New Concepts in Radiology: Update Course 2017

Hold it. Shockingly, this is one of the common questions I get, I get asked is how much radiation does one receive going through an airport X-ray scanner. Initially I, I, I didn't know if there was going to be scanning where you, where you, where you're punching the answer to the question. Um, I realize now that there is not. Um, so people are just, no, there is. Oh, there is. OK. Oh, OK. OK, OK. So let's see, we have to wait about, uh, About 20 seconds. So right now I can tell you it's about 50% of the people say B OK. Well, B is the wrong answer. hopefully no one says A because 6 sieverts is a lethal dose. 3 millisieverts, that's really a good number to remember actually because that's the amount of radiation you get from walking on the Earth from radon in the ground, from cosmic radiation. And actually that's that's also a good number because that's the kind of the average range of a normal CT scan in a pediatric hospital is about 1 to 10 millisieverts. So a lot of times it's easy if you're getting a chest CT that may be 1 or 2 or 3 millisieverts. It's basically the same amount of radiation you get from being on the Earth for 1 year. And the X-ray scanners at the airport are 11 nanosieverts, which is actually 11 billionth of a sievert. So they're they're they're very ultra low dose scanners. This is the next question I have for people. So, um, what I, so Mike, we'll talk about it here while we're waiting for the virtual audience because it's about a 20. So what, so, um, let's go back to that last question you just showed, uh, it's the bottom arrow goes back. Thank you. Go back, go back, there you go. So how worried are you that a CT scan in children will cause radiation induced cancer in the future? So I can tell you in our group we all radically disagree about this. OK? So, uh, Dan, what are your thoughts? I would say it's uh very low or not at all, and it's based on, uh. The fact that we don't, I don't think there's good data on that, and I think that the technology has improved dramatically, and I'm not sure where your talk is going, but I know in our institution, you know, I think the radiation exposure from a CT scan with the new image gently criteria and such is dramatically less than it was before. That assumes that you're in a pediatric institution that's giving pediatric doses. So does anyone disagree with that? Speak now or forever hold your peace. Yes, I'm still worried, and I'll tell you, I was, I was a little, I wasn't super worried when the original studies came out because it was all based on atomic atomic bomb data. But then when the data came out talking about your risk of a childhood malignancy from, from a childhood CT scan. Um, then I basically had to say, all right, wow, how much, how much radiation are we giving these little brains? And so, um, so yeah, I'd say I'm, I'm more concerned than I was 10 years ago when I first started becoming concerned. Now David, 53.8% of the virtual audience agree with you. So most people are custodian. I'm used to people not agreeing. I agree with you though. So was, was, um. Uh, was that a B answer or a C answer? That was a C. OK, I was, I was in the B category, OK, me too, but I must, I must tell you that I am concerned that we're bending over backwards not to do CT scans and so there's risk to that and there's risk to that too. So I think we need to, we're in a. In a transition period that we need to find a good medium between a concern of days and no no concern at all. So, so I'm a C, but I'm concerned, but I do think that as we have other modalities that don't have radiation, given the choice between radiation and no radiation, I'd rather have no radiation. And there are other modalities, you know, we're we're talking in our institution about not just the ultrasound, uh, contrast because that looks like it's very promising, but also how can we get a rapid MRI. Mhm. All right, so Mike, what are your, what are your thoughts? Yeah, and, and you know, initially when the, when the, when the, the first studies came out back in 2001, uh, which they, which they compared to atomic bomb survivors, um, you know, you know, I, I was very concerned. Obviously, the entire pediatric radiology community was very concerned, and I've actually over the last now 15 years in, in reading almost most of the literature that comes out in radiation safety, I've really moved to just being a little concerned, um. I agree with that and, and, and, uh, the old, the old guys. By the way, let's see here. I'll just kind of move some of these forward just because I think it'll take too much time, but this is a position statement that came from the American Association of Physicists and Medicine, and, and this came out in 2011, and I'm actually more on board with their statement that that the. Medical medical imaging at doses of around 50 to 100 millisievers, which are actually much more than a routine CT and would be multiple CTs, maybe the, the risks are are are are low and maybe non-existent, and they basically then followed up saying that um you know, predictions in the media are