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for Pediatric 1978

Radiology Meeting

cation of this interval of change from the newborn to the adult pattern of mortality will allow correlation with nutritional, hormonal, biochemical, and morphological events and may lead to further insight into means of protection against pulmonary oxygen toxicity.

The Society for Pediatric Radiology met in Denver, Colorado, September 22-24, 1978, and was invited to submit abstracts from its formal scientific program for publication. Thorne Griscom, secretary-treasurer of the society, edited the abstracts in conjunction with the authors. Abstracts are arranged in the order of presentation.

Unilateral Pulnonary hypoplasia Following lulrnonary Artery Banding: Fletcher 80, liarcia U, Fink R, Borkat G (Rainbow Babies and Childrens hospital, Cleveland, OH 44106)

CONTENTS Maturation

as a Factor


Unilateral Fletcher



Pulmonary BD,









Hypoplasia EJ,









Two patients, one with truncus arteriosus type I, the other wi th coarctation of the aorta wi th ventri Cular septal defect, underwent pulmonary artery banding during early infancy because of intractable congestive heart failure. In both cases, the right pulmonary artery was inadvertently completely occluded. Subsequent chest radiographs showed diminished pulnonary vasculature on the right, and follow-up examinations over 2 years showed a relative lack of lung growth on that side. Fluoroscopic studies and lung scans demonstrated normal ventilation. Mastic repair of the right pulmonary artery and insertion of a right ventricular-pulmonary artery conduit resulted in partial restoration of lung volume in one of the patients. The other patient died a few years later, and autopsy confirmed ipsilateral pulmonary hypoplasia. A third patient, with pulmonary atresia and a surgical shunt between the ascending aorta and rignt pulmonary artery, developed surgical obstruction of the left pulrionary artery. Post-operative radiographs over many years also showed hypoplasia of the underperfused left lung. The radiographic findings in these patients must be differentiated from “unilateral hyperlucent lung syndrome” and congenital interruption of a pulmonary artery. They suggest that pulmonary arterial perfusion exerts a major influence on postnatal lung growth. Pulmonary artery obstructions should be corrected as early as possible in order to F1inirize interference with alveolar multiplication.

Pleural Telangiectasia and Pulmonary Agenesis. Kleinman PK Membranous Laryngotracheobronchitis (Membranous Croup). Han B, Dunbar JS, Striker TW Appendiceal Abscess and the Pediatric Cul-de-sac. Barnes JC, Kirks, DR, Currarino G Veno-occlusive Hepatic Disease in Acute Myelocytic Leukemia (AML): Evaluation by Serial Liver Imaging. Harcke HT, Naiman JL, Huff DS Chemotherapy-Induced Inhibition of Compensatory Renal Growth in the Ininature Mouse. Moskowitz PS, Donaldson 55 The Whitaker Test: Differentiation of Obstructive from Nonobstructive Uropathy. Jaffe RB The Uroradiographic Evaluation of the Enuretic Child. Seibert J, Redman J The So-Called “Megaureter-Megacystis Syndrome”. Lebowitz RL, Willi U Comparison of Radiologic Methods for Measuring Femoral Anteversion in Infancy and Childhood. O’Connor JF, Mital MA, Ruby L, Spira J Arthrographic Evaluation of the Joint Cartilage in Avascular Necrosis of the Femoral Head. Ozonoff MB Coracoclavicular Fracture Separation The Pediatric Equivalent of Acromioclavicular Separation. Reed MH An Efficacy Study for the Value of Comparison Views in Extremity Injuries in Children. McCauley RGK, Schwartz AM, Leonidas JL, Darling DB Relative Efficacy of Radiographs and Bone Scans in the Detection of the Skeletal Lesions of Histiocytosis-X. Parker BR, Pinckney LE, Etcubanas E, Goris ML The Radiographic Features of Eosinophilic Gastroenteritis (Allergic Gastroenteropathy)of Childhood. Teele RL, Katz AJ, Goldman H The Diagnosis of Hiatus Hernia, Reflux and Esophagitis. Knapp K, Del Hoyo ML, Diez-Pardo J, Martinez A Radiology and Manometry in the Selection of Patients for Antireflux Surgery. Cuming WA The Diagnosis and Management of Gastro-esophageal Reflux in the Pediatric Patient. Smith LE, Byrne WJ, Fonkalsrud EW, Kangarloo

