1. The cloacal malformation is a rare birth defect where the urinary, genital, and intestinal tracts converge into a single opening, known as the cloaca.
2. The authors reviewed imaging studies and records of 65 patients with cloacal malformation seen over 20 years to describe the spectrum of abnormalities.
3. Adequate preoperative planning requires precise radiological definition of the abnormal anatomy using imaging studies like cystoscopy, sonography, voiding cystourethrography, and MR imaging to discover coexisting anomalies and plan diversion of the fecal stream.
This document discusses the embryology, classification, variations, investigations, and surgical approaches for cloacal malformations. Cloacal malformations occur when the rectum, vagina, and urinary tract converge into a single common channel. The length of the common channel determines the surgical approach, with common channels less than 3 cm often repaired via posterior sagittal anorectovaginoplasty, and those 3-5 cm sometimes requiring additional abdominal mobilization of the urogenital tract. The goals of cloacal surgery are to achieve urinary and bowel control and normal sexual and obstetric function.
By using transvaginal sonography, the bladder can be seen as early as 11 weeks of gestation. By 12 to 13 weeks, the bladder is visualized in 98% of cases using both transabdominal and transvaginal sonography.
This document provides an overview of duodenal atresia, including its definition, epidemiology, etiology, clinical features, diagnosis, management, complications, and differential diagnosis. Duodenal atresia is a congenital absence or closure of part of the duodenum due to defective fusion during development. It commonly presents after birth with vomiting, jaundice, and abdominal distension. Diagnosis is typically made through imaging findings like the "double bubble" sign on x-ray. Surgical management involves bypassing the blocked portion of duodenum through procedures like duodenoduodenostomy. Complications can include anastomotic issues or problems from associated anomalies.
This document discusses various fetal gastrointestinal anomalies that can be imaged prenatally. It begins by describing the normal development of the gut tube from the endoderm. It then classifies common GI anomalies such as esophageal atresia, duodenal atresia presenting as a "double bubble" sign, small bowel atresia seen as dilated fluid-filled bowel loops, and anorectal atresia appearing as an overdistended rectum and sigmoid colon. It also discusses anomalies of the abdominal wall including omphalocele appearing as a bulging structure arising from the anterior abdominal wall, and gastroschisis seen as freely floating bowel outside the fetal abdomen through a paraumbilical wall defect. Dif
Anorectal malformations (ARMs) are congenital anomalies involving the distal anus and rectum. ARMs can involve the urinary and genital tracts in many cases and the spine is often involved as well. ARMs occur due to abnormalities in the development of the embryonic cloaca. Imaging studies like ultrasound and MRI are important for evaluating ARMs and any associated anomalies. Pelvic floor musculature anatomy is key to understanding ARMs and their surgical treatment.
- Anorectal malformations (ARMs) range from minor defects to complex anomalies associated with other issues. They occur in approximately 1 in 5,000 births.
- Evaluation of newborns with ARMs involves examining the anus, genitals, and spine. Imaging studies like ultrasound, MRI and contrast enemas are used to characterize the anatomy and identify any associated anomalies in other organ systems.
- Treatment depends on the specific type of ARM, but may involve procedures like colostomy to allow the distal anatomy to develop before definitive repair. The long-term goals are to establish bowel and urinary continence.
This document discusses anorectal malformations (ARM), which involve abnormalities in the development of the anus and rectum. It first covers the normal embryology of the hindgut and two theories for how ARM develops. The document then describes the various types of ARM based on their location, including low, intermediate, and high anomalies in both males and females. It also addresses complex malformations and outlines the presentation, radiological evaluation, and initial treatment options, which may involve anoplasty or colostomy to repair the malformation or relieve symptoms.
This document discusses various types of intestinal obstructions in neonates. It describes high intestinal obstructions, which occur proximal to the ileum such as gastric, duodenal or jejunal obstructions. It also describes low intestinal obstructions, which occur distal to the ileum and in the colon. Specific causes of obstruction discussed include duodenal atresia, intestinal malrotation, necrotizing enterocolitis, meconium ileus and Hirschsprung's disease. Diagnosis involves abdominal x-rays and contrast studies to identify the location and cause of obstruction.
This document discusses the embryology, classification, variations, investigations, and surgical approaches for cloacal malformations. Cloacal malformations occur when the rectum, vagina, and urinary tract converge into a single common channel. The length of the common channel determines the surgical approach, with common channels less than 3 cm often repaired via posterior sagittal anorectovaginoplasty, and those 3-5 cm sometimes requiring additional abdominal mobilization of the urogenital tract. The goals of cloacal surgery are to achieve urinary and bowel control and normal sexual and obstetric function.
By using transvaginal sonography, the bladder can be seen as early as 11 weeks of gestation. By 12 to 13 weeks, the bladder is visualized in 98% of cases using both transabdominal and transvaginal sonography.
This document provides an overview of duodenal atresia, including its definition, epidemiology, etiology, clinical features, diagnosis, management, complications, and differential diagnosis. Duodenal atresia is a congenital absence or closure of part of the duodenum due to defective fusion during development. It commonly presents after birth with vomiting, jaundice, and abdominal distension. Diagnosis is typically made through imaging findings like the "double bubble" sign on x-ray. Surgical management involves bypassing the blocked portion of duodenum through procedures like duodenoduodenostomy. Complications can include anastomotic issues or problems from associated anomalies.
This document discusses various fetal gastrointestinal anomalies that can be imaged prenatally. It begins by describing the normal development of the gut tube from the endoderm. It then classifies common GI anomalies such as esophageal atresia, duodenal atresia presenting as a "double bubble" sign, small bowel atresia seen as dilated fluid-filled bowel loops, and anorectal atresia appearing as an overdistended rectum and sigmoid colon. It also discusses anomalies of the abdominal wall including omphalocele appearing as a bulging structure arising from the anterior abdominal wall, and gastroschisis seen as freely floating bowel outside the fetal abdomen through a paraumbilical wall defect. Dif
Anorectal malformations (ARMs) are congenital anomalies involving the distal anus and rectum. ARMs can involve the urinary and genital tracts in many cases and the spine is often involved as well. ARMs occur due to abnormalities in the development of the embryonic cloaca. Imaging studies like ultrasound and MRI are important for evaluating ARMs and any associated anomalies. Pelvic floor musculature anatomy is key to understanding ARMs and their surgical treatment.
- Anorectal malformations (ARMs) range from minor defects to complex anomalies associated with other issues. They occur in approximately 1 in 5,000 births.
- Evaluation of newborns with ARMs involves examining the anus, genitals, and spine. Imaging studies like ultrasound, MRI and contrast enemas are used to characterize the anatomy and identify any associated anomalies in other organ systems.
- Treatment depends on the specific type of ARM, but may involve procedures like colostomy to allow the distal anatomy to develop before definitive repair. The long-term goals are to establish bowel and urinary continence.
This document discusses anorectal malformations (ARM), which involve abnormalities in the development of the anus and rectum. It first covers the normal embryology of the hindgut and two theories for how ARM develops. The document then describes the various types of ARM based on their location, including low, intermediate, and high anomalies in both males and females. It also addresses complex malformations and outlines the presentation, radiological evaluation, and initial treatment options, which may involve anoplasty or colostomy to repair the malformation or relieve symptoms.
This document discusses various types of intestinal obstructions in neonates. It describes high intestinal obstructions, which occur proximal to the ileum such as gastric, duodenal or jejunal obstructions. It also describes low intestinal obstructions, which occur distal to the ileum and in the colon. Specific causes of obstruction discussed include duodenal atresia, intestinal malrotation, necrotizing enterocolitis, meconium ileus and Hirschsprung's disease. Diagnosis involves abdominal x-rays and contrast studies to identify the location and cause of obstruction.
Duodenal atresia is a common cause of intestinal obstruction in neonates, occurring in about 1 in 5,000-10,000 live births. It results from a failure of recanalization of the fetal duodenum, leading to a complete obstruction. Clinically, it presents with bilious vomiting within the first few hours of life. Diagnosis involves finding the classic "double bubble" sign on abdominal x-ray. Surgical treatment involves reconstructing bowel continuity, usually via a diamond-shaped duodenoduodenostomy. With proper management, over 95% of patients will recover successfully from duodenal atresia.
This document provides a summary of embryonic development and fetal anatomy as assessed by ultrasound. It describes the normal development of the bilaminar embryo into a trilaminar embryo during gastrulation in the third week. It then discusses the folding and development of various organs over subsequent weeks, including the esophagus, stomach, small and large intestines, liver, gallbladder, pancreas, and anorectal region. It highlights various congenital anomalies that can be assessed prenatally using ultrasound, such as esophageal atresia, intestinal atresias or obstructions, anomalies of the biliary system and pancreas.
1. Congenital diaphragmatic hernia is a birth defect where abdominal organs protrude into the chest cavity through a hole in the diaphragm, interfering with lung development and potentially causing life-threatening breathing issues in newborns.
2. Prenatal ultrasound examination can detect a CDH, shown as a chest mass that may move or contain fluid/bowel above the diaphragm with associated shifting of the mediastinum.
3. Prognosis is worse when additional abnormalities are present, the defect is on the right side, or the liver protrudes through the diaphragm. Stabilization before surgery and careful postoperative respiratory support are crucial for survival.
Presentation11, radiological imaging of ovarian torsion.Abdellah Nazeer
Ovarian torsion refers to the twisting of an ovary on its vascular pedicle, which can cut off its blood supply. It is a gynecological emergency that requires urgent surgery. Radiological imaging plays an important role in the diagnosis. Ultrasound is usually the initial imaging method, showing signs such as an enlarged ovary without blood flow. CT and MRI can further evaluate for complications like hemorrhage or infarction. Prompt diagnosis and treatment are needed to prevent ovarian necrosis from the loss of blood supply.
The document describes the retroperitoneal space and structures contained within it. The retroperitoneal space lies between the peritoneum and posterior abdominal wall from the diaphragm to the pelvic floor. It contains various organs like the kidneys, ureters, parts of the colon, pancreas and more. The space is further divided into the anterior pararenal space, perirenal space, and posterior pararenal space by fascial planes. The document outlines the boundaries and structures of the retroperitoneal space.
The document provides guidance on performing and interpreting a fetal anomaly scan in the second trimester. It outlines key structures to examine in the brain, head, face, thorax, heart, abdomen and gastrointestinal system. Normal anatomy is described along with variants and common anomalies. For the brain, it details the standard thalamic, ventricular and cerebellar views and structures to assess such as ventricle size and cavum septi pellucidi. Common cranial anomalies like holoprosencephaly and Dandy-Walker malformation are also outlined.
