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Chapters
Case- Ingested Foreign Bodies- Coins | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Coins | OMG: Interesting Cases in Pediatric Radiology
chapterRemoval of penny from esophagus endoscopicallysuspected possible reflux disease
Case 6: Pelvic Fracture | Emoblization: Bleeding and Trauma
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
chapterday 3 pain reappearsdischarged with instructions that object would pass in stoolfeverguardingIV fluidsobservationpalerebound tendernessrigid abdomensurgical consult obtained.vomiting
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies- Magnets | OMG: Interesting Cases in Pediatric Radiology
Abdominal US suggests appendicitischapterGastroenteritisrebound tendernessWorsening pain
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
Case 10: Peritoneal Hematoma | Emoblization: Bleeding and Trauma
chaptercoilembolizationmicrocatheterPeritoneal hematoma
Case- Vaginal Foreign Bodies- 11 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 11 year old female | OMG: Interesting Cases in Pediatric Radiology
chapterHysterotomy finds golf tee in uterusobject foundsuspicious of UTI
Case- Vaginal Foreign Bodies- 10 year old female | OMG: Interesting Cases in Pediatric Radiology
Case- Vaginal Foreign Bodies- 10 year old female | OMG: Interesting Cases in Pediatric Radiology
chapterMRI showed a smooth image in upper vaginaobject foundvaginal adhesion hiding the cervix
Case 7: Retroperitoneal Hematoma | Emoblization: Bleeding and Trauma
Case 7: Retroperitoneal Hematoma | Emoblization: Bleeding and Trauma
chaptercoilsembolizationmicrocatheterRetroperitoneal hematoma due to a transverse process fracture
Case- Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
Case- Ingested Foreign Bodies | OMG: Interesting Cases in Pediatric Radiology
bowel restchapterIngestion of a piece of wire bristle from BBQIV antibioticslaparoscopic explorationPain continuespain palliationsurgical removal recommended
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
Case 5: Liver Trauma | Emoblization: Bleeding and Trauma
chaptercoilsembolizationLiver Traumamicrocatheter
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
Case 11: Bleeding Tracheostomy Site | Emoblization: Bleeding and Trauma
Bleeding from the tracheostomy sitechapterCoverage Stentembolization
Case- Not all wheezing is asthma | OMG: Interesting Cases in Pediatric Radiology
Case- Not all wheezing is asthma | OMG: Interesting Cases in Pediatric Radiology
antibioticschapterminimal peribronchial thickeningneb treatmentsno pneumonia or air trappingpost tussive emesissteroids
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
Case 9: Embolizing a Pseudoaneurysm Rrising from the Branch of the Inferior Epigastric Artery | Emoblization: Bleeding and Trauma
chaptercoilembolizationmicrocatheterPseudoaneurysm arising from the branch of the inferior epigastric artery
Transcript

good morning everybody and I'm always excited when there's pediatric content anywhere so when Nancy Michelle and I were we're talking we were trying to figure out a topic and I had some experience with some foreign bodies in MRI and such in my experience so we

thought it would be interesting to talk about interesting cases in pediatric radiology okay our objectives for today are to identify potential risk factors that present in Pediatric Radiology patients discuss some pre screening

assessments for common pediatric comorbid conditions using a case base case based methodology and reviews and radiologic images of unique pediatric cases so we know that kids have a tendency to put things into small

objects into their mouths and other or orifices their nose their ears their vaginas so we are going to be discussing some cases throughout this presentation and we know that kids not only ingest objects but they also insert them and

they may actually inhale them as well most of these objects will pass spontaneously 10 to 20 percent of those that they swallow will require removal by endoscopy and about 1% require surgical removal and why is this a

problem with kids we know that kids are in the oral phase of development so they their teeth are not formed so they have inadequate dentition so they can't chew things so those pieces of hotdog those peanuts and and such are difficult for

them to chew which we know is the first phase of digestion their epiglottis is higher so it can make it more difficult for them to swallow and they have immature swallowing coordination so hence things are more likely to get

stuck so the incidence of foreign bodies is about six months to four years of age makes sense there's a slight predominance of males I can tell you I have a son and a daughter my daughter never put anything in her mouth or nose

or whatever but my son was certainly broke that record there's a slight predominance of males the most common objects are coins earrings marbles barrettes and rocks and objects that are typically longer than five centimeters

or greater than two centimeters in diameter are less likely to pass through the pylorus which makes sense and most pass within four to six days but some take up to four weeks of ingestion so why do we need radiologic imaging so

x-rays we know that the object would have to be radio opaque to be visualized on x-ray we know there's a challenge in cooperating for expiratory films and I'll talk about that in a couple of more slides we want to avoid CT scan if

possible because of the radio the exposure but ultrasound is really up and coming in terms of determining the location and the status of the object and provides dynamic imaging when you're thinking about foreign body foreign body

ingestion so ingestion versus aspiration foreign body aspiration is the fifth leading cause of death among one to three year olds and the primary cause of unintentional death in infants so the initial choking episode may be

unwitnessed it doesn't take very long for it for a six-month-old who's sitting up to grab something and put it in his mouth and toys pieces of toys account for ninety percent of these cases there's often a delay in diagnosing

these cases in patients that have a history of asthma croup or pneumonia because they always COFF so when they have an episode of coughing say oh it just must be the start of an asthma flare not thinking about foreign body

aspiration in the mix and of course early and up too late complications maybe it's fixing cardiac arrest dis Nia and laryngeal edema because as I said the epiglottis is high those Airways are narrow so there can be swelling

they swallow or ingest something and not

know if they know more how to work an iPhone than I do so they also know how to disconnect things as well kids with attention-seeking behavior and

that will come into play a little further in our presentation forty percent of all foreign body ingestions are unwitnessed so which is kind of scary so history is important but sometimes we don't always have a history

of what happened and diagnosing and treating early and disposing of used batteries because even the used batteries can still cause damage so kids less than age three years have with a vague history of foreign body ingestion

where they've been to the ER before force ingesting something and if they have a suggested suggestive chest x-ray should be presumed to have a foreign body of a lithium button battery and treated managed very quickly and those

patients with the button batteries often get IV steroids before and after and that can help to improve the outcomes but obviously that we need more research okay I'm gonna pass the mic over to Michelle who's gonna move on further

we're gonna move on to coins and other metallic objects so coins are the most commonly ingested for our body in children other things that we see pretty often are needles safety pins straight pins earrings keys screws and toys keys

obviously we've already seen here and toys the signs and symptoms can vary a lot of times we'll see vomiting drooling dysphasia difficulty swallowing the feeling of having a lump or stump something lodged in their

throat and then the respiratory symptoms of coughing choking and stridor but what we really need to remember is sometimes there are no symptoms at all especially initially so our first case today is a four year old who comes into the

emergency room for the third time she has vomiting of undigested food an Associated weight loss she's been to the this is her third visit the first two she was giving fluid challenges tolerated those and was sent home with a

GI visit scheduled for the future to work her up for possible reflux disease one physical exam now this has been going on for months she is now severely wasted she's three years old she weighs ten kilos she's below the point four

percentile she is on the threshold of severe malnutrition although she has no other physical signs that would lead to an underlying disease process but in all of this the only imaging they had gotten in the prior edie visits was abdominal

injury imaging nobody ever thought to do a chest x-ray because she didn't have any respiratory symptoms so lo and behold here's the circular dense object just below the clavicles and it as Laurie talked about with the button

batteries they can tell or highly suspect that this is a coin because there's no rim around it so on further evaluation and talking to this child and really asking her she did admit to swallowing a coin in the summer but

hatton told anybody because she was afraid she would get in trouble so as Laurie said they're often 40% unwitnessed so we don't know that it's happened and even when you ask they may be apprehensive to share that

information with you so a lot of times it's about the verbage you know making it friendly and it's okay we just want to know what's making you sick or we want to make you feel better so have you you know

eaten anything unusual did you accidentally swallow something that maybe you shouldn't have so that we're not scaring these kids she had this removed and escaped eclis without complication she had a great

recovery and there are before-and-after pictures it's pretty amazing that it could actually have gotten that far without a further evaluation with that kind of weight loss the take-home points for this would be that retained

esophagus foreign bodies are common in the emergency room Department but most often they present with little diagnostic difficulty however the signs and symptoms you're seeing may not reflect what's actually happening and in

young children they may not be forthcoming with the history it may not be witnessed they may not be willing to share so you really have to dig and there is a need for a low threshold of suspicion to avoid diagnostic delay and

potential complications with timely treatment so we're going to move on to

patient 40s year-old patient again car accident lower abdominal pain and bruising so it sounds like you guys can appreciate that's an injury alright so we'll move past that so here's a CT scan these are four separate images from the

