Enteric Contrast Media for Pediatric Imaging

Transcription

1 Enteric Contrast Media for Pediatric Imaging Michael J. Callahan, M.D. Department of Radiology Boston Children s Hospital Associate Professor of Radiology Harvard Medical School

2 What is a contrast medium?

3 Contrast Medium In the context of medical imaging: Substance used to enhance the contrast of certain structures or fluids within the body

4 Contrast Media Vascular Enteric Cavity Joint CNS

5 Enteric Contrast Media Fluoroscopy X-ray attenuation CT X-ray attenuation MRI signal intensity Ultrasound attenuation coefficient

6 Enteric Contrast Media Advantages (Potentially) improves diagnosis (Potentially) increases dx accuracy Allows for use of fluoroscopy Disadvantages Time Cost Adverse or allergic-like reactions

7 Outline Fluoroscopy Ultrasound Computed Tomography MRI Shortages

8 Outline Fluoroscopy Ultrasound Computed Tomography MRI Shortages

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10 Fluoroscopy Established ACR guidelines for enteric contrast media for adults Special considerations in children

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12 Fluid shifts, hyperosmolar media Aspiration pneumonitis

13 Fluoroscopy Barium Sulfate Versatile High or low scatter environments

14 Fluoroscopy Barium Sulfate Suspension Oral, transesophageal catheter, gastrostomy, jejunostomy, ileostomy Cecostomy, colostomy, mucous fistula NOT used for enemas at BCH Limited in setting of suspected perforation

15 Fluoroscopy Iodine-based Water soluble IOCM, LOCM, HOCM Ionic and non-ionic Bitter taste Expensive

16 Fluoroscopy Iodine-based water-soluble as enteric media Version 10.3 (2017) of the ACR Manual on Contrast Media, pg 60. (Any) iodinated contrast media supplied for intravenous use also can be administered safely by mouth or per rectum. Enteric use is generally off label, with the exception of Iohexol (Omnipaque, GE Healthcare; Princeton, NJ) which has an FDA-approved indication for oral use in select concentrations

17 Technical considerations

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19 20 cm Large 5 cm Adult Small Child

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21 5 cm 20 cm

22 Barium Sulfate vs IBCM

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25 Case Examples

26 5-month-old female with LGEA rule out leak OPTIRAY 240

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28 19-year-old female morbid obesity OPTIRAY 320

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30 Post op UGI OPTI 320

31 2-day-old with bilious emesis Cysto-Conray II vs. BARIUM

32 2-day-old male, bilious emesis

33 US CT MRI

34 Outline Fluoroscopy Ultrasound Computed Tomography MRI Shortages

35 Ultrasound Air has a higher attenuation coefficient relative to soft tissue or fluid Air reflects sound waves

36 Ultrasound Reflection occurs at a boundary of 2 materials with different acoustic impedances

37 Normal Pylorus

38 Antrum DB

39 4-day-old boy with vomiting. Soft tissue mass at gastric outlet B

40 4-day-old boy with vomiting. Soft tissue mass at gastric outlet A

41 Outline Fluoroscopy Ultrasound Computed Tomography MRI Shortages

42 CT Is enteric contrast necessary?

43 CT Variable opinions on need of enteric contrast media for pediatric CT abdominal imaging

44 CT: Is enteric contrast (really) necessary? No Can be helpful in children w paucity of retroperitoneal and intraperitoneal fat, increased image noise?? Anesthesia

45 Yes CT enteric contrast Oncology Suspected intra-abdominal abscess Abdominal pain NOS No Suspected acute appendicitis Trauma Suspected renal stones CT angiography

46 Dilute Iodinebased or dilute barium-based media CT

47 Optiray 320 enteric CT prep Dilute 1 ml Optiray 320 into 30 ml of clear liquid Age-adjusted doses 90 minutes prior to study 30 minutes Just prior to study

48 CT enteric media Abdomen B A = Air B = Optiray 320 Bone A C C = Dilute Optiray 320 (30:1) B A C

49 15-year-old female with left sided abdominal pain, fever and vomiting

50 US, 10/16/16

51 CT, 10/17/16

52 CT, 10/17/16

53 Diagnosis: Mesenteric cyst vs. LM Drainage by IR Ruptured, resulting in hypotension and ICU stay Discharged w tumor markers sent Back to ED 10 days later, abdominal pain

54 MRI, 11/2/16

55 11/7/17 OR Small Round Blue Cell tumor

56 Barium sulfate suspension A B Single detector CT, 2003

57 Optiray y.o. male, G-tube check KUB next day, CT requested

58 Optiray 240 Optiray 240 Optiray 320, diluted 30:1 Modern MDCT, 2018

59 CTE PEG (MiraLAX), Psyllium (Metamucil) Dilute barium suspension (VoLumen)

60 Outline Fluoroscopy Ultrasound Computed Tomography MRI Shortages

61 MR Enterography (MRE) Similar oral prep as CTE PEG (MiraLAX), Psyllium (Metamucil), Dilute barium suspension (VoLumen)

62 PEG (MiraLAX) oral prep Poly ethylene glycol Doses < 25 kg = 2 packets kg = 3 packets > 50 kg = 4 packets

63 AX VIBE FS post gad A Optimal enteric prep B Patient refused enteric prep

64 MRCP

65 MRCP

66 Cor 3-D MRCP sequence Nature s Place Organic Blueberry Juice True Blue Blueberry Juice Walgreen s Distilled Water

67 A AJ H2O B AJ H2O

68 A B

69 Pre BBJ Post BBJ

70 16-year-old female w recurrent pancreatitis. Small pseudocyts (asteriks) in the pancreatic tail are well delineated by BBJ in stomach and jejunum

71 Outline Fluoroscopy Ultrasound Computed Tomography MRI Shortages

72 Contrast shortages

73 Shortage CC-II = 81 mg/ml iodine 1 part Optiray 320 and 3 parts saline Similar iodine content CC-II Lower osmolality Time $$

74 Shortage

75 Shortage H2O PJ

76 Take Home Points

77 Take Home Points Enteric contrast can be an important component for certain pediatric imaging studies Knowledge of basic concepts is key for effective utilization

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79 Take Home Points Certain beverages or over-thecounter medications can be used as contrast media for CT, MRI and US

80 Antrum DB

81 B

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