Presentation1, radiological imaging of hirshsprung disease.Abdellah Nazeer
Hirschsprung disease is a congenital disorder causing colonic obstruction. It results from the absence of ganglion cells in portions of the colon and rectum. This document discusses the epidemiology, clinical presentation, pathology, diagnosis and radiological findings of Hirschsprung disease. Key points include that it typically presents in newborn infants as failure to pass meconium. Diagnosis involves rectal biopsy and contrast enema to identify the transition zone between normal and aganglionic segments. Radiography may show dilated bowel and a narrow rectum. Barium enema can further define the transition zone location.
This document discusses various gallbladder and biliary tree pathologies that can be detected on sonography. It describes the sonographic appearance and features of gallstones, biliary sludge, acute and chronic cholecystitis, porcelain gallbladder, adenomyomatosis, cholesterol polyps, gallbladder carcinoma, choledochal cysts, Caroli's disease, primary sclerosing cholangitis, Mirizzi syndrome, bacterial cholangitis, and cholangiocarcinoma. Mobility is key to differentiating stones from other entities. Sludge appears as low-level echoes without shadowing. Gallbladder wall thickening and distention indicate acute cholecystitis. Calcification causes hyperechoic
Vacterl association is a non-random grouping of birth defects that includes vertebral anomalies, anal atresia, cardiac defects, tracheo-esophageal fistula with or without esophageal atresia, and renal and limb abnormalities. It is considered an association because the defects do not have a predictable pattern and the underlying etiology is unknown. Proposed causes include abnormal segmentation of the vertebrae, effects of teratogenic agents, malformation sequences initiated by vertebral defects, and disturbances in fundamental embryological processes of mesoderm development and migration. Diagnosis requires at least three components of the association to be present.
This document discusses anorectal malformations, which are anomalies of the anorectal system, urogenital system, sacral spine, and perineal musculature. It describes the embryological development of the hindgut and cloaca. Various classifications of anorectal malformations are presented, including the Wingspread, Pena, Krickenbeck, and anatomic classifications. Associated anomalies are discussed. The document outlines the approach to examining and investigating a newborn with an anorectal malformation, including history, physical exam, and imaging studies. It discusses early management decisions and various surgical procedures for treating anorectal malformations.
1. The müllerian ducts normally develop into the fallopian tubes, uterus, cervix, and upper two-thirds of the vagina. Failures or abnormalities during development can result in müllerian duct anomalies.
2. Development occurs through three phases - organogenesis, fusion, and septal resorption. Failures in fusion can lead to bicornuate or didelphys uterus, while failed septal resorption causes septate uterus.
3. Müllerian duct anomalies have a variety of presentations including infertility, miscarriage, and obstructed reproductive systems. Diagnosis is made through ultrasound, hysterosalpingography, or laparoscopy.
This document discusses Doppler ultrasound findings related to portal vein thrombosis and Budd-Chiari syndrome. It provides details on the causes, classifications, and diagnostic criteria for each condition based on ultrasound appearance. Key findings include identifying partial or complete thrombosis, portal cavernoma formation, presence of collateral vessels, and reversed or absent flow in involved vessels. Ultrasound is established as the primary imaging method for diagnosing Budd-Chiari syndrome by detecting thrombus or narrowing of hepatic veins.
1. The ductus venosus is a blood vessel that shunts oxygenated blood from the umbilical vein directly into the inferior vena cava, bypassing the liver.
2. Abnormalities in the ductus venosus blood flow waveform, such as reversal of the a-wave, have been associated with fetal growth restriction and adverse pregnancy outcomes like stillbirth.
3. Monitoring ductus venosus blood flow using Doppler ultrasound is useful for assessing fetal well-being and timing of delivery in high-risk pregnancies complicated by fetal growth restriction.
Disorders of sexual development (DSD) refer to congenital conditions where chromosomal sex, gonadal sex, and anatomical sex are incongruent. DSD results from atypical development of chromosomal, gonadal or anatomical sex. Evaluation involves assessing family history, physical exam, karyotype, internal anatomy by ultrasound, and hormone levels. Management includes counseling, treatment of medical issues, determining gender of rearing, and surgery. The goal is to optimize health outcomes and psychosocial well-being for individuals with DSD.
Generally occurs secondary to pulmonary atresia with intact IVS .
Pathophysiology- it develops because of a reduction in the blood flow secondary to inflow impedence from tricuspid atresia or outflow impedence from pulmonary arterial atresia .
Typical findings- a small , hypertrophic RV and a small or absent pulmonary artery
This document discusses intestinal malrotation, beginning with a definition and incidence. It describes the normal stages of intestinal rotation during embryonic development and defines different types of rotational disorders including nonrotation, incomplete rotation, and reverse rotation. Clinical presentations are outlined for acute midgut volvulus, chronic midgut volvulus, acute duodenal obstruction, and internal hernia. Radiologic findings that help diagnose malrotation are presented. Treatment involves reducing the risk of volvulus recurrence through the Ladd's procedure. Post-operative care and potential complications are also summarized.
A 10-year old female presented with abdominal pain, bilious vomiting, and an epigastric lump. Imaging studies including ultrasound, barium study, and surgery revealed malrotation of the gut with midgut volvulus. Normally during fetal development the gut rotates to position the duodenojejunal flexure on the left, but in this patient malrotation left the bowel susceptible to twisting around the superior mesenteric artery, known as midgut volvulus. The barium study and ultrasound were able to diagnose malrotation and volvulus without other tests.
This document discusses the anatomy of peritoneal spaces. It defines the peritoneum and its two layers - parietal and visceral. It describes various peritoneal ligaments that connect organs, including the falciform, triangular, lesser and greater omentum. It outlines the major peritoneal spaces such as the supramesocolic, inframesocolic, pelvic and lesser sac spaces. It provides details on boundaries and locations of collections in each space. In summary, the document provides a comprehensive overview of the peritoneal anatomy and spaces in the abdomen and pelvis.
This document discusses the approach of a pediatrician to a newborn with anorectal malformation (ARM). It describes the pediatrician's role in diagnosis, initial stabilization, and referral to a pediatric surgeon. It provides details on clinical examination findings for ARM in males and females. It also discusses associated malformations, initial management including antibiotics and fluids, and investigations like invertogram to classify the ARM.
This document discusses the case of a 2 year old male child presenting with recurrent lower respiratory tract infections. On examination, a systolic murmur was heard. Echocardiogram showed a patent ductus arteriosus (PDA) of size 8mm with left to right shunting. Cardiac catheterization found a Qp/Qs ratio of 1.83, confirming a left to right shunt. Post oxygen, the Qp/Qs ratio increased to 2.94, and PVR decreased, indicating reactivity. The document then discusses two other cases and provides information on indications for catheterization in PDA, angiographic views, classifications of PDA, and factors affecting shunting through a PDA
Duodenal atresia is a common cause of intestinal obstruction in neonates, occurring in about 1 in 5,000-10,000 live births. It results from a failure of recanalization of the fetal duodenum, leading to a complete obstruction. Clinically, it presents with bilious vomiting within the first few hours of life. Diagnosis involves finding the classic "double bubble" sign on abdominal x-ray. Surgical treatment involves reconstructing bowel continuity, usually via a diamond-shaped duodenoduodenostomy. With proper management, over 95% of patients will recover successfully from duodenal atresia.
This document provides a summary of embryonic development and fetal anatomy as assessed by ultrasound. It describes the normal development of the bilaminar embryo into a trilaminar embryo during gastrulation in the third week. It then discusses the folding and development of various organs over subsequent weeks, including the esophagus, stomach, small and large intestines, liver, gallbladder, pancreas, and anorectal region. It highlights various congenital anomalies that can be assessed prenatally using ultrasound, such as esophageal atresia, intestinal atresias or obstructions, anomalies of the biliary system and pancreas.
1. Congenital diaphragmatic hernia is a birth defect where abdominal organs protrude into the chest cavity through a hole in the diaphragm, interfering with lung development and potentially causing life-threatening breathing issues in newborns.
2. Prenatal ultrasound examination can detect a CDH, shown as a chest mass that may move or contain fluid/bowel above the diaphragm with associated shifting of the mediastinum.
3. Prognosis is worse when additional abnormalities are present, the defect is on the right side, or the liver protrudes through the diaphragm. Stabilization before surgery and careful postoperative respiratory support are crucial for survival.
Presentation11, radiological imaging of ovarian torsion.Abdellah Nazeer
Ovarian torsion refers to the twisting of an ovary on its vascular pedicle, which can cut off its blood supply. It is a gynecological emergency that requires urgent surgery. Radiological imaging plays an important role in the diagnosis. Ultrasound is usually the initial imaging method, showing signs such as an enlarged ovary without blood flow. CT and MRI can further evaluate for complications like hemorrhage or infarction. Prompt diagnosis and treatment are needed to prevent ovarian necrosis from the loss of blood supply.
The document describes the retroperitoneal space and structures contained within it. The retroperitoneal space lies between the peritoneum and posterior abdominal wall from the diaphragm to the pelvic floor. It contains various organs like the kidneys, ureters, parts of the colon, pancreas and more. The space is further divided into the anterior pararenal space, perirenal space, and posterior pararenal space by fascial planes. The document outlines the boundaries and structures of the retroperitoneal space.
The document provides guidance on performing and interpreting a fetal anomaly scan in the second trimester. It outlines key structures to examine in the brain, head, face, thorax, heart, abdomen and gastrointestinal system. Normal anatomy is described along with variants and common anomalies. For the brain, it details the standard thalamic, ventricular and cerebellar views and structures to assess such as ventricle size and cavum septi pellucidi. Common cranial anomalies like holoprosencephaly and Dandy-Walker malformation are also outlined.
Presentation1, radiological imaging of hirshsprung disease.Abdellah Nazeer
Hirschsprung disease is a congenital disorder causing colonic obstruction. It results from the absence of ganglion cells in portions of the colon and rectum. This document discusses the epidemiology, clinical presentation, pathology, diagnosis and radiological findings of Hirschsprung disease. Key points include that it typically presents in newborn infants as failure to pass meconium. Diagnosis involves rectal biopsy and contrast enema to identify the transition zone between normal and aganglionic segments. Radiography may show dilated bowel and a narrow rectum. Barium enema can further define the transition zone location.
This document discusses various gallbladder and biliary tree pathologies that can be detected on sonography. It describes the sonographic appearance and features of gallstones, biliary sludge, acute and chronic cholecystitis, porcelain gallbladder, adenomyomatosis, cholesterol polyps, gallbladder carcinoma, choledochal cysts, Caroli's disease, primary sclerosing cholangitis, Mirizzi syndrome, bacterial cholangitis, and cholangiocarcinoma. Mobility is key to differentiating stones from other entities. Sludge appears as low-level echoes without shadowing. Gallbladder wall thickening and distention indicate acute cholecystitis. Calcification causes hyperechoic
Vacterl association is a non-random grouping of birth defects that includes vertebral anomalies, anal atresia, cardiac defects, tracheo-esophageal fistula with or without esophageal atresia, and renal and limb abnormalities. It is considered an association because the defects do not have a predictable pattern and the underlying etiology is unknown. Proposed causes include abnormal segmentation of the vertebrae, effects of teratogenic agents, malformation sequences initiated by vertebral defects, and disturbances in fundamental embryological processes of mesoderm development and migration. Diagnosis requires at least three components of the association to be present.
