Relan Ramit,  Lawrence Charles

Final Pr. ID: Poster #: CR-007

Internal hernias are a rare cause of chronic abdominal pain and bowel obstruction in pediatric patients. Furthermore, congenital trans-mesenteric hernias constitute only 5–10% of internal hernias. Internal paraduodenal hernias are more common in adults secondary to postoperative mesentery defects. However, transmesenteric hernias in children are caused from a congenital defect in small bowel mesentery near the ileoceclal region or ligament of trietz.

The subject of the case report is a 17 year old male who presented to primary care for several weeks of chronic abdominal pain and recurrent billious emesis. Initial abdominal radiographs demonstrated no evidence of obstruction. The patient presented to radiology for CT evaluation which demonstrated herniated loops of mid small bowel in the left hemiabdomen through a mesenteric defect. Patient was taken to the operating room for an elective exploratory laporotomy which demonstrated herniated loops of jejunum at the mesenteric defect near the ligament of trietz. The herniated loops of jejunum were anchored to duodenum and the mesenteric defect was closed. Patient tolerated the surgery without any complications and reports resolution of symptoms.

Trans-mesenteric hernias are difficult to diagnose due to lack of specific physical symptoms or laboratory findings to confirm the suspicion. Therefore, imaging findings play a vital role in diagnosis. CT imaging is useful to evaluate for mesenteric defects, obstruction and ischemia. Internal hernias with congenital mesenteric defects should be included in the differential for chronic abdominal and small bowel obstructions. Read More

Authors:  Relan Ramit , Lawrence Charles

Keywords:  Internal hernia, Congenital mesenteric defect

Schold Andrew,  Marine Megan,  Brown Brandon,  Gray Brian,  Karmazyn Boaz

Final Pr. ID: Poster #: SCI-014

Radiographic findings of right diaphragmatic eventration may overlap with true hernia if only liver herniates without bowel. We thus wanted to know the accuracy of ultrasonography (US) in the diagnosis of right diaphragmatic hernia. Read More

Authors:  Schold Andrew , Marine Megan , Brown Brandon , Gray Brian , Karmazyn Boaz

Keywords:  Diaphragm, Hernia, Ultrasound

Abdulla Sarah,  Tadros Sameh,  Squires Judy

Final Pr. ID: Poster #: CR-058

The female anatomic equivalent of the male processus vaginalis is the canal of Nuck. The canal is formed from a small peritoneal protuberance from the round ligament that extends through the inguinal ring, into the inguinal canal, and terminates in the labia majora. Obliteration of the canal occurs in a superior to inferior direction and usually completes within the first year of life. Non-closure results in a persistent canal of Nuck. Very rarely herniation of abdominal and pelvic contents into the canal of Nuck can occur, much less commonly in females than in the male equivalent. Hernias can present at any age but are most common in children. Recognition of this entity is especially important in cases of ovarian herniation due to the risk of incarceration.
We will provide a review normal anatomy, potential canal contents, the imaging appearance on ultrasound, CT, as well as MRI, and discuss differential diagnosis using cases of canal of Nuck hernia in 4 patients aged 22 days though 17 years. Read More

Authors:  Abdulla Sarah , Tadros Sameh , Squires Judy

Keywords:  Canal of Nuck, hernia, ultrasound, MRI, CT

Nosaka Shunsuke,  Fujino Akihiro,  Kanamori Yutaka,  Niiya Noriko,  Okamoto Reiko,  Miyazaki Osamu,  Muto Ayako,  Miyasaka Mikiko,  Tsutsumi Yoshiyuki,  Aoki Hidekazu,  Uematsu Satoko

Final Pr. ID: Poster #: EDU-105

Congenital diaphragmatic hernia (CDH) is the result of incomplete closure of the normal pleuroperitoneal canal. CDH is usually detected prenatally or present in the newborn period with severe respiratory distress. In contrast, delayed presentation of CDH (D-CDH), defined as CDH diagnosed at later than 30 days of age, is known as rare subset of CDH. The outcome of patients with D-CDH is generally favorable, but misdiagnosis can result in morbidity and mortality. This educational exhibit will demonstrate clinico-radiological characteristics of D-CDH. Read More

Authors:  Nosaka Shunsuke , Fujino Akihiro , Kanamori Yutaka , Niiya Noriko , Okamoto Reiko , Miyazaki Osamu , Muto Ayako , Miyasaka Mikiko , Tsutsumi Yoshiyuki , Aoki Hidekazu , Uematsu Satoko

Keywords:  Delayed presentation, Congenital diaphrargmatic hernia

Didier Ryne,  Martin-saavedra Juan,  Sridharan Anush,  Larson Abby,  Coons Barbara,  Coleman Beverly,  Davey Marcus,  Hedrick Holly,  Flake Alan