same patient CT scan and it is a bit more subtle I'm not suggesting it's easy to see you know we can appreciate the injury but one thing that you should be able to notice again is that concept of symmetry so when our residence or even

myself or anybody reads a cat scan we always want to kind of appreciate all the differences in the symmetry that we're seeing and so what you can see here is especially on that upper left hand side you can see the penis coming

out of the patient almost coming out of the patient and if you just draw a line straight back from there you should notice that there's a bit more tissue on the left side of the patient than the right side of the patient but that's

what we're looking at and if you go to the image over to the right the top right image right at that same area there's a little bit of a white blush which just shows that there is some bleeding going on there and if you look

at the third image which is the one on the bottom left right below one of the bones or there's another area of a white contrast collection or bleeding all right you can maybe see that again on the fourth image so that's what we're

looking for on the CT that asymmetry or the thickening of the tissue and we're looking for an escape of some contrast from where we should expect it to be all right so many of these patients will be

unstable those are the patients that probably need to go right to the or but for the patients who are really you know doing okay we have a chance to intervene on them and the reason why that's important is the more unstable they are

the higher the chance of mortality especially with the pelvic fracture so pelvic fractures are a big deal if you have a hemodynamically unstable patient with a pelvic fracture that's something to take very seriously

all right many of these patients will get CTS or C if we see extravasation they often come to us for angiography so here's the angiogram again a great example if you only look at one picture or two pictures

you're not going to see the problem all right so if you look at the first two pictures you really don't see anything I would I would argue it looks normal but as you get to that third picture you see that kind of collection of contrast

on the bottom right-hand side of the picture all right that's why you need to look at all the pictures of the and reom not just one picture you watch them it's like watching a

little movie now you just stand there and watch it over and over again I get a sense of what it looks like at the beginning middle and end of the angiographic run or set of images the other thing is it's very hard to see

extravasation of contrast when you're in the aorta so many times we do an aorta gram we take some pictures and we may or may not see anything but if we know there's a pelvic fraction we know it's more on the left side we'll go into the

left internal iliac artery and do a more selective angiogram and here's a picture of that selective angiogram and now you can see the extrapolation even more clearly hopefully you can all see it the bottom kind of leftish part of the image

all right here's a more selective now we say okay we definitely see something now we're going to get a little bit further into the system here's a picture now it's very clear you can go if you don't see it all right so you should see it on

the bottom all right and now our goal is to just get as close as we can and so we got all the way down then we put some coils there and again our goal is to make sure that we get just into the vessel that we treat and embolize it now

people will say what agent should we use do we use gel foam do we use particles do we use coils do we use glue or onyx the truth is you can you can really use anything but the thing with the most control so for trauma we tend to use

coils for trauma alright because our goal is to deposit an embolic agent right at the site of the injury that's our goal if we use particles we don't have as much control or a liquid we don't have

as much control they could go somewhere we don't want it to go all right here you're dealing with the blood supply of the penis the rectum the bladder other things which you know most of us would prefer not be injured during an

angiogram all right so we don't want to do something that we don't have complete control over and coils give us that type of control

so on to case number two so this is a three-year-old child and you can see

very clearly he comes to the IDI and he said 24 hours of pain vomiting he's a febrile doesn't look like he's ill at all and in this case the mother recognizes this this is a little stick magnetic stick from a construction type

of toy so so it's one single piece so he's admitted for eight hours of observation just to be conservative they give him IV fluids he begins to improve he's not vomiting he's not having any pain anymore he sent home with

instructions letting them know that this should pass eventually through his stool and two days post-op on follow-up he's back at baseline as far as playing he's eating normally and everything seems fine then on day three he started to

have abdominal pain again and you can see his white blood Khaled cell count went up he's now has a rigid abdomen he's guarding and he's having a lot of pain so they decide to do a surgical consult

okay so now we see this same object right it's moved which is what should happen but there's all this free air now all around it which is different so they begin to do some IV fluid resuscitation and he's emergently taken to the or so

he had two perforations in the jejunum and what had happened was those pieces of magnet were actually covered by this outside covering and that piece that looked like it was one piece was actually five individual magnets so

inside of the GI system the whole covering basically II rotate and then these little magnets some of them stuck together but they started moving and you can see how small they are and so that's why he had those major

complications so this is one situation where we thought that there was just one magnet but in reality they were multiple so in a sense you know this has come up as an issue there's not a lot of big Studies on this because it doesn't

happen that frequently but there was one good review that was done and this was done a few years ago where looked at 80 some odd cases and they used to children's hospitals and they just tried to find out so you know what happens in

terms of the progression of the the ingestion so again 56 percent were males not a surprise that that happened and I want you to note the age so about eight years old you know you kind of start thinking maybe they would know better

but I guess not so the age I never really think too much about age as much I had some really bad ingestions with people that were developmentally normal that were 14 and 15 years old and then the other thing you need to note 67% had

multiple magnets or they had a magnet and also ingested another metallic object so there's a CO ingestion there and those definitely were the situations where they were more likely to have to have some surgical type of procedure

because there were difficulties so 39 not many presented with symptoms and the most common one was abdominal pain and that could be just about anything and so 53% initially did not have operative management and of those 38 of them 37

percent failed it and then they've 47% had an endoscopy or they would have endoscopy and surgery combination so the take home the ingestion think about magnet ingestion a lot of people don't just because the magnets are hidden in a

lot of different toys and it is definitely a problem and that could become emergent so based on that study there's now an algorithm that basically has you be somewhat watchful but to go ahead and basically unless you're a

hundred percent certain assume that there's more than one magnet there and they're more likely to actually take them to have a procedure to remove it another thing to think about there's a few articles about

this about using handheld metal detectors not just for magnets but for other metallic objects and this it can be used in the emergency department so this is just a commercial type of handheld detector and this could be

maybe the parent is refusing to have an x-ray or the child is you know really difficult to get you know any sort of cooperation to do it or it's gonna take a really long time to get this x-ray so a few places have used this to be able

to just do a quick identification and localization of whether or not there's a metal object so I don't know if any of your places are using this but if you do some things to know first of all it is not fda-approved for this purpose but

they are medical grade because they're the same ones that are approved to be used when you go through TSA so it's not going to be harmful so you want to put the child in the center of the room away from metal objects they can't have any

zippers or clasp or anything like that and you want to ask them to put their hands up in this way and then we're wandering from the top all the way down to the pubis looking for any type of sounds okay it's bizarro or bizarro

we're gonna move on I have Nancy for the

final piece good morning everybody so I'm going to start with attraction the attraction of magnets that children seem to have so you can see here on the right that the incidence of these types of ingestion is relatively low but what you

need to know is that there's been a major increase in the number of times that we see this because there's so many toys and other objects that contain magnets in them and the magnets that are in there are extremely high-powered so

just because it's a small magnet doesn't mean that it's less of a problem so as you can see there are packaged warning labels on them but a lot of people still don't really actually I think believe that ingesting a magnet can be fatal but

there have been several fatalities and children from magnet ingestions and this is just really cool-looking puzzle I would be attracted to it if I was a child but this contains over 200 magnetic balls in there so I like x-men

so I'm calling this the case of magneto so this is a ten year old boy with a one-day history of recurrent vomiting who basically had some abdominal pain which is you've heard multiple times this is a very common presentation and

he had some abdominal tenderness so they started treatment for gastroenteritis which seemed totally appropriate but then his pain got worse and he started to have rebound tenderness so of course they're thinking

maybe appendicitis they did in a abdominal ultrasound and then they got the x-ray and then they got the x-ray there we go any guesses on what this is like a bracelet right like a little small brace

that's what I thought when I saw this so when you see that what type of material do you think this could be if you're thinking it's a bracelet yeah like a hard plastic right so obviously we're talking about magnets so here you go

foreshadowing not really it's a magnet but when you would first look at it I think you would think maybe hard plastic or some sort of jewelry some sort of that type of metal so they took him to the operating room and this is the

segment that they took out he had one of those rainbow magnet puzzles that I showed you at the beginning so when they removed it they found 16 separate little magnet balls so what people don't understand about the magnets is when

they travel through the GI system they continue to attract each other so in this situation you can see here that there is a fistula that's developed and that's because two magnets were on the opposite side of bowel and so they

attract each other and they pressed together this can cause perforations this can cause fistula x' and this can cause necrosis of those parts of the intestine and so in this case he had seven

fistulas several perforations and they had to actually remove part of his ileum because he had so many of them and then just because this poor child he's never gonna or he or she he will never do this again he had a wound