This document discusses anorectal malformations, which are anomalies of the anorectal system, urogenital system, sacral spine, and perineal musculature. It describes the embryological development of the hindgut and cloaca. Various classifications of anorectal malformations are presented, including the Wingspread, Pena, Krickenbeck, and anatomic classifications. Associated anomalies are discussed. The document outlines the approach to examining and investigating a newborn with an anorectal malformation, including history, physical exam, and imaging studies. It discusses early management decisions and various surgical procedures for treating anorectal malformations.
1. The müllerian ducts normally develop into the fallopian tubes, uterus, cervix, and upper two-thirds of the vagina. Failures or abnormalities during development can result in müllerian duct anomalies.
2. Development occurs through three phases - organogenesis, fusion, and septal resorption. Failures in fusion can lead to bicornuate or didelphys uterus, while failed septal resorption causes septate uterus.
3. Müllerian duct anomalies have a variety of presentations including infertility, miscarriage, and obstructed reproductive systems. Diagnosis is made through ultrasound, hysterosalpingography, or laparoscopy.
This document discusses Doppler ultrasound findings related to portal vein thrombosis and Budd-Chiari syndrome. It provides details on the causes, classifications, and diagnostic criteria for each condition based on ultrasound appearance. Key findings include identifying partial or complete thrombosis, portal cavernoma formation, presence of collateral vessels, and reversed or absent flow in involved vessels. Ultrasound is established as the primary imaging method for diagnosing Budd-Chiari syndrome by detecting thrombus or narrowing of hepatic veins.
1. The ductus venosus is a blood vessel that shunts oxygenated blood from the umbilical vein directly into the inferior vena cava, bypassing the liver.
2. Abnormalities in the ductus venosus blood flow waveform, such as reversal of the a-wave, have been associated with fetal growth restriction and adverse pregnancy outcomes like stillbirth.
3. Monitoring ductus venosus blood flow using Doppler ultrasound is useful for assessing fetal well-being and timing of delivery in high-risk pregnancies complicated by fetal growth restriction.
Disorders of sexual development (DSD) refer to congenital conditions where chromosomal sex, gonadal sex, and anatomical sex are incongruent. DSD results from atypical development of chromosomal, gonadal or anatomical sex. Evaluation involves assessing family history, physical exam, karyotype, internal anatomy by ultrasound, and hormone levels. Management includes counseling, treatment of medical issues, determining gender of rearing, and surgery. The goal is to optimize health outcomes and psychosocial well-being for individuals with DSD.
Generally occurs secondary to pulmonary atresia with intact IVS .
Pathophysiology- it develops because of a reduction in the blood flow secondary to inflow impedence from tricuspid atresia or outflow impedence from pulmonary arterial atresia .
Typical findings- a small , hypertrophic RV and a small or absent pulmonary artery
This document discusses intestinal malrotation, beginning with a definition and incidence. It describes the normal stages of intestinal rotation during embryonic development and defines different types of rotational disorders including nonrotation, incomplete rotation, and reverse rotation. Clinical presentations are outlined for acute midgut volvulus, chronic midgut volvulus, acute duodenal obstruction, and internal hernia. Radiologic findings that help diagnose malrotation are presented. Treatment involves reducing the risk of volvulus recurrence through the Ladd's procedure. Post-operative care and potential complications are also summarized.
A 10-year old female presented with abdominal pain, bilious vomiting, and an epigastric lump. Imaging studies including ultrasound, barium study, and surgery revealed malrotation of the gut with midgut volvulus. Normally during fetal development the gut rotates to position the duodenojejunal flexure on the left, but in this patient malrotation left the bowel susceptible to twisting around the superior mesenteric artery, known as midgut volvulus. The barium study and ultrasound were able to diagnose malrotation and volvulus without other tests.
This document discusses the anatomy of peritoneal spaces. It defines the peritoneum and its two layers - parietal and visceral. It describes various peritoneal ligaments that connect organs, including the falciform, triangular, lesser and greater omentum. It outlines the major peritoneal spaces such as the supramesocolic, inframesocolic, pelvic and lesser sac spaces. It provides details on boundaries and locations of collections in each space. In summary, the document provides a comprehensive overview of the peritoneal anatomy and spaces in the abdomen and pelvis.
This document discusses the approach of a pediatrician to a newborn with anorectal malformation (ARM). It describes the pediatrician's role in diagnosis, initial stabilization, and referral to a pediatric surgeon. It provides details on clinical examination findings for ARM in males and females. It also discusses associated malformations, initial management including antibiotics and fluids, and investigations like invertogram to classify the ARM.
This document discusses the case of a 2 year old male child presenting with recurrent lower respiratory tract infections. On examination, a systolic murmur was heard. Echocardiogram showed a patent ductus arteriosus (PDA) of size 8mm with left to right shunting. Cardiac catheterization found a Qp/Qs ratio of 1.83, confirming a left to right shunt. Post oxygen, the Qp/Qs ratio increased to 2.94, and PVR decreased, indicating reactivity. The document then discusses two other cases and provides information on indications for catheterization in PDA, angiographic views, classifications of PDA, and factors affecting shunting through a PDA
The document discusses excretory urography, which involves administering intravenous contrast and taking timed radiographic images of the urinary system. It describes the indications for excretory urography such as suspected urinary tract pathology or repeated infections. It outlines the procedure, potential findings on images including abnormalities of the kidneys, ureters and bladder, and complications to watch for like contrast reactions. Key phases of kidney imaging and abnormalities that can be identified are also summarized.
Cryptorchidism, or undescended testes, is a common birth defect where one or both testes fail to descend into the scrotum. It results from complex interactions between hormonal and mechanical factors during fetal development. The condition affects 1-4% of full-term and up to 45% of preterm male infants. Risk factors include low birth weight, prematurity, and genetic susceptibility. While often isolated, cryptorchidism can also be associated with syndromes involving reduced androgen production or action. Spontaneous descent is more likely in premature infants and may occur later in the first year of life.
The excretory system eliminates wastes from the body through various organs. The lungs, skin, large intestine, liver, and urinary system all play roles in excretion. The kidneys are the primary excretory organs, filtering wastes from the blood and regulating fluid and electrolyte balance. Nephrons are the functional units of the kidney that filter blood to form urine, reabsorbing necessary substances while excreting waste.
This document summarizes Toll-like receptors (TLRs), which are a family of pattern recognition receptors involved in the innate immune system. TLRs recognize molecular patterns from bacteria, viruses and other microbes. They are type I transmembrane proteins containing leucine-rich repeats in their extracellular domain and a Toll/interleukin-1 receptor domain in their cytoplasmic tail. Different TLRs recognize distinct pathogen-associated molecular patterns, such as TLR4 which recognizes lipopolysaccharide, TLR3 which recognizes double-stranded RNA, and TLR9 which recognizes unmethylated CpG motifs in bacterial DNA. TLR signaling activates immune response pathways to defend against infection.
Toll-like receptors (TLRs) are a family of proteins that play a key role in the innate immune system by recognizing molecular patterns from microbes. They are expressed on immune cells like neutrophils, macrophages, and dendritic cells as well as non-immune cells. Most TLRs are located on the cell surface but TLR9 is intracellular. Stimulation of different TLRs induces distinct patterns of gene expression to activate innate immunity and instruct the development of acquired immunity. The first human TLR was discovered in 1994 and TLRs were shown to induce adaptive immune responses in 1997. TLR signaling involves intracellular adapter proteins and transcription factors that trigger inflammatory responses.
Malrotation is a congenital anomaly resulting from abnormal intestinal rotation during gestation. It can cause midgut volvulus and obstruction. Clinical presentation varies from asymptomatic to symptoms of obstruction. Diagnosis is made through imaging findings showing abnormal relationships of intestines and superior mesenteric vessels. Treatment is surgical correction through Ladd's procedure to unwind volvulus and fix intestines in normal position. Complications include recurrent volvulus and adhesive bowel obstruction.
This document discusses malrotation, a condition that results from abnormal rotation of the embryonic gut. Malrotation can present at any age, but most commonly in infants under 1 month old, with bilious vomiting being the main symptom. The diagnosis is made through imaging studies like ultrasound or CT scan. Treatment involves surgery to untwist the bowel (Ladd's procedure), divide bands, and position the intestines in the correct locations to prevent future twisting. Early diagnosis and surgical intervention are important to reduce risks of complications like intestinal gangrene.
Retention of urine occurs when one is unable to completely empty the bladder. It can be acute, occurring suddenly due to obstruction, or chronic, developing over time. Acute retention requires immediate catheterization to drain the bladder, while chronic retention involves identifying and treating the underlying cause of the partial obstruction. A thorough history, exam, and testing is needed to determine if the retention is due to issues in the bladder, prostate, urethra, or other causes and select the appropriate management.
The hepatic portal vein drains blood from the abdominal organs into the liver before exiting into the inferior vena cava. It forms at the union of the superior mesenteric and splenic veins. In the liver, it divides into right and left branches that further branch into hepatic sinusoids. Portosystemic anastomoses allow blood to bypass the liver in portal hypertension, leading to collateral circulation and varices in locations like the esophagus, anus, and abdomen.
This document summarizes key information about Toll-like receptors (TLRs):
- TLRs are pattern recognition receptors that recognize pathogens and activate immune responses. They play a role in both innate and adaptive immunity.
- TLRs recognize specific microbial ligands and signal through either MyD88-dependent or MyD88-independent pathways to induce inflammatory responses.
- Genetic variations in TLRs have been linked to susceptibility or resistance to various diseases like leprosy, tuberculosis, and cancer. Targeting TLR pathways may offer therapeutic approaches for neurological diseases like Alzheimer's disease.
Course in facial development for European Course in Neuroradiology in Tarragona, Spain, originally on 12 octobre 2008. Revised for November, 2010. For questions, e-mail to etchevers at free dot fr. Download for the animations to take place, as some pictures are covered by others.
Anorectal malformations are a major problem in newborns, occurring in about 1 in 5000 births. They result from abnormalities in the development of the anorectum during the first 9 weeks of pregnancy. Anorectal malformations can be classified based on the location of the blind rectal pouch in relation to the levator ani muscle. Treatment involves surgical correction, which may be done in one or multiple stages depending on the type of malformation. Prognosis is generally good for low anomalies treated with a single surgery, but higher anomalies have a lower chance of achieving absolute continence due to the complexity of the condition.