Final Pr. ID: Paper #: 118

Assessment of fetal brain perfusion with contrast-enhanced ultrasound (CEUS) has not been performed in vivo in congenital diaphragmatic hernia (CDH). The development of the EXTra-uterine Environment for Neonatal Development allows investigation of CEUS and fetal brain perfusion parameters. The purpose of this study was to assess for aberrations in brain perfusion using CEUS in fetal lambs with CDH and correlate with cardiac output data. Read More

Authors:  Didier Ryne , Martin-saavedra Juan , Sridharan Anush , Larson Abby , Coons Barbara , Coleman Beverly , Davey Marcus , Hedrick Holly , Flake Alan

Keywords:  Congenital Diaphragmatic Hernia, Brain Perfusion, Contrast Enhanced Ultrasound

Stern Joseph,  Ramirez Suarez Karen,  Victoria Teresa,  Otero Hansel

Final Pr. ID: Poster #: CR-033

Hepatopulmonary fusion (HPF) is a very rare type of right-sided congenital diaphragmatic hernia (CDH) with a reported prevalence of 3 in 1000 right-sided CDH cases. By June 2020, less than 50 cases have been reported in the literature. Out of 147 patients with right CDH managed at our institution, we found only one case (0.68%) of HPF, which is presented here.

HPF is typically not identified preoperatively, and the presence of HPF changes the operative management. It has been reported that a large right CDH without leftward cardiomediastinal shift and atelectatic lung adherent to the liver are imaging features of HPF.

This patient was a full-term, newborn girl with a normal prenatal course who developed respiratory distress immediately after birth. Chest radiograph at birth demonstrated a right CDH. On day four of life, the patient underwent surgical repair of right CDH. During the procedure, hepatopulmonary fusion involving the cephalad portion of the liver was discovered. The lung and liver could not be separated safely so the diaphragmatic defect was closed around the portion of the liver that extended into the thorax. Postoperative CT angiography of the chest and abdomen demonstrated no abnormal vascular communication between the lungs and liver; however, anomalies of systemic veins were identified. Follow-up chest radiograph at 9 months of age demonstrated a large right CDH that did not include bowel or right-sided colon and was without leftward mediastinal deviation. Concurrent contrast-enhanced CT images of the thorax at this time confirm the right CDH with herniated liver occupying most of the right hemothorax and expected rightward traction of the liver vasculature. However, no significant leftward mediastinal deviation was noted. A small amount of atelectatic lung overlying the liver was also noted, another imaging sign expected with HPF. Last follow-up at age 4, patient was thriving with normal growth and development. Read More

Authors:  Stern Joseph , Ramirez Suarez Karen , Victoria Teresa , Otero Hansel

Keywords:  Hepatopulmonary Fusion, Congenital diaphragmatic hernia, CTA

Kim Wendy,  Courtier Jesse,  Morin Cara,  Shet Narendra,  Strauch Eric,  Kim Jane

Final Pr. ID: Poster #: EDU-035

Late-presenting or recurrent diaphragmatic defects can pose a diagnostic challenge due to varying clinical presentations. Current diagnostic approaches include plain film radiograph for initial assessment, with other imaging modalities such as fluoroscopy, ultrasound, CT and MRI mainly employed for troubleshooting. As a radiation-free modality, MRI can provide a more definitive diagnosis in particular cases due to its ability to visualize discontinuity of the diaphragm (distinguishing it from eventration), hernia contents, defect location and size.

In this exhibit, we will:
1. Review the normal appearance of the diaphragm.
2. Share our institutional MRI protocol for optimal evaluation of the diaphragm, including use of CINE steady state free precession sequences and use of negative slice spacing in T2 weighted images.
3. Discuss important postnatal MR imaging findings of late presenting and recurrent diaphragmatic hernias in children.
4. Describe potential diagnostic pitfalls in the imaging of the diaphragm. Read More

Authors:  Kim Wendy , Courtier Jesse , Morin Cara , Shet Narendra , Strauch Eric , Kim Jane

Keywords:  Diaphragmatic hernia, MRI, Hiatal hernia, Bochdalek hernia, Morgagni hernia

Alford Raphael,  Rubesova Erika,  Halabi Safwan,  Blumenfeld Yair,  Hintz Susan,  Barth Richard

Final Pr. ID: Poster #: SCI-049

The purpose of this study is to determine the reliability of sonographic (US) lung measurements compared with Fetal MR in fetuses with congenital diaphragmatic hernia. The sonographic lung head ratio (LHR) is a widely used prognostic tool in CDH, but can be difficult to obtain due to shifted mediastinum and fetal position. To our knowledge, comparison of MRI measured LHR with US has not been previously reported. Read More

