IAP Textbook of PEDIATRIC RADIOLOGY
IAP Textbook of PEDIATRIC RADIOLOGY
Second Edition
Editors-in-Chief
TM Ananda Kesavan MD (Pediatrics) DNB MNAMS FIAP FIAMS FRCP (Edinburgh) PGDDN (Postgraduate Diploma in Developmental Neurology)
Additional Professor Department of Pediatrics Government Medical College Thrissur,
Kerala, India
S Venkateswaran MD (Pediatrics) DCH DMRD
Former Professor of Pediatrics Madurai Medical College Former Chief-in-Charge of Division of Neonatology Institute of Child Health and Research Center Madurai Medical College and Government Rajaji Hospital Madurai,
Tamil Nadu, India
Editors
Mona D Shastri MD (Radiodiagnosis)
Professor and Head Department of Radiodiagnosis SMIMER Surat,
Gujarat, India
G Vijayalakshmi DMRD DNB PhD Professor and HOD
Department of Pediatric Radiology and Imaging Institute of Child Health & Hospital for Children Chennai,
Tamil Nadu, India
Anoop Verma MD FIAP FCGP FIAMS FPAI Director
Swapnil Institute of Child Health Raipur,
Chhattisgarh, India
M Zulfikar Ahamed MBBS DCH MD (Pediatrics) DM (Cardiology)
Senior Consultant Pediatric Cardiologist KIMS Hospital Thiruvananthapuram Professor of Cardiology Pushpagiri Medical College, Thiruvalla Clinical Professor of Pediatric and Adolescent Cardiology Child Development Center Thiruvananthapuram,
Kerala, India
Anand S Vasudev DNB DPed MNAMS FIAP FIMSA Senior Consultant, Pediatric Nephrology
Department of Pediatrics Indraprasth Apollo Hospital, Max Hospital
New Delhi, India
TK Nandakumaran MBBS MS MCh Professor
Department of Pediatric Surgery Government Medical College Kannur,
Kerala, India
Manish Kumar MD (Pediatrics) ISPN Fellow Pediatric Nephrology Associate Professor
Department of Pediatrics Chacha Nehru Bal Chikitsalaya
Delhi, India
Kavita Menghani MBBS DCH Consultant Pediatrician
Dr Kavita Menghani Clinic Raipur,
Chhattisgarh, India
Pulak Parag MS (General Surgery) MCh (Pediatric Surgery)
(Freelance) Senior Consultant Pediatric Surgery Raipur,
Chhattisgarh, India
Executive Editors
TU Sukumaran MD MNAMS FIAP MPhil PhD Head,
Department of Pediatrics Pushpagiri Institute of Medical Sciences Thiruvalla,
Kerala, India
Digant D Shastri MD (Pediatrics) FIAP PGDHHM President,
Indian Academy of Pediatrics Member, Standing Committee International Pediatric Association 2019-21 Managing Editor Asia Pacific Journal of Pediatrics and Child Health Mumbai,
Maharashtra, India
Foreword
Digant D Shastri
Jaypee Brothers Medical Publishers (P) Ltd
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
New Delhi 110 002, India
Phone: +91-11-43574357
Fax: +91-11-43574314
Email: jaypee@jaypeebrothers.com
Overseas Offices
J.P. Medical Ltd
83 Victoria Street, London
SW1H 0HW (UK)
Phone: +44 20 3170 8910
Fax: +44 (0)20 3008 6180
Email: info@jpmedpub.com
Website: www.jaypeebrothers.com
Website: www.jaypeedigital.com
© 2020, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission in writing of the publishers.
All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book.
Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contraindications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.
This book is sold on the understanding that the publisher is not engaged in providing professional medical services. If such advice or services are required, the services of a competent medical professional should be sought.
Every effort has been made where necessary to contact holders of copyright to obtain permission to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be pleased to make the necessary arrangements at the first opportunity. The CD/DVD-ROM (if any) provided in the sealed envelope with this book is complimentary and free of cost. Not meant for sale.
Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com
IAP Textbook of Pediatric Radiology
First Edition: 2013
Second Edition: 2020
9789389188974
Printed at
All those stalwarts of Indian Academy of Pediatrics, who strived hard and relentlessly to build the organization to international standard.