infection afterwards so this became a very complicated thing so he's in the hospital for quite a while but was able to be discharged successfully so the question comes up about well if the problem is that there are two magnets

that attract each other and that's what causes a problem then if there's a single magnet then in theory that shouldn't be an issue it should be able to pass so when you look at some of the algorithms for treatment of magnets

it'll say that if you believe that it's a single magnet that we should attempt to let it pass so that's sort of the conventional wisdom for it

go through some more cases foreign body aspiration 20 month old has a two-day history of fever fussiness non-productive cough and he's not eating quite so much his Pio intake is

decreased chest x-rays is obtained and it's unsure if it's left lower lobe atelectasis versus pneumonia and his condition gets worse so they decide to do a CT scan of the chest and note that there's a point 5cm by 0.4 cm object

obstructing the left mainstem bronchus so the next step is wrong kosgeb II to see what's in there and you could see on the let's see we could see an uncooked pinto bean was removed on bronchoscopy so so obviously uncooked being a little

harder than it being soft being cooked and softer and these I thought these were very interesting images the one on the left is a CT scan of the paranasal sinuses and you could see on the arrow that there's a button battery which I'm

going to talk about in a few moments button battery in the right NER and a used eraser piece of eraser in the left narrow our middle picture here is a raid there's a radiopaque foreign body in the left mainstem bronchus which is a peanut

right here in the airway and here is a fish bone that's in the hypopharynx and that's just on a plane neck x-ray so you could see all different foreign bodies

let's move on here is another patient who took a fall skiing we see a lot of these patients up in upstate New York and they presented with severe left-sided abdominal pain and here's the cat scan

all right who's up for it what do you think what looks bad you look like you're into it what do you think yeah the right the bottom right-hand side of the picture should be spleen and it just looks like a big pool of blood that's

pretty good you did pretty good spleens a little higher so we're gonna presume spleen is there Graham this is just one image one slice through the picture through the body so we're just not at the level of the spleen but that's the

kidney that's exactly right that white thing on the right side of the image of the patient's left side is the kidney and the one thing I'd like everyone who appreciates that doesn't look at all like the other side all right so when

you look at a cat-scan like this you want to look for symmetry that's really important all right that's the cool thing is we're kind of meant to be similar looking on both sides of our body and in this particular

case you can see that the left kidney has been pushed way forward in the body compared to the right side and there is a kind of a hematoma sitting in the retroperitoneum posterior behind the kidney that's bad

the other thing you should notice is if you look at that left kidney you notice that white squiggly line that doesn't belong there okay that's contrast that's not really constrained inside an artery that's extravagant of

contrast that's bad all right we don't want to see that all right again there's a grading system for renal trauma and you're gonna hear people talk about grade 1 2 3 4 injuries all right obviously as the number gets higher the

extents of the injury gets more significant all right so again here's that picture think you can appreciate that it's at least a grade 4 laceration of the kidney so we went in and we did an angiogram now we can watch these

patients we can surgically manage them by taking out their kidney in some ways that's the easy part excuse me it's a lot more elegant to try and embolize these patients if they're hemodynamically stable and can take you

know getting to angio and doing the case now in general we do embolization for patients with lower grade injuries and usually penetrating injuries a penetrating trauma that's seen on CT I think this is something that's changing

I if any of you work at high-volume trauma centers the reality is that we're doing more and more renal angiography for trauma than we used to because it's just becoming a more accepted thing for us to

be doing that all right so here's the angiogram and again I think you can notice it really correlates very well to what we saw on the CT scan you see that first image on the left and on the delayed image you see that that kind of

poorly constrained contrast going out into space now we were never really quite sure what this was if it was extravasation or if it was potentially an arteriovenous fistula with early filling of a renal vein regardless of

which it's not normal all right so what we did was we went in and we embolized and I only included this picture because I'm a big drawer during cases so when I'm working with a resident or a fellow I like to really

lay out our plan on a piece of paper and try and stick to the plan and this particular picture look really good so I included on the lecture but basically you can see that the coils the goal here for any embolization procedure

when it comes to trauma is to preserve as much of the normal organ as we can and to simply get you know to the source of the bleeding and to get it to stop and that's what we did there so what you can appreciate on this is kind of the

renal parenchyma or the tissue of the kidney is largely maintained you can see the dark black kind of blush within the kidney and all that really stands for properly working kidney all right and yet we embolize the pathology so that's

our goal here's a similar patient not

patient female patient who has the sudden onset of upper abdominal pain here's the CT we did all these cases in one day it was crazy it was terrible so so here's a big hematoma a big peritoneal hematoma you

can see it anterior to the right kidney you can see the white blob of contrast right in the middle of the hematoma that's a pseudoaneurysm or even active extravagance um less experienced people would probably say it's active

extravagant I think most of us would prefer that it be called kind of a pseudoaneurysm this active extrapolation would be much more cloudy and spread out this is more constrained and you can see on the

coronal image you get a sense that there's that hematoma same type of problem all right is there more imaging that we can do to figure out the next step again I said earlier earlier in this lecture

that sometimes we use CTA now sometimes a CTA is worthwhile I do find that for a lot of these patients I think we're getting smarter and we're doing CTAs right at the beginning of this whole thing you know when a trauma

patient comes in we're getting CTAs so we can max out the amount of information that we get on the initial diagnostic imaging here's what we're seeing on the CTA and in this particular case I think it's pretty clear that you can see the

pseudoaneurysm arising from what looks like a branch of the superior mesenteric artery so this is just an odd visceral and Jake visceral aneurysm which looks like it probably ruptured I don't have an explanation for it led to a big

hematoma here's what that is and now we're gonna do an angiogram the neat thing is it just perfectly correlated with a conventional angiogram so here's our super mesenteric angiogram all right the supreme mesenteric artery

on the first image to the left is that vessel going downward towards the right side of the screen all those vessels coming off are really just collateral vessels going up to the liver through the gastroduodenal artery again that

left one looks pretty good it's not until you see the delayed image on the right that you see that area of contrast all right so that's the finding that correlates with the CT scan all right here we're able to get in there you put

a micro catheter in that vessel alright the key next step for this patient as I mentioned earlier is the whole concept of front door and back door so here we're technically in the front door the next thing that we do is we put the

catheter past the area of injury and now we embolize right across the injury because remember once you embolize one thing flow is gonna change we screw it up body the body wants to preserve its flow if we block flow

somewhere the body's gonna reroute blood to get to where we blocked it so we want to think ahead and we want to say okay we're blocking this vessel how's the body going to react and let's let's get in the way of that happening that's what

we did here so we saw the pathology we went past it we embolized all across the pathology and boom now we don't have anymore bleeding and the likelihood of recurrence is gonna be very low for that patient because we went all the way

across the abnormality and I think from

then real quick just mercury ingestion again they're not selling the mercury

the liquid mercury thermometers anymore but there's still a lot of them out there and we do still occasionally in the DDC some of these come in the mercury is a dense silver white odorless heavy metal it can penetrate cell

membranes and accumulate in several organs and become toxic in several systems including the urinary CNS endocrine and Gi it's unusual to cause toxicity if the integrity of the mucosa is intact

and it does not enter further into the system if ingested from like a single thermometer 500 to 700 milligrams of Elemental mercury it's virtually non-toxic other sources are barometers batteries and sigma m-- fig manometers

you think after 30 years in nursing I could say that better so this is a two-year-old and the mother noted the broken thermometer with no evidence of mercury so he didn't have any symptoms that he wasn't complaining of pain he

wasn't coughing no breathing or swallowing but the mom brought him in anyway because it was mercury and she knew that it could be toxic he was stable vital signs stable no oral cuts abrasions glass particles but this

is what his x-ray looked like so it's just multiple scattered round densities throughout they did admit him for observation they repeated the x-ray in a serial course on day two he had complete clearance of the densities and was

discharged without complications so again our take homes usually it is with small amounts of mercury that have not gotten further into the system it's rarely toxic so you need to know the dose and the

the level of exposure the really important thing here is do not induce emesis or administer activated charcoal and do not use glass mercury containing thermometers in the home that's it and

five-year-old with excessive vaginal bleeding bleeding has no other symptoms

her she had a normal ultrasound of the lower abdomen there was no evidence of trauma or sexual abuse again very very important part of your history to obtain so they get a decide to do an MRI of her abdomen to see what's going on because

then ultrasound was negative and the metal detector went off when she went in the scanner so they pull her out and they get an x-ray a plain abdominal film that was done later and see a foreign body anybody want to take a guess at

what that might be metal so it definitely definitely shows up whoops those are actually keys to her diary so she was writing in her diary and she didn't want her mother to find that she

