intussusception (arrows). Arrowheads point to enlarged mesenteric lymph nodes within the intussusceptum.

A transverse US image shows a "target" sign with a hypoechoic ring of the intussuscepiens surrouning the central echogenic area of intussusceptum. Arrowheads point to enlarged nodes.

Facts

• A segment of bowel (intussusceptum) prolapses into a more distal bowel segment (intussuscepiens)
• Most frequently seen in the first two years of life but can be seen up to 4 years. If older child has intussusception, looks for a lead point such as polyp, Meckel diverticulum, lymphoma, duplication cyst.
• Classic triad: colicky pain, vomiting and bloody (red currant jelly) stools (seen in less than 25% of cases)
• X-ray is positive in only 50% of cases, and is not reliable in diagnosing this condition

Ultrasound Findings

• Modality of choice to diagnose intussusception
• "Target" sign = hypoechoic ring with an echogenic center on transverse US image
• "Pseudokidney" sign = hypoechoic bowell wall extending along a hyperechoic mucosa
• Helpful in searching for a lead point. US can provide a specific diagnosis in one-third of these cases.

Reference:

1. Daldrup-Link HE, Gooding CA. Essentials of Pediatric Radiology: A Multimodality Approach, 2010.

2. Hodler J, Von Schulthess GK, Zollikofer CL. Diseases of the Abdomen and Pelvis 2010-2013: Diagnostic Imaging and Interventional Techniques, 2010.

Tension Pneumothorax

Chest radiograph shows a very large left pneumothorax (stars) causing mass effect to the mediastinum (shifting, arrows), deep costophrenic sulcus and collapsed left lung.

Facts

• One-way valve effect causing continuous air collection within pleural space resulting in collapse of the lung on the affected side and compression of opposite lung
• Poor lung compliance and increased airway pressure leads to ineffective gas exchange
• Mass effect on mediastinal structures cause decreased venous return and decreased cardiac output
• Symptoms and signs: chest pain, dyspnea, respiratory distress, tachypnea, dyspnea, cyanosis, elevated jugular venous pressure, absent breath sounds, tracheal deviation and hemodynamic compromise
• This is a clinical diagnosis and confirmation with radiography is not recommended. Needle decompression should be immediately performed

Imaging

• Again, this is a clinical diagnosis. Yet imaging may be performed and shows large pneumothorax, mediastinal shifting, flat hemidiaphragm

Reference:

Greenberg MI. Greenberg's Text-atlas of Emergency Medicine, 2005.

Fracture of the Lateral Process of Talus

AP view of the foot shows a small avulsion fracture (arrow) of the lateral process of the talus.

Facts: Lateral Process of Talus

• Lateral process is a broad-based, wedge-shaped prominence of the lateral talar body that articulates with the fibula and posterior facet of talus
• Anchor point for lateral talocalcaneal, anterior and posterior talofibular ligaments

Facts: Fracture of the Lateral Process of Talus

• Axial loading with elements of dorsiflexion and eversion or external rotation
• High incidence among snowboarders, sometimes called "snowboarder fracture"
• Can be difficult to diagnose clinically, easily confused with ankle sprain
• Pain localized anteroinferior to the distal end of fibula

Imaging

• Important to look specifically at this area in patients presenting with lateral ankle pain following trauma
• Small, nondisplaced fracture can be overlooked. CT may be warranted if suspicion persists in a normal-looking x-ray series
• Hawkins classified this fracture into 3 types: 1) large single fragment, 2) large comminuted fragment, 3) small, extra-articular fragment

Reference:

Browner BD, Levine AM, Jupiter JB, et al. Skeletal Trauma: Basic Science, Management, and Reconstruction, 2009.

Ileal Diverticulitis

Axial CT image shows an ileal diverticulum (arrow) with surrounding inflammation (arrowheads). Thin arrow = normal appendix.

Sagittal CT image again confirms the presence of an inflamed ileal diverticulum. Note a normal cecum.

Facts

• Two percents of population have small-bowel diverticula
• These can be congenital or acquired.
• Acquired diverticula are common in jejunum and terminal ileum. They are mucosal herniation along the mesenteric border.
• About 6-10% of patients with small-bowel diverticula develop complications (-itis, hemorrhage, obstruction, intussusception)

Imaging

• CT can show inflammatory change around the diverticulum with mural thickening of the adjacent bowel loops. The appendix and cecum are normal.

Reference:

Gourtsoyiannis NC. Radiologic Imaging of the Small Intestine, 2002.

Kaposi's Sarcoma

Axial CT image shows perihilar peribronchovascular thickening (arrows) and several small ill-defined nodules in the peribronchovascular distribution.

Axial CT image shows patchy groundglass opacities and consolidation in the right middle and lower lobes.

Facts

• Multicentric neoplasm occuring in three distinct clinical settings: classic (middle-aged adults or elderly men with indolent course), endemic (native populations of equatorial Africans) and disseminated forms (AIDS and immunosuppressed recipients of organ transplants)
• Associated with human herpesvirus type 8
• Cutaneous manifestations usually precede visceral disease
• Respiratory disease is a late manifestation of the disease, it can involve trachea, bronchial tree, pleura and lung parenchyma
• Diagnosis of respiratory disease is often made presumptively based on clinical/imaging appearance and exclusion of other entities. Biopsy is most definitive.
• Treatment of pulmonary disease almost always involves chemotherapy

Thoracic Imaging Findings

• Two patterns: interstitial and nodular
• Interstitial pattern -- septal lines, localized/focal consolidations, perihilar distribution, "flame-shaped" opacities
• Nodular pattern -- ill-defined nodules of various sizes that may coalesce into areas of patchy consolidation
• Up to 60% has pleural effusion
• Up to 16% has hilar/mediastinal lymphadenopathy

Our case: Kaposi's sarcoma, biopsy-proven

References:

Humes HD. Kelley's Essentials of Internal Medicine, 2001.

Parsons PE, Heffner JE. Pulmonary/reespiratory Therapy Secrets, 2002.