very essential to LaSI and and. Um, cause patients to possibly not get the clinical benefits from a CT scan. So I've actually kind of swung from being very concerned to just being a little concerned, you know, a lot of the things too, when you look at CT, I mean we should be judicious, but the new CT scanners that we have are so much lower than they were in the past. You know, most pediatric institutions are trying to do lower and lower CT doses. Some of our doses for limited sinuses are, are actually lower than the sinus X-rays that we use. So um I'm actually much less concerned than I used to be. And here's the next question, your institution, uh, following a tube of your chest for a foreign body in the ER, what is, what is typically done next? So let's just take this. So this is a kid, uh, parents say he was eating something, started coughing, uh, and they got a two view, uh, chest X-ray. So, um, I said, what does the ER do? Not, not necessarily what you guys would do, but most of the time, at least in our ER, the, the ER has, is, has moved to the next image, uh, has done, uh, something else. So what do you guys say, uh. Anyone here, so who wants to take a shot at this? Anyone here or faculty up there? So Dan or David, what's that? I would say A. You would say inspiration, expiration views, David. Um, I'll tell you what we do is inspiration, expiration dues. What we should do is just bronk them. Interesting. Bronk our institution, they would get a consult. And OK, bronc, just on the history alone, what are the symptoms? Are you concerned about an aspiration event or concerned about a clinical story concerning for aspiration. I assume this is bronch on history. Who says bronc on history? Everyone, what, what do you say? An exam, yeah, yeah, I mean, and what are you looking for on exam? So I, I think that if there is, if you hear something, if you hear some rattling or anything, and there's a, and there's a good history, I think you need the Bronx because the I mean the sensitivity and specificity of inspiration and exploration films are not perfect. Um, you know, I, because a lot of times we'll bring these kids in, we sort of him and ha, the films look normal. You watch them overnight and then you're like, well, maybe do we repeat the films? you just put a bronc in, put the thing to rest. Well, I feel a fight coming on because I, you're not gonna like what Mike's gonna say because I'll flip it around on it and you say physical examination doesn't help you because even if it's normal, it's not, yeah, well, so my answer was based on what the question says, what is done next, not what you would necessarily do next. Good point. So what is done next in the ER, I think, are inspiration, exploration view. OK, Steve Rothenberg, go ahead. So, and so as a kid he was blowing a balloon up in the backseat of the car and he's inhaled and coughed and mom can't find any remnants, may have popped, may not have popped, and So the ER calls me at 10 o'clock at night to come emergently bronc the kid. And they, and the kid, they, they did get the views. The X-rays are normal. The kid's completely asymptomatic, and I said, just send him to my office the next day. I see him in the office. He's completely asymptomatic. He's got normal X-rays. Um, he's got a totally normal physical exam, and you would bronk him. Based on that history, based on a history of choking, that's what Mom says. Yeah, I'd, yeah, I'd bronk that. Yeah, I, I would, I would never do that. Why, why, I mean, then you get into, well, should you give a kid an unnecessary anesthetic. So we're gonna I'll give you the, the, the contra case to that which is a kid who may or may not have aspirated a peanut. There's nothing, nothing's done about it because everything is normal. The films are normal, and 5 years later the kid comes back with horrible bronchi. in that lobe and needs a lobectomy. Well, I would argue that you guys missed something on exam. No, I'm serious. A peanut, and that's different, a peanut. I think it depends on what you think they've aspirated. So I would agree, peanuts and articles like that are much more suspicious, but this is foreign bodies, so I guess historically bad historians about what exactly went in, but it would be very unusual to have A foreign body of any significance and have absolutely no findings on physical exam. So Mike Bozos chest CT, wait, so, so this is clearly not controversial. So Mike, uh, talk us through this here. So, so finally someone said the right answer. Yes, and by the way, by the way, uh, the virtual audience, 47.8% say pediatric surgical consult, 26% say CT scan, 221% say. Inspiration exploration views and a non-negligible number said bilateral to QB. So go ahead. Yeah, so most institutions, you know, most ERs do, you know, if a child is able to cooperate, you do an expiration view. If a child can't cooperate, they're 123, you do the cube views. And what happened one night, I was on call. A kid came in, ruled out foreign body that the cube is film looked like there was air trapping out the right. I said, Oh, it looks like there might be a foreign body. It's