Maturation Worthway Stanford,

Pleural Telangiectasia Kleinman PK (Univ. of Worcester, MA 01605)

in Pulmonary Oxygen R, Canty E (Stanford

Toxicity: Univ.,

Previous investigation suggests that newborn animals are less susceptible to pulmonary oxygen toxicity than the adult of the same species. Sixty percent of newborn C7BL mice survive continuous exposure to 100 percent oxygen for one week, and 18 percent survive continuous exposure for six weeks. All adult C57BL mice exposed continuously to 100 percent oxygen die by six days of exposur.. The time for the newborn mouse to becor.e “adult” in its mortality response to continuous exposure to 100 percent oxygen was investigated by allowing newborn C57BL mice to live in room air a predetermined period before exposure. The age at which the newborn mouse becomes “adult” in its riortality response was gauged by using death by six days of exposure to define “adultness”. The littermate mixing and assignment to a “standard litter” were done i a standard fashion. Preliminary results indicate that the change to “adult” mortality response with continuous exposure to 100 percent oxygen occurs between 14 and 28 days of life, approximately the age of weaning. Identifi-

AJR 132:305-308, C



February Roentgen

1979 Ray Society

and Pulmonary Massachusetts

Agenesis: MedicaV Center,

The radiologic features of unilateral pulmonary artery agenesis are often sufficiently cnaracteristic to allow a plain film diagnosis. They include a small hemithorax, ipsilateral displacement of the mediastinum, and an absent corresponding pulmonary artery. A source of collateral blood supply is the bronchial circulation, which produces a branching reticulated appearance in the lung fields. Larger confluent shadows are also encountered in pulmonary artery agenesis, and their presence is often ascribed to bronchial collateral circulation. An examination of six cases of unilateral pulmonary agenesis (5 right, 1 left) revealed peripheral hazy confluent densities in association with pleural thickening in 3 cases. Aortography disclosed extensive intercostal and subdiaphragmatic transpleural collaterals which fori,ed telangiectatic networks within the pleura of the oligemic lungs. The telanyiectasia corresponded to the peripheral areas of increased density noted on the plain film. In two instances, rib notching was present. Others have described similar densities, but restricted to the apices, in patients with cyanotic congenital hear di sease. Thus, the development of pleural telangiectasia appears to be a non-specific response to profounu, long-standing pulmonary oligemia. An assessment of collateral blood supply in such conditions should include examination of the intercostal circulation as well as any contribution from transdiaphragriatic collaterals. The appearance of these pleural collaterals is sufficiently characteristic to serve as a helpful clue in the radiologic diagnosis of


as a Factor W, Petriceks CA 94305)



0361 -803X/79/1322-0305





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pulnonary artery agenesis. Pleural telatigiectasis in association with any cause of prolonged pulmonary oligemia indicates the presence of significant trailsp1 eural col laterals. flembranous Laryngotracheobronchitis (liembranous Han B, Dunbar JS, Striker TW (Children’s Hospital Medical Center, Cincinnati , Oil 45229)


The clinical and roentgen findings of ordinary laryngotracheobronchitis (croup) are well known. We have studied twenty-eight cases of membranous larynyotracheobronchitis (membranous croup). It differs in the following respects from ordinary croup: 1. The clinical findings are more severe. 2. It tends to affect a slightly older age group. 3. The subglottic obstruction shown radiologically may be more severe. 4. The mucosa of the upper trachea may be thickened and irregular. 5. The detached or semi-detached membranes, formed of mucus, inflammatory cells, and fibrin, may be visible in the upper trachea and are diagnostic of the disease. If their nature is not recognized, they may be mistaken for foreign bodies. 6. Probably membranous croup is due to bacterial infection, alone or superimposed on viral croup, since pathogenic bacteria were usually cultured from tracheal secretions or membranes. Furthermore, most patients did not respond to racemic epinephrine but did respond to antibiotic therapy.


pattern. colloid


Serial appears

radionuclide imaging useful in documenting



the leisature






PS, bnaldson



with sulfur recovery.

Renal Growth In SS (Stanford Univ.,

CA 94305)

Recent reports have drawn attention to adverse long-term effects of radiation and chemotherapy on renal function in

children. Little is known of the effects of chemotherapy on renal growth. Our observation of two children treated for Wilms’ tumor in whom normal renal compensatory hypertrophy failed to develop following nephrectomy, whole-abdominal radiation and chemotherapy with Actinomycin-D (AMD), Vincristine (VCR), and Adriamycin (ADR) prompted us to study the effect of AND, VCR, and ADR on compensatory growth In the Immature mouse kidney.