- Anand S Vasudev DNB DPed MNAMS FIAP FIMSA
- Senior Consultant, Pediatric Nephrology
- Department of Pediatrics
- Indraprasth Apollo Hospital, Max Hospital
- New Delhi, India
- Anoop Verma MD FIAP FCGP FIAMS FPAI
- Director
- Swapnil Institute of Child Health
- Raipur, Chhattisgarh, India
- G Vijayalakshmi DMRD DNB PhD
- Professor and HOD
- Department of Pediatric Radiology and Imaging
- Institute of Child Health & Hospital for Children
- Chennai, Tamil Nadu, India
- Kavita Menghani MBBS DCH
- Consultant Pediatrician
- Dr Kavita Menghani Clinic
- Raipur, Chhattisgarh, India
- M Zulfikar Ahamed MBBS DCH MD (Pediatrics) DM (Cardiology)
- Senior Consultant Pediatric Cardiologist
- KIMS Hospital, Thiruvananthapuram
- Professor of Cardiology
- Pushpagiri Medical College, Thiruvalla
- Clinical Professor of Pediatric and Adolescent Cardiology
- Child Development Center Thiruvananthapuram, Kerala, India
- Manish Kumar MD (Pediatrics) ISPN Fellow Pediatric Nephrology
- Associate Professor
- Department of Pediatrics
- Chacha Nehru Bal Chikitsalaya
- Delhi, India
- Mona D Shastri MD (Radiodiagnosis)
- Professor and Head
- Department of Radiodiagnosis
- SMIMER
- Surat, Gujarat, India
- Pulak Parag MS (General Surgery) MCh (Pediatric Surgery)
- (Freelance) Senior Consultant
- Pediatric Surgery
- Raipur, Chhattisgarh, India
- S Venkateswaran MD (Pediatrics) DCH DMRD
- Former Professor of Pediatrics
- Madurai Medical College
- Former Chief-in-Charge of
- Division of Neonatology
- Institute of Child Health and
- Research Center
- Madurai Medical College and
- Government Rajaji Hospital
- Madurai, Tamil Nadu, India
- TK Nandakumaran MBBS MS MCh
- Professor
- Department of Pediatric Surgery
- Government Medical College
- Kannur, Kerala, India
- TM Ananda Kesavan MD (Pediatrics) DNB MNAMS FIAP FIAMS FRCP (Edinburgh) PGDDN
- (Postgraduate Diploma in Developmental Neurology)
- Additional Professor
- Department of Pediatrics
- Government Medical College
- Thrissur, Kerala, India
- TU Sukumaran MD MNAMS FIAP MPhil PhD
- Head, Department of Pediatrics
- Pushpagiri Institute of Medical Sciences
- Thiruvalla, Kerala, India
Indeed it is proud privilege for me to write the foreword for the 2nd Edition of IAP Textbook of Pediatric Radiology.
Recent growth in the field of diagnostic radiology has dramatically increased the complexity of this field. Diagnostic imaging has become widely available and plays an increasing role in diagnosis and therapy.
With availability of many modalities and availability of radiology facilities at district and taluka places at time it is found that it leads to the ordering of incorrect imaging studies, duplication of orders, unnecessary requests for follow-up imaging, too many exam orders, and other problems. The risk of radiation hazard is also to be kept in mind while submitting children for any radiological investigations.
Child health and well-being are the core areas of mission statement of Indian Academy of Pediatrics and for that IAP is involved in knowledge upgradation of pediatricians through organizing CMEs, conferences, workshops and publishing books. Earlier IAP Textbook of Pediatric Radiology was published in 2013 and was found to be very successful and popular amongst pediatricians. With the recent growth in the field of diagnostic radiology, it was necessary to publish the second edition of IAP Textbook of Pediatric Radiology.
As president of IAP I am happy that editorial team led by Dr TM Ananda Kesavan and Dr S Venkateswaran worked hard to bring this second edition. The book is written, with general pediatricians in mind, as an alternative to the traditionally large (and hard to learn) reference textbooks. This book does not detail the literature of all disease processes. Instead, it is focused on the most common clinical scenarios encountered in daily practice. It also includes practical imaging techniques and protocols used to address common problems, and can give readers easily accessible tools to aid in reaching a specific diagnosis.
I congratulate the editorial team and contributors and thank them for their contribution. I am sure it will be proved as one of the most popular publications of IAP.
Digant D Shastri MD (Pediatrics) FIAP PGDHHM
President, Indian Academy of Pediatrics
Member, Standing Committee
International Pediatric Association 2019-21
Managing Editor
Asia Pacific Journal of Pediatrics and Child Health
Mumbai, Maharashtra, India
Preface to the Second Edition
“Retain the past and Refresh with new” is the concept we have adopted in this edition. Since the first edition is a Master edition with the excellent proposition of chapters and topics, the essential style and format have been retained and we have added few interesting topics and case scenarios. As a face lifting to previous edition, Dr Mona D Shastri has presented an excellent start up writing about the discovery and evolution of X-rays. Also she has given an outline of radiation hazards, types of X-rays and most important radiographic positions in pediatrics which is easy to understand by any pediatrician. Since the X-ray chest is the most commonly utilized investigation, the advent of Digital chest X-ray and respiratory clinical case scenarios added by Dr S Venkateswaran is an important practical addition in this text. The cardiovascular system by Dr M Zulfikar Ahamed is face lifted by addition of interesting X-rays and cases. The add up cases in Bone and Metabolic diseases by Dr G Vijayalakshmi elevates the chapter to completion. The additional insertion of case scenarios by Dr TM Ananda Kesavan adds color to this edition.
