| Shunting
of cerebrospinal fluid (CSF) into extracranial sites usually include
the use of the peritoneum (ventriculo-peritoneal shunt) and atrium
(ventriculo-atrial shunt) for palliation of symptoms associated with
hydrocephalus. Another alternative includes the use of the pleura for
absorption of the CSF using a ventriculo-pleural shunt in selected
patient when conventional sites not suitable either due to
adhesions, infection, thrombosis or obliteration. Ventriculo-pleural
shunts are an acceptable alternative for CSF decompression in children
as well among adults patients. It is estimated that up to 50% of
children will experience a failure of any shunt within the first year.
Clinical manifestations of early shunt failure include nausea,
vomiting, irritability, altered consciousness, bulging fontanelle among
infants. Depress level of consciousness and loss of milestone are the
main indication of late shunt failure. CSF shunts complications are
either mechanical, functional or infectious in nature. Mechanical
complications include obstruction of the shunt, fracture or
disconnection of the device and migration. In-growth of portions of the
choroid plexus or ependymal surface of the ventricles into the inlet
holes of the proximal catheter accounts for the most common cause of
obstruction. CSF malabsorption leads to abnormal accumulation of the
fluid resulting in functional failure of the shunt. The most common
complication of ventriculo-pleural shunts (VPLS) is pleural effusion.
Only 20% of the pleural effusions are symptomatic requiring revision
and most of these patients are infants. Anti-siphon devices seem to
reduce the incidence of pleural effusion. The hydrothorax associated
with VPLS is due to impaired pleural absorption and excessive drainage
of CSF into the pleural space. The fluid is clear transudate with some
mononuclear cells. In most cases of pleural effusion the fluid resolves
spontaneously. Pleural CSF effusion might result in respiratory
distress needing thoracentesis. Administration of acetazolamide reduces
CSF production and reduces respiratory symptoms. With recurrent or
worsening of symptom shunt replacement must be undertaken. References: 1- Khan TA, Khalil-Marzouk JF: Fibrothorax in adulthood caused by a cerebrospinal fluid shunt in the treatment of hydrocephalus. J Neurosurg. 109(3):478-9, 2008 2- Irani F, Elkambergy H, Okoli K, Abou DS: Recurrent symptomatic pleural effusion due to a ventriculopleural shunt. Respir Care. 54(8):1112-4, 2009 3- Kupeli E, Yilmaz C, Akcay S: Pleural effusion following ventriculopleural shunt: Case reports and review of the literature. Ann Thorac Med 5(3): 166-170, 2010 4- Richardson MD, Handler MH: Minimally invasive technique for insertion of ventriculopleural shunt catheters. J Neurosurg Pediatr. 12(5):501-4, 2013 5- Alam S, Manjunath NM: Severe respiratory failure following ventriculopleural shunt. Indian J Crit Care Med. 19(11): 690-692, 2015 6- Hanak BW, Bonow RH, Harris CA, Browd SR: Cerebrospinal Fluid Shunting Complications in Children. Pediatr Neurosurg. 52(6):381-400, 2017 |
| Thyroid
cancer in children carries a good prognosis. It is followed after total
thyroidectomy with serial measurement of serum thyroglobulin (Tg),
antithyroglobulin antibody (TgAb), neck ultrasound and radio-iodine
(RAI) whole body scan. Elevated thyroglobulin with normal
antithyroglobulin autoantibodies after surgery and radioiodine ablation
therapy indicates recurrent thyroid carcinoma or metastatic disease.
RAI scan is more than 90% specific for detecting recurrence or
metastatic disease. 30-50% with recurrent/metastatic disease can have a
negative RAI scan specially small size tumors or poorly differentiated
carcinomas. PET Scan using fluorine-18-fluorodeoxyglucose (FDG) is an
effective tumor imaging tool in thyroid cancer patients with high Tg
levels specially in cases where RAI whole body scan cannot detect
metastasis due to lack of accumulation by the tumor. Other potential
indications for PET Scan are locating disease in positive RAI whole
body scan patients looking for other sites of metastasis, high level of
antithyroglobulin and determination of prognosis. Thyroid
differentiated cancer cells express the sodium iodide symporter and
concentrate radioiodine. As the disease becomes more aggressive, they
lose that symporter ability making RAI whole body scan negative
(non-functioning metastasis) but the remnant tumor/metastasis still
secreting Tg. Due to the increase growth rate these cells are detected
by PET 18-FDG Scan and are more amenable to surgical extirpation if
identified. While this process of dedifferentiation between the tumor
cells occurs, patients can have both RAI whole body scan and PET Scan
with positive disease in different anatomical areas of the body.
Combining both localizing studies increase the sensitivity of finding
tumor to 94%. The tall cell variant of thyroid differentiated cancer
associated with a poor prognosis is associated with a positive PET Scan
more frequent that the classic cell type. PET Scans are more sensitive
in patients with low TSH levels. In cases of high TgAb with negative
RAI scan the Tg level even if normal carries a clinical problem of
interpretation and PET Scan can detect recurrence/metastatic disease.