The peritoneum is a serous membrane that lines the abdominal cavity and covers organs. It has two layers, with a potential space between called the peritoneal cavity filled with fluid. The peritoneal cavity is divided into greater and lesser sacs connected by the epiploic foramen. Various peritoneal folds, ligaments and omenta attach organs and allow for movement. The peritoneum facilitates organ movement and absorption within the abdominal cavity.
This document summarizes methods for diagnosing tuberculous infections. Key methods include:
1. Clinical examination, routine lab tests like ESR, sputum smear microscopy, culture and nucleic acid amplification tests from clinical samples.
2. Chest radiography and collection of appropriate clinical samples from sites of disease are important.
3. Newer rapid diagnostics like Xpert MTB/RIF and line probe assays can directly detect tuberculosis and multidrug-resistant strains in a few hours.
Faecal incontinence has many potential causes including injuries during childbirth, neurological conditions, and diseases affecting the colon or rectum. Assessment involves a detailed history, examination, and tests like endoanal ultrasound and MRI to evaluate the sphincter muscles and detect any anatomical defects. Initial management focuses on lifestyle modifications, biofeedback training, bulking agents, and topical therapies. Surgery is usually only considered if other options fail, with options like sphincter repair, injectable bulking agents, sacral nerve stimulation, graciloplasty, or an artificial bowel sphincter depending on the individual case. Stoma formation is effective but often avoidable in most patients.
This document provides information on thoracic outlet syndrome (TOS). It begins with a brief history and defines TOS as abnormal compression of the neurovascular bundle in the thoracic outlet. It describes the relevant anatomy and compartments of the thoracic outlet. The document discusses the causes, types, symptoms, and diagnostic approaches for the neurogenic, venous, and arterial forms of TOS. It provides details on conservative and surgical treatment options.
The document discusses the development of the face and its structures from early embryonic development through the formation of the branchial arches and facial prominences. It describes how the frontonasal, maxillary, and mandibular processes merge in the midline to form structures of the face, including the lips, nose, and palate. The development of specific structures like the nose, paranasal sinuses, jaws, and palate are then examined in more detail. The role of the branchial arches and Meckel's cartilage in mandibular development is also summarized.
This study evaluated the use of real-time ultrasound in diagnosing congenital hip dislocation and dysplasia in infants. The researchers examined 131 hips in 104 patients, finding real-time ultrasound to be reliable and accurate with few false positives or negatives. Ultrasound clearly images cartilaginous structures in the infant hip joint that are poorly visualized on radiographs. The advantages of ultrasound are that it is non-invasive, portable, and does not use radiation. The researchers conclude that ultrasound is a useful adjunct to radiography in diagnosing instability and abnormalities in the infant hip.
This document describes an omphalocele, which is an extrusion of fetal abdominal contents into the base of the umbilical cord. The findings in this case show a herniated anterior abdominal mass covered by membrane, with the liver and small bowel herniated. This is consistent with an omphalocele with extracorporeal liver. Omphaloceles can be associated with chromosomal abnormalities and other congenital anomalies. Ultrasound is used to diagnose omphaloceles by identifying the herniated contents and covering membranes.
Congenital Anomalies of the Kidney & Urinary TractAbhineet Dey
Congenital anomalies of the kidney and urinary tract (CAKUT) represent a broad range of disorders that result from developmental abnormalities of the lower urinary tract, urinary collecting system, disrupted embryonic migration of the kidney(s), or abnormal renal parenchymal development.
Despite significant variation in phenotype and clinical implications, CAKUT shares a common genetic basis and molecular signaling that affect kidney development.
This 4-year-old boy presented with a left upper quadrant mass. Imaging showed a complex cystic renal mass with locules separated by enhancing soft tissue on CT. The most likely diagnosis is multilocular cystic nephroma. This lesion is characterized by multiple cysts of varying sizes separated by septa that enhance after contrast administration. While Wilms tumor and mesoblastic nephroma were considered, the cystic nature and imaging appearance of the mass are not consistent with these entities.
The document describes an ultrasound examination of a 25-year-old female with a palpable right adnexal mass. Longitudinal and transverse endovaginal images show a 4 cm predominantly cystic mass with a heterogeneous echotexture arising from the right ovary. This is most consistent with a dermoid cyst, as dermoids can appear cystic with an echogenic mural nodule or "dermoid plug".
Radiological diagnostics of Urinary SystemEneutron
This document discusses the radiological semiotics of diseases of the urinary and genital systems using different imaging modalities including radiography, computed tomography, magnetic resonance imaging, ultrasound, and radionuclide imaging. Key findings that can be seen include stones appearing as opaque densities, tumors appearing as atypical focal masses or densities, cysts appearing as round areas of lower density or signal, and obstructions appearing as filling defects or dilations of organs and ducts. Renal function can be assessed using radionuclide imaging by analyzing the vascular, secretory, and excretory phases of renograms.
The document discusses the embryonic and evolutionary development of the urogenital system in vertebrates. It describes the three primitive kidney types - pronephros, mesonephros and metanephros. The pronephros is the first to develop and later involutes. The mesonephros functions as the adult kidney in fish and amphibians. In amniotes, the mesonephros is replaced by the metanephros. The document also covers the differentiation of sexual structures in embryos and lists homologous structures between male and female urogenital systems.
1. Anorectal malformations occur due to abnormal development of the cloaca during early embryonic development.
2. Imperforate anus is when the anus is either absent or abnormally located and is often associated with anomalies of the sacrum, genitourinary tract, and other systems.
3. Classification and treatment of imperforate anus depends on the specific type of defect and presence of any associated abnormalities.
This document discusses vitelline duct (also called the yolk stalk or omphalomesenteric duct), which is the embryonic structure that connects the midgut of an embryo to the yolk sac. It provides details on the constituents of the vitelline duct including vitelline veins and arteries. Doppler values for the vitelline artery are also presented. The document then discusses arachnoid cysts, including their locations, differential diagnosis depending on location, and fetal MR and ultrasound images of a large arachnoid cyst.
The document summarizes kidney development from the pronephros, mesonephros, and metanephros stages. It describes how the ureteric bud and metanephric blastema form the metanephros which becomes the definitive kidney. Several congenital renal anomalies are discussed, including pelvic kidney, horseshoe kidney, crossed ectopia, and multicystic dysplastic kidney. Autosomal recessive polycystic kidney disease is noted to affect the kidneys, lungs, and liver due to mutations in the PKHD1 gene.
This document describes a case report of a 24-year-old woman who presented with low back pain, difficulty defecating, and infertility. Imaging revealed a large retrorectal cyst pushing the rectum anteriorly, along with other anomalies including a hemisacral deficiency, uterus didelphys, and double inferior vena cava. The patient underwent excision of the retrorectal cyst, which pathology confirmed was a tailgut cyst. Tailgut cysts are rare retrorectal developmental cysts. This case was unique due to the associated uterine, sacral, and vascular anomalies not previously reported with tailgut cysts.
Squamous cell carcinoma in the native kidney of a renal transplant recipient ...Apollo Hospitals
A 54-year-old man who received a kidney transplant 3 years prior presented with flank pain. Imaging showed a large mass in his native left kidney. He underwent a nephrectomy and the mass was found to be a squamous cell carcinoma. He later developed a squamous cell carcinoma in his urethra, which was excised. The patient received adjuvant radiation therapy to the tumor bed to reduce the risk of recurrence, while avoiding damage to surrounding structures like the transplanted kidney. This case report discusses the rare occurrence of squamous cell carcinoma in the native kidney of a transplant recipient and the challenges of postoperative management.
This document discusses radiology of the urinary tract system and disorders. It describes how different imaging modalities like CT, ultrasound, and IVU can be used to identify urinary tract calculi, nephrocalcinosis, and obstruction at different levels of the urinary tract. Causes of obstruction include calculi, tumors, strictures, congenital issues, and extrinsic compression that are best evaluated using CT, ultrasound, or IVU depending on the level and nature of obstruction.
The document discusses ureteroceles, which are saccular dilations of the terminal portion of the ureter. Ureteroceles are birth defects that occur in about 1 in 500 to 4,000 people and are more common in females. They can be caused by delayed or incomplete development of the ureteral bud leading to early prenatal obstruction. Ureteroceles are classified as ectopic or intravesical and may cause urinary tract infections, masses, incontinence or obstruction. Diagnosis involves imaging tests like ultrasound, VCUG, IVP or CT scan. Treatment depends on symptoms but may include antibiotics, endoscopic incision, upper pole nephrectomy, u
The document reviews the anatomical basis for Wilms tumor surgery, focusing on the surgical anatomy of the retroperitoneal space, aorta, vena cava and their branches. It discusses the goals of Wilms tumor surgery as obtaining an exact staging and safe complete resection of the tumor without spillage. The review also covers the types of vascular injuries that can occur during Wilms tumor surgery and their management.
CT urography involves CT imaging of the urinary tract before and after intravenous contrast administration. It provides both anatomical and functional information about the kidneys, ureters, and bladder. CT urography can be used to evaluate hematuria, urothelial cancer, hydronephrosis, congenital anomalies, infections, stones, and masses. The exam involves unenhanced imaging followed by contrast-enhanced nephrographic and excretory phases to evaluate the renal parenchyma, vasculature, and subtle urothelial abnormalities. Common findings include cysts, masses, urolithiasis, infections such as pyelonephritis, and urothelial neoplasms of
CT urography involves CT imaging of the urinary tract before and after intravenous contrast administration. It provides both anatomical and functional information about the kidneys, ureters, and bladder. CT urography can be used to evaluate hematuria, urothelial cancer, hydronephrosis, congenital anomalies, infections, stones, and masses. The exam involves unenhanced imaging followed by contrast-enhanced nephrographic and excretory phases to fully assess the urinary tract. Common findings include cysts, masses, stones, infections, anomalies, and urothelial neoplasms.
This document discusses congenital pelvi-ureteric junction obstruction (PUJO). It covers the etiology, pathogenesis, pathological changes, and clinical presentation of PUJO. The main causes of PUJO are believed to be intrinsic abnormalities at the pelvi-ureteric junction that cause an aperistaltic segment and prevent normal urine flow. This can result from developmental arrest or incomplete recanalization. PUJO can also be caused by external compression from aberrant vessels. Longstanding obstruction leads to hydronephrosis, tubular dilation, interstitial fibrosis and loss of renal function over time. Clinically, PUJO usually presents with hydronephrosis in infants and children.