Weanling kidney doses


BLcF1 female

and initial

of (LD1) of five consecutive

mice underwent




body weights

were recorded. Minimal lethal AMD, VcR, or ADR were given Intraperitoneally

days starting




Control animals followed an identical protocol but received intraperitoneal saline. Mlmals were sacrificed 3, 5, 8, 14, 21 and 28 days after nephrectotny. At sacrifice, right kidney and final body weights were compared to left kjdney and initial body weights, and measurements of kidney “H-thymidlne uptake, DNA and protein concentration re obtained. AMD


8 days ; body growth






and body growth, proportionatety

VCR Inhibited



with exceeded growth






body growth; recovery occurred by 8 days. ADR Inhibited kidney growth for 21 days; body growth inhibition persisted at 28 days and was proportionate to kicktey growth inhibition. 3H-thymidine uptake was decreased at 5 days and increased at 14 days with AMD, VcR, and ADR. DNA concentration was diminished at 8 days with AMD and VCR and increased at 8 and 14 days with ADR.

Appendiceal Abscess and the Pediatric Cul-de-sac: Barnes JC, Kirks DR, Currarino G Children’s Medical Center, Univ. of Texas Southwestern Med. School, Dallas, TX 75235)

Protein concentration was increased at 3 days with AMD, decreased with VCR from 3 to 14 days, and unchanged with ADR. Thus, AMD and ADR inhibit compensatory renal growth and body growth in the limnature mouse. VCR selectively Inhibits renal growth. Renal growth inhibition with AMD and ADR is related to

Appendicitis in children is sometimes complicated by a large mass of purulent material in the cul-de-sac, the peritoneal recess found between the bladder and the rectum in the male and between the uterus and the rectum in the female. The symptoms and physical findings usually point to an abdominal process but r.iay be too vague to permit exact diagnosis. Other entities are often mimicked. For this reason, radiographic procedures are requested, especially urographic and gastrointestinal studies. Once diagnosis is suspected, confirmation can be obtained by simultaneous cystography and barium enema with the patient in the lateral projection. Sonography and computed tomography also help. lie present 17 such cases, 4 representing abscesses forming after appendectomy, the other 13 developing before operation was undertaken.

generalized body growth suppression, and with AMD, VcR, and ADR to a delay in the mitotic response to contralateral nephrectomy. (Supported by the James Picker Foundation, Grant No. 830, from the American Cancer Society, California Division, and

Veno-occlusive lepatic Disease in Acute Myelocytic Leukemia (AML: [valuation by Serial Liver Imaging: Harcke HT, Naiman JL, fluff DS fSt. ChrTstopher’s Hospital for Children, Philadelphia, PA 19133) Veno-occlusive disease of the liver is a recently identified complication of chemotherapy in patients with AML. Serial liver imaging with Technetium-99m sulfur colloid was performed on .4 children with AIlL (total of 12 studies) who developed hepatomegaly and abdominal distention following chemotherapy with daunorubicin,ara-c, and thioguanine. All had a marked increase in liver size and decreased reticuloendothelial activity in a patchy, non-homogeneous distribution. Splenomegaly and increased marrow uptake were present. Biopsies revealed intense congestion around the central veins, thickened venous walls, and hemorrhage but no significant leukemic infiltration. The










The Whitaker Test: from Nonobstructive Children’s Medical

Differentiation of Obstructive Uropathy: Jaffe RB (Primary Center, Salt Lake City, UT 84103)

The Whitaker test, a urodynamic nd radiographic study, has been utilized recently to evaluate persistent upper urinary tract dilatation after operative correction of obstruction. This test helps to differentiate patients with residual or recurrent obstruction from those with dilatation secondary to permanent changes in the musculature. It is also useful in evaluating patients with questionable ureteropelvic junction obstruction or primary defects in the ureteral musculature, as in the prune belly syndrome. Percutaneous puncture of the renal pelvis is performed, or an indwelling nephrostomy tube is used. The upper urinary tract is then perfused at a constant ratu of 5 to 10 cc/mm with saline or dilute contrast material, and serial pressure recording is riade in the renal pelvis and bladder. The high flow rate utilized will be tolerated easily in a nonobstructed system without a progressive rise in renal pelvic pressure. In obstructed systems abnormally high pressure (above 12 cii of water) or a constant rise in pressure will be recorded. Videotaping of ureteral peristalsis and spot films of the upper urinary tract complete the evaluation. The utility of this study has been shown by a series of 10 examinations in 7 patients. 10 coniplications have occurred.