suspicious. Um, so, so the surgeon came in, bronced him, and then as I'm sitting reading films from my office, I hear, you know, code blue ICU, uh, the child coded up there. Uh, the next day, I talked to the surgeon and the child did OK, just, just had a, had a quick code, but, but the bronch was negative. And so I said, you know, to myself, is, is there a better way? Is there something else we could be doing? And, um, And, and, um, you know, the bottom line, go back to that last slide, right, sorry, yeah, you know, the, the, I, I, I didn't know how this system works, no, no, bottom one, yep, keep going. Uh, it was 38 1 more back, one more back, yep, there you go. So, so in this, this study that, that, you know, 30 to 50% with a foreign body can have a normal chest radiograph, um. The next, this, this study talked about using decubits views and inspiration, exploration views, and basically, um, you know, with the cubist views, actually specificity went down, sensitivity didn't change. They didn't think they were of any benefit. Uh, the same paper did exploration views, although sensitivity improved. Specificity didn't help very much. And then I recalled um. Reading this article, it was back actually in 2004, where low dose CT in 23 patients for foreign bodies. They all got bronched right after the CT. All 15 foreign bodies seen on bronchoscopy were seen on CT, and there was no, no discordance between the two studies. You know, we talked about this in our surgery conference, and then we had a couple cases just shortly after that. This is a child, 4 days, 4 year old with 2 days of wheezing and may have choked on a peanut. Tub your chest was normal. The cubes were normal, and then gets a foreign body and you can see there in the bronchus intermedius. Let's see, is this the, the top button if you push and hold it, OK. Right, right, you can see the, the peanut in, in the main stem or in the bronchus intermedius. You can see the air trapping, which actually we commonly see. Here's the, the, the other view. Here's the, the, the foreign body sitting in there with the, with the air trapping. And then this is a 16 month old who may have choked on a hot dog yesterday. Uh, the chest view, a little streakiness on the right side. On the decubitus views, uh, there was no volume loss on the decubitus view you can see the right, there really isn't volume loss. It actually looks like the right lung. There might be some air trapping. Uh, he got a volumetric CT that was completely normal, uh, was diagnosed with bronchiolitis, and went home the next day, and hasn't been back since the CT. And so far, you know, we've had, uh, about 12 to 15 patients, um, that we've done volumetric CT for foreign body, uh, most of them are positive. We've had 4 or 5 negatives. Those haven't gone on to, to, to broning, um, so we've had a 100% concordance, you know, we'll, we'll get a false positive because there'll be some mucous plugging, there'll be some atelectasis. Um, the nice thing about these is the patient comes into the ER, um, our, our scanner sits in the ER. They can go right to the CT scanner. They get a low dose CT. They don't need sedation. They don't need an IV. Um, the scanner is so fast, even if they move, we found that we can see the foreign body. Um, Another real benefit for us is we have a hospital that's 60 miles away, and so if a child comes in with a foreign body there, they, and they're going to transfer him to our hospital, they're going to get a helicopter ride, they're going to get an ambulance ride if they have a high deductible health plan. We've had some patients get stuck with $5000 bills, um, and if you do the CT and there's no foreign body, um, um, they need to get transferred. The other thing is on call, you know, 234 in the morning, depending on who's doing the chest X-rays. You, you get a volumetric CT, it's negative. Um, you can be, um, you know, in our literature, um, uh, almost assured that there's not a foreign body in, in the bronchus or, or, or segmental bronchi, first order bronchi. So I really think that, that, that not in every patient, but certainly in patients, um, you know, it's a great, uh, it's a great tool to use to, to, well, let's see if they think it's a great tool. I think it's a great tool. Who doesn't like this? I like the idea. Um, you said no IV, so no IV contrast, right? No IV contrast, no sedation. And where, where can I find your, uh, your low dose protocol so I can have my radiologist copy it? Yes, you know, we, we actually give it out. It's, it's most, most people are probably using a protocol, you know. We have a 320 slice CT scanner. Most large children's hospitals have that, but, but whatever their dose is for chest CT, you can actually lower it because you're really not looking at the, you're not looking for tiny nodules. You're looking for that big foreign body sitting in the airway that's, that's going to look completely opacified. And, and you know, the most common thing that's taken out of our institution is vegetable matter, but. So, so David, let me, let me there are rarely things that happen that are major changes in protocol, and