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Log Of 6/15/97 session
Hydronephrosis With Rama Jayanthi from Columbus Childen's Hospital
Session Start: Sun Jun 15 14:21:20 1997
* Logging #pediatrics to: [#pediatrics.log]
<german> Rama...does the vesical badfunction still after birth?
<JuliusE> welcome vulic from Croatia
<Rama> 10 mm pelvic separation may be considered hydro but I think such definitions are arbitrary.
<Rama> German: There is transient poor bladder function after birth.
<german> and you can detect it thru urodinamic test?
<Rama> I think the important point in diagnosing obstruction is that serial observations have been made on the
kidney.
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<JuliusE> Bienvenidos to International Pediatric Chat cajuntex
<Rama> One cannot diagnose obstruction at one point in time.
<gino> It sounds like all newborns with antenatal hydronephrosis should be w/u for obstruction.When (age)do you
start the w/u?
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<JuliusE> welcome chris
<Jim> Does the country doctor do serial US or what? How often?
<Jim> Are my questions coming through?
<Rama> If a child has unilateral hydro, I think all bables need a post-natal US and a VCUG for starters.
<Jim> I can't tell.
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<JuliusE> Bienvenidos to International Pediatric Chat christoph
<Rama> Jim: One has to individualize based on specifics.
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<JuliusE> Bienvenidos to International Pediatric Chat Joyce
<JuliusE> welcome christopher from gernmany
<Jim> Thank you...
<christoph> hello dr. julius
<Rama> Jim: Perhaps at the end I could comment directly about your patient.
<Vlady> what is w/u
<Vlady> ?
<gino> work up, sorry
<Jim> I don't suppose a country pediatrician would be following one of these kids without the help of a
nephrologist or urologist. I don't have a specific patient.
<gino> w/u=work up
<JuliusE> What are the differences between hydro in neonates and older kids?
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<JuliusE> Bienvenidos to International Pediatric Chat Phill
<Rama> Work-up at the very least involves an US and VCUG. I feel strongly that all babies with antenatal hydro
should have a VCUG postnatally.
<JuliusE> welcome phil from hennepin county Minnesota
<Rama> Neonates are in a special category because there kidneys continue to develop postnatally and the hydro
may completle go away.
<Rama> Neonates are more likely to experience loss of function if there is obstruction.
<gino> How soon after birth you do the VCUG?
<Rama> Older kids more oftern present with symptoms: UTI or pain.
<Jim> Is there a specific age beyond which hydronephrosis is
unlikely to resolve spontaneously>
<Rama> I typically get a VCUG within the first few weeks after birth.
<cajuntex> Are subsequent newborns screened for obstructions, etc.?
<Phill> Thank You. It's nice to be here, and I hope to be here again next Sunday fromthe Republic of Moldova.
It will be one more area to exchange information!!
<gino> thanks Rama
<Rama> Jim: Hydro will typically resolve over the first two years.
<Rama> Even if it doesn't, it doesn't mean there is obstruction.
<Jim> So, after that, surgery is likely to be needed?
<gino> VCUG=voiding cystourethrogram
<Jim> Wow, this really is international, isn't it.. We must avoid idioms...
<Rama> I would only operate if there is evidence of pathology: decreasing function, worsening hydro, UTI, pain.
Stable dilation is not necessarily an indication.
<Rama> Yes, gino
<german> if Rama which is your opinion about Whitaker test? and DTPA test?
<Jim> Does otherwise benign hydronephrosis predispose a child to hematuria after blunt abdominal trauma the way
the polycystic kidneys do?
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<JuliusE> Bienvenidos to International Pediatric Chat Rama
<Jim> Well, there goes our expert
<Rama> Sorry all. I got disconnected.
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<Rama> The renal scan is also very important.
<gino> say the VCUG is negative for reflux; how do you complete the work up?
<Phill> What is the best way to get a profile of the guest involved in this a discussion?
<Rama> This gives baseline relative function.