was writing so she stuck the keys inside and I guess never took them out again so that was those were two keys so very interesting cases okay let's talk about

in there okay so foreign bodies she put it where so females may present with

abdominal pain and what we think about with females with abdominal pain we think about constipation gastritis UTIs pyelonephritis or renal stones and we but what about a vaginal foreign body four percent of cases of girls with

genital complaints in the emergency room have been found to have a vaginal foreign body those bought foreign bodies include toilet paper hair ties safety pins pencils candy and more common in three to nine year olds of course in

history you would ask about tampon use but these foreign bodies can my great all the way up through the cervix and the signs and symptoms that they present with our vaginal bleeding dysuria hematuria foul odor and lower

abdominal pain okay so when you're looking at diagnosing vaginal foreign bodies x-rays are really less sensitive to objects that are made of wood and plastic you may not see it on an x-ray ultrasound and MRI are sensitive to

differences in water content and inflammation and again ultrasound can provide dynamic imaging so you may be able to see as that object has migrated CT scan is less sensitive especially if the objects been there for a while and

has retained fluid and the clinical picture and the imaging may not exactly reveal the diagnosis so this case is an 11 year old with menarche she has a history of ADHD she's been complaining of abdominal pain 7 on a scale of 1 to

10 and she's had a fever for two days her pain is worse with activity it's improved when she takes a warm bath she's not as active as usual and her Pio in takis is down a little bit but she has no sore throat no congestion no

coughs s pain nausea vomiting diarrhea no hematuria no dysuria no headache and no rash she's had vaginal bleeding for about two days and suspicious of a UTI her abdominal ultrasound she notes some free fluid in the pelvis and they do a

history t'me and find a golf tee found in her uterus which created an abscess and required a washout and dream and I'll show you some of that okay so we could see here you could see the foreign body noted here on CT scan and here's

the piece of the golf tee so you're able to see that I'm glad I'm doing this before lunch instead of after lunch right

patient who experienced the heart attack who had right little quadrant pain after a cardiac catheterization all you like oh so here's the cat scan and what you should appreciate there is in the front of that first image which is the axial

image all right you can see the hematoma that's brewing kind of in the front you notice how all these pictures kind of look the same that's the good part about giving a lecture on bleeding and trauma because they all kind of look the same

so that's the hematoma on the front part of the pelvis and on the on the right image which is more of a coronal like looking at the patient image you can see it right near the right groin you can see that hematoma all right so our next

step was to do an angiogram and this is what the angiogram looks like who wants to volunteer what do they say all right I saw someone raise his hand over here some walk over here what do you think yeah well yes so it is a retro hematoma

would you say describe the angiogram for everybody right where it's at the external iliac down the common femoral looks like there's contrast going up to the left and down to the right probably close to where they accessed yeah

probably but so yeah probably probably too high but the other thing is that's probably a pseudoaneurysm that probably is the evidence that there was a bleed there we're not seeing Frank extrapolation of contrast in a literally

contrast pouring out but we are seeing the effects of an injury to the artery and the constraining of the the remaining normal tissue to hold on to that bleed so the question is what do we want to do no that was very good because

I fooled you it's not always embolization so sorry I lied so in today's world a lot of times when we see this type of pathology we have again relatively new technology available to us again we

could go into that pseudoaneurysm and embolize it and that would be a legitimate treatment but my friend here is right you know this is a great case for a covered stent so we could go in and put a stent right across that area

of injury and stent it so these days looking at coverage stands as an option for patients with arterial injury is a very legitimate option you just have to be able to deliver it has to be the right artery you have to be able to get

the stent where it needs to go we all work with vascular surgeons who are great and they can put these stents and iliacs and aortas but they can't make those turns into livers and kidneys and spleens it's got to be the right artery

this is this is the right artery okay we saw this patient and we said well we could kind of get a micro catheter into that area of injury and embolize it or we could just put a cover sent across it and all go home to have dinner with our

kids so that was option B is what we chose here so this is a great cover stent case okay here's another patient

okay all right let's go over another case we have a ten-year-old with smelly

and bloody leukorrhea itching and vulva irritation always want to rule out sexual abuse of course when there's any vaginal discharge or any vaginal bleeding as well okay they're on trans abdominal ultrasound

there was an echogenic image that was noted in the upper part of her vagina and she had a badge on ah Skippy under general anesthesia and what that noted was a vaginal adhesion that was hiding the cervix so they decided to do an MRI

and the MRI showed a smooth image in the upper vagina so here's a couple of our images here on the Left we have a coronal MRI t2-weighted images sequence in the upper part of the vagina they can see a foreign body okay on that janaki

right here on the right you can see an adhesion that's kind of hiding the cervix and there's a flap on the side a flap of tissue that's how that's hiding a small orifice which is leading to the cavity of the foreign body and this is

the foreign body that was found it's a plastic dolls house glass and they suspect that it had been present there for several years okay next case a

all right another patient 52 year old patient ATV accident we get a lot of

lunatics on ATVs in our area and they presented with severe back pain here's the cat scan you see that white thing kind of in the back on the right side it almost looks exactly like that liver one I showed you two patients ago the

difference is that that's not conscious that's a part of the patient's bone that's the spine that fractured off and is now sitting in the middle of a big hematoma so that's why my kids don't have ATVs all right so basically that's

a big retroperitoneal hematoma due to a transverse process fracture all right in light of an ATV injury here's the angiogram now look at the picture on the left first that's an aorta gram you see the renal

artery at the top you see the bifurcation of the aorta kind of in the middle going down to each side and maybe just on that first image you see a hint of maybe some cloudy extravasated on the left side of the spine excuse me the

right side of the spine the left side of the image now remember I just I know I keep hammering this point home but you need the delayed image to make the diagnosis that's normally going to tell you if there's a real problem and on

that image on the right which is a bit more delayed you can see the extravagant Rast next to where the spine was that's an injury that's a lumbar artery injury and as we get closer all right we put a micro catheter in that lumbar artery now

you see the extraction and the question always comes up how much of that space do we need to fill that's an abnormal space that's just receiving all the blood that's leaking out of the artery and basically we don't have to fill all

of it we try we try to but it takes a lot to fill that up so we'll go in there you can see we put a lot of coils in this space and then we started packing coils back into the artery that was injured and I know it looks really big

on that image but if you go back into a finally orna gram you can appreciate that we were in a very small artery there but the technology that we have now allows us to get very far into very small arteries and that I think is

what's changed over the 20 years that I've been doing this at the very beginning of my career we wouldn't think about doing any of these things since we didn't have the tools to get that far out we had to

embolize these vessels very close to their origin and that led to a failure rate and an adverse injury rate that we don't see now that we can get this far out keypoint another case we have an older

is example as I mentioned about doing very large ablation so this is a lady who hadn't malignant melanoma and she

had metastases to liver we basically placed six probes into this mass as you can see there on that CT the image on the right is the appearance of those six probes it's all excited about how many probes I placed in this patient

like it's a game and then I just watched an ablation talk with a guy put 16 in so that didn't really make me feel much better so so we have six probes here and you can see what we what you do when you have lesions that are in the soft

tissues and you're worried about freezing to the skin you can have injury to the skin right essentially frostburn and so frostbite sorry and so what you can do is you can take either a warm glove fill it up with saline and put it

with the fingers amongst the probes so it keeps the skin warm because you don't want to freeze the skin or what people are doing sometimes as well as they've just put some gauze around all the probes and they spray that goes with

warm saline I just take one of those leader bags of saline put it in the microwave for a couple minutes and then just fill fill the bowl up with it and just spray the gauze on that or you can do the glove technique the main idea

here once again is you don't want to get skin injury when you do these and as you can see a pretty sizable ablation around that entire tumor you can even see the lightening sign which is the low attenuation sort of lightening looking

structures within the ice ball which is cracking of the ice ball as you form but you will see what this is immediately after the procedure the patient will have a very hard ice ball under their chest and it takes about an hour

for that to melt so if you notice bleeding off towards or what is perceived as bleeding before you panic you should realize that that ice pole is going to melt and it's going to come out the holes seep out of the holes that you

created so oftentimes if it's sort of a blood tinge fluid that's really just the ice ball melting in the fluid coming out of the the sites that you've punctured

but at button batteries and I say yikes because these are scary scary things

button batteries or disk batteries are made of lithium are very popular now they are they are popular because they have a very high capacity for energy and voltage they are very resistant they have a longer shelf life and they're

very stable at cold temperatures and they are pressing in watches these fobs remote control devices hearing aids calculators keychains and electronic toys so they the great thing is a lot of advantages but they have a lot of

