PPT - Cochin GUT Club

Report
Mesenteric adenitis in children
Geetha M
Pediatric Gastroenterologist
Amrita Hospital, Cochin
Scenario
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Mesenteric Lymphadenopathy not a diagnosis
Incidental finding in Recurrent Abdominal Pain
USG abdomen is one primary investigation
Organic causes 4-11%
USG findings- Mesenteric nodes, GB Stones
? Significance
MLN
• Medical literature
• Pediatric Literature – specific inflammation by
Yersinia, Staph, Salmonella
• Radiological literature - LN > 5mm size
• What is the significance?
What is mesenteric adenitis?
• 3 or > LN
• 4 mm or > in short axis: 8mm > in long axis
Rao PM, Rhea JT, Novelline RA. CT diagnosis of mesenteric adenitis.
Radiology 1997; 202:145–149.
• Primary- when LN are the only finding
• Secondary – when another pathology is
identified
• Incidence varies
Measurement of LN
Causes - Local Infections
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Gastroenteritis
Appendicitis
Parasitic infections
IBD
Parasitic Infection
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Parasitic infec is a cause of RAP
?? Cause for MLN??
2002-2008 , 224 children with RAP
89 boys: 135 girls ; Mean age 9 yrs
Ped sonologist
Short axis >8mm = enlarged MLN
Enlarged mesenteric lymph nodes in children with recurrent abdominal pain: Is
there an association with intestinal parasitic infections?
Fraukje Wiersma et al
Contd……..
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All children had MLN at least 5mm
86% (193/224) - had all nodes < 5mm
6/224 (2.5%) > 8mm: 25/224 (11.2%) 5-7mm
None of the 6 had parasites
25% (56) had parasitic infection
– 47 - < 5mm
– 9 – 5-7 mm
• Concluded – not related to parasitic infection
Simanovsky N et al. Importance of sonographic detection of enlarged abdominal lymph nodes in
children. J Ultrasound Med 2007; 26:581-584
Infections associated with MLN
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Yersinia enterocolitica - RIF syndrome
Atypical Mycobacteria
Campylobacter spp
Coxackie virus, EBV
HIV
Jelloul I, Fremond B, Dyon JF, Orme RI, Babut JM. Mesenteric adenitis caused by Yersinia
pseudotuberculosis presenting as abdominal mass. Eur J Pediatr Surg 1997; 7:180–183.
Nilehn B, Sjostrom B. Studies on Yersinia enterocolitica. Occurrence in various groups
of acute abdominal disease. Acta Pathol Microbiol Scand 1967; 71:612-628.
Symptomatology
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Mostly asymptomatic
Diffuse abd pain – sometimes localised in RLQ
Concomittant/ antecedent URI
Anorexia
Diarrhoea
Nausea/ vomiting
Symptoms………….Contd
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Fever
Rhinorrhoea
RLQ tenderness
20% peripheral lymphadenopathy
LN Biopsy – mostly reactive/ non – specific
inflammation
Early Studies
• LN > 4mm in AP diameter – 4% asymp children
Sivit CJ, et al. Visualization of enlarged mesenteric lymph nodes at US examination.
Pediatr Radiol 1993; 23:471-475
• 10-20 mm long axis 89% asymp children
Healy MV, Graham PM. Assessment of abdominal lymph nodes in a normal pediatric
population: an ultrasound study. Australas Radiol 1993; 37:171–172.
• MLN (long axis) in almost all children
Watanabe M, Ishii E, Hirowatari Y, et al. Evaluation of abdominal lymphadenopathy in
children by ultrasonography. Pediatr Radiol 1997; 27:860–864
CT and MLN
• All non contrast CT images done for renal
stones were evaluated for MLN
• 33/61 had MLN mostly in RLQ
• Max size 10 mm – also in RLQ
• Cluster of 3 nodes – RLQ
• 5mm size nodes – in almost all
• Hence a measurement of 8mm or > chosen
Karmazyn B, Werner EA, Rejaie B, Applegate KE. Mesenteric lymph nodes in children:
what is normal? Pediatr Radiol 2005; 35:774-777
Which size is significant ?
• MLN in children – asymptomatic and RAP
• 200 children
• Acute abd / RAP/ others
Group I (24)
Group II (65)
Group III (111)
> 5mm
83.3%
73.8%
64%
> 8 mm
41.6%
32.3%
27%
> 10mm
22.1%
27.6%
9.9%
• Only > 10 mm was statistically significant
Importance of Sonographic Detection of Enlarged Abdominal Lymph Nodes in Children
Natalia Simanovsky, MD, Nurith Hiller, MD. J Ultrasound Med 2007; 26:581–584
Does Size Matter ?
• LN > 4mm seen in 4-64% asymp children
Sivit CJ, et al. Visualization of enlarged mesenteric lymph nodes at US examination. Pediatr Radiol
1993; 23:471-475
Rathaus Vet al Enlarged mesenteric lymph nodes in asymptomatic children: the value of the finding
in various imaging modalities. Br J Radiol 2005; 78:30-33
• 14-83% of symp children
• MLN are seen in all children – asymp, sympacute abd, CAP, gastroenteritis
• Tendency to have larger nodes in acute infect
• As an isolated finding – not much importance
Nan Fang Yi Ke Da Xue Xue Bao. 2011 Mar;31(3):522-4.
[Enlarged mesenteric lymph nodes in children: a clinical analysis with ultrasonography and the
implications].
[WANG WG, TIAN H, YAN JY, LI T, ZHANG TD, ZHAO YP, ZHANG LY, XING HG.
Distribution of EALNs of 5 mm or
larger in the shortest diameter by age
Importance of Sonographic Detection of Enlarged Abdominal Lymph Nodes in Children
Natalia Simanovsky, MD, Nurith Hiller, MD. J Ultrasound Med 2007; 26:581–584
Indian Experience
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MLN almost universally seen
Enlarged nodes > 8mm upto 20mm
If isolated and clinically well – only follow up
If symptomatic - course of antibiotics
Usually pain tends to settle but nodes persist
If persistent and symptomatic - evaluate
Conclusions
• Frequent in asymptomatic children
• Nodes 10 mm or > in setting of abdominal
pain – considered as ML
• Usually increase in size till 10 yrs and then
regress
• Mostly non specific – but follow up if
necessary

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