at our hospital this was one of those major changes that happened that, that we love. If you're going to go with the first part of the talk that CT scans may not be as concerning as we think. That a low dose CT scan may be a nice approach for suspected airway foreign bodies. So all of our kids now, most, almost all of our kids go ahead for suspected airway foreign body with history. Now if they're an extremist, they're going to the operating room, but a stable child that comes in with suspected history of airway foreign body is gonna go get a CAT scan. How many X-rays does it take to get up to one millisiever? Chest X-ray. A chest, yeah, yeah, a chest X-ray is, is, is pretty low dose. So chest X-ray is, is, um, 0, 0.02 millisievert. So, so 50, yeah, but that's, that's an irrelevant question. No, it's not because you told me that's irrelevant. It was 10 chest X-rays. If you get one, you get two views, you get a, you go to bronc, get a post bronc X-ray, you're up to 4 or 5. But, but you missed the key point is the bronc. So the question is how many broncs does it take? I mean, what the, the, what you're comparing is CT to negative bronc, right? And I would say if it was my kid, if, if it could have a low dose CT versus going to the operating room for a general anesthetic for a. Probable negative bronch or you know then I mean because if I have a super high suspicion you could probably just go right but if you don't know I would rather not go to the OR for a bronc. Now this is one of those things that we will probably be divided on this this always happens. Would you rather have a negative laparoscopy or for appendicitis or CT scan? Same thing's true here. So I'm wondering. Would people here like this protocol or not like this protocol? I'm Mark or Dave, what do you think? I think it's great. I love it, yeah, because you know, you, you, a lot of these kids, first of all, they, they have some respiratory symptom or you wouldn't be bronching them. So what you're talking about is an unnecessary general anesthetic and a kid bronchiolitis or asthma or something versus just a non-sedated quick CT of the chest. I mean that it's a no-brainer. You, you just brought up a great point. Not only are you doing a bronc, you're doing a bronc in someone who's probably got some pulmonary issue that's if they don't have a foreign body, they've got something going on with their lungs that the bronx's not gonna help, right? I will tell you my concern is sort of the same thing that we talked about previously about fast is that the ER docs are gonna be. Getting a CT scan on everybody who sneezes and as opposed to getting a pediatric surgery consult and some thought about it and then going to the CT scanner and and so anyway that's I think the, the algorithm, the, the algorithm change is when we would make the decision to go for a bronc. That's when it changes so they call us, we evaluate, we say this child needs a bronc to rule it out and at that point instead of the bronc we would get a CT. In other words, they've had to have made it down to the point where we were suspicious enough that they were going to go for a bronchoscopy. So this is a great, this is be a great longitudinal study. Say 5 years from now, look and see how many kids have gotten a CT for this concern. And see what the sensitivity is for that. I mean, so if you're, you know, if the sensitive, I mean if you're getting a lot of negative scans, it means you're overutilizing the technology, correct? And I would propose that with 5 or 7 senators it would even be a better study. So I would like to invite everyone here to join us in a prospective trial in evaluating this. Can you, uh, what can you not see? Can you see a balloon? You know, you know, well, the, the Legos are easy. The vegetable matter is easy. We, we've had a few things that, that. I'm trying to think of the, the few things, you know, there's been peanuts. Um, there was one that was just very subtle again, it came out as vegetable matter that looked just, just like a, almost looked like a ring um in there. So, so, you know, you know you've got that complete air in there. So really anything that's opacifying that air, so it'd have to be almost completely radial, you know. I'm trying to think of anything. So what about a? What about a Barbie shoe? Yeah, that's, that's, that was my favorite one. Yeah, you know, um, that, that again, just about any foreign body in there because it don't, the only thing you won't see is the same that has a sensitive of air. So you're thinking, well, what could they swallow that has air but no rim around it. So, but what you have, you know, what you have on the scans though is you can see the subtle hyperinflation, right? So even if there's just a little bit of air trap. Or if there's different differential aeration with any lobe or anything, I think that was pretty dramatic. Yeah, you know, and that's not always, but most of the studies have the air trapping too, which really helps too. Plus it shows you exactly where the foreign body is for the bronching, and, and we just thought, I just thought it's just such a nice