institution of therapy. Follow-up studies over b to 8 months remained abnormal, but in all 3 patients the liver size diminished and the colloid distribution within the liver became more homogeneous. Reintroduction of chemotherapy in one patient produced an exacerbation of toxicity in that the liver enlarged and the colloid uptake diminished. Veno-occlusive disease must not be mistaken for leukemic infiltration. The diagnosis is suggested by the acute onset, the drug history, and the image

The Uroradiographic Lvaluation Seibert J, Redman J fArkansas Little Rock, AR 72201)

of the Lnuretic Chilu: ChildrenTs liospitiT

In an effort to decrease the number of enuretic children undergoing radiologic examination without diminishing the chances of uncovering important anatomic abnormalities, we have standardized our approach. Over a five-year period, 138 children were

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evaluated uroradiographically. Twenty-one children had a significant anatomic abnormality. These abnormalities were found only in children with 1) a history of a urinary tract infection, 2) infected urine at the time of examination, or 3) obstructive signs or symptoms. A simple algorithm allows separation of those few enuretic children likely to have organic problems from the riany with virtually no probability




The So-Called “Megaureter-Megacystis Lebowitz RL, Willi U (Children’s center, Boston, MA U21l5)

Syndrome”: Hospital Medical

The “megaureter-megacystis syndrome” is not a syndrome. However, this term has been used for at least 25 years to describe a group of children with





a very




21 children will be presented with the so-called “megaureter-megacystis syndrome”. All were boys. They ranged in age from 1 day to 13 years. They presented in various ways including urinary tract infection, abdominal mass, increasing abdominal girth, abdominal pain, dysuria, hematuria, and failure to thrive. The diagnosis could have been made in each case by means of intravenous urography and fluoroscopically monitored voiding cystourethrography. In all, the underlying problem was massive vesico-ureteric reflux, either unilateral, bilateral, or into the lower moiety of a duplex collecting system. The reflux often mimicked function at urography The function of the bladder, the bladder neck, and the urethra were normal in all. Apparent poor emptying of the bladder and the belief that there must be some underlying obstruction were common diagnostic misconceptions and led to many unnecessary operations. Anti-reflux surgery alone would presumably have resolved the underlying problem.

Coriparison of Radiologic Methods for Measuring Anteversion in Infancy and Childhood: O’Connor Mital MA, Ruby L, SpiraJ (Boston City Hospital, Boston, MA 02118)

Femoral JF,

The presence of excessive anteversion is a common clinical problem complicating the measurement of patients with congenital dislocation of the hip, Legg-Perthes disease and in-toeing. Several techniques for measuring femoral anteversion in living subjects have been described and are in use. We measured the accuracy and reproducibility of the fluoroscopic method, the bi-plane radiographic method, and the axial roentgenographic method with an experimental model and have also measured the clinical reproducibility of these methods in 64 patients. All three methods are reasonably accurate, the fluoroscopic


the others in graphic method

Arthrographic Avascular (Newington



experienced hands. carries the least

Evaluation Necrosis of Children’s



cartilage flattening over the ossification center fracture occurs. Uith time, this localized incongruence becomes larger, and the normal femoral head sphericity changes to a more ovoid configuration. In intermediate stages, the cartilaginous femoral head outline usually retains its surface regularity despite extensive resorption of the ossific epiphysis. In later stages, lateral growth and extrusion of the cartilage beyond the acetabular labrum may occur. Repeat arthrography in selected cases has shown cartilage remodelling as a confirmation of the biological plasticity of the growing chondroepiphysis.