Authors:  Alford Raphael , Rubesova Erika , Halabi Safwan , Blumenfeld Yair , Hintz Susan , Barth Richard

Keywords:  Congenital diaphragmatic hernia, Lung head ratio, LHR, Fetal MRI, Lung volumes

Cassella Katharyn,  Brown Brandon

Final Pr. ID: Poster #: EDU-016

With the increasing utilization of imaging in prenatal diagnosis, the fetal MR appearance of omphalocele has been well-described. However, as fetal MR plays a critical role not only for diagnosis but also for planning and family counseling, the radiologist is required to risk stratify the range of presentations of this anomaly. There is a broad spectrum of severity within this single diagnosis: ranging from a small and covered bowel-only defect, to a large and ruptured multi-organ hernia, to a complex omphalocele within a nonkaryotype fetal syndrome. Outcomes are highly variable, ranging from a simple hernia repaired with primary closure, to a protracted postnatal course with staged surgical repairs, to expected intrapartum demise. Further, neonatal pulmonary hypoplasia and hypertension often complicate more severe cases. Thus, accurate prognostication is essential to properly equip and prepare families, and thereby add value to perinatal care.

In this presentation, we outline a 7-point, systematic method for analyzing the varied presentations of omphalocele, as seen on both 1.5T and 3T MR field strengths. The approach we describe details the following diagnostic criteria: (1) the size of the defect, (2) type and volume of herniated organ contents, (3) presence/absence of an intact membrane, (4) presence/absence of hernia sac ascites, (5) associated pulmonary hypoplasia, (6) insertion of the umbilical cord, and (7) presence of irregular cord vessels. Finally, we demonstrate how this diagnosis can correlate with associated ischemic changes in the placenta, a finding which can further aid delivery planning and prognostication.
Read More

Authors:  Cassella Katharyn , Brown Brandon

Keywords:  Omphalocele, Ventral hernia, Abdominoscisis

Schneeman Libby,  Hutchinson Marcy,  Ho-fung Victor,  Otero Hansel

Final Pr. ID: Poster #: EDU-046

Muscle hernias occur when a muscle protrudes through a fascial defect into the subcutaneous fat, hence presenting as a subcutaneous palpable mass. While the palpable abnormality is usually asymptomatic, it can also present with pain. Muscles hernias occur most often in adolescents and young adults and might be due to sporting activities, trauma, or overlying fascia weakness.

Because of its dynamic real-time imaging capabilities, ultrasound is best suited for the evaluation of these lesions. Moreover, a definitive diagnosis can be reached with ultrasound hence avoding additional time and expenses while promptly providing reassurance to the patients and families. US has excellent sensitivity and specificity for the identification of muscles hernias. However, baseline knowledge of this disease as well as close attention to technique are needed to reliably reach the proper diagnosis. Our educational poster will:
1. Summarize proper US equipment, technique and protocol for diagnosing muscle hernia
2. Discuss advantages and benefits of US over other imaging modalities
3. Illustrate the sonographic findings of muscles hernias

Read More

Authors:  Schneeman Libby , Hutchinson Marcy , Ho-fung Victor , Otero Hansel

Keywords:  muscle, hernia, ultrasound

Jarboe Marcus,  Ladino-torres Maria,  Hirschl Ron

Final Pr. ID: Paper #: 076

There are a number of techniques used to repair inguinal hernias, both open a laparoscopic. Here we report a case series of a novel method, inguinal herniorrhaphy using ultrasound guidance. Read More

Authors:  Jarboe Marcus , Ladino-torres Maria , Hirschl Ron

Keywords:  inguinal, ultrasound, hernia

Mar Melody,  Gokli Ami,  Jeremy Neuman,  Raden Mark,  Koshy June

Final Pr. ID: Poster #: EDU-047

The canal of Nuck is an evagination of the parietal peritoneum in females which extends along the round ligament of the uterus through the inguinal canal to the labium majorum and is usually obliterated by 8 months of gestation. Incomplete obliteration of the canal can predispose to an indirect inguinal hernia or a hydrocele in female children. In addition, other pathologies such as cysts or endometriosis can rarely occur. We present two cases of canal of Nuck pathology including a 5 year old female with a palpable left labial mass shown on ultrasound to be a canal of Nuck cyst and a 3 week old female with a left labial mass which on ultrasound showed a canal of Nuck hernia containing the left ovary. We will review the presenting history and characteristic imaging features in each case. Read More

Authors:  Mar Melody , Gokli Ami , Jeremy Neuman , Raden Mark , Koshy June

Keywords:  Canal of Nuck, hernia, labia