potential for injury because of all of these you know all these benefits of them they are smooth and shiny very attractive to children especially the average age being two years 56% of cases are unwitnessed when kids ingest them

and they represent approximately 2% of all ingested foreign bodies but they probably are the most dangerous things that kids can ingest and 36% of patients are initially asymptomatic so it's very challenging to diagnose and even if they

ingest a battery that's already a bit spent meaning that it's a dead battery they are still at risk to cause injury if they swallow okay so these batteries generate an electric current when it meets the moist environment of the GI

tract and the battery contents leak and even though the outside casing remains intact the contents are still leaking there's a heavy metal toxicity burning burning burning and aside the symptoms of ingestion if

missed the child will choke or gag you'll see bloody saliva may have chest pain a new onset of wheezing or stridor and they may have a history of a viral syndrome so they've been coughing but coincidentally have ingested something

in the meantime they may have dark stools because of the bleeding or a rash and obviously the the worst case scenario may cause tracheal esophageal fistula media cyanide Asst and may erode major blood vessels and may actually

cause hemorrhage so button batteries can about 60 to 70 percent can become lodged in the esophagus and the more likely ones there's different sizes there's 20 millimeters and 15 millimeters and even though that doesn't sound like a lot of

difference the 20 millimeter ones are the ones that are more likely to become lodged and the duration of the lithium button battery the LV bfb the lit lithium button battery foreign body ingestion ingestion really has no

correlation with the length of how when it happened with the chances of its impaction it's kind of random where it gets stuck along the way so one of the treatments for suspected foreign body with button battery is that Children's

Hospital of Philadelphia we have adopted is to give that they suggest that the kids take honey on the way to the hospital if that's suspected and what the honey does is provides a protective barrier for the throat and helps to

neutralize the alkaline levels so even though it's they're not NPO for this impending surgical removal they find that there's a benefit of ingesting honey so even after removal by endoscopy of button batteries the injury can occur

days two weeks later and that's because of the leftover alkali the alkaline environment and the weakened tissues that are occurred so it takes a long time for this for these injuries to heal so in foreign body ingestion should

really be treated as button battery ingestion unless they're proven otherwise okay so in terms of imaging AP and lateral chest films are obtained along with neck and abdominal films because we

don't know where that button battery is along the pathway so it may look like a coin on x-ray but the difference we should treat it as a button battery and less proven otherwise and assume that there's some acid leaking and try to

remove that foreign body as quickly as possible so what you see on x-ray is you look for the halo it's a little bit hard in the lighting of this room but there's actually kind of a halo around that round object that's gonna differentiate

it from a coin and sideways it's not quite completely round like a coin would be there's a step off because if you notice that a button battery has a little bit of a lip on it so there's a step off sign that's seen on the lateral

film here and here are some other images so here's a button battery that's in the esophagus and you could see on close-up that there's a double ring and that is it's in the esophagus just above the Carina and that it's a little bit hard

to see on that image and here's another image where it's in that this is a 2.0 millimeter one and it's stuck in the mid esophagus okay and this is the step off so it's not quite it'll look a little bit different than a coin the step off

on the lateral view hence the reason to get ap and lateral films and then this is actually a child that swallowed magnets and so that magnets have all kind of stuck together okay and here's a lateral film of a button battery and

here's a more focused view where you could actually see the rim so you see in this these images a rounded radio-opaque foreign body with a double rim and the halo sign by the arrow and that's concerned for a button battery that's

overlying the stomach

here we have a MRI that shows a lesion in the left kidney sorry I don't have a

pointer here really but you can see the lesion in the medial part of the left kidney there couple probes are placed under CT guidance you can already see the beginning of the formation of an ice ball there this is the second probe you

can see the ice ball forming and there's a good example of the ice ball it's got good coverage of the the lesion as well as a good margin around that cryoablation tends to be less detrimental to the collecting system of

the kidney so some of the concerns when you do renal ablation is that you're gonna cause your read or strictures or urine leaks because you're burning the collecting system essentially with cryoablation you tend not to see that

you don't have to use something called pilar profusion is often right the idea with pilo profusion is you put a small catheter into the ureter and you infuse the kidney with cold saline so that the collecting system stays cold while you

while you burn the tumor well you don't often times have to do that with cryoablation so that's one benefit of it and then this is a one month later scan this is the normal appearance you can see the ablation zone that and the

resolution of the tumor will follow these up for a few years to make sure that all that tissue goes away and this

a what this is a 16 year old who

presented to the GI clinic with a 2-day history of sharp abdominal pain and I know we all think oh my gosh a teenager with abdominal pain how often do we see that it was accompanied by sweats she'd had one episode of non bloody vomiting

decreased oral intake and some diarrhea although she no longer has vomiting and diarrhea denies fever or trauma she does have a history of irritable bowel and chronic constipation and an ovarian cyst rupture so again you have a lot going on

with the abdomen with this kiddo and you know somewhat broad symptoms so on further examination she describes this pain as clearly different from any of her pain associated with IBS and constipation she specifically said it

feels like there is a bubble that is about to burst it was exacerbated by eating coughing and sneezing her she appeared a mild distress but her vital signs were stable and her tenderness was localized to and to the right upper

quadrant with palpation and percussion so the x-ray shows a your object 13 millimeters in length adjacent to the large bowel and liver she was transferred to the emergency department where her pain continued to

intensify they got a CT the IDI doc dug for some more history this goes just you know history history is important keep digging you know as long as you don't know what's going on keep digging and then

finally when talking about food and anything that she could have eaten different they did figure out they had just gotten the grill out about a week ago and the dad had cleaned it real good and they'd been eating barbecue so they

suspected a wire ingestion from the cleaning brush for the grill surgery was consulted there was no signs or symptoms of sepsis or peritonitis so she was admitted for observation this is the CT so you well it's got a narrow good so

you can see and then down here she got to the floor they decided on bowel rest pain control and antibiotics however the pain continued to intensify again feels like a needle poking me she was very specific about the pain where

it was how it felt so surgical removal was recommended and here you see the wire brush or bristle that they removed post-op uneventful discharged after two days with no complications she did continue to be treated for her IBS again

this really just highlights a really common outpatient IDI complaint with a really uncommon diagnosis keep in mind you know we've talked about unwitnessed and kids that you know don't want to tell well this was really you know a

whole different story it was an unknown ingestion take-homes in the last decade there has been a huge increase in reported incidence of this type with wire bristle detailed history preceding the onset of acute and focal

symptoms should prompt physicians to consider unintentional foreign body ingestion and continue digging for that history and

something some case examples of where I use cryoablation right so this is a

patient who has a nodule in the in the back of their lungs in the right lower lobe and basically I'll place two probes into that notch on either side of Brackett the lesion and then three months later fall up you can see a nice

resolution of that nodule so when it comes to lung a couple things I'll mention is if the nodule is greater than eight millimeters I'll immediately go to two probes I want to make sure that I cover the lesion whereas microwave it's

pretty rare depending on what device you're using for you to put more than one probe in so some people's concern with cryo in the lung is more probes means more risk of pneumothorax but you can also see surrounding and proximal to

where we did the place you can see the hemorrhage that you see so if those of you out there that are doing the lung ablations you probably have physicians that are using something called the triple freeze protocol right so the

double freeze protocol is the idea that you go ten minutes freeze five minutes 30 minutes freeze five minutes thought well what we saw was lung early on in the studies was a very large ablation a freeze to start with caused massive

hemorrhage patients were having very large amounts of hemorrhage so what we do now in lung is something called a triple freeze protocol we'll do a very short freeze about three minutes and that'll cause an ice ball to form and

then we'll thaw that in other three minutes three minutes of thawr and as soon as that starts to thaw we'll freeze it again and we've shown us a substantial decrease in the amount of hemorrhage so if you're doing long and

you and you you're told to do a double freeze protocol perhaps suggest the triple freeze is a better idea so that's three months later so another example

today's objectives I'll start with reviewing hepatocellular carcinoma HCC

and the current treatment options I'll share the protocol inclusion and exclusion criteria and I will discuss the research treatment protocol briefly and next transitioning to research the preparation taken in the department with

staff members for trial lastly I will talk about what's involved intraoperatively from a nursing standpoint so hepatocellular carcinoma HCC is the most common primary liver manely malignancy and is a leading cause

of cancer-related deaths worldwide cirrhosis is a condition in which there is scarring to the liver causing permanent damage chronic medical conditions such as diabetes mellitus and obesity lead to chronic liver disease

obesity is a risk factor to diabetes and diabetes directly affects the liver because of the essential role the liver plays in glucose metabolism both cirrhosis and chronic liver disease remain the most important risk factor

for the development of HCC a which viral hepatitis and excessive alcohol intake are the leading risk factors of cirrhosis non-alcoholic fatty liver disease and non-alcoholic steatohepatitis which is nash our

conditions in which fat builds up in your liver thus having inflammation and liver cell damage along with fat in your liver these are other risk factors for HCC the incidence of HCC will continue to escalate as hepatitis C and obesity

become more prevalent in the United States so unfortunately the diagnosis of HCC is too often made with advanced liver disease when patients have become symptomatic and have some degree of

liver impairment at this late stage there is virtually no effective treatment that would improve survival in addition the morbidity associated with therapies unacceptably high modalities available for HCC screening include both

radiographic tests and serological markers radiological tests commonly used for surveillance include ultra sonography multi-phase CT and MRI with contrast ultrasound has historically been utilized to identify intrahepatic

lesions since the early 1980s both the photograph above shows a cirrhotic liver versus a normal liver there are visible differences in the portal and hepatic veins between the cirrhotic liver when compared to the non cirrhotic liver so