tool to have, um, especially, you know, for the surgeon in case you're not sure of. Or you know, again for call or again for transferring from other institutions that they may have to come by ambulance or helicopter. So, uh, we, I want you to move on because I know you have more to present. Aaron Lipscar has one question. Yeah, I just wanna circle back, I guess, and ask the question or make a comment. It's great that you started by asking us what we, how we care about CAT scans and whether they cause cancer in children because whether we care, whether we believe it or not, we had this conversation more times than all of us wish we had to have with families, with our consultants. But to circle back to what, what David's question was, it, it is not irrelevant how many X-rays. Maybe we don't care, but our consultants are gonna care. Our our parents are gonna care, and, uh, you know, we can say everything we want about an anesthesia too. We don't have data that there's anesthesia risk, but our families are worried about. My only point was you're not comparing X-rays to CT. You're comparing Bronk to CT. That was the only point I was making. Because we need to have these conversations with the families then and go over that, the, you know, the for, for a long time to explain that, you know, uh, with cert with, with not certainty because when most of us said a little, not, not at all, that these X-rays or CAT scans are not gonna be harmful to the kids, right, uh, it's just that, you know, you're, it's, it's CT scan versus a kid. That has a pulmonary issue is going under a higher risk procedure and we haven't even got into the brain effects of general anesthesia, right? And we're not, right, that's not even getting into that. I'm just talking about doing an anesthesia, you know, they don't like to do anesthesia in kids that have a cold, so doing it under someone who's got respiratory symptoms enough is, is could be harmful. All right, Mike, what else you got? OK. And then this question, I, I, I, um, at your institution are late attempts done for unsuccessful first attempt interception reductions. I would say almost always, yeah, always, unless, unless we did talk about this last year, so we'll go quick. Go ahead. What was that? Almost always if the patient has peritoneal signs or they're unstable in some way, uh, or there's concern about perforation from the initial reduction attempt, we wouldn't, but almost always we do a delayed. Uh, attempt at reduction. Sometimes they're even admitted overnight and try again in the morning. So is there anyone here that does not get a delayed attempt, so you do it, it fails. Does everyone here try it again? Well, I would say that the, the small subset that is probably not helpful is the one that the there's no difference by doing it the first time. There's no movement in the in the septum, uh, and if there's no movement. Then I'm not sure that delaying it's going to cause and and redoing it's going to cause movement. Mike. Now, having said that, most patients, there is movement of the innois up, but the benefit is you may get a different radiologist in the morning that's more comfortable. So I think that's the real-time issue that we face. So, um, who has a protocol and who just does it? We have a protocol. We don't even get called. The, the ED, they won't do an, yeah, they send them for a reduction attempt and if. If it fails, they're admitted to the Jin Ped's team and they attempt reduction in the morning and we're only called if that fails. wow. All right, I got, I got why are they admitted? I admitted for an attempted, a second attempt at reduction. So who admits them if they're, uh, if they're successfully reduced? They're not by radiology. They go home. Anybody admit them. We send them home, 4 hours of observation. So when we published a paper about the success of 2, Attempt, our radiologist said, Well, does that mean I cannot come in at 3 in the morning and I can come in at 7 in the morning for the first attempt, delayed first attempt. You know, always thinking, you know, well, first answer one question, um, I would agree with the movement. I found, you know, if that, if that interception is in the, you know, sigmoid colon or splenic flexure and you try it for 3 minutes, uh, you know, 3 times for 3 minutes and it doesn't move at all, I, I found the second attempts really are worthless, you know, that, that baby's stuck. It. Not going anywhere, just about anything else, as long as there's some movement, you know, we always try, we'll always try a second attempt. And again, if you get movement all the way to the ileocecal valve, then usually the second attempts I found are, are mostly are positive. For us, it really depends. Usually at night, you know, it's about an 1 hour delay because if it's me, I just stayed for the hour and then I, I try again. Um, during the day, uh, typically a patient goes back to the floor and by the time we get him back down it's usually 2 or 3 hours, um, and that was actually one of the questions I was going to ask because you know when I was first. When I was first training, um, let's see. That