Radiografía de tórax. patología común rn y lactanteLizbet Marrero
El documento describe las características radiográficas normales y patológicas comunes en recién nacidos y lactantes. En 3 oraciones:
Describe las características normales de la radiografía de tórax en recién nacidos y lactantes, incluyendo la forma trapezoidal de los campos pulmonares. Explica algunas patologías comunes como la enfermedad de membrana hialina y la aspiración de meconio, y cómo se manifiestan radiográficamente. Finalmente, enfatiza la importancia de considerar
Este documento describe el caso de una niña de 12 años con dolor y aumento de volumen en la pierna derecha después de una herida cortante por vidrio. Una ecografía mostró un pseudoaneurisma postraumático de 3.15 cm en la pierna. El pseudoaneurisma exhibió el "signo del yin y yang" en Doppler color, indicando flujo sanguíneo de entrada y salida. Se recomendó el tratamiento de embolización del pseudoaneurisma con coils.
El documento presenta 4 casos de ectasia ductal mamaria en niños y lactantes evaluados mediante ultrasonido. La ectasia ductal mamaria se caracteriza por la dilatación de los ductos glandulares mamarios, generalmente de forma unilateral y espontáneamente reversible. El ultrasonido muestra quistes o estructuras tubulares dilatados correspondientes a los ductos, pudiendo observarse flujo a Doppler. La mayoría de los casos se resuelven espontáneamente en semanas.
La Unión Europea ha acordado un paquete de sanciones contra Rusia por su invasión de Ucrania. Las sanciones incluyen restricciones a las importaciones de productos rusos de alta tecnología y a las exportaciones de bienes de lujo a Rusia. Además, se congelarán los activos de varios oligarcas rusos y se prohibirá el acceso de los bancos rusos a los mercados financieros de la UE.
Semiología de la RXTX en la IRB del niño. Parte 1Lizbet Marrero
Este documento médico describe tres casos de pacientes (C. Menor, C. Mayor, C. Mayor) que experimentaron dificultades respiratorias. Se realizaron exámenes de tomografía computarizada que mostraron atelectasia (colapso parcial de los pulmones) en un paciente y desplazamiento del mediastino (estructuras en el centro del tórax) en otro.
La niña de 9 años presenta incontinencia urinaria desde hace 1 año. La ecografía pelviana muestra reflujo vesicovaginal, con líquido en el canal vaginal antes y después de la micción. El diagnóstico ecográfico es reflujo vesicovaginal, una causa común de incontinencia urinaria en niñas.
Se realizó una autopsia virtual mediante TCMD de un feto con sospecha de displasia ósea letal. Los hallazgos son consistentes con displasia tanatofórica tipo I, caracterizada por huesos cortos y deformados en cráneo, extremidades y columna vertebral.
El documento describe diferentes tipos de quistes pulmonares en niños. Explica que la radiografía y TC del caso índice muestran un quiste pulmonar congénito único de 3 cm con contenido de aire/líquido, sin estructuras vasculares anómalas, por lo que probablemente no es maligno.
Rickets is a disease causing decreased mineralization in growth plates, resulting in growth retardation and delayed skeletal development. Plain radiography is preferred for examination, showing widening and cupping of metaphyses, fraying of the growth plate, and bowing of long bones. Findings are pathognomonic in advanced stages but biochemical testing is needed to identify the underlying cause, as radiographs may be normal in early stages.
Rickets is a disease causing decreased mineralization of growth plates, resulting in growth retardation and delayed skeletal development. It occurs in children before growth plate closure. Osteomalacia affects mineralization of trabecular bone in both children and adults. Plain radiography of affected bones such as the wrist is preferred for examination, showing changes like cupping and fraying of the growth plate. Clinical findings depend on the skeletal site and can include bowing of the legs from weight bearing.
Una niña de 13 años acudió a urgencias por dolor abdominal de 6 meses de evolución. La exploración física reveló una masa abdominal y la ecografía confirmó una mola hidatidiforme. La mola hidatidiforme es una enfermedad gestacional trofoblástica causada por una fertilización aberrante que puede ser benigna o maligna. Requiere tratamiento quirúrgico y seguimiento por el riesgo de recidiva o progresión a coriocarcinoma.
Sesión 2 torax imaginología de la patología pediatricaLizbet Marrero
Este documento describe el enfoque radiológico para la neumopatía aguda en niños. Explica el rol de la radiografía de tórax para diagnosticar síndrome bronquial obstructivo, neumonía y sus complicaciones. También analiza factores como la clínica del paciente, el tiempo de evolución de la enfermedad, la experiencia del radiólogo y la calidad de la imagen para determinar la sensibilidad y especificidad de la radiografía. Finalmente, presenta casos radiológicos de patrones normales y anormales en la ne
Sesión 2 imaginología de la patología pediatrica Lizbet Marrero
Este documento resume una presentación sobre la patología de las caderas en niños mediante imágenes. Cubre temas como lesiones traumáticas del esqueleto, displasia del desarrollo de las caderas y neumopatía aguda. Incluye detalles sobre la técnica radiológica óptima, factores de riesgo, diagnóstico, clasificación y tratamiento de la displasia de caderas. También describe los métodos estático y dinámico de ultrasonido para evaluar la estabilidad de las caderas.
El documento describe un caso de un niño de 8 años con dolor en el tobillo izquierdo. La radiografía mostró un área radiolúcida mal definida en el astrágalo. La resonancia magnética reveló compromiso inflamatorio del astrágalo con una caries ósea y compromiso periarticular, confirmando el diagnóstico de osteomielitis subaguda del astrágalo.
Sesión 1 Imaginología de la patología pediatricaLizbet Marrero
El documento describe que el desarrollo anatómico, fisiológico, cognitivo y psicológico de los niños es diferente en cada etapa de crecimiento, por lo que el diagnóstico por imágenes requiere una estrategia específica para cada edad. Además, las patologías propias de cada edad requieren un tratamiento diferenciado.
Un niño inmigrante de 14 años presentó tos y hemoptisis durante 24 horas. Su radiografía de tórax mostró nodulillos confluentes, una condensación excavada, adenopatía y un foco de condensación. Su baciloscopia fue positiva. Fue diagnosticado con tuberculosis pulmonar postprimaria y será controlado durante el tratamiento.
This study summarizes the radiographic and CT findings of pulmonary tuberculosis in 25 infants. The most common radiographic findings were air-space consolidation (80%) and mediastinal bulging suggestive of lymphadenopathy (72%). On CT scans, all patients demonstrated air-space consolidation, and frequent findings included masslike consolidation (59%), low attenuation areas within consolidations (41%), cavities within consolidations (29%), and disseminated pulmonary nodules (29%). CT also better depicted lymphadenopathy and associated central necrosis in all patients, as well as frequent airway complications like bronchial narrowing (65%). CT provided additional diagnostic information beyond chest radiography in all 17 patients who received CT scans.
1. Mediastinal or hilar lymphadenopathy, seen in 83% of patients, was the most common CT finding of pulmonary tuberculosis in children. Enlarged lymph nodes often had low attenuation centers and enhancing rims.
2. Segmental or lobar air space consolidation was seen in 49% of patients, and nodular lesions of bronchogenic spread were seen in 29%.
3. CT provided additional diagnostic information in 20% of cases, suggesting tuberculosis when chest radiographs were normal or inconclusive, and altered clinical management in 37% of cases. CT was useful for evaluating suspected tuberculosis in children.
Una niña de 9 meses fue llevada al hospital con síntomas leves de obstrucción intestinal. Las radiografías de tórax y esófago, estómago y duodeno mostraron una hernia hiatal con volvulo gástrico. A pesar del diagnóstico por imagen, se solicitó una tomografía computada adicional para confirmarlo.
Renal involvement is a known complication of leukemia in children. This study reviewed the CT imaging findings of renal involvement in 12 children with various forms of leukemia. The most common CT finding was multiple bilateral low-attenuation renal masses, seen in 5 patients. Nephromegaly (enlarged kidneys) was present in most patients. While renal involvement was seen, most patients did not have impaired renal function based on creatinine levels. This study demonstrated that renal involvement in pediatric leukemia can present with diverse CT imaging appearances.
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachAyurveda ForAll
Explore the benefits of combining Ayurveda with conventional Parkinson's treatments. Learn how a holistic approach can manage symptoms, enhance well-being, and balance body energies. Discover the steps to safely integrate Ayurvedic practices into your Parkinson’s care plan, including expert guidance on diet, herbal remedies, and lifestyle modifications.
Promoting Wellbeing - Applied Social Psychology - Psychology SuperNotesPsychoTech Services
A proprietary approach developed by bringing together the best of learning theories from Psychology, design principles from the world of visualization, and pedagogical methods from over a decade of training experience, that enables you to: Learn better, faster!
Hiranandani Hospital in Powai, Mumbai, is a premier healthcare institution that has been serving the community with exceptional medical care since its establishment. As a part of the renowned Hiranandani Group, the hospital is committed to delivering world-class healthcare services across a wide range of specialties, including kidney transplantation. With its state-of-the-art facilities, advanced medical technology, and a team of highly skilled healthcare professionals, Hiranandani Hospital has earned a reputation as a trusted name in the healthcare industry. The hospital's patient-centric approach, coupled with its focus on innovation and excellence, ensures that patients receive the highest standard of care in a compassionate and supportive environment.
Adhd Medication Shortage Uk - trinexpharmacy.comreignlana06
The UK is currently facing a Adhd Medication Shortage Uk, which has left many patients and their families grappling with uncertainty and frustration. ADHD, or Attention Deficit Hyperactivity Disorder, is a chronic condition that requires consistent medication to manage effectively. This shortage has highlighted the critical role these medications play in the daily lives of those affected by ADHD. Contact : +1 (747) 209 – 3649 E-mail : sales@trinexpharmacy.com
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Our backs are like superheroes, holding us up and helping us move around. But sometimes, even superheroes can get hurt. That’s where slip discs come in.
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
Post-Menstrual Smell- When to Suspect Vaginitis.pptx
Cloacal malformation.full
1. Diego Jaramillo, MD2 Robert
#{149} L Lebowitz, MD W.