AFP alpha-fetoprotein has been used as a serum marker for the detection of HCC an AFP level of less than 10 is normal for adults an extremely high level of AFP in your blood greater than 500 could be a sign of liver tumors liver function

tests or lfts look at the part of your liver that is not affected by cancer to see how well your liver is working the lfts will be considered for diagnosis and determining the stage of HCC the tests look for levels of certain

substance in your blood such as bilirubin albumin ALP ast alt and GGT despite advances in prevention techniques screening and new technologies in both diagnosis and treatment incidence and mortality

continue to rise so treatment options for HCC can be divided into three categories surgical options non-surgical options and systemic therapy patients are screened diagnosed and treated accordingly of

these three options interventional radiologists offer the non-surgical approach which include trans arterial embolisation percutaneous ethanol injection radiofrequency ablation and microwave ablation so I want to talk

about the child pu classification the child pious core consists of five clinical measures and is used to assess the prognosis of liver disease and cirrhosis including the required strength of treatment and necessity of

liver transplant the child piu score was originally developed in 1973 to predict surgical outcomes in patients presenting with bleeding esophageal varices today it continues to provide a forecast of the increased increasing severity of

your liver disease and you're expected survival rate the Chao few score is determined by scoring five clinical measures of liver disease the five clinical measures are total bilirubin serum albumin prothrombin time ascites

and hepatic encephalopathy once scores are available in each of the five clinical measures all scores are added and the result is a child piu score their interpretation of the clinical measure is as follows so Class A would

be five to six points lease liver disease with one to five year survival weight at 95 percent Class B seven to nine points moderately severe liver disease one to five year survival rate at seventy five percent and Class C ten

to fifteen points most severe liver disease one to five year survival rate at fifty percent so which child pew scores do I our patients fall into for a research with the CPC and the majority of the HCC child pew scores a and B

seven with the survival rate of one to five years for 95% the best outcomes are achieved when patients are carefully selected for each treatment option regardless of the treatment approach

patients with HCC require a multidisciplinary approach to care to ensure optimal outcomes what we refer to as tumor board tumor board are meetings where specialists from surgery medical oncology radiation oncology

interventional radiology and others collaboratively review a patient's condition and determine the best treatment plan through this multidisciplinary approach patients have access to a diverse team of experts

instead of relying on a single opinion each specialty will have unique contributions to ensure optimal long term outcomes for patients with HCC so there are various algorithms for HCC treatment I actually have one on top of

the other there just to show you that if you're interested in the process you can look it up it's there's a few out there all right so how are the patients selected for treatment like I said tumor board and moving on now to the surgical

options there are two surgical options liver resection and liver transplant surgical resection is currently considered to be the definitive treatment for HCC and the only one that offers the prospect of cure or at least

long-term survival however most patients have unresectable disease at presentation because of poor liver function the overall resect ability rate for HCC is only 10 to 25 percent and even among those who undergo surgical

resection with curative intent there is a recurrence rate of it to 80% at five years post resection survival rates are in the range of 80 to 92% at one year sixty-one to 86 three years and 41 to 74 at five years

the most common sight of post resection recurrence is a remaining liver for patients who are not surgically resectable liver transplant is the only other potentially curative option virtually all patients who are

considered for liver transplant are unresectable because of the degree of underlying liver dysfunction rather than tumor extent down staging using local regional therapies can also be used to increase eligibility for orthotopic

liver transplant while on the transplant list patients disease progress and meeting criteria gets complicated so patients on the transplant list are and do get some other therapies

which I will later discuss so we're surgical resection is not possible for poor liver function liver transplant is a treatment of choice prior to 2008 no systemic therapy was available that demonstrated an improvement in survival

with the publication of two randomized placebo-controlled phase 3 trials the oral multi targeted tyrosine kinase inhibitor sorafenib has become the new standard of treatment for advanced HCC with an increased median survival from

seven point nine months and the placebo group to ten point seven months in the treatment group systemic therapy can be difficult to tolerate because of the side effects dose reduction or treatment interruption is often needed

despite the side-effects treatment is recommended and to be continued into a progression of the tumor is demonstrated the majority of diagnosed patients with HCC present with advanced disease oral therapy has taken two pills twice daily

equaling 400 milligrams B ID so interventional radiology it's like surgery only magic so I I always think about this when patients come in and pre-op beam and they think they're having surgery you know it's well a lot

of benefits to ir what we're doing so interventional radiology is where the magic happens and non-surgical approach procedures are performed percutaneous local ablation include ethanol injection and radiofrequency ablation microwave

ablation is utilized both percutaneously and intraoperatively and lastly there is trans arterial embolisation which depending on the embolization agent can either be chemo bland or radioisotopes percutaneous ethanol injection known as

Pei has a long track record and is very effective in destroying HCC tumors that are less than or equal to 2 centimeters in diameter performed under percutaneous ultrasound guidance a needle is placed into the tumor and absolute alcohol is

injected over recent years radiofrequency ablation referred to as RFA has largely replaced Pei at most centres RFA's also performed percutaneously advancing a specially designed electrode into the tumor and

applying radiofrequency energy to generate a zone of thermal destruction that encompasses the tumor and a 1 centimeter margarine surrounding liver RFA is thus preferable to ethanol injection for patients with solitary

tumors 2 to 4 centimeters in size for tumors smaller than 4 centimeters RFA can achieve initial complete response rates of over 90% in microwave ablation MWA microwaves are created from the needle to create small

regionals regions of heat the heat destroy the liver cancer cells RFA and microwave are effective treatment options for patients who might have difficulty with surgery or those whose tumors are less than one and a half inch

in diameter the success rate for completely eliminating small liver tumors is greater than 85% so can I get a show of hands from the audience on who what facilities are doing chemo embolization everybody pretty much are

you guys doing them next to the gentleman yeah okay so this is gonna be a boring review here alright so trans arterial embolisation a minimally invasive procedure performed to restrict to tumors blood supply it is performed

by advancing and angiography catheter into the branches of the hepatic artery supplying the tumor and injecting an agent mixed with orally contrast followed by a cluding agent known as beads the beads which range from 100 to

300 micrometers in diameter are carried by the circulation into the terminal hepatic arterioles where they lodge and include the vessel resulting in the schema tumor necrosis the procedure is done using moderate sedation patients

are monitored for 23 hours or less for pain and post embolization syndrome trans arterial chemo embolization thus is where the chemo therapeutic agent mixed with beads is injected to the tumor

these particles both blocked the blood supply and induced cytotoxicity attacking the tumor in several ways taste is the treatment of choice when the tumor is greater than four centimeters or there are multiple

lesions within the liver taste takes advantage of the fact that while the liver is refused by both the portal vein and the hepatic artery HCC survives its blood supply almost entirely hepatic artery tastes has been shown to

prolong survival in patients with intermediate stage HCC and objective responses were observed in the majority of patients tear trans arterial radioembolisation is a form of catheter directed internal radiation that

delivers small microspheres with Radio isotopes directly into the tumor y9t microspheres are administered and a procedure similar to taste the procedure has been shown to be safe and effective in cirrhotic patients with HCC the side

effects are usually well title tolerated one major advantage of y9t over taste is that it is indicated in the case of portal vein neoplastic thrombosis while taste traditionally has been considered a contraindication all right so there's

so these are collections of indigestion material that can get stuck in the GI tract and they're usually either plant material or it can also be hair and the ones that I've seen the most are hair the most common one for the plant one is