Coracoclavicular Fracture Separation The Pediatric Equivalent of Acror#{241}ioclavicular Separation: Reed HIT (Health Sciences Children’s Centre, Winnipeg, ManitobaCAN R3E OWl


bladder without obstructive uropathy. It was thought that the large bladder was responsible for the reflux, but this cause-and-effect relationship is an illusion. These children simply have massive vesico-ureteric





The bi-plane radioradiation hazard.

of the Joint Cartilage in the Femoral Head: Ozonoff MB Uospital, Ilewington, CT 06111)

Since plain roentgenography of the hip fails to delineate the critical femoral head and acetabular cartilage interfaces, these relationships were studied by positive contrast arthrography in 185 patients with idiopathic avascular necrosis of the femoral head (Legg-Perthes disease). Measurement of the depth and diameter of the involved (as compared with the contralateral normal) cartilage reveals that overgrowth of both femoral head and acetabular cartilages occurs very early in the course of the disease, even before symptoms occur, and continues for many months or several years. In most instances, this cartilage overgrowth explains the apparent subluxation of the ossification center seen early in the disease; in other cases, actual ‘lateral displacement was present. In the earlier phases, minimal but definite

Shoulder dislocations, including acromioclavicular separations, are rare in children. However, one injury in older children is quite similar to an acromioclavicular separation. The injury comprises a fracture, sometimes through bone, sometimes merely through the cartilaginous tip, of the lateral end of the clavicle. Radiologically the acromion and clavicular tip are depressed with respect to the shaft of the clavicle, The lateral fragment of the clavicle remains with the acromion because the acromioclavicular joint is essentially intact. The coracoid is displaced downward from the clavicle, and the coracoclavicular ligament is torn or its periosteal attachment to the clavicle is stripped off. Since









injury ranging in age from 7 to 15 years. Eleven were boys. In all seven patients where the information was available, the injury resulted from a direct blow to the shoulder. In 4 cases the injury was severe enough to require open reduction and internal fixation. In the same period we have seen only 5 children with true acromioclavicular separations. A coracoclavicular fracture-separation seems, therefore, to be the pediatric equivalent of the acromioclavicular separation of adult life. An Efficacy Study for the Value of Comparison Views Extremity Injuries in Children: McCaufey RGK, Schwartz AM, Leonidas JL, Darling DB (Tufts Univ., Boston, MA 02111)


The radiographs of 300 children referred because of extremity trauma were reviewed prospectively by staff pediatric radiologists. Comparison radiographs (which heretofore were routinely taken in our department) were not viewed before diagnosis, which was based on the films of the involved side only. Tne need, if any, to view comparison radiographs before establishing a diagnosis was recorded, as well as any change in diagnosis caused by information gained from the contralateral side. Tnese cases were read later by two radiology residents in a simulated clinical setting; the comparison views were withheld unless requested. The medical record of each case was subsequently reviewed and the ultimate accuracy of the initial radiologic diagnosis verified. In 23 cases comparison views were considered necessary by the pediatric radiologists (8%). In some of these 23 cases, the comparison views changed an equivocal report to a firm report. Usually they were of little value. Similarly, the main value of comparison views for residents was to change the initial reading from equivocal to confident. Therefore, when radiographs for peripheral trauma in children are interpreted by pediatric radiologists, comparison views are seldom necessary. In the few cases when they are needed, they may be obtained after the injured side has been examined. This approach, which we are adopting, is efficient in cost and radiation.

Relative Lfficacy of Radiographs and Detection of the Skeletal Lesions of Parker BR, Pinckney LE, Etcubanas E, (Stanford Univ. , Stanford, CA 94305)


Recent scans

reports provide

Bone Scans in Histiocytosis-X: Goris ML

have suggested that a screening mechanism

radioisotopic for the



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detection of the skeletal lesions of histiocytosis-X and, in fact, may be more sensitive than skeletal radiographs for this purpose. We have reviewed the records of 19 consecutive, previously-untreated patients with histiocytosis-X seen over a five year period. Bone scans were not performed in five patients and only after therapy in another five patients. Scans and skeletal radiographs were performed prior to therapy, and within ten days of one another, in the remaining nine patients. One of these patients had no lesions identified by either modality. The scans and radiographs of three patients correlated precisely with one another. One patient with a solitary eosinophilic granuloria by radiography had a completely negative scan, while four patients in whom both radiographs and scans were positive had more lesions detected radiographically than by scan. Of the 34 lesions identified radiographically in these eight patients, only 12 were detected by the bone scan. All isotopically demonstrable lesions were detected on the radiographs. Factors such as age of patient, presence and duration of symptoms, number of lesions, anatomic location, and radiographic appearance did not correlate with the lack of bone scan accuracy. Our data suggest that the radiographic skeletal survey is a more sensitive detector of the bony lesions of histiocytosis-X than is the radioisotopic bone scan.