<Rama> So for neonates, the workup is an initiaal US, cystogram and renal scan.
<Vlady> VCGU=cistouretrograma miccional
<Rama> Of course if the VCUG is positve, no renal scan is needed.
<gino> thanks Vlady
<german> to make the differece betweem obstruction and not
obstruction is the Whitaker test a good idea?
<Rama> Regardless of initial findings, all children are initailly observed.
<Jim> Well, there goes our expert
<Rama> Whitaker test is usually not needed. Noninvasive
studies are usually adequate.
<gino> what type of renal scans do you recommend?
<Jim> What is kWhitaker test?
<Rama> DTPA or MAG-3.
<JuliusE> jim beat me to it
<gino> post lasix?
<gesol> Yes
<Rama> Whitaker test is a "urodynamic test" of the kidneys. It
is rarely done.
<Rama> Lasix is needed to stress the kidneys drainage
abilities.
<Jim> I don't think we have those in Tennessee...
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<JuliusE> Bienvenidos to International Pediatric Chat kamoilan
<Rama> Only academic urologists will do this test. It is labor intensive so I would
forget that term if I were you!
<Jim> Is that like a diuresis renogram?
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<JuliusE> Bienvenidos to International Pediatric Chat nony
<JuliusE> welcome kira from Finland
<JuliusE> welcome amnon from Jerusalem
<nony> hi
<Rama> In my opinion one cannot diagnose obstructon from a single diuresis renogram.
<german> which is the sensibility of the DTPA test to make the diference between obstruction or
fuctional hydronefrosis
<Rama> I don't understand your question, german.
<Jim> Perhaps he means sensitivity...
<Rama> The sensitivity of diagnosing obstruction depends on your definition of obstruciton.
<Rama> If your definition is delayed drainage on one study, the specificity is very very poor.
<Rama> If one looks at decreasing function as the definition, then the sensitivity and specificity is
very high.
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<JuliusE> Bienvenidos to International Pediatric Chat maumau
<german> thanks
<Rama> No one test is perfect given the rapidly changing physiology of the newborn kidney.
<maumau> maumau:ola para todos
<JuliusE> Rama what else should we discuss related to this subject
<JuliusE> Would everyone take a few minutes to introduce themselves
<JuliusE> I am Julius Edlavitch From Minneapolis Minnesota
<Rama> Older children present a different set of problems.
<JuliusE> like what rama
<Rama> Perhaps we could talk about that.
<german> if tou used Whitaker test.....when you did it?
<Rama> They present more often with pain. Less often with UTI.
<JuliusE> let us do that how would you diagnose and older child with hydro
<gesol> I am still not sure how common hydronephrosis is in neonates? How common is it in the
community, ie not a referred population?
<Rama> Diagnosis of hydronephrosis is very easy. Either an ultrasound or intravenous pyelogram will show
dilation.
<Rama> The issue is is there obstruction?
<kamoilan> I am Kari Moilanen from Kuusamo Finland
<christoph> I am christoph Stangier, physiotherapist from germany
<Rama> For this a diuretic renogram is needed.
<Rama> If the study shows very poor drainage or if it recreastes the pain the child feels, then
obstruction may be diagnosed.
<maumau> maumau:I am Maurício Guimarães,from Itamonte,Minas Gerais,Brasil.
<JuliusE> what would lead to look for this diagnosis in an older child
<kamoilan> Do somebody know the insidence of hydronefrosis in neonates, minimal pelvic dilatation is
quite common ?
<Rama> german: you were asking about Whitaker tests. I only do that for equivocal cases.
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<Rama> The incidence of renal anomalies as detected on antenatal US is roughly 1:1000.
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<JuliusE> Bienvenidos to International Pediatric Chat Gamal
<Phill> It seems that this is working well. I will have the Pediatrics community of Moldova on line
with me next Sunday. I will be in Chisinau, Moldova.
<Jim> Where is Moldova?