#{149} Hardy Hendren, MD
The Cloacal Malformation: Radiologic Findings
and Imaging Recommendations’
The imaging studies and records of T HE cloacal malformation is a con- tion has improved significantly, and
65 patients with the cloacal malfor- stellation of congenital abnor- surgical repair with good functional
mation seen from 1969 to 1989 were malities in which the urinary, geni- outcome is now possible (7-9). Ade-
reviewed. The malformations were tab, and intestinal tracts converge quate surgical planning requires pne-
described according to cloacal con- into a common outflow structure, the cisc preoperative definition of the
figuration (urethral, vaginal), type cloaca (Latin for sewer). It is seen cx- abnormal anatomy by means of imag-
of uninary-cloacal communication clusively in phenotypic females (i) ing studies and cystoscopy. Preven-
(urethral, vesical), and level of rectal and occurs in one of every 40,000- tion of renal damage, which is the
communication (vaginal, cloacal, 50,000 newborns (2). The perineum most significant potential cause of
vesical, other). Lower urinary tract of the typical patient has a single morbidity in these patients (9), re-
abnormalities were frequent (reflux, opening that serves as the outlet for quines detection and treatment of uri-
ureteral ectopia, bladder diverticula, urine, genital secretions, and feces! nary tract obstruction and reflux,
bladder duplication, urachal rem- meconium, and the abdominal wall is plus early diversion of the fecal
nants, urethral duplication), as were normal (i) (Fig 1). stream by means of a colostomy. Ad-
genital abnormalities (uterine du- The term persistent cloaca has also ditionally, radiology has an impor-
plication, vaginal duplication, uter- been used to describe this anomaly tant role to play in discovering and
inc atresia, vaginal atresia), abnor- (3). In nonpiacental vertebrates such characterizing coexisting anomalies
malities of the bony pelvis (partial as fish, amphibians, reptiles, birds, in other organ systems.
sacral agenesis, pubic diastasis), and and monotremes, the cboaca is the or- Herein we describe our experience
renal abnormalities (agenesis, ob- gan for genitourinary and intestinal with 65 female infants and children
struction, horseshoe kidney). Con- storage and expulsion (4). A similar with the cloacal malformation seen at
trast material studies of the cloaca structure is present in the human em- our institution during the past 20
and the distal limb of the colostomy bryo at 4 weeks (5). However, unlike years. We will describe the spectrum
with fluoroscopy in various projec- the structure in animals and human of the malformation; the genitouri-
tions were essential for diagnosis. embryos, the cboaca seen in the mal- nary, intestinal, lower spinal cord,
Voiding cystourethrography was formation is a channel rather than a and pelvic wall abnormalities that oc-
important for detecting vesicoure- storage chamber. cur in close association with the mal-
teric reflux. Sonography was of lim- The cboacal malformation should formation; the extrapelvic abnormali-
ited value for evaluation of the mal- not be confused with exstrophy of ties that coexist; and the approach to
formation but was valuable for im- the cboaca, an entity having a similar imaging.
aging the kidneys. MR imaging name but differing greatly in em-
revealed that spinal cord abnormali- bryogenesis and clinical features. Ex-
MATERIALS AND METHODS
ties cannot be predicted based on strophy of the cloaca is seen in both
the appearance of the lumbosacral boys and girls, and there is a failure We reviewed the imaging, clinical, cys-
spine and are more common than of closure of the lower abdominal toscopic, and surgical findings in 65 fe-
previously thought. wall (6). male subjects (newborn to 21 years of age)
with the cloaca! malformation seen at our
In recent years, the prognosis of
hospital during the years 1969-1989. At
infants with the cboacal malfonma-
least one of us participated in the evalua-
tion of every patient, and one of us pen-
formed surgery in all but four of them.
We imaged 28 patients before repair of
I From the Departments of Radiology (D.J., the cloacal malformation. Their ages at
Index terms: Anus, abnormalities, 757.1433.
R.L.L.) and Surgery (W.H.H.), Children’s Hos- examination ranged from 1 day to 4 years
Anus, imperforate, 757.1433 Bladder,
#{149} abnor-
pita!, Harvard Medical School, 300 Longwood (except for one patient evaluated when
malities, 83.1469 Children,
#{149} genitouninary sys-
Ave. Boston, MA 021 15. Received April 6, 1990; she was 1 1 years old). Twenty-five of
tem, 80.1469 Genitourinary
#{149} system, abnor-
revision requested May 9; revision received these 28 patients had undergone divert-
malities, 80.1469 Infants,
#{149} genitourinary sys-
June 15; accepted June 22. Address reprint re- ing colostomy prior to imaging. All 28 pa-
tern, 80.1469 Magnetic
#{149} resonance (MR), in
quests to R.L.L.
infants and children Rectum,
#{149} abnormalities, tients had undergone one or more fluoro-
2 Current address: Department of Pediatric
757.1433 Urethra,
#{149} abnormalities, 851.1469. scopically monitored injection studies us-
Radiology, Massachusetts General Hospital,
Uterus, abnormalities, 854.1469 Vagina,
#{149} ab- Boston.
ing water-soluble contrast material for
normalities, 855.1469 C RSNA, 1990 evaluation of the malformation (26 injec-
See also the editorial by Wood (pp 326-327) tions into the perineal opening, 17 injec-
Radiology 1990; 177:441-448 in this issue. tions into the distal limb of the colosto-
441
2. Urethral Vaginal
a.
R
Figure 1. Perineum of a patient with do-
acal malformation. Featureless or blank pen-
neum has a single penineal opening, and the
anus is absent.
my, and 10 injections through catheters I
placed intraoperatively or into vesicos- b. C.
tomy on vaginostomy stomas) and at least Figure 2. (a) Cloacal configuration. Sagittal diagrams show the narrow urethral configura-
one study of the upper urinary tract (15 tion (left) and the wide vaginal configuration (right). Vagina can often be identified by the
sonographic, 15 excretory urographic, cervical impression. Sacrum is short, a frequent finding in the malformation. (b) Urethral
and eight scintigraphic studies). Nine pa- configuration. Contrast material was injected into a catheter in the cloaca with use of a nip-
tients in this group underwent magnetic ple for occlusion (straight arrow). Cloaca is long and narrow and communicates with the
resonance (MR) imaging for evaluation of urethra and the rectum (R). A small chamber lies between the cloaca and the rectum (solid
the lower spinal cord. curved arrow). Vaginal lumen is not opacified (open curved arrow) but is distended. Vagina
The other 37 patients were seen follow- indents the bladder (B) and rectum (R). (c) Vaginal configuration. A wide, short cloaca has
been opacified. Two vaginas (V) are present, one of which is partially hidden by the bladder.
ing some degree of repair of the cboacal
The communication with the rectum is not opacified.
malformation performed elsewhere.
Their imaging studies were reviewed,
and often new ones were performed.
The surgical treatment of these patients
has been reported elsewhere (7,8). (Fig 2b). The latter was a wide, usual- curred higher in the vagina. In two
ly straight cloaca that tended to be a cases the communication was with
continuation of the vagina (Fig 2c). the anterior wall (Fig 5a, 5b). In cases
RESULTS
The type of uninary-cloacal com- of cboacal communication, there was
We described the cboacal malfor- munication (Fig 3a) was urethral in direct communication between the
mation according to its radiobogic ap- 50 patients [77%]; in these patients rectum and the cloaca. In five cases,
peanance. The following categoriza- there was a well-formed urethra, usu- there was a tiny chamber acting as a
tion of the malformation, which is ally with a normal sphincter, joining passageway between the rectum and
based on radiologic findings, is an at- the bladder to the cboaca (Fig 3b). The the cloaca (Fig 2b). Three of these
tempt to serve as a guide to the radi- communication was vesical in 15 pa- five patients had a separate, blind-
ologist performing the imaging stud- tients (23%); the urethra was absent, ending vagina, distended with geni-
ies. The categorization is indepen- and there was direct communication tal secnetions (Fig 2b). In five other
dent of, but complementary to, the between the bladder and the cloaca patients, communication occurred
classification of the level of conflu- (Fig 3c). between the intestine and the blad-
ence of the cboacal malformation The level of rectal communication den when there was either no vagina
based on cystoscopic and operative (Fig 4a) was categorized as vaginal or when the vagina was malposi-
findings (7). (44 patients [68%]), cloacal (seven pa- tioned (Fig 6). These five also had pu-
The cloacal configuration (Fig 2a) tients [11%]), or other (ten patients bic diastasis.
was categorized as either urethral (34 [15%]). Vaginal communication usu- In four cases the rectum opened
patients [52%] or vaginal (31 patients ally occurred at the posterior wall of onto the perineum through an ante-
[48%)] . The former was a narrow, of- the lower vagina, or, in cases of vagi- riorly malpositioned anus (cboacal
ten long and curved cloaca with a nab duplication, at the lower end of variant, Fig. 4a). In one patient there
small penineal opening that tended the vaginal septum (Fig 4b, 4c). Less was a rectouterine communication.
to be a continuation of the urethra frequently, the communication oc- Four patients (6%) had had prior
442 Radiology
#{149} November 1990
3. pull-through operations elsewhere, dynamic examinations, and operative always had pubic diastasis (generally
and the level of the communication findings showed that the urinary wider than 4 cm) and severe genital
could not be determined. sphincter was located around the and rectal abnormalities (Fig 8). More
Abnormalities of the pelvic struc- urethra in 37 patients (57%) and than half of the patients had uretenal
tunes were common (Table 1). Three around the cboaca in 14 (22%). Four- reflux, usually bilateral (22 of 39
patients had an accessory urethra teen (22%) had no sphincter. cases). Uretenal ectopia was frequent
that exited just below a clitonislike Diverticula of the bladder were and ranged from lateral or inferior
structure (Fig 7a). This “phallic seen in 13 patients (20%). All six pa- location of the ureteral orifice in the
urethra” (2) was very small. There tients with peniuretenal diverticula bladder to insertion in the vagina
was a second, larger, more normal had reflux. Patients with either du- (five patients) or the cboaca (one pa-
urethra located posterior and inferior plication of the bladder or a common tient).
to it (Fig 7b). Imaging studies, uro- vesicovaginal or vesicocecal chamber Duplication of the uterus, usually
associated with vaginal duplication,
was seen in 36 patients (55%) (Figs 2c,
4c, 5b, 8, 9). Obstruction of the geni-
tab tract was present in 16 patients
(25%) and usually was at the level of
the vagina. Patients with obstruction
frequently had hydrometrocolpos at
birth (14 of 16 cases). Two patients
developed hematocolpos at puberty,
and one presented at age 16 with bi-
Figure 3. (a) Diagrammatic representation
of the types of urinary-cloacal communica-
Lirethro-cloacal Vesico-cloacal tion. The communication is called urethro-
cloacal when a well-formed urethra joins
the bladder to the cloaca (left). If the urethra
is absent or rudimentary, the communica-
tion is called vesicocloacal (right). (b) Ureth-
rocloaca! communication. Contrast material
V has been injected into a cloaca by means of
the nipple-occlusion technique. There is ret-
B rograde filling of the urethra (straight an-
row), which is opacified only to the level of
the urinary sphincter, indicating that the
sphincter is competent. The vagina (V) and
rectum (R) are also opacified. The rectoc!oa-
cal communication is very narrow (curved
arrow). The bladder (B) is faintly opacified.
(c) Vesicoc!oaca! communication. There is
,, opacification
uration
of a cloaca with vagina!
that communicates
config-
freely with both
the vagina (V) and the bladder (B). There is
, . , ,J.
no urethra. The rectum is not opacified.
‘..
Vaginal Cloacal
c#{231}
:
‘ .‘
#{149} jUro
. - ..
enitol Sinus
with nteriorty
Cloocol Variant)
Ptoced Anus
b. C.
Figure 4. (a) Diagrammatic representation of the level of rectal communication. The rectum usually joins the vagina low on its posterior
wall (upper left). The rectum can also join the cloaca (upper right). In the so-called cloacal variant (lower illustration), the rectum drains
through an anteriorly placed anus, very close to the opening of the urogenital sinus. (b, c) Low rectovaginal communication. The bladder
(which contains an air-filled urinary catheter balloon), vaginas (V), and rectum (R) are opacified by simultaneous injection into the suprapu-
bic bladder catheter and the distal limb of the colostomy. (b) Lateral projection. The communication (arrow) is between the rectum and the
lower portion of the superimposed vaginas. (c) Frontal projection. The communication (arrow) is into the incomplete septum that divides
the vagina into two chambers inferior!y.
Volume 177 Number
#{149} 2 Radiology #{149}443
4. lateral adnexal masses that were
found to be dilated fallopian tubes in
an otherwise atretic genital tract.
Eleven patients had abnormal sep-
aration of the pubic symphysis (Fig
8). Of eight patients with a diastasis
greater than 2 cm, six had no cvi-
dence of a functional urinary sphinc-
ten, and four had a common vesicova-
ginal chamber.
Some degree of sacnal agenesis was
seen in nearly half of the patients (26
of 65 [40%]). Spinal anomalies in-
cluded dysraphism, segmentation
anomalies, and spinal stcnosis.
The most frequent abnormality of
the spinal cord was tethering. A
high, stubby conus was seen in two
patients, each of whom had segmen-
tal sacral agcnesis. More than half of Figure 5. Anterior
rectovagina! communication. Curved arrows = cervical impression.
the cases of spinal cord anomalies (a) Oblique projection.
The rectum (R) passes over the vagina! septum to joint the lower por-
were detected since we began to use tion of the vagina (V) on its anterior wall (straight arrows). B = bladder. (b) Frontal projec-
MR imaging as a screening tool. Of tion. A midline septum separates two vaginas, and a cervical impression is seen at each apex
(curved arrows).
16 patients who underwent MR im-
aging, seven had some degree of spi-
nal cord abnormality. Of the six pa-
tients with tethered cord, three had
only minimal sacral abnormality, and
in one the sacrum was normal.
Multiple abnormalities of the cx-
trapelvic organs were seen (Table 2).
Seven of nine patients with only one
kidney had significant genital anom-
alies. However, only one of the seven
had ipsilatenal atnesia of a duplicated
genital tract. Only eight patients had
congenital anomalies of the upper
urinary tract that required surgery
(six with obstruction at the uretero-
pelvic junction and two with obstruc-
tion at the ureterovesical junction).
Congenital heart disease, although
Figure 6. (a) Frontal projection. This patient had a partially duplicated bladder (B) into
rare, was the cause of the only two which the rectum (R) drained. (b) Lateral projection. The vagina (V) has two cervices (an-
deaths. rows) and is infeniorly malpositioned. The cloaca has a urethral configuration. Confusing
anatomy in this patient necessitated four imaging examinations. The last was performed
with the patient under anesthesia during cystoscopy; contrast material was injected through
DISCUSSION catheters placed at that time.
A cow with a malformation result-
ing from confluence of the urinary,
genital, and alimentary tracts was de-
scnibed by Aristotle (10). In 1692, Sa-
viard performed an autopsy on an in-
fant who had died several days after
birth who had “no apparent marks of
either [sex] externally, . . . two kid-
neys fastened together . . . [which]
discharged . . . into a large hole, the
Cystis Communis, . . . whose aperture
was the only one external.” By using
a blow-pipe introduced into the “cys-
tis,” has was able to inflate the com-
municating structures and “found
two small wombs, . . . each [with] a
short vagina . . . which evacuated ...
Figure 7. (a) Diagrammatic representation of urethral duplication. A narrow accessory on
into that cystis, and this, to speak the
“phallic” urethra opens onto the perineum just beneath a large clitoris. The functional, more
truth, was only the extremity of the posterior on ventral urethra joins the cloaca. (b) A narrow, dorsal accessory urethra (arrow)
rectum a little dilated.” Saviard ends that exits beneath the clitoris is opacified, as is a wide ventral urethra that merges with the
his description with an insightful cloaca. The vagina is not opacified. B = bladder, R = rectum.
444 S Radiology November 1990
5. the rectum and the urogenital sinus.
Table 1
The cboacal membrane, which covers
Abnormalities of the Pelvic Structures
the perineum at this stage, cannot
No.of rupture if it is not joined by the uro-
Structure Patients rectal septum, so the normal penineal
openings do not develop. Further-
Lower urinary tract
Urethra more, abnormalities in cboacal septa-
Accessory or “phallic” urethra 3(5) tion and urogenital sinus formation
Absent or poorly developed 4(6)
Atresia or obstruction 5 (8) interfere with normal mesonephric
Bladder and paramcsonephnic duct develop-
Diverticula 13 (20)
ment. This may explain the very fre-
Duplication 6 (9)
Urachus 5(8) quent association of the cloacal mal-
Common vesicovagina! chamber 5 (8) formation with duplication or agene-
Hypoplasia 3 (5)
Lower ureter and ureterovesica! junction sis of genital structures and with the
Reflux 39 (60)* less frequent but still common anom-
Grade 1 0
alies of number and position of the
Grade 2 10
Grade 3 5 kidneys. As with imperforate anus,
Grade 4 7 primary obstruction of the rectum
Grade 5 5
Ectopia 18 (28)t with secondary formation of commu-
Genital tract nication between the rectum and ad-
Vagina
Duplication 30 (46)
jacent structures has also been postu-
Agenesis or atresia 16(25)1 bated and helps to explain some of
Hydrometrocolpos at birth 14(22) the unusual connections (13) (Fig 5).
Hematometrocolpos at puberty 2 (3)
Uterus The multiplicity of associated find-
Duplication 36 (55) ings, particularly in the lower spinal
Agenesis 10(15)
Adnexa (surgical data)
cord, lumbosacral spine, and bladder,
Absent or hypoplastic ovaries 4 (6) suggests that more complex and
Paraovanian and fallopian tube cysts 3 (5) probably multiple disturbances have
Cystic ovaries 2 (3)
Pelvic osseous structures occurred during the process of devel-
Sacral agenesis or hypoplasia 26(40) opment of the caudal pole of the em-
Pubic diastasis 11 (17)
Dysraphism 9(14)
bryo (15,16).
Lower spinal cord (data from 16 MR studies, seven abnormal) The few cases that are intermediate
Tethered cord 8(12)t between the cloacal malformation
Lipomyelomeningocele 3(5)11
High cord 2(3)1l and cboacal exstrophy are puzzling.
Retrorectal presacral space Abnormal separation of the pubic
Rectal diverticulum 1 (2)
Presacra! dermoid 1 (2)
symphysis, previously thought to be
Sacrococcygeal teratoma 1 (2) characteristic of exstrophy of the
Note-Percentages in parentheses. bladder or the cboaca, has been found
* Twenty-two bilateral cases. The grade of reflux was unavailable in 12 of the 39 patients. in association with other genitouri-
t Five extravesical cases. nary anomalies (17) and was present
I Includes four with rudimentary vaginal chambers. in 1 1 of the patients in this series.
§ Six cases found with MR imaging.
1 One case found with MR imaging. Two of these patients had a vesicoce-
cal communication, reminiscent of
the visceral configuration of cloacal
exstrophy. Failure of regression of
statement about the cboacal malfor- the cloacal membrane has been sug-
mation that is still valid: “It is very gested as one causative factor in both
probable . . . that if this child had the cloacal malformation and cboacal
lived to be adult, it would have been exstrophy; however, in cloacal cx-
incapable of generation from the strophy, the cloacal membrane be-
mixture of the seed with the stercoral comes interposed between the fusing
and urinary excrements. Besides, genital tubercles and interferes with
both these excrements would have the normal closure of the anterior
had an involuntary exit.” In the early pelvic wall (6,18). It is likely that this
19th century Meckel introduced the process operates to some degree in
term “cloaca congcnita” to describe the cases of the cloacal malformation
the malformation (10). with features of cloacal exstrophy.
The embryologic basis of the mal- A small group of patients had
formation is still a subject of contro- esophageal atresia (11%) and other
versy (5,1 1-14). What follows is a features of the VATER association
brief summary of the most widely ac- (vertebral, anal, tracheoesophageal,
cepted theories. The cboacal malfor- and radial and renal defects), but
mation is believed to result from fail- they had lower-limb anomalies and
ure of the urorectal septum to join not radial abnormalities.
Figure 8. Bladder duplication. Frontal pro-
the cloacal membrane during the 4th Until about 20 years ago the cboacal
jection shows two hemibladders (B), each
having its own refluxing ureter, and wide
to 6th weeks of embryonic develop- malformation was an embryologic
pubic diastasis. Two vaginas (V) are partially ment. This failure could result in a curiosity, rarely reported (3,16,19)
obscured by the left hemibladder. persistent communication between and having devastating effects and a
Volume 177 #{149}Number 2 Radiology 445
#{149}
6. Figure 9. Vaginal duplication. Two distended vaginas (1/) separated by an incomplete sep-
tum are we!! demonstrated by (a) the injection studs’ and (b) sonography. Sonogram is on-
ented to correspond to the vaginogram.
grim prognosis (20,21). In a series as
Table 2
recent as 1959 (3), the mortality was
Extrapelvic Abnormalities
greater than 50% because of urosep-
sis, renal failure, and cardiovascular
anomalies.
Today, however, repair of the mal- Upper urinary tract
formation and management of its Unilateral renal agenesis 9(14)’ b.
Ureteral obstruction 8 (12)t Figure 10. (a) Frontal radiograph shortly
complications have become possible.
Abnormalities of rena!
Death is very rare, and the morbidity after delivery shows a large pelvic mass oc-
position and rotation 6(9)
cupying most of the lower abdomen. There
related to the urinary and intestinal Horseshoe kidney 4(6)
Duplication of collecting is a linear calcification in the abdomen (an-
tract has been markedly reduced, system 4 (6) row) suggestive of meconium peritonitis.
mainly due to the recognition of the Gastrointestinal tract The sacrum is hypoplastic, and there is wide
Esophageal atresia 7(11)
importance of early colostomy to di- pubic diastasis. (b) Sagittal sonogram of the
Meckel diverticulum 6(9)
vent the fecal stream and decompres- Malrotation 5(8)
same infant shows a vagina with a fluid-
sion of the urinary tract. A divided- Intestinal atresia 3 (5)1 debris level. The compressed bladder (an-
Meconium peritonitis, row) is located anteriorly.
loop right-transverse colostomy to without bowel
avoid fecal contamination of the perforation 2(3)
urine is preferred for reasons out- Cardiovascular system
Ventricular septal defect 6(9)
lined previously (8). Intermittent Tetra!ogy of Fallot 2(3)
catheterization of the cloaca is often Musculoskeletal system
Vertebral anomalies 13 (20)
necessary in the neonatal period to Lower-limb anomalies 5(8)
drain urine from the distended vagi- Congenital hip dysplasia 4 (6)
Head and neck
na(s). Vaginostomy or vesicostomy
Craniofacial anomalies 6(9)
arc almost never needed. Correction Hydrocephalus 2(3)
of severe reflux is often performed
Note-Percentages in parentheses.
prior to definitive repair of the mal-
- Seven with significant genital anomalies.
formation. The definitive repair is , Six ureteropelvic junction. six ureterovesi-
complex and involves the separation cal unction.
I Two duodenal.
of the rectum, vagina(s), and urinary
tract, bringing each to the perineum
in a more normal fashion. The poste-
nor sagittal approach is preferred the immediate postnatal period in or- .,,.i,.,
(8,9). Functional repair of the cloacal den to prevent fecal contamination of
malformation can result in a conti- the urinary tract (8,9). Since the state Figure 11. Same patient as in Figure 4b
nent bladder and rectum, and in a va- of the urinary tract is the main factor and 4c. The bladder (B), vagina (V), and
gina of near anatomic configuration. deciding the prognosis of patients uterine horns (arrows) are opacified.
The outcome of repair of the genital with the cboacal malformation (9), de-
tract is difficult to assess at this time tection of reflux and obstruction
because most survivors arc only now should be done early. Imaging stud- studies to detect and characterize as-
reaching the reproductive age (8,9). ies to define the cloacal anatomy be- sociated anomalies.
The first step in the management fore planning the definitive repair Every newborn girl with imperfo-
of the malformation is the perfor- can then be performed electively. rate anus and a single penineal open-
mance of a diverting colostomy in Further imaging should include ing should be considered to have the
446 . Radiology November 1990
7. cloacal malformation until proved nipple (Poznanski technique) (24) throgram. Vesicoureteric reflux can-
otherwise. Just as there is wide varia- (Figs 2b, 3b) or with the balloon of a not be detected and characterized
tion in the internal anatomy, there is Foley catheter. without a cystogram. Catheterization
a spectrum of severity in the appear- Accessory penineal openings of the bladder may be difficult, even
ance of the abnormal perineum. Fig- should be soht. A tiny opening at with a coud#{233}atheter.
c In a few cases
ure 1 shows the typical cboacal anato- the base or the tip of the clitoris is the catheter can be placed in the
my. However, in some cases the in- usually the opening of a second ure- bladder only at the time of cystos-
troitus may have a more normal thra, sometimes called a phallic ure- copy.
appearance, and in others there is a thra. As in urethral duplication in In patients who have already had a
rudimentary phalliclike structure males, this uppermost (dorsal) ure- colostomy, injection into the distal
with poorly formed labia. thra is usually rudimentary, whereas limb of the colostomy should be
Imaging evaluation should begin the lower (ventral) urethra is the done. We usually do this as the first
with plain radiognaphs. A pelvic more functional of the two (25). injection study because, if all of the
mass is almost always a distended va- Imaging during injection of con- pelvic structures are shown, a cboacal
gina and/on uterus, secondary to ob- trast material into the cloacal open- injection is not needed. Injection into
struction (Fig 10). The level of this ing should begin in the lateral pro- the distal limb of the colostomy regu-
obstruction determines whether the jection to display the various commu- larly demonstrates the level of the
vagina is only distended by genital nications optimally. Examination in rectal communication and distin-
secretions on whether it contains the frontal projection is important for guishes the rectum from the vagina.
urine and meconium as well. If the showing vaginal and bladder dupli- This differentiation can sometimes
mass contains gas, the gas is most cation (Figs 4c, 5b, 8, 9). For all injec- be difficult during the cboacal injec-
likely from the colon and is a sign of tion studies, water-soluble contrast tion, particularly when the vagina is
rectovaginal communication (22). material (17% meglumine diatrizoate) distended and the rectum is poorly
Linear calcifications in the abdomen is preferred over barium because of opacified (Fig 3b).
along the peritoneal surfaces indicate the possibility of reflux into the up- Sonographic evaluation of the pd-
calcified meconium from meconium per urinary tract on flow into the vic viscera can occasionally help
peritonitis (Fig 10). This can occur in peritoneal cavity, because repeated characterize the cloacal malforma-
patients with the cboacal malfonma- injections are more readily done, and tiort, particularly when the vagina is
tion when meconium spills into the because rarely (in one case in our se- dilated (Figs 9, 10). However, in this
peritoneal cavity via the fallopian ries) barium may fail to demonstrate series, sonography was useful for
tubes and not necessarily from intes- a narrow communication that less evaluation of the pelvic structures in
tinal perforation (23). Granular calci- viscous water-soluble contrast mate- only one-third of patients, primarily
fications in the abdomen correspond- rial shows. due to difficulty in obtaining a full
ing to the course of the colon suggest It is important to distinguish be- bladder to use as an acoustic window.
calcified intnaluminal meconium, tween the bladder and vagina, but We evaluate the upper urinary
which can occur when there is mix- this can be difficult (Figs 4b,10). In tract initially with ultrasound (US)
ing of urine and meconium in the lu- one case initially treated elsewhere, and later with a functional urogna-
men of the colon. This is more likely this confusion led to performing a phic or scintigraphic study. If the
in patients with the cboacal malfor- vaginostomy instead of the planned sonogram is normal, either scintigra-
mation when there is vaginal atresia vesicostomy. Reflux into a ureter or phy or excretory urognaphy is used.
on stenosis and rectovesical or nec- into a urachal remnant helps to iden- If the sonogram is abnormal, we use
tounethral communication. Severe tify a structure as the bladder. A cen- excretory urography because precise
diastasis of the pubic symphysis sug- vical impression, which is not always anatomic definition is so important
gests poor development of the une- present, and a septum help to identi- in this complex malformation.
thral sphincter, rectovesical commu- fy the vagina (Figs 5, 6b). The posi- Since the prevalence of anomalies
nication, or a common vesicovaginal tion of a structure is not always a clue of the lower spinal cord is very high
chamber. as to its identity (Fig 6b). (43% in the patients evaluated with
Injection studies with fluonoscopic Failure to opacify the bladder, if MR imaging) and since the plain ra-
monitoring are the most important the retrograde injection of contrast diographs correlate poorly with
part of the nadiobogic evaluation of material stops at the urethral sphinc- pathologic features of the cord, we
the cboacal malformation. Cross-sec- ten, indicates that the sphincter is now evaluate the lower spinal cord
tional imaging techniques are not competent (Fig 3b). Failure to opacify in every patient with the cboacal ma!-
usually helpful because the multiple the vagina may indicate either vagi- formation. This can be done with US
structures involved and the unpre- nab atresia or obstruction (Fig 2b). If during the neonatal period, or with
dictable and erratic courses of the the obstruction is untreated, and the MR imaging later (16).
communications between them do patient has a uterus, she may develop Postoperative MR imaging for
not lend themselves well to studies hematocolpos at puberty. During do- evaluation of the adequacy of the nec-
in orthogonal planes. The structures acal injection, the rectum often fails tal pull-through (26) can be done si-
are readily accessible for catheteriza- to opacify. This occurred in 15 of 28 multaneously with the examination
tion, and studies with contrast mate- patients studied by us prior to repair. of the cord, as was done in six of 16
nial also provide functional infonma- Opacification of the endometrial cay- patients. MR evaluation of the uterus
tion about reflux and continence. Se- ity is extremely rare (the uterus was and ovaries was not helpful. This
dation is usually not necessary. seen in only two of these 28 patients) may be related to two factors, that
If the single perineal opening is (Fig 11). most patients were examined in in-
small, catheterization can usually be Following injection into the cloaca, fancy and that these structures were
accomplished with an 8-F feeding an attempt to advance the catheter frequently hypoplastic and located in
tube. If the opening is patulous, it into the bladder should be made in abnormal positions. Evaluation of ab-
should be partially occluded with a order to perform a voiding cystoure- normalities in other organ systems is
Volume 177 Number
#{149} 2 Radiology 447
#{149}
8. guided by the physical examination. 5. Moore KL. The developing human. 4th 16. Carson JA, Barnes PD, Tune!! WP, Smith
ed. Philadelphia: Saunders, 1988; 236-245, El, Jolley SC. Impenforate anus: the neu-
In summary, the cboacal malfonma-
257-285. rologic implication of sacral abnormali-
tion represents a spectrum of abnor- 6. Hurwitz RS, Manzoni GAM, Ransley PG, ties. J Pediatr Surg 1984; 19:838-842.
malities of the lower urinary, genital, Stephens DF. Cloacal exstrophy: a report 17. Steidle CP, Kennedy HA, Mitchell ME,
and intestinal tracts. Knowledge of of 34 cases. J Urol 1987; 138:1060-1064. Rink RC. Symphyseal diastasis in the ab-
the main anatomic patterns before ra- 7. Hendren WH. Further experience in re- sence of the exstrophy-epispadias corn-
constructive surgery for cloacal anoma- plex. J Uro! 1988; 140:349-350.
diobogic investigation is important. lies. J Pediatr Sung 1982; 17:695-717. 18. Mildenberger H, K!uth D, Dziuba M.
Injection studies with fluoroscopic 8. Hendren WH. Repair of cloaca! anoma- Embryology of bladder exstrophy. J Pc-
monitoring in the awake child arc lies: current techniques. J Pediatr Sung diatr Surg 1988; 23:166-170.
the mainstay of radiobogic evalua- 1986; 21:1159-1 176. 19. Stone HB. Imperforate anus with recto-
9. Hendren WH. Urological aspects of do- vagina! cloaca. Ann Sung 1936; 104:651-
tion. They are a challenge to perform acal malformations. J Urol 1988; 140:1207- 658.
and interpret. Coexisting anomalies 1213. 20. Snyder WH Jr. Some unusual forms of
are frequent and often important, 10. Bodenhamer W. A practical treatise on impenforate anus in female infants. Am
and they should be sought. #{149} the aetiology, pathology and treatment of Sung 1966; 111:319-325.
the congenital malformation of the rec- 21. RaffenspengerJG, Ramenofsky ML. The
tum and anus. New York: Wood, 1860; management of a c!oaca. J Pediatr Surg
Acknowledgments: We thank Diane de Al-
225-277. 1973; 8:647-657.
derete for secretarial assistance, Donald Sucher
1 1. Van den Putte SCJ. Normal and abnormal 22. Reed MH, Griscom NT. Hydrometnoco!-
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