Preoperative PET Scan is not useful for prediction of thyroid cancer
recurrence. Lymph node stage is the only predictor of recurrence. Reference: 1- Elboga U, Karaoglan H, Sahin E, et al: F-18 FDG PET/CT imaging in the diagnostic work-up of thyroid cancer patients with high serum thyroglobulin, negative I-131 whole body scan and suppressed thyrotropin: 8-year experience. Eur Rev Med Pharmacol Sci. 19(3):396-401, 2015 2- Kim H, Na KJ, Choi JH, Ahn BC, Ahn D, Sohn JH: Feasibility of FDG-PET/CT for the initial diagnosis of papillary thyroid cancer. Eur Arch Otorhinolaryngol. 273(6):1569-76, 2016 3- Choi SJ, Jung KP, Lee SS, Park YS, Lee SM, Bae SK: Clinical Usefulness of F-18 FDG PET/CT in Papillary Thyroid Cancer with Negative Radioiodine Scan and Elevated Thyroglobulin Level or Positive Anti-thyroglobulin Antibody. Nucl Med Mol Imaging. 50(2):130-6, 2016 4- Kim SK, So Y, Chung HW, et al: Analysis of predictability of F-18 fluorodeoxyglucose-PET/CT in the recurrence of papillary thyroid carcinoma. Cancer Med. 5(10):2756-2762, 2016 5- Qiu ZL, Wei WJ, Shen CT, et al: Diagnostic Performance of 18F-FDG PET/CT in Papillary Thyroid Carcinoma with Negative 131I-WBS at first Postablation, Negative Tg and Progressively Increased TgAb Level. Sci Rep. 7(1):2849, 2017 6- Salvatore B, Klain M, Nicolai E,et al: Prognostic role of FDG PET/CT in patients with differentiated thyroid cancer treated with 131-iodine empiric therapy. Medicine (Baltimore). 96(42):e8344, 2017 |
| The
terminal ileum is the most distal segments of the small bowel and hosts
many toxic substances including bacteria, viruses, parasites and
digested food. The term acute ileitis describes episodes of right lower
quadrant abdominal pain not identified as acute appendicitis but
participation of the terminal ileum is identified or suspected. It
occurs in 33 cases per 100000 presenting to the ER. The term ileitis
became famous with the recognition of Crohn's disease terminal ileitis.
The diagnosis of acute ileitis is suspected or established with US
and/or CT-Scan. CT-Scan is needed when the child has atypical clinical
findings, equivocal sonographic results or a pediatric surgeon ask for
the study. The causes of acute ileitis include infectious (most common
cause), inflammatory bowel disease and nonsteroidal antiinflammatory
drug therapy. The most common infectious microorganisms causing ileitis
include Yersinia enterocolitica (most common frequent organisms),
Campylobacter jejuni, Salmonella enteritides and Anisakis simplex. They
start with colicky right lower pain followed later by fever and
diarrhea. Stool cultures are false negative. Anisakis infestation is
associated with eating raw, marinated or smoked fish 48-72 hours before
the onset of symptoms. One third of the patients with Crohn suffer from
an acute episode of ileitis. Suspicion of Crohn's ileitis should arise
on a combination of clinical and biochemical findings, imaging data,
absence of alterative diagnosis and history of preceding episodes. With
chronic symptoms of pain and diarrhea an ileal endoscopic biopsy is
warranted. Exposure to nonsteroidal antiinflammatory drugs can induce
ileitis. These lesions respond to discontinuation of the drugs that its
causing it. Almost 20% of acute ileitis cases are nonspecific and a
specific cause cannot be determined. In females gynecological
conditions (uterine disorders, ovarian pathology and pelvic
inflammatory disease) can mimic the symptoms of acute ileitis. US is
the initial preferred imaging study in young females to avoid
irradiating the pelvic organs. References: 1- Garrido E, Sanroman AL, Rodriguez-Gandia MA, et al: Optimized protocol for diagnosis of acute ileitis. Clin Gastroenterol Hepatol. 7(11):1183-8, 2009 2- Koksal AR, Boga S, Alkim H, et al: How does a biopsy of endoscopically normal terminal ileum contribute to the diagnosis? Which patients should undergo biopsy? Libyan J Med. 9:23441, 2014 3- Lin WC, Lin CH: Multidetector computed tomography in the evaluation of pediatric acute abdominal pain in the emergency department. Biomedicine (Taipei). 6(2):10, 2016 4- Sojo Aguirre A, Alvarez Pitti J, Morteruel Arizkuren E, et al: [Terminal ileitis due to Yersinia enterocolitica in infants]. An Pediatr (Barc). 63(6):555-7, 2005 5- Molina Gutierrez MA, Martinez-Ojinaga Nodal E, et al: Acute Terminal Ileitis in Children: A Retrospective Study in Pediatric Emergency Department. Pediatr Emerg Care. 2018 Mar 28. doi: 10.1097/PEC.0000000000001461. 6- Chang YJ, Chao HC, Kong MS, Hsia SH, Yan DC: Misdiagnosed acute appendicitis in children in the emergency department. Chang Gung Med J. 33(5):551-7, 2010 |
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