<Jim> It's not near Tennessee, is it?
<Rama> Various degrees of hydro are very common. In our city of 1.4 million people we see dozens of
patients yearly but perhaps less than 12 babies will need surgery.
<gesol> What % of that is due to hydronephrosis?
<Rama> gesol: almost all those cases are hydro.
<gesol> OK, that ' the population of my country!
<JuliusE> let us stay on topic for today a little longer then chit chat about moldova
<Jim> blush
<Rama> The important point is that hydro does not equal obstrcution and perhaps may even be physilogic
in many.
<christoph> :)
<Gamal> hi everybody.I am dr/ Gamal from Egypt
<JuliusE> saalam gamal
<gesol> Long term studies?
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<JuliusE> Bienvenidos to International Pediatric Chat kamoilan
<wandl> Would you recommend a screening-US for hydro in the age of 6 month? Mabe its a coincidence but
since January i found in 150 non-selected children to hydros with obstruction.
<kamoilan> Press Enter to connect.
<Rama> What do you mean geosol?
<Rama> wandl: do you mean post-natal screening?
<gesol> Are thereany long term studies going on to determine what happens to these kids?
<wandl> Yes i mean postnatal screening - nearly all children are screened antenatal
<Rama> There are very few long term studies because in the US most children have had surgery. Only a few
centers worldwide have tried to determine the natural history.
<Rama> Our early data s
<Gamal> I want to ask about some antenatal hydronephrosis which proved to be normal after delivery
<nony> mild pelvic dilatation in neonates are very common and very benign
<Rama> gamal: I think these babies need to have cystography.
<Rama> nony; in this situation reflux is more likely.
<Gamal> do you recommend certain age for that
<kamoilan> they also can be followed by ultrasound
<nony> most of them resolved by my experience
<Rama> I would get the cystogram within the first few weeks after birth. If normal, antibiotics are
needed.
<Rama> One can have marker reflux in the face of minimal to no hydro.
<Gamal> why antibiotics
<Jim> Do you mean antibiotics if ABnormal?
<Rama> I always keep babies on antibiotics while I work them up.
<kamoilan> cystogram is quite invasive if they have mild dilatation
<Gamal> do you think to evaluate their kidney functions
<Rama> Irregardles of how invasive it is, one needs to exclude reflux. Just this past week I saw in
consultation a baby with a normal post-natal US but grade V reflux!
<Rama> If there is significant dilation, then a renal scan will help determine relative function.
<Gamal> in this case of reflux ,do you interfere early
<Rama> With minimal dilation, I don't think a renal scan is needed.
<kamoilan> was it peditatric radiologist who had made the US ?
<Rama> I observe all babies with reflux irregradless of severity, at least initially.
<Rama> What di you mean, kamoilan?
<Jim> Gotta go. Thank you, Rama...See you all Monday night, I hope.
<Rama> US can be a very difficult test to perform. The person doing the study has to take much time to
get good pictures.
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<Gamal> I had a case of imperforate anus with bilateral hydronephrosis few weeks ago
<Rama> I often have to have studies repeated by our pediatric radiologists.
<kamoilan> For me it seems that if the US is made by radiologist who is working only whit children one
can tust them more and is it very common that one can have IV grade refluks whitout any suspicion in
US ?
<Rama> kamolian: A recent study in the utrology literature showed that 66% of children with grade III or
greater had normal US. 10% with grade V had normal US.
<Rama> With the significant risk of scarring in young babies, I think it is vital to rule out reflux.
<gino> is hydronephrosis a transient event then on kids with severe reflux?
<kamoilan> OK in what contry was it ?
<Rama> Plus if there is minimal hydro and no reflux, I can with certainty tell teh parents there is
nothing to worryy about.
<Phill> I would like to extend an invitation to all in the group to be onhand next Sunday, and if you
have any ? about Moldova, or their health care, please ask the experts when I'm in Moldova.