was optimal time, but this was the next question. Is there. Is there a certain time that the first attempt can wait until the morning and you know when I was first training, a patient came in at midnight or 1, had acute appendicitis, the surgeon came in did surgery, and all of a sudden, you know, time showed that it didn't matter, it could wait and be done the first thing in the morning and You know, I would say certainly after 6:00 a.m. I think probably first time in the morning is OK. Um, I don't know what other people think. I just put this in there because nothing, there's only one PS radiologist here and so many pediatric surgeons, um, I, I was, you know, um, right now we come in and do them as soon as they come in, um, usually after 6 we'll say just wait till first thing in the morning, but I don't know if any, if any institution here is waiting till first thing in the morning. I impedes radiology. Most people are again trying it right when they come in, and then if it's unsuccessful, a lot of people are waiting to do the second one first thing in the morning, depending on the initial time. I sometimes worry that if you wait 56 hours, that if you move it, the old cecal valve is going to be back where it was before. I don't know what what if anybody else is any institution here is having where they're just doing it first thing in the morning. Uh, 52.9% said never. Uh right, right, that's true. And then there was, uh, 22.2% that, well, now it keeps going up 2 uh 26% said after 6 a.m., you're right, so between, so 26 plus 50, so most people say 6 a.m. at the latest. No, I don't disagree with that. So was there, was there a study that, that, that, that showed there is an optimal time to no, no, there wasn't do the second attempt. I, I haven't seen that. And, and you know, the, the, the papers I read, you know, a lot of places, some places it's 15 minutes, some places it's it's an hour, some it's 2 or 3, and then some it's, you know, the next morning, which is any variable part of time, and I haven't, it seems like most people it's around 50% success rate, you know, give or take 5, 10%. Um, is there data? Our protocol is they'll do it up to 3 times. With several hours in between each attempt, you know, I, I didn't run across that. What we're typically doing is the first attempt and then anywhere from probably 1 hour to a few hours later for the second time, but we aren't doing a third attempt. And then this, this question at your institution oral contrast for CTs, how often is it given? I'm not. Very rarely I'll tell you there's really in trauma there's really good studies showing that you don't need oral contrast, and I, there's nothing as a trauma surgeon, I think there's nothing worse than than taking a patient who's had an abdominal injury and filling their belly full of contrast when you may have to operate on them. I just, I hate that. And good studies showing that we don't do it for trauma. Um, is this specifically for trauma or just for anything? I think it depends on, so I would say for selective select cases, and that's what 55% of people, we don't use it for trauma or for appendicitis, but like a partial small bowel obstruction we might give contrast. We do it when the radiologist makes us, yeah, yeah, and, and, and actually I disagree with some of my colleagues at, at my place. I think it should almost never be given for anything, um. Uh, this is a nice example. Um, you know, this was a nine year old male with past medical history, um, with, with, uh, everybody had gastroenteritis. He wasn't getting better. He had this film that, that's a little concerning for obstruction, um, but, but everybody had gastroenteritis. I get a CT scan and, um, you know, you can see here in these kids, you, you've got, especially the ones that are for partial bowel obstruction or bowel obstruction, you've got, you know, fluid is, is your. I is your contrast agent. This patient had a Meckels you can see right here. Um, it's hard to see the over here is the, the more distal loop of ileum coming out of it. It was actually twisted around the Meckle it was phal mesenteric cyst, but you know this patient came in after the X-ray. He gets the CT scan, um, literally within minutes and you have an answer, um. This is a patient and this happens to us all the time for rule out abscess, you know, the patient, uh, we do, we do where they get contrast 1 hour or 2 hours before, 1 hour before, 30 minutes before, or else 32, and 1 hour before. Uh, and this is the history. This kid got contrast 32, and 1 hours before. It's all sitting in the stomach. When you read the note, he was throwing it up, put an NG tube down, you know, these loops of all are pacified. None of these distal loops are. Here's actually the abscess sitting in the low pelvis, nowhere near where the contrast is. Uh, the other thing that happens in our institution too is they order the CT at 10. I protocol it. The contrast at 11 comes from the pharmacy. The patient doesn't want to drink it. Then they call. Do we need a nasogastric tube, and they call for an order for that. The patient vomits some of that up. And