IAP Textbook of Pediatric Radiology Anoop Verma, M Zulfikar Ahamed, TM Ananda Kesavan, S Venkateswaran, G Vijayalakshmi, Anand S Vasudev, TK Nandakumaran, TU Sukumaran
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IAP TEXTBOOK OF Pediatric Radiologyfm2
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IAP TEXTBOOK OF Pediatric Radiology
Editor-in-Chief Dr. TM Ananda Kesavan Associate Professor of Pediatrics Govt. Medical College, Thrissur, Kerala, India Editors Dr. S Venkateswaran Chief Incharge of Division Neonatology Institute of Child Health and Research Centre Madurai Medical College Madurai, Tamil Nadu, India Dr. G Vijayalakshmi Professor of Radiology Chenglepattu Medical College Chennai, Tamil Nadu, India Dr. Anoop Verma Swapnil Nursing Home and Research Centre Civil Lines, Katora Talab Raipur, MP, India Dr. M Zulfikar Ahamed Professor and HOD Pediatric Cardiology SAT Hospital Govt. Medical College Thiruvananthapuram, Kerala, India Dr. Anand S Vasudev Pediatric Nephrologist 498 Pocket E, Mayur Vihar Phase II New Delhi, India Dr. TK Nandakumaran Professor of Paediatric Surgery Govt. Medical College Thrissur, Kerala, India Executive Editor Dr. TU Sukumaran IAP President 2011 Indian Academy of Pediatrics Kailash Darshan Kennedy Bridge Mumbai, Maharashtra, India Foreword Dr. CP Bansal IAP President 2013 Dr. Rohit Agrawal IAP President 2012 Dr. Sailesh Gupta Honorary Secretary General, IAP
IAP National Publication House, Gwalior
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© 2013, Jaypee Brothers Medical Publishers
All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher.
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This book has been published in good faith that the contents provided by the editors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the editors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the editors. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device.
IAP Textbook of Pediatric Radiology
First Edition: 2013
9789350904275
Printed at
fm5Contributors
  • Anand S Vasudev
  • Pediatric Nephrologist
  • 498 Pocket E, Mayur Vihar Phase II
  • New Delhi, India
  • Email: asvasudev@yahoo.com
  • Anoop Verma
  • Swapnil Nursing Home & Research Centre
  • Civil Lines, Katora Talab
  • Raipur, Madhya Pradesh, India
  • Email: anoopve@yahoo.com
  • G Vijayalakshmi
  • Professor of Radiology
  • Chenglepattu Medical College
  • Chennai, Tamil Nadu, India
  • Email: drviji_rad@yahoo.co.in
  • M Zulfikar Ahamed
  • Professor and HOD, Pediatric Cardiology
  • SAT Hospital, Govt. Medical College
  • Thiruvananthapuram, Kerala, India
  • Email: zulfikarahamed@gmail.com
  • S Venkateswaran
  • Chief Incharge of Division
  • Neonatology Institute of Child Health and Research Centre, Madurai Medical College
  • Madurai, Tamil Nadu, India
  • Email: venkatratha@yahoo.co.in
  • TM Ananda Kesavan
  • Associate Professor of Pediatrics
  • Govt. Medical College
  • Thrissur, Kerala, India
  • Email: dranandiap@gmail.comfm6
fm7Foreword
Dear Readers,
The book that you hold is the fulfilment of the dreams of the doyens of Indian Academy of Pediatrics. For many years, the need for good Indian books in every specialty of Pediatrics was felt. Indian Academy of Pediatrics has no dearth of great teachers and writers in the various subspecialties to author these books. Their dedicated and diligent labor has created the beautiful and eminently readable book that you hold. An Indian book by Indian authors will appropriately suit the needs of the readers in India and in countries with similar geographical and sociocultural milieus. While the first editions of the IAP subspecialty series were published in 2006, we proudly present to you a second, completely revised and updated edition.
The IAP specialty series books serve the purpose of providing evidence based, authentic and uniform information to IAP members, other Pediatricians, and students of Pediatrics in the country. Guidelines and established protocols on disease management will be very helpful for pediatricians in their everyday practice.
Creating a book is like the birth of a baby. Right from conception to delivery, there is a long and complex process. It is very labor intensive, time consuming work that involves considerable financial expense too. To streamline the entire process from writing to editing to publishing to distribution and sales of books, it was envisioned to have an additional wing of IAP, and which is established as “IAP National Publication House” at Gwalior.
Knowledge has no limits and seekers of knowledge can access the subject from anywhere in the world. We understand that books published by IAP NPH will be read and referred not only in India but in many parts of the world. Objective of IAP NPH therefore is to provide standardised content and world class quality. With this objective, printed books are to be made available throughout the globe and distribution will also be done through online editions. Publishing 7 books at a time is a mammoth task and for this we collaborated with second largest medical publisher in the world, i.e. Jaypee Brothers Medical Publishers (P) Ltd., New Delhi.
What you are reading, the world is also reading. Our writers are getting worldwide exposure and readers are getting world class books at reasonable cost.
It needs to be mentioned here that all authors and editors have dedicated the royalty from sale of books to IAP and have thereby done a selfless service for our mother organisation. By buying this book you are also contributing to IAP in a significant manner.
Finally, we express our pride and happiness in being associated with this project and in reaching this valuable book to you. We wish you a happy and contented reading.
Dr CP Bansal
IAP President 2013
Dr Rohit Agrawal
IAP President 2012
Dr Sailesh Gupta
Honorary Secretary General, IAP 2012-13fm8
fm9Preface
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 Teamfm10
fm11Acknowledgments
I acknowledge the constant support and encouragement provided by the Executive Committee (2011) of the Indian Academy of Pediatrics for the initiation and completion of this venture to develop a unique clinical textbook on Pediatric Radiology.
I would also like to acknowledge the support and encouragement extended by our IAP National President Dr TU Sukumaran. I appreciate all the section editors who contributed their topics well ahead of time and made this project a reality. Special thanks to Dr S Venkateswaran, Dr G Vijayalakshmi, Dr Anoop Verma, Dr M Zulfikar Ahamed, Dr Anand Vasudev and Dr TK Nandakumaran who contributed different chapters of this book. I would like to express my sincere gratitude to Dr S Venkateswaran, and Dr G Vijayalakshmi who had given advice and encouragement in all the phases of development of this book.
TM Ananda Kesavanfm12fm13fm14
fm15Introduction
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 need 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 as 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 MR 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.
fm16It 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.