<Rama> Kamoilann: the US
<JuliusE> don't forget tomorrow night we will have at 10PM NY time a discussion on AIDS AND
BREASTFEEDING*****Also Everyone introduce tehmselves and where they are from***Gesol do you know Helen
Tomwing, my sisters neighbor is from trinidad****3PM Chit Chat time
<Rama> gino: hydro can be transient with reflux.
<gino> thanks Rama
<gesol> No Julius but the surname is familiar, small place but we travel far...
<JuliusE> Thanks rama for a very interesting and thought provoking session
<JuliusE> rama is aour international pediatric CHat resident urologist
* Vlady le da a Rama un GRAN ((((: ABRAZOTE :))))
<Rama> kamoilan: many centers do not do VCUG in newborns with minimal hydro. I personally do not agree
with that approach.
<gesol> Thanks Rama.
<Gamal> this case was operated upon for the high type imperforate anus and we follow up the
hydronephrosis, so what do you suggest for follow up
<Rama> This is a very difficult topic becuse it is not a primary care topic.
<JuliusE> phil gill will be in Moldova next weekend and bring them to the sunday session with Tom Hale
<Vlady> for those who are new, schedule of meetings and CV of moderators on http://www.pedschat.org/meeti
ng.htm
<Phill> I am the donations and information coordinator for the Mpls/Moldova Partnership. This is an
AIHA project that haws been going for the last 4 years. It deals with trauma, endoscopy, urology,
cardiac surgery, womens health issues, and now PEDIATRICS.
<Rama> gamal: has this baby had a cystogram? Is there a spinal dysraphism?
<JuliusE> does everyone know where moldova is
<kamoilan> In finlan we do do that if they will be any suspicion and everyone who has his first
urinarytract infection
<Gamal> there is no other anomalies
<gesol> Bye, everyone.
<Rama> gamal: How old is this baby? Was a colostomy performed? Are the ureters dilated?
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<Rama> kamoilan: I like to be able to definitively tell the parents they have nothing to worry about.
<Gamal> colostomy was done and the ureters are mildly dilated
<Rama> gamal: how about a renal scan?
<Gamal> we did that but it added nothing
<Rama> kamoilan: There was an article by J.S. Elder in the journal of Urology a few years ago reflux and
antenal hydro. You find it of interest. Nov 1992 I think.
<Vlady> Kamoilan: need the name of your city..also go to http://www.pedschat.org/flags.htm
<Rama> Gamal. These children often ahve an underlying neurogenic bladder. That could account for the dilation.
<kamoilan> Thanks for everybody, i will write them to you
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<JuliusE> Bienvenidos to International Pediatric Chat kamoilan
<Rama> I would probably follow this child with serial US.
<Vlady> kamoilan: which city are you from in Finland?
<Gamal> thanks everybody and bye
<Rama> Any more questions or comments?
<german> thanks to everybody...see you, Congratulations Dr. Rama
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<JuliusE> thanks rama
<JuliusE> are there any other peds urology conferences subjects
<Rama> I always enjoy this, though my fingers don't!
<gino> Thx a lot rama
<JuliusE> you are great and very helpfull
<vulic> nice meeting
<Rama> I hate to say this but how about enuresis?
<JuliusE> I have leanred a lot
<Vlady> Are you there Kamoilan?
<JuliusE> lets us do it on July 27th is this a sunday
<Rama> I will be going to India for most of July. Sorry.
<JuliusE> will you get us some INDAIN IPC MEBERS
<JuliusE> we will do it in august give me a date
<vulic> phill when you going to moldava
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<maumau> maumau:Meu nome é Maurício Guimarães.
<Phill> I hope to chat with all next Sunday. Thanks Julius and everyone for the opprotunity to be here!!!
<Phill> I leave on Tues, and will be back on the 2nd of July.
<Rama> I can't give you a date yet.
<JuliusE> thanks I must join the other peole in this house
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<Rama> Goodbye all!
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