then at 4, 4:30 they're scanning instead of they, they call at 10:00 and at 10:30 you're done with the scan. Um, true. Wait that oral contrast leave the data that oral contrast helps in partial small bowel partial adhesive small bowel obstructions. You know, there are a few things where it can be helpful, you know, most of the time, and actually when I first came in here, I really was panicking because this is my preliminary slide presentation, not my final one, and I had a couple of ball obstructions and You, you know, certainly the higher grade are are easy, you know, if the patient's had multiple bowel surgeries, and, and, you know, I still think CT is the way to go because usually still on a partial obstruction you can see the transition zone. Um, I, I, I, I felt bad I didn't have the case in that, that I had before, but it, it's just, you can, if, if you get a CT scan, usually you'll see those, those proximal loops are just a little more dilated than the distal loops, and they'll contain some fluid. So. There were 2 papers and a Cochrane review that they did of those two papers of these suggestions that it's actually treatment that it helps treat an adhesive small bowel obstruction that you watched. I don't think they were CTs and I think they were small bowel follow-throughs, so. I keep hearing from people in the community to use the CT scan and just use that oral contrast in a treatment method, and I, I don't know if that's really true, if that's a meaningful thing. I, I, I haven't really seen that in the Peach literature. I know for adults that there's some people that, that, that, that that's being done. I, I haven't read that literature close to really know the right answer for that. It's just, you know, I've just found. And so when I'm on the, the CT MR body surface there by my at Akron, when I'm on, I, I never give contrast now for, for, for CT scans, you know, again, there's a few exceptions, you know, if it's an enterography for Crohn's because they can't, we usually do MRI, but sometimes you can't. Insurance. I'll do it for that. In the kids less than age one, there's just so little mesenteric fat. Sometimes that's helpful, but I typically have found it really doesn't make a difference. In fact, I've challenged our group, show me a case that's made a difference. Um, and Erin, we, we use for a bowel obstruction. I mean, I guess it's not therapeutic, but we'll, we'll do an MRE for a bowel obstruction too because I think that gives you a lot of information as well. I don't know if it's any different than it's non-contrast CT, but. You know, it's, it, it, it's, you've got the same principle. You've just got a longer scan and so, um, you know, for, for patients coming to the ER, it's not as practical or kids that need to be sedated for it. Are you giving, uh, glucagon or are you giving anything for if you get an MRI for a bowel obstruction? Are you giving any medications to make it more, uh, uh, clearer, or are you just doing a regular? Well, we ordered is an MRE and what they do beyond that I actually don't know. Yeah, I, I, I, I doubt they would give glucagon for, for, for the question of bowel obstruction, but, but that would hurt. What, and what do you do for your typical MREs? Typically, almost all our MREs are, are really for Crohn's disease. So we actually don't give glucagon, um, where we're at. But, but I would say that, you know, 50% of, of public children's hospitals do, 50% don't. She's she. How many scanners do you guys have? I don't think she, so we have, uh, what do we have? 2 or 3 MRIs, but I mean they are, but they're hard. It's hard to get them though because they're cranking. I mean they're literally cranking 24/7. I mean it's just the volume of imaging is just spectacular. We're in the same situation, which is just, it's so hard, you know, yeah, you, you need an MRI scan and they're like, Well, who are we gonna bump? Yeah, yeah. And then if you, if you order one electively, it's, it's being done at 10 o'clock at night. Yeah, let me ask you a question. So in today's world, and I don't need the absolute numbers for dollars, but how much more expensive is an MRI versus a CT? You know, I, I I'm gonna guess it's, it's a, it's, it's double to triple, roughly plus you have to add to that potentially sedation if it's a if it's sedation, yeah, yeah, you know, you know, a good number is, is typically kids 6 and under need sedation for an MRI. Typically 7 and over don't, um, you know, the again, the only issue for, you know, we haven't done too many appendicitis MRIs in our institution. We're still, you know, I mean, we do ultrasound first. We'll, we'll, um, we'll, uh, Uh, if they're negative, the surgery typically will follow up with the CT if they're worried, um, but, but an ultrafast MR for, for appendicitis, you can get. Most of the problem with those studies is, is the time to get the patient on the table, get the coil on them, get them relaxed, then you can do, you know, sequences in about 6 minutes, but a lot of the time it's the table prep. Again, CT is just so much faster, um, and, and under the age of, of 6, you don't, you don't