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In the context of health care, risk assessment is the identification, evaluation and estimation of risk related to a particular clinical situation or intervention compared to accepted medical practice standards. The goal of risk assessment is to determine an acceptable level of risk for a given clinical treatment or intervention in association with the provided clinical circumstances for a patient or group of patients. In spite of the inherent challenges related to risk assessment in pediatric cross-sectional imaging, the potential risks of ionizing radiation and sedation/anesthesia in the pediatric population are thought to be quite small. Nevertheless both issues continue to be topics of discussion concerning risk and generate significant anxiety and concern for patients, parents and practicing pediatricians. Recent advances in CT technology allow for more rapid imaging with substantially lower radiation exposures, obviating the need for anesthesia for many indications and potentially mitigating concerns related to radiation exposure. In this review, we compare and contrast the potential risks of CT without anesthesia against the potential risks of MRI with anesthesia, and discuss the implications of this analysis on exam selection, providing specific examples related to neuroblastoma surveillance imaging.

Background Triple gallbladder is a rare congenital anomaly of the biliary tract that can be associated with heterotopic tissue. Gallbladder triplication results from the failure of rudimentary bile ducts to regress during embryological development, and can be difficult to distinguish from Todani type II choledochal cysts and biliary duplication cysts. Case presentation A 2-year-old patient presented to our institution with intermittent abdominal pain for 1 year. She had elevated transaminases with imaging concerning for a choledochal cyst. After assessment with magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography, she was diagnosed with a gallbladder multiplication and a common bile duct stricture. She underwent laparoscopic cholecystectomy, which confirmed the diagnosis of triple gallbladder. One of the three gallbladders demonstrated heterotopic gastric mucosa on final pathology, including at the cystic duct margin. Follow up testing with a technetium 99 m scan demonstrated a subtle focus of increased activity in the right upper abdomen at the expected location of the common bile duct, concerning for the presence of residual gastric mucosa. The patient remains well without abdominal pain. Conclusions We describe the first case of heterotopic gastric mucosa in a triple gallbladder in a young patient presenting with chronic abdominal pain. We also demonstrate the safety and feasibility of laparoscopic cholecystectomy in young children with triple gallbladder. Finally, we propose an interdisciplinary approach to the management of common bile duct strictures in the setting of ectopic acid secretion, involving a combination of medical management, endoscopic intervention, and possible salvage laparoscopic Roux-en-Y hepaticojejunostomy.

Size‐based diagnostic reference ranges (DRRs) for contrast‐enhanced pediatric abdominal computed tomography (CT) have been published in order to establish practical upper and lower limits of CTDI, DLP, and SSDE. Based on these DRRs, guidelines for establishing size‐based SSDE target levels from the SSDE of a standard adult by applying a linear correction factor have been published and provide a great reference for dose optimization initiatives. The necessary step of designing manufacturer‐specific CT protocols to achieve established SSDE targets is the responsibility of the Qualified Medical Physicist. The task is straightforward if fixed‐mA protocols are used, however, more difficult when automatic exposure control (AEC) and automatic kV selection are considered. In such cases, the physicist must deduce the operation of AEC algorithms from technical documentation or through testing, using a wide range of phantom sizes. Our study presents the results of such testing using anthropomorphic phantoms ranging in size from the newborn to the obese adult. The effect of each user‐controlled parameter was modeled for a single‐manufacturer AEC algorithm (Siemens CARE Dose4D) and automatic kV selection algorithm (Siemens CARE kV). Based on the results presented in this study, a process for designing mA‐modulated, pediatric abdominal CT protocols that achieve user‐defined SSDE and kV targets is described. PACS numbers: 87.57.Q‐, 87.57.qp, 87.53.Bn

In the context of pediatric cross-sectional imaging, the risk of ionizing radiation for CT and the potential adverse effects associated with sedation/anesthesia for MRI continue to provoke lively discussions in the pediatric literature and lay press. This is particularly true for issues relating to the risks of ionizing radiation for CT, which has been a topic of discussion for nearly two decades. In addition to understanding these potential risks and the importance of minimizing individual pediatric patient exposure to ionizing radiation, it is equally important for radiologists to be able to frame these risks with respect to the potential for adverse outcomes associated with the use of anesthesia for cross-sectional imaging in the pediatric population. Notably, before such risks can be estimated and compared, one should always consider the potential utility of each imaging modality for a given diagnosis. If one cross-sectional imaging modality is likely to be far superior to the other for a specific clinical question, every effort must be made to safely image the child, even if sedation/anesthesia is required.