actually rhubarb I don't know who's eating rhubarb but apparently there's some really bad things that can happen from it there's several cases of that but I'm going to talk about trickle but B sores which are hair balls so it's

pretty rare but it is more common in girls and it's secondary to the ingestion of hair this is a hairy tale so there are hair balls and that's because the surface of the hair is so smooth it can be difficult for it to be

digested and move through the intestinal tract it'll get caught in the gastric mucosa and then food and mucus will also accumulate in there and they can become quite large and this will be over time so it's like an impact

that can occur there is something called Rapunzel syndrome not that common but that's where this hairball can actually extend into the jejunum into the lower parts and parts of it could break off and actually obstruct the intestine so

not a lot of symptoms we do look for some psychiatric comorbidity so the child that is pulling their hair or Piko or other kinds of things can be indicators some complications as this enlarges there's been episodes where

there's been obstructive where there's perforations and ulcerations so in this case this was a nine year old female who had no chronic abdominal pain just vomiting and weight loss she had no alopecia so that's something if you see

somebody and you want to know whom where's that hair going if they're pulling it out but she had a big palpable mass and you can see it right there she did have a history of a psychiatric comorbidity and they tried

to do an endoscopy it was unsuccessful and that you see why so you can see the size of what they removed from her stomach look I purposely left the image there of the hand so that you could see this and this is what Rapunzel's sink

syndrome is so you can see how long this can be and how it could be very obstructive so these are rare they're difficult to recognize consider this in children with pica or other psychiatric illnesses consider alopecia without a

medical cause as a possibly on assessment and then remember that they need a referral for psychiatric follow-up so in conclusion detailed assessment and history are very critical and identifying potential

presence of foreign bodies radiological imaging is helpful but you need to know that it is not a hundred percent accurate all the time and then just think about some evidence-based practices and what I wanted to leave

with you and this is here BMJ hopefully you can see the website this is actually a very nice algorithm that helps in deciding what to do depending on where the object is and what types of objects could possibly be coming through thank

you very much

24 year old patient after a car accident has lower abdominal pain and melena so blood coming out of the rectum here's the CT scan anyone want to take a stab but you can just shout it out

so this time we're looking at the liver right so the liver is the big thing on the right side of the screen and what you can see is the dark hematoma posterior to the liver but you should also notice that big white dots sitting

right in the hematoma all right that's important because that's active bleeding that's the report when you guys when you guys get called in for these cases and someone says oh this you know liver trauma with active

bleeding this is the picture that is spurring that announcement okay this is what active bleeding and the liver looks like again there's a bleeding scale there's an injury scale for a liver trauma we don't need to go into that

slides are available if you want them alright here is the angiogram now again my rule works all right if you see vessels get smaller and then big again something's abnormal so in this particular picture I want you to notice

the catheter sitting in the right hepatic artery the blood is going up into the right lobe of the liver and right near the top of the pictures that big circular kind of blobby thing now this is by definition extravasation

sometimes we use the term pseudoaneurysm to describe this I just want you to appreciate what a pseudoaneurysm means it means that there's a hole in the artery that contrasts or blood is leaking out of that hole and the body is

essentially constraining the bleeding it's not going all over the place it's being constrained that's what we call a pseudoaneurysm all right that's just one way to look at it and geographically so this is an injury to the artery blood is

leaking out of the artery but maybe one layer of a three-layered blood vessel or even just the surrounding tissue is constraining that bleeding alright so what do we want to do for this exactly exactly you're getting it all right so

here we can get our microcatheter all the way out there the closer we get to it the better now in end organs like the liver or the kidney we don't actually have to get all the way out there getting close to it's going to be good

enough but the closer we get to it the better for stopping the bleeding and preserving the function of that organ all right so look how close we literally got right into the injury and then we're able to embolize it that's the goal all

right now the liver is a nice place the treat because as you know there's two sets of blood vessels going to the liver there's the portal veins in the apat ik artery so if we just embolize a little a patek artery the

liver is not going to notice that at all because it still has the portal venous flow bringing blood to that liver but our goal is to get in there preserve as much of the liver that we can and address that injury okay here's another

my last case here you have a 54 year old patient recent case who had head and neck cancer who presents with severe bleeding from a tracheostomy alright for some bizarre reason we had two of these

in like a week all right kind of crazy so here's the CT scan you can see the asymmetry of the soft tissue this is a patient who had had a neck cancer was irradiated and hopefully what you can notice on the

right side of the screen is the the large white circles of contrast which really don't belong there they were considered to be pseudo aneurysms arising from the carotid artery all right that's evidence of a bleed he was

bleeding out of his tracheostomy site so here's a CTA I think the better image is the image on the right side of the screen the sagittal image and you can see the carotid artery coming up from the bottom and you can see that round

circle coming off of the carotid artery you guys see that so here's the angiogram all that stuff that is to the right to the you know kind of posterior to the right of the screen there it doesn't belong there that's just

contrast that's exiting the carotid artery this is a carotid blowout we'll call it okay just that word sounds bad all right so that's bad so another question right what do you want to do here

I think embolization is reasonable but probably not the thing we can do the fastest to present a patient to treat a patient is bleeding out of the tracheostomy site so in this particular case this is a great covered stent case

alright and here's what it looked like after so we can go right up and just literally a cover sent right across the origin of that pseudoaneurysm and address the patient's bleeding alright

case I can make up the ages anyway so it doesn't matter so 43 year old patient on a motorcycle that collided with a deer all right presents with left upper quadrant abdominal pain and now we're looking at a cat scan all right who

wants to look at a cat scan you look like you're up for it what do you think what do you see no no you're not sure so we're looking so the key is the left upper quadrant pain right the patient presented with left-sided pain you

should know that whenever we're looking at a study like this we're looking as if we're talking to the person so the right side is on the left the image the left is on the right side and so if you look on the these are two

images if you look at the right side of the image you can actually see the spleen that's like that beam shape thing towards the back of the patient and what we should see is a homogeneous appearance of the organ but what we're

seeing are some kind of dark grayish lines going through it that's essentially a laceration of the screen that's what we're looking at that's the pathology that will prompt us doing a procedure like this and when we ever we

see a patient with splenic trauma we try and grade the trauma so one thing you're going to hear about is it's a patient with a grey 2 laceration or a great 4 laceration or something like that and that basically just describes the extent

of the laceration through the spleen the further through the spleen it goes the higher the number is the worse it is for the patient okay we tend to get involved with patients who who essentially have grade 3 or higher lacerations and are

hemodynamically stable so in this particular patient this was thought to be a grade 3 splenic laceration but there was not a whole lot of blood around the spleen so we thought this patient had some time to come to

angiography and embolization so here's the angiogram lo and behold what we see is again a blobby thing which is the theme of this lecture remember this is bleeding so we're looking for blobby things and all the way on the right side

of that image you can see that cloud of contrasts that black contrast that's extravasated of contrast that's not normal all the way to the right you guys see it are you good so going all the way to the right that's

what we're trying to do now when we do splenic embolization there's two ways we think about this do we want to go all the way to where the bleeding is all the way out into the screen and embolize one little branch that's injured or do we

want to do something called the proximal splenic embolization we would just put like some coils or plugs right at the origin of the splenic artery with the goal of being to slow down the flow and allow the spleen to heal a lot of it is

just what's possible maybe what time it is how tired we are things like that all factors that weigh into it but here's a little bit of a better view you can see the area of extravasation now here's another picture now we put

our microcatheter out there now you're getting a bit more of a sense of what's going on there you can see the extravagance II the vessel that it's coming from and then we put our catheter all the way out there and now we're

right at the source of the bleeding so our philosophy is if we see bleeding we want to go as far as we can towards the source of the bleeding keeping in mind that whenever we don't get as close to the bleeding as possible we're

sacrificing normal parts of the organ that we're treating and that's the philosophical leap that we make during these procedures so we were able to get out there and then we embolize leaving a lot of flow through the rest of the

spleen and the patient was able to survive like we never did anything alright that's our goal now here's a

all wheezing is asthma I'm going to start with some interesting cases so a six-year-old has a one-month history of a cough URI and it progresses to wheezing chest x-rays obtained and

you see minimal peribronchial thickening but there's no pneumonia or air trapping he's treated with antibiotics and nebulizers and steroids and he gets better in a couple of days but about two weeks later he returns for similar

symptoms so while he's being worked up two weeks later he has post tussah emphasis and expels a tooth so this is okay this is the x-ray that was done at the initial start of his coughing where foreign body was not suspected in the

initial workup and so the foreign body was missed but in hindsight the mother recalls and I teach a physical assessment course and I always talk about it's all in the history it's all in the history it's all in the history