need sedation, so. And an ultrasound is a lot cheaper, yeah. So does it, can I ask a potentially heretical question, which is, does anybody operate on bowel obstructions anymore without getting a CT? It's a great question. It, I always chip at our, you always get a CT fellows and residents when some kid comes in with a clear bowel obstruction just go straight to the OR and they go to the CT scanner. I'm like, why don't you just take this child to the operating room. So I, I, I guess it, yes, I would operate on them without a CT scan. I don't stand, can you stand up because we can't see you. Sorry. Yeah. I mean, I, it, it depends on the clinical setting, but I mean, I, generally, I, I wouldn't operate on a kid with a bowel obstruction immediately as long as I thought they were extremists. I would try to decompress them. For 24 hours to see if it's partial and they improved, but then I would need a CT scan to. If they didn't improve, would you get a CT or would you take them to the operating room? If I, and I already had X-rays that showed a significant air fluid levels and no, I'd just operate on them. I'll say, Dan, you know, one of the reasons that, and, and I'm, I'm an advocate of getting the, the CT scan, but one of the reasons I'm an advocate for it is I think that periodically you're gonna have a kid who's twisted and you're gonna pick it up and you're not going to give that guy, that child a, a trial of non-operative management. You're gonna say, look, those vessels are swirling. We're going to the OR right now. So what's the accuracy? How accurately can you determine whether bowel's twisted on the CT? Um, you know, there's, well, I mean, in the past few years, you know, we've had several that, you know, you can see the mesenteric, you know, especially with, with the volumetric CTs and all the reconstruction, you can actually see the vessels swirling. Um, we've had a couple closed loops that, you know, you just see this big fat loop, um, mid the wall may or may not enhance. So, so I think in, in, I'm trying to, you know, give a rough in the thing in, in, in what we've called they're suspicious for either malrotation or. Um, closed loop, um, clinical correlation recommended. Well, you, you know, the, the last one, I actually try to call closed loops, and anytime I think it's Malroad, we, we think it's Malroad. So we've probably had, I, I don't know, Todd might have a good number, probably 12 that I can think of in the last couple of years that the CT showed that, you know, we had a colonic volvulus. We had several, not, not mid-gut volvuluses, but, you know, there was a, a defect in the, in the in the momentum and the loopid ball had went in there, um. We've had a, um, so it's been nice because the case I showed that wasn't there was a kid that came in that the plain film really he had a history of surgery, uh, 9 years prior for appendicitis, got a plain film that really didn't look too bad. And they'd ordered an upper GI small ball follow through. We ended up doing literally within a half hour did the CT. He had a closed loop, um, and dead gut and went to the OR within 30 minutes. He wouldn't have even been from the ER to our department because to transfer. So, so that's, that's the one nice thing I think about CT scan is it's just, you know, the patient's in the ER and literally you can know the answer in 30 minutes. I'm not saying that it's a definite high grade obstruction, you shouldn't, you know, you need to get a CT scanner, but, but, um. Um, I would always do CT, especially before any type of small bowel follow through if, if the patients for partial obstruction, but, uh, what do, do people people here convinced that we prob, you know, this is a big thing, we don't need oral contrast very often and we use it all the time. So, uh, does anyone here disagree with this concept? So we've already. Was any, or were you guys already barely using oral contrast? barely using, yeah, barely barely using my IVD patients or either enterography, enterography their MR enterography or oral contrast on a CAT scan for that indication, but in general I agree. My, oh yeah, definitely for, for, for, for Crohn's disease for MR enterography you have to. stem the bowel. So, so, so, so there are a few indications, but you know, for these, a lot of these kids that come in generalized abdominal pain, um, and, and we get a CT, uh, especially in those, you know, I, I think oral contrast has so little value. OK, great. Any last points or are you done? I think we probably could stop there. So, OK, so thank you, Mike. Uh, I'm gonna actually, sorry, Mark, I'm gonna walk up here. I, I, I think you see now why I wanted to invite Mike. I mean this was, these are, these were kind of two game changing things for us. I was using oral contrast anytime I was trying to rule out bowel obstruction, which I was taught that that's unnecessary, that the, the bowel fluid is a good contrast agent. And uh and the the airway foreign bodies is that we really don't go straight to Bronx we will get a CT so those are the two big take home points and the repeat delayed reduction for interception.