PET/CT plays an important role in the diagnosis, staging and management of many pediatric malignancies. The techniques for performing PET/CT examinations in children have evolved, with increasing attention focused on reducing patient exposure to ionizing radiation dose whenever possible and minimizing scan duration and sedation times, with a goal toward optimizing the overall patient experience. This review outlines our approach to performing PET/CT, including a discussion of the indications for a PET/CT exam, approaches for optimizing the exam protocol, and a review of different approaches for acquiring the CT portion of the PET/CT exam. Strategies for PACS integration, image display, interpretation and reporting are also provided. Most practices will develop a strategy for performing PET/CT that best meets their respective needs. The purpose of this article is to provide a comprehensive overview for radiologists who are new to pediatric PET/CT, and also to provide experienced PET/CT practitioners with an update on state-of-the art CT techniques that we have incorporated into our protocols and that have enabled us to make considerable improvements to our PET/CT practice.

BackgroundThere is no consensus as to when surgical intervention should be considered for recurrent ileocolic intussusceptions in a stable patient after previous successful air contrast enema.ObjectiveTo review the patterns of ileocolic intussusceptions, air contrast enema success rates, and pathologic lead point rates in patients with and without recurrence to evaluate whether treatment outcomes depend on the number and timing between episodes.Materials and methodsWe retrospectively reviewed 683 children with air contrast enema performed for ileocolic intussusception between January 2000 and May 2018. Recurrent intussusceptions were separated into mutually exclusive categories: short-term only (≤7 days between episodes) and long-term (>7 days between episodes) intussusceptions. Long-term recurrences included both long-term only and long- and short-term intussusceptions.ResultsOf the 683 patients, 606 (89%) had at least 1 successful air contrast enema. Of the 606, 115 (19%) had recurrent intussusceptions after successful reduction. The air contrast enema success rate for a single intussusception was 86% (491/568) and for recurrent intussusceptions was 96% (110/115) (P=0.004). Single and recurrent intussusceptions had similar pathologic lead point rates (3.5% vs. 4.3%; P=0.593). Short-term and long-term recurrences did not differ in air contrast enema success rates (96% vs. 95%). Long-term recurrences had higher pathologic lead point rate compared to short-term only (13% vs. 0%; P=0.003). Of short-term recurrences, 99% (76/77) were ≤5 intussusceptions; 92% had successful air contrast enema without surgery.ConclusionThe majority of recurrent intussusceptions were successfully treated by air contrast enema. Short-term recurrences have lower pathologic lead point rates, suggesting that a higher surgical threshold may be plausible relative to long-term recurrences. In the appropriate clinical context, repeat air contrast enemas are a safe option for short-term recurrences, which can be attempted at least five times, potentially precluding the need for surgical intervention.

BackgroundThe causes of idiopathic ileocolic intussusception are unknown, with infection as the most likely culprit. Recently, social distancing measures were implemented during the coronavirus disease 2019 (COVID-19) pandemic to decrease transmissible infectious diseases, creating an opportune setting to study the role of infection on the pathogenesis of intussusception on a population level.ObjectiveTo investigate the impact of social distancing on intussusception.Materials and methodsWe retrospectively reviewed air contrast enemas and pylorus ultrasounds performed between March 2010 and March 2021 to identify cases of ileocolic intussusception and hypertrophic pyloric stenosis (HPS), using the latter as a negative control. The study time frame was divided into two periods: pre-pandemic (March 2010–February 2020) and pandemic (April 2020–March 2021). The number of cases that occurred in these two time periods were compared using the Poisson regression model.ResultsOf the 407 cases of idiopathic ileocolic intussusception identified, 396 occurred in the pre-pandemic time period (mean = 39.6 per 12-month period) and 11 occurred in the 12-month pandemic time period. The mean monthly number of intussusceptions showed a decline of 72% (95% confidence interval [CI] 49–85%) between the pre-pandemic and pandemic time periods (3.3 vs. 0.9 monthly cases; P < 0.001). In contrast, the mean monthly number of HPS did not differ significantly (P = 0.19).ConclusionSocial distancing—imposed to curb the spread of infection during the COVID-19 pandemic—resulted in a significant decline in ileocolic intussusception, lending strong support to the theory that infection is the dominant cause of intussusception.

Pediatric acute pancreatitis has distinct etiologic, clinical and prognostic characteristics in contrast to the adult form of the disease. This review offers a comprehensive imaging update that emphasizes the importance of recognizing specific findings that are relevant from the clinical standpoint. Knowledge of these features facilitates communication among multidisciplinary team members and ultimately could lead to the improved care of pediatric acute pancreatitis patients.