The Radiographic Features of Eosinophil ic Gastroenteritis (Allergic Gastroenteropathy) of Childnood: Teele RL, Katz AJ, Goldman H (The Children’s hospital Medical Center, Boston, MA 02115) The child with eosinophilic gastroenteritis has failure to thrive, a history of allergy or asthma, iron deficiency anemia, and peripheral eosinophilia. This report presents the radiographs of six such children. Pathologic change in the gastric antrum, present in all patients by biopsy, correlated with an abnormal air-contrast examination of the antrum; the affected children had an irregular, lacy antral surface rather than the smooth, bald surface seen in normal children. The small bowel in eosinophilic gastroenteritis is usually abnormal, though the mucosal thickening shown is non-specific. Much more specific is the combination of small bowel and gastric antral abnormalitTes. As a result of our findings, we encourage air contrast radiographs of the antrum in children suspected of having eosinophilic gastroenteri



The Diagnosis Knapp i, Del Infantil “La SPAIN)

of iatus hernia, IhoyoML, Diez-Pardo Paz” Universidad

Reflux and J, Martinez Autonoma -

Lsopha9itis: A (Clinica Madrid,

In the last twelve years, we have seen 1371 infants and children with hiatus hernia, 92 cases of esophagitis, and 89 esophageal stenoses caused by gastro-esophageal reflux. Since the radiologic diagnosis of hiatus hernia and gastro-esophageal reflux is reasonably standard, there is clearly a higher incidence of these conditions in Spain than in North America. Many of these children have required surgery. “Chalasia” is rarely diagnosed; most cases of “chalasia” actually have hiatus hernias.


Radiology and for Anti-reflux Sick Children,


Manometry Surgery: Toronto,




the Selection of Patients Cumming WA (Hospital for Ontario, CAN M5G lX8)

We reviewed the 42 patients who had anti-reflux surgery at our hospital in the past five years. All 42 had barium examinations, and 31 showed gastroesophageal reflux. 21 had manometric examinations, done with fluoroscopic monitoring, and 15 had lowpressure lower esophageal sphincters. All patients with low-pressure lower esophageal sphincters showed reflux with barium. 3 patients showed reflux with barium but had normal pressures. This suggests that barium may be better than manometry at detecting refl ux. In our opinion, the patients with symptoms suggesting reflux fall into three groups. Some have normal-pressure sphincters and no reflux by barium swallow; surgery is not necessary. Some have normal-pressure






these probably require non-operative therapy only. The last group have low-pressure sphincters and also reflux with barium; these probably need operation, especially if complications are severe.

The Dianosis Reflux lfl Fonkalsrud Los Angeles,

and Management of the Pediatric Patient: EW, Kangarloo I (U[A CA 90024)

Gastro-esophageal Smith LE, Byrne Sch. of Med.,


Between May 1977 and May 1978 105 pediatric patients presented with symptoms suggesting gastroesophageal reflux. Of these patients, 51 had recurrent pneumonia; 34 were subsequently shown to have gastro-esophageal reflux, as is described below. 53 patients were seen because of vomiting, and 27 were demonstrated to have gastro-esophageal reflux. done

Investigation using a

for combination

gastro-esophageal of barium




Tuttle (phi) test, and esophageal manometry. The diagnosis of gastro-esophageal reflux was considered established in 48 patients by demonstrating that two of these studies were positive. In 32 of the 48, both the Tuttle test and barium swallow were positive, in 12 patients the Tuttle test and nianometry study were positive, and in 4 patients the barium swallow and manometry study were positive. In a further 17 patients the barium swallow was the only positive examination, and in 7 patients the Tuttle test was the only positive study. 20 of our patients were medically managed. Of these, 11 patients are asymptomatic and 9 patients continue to have symptoms. 28 patients were surgically treated, and 25 of these remain symptom free, while 3 patients continue to have symptoms. We prefer to use the Tuttle test and barium swallow examination as complementary tools in diagnosis. Esophageal manometry seems less reliable and is in less routine use. We are concerned that there may be false positive findings from the Tuttle test and false negative findings from the barium esophagram.

Society for Pediatric Radiology abstracts: 1978 meeting.

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