Are DMSA Scans Reliable for Diagnosing Vesicoureteral Reflux in Infants and Children?
ABSTRACT
A retrospective study for data record of 106 patients subjected to voiding cystourethrogram test (VCUG), sonography test, and dimercaptosuccinic acid (DMSA) scintigraphy take place at King Abdulaziz University, radiology department to find out the possibilities of detecting vesicoureteral reflux (VUR) in infants and children. Hydronephrosis & Renal pelvis dilatation were the highest frequency reason for VUR scan study and represent 36% of the overall cases with 53% positive finding, while Recurrent UTI frequency was 22.6% with 83% positive finding, and patients who had history of VUR come at the third place with 15% frequency and 81% positive finding. VUR was found in 65 of 106 children representing 61%. Male children are more likely to diagnostic with VUR than female and they represented 69% while 31% for female. Among the children with VUR, 39 had high-grade reflux (grade IV or V), while 26 had low-grade reflux (grades I, II or III). When we classified VUR into low-grade and high-grade, we found the majority of children with high-grade VUR had an abnormal DMSA and represented 77.4%, while 13 children with low-grade VUR had normal study. These studies are agreed with the present study; most children with normal DMSA scan finding had low grade reflux. In this study, 48 of 65 children (74%) the DMSA scintigraphy shows abnormal findings during the period of UTI while the VCUG scan study shows VUR in 75% of the children during the period of UTI. Comparing results of ultrasound and VCUG scan, 59% of the ultrasound findings gave the same result as VCUG in detecting the VUR in children. Then we confirm it all with the urine culture results of the same children. We found the majority of children with VUR had abnormal US finding during the period of UTI and represented 83%.
A retrospective study for data record of 106 patients subjected to voiding cystourethrogram test (VCUG), sonography test, and dimercaptosuccinic acid (DMSA) scintigraphy take place at King Abdulaziz University, radiology department to find out the possibilities of detecting vesicoureteral reflux (VUR) in infants and children. Hydronephrosis & Renal pelvis dilatation were the highest frequency reason for VUR scan study and represent 36% of the overall cases with 53% positive finding, while Recurrent UTI frequency was 22.6% with 83% positive finding, and patients who had history of VUR come at the third place with 15% frequency and 81% positive finding. VUR was found in 65 of 106 children representing 61%. Male children are more likely to diagnostic with VUR than female and they represented 69% while 31% for female. Among the children with VUR, 39 had high-grade reflux (grade IV or V), while 26 had low-grade reflux (grades I, II or III). When we classified VUR into low-grade and high-grade, we found the majority of children with high-grade VUR had an abnormal DMSA and represented 77.4%, while 13 children with low-grade VUR had normal study. These studies are agreed with the present study; most children with normal DMSA scan finding had low grade reflux. In this study, 48 of 65 children (74%) the DMSA scintigraphy shows abnormal findings during the period of UTI while the VCUG scan study shows VUR in 75% of the children during the period of UTI. Comparing results of ultrasound and VCUG scan, 59% of the ultrasound findings gave the same result as VCUG in detecting the VUR in children. Then we confirm it all with the urine culture results of the same children. We found the majority of children with VUR had abnormal US finding during the period of UTI and represented 83%.
Cite this paper
Bafaraj, S. and Alahmadi, R. (2014) Are DMSA Scans Reliable for Diagnosing Vesicoureteral Reflux in Infants and Children?. Open Journal of Medical Imaging, 4, 187-198. doi: 10.4236/ojmi.2014.44026.
Bafaraj, S. and Alahmadi, R. (2014) Are DMSA Scans Reliable for Diagnosing Vesicoureteral Reflux in Infants and Children?. Open Journal of Medical Imaging, 4, 187-198. doi: 10.4236/ojmi.2014.44026.
References
[1] Bartholomew, M. (2012) Essentials of Anatomy and Physiology. Person. [2] Marieb, E.N. and Hoehn, K. (2006) Human Anatomy and Physiology. 7th Edition, Person. [3] Armstrong, P., Wastie, M. and Rockall, A. (2012) Diagnostic Imaging. 6th Edition, Wiley-Blackwell. [4] Gross, G.W. and Lebowitz, R.L. (1981) Infection Does Not Cause Reflux. American Journal of Roentgenology, 137, 929-932.
http://dx.doi.org/10.2214/ajr.137.5.929 [5] Smellie, J.M. and Normand, I.C.S. (1975) Bacteriuria, Reflux and Renal Scarring. Archives of Disease in Childhood, 50, 581-558.