but in hindsight the mother stated that just before the child started with the coughing episodes a few weeks prior he had lost a tooth and he guessed when it fell out they never found the tooth and they just assumed that he had swallowed

it but in fact he had actually aspirated the tooth so the incidence of foreign body aspiration it's most common again those boys in boys less than 3 years of age with the peak age being one to two years it's usually noted in the right

mainstem because that's the path of least resistance but it can get lodged in the larynx or the trachea the most commonly aspirated objects are peanuts legumes seeds popcorn hardware marbles and balls so infants and toddlers would

be food tends to be the culprit older children coins and paper clips have also been implicated with foreign body aspiration and inflatable objects are the most dangerous so hence stay away from those latex

balloons because kids can aspirate and though objects in the airway expand even further and can cause more obstruction of their Airways and complete airway obstruction in cases where they're in

there eating uncut hotdogs grapes or gel candies and in my experience in the pediatric ICU at Children's Hospital of Philadelphia I've taken care of several children who had air complete airway obstruction and subsequent demise and

hot dogs on autopsy pieces of hotdogs you know being removed from the airway so I could certainly speak to that so there should always be a high index of suspicion and a low threshold for radiologic studies look in the nose

first you'll be amazed at what kids can fit up there plain x-ray films anterior posterior and lateral views the objects are seen in about 62% of the cases an expert Ori films chest films help with a diagnosis so there was a study down back

in 1979 that looked at expert ory films that which correctly diagnosed 47 out of 50 cases of kids with foreign bodies in their airway so it's difficult if the if the if the foreign body is in the trachea because you would have the

changes would be bilateral but what expiratory films helped to do is eliminate the need for fluoroscopy CT and bronchoscopy so you could see in the picture on on your left and the picture on the right it's you could see that

there is a the either the tack or the physician wears a lead glove and applies epigastric pressure to prevent lung expansion and to help visualize a foreign body so you could see the picture on the right where there's

actually hyperinflation that seen let's

long sharp objects up to 90% and I think Laurie mentioned that to of ingested foreign bodies passed through the GI tract without complication however there

are exceptions to that and foreign bodies greater than four centimeters by two centimeters are those most likely to get caught up either in the constrictions of the esophagus in the pylorus or

the ileocecal Junction so our second case today is a nine-year-old who presented to the emergency department with the history of swallowing a pin ten hours ago again he did this at school doing a project but was afraid to tell

anyone but then when he came home he was afraid that something would happen so he finally confessed and he was he was asymptomatic but the parents decided to follow up just to make sure because it was a pin

he had an unremarkable exam they did do the x-rays so you can see there so there's the pin and if something to notice here is right now it is going with the point side down on the blunt side up and here it is here luckily

these show no evidence of impaction or perforation so they decided to just admit him with serial x-rays to follow through and hopefully it would pass most of the time they do pass and most of the time watch this pin they will go blunt

side down which decreases your risk of injury perforation or impaction so here we are moving so that those images were ten hours and now we're at about fifteen hours and you can see well on this one first of all it's starting to rotate

you'll see that looks a little concerning to me just the way it's facing but the blunt side is actually starting to go down and then over here were further down into the colon and then when we move on four hours later 26

hours after he initially ingested this he passed spontaneously past this with no complications was discharged to him the following morning so pretty amazing and that was just about the blunt end so the take homes here is that

you really can have spontaneous passage wait watchful waiting is okay to do as long as there are no signs or symptoms to be concerned about at that point however anything sharp or cutting does need an urgent examination because there

is a high risk of serious complications so there's complications most likely to occur with long sharp objects mucosal abrasions bleeding GI perforations peritonitis and medius tinnitus so this

60s year old patient with afib who fell and presented with abdominal pain and bruising in their anterior abdominal

wall for whatever reason we see a lot of these patients who come in with kind of bruising after they fall on their abdomen here you can see why hopefully you can see the big hematoma and the anterior abdominal wall so you can

imagine what this patient look like they have this kind of you know ball sized thing under their abdominal wall all right here's our angiogram in this particular case we went into the inferior epigastric artery which kind of

runs up from the pelvis up along the anterior abdominal wall you can see how small it is we were able to get a micro catheter in there and just in the middle just to the left of the middle of the picture you can see that kind of black

your circle that's again a pseudoaneurysm arising from the branch of the inferior epigastric artery and boom we can go in and coil it all right so that's what that looks like so now all of you kind of maybe I used to

sitting in the background we'll know when you're getting called in for these patients this is the type of pathology that we're looking at on CT and on angiography all right another patient 68 year old

terms of imaging my favorite aspect of cryoablation is the fact that you can see the ice ball very well on CT and most procedures are done with CT guidance right so as you can see this is

a renal ablation the probe has been placed you can see the ice bowl forming around the probe right so that's very predictable you can see exactly where it is the only problem with cryoablation is that that ice bowl is not

necessarily the lethal ice ball right so that maximal ice ball is really your zero Degree and in actual fact the lethal zone is about five millimeters in from that so anytime you do a cryoablation you want to weigh over

freeze essentially to get those margins that you want so that's one important thing to remember the ice ball is not the lethal it's really five millimeters short of that okay so a little more information by cryoablation you don't

have to spend too much time on this but the idea is that the more energy you put in the larger ice ball you can get and so essentially more probes you place can just supplement that energy to increase the size of the ice ball so advantages

similar but similar story an older patient who presented for a biopsy of a right renal mass now sometimes it's a skiing accident sometimes it's a car accident sometimes it's us that causes

these problems so here's a patient who came in for a biopsy of a renal mass here's the CT scan hopefully you can appreciate that the patient is face down or prone on this scan this by the spine is on the top side you can see our

biopsy needle going into a mass in the left kidney excuse me the right kidney and now this is the she comes back later because of some pain and now in a manner that's similar to what you said earlier on that first CT scan you can now see

the right kidney is pushed forward by a very large retroperitoneal hematoma so this is probably a post biopsy bleed this doesn't happen very often in fact as someone who does kidney biopsies once or twice every day I'm shocked that this

doesn't happen more often we're sticking big needles into vascular organs or vascular masses it's amazing that we don't have more patients come back for this it only happens about 2% of the time and usually people who have these

types of risk factors are at risk for this type of bleeding after a biopsy but we can do is we can go in do an angiogram and again I want you to just appreciate look at the picture I think everyone hopefully can see on the bottom

of the picture there's this active extrav enough contrast from the lower pol renal arteries all right lo pol renal artery and that's bad if it's great in a lecture because it's very easy for everyone to see but the reality

is it really signifies very significant bleeding and that's what everyone here should appreciate if you're managing the trauma patient or the bleeding patient if you see if this Cleary this clearly means everyone's got to move a little

faster to address it because this is a bad bleed but the great news is that we have the technology now to go all the way into the renal arteries or frankly the arteries of any organ get very far distant land just embolize it and so

look how far we got here for this patient we took care of it this patients kidney function didn't pump an inch because the reality is there was very little impact on the normal parts of the kidney so that's the goal if you guys

work with people who say oh we don't have to get that far out just throw some coils you know near the origin it's fine it'll accomplish the same goal but at the same time they will have killed half of the patients kidney so it is always

worth making some effort to get as far as you can into the organ that you're treating but at the same time you don't want to take an hour to do that because the patient's bleeding pretty heavily and you have to address it so that's our

goal during these procedures next case

one is a little bit more rare in that

this is a farm body that migrates so migration of the foreign body towards abdominal organ and it is rare but it can and does happen so here we have a 2 year old with a sewing needle ingestion who they followed for three months

without evidence of expulsion but this kid continued to have intermittent abdominal pain fussiness just overall crankiness and the parents decided that they were tired of just following this so they went for a second opinion and

they awry when they got for their second opinion they did indeed get more x-rays and it showed this and I'll show you in a minute they it showed the sewing needle in the lower abdominal quadrant they could not see it by practice Coupee

excuse me but what they did which in as you read along it didn't look like they had done anywhere else was they did a complete hands-on physical exam as well and they could actually palpate by rectal exam and then determined that it

had migrated and maybe you know maybe the migration had occurred over time and was not there when it was looked at earlier so this child ended up with a mini laparotomy do to the concerns of the migration out of

the lumen the needle was found in the meso : he had a significant recovery and three month post procedure follow-up showed no complication here this one's a little harder to see sorry I'm pointing problems it's the long straight can you

guys say it so again our take-home points although they are rare make em migrate outside if not removed early radiological follow-up as well as physical examination is important to identify potential complications and any

foreign body suggested to have migrated outside of the lumen should be considered for removal without delay because of the potential for traumatic complications okay alright she swallowed

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