Although many of us are comfortable with new imaging modalities and contemporary techniques, it is not possible with all the patients and with all the pediatricians. The approach in this book provides an effective and cost containing evaluation in a medical environment beset with financial constraints and unfamiliar imaging modalities. For this reason, the text is additionally and especially suited to pediatricians practicing primary care pediatrics and emergency room pediatrics.
We have tried to limit all changes to those that are truly significant in a practical sense, rather than change for the sake of change. It is our hope and belief that a pediatrician with the content of this book will be able to approach sick children professionally with skill and confidence. We hope that this book meets our goals, and we remain grateful for any comments and criticisms that our readers may wish to offer.
TM Ananda Kesavan
S Venkateswaran
Preface to the First Edition
The aim of this Textbook of Pediatric Radiology is to provide valid and vibrant information to practicing pediatricians at all levels especially who are dealing with level one care.
It is an undeniable fact that pediatric radiology differs from adult radiology and many a time even many of the general radiologists and even few of the so called pediatric radiologist may find it difficult to interpret and may feel uncomfortable in arriving at a final diagnosis.
We as pediatricians have an additional advantage of approaching the child based on well-defined clinical symptoms which may suggest limited differential diagnosis and also taking the child's age into consideration, diagnostic possibility may be best explored and our vision may be narrowed down sharply towards better radiological diagnosis.
We have carefully concentrated more on the conventional, day-to-day method of basic radiological approach and restricted our approach to the unfamiliar imaging techniques.
In a true practical sense, the images given and the approaches aimed will be most useful to all of the pediatricians especially in the Indian context of restrained financial background and thus burden of investigation may not be much felt by the parents of sick children.
We have carefully dealt with the most of the acute conditions which are commonly seen in our outpatient clinic, pediatric casualty, PICU, NICU and in our day-to-day chamber practice.
We, the contributors will feel extremely happy if you are able to make a valid diagnosis after going through book and that ray of hope when radiated from you will be the day of success for this book.
The Editorial Team
Acknowledgments
With deep gratitude we acknowledge the Past National President of IAP Dr TU Sukumaran who whole heartedly supported and encouraged us to come out with a book in Basic classical X-rays in pediatrics. We are also very much pleased to acknowledge the current National President Dr Digant D Shastri for his encouragement extended to go for Second edition of this book. We very much appreciate all the editors of various chapters of this book, Dr Mona D Shastri, Dr G Vijayalakshmi, Dr Anoop Verma, Dr M Zulfikar Ahamed, Dr Anand Vasudev, Dr TK Nandakumaran, Dr Manish Kumar, Dr Kavita Menghani, and Dr Pulak Parag who have contributed much to revise this edition to the level of current requirement.