http://dx.doi.org/10.1136/adc.50.8.581 [6] Steinhardt, J.M., Kuhn, L.P. and Eisenberg, B. (1988) Ultrasound Screening of Healthy Infants for Urinary Tract Abnormalities. Pediatrics, 82, 609-612. [7] Elder, J.S., Peters, C.A., Arant, B.S., et al. (1997) Pediatric Vesicoureteral Reflux Guidelines: Panel Summary Report on the Management of Primary Vesicoureteral Reflux in Children. Journal of Urology, 157, 1846-1851.
http://dx.doi.org/10.1016/S0022-5347(01)64882-1 [8] Mattoo, T.K. (2011) Vesicoureteral Reflux and Reflux Nephropathy. Advances in Chronic Kidney Disease, 18, 348- 354.
http://dx.doi.org/10.1053/j.ackd.2011.07.006 [9] Ansari, M.S., Gulia, A., Srivastava, A. and Kapoor, R. (2010) Risk Factors for Progression to End-Stage Renal Disease in Children with Posterior Urethral Valves. Journal of Pediatric Urology, 6, 261-264.
http://dx.doi.org/10.1016/j.jpurol.2009.09.001 [10] Murawski, I.J. and Gupta, I.R. (2006) Vesicoureteric Reflux and Renal Malformations: A Developmental Problem. Clinical Genetics, 69, 105-117.
http://dx.doi.org/10.1111/j.1399-0004.2005.00562.x [11] Rubben, I., Goepel, M. and van Gool, J.D. (2011) Non-Neurogenic Bladder Dysfunction and Vesicoureteral Reflux in Children. Urologe A, 50, 551-556. [12] Berrocal, T., López-Pereira, P., Arjonilla, A. and Gutié, J. (2002) Anomalies of the Distal Ureter, Bladder, and Urethra in Children: Embryologic, Radiologic, and Pathologic Features. Radiographics, 22, 1139-1164. [13] Lebowitz, R.L., Olbing, H., Parkkulainen, K.V., Smellie, J.M. and Tamminen-Mobius, T.E. (1985) International System of Radiographic Grading of Vesicoureteric Reflux. Pediatric Radiology, 15, 105-109.
http://dx.doi.org/10.1007/BF02388714 [14] Lim, R. (2009) Vesicoureteral Reflux and Urinary Tract Infection: Evolving Practices and Current Controversies in Pediatric Imaging. American Journal of Roentgenology, 192, 1197-1208.
http://dx.doi.org/10.2214/AJR.08.2187 [15] http://www.radiologyinfo.org/en/photocat/gallery2.cfm?pid=1&pg=voidcysto [16] Howard, R.G., Roebuck, D.J., Yeung, P.A., Chan, K.W. and Metreweli, C. (2001) Vesicoureteric Reflux and Renal Scarring in Chinese Children. The British Journal of Radiology, 74, 331-334.
http://dx.doi.org/10.1259/bjr.74.880.740331 [17] Lee, J.H., Kim, M.K. and Park, S.E. (2012) Is a Routine Voiding Cystourethrogram Necessary in Children after the First Febrile Urinary Tract Infection? Acta Paediatrica, 101, e105-e109.
http://dx.doi.org/10.1111/j.1651-2227.2011.02507.x [18] Easton, S. (2008) An Introduction to Radiography. Churchill Livingstone, London. [19] Perisinakis, K., Raissaki, M., Damilakis, J., Stratakis, J., Neratzoulakis, J. and Gourtsoyiannis, N (2006) Fluoroscopy-Controlled Voiding Cystourethrography in Infants and children: Are the Radiation Risks Trivial? European Radiology, 16, 846-851.
http://dx.doi.org/10.1007/s00330-005-0072-6 [20] International Atomic Energy Agency (IAEA) (2006) Nuclear Medicine Resources Manual. IAEA, Vienna, 517. [21] Riccabona, M. and Fotter, R. (2004) Urinary Tract Infection in Infants and Children: An Update with Special Regard to the Changing Role of Reflux. European Radiology, 14, L78-L88.
http://dx.doi.org/10.1007/s00330-003-2030-5 [22] Elder, J.S., Peters, C.A., Arant Jr., B.S., et al. (1997) Pediatric Vesicoureteral Reflux Guidelines Panel Summary Report on the Management of Primary Vesicoureteral Reflux in Children. The Journal of Urology, 157, 1846-1851.
http://dx.doi.org/10.1016/S0022-5347(01)64882-1 [23] Gearhart, J.G., Rink, R.C. and Mouriquan, P.D.E. (2009) Pediatric Urology. 2nd Edition, Elsevier Health Sciences, Amsterdam. [24] Jequier, S. and Jequier, J.C. (1989) Reliability of Voiding Cystourethrography to Detect Reflux. American Journal of Roentgenology, 153, 807-810.
http://dx.doi.org/10.2214/ajr.153.4.807 [25] Charsoula, A. (2014) Imