Search

The role of MRI in evaluating children with an in situ gallbladder and suspected choledocholithiasis following a negative or inconclusive US is unclear.To determine whether MRI benefits children with suspected choledocholithiasis and a normal common bile duct (CBD) without stones on US.We conducted a retrospective 10-year review of paired US and MRI (within 10 days) in children 18 years or younger with suspected choledocholithiasis. With MRI as a reference standard, two reviewers independently evaluated the images for CBD diameter, choledocholithiasis, cholelithiasis and pancreatic edema. Serum lipase was recorded. We calculated exact binomial confidence limits for test positive predictive values (PPVs) and negative predictive values (NPVs) using R library epiR.Of 87 patients (46 female, 41 male; mean age 14 years, standard deviation [SD] 4.6 years; mean interval between US and MRI 1.6 days, SD 1.8 days), 55% (48/87) had true-negative US, without CBD dilation/stones confirmed on MRI; 5% (4/87) had false-positive US showing CBD dilatation without stones, not confirmed on MRI; 33% (29/87) had true-positive US, with MRI confirming CBD dilatation; and 7% (6/87) had false-negative US, where MRI revealed CBD stones without dilatation (2 patients) and CBD dilatation with or without stones (4 patients). Patients with false-negative US had persistent or worsening symptoms, pancreatitis or SCD. The overall US false-negative rate was 17% (6/35). Normal-caliber CBD on US without stones had an NPV of 89% (48/54, 95% confidence interval: 0.77-0.96).MRI adds little information in children with a sonographically normal CBD except in the setting of pancreatitis or worsening clinical symptoms. Further evaluation is warranted in children with elevated risk of stone disease.

Introduction Intraabdominal fluid collections that previously required surgical intervention can now be drained with less invasive techniques. The use of lumen-apposing metal stents (LAMS) to treat pancreatic pseudocysts and perirectal abscesses has been shown to be a safe and effective technique in adults. We aim to evaluate the indications, outcomes, and complications of the use of LAMS in pediatric patients at our institution. Methods A retrospective chart review was performed to study patients up to 18 years of age at the Children's Hospital at Montefiore who underwent drainage of intraabdominal fluid collections with the use of LAMS. The main outcome measures were technical and clinical success and associated adverse events with LAMS placement. Results Seven patients (2 girls) ranging from 9 to 18 years were identified. Four patients had perirectal abscess postperforated appendicitis and 3 patients had pancreatic pseudocysts. All of the patients had complete resolution of the collections, with no recurrence, and our technical and clinical success rate was 100%. Only 1 patient had mild bleeding after placement that spontaneously resolved. Discussion Our study demonstrates the efficacy and safety of the use of LAMS for the drainage of intraabdominal fluid collections in pediatric patients, although the number of patients included is limited.

1. Debra H. Pan, MD* 2. Yolanda Rivas, MD* 1. *Division of Pediatric Gastroenterology and Nutrition, The Children’s Hospital at Montefiore, Bronx, NY * Abbreviations: AAP: : American Academy of Pediatrics ALT: : alanine aminotransferase AST: : aspartate aminotransferase BA: : biliary atresia BUGT: : bilirubin uridine diphosphate-glucuronosyltransferase GALD: : gestational alloimmune liver disease GGT: : γ-glutamyl transpeptidase G6PD: : glucose-6-phosphate dehydrogenase Ig: : immunoglobulin IVIg: : intravenous Ig MCT: : medium-chain triglyceride MR: : magnetic resonance MRCP: : MR cholangiopancreatography PFIC: : progressive familial intrahepatic cholestasis PN: : parenteral nutrition PT: : prothrombin time TORCH: : toxoplasmosis, other (syphilis, varicella-zoster, parvovirus B19), rubella, cytomegalovirus, and herpes simplex Neonatal jaundice is a common clinical sign that indicates hyperbilirubinemia. Clinicians should become familiar with the differential diagnoses of hyperbilirubinemia in newborns and young infants and the importance of early referral of all patients with cholestatic jaundice to a pediatric gastroenterologist or hepatologist. After completing this article, readers should be able to: 1. Recognize jaundice as a sign of hyperbilirubinemia and identify risk factors for neonatal jaundice. 2. Explain bilirubin metabolism. 3. Define hyperbilirubinemia and differentiate between the types of hyperbilirubinemia in newborns and young infants. 4. Explain the broad differential diagnoses of neonatal jaundice. 5. Recognize the importance of screening and postdischarge follow-up to prevent severe unconjugated hyperbilirubinemia. 6. Describe the management of neonatal jaundice, including cholestasis. The term jaundice, derived from the French word jaune , meaning yellow, is a yellowish discoloration of the skin, sclerae, and mucous membranes that is caused by tissue deposition of pigmented bilirubin. Jaundice is also known as icterus, from the ancient Greek word ikteros, signifying jaundice. Jaundice is a common clinical sign in newborns, especially during the first 2 weeks after birth. The first description of neonatal jaundice and bilirubin staining of the newborn brain goes back to the eighteenth century. The finding of jaundice on physical examination is an indicator of hyperbilirubinemia. This differs from carotenemia, which can also manifest as a pale yellow-red skin color and is caused by a high level of carotene in the blood. Older children and adults have a normal total serum bilirubin level less than 1.5 mg/dL (26 μmol/L), with the conjugated fraction accounting for less than 5%. (1) Hyperbilirubinemia is defined as a total serum bilirubin level greater than 1.5 …

BACKGROUND AND OBJECTIVE: Pediatric endoscopic procedures are essential in the evaluation and treatment of gastrointestinal diseases in children. Although pediatric endoscopists are greatly interested in increasing efficiency and through-put in pediatric endoscopy units, there is scarcely any literature on this critical process. The goal of this study was to improve the timeliness of pediatric endoscopy procedures at Children’s Hospital at Montefiore. METHODS: In June 2010, a pediatric endoscopy quality improvement initiative was formed at Children’s Hospital at Montefiore. We identified patient-, equipment-, and physician-related causes for case delays. Pareto charts, cause and effect diagrams, process flow mapping, and statistical process control charts were used for analysis. RESULTS: From June 2010 to December 2012, we were able to significantly decrease the first case endoscopy delay from an average of 17 to 10 minutes (P < .001), second case delay from 39 to 25 minutes (P = .01), third case delay from 61 to 45 minutes (P = .05), and fourth case delay from 79 to 51 minutes (P = .05). Total delay time decreased from 196 to 131 minutes, resulting in a reduction of 65 minutes (P = .02). From June 2010 to August 2011 (preintervention period), an average of 36% of first endoscopy cases started within 5 minutes, 51% within 10 minutes, and 61% within 15 minutes of the scheduled time. From September 2011 to December 2012 (postintervention period), the percentage of cases starting within 5 minutes, 10 minutes, and 15 minutes increased to 47% (P = .07), 61% (P = .04), and 79% (P = .01), respectively. CONCLUSIONS: Applying quality improvement methods and tools helped improve pediatric endoscopy timeliness and significantly decreased total delays.

Objectives The 1-step low-profile percutaneous endoscopic gastrostomy (1-step PEG) uses a single procedure that allows immediate use of a low-profile device. The aim of the present study was to provide our experience with this device and to analyze complications and outcomes after the initial placement. Methods We performed a retrospective chart review of pediatric patients with 1-step PEG placement done by our pediatric gastroenterologists between 2006 and June 2011. Patients were studied for a minimum period of 6 months. Results A total of 121 patients were included in our study, with 23% infants. The most common indication for 1-step PEG placement was swallowing dysfunction in children with neurological impairment (49%). Postplacement complications included granulation tissue (52%), cellulitis (23%), leakage (21%), vomiting (17%), tissue breakdown (8%), failed placement (6%), embedded bolster (5%), perforation (0.8%), and bowel obstruction (0.8%). One-step PEG was maintained in 46 patients (38%). In the remaining 75 patients (62%), PEGs were changed to a balloon device in 66 patients and were completely removed in 9 patients. The most common indications for change were damaged PEG (19/75) and issues with size (11/75). The time to change ranged from 4 years (14 ± 1.3 months). Sixty-eight percent of 1-step PEG changes/removal was performed with an obturator under brief inhalated anesthesia. Conclusions The 1-step PEG has complication rates and outcomes comparable with standard PEGs.

Gastric diverticulum is a rare entity; the patient usually presents with vague abdominal pain, nausea, vomiting, and weight loss. Diverticulectomy is required for patients with intractable symptoms or complications. We report the laparoscopic excision of a gastric diverticulum in a 15-year-old girl who had been symptomatic for 5 years. A five-port technique and a linear cutting and stapling device were used.

1. Bryan Rudolph, MD 2. Yolanda Rivas, MD 1. Children's Hospital at Montefiore Bronx, NY Nonalcoholic fatty liver disease (NAFLD) is a generic term encompassing a spectrum of disorders defined by their histopathology. On one end of the continuum is simple macrovesicular steatosis, which is defined by large fat droplets within hepatocytes. Over time, however, simple steatosis may progress. When inflammation is present, with or without fibrosis, the condition is known as nonalcoholic steatohepatitis (NASH). The far end of the spectrum is frank cirrhosis. All of the entities constituting NAFLD are associated with obesity and insulin resistance and, by definition, occur in the absence of alcohol consumption. First described in the pediatric literature just over 25 years ago, NAFLD today is recognized as an increasingly significant cause of liver disease. Estimates of the overall prevalence of NAFLD vary, based on the method of detection, but it likely is present in approximately 9% of all children and in up to 80% of obese children. With the obesity epidemic and increased physician awareness, these figures are almost sure to increase. Currently, the average age at diagnosis is 12 years, with the earliest reported cases at about 2 years of age. Evidence also suggests that children are developing more advanced stages of NAFLD at earlier ages. In 2006, for example, it was estimated that 25% of …