TM Ananda Kesavan
S Venkateswaran
Abbreviations
ACHD
Acyanotic Congenital Heart Disease
AHD
Acquired Heart Disease
ALCAPA
Anomalies Left Coronary Artery from Pulmonary Artery
AP
Anteroposterior
AP Window
Aortopulmonary Window
AR
Aortic Regurgitation
AS
Aortic Stenosis
ASD
Atrial Septal Defect
AVSD
Atrioventricular Septal Defect
BT Shunt
Blalock Taussig Shunt
CCHD
Congenital Cyanotic Heart Disease
CDH
Congenital Diaphragmatic Hernia
CHD
Congenital Heart Disease
CoA
Coarctation of Aorta
CR
Computerized Radiograph
CTR
Cardiothoracic Ratio
DCM
Dilated Cardiomyopathy
DILV
Double Inlet Left Ventricle
DORV
Double Outlet Right Ventricle
DR
Digital Radiograph
d-TGA
d-Transportation of Great Arteries
HAPVC
Hemi Anomalous Pulmonary Venous Connection
HLHS
Hypoplastic Left Heart Syndrome
HMD
Hyaline Membrane Disease
IDPA
Idiopathic Dilatation of Pulmonary Artery
IVC
Inferior Vena Cava
LA
Left Atrium
LAE
Left Atrial Enlargement
LPA
Left Pulmonary Artery
L-TGA
L-Transposition of Great Arteries
LV
Left Ventricle
MAPCA
Major Aortopulmonary Collateral Arteries
MPA
Main Pulmonary Artery
MR
Mitral Regurgitation
MRI
Magnetic Resonance Imaging
MS
Mitral Stenosis
PA
Posteroanterior
PAH
Pulmonary Arterial Hypertension
PAWP
Pulmonary Artery Wedge Pressure
PBF
Pulmonary Blood Flow
PDA
Patent Ductus Arteriosus
PEM
Protein Energy Malnutrition
PR
Pulmonary Regurgitation
PS
Pulmonary Stenosis
PV
Pulmonary Vein
PVH
Pulmonary Venous Hypertension
PVOD
Pulmonary Vascular Occlusive Disease
RA
Right Atrium
RAE
Right Atrial Enlargement
RDPA
Right Descending Pulmonary Artery
RPA
Right Pulmonary Artery
RUPA
Right Upper Pulmonary Artery
RV
Right Ventricle
RV EMF
RV Endomyocardial Fibrosis
RVH
Right Ventricular Hypertrophy
RVOT
Right Ventricular Outflow Tract
SVC
Superior Vena Cava
TA
Tricuspid Atresia
TAPVC
Total Anomalous Pulmonary Vein Connection
TOF
Tetralogy of Fallot
VSD
Ventricular Septal Defect
Introduction
X-rays are most commonly used radiological investigation all over the world. Most of us are very familiar with chest X-rays (for many people X-ray means X-ray of chest!), because we can interpret it easily, freely available, cheap, and one can repeat it. The only disadvantage is the risk of radiation.
X-rays were discovered way back in 1825 and even now its use has not dimmed. X-rays are electromagnetic radiations. They are produced in a cathode ray tube where fast moving electrons from a filament strike a tungsten anode and the energy is converted into X-rays. When X-rays pass through the body they are absorbed to varying amounts, bone absorbing the most. The X-rays that exit the body are made to form an image on X-ray film, on an activated cassette (computerized radiography) or is directly digitized and is viewed on a computer (digital radiography). The image obtained of the body shows the internal body structures in white, black and shades of gray. Air is black in color as it is least dense, has not absorbed any radiation, and allows the X-rays to pass through easily. Bone and metal are white as they are very dense. Soft tissues like liver and spleen and fluid that may accumulate in the pleural cavity appear white, but not as densely white as bone.
Fluoroscopy using an image intensifier allows real-time imaging using X-rays. In this, the image is intensified and put on a TV monitor. This imaging is useful when motion in internal organs needs to be studied, e.g. respiratory motion in obstructive emphysema. Since radiation dose is high in this, intermittent rather than constant radiation exposure is used.
Fluoroscopy is also used for contrast studies. In this, an opaque medium like barium is used to line and fill hollow internal viscera. Barium is very dense and absorbs X-rays, thus appearing white. Barium can be ingested in Barium swallow and meal or can be instilled into the rectum and colon for a barium enema study. Air is also used as a contrast medium as in double contrast enema for rectal and colonic polyps. Barium enema is given, then evacuated and air is instilled into the colon under fluoroscopic guidance. This clearly brings out barium-coated white mucosal lesions against the black background of air.
Angiography is the study of blood vessels. The contrast media used here are iodine compounds. A peripheral artery is catheterized and contrast is injected into the required branches. Images are timed and taken rapidly and fine vascular detail is obtained in the X-rays. Computerized tomography of blood vessels uses contrast medium, but without invasive catheterization. In magnetic resonance angiography, blood vessels can be studied even without contrast, by computer manipulation.
The quest for better images and more precise diagnoses has led to rapid advancements in the field of radiology. The wide spectrum of modalities that are available in present times, enable us to study the morphology and function of the human body in explicit detail. However, in children almost 75% of questions arising from clinical problems are solved by X-rays and ultrasound. Even when other techniques are used, the X-ray usually serves as guidance to the choice of the next investigative modality (e.g. mediastinal masses discovered in chest X-ray is followed by CT). So X-rays need to be interpreted correctly. This book focusing only on X-ray radiography is a sincere effort aimed at sharpening the X-ray reading skills that will help in solving the majority of daily clinical problems.
It may be felt that imaging is now playing a large part in clinical diagnosis and that final diagnoses are obtained from imaging. While this may be true to a certain extent it should be remembered that clinical history and examination is the base and images have to be interpreted on the basis of clinical findings. Sharpening X-ray interpretation skills will help in mastering the use of the primary investigative modality that will help in diagnostic evaluation and treatment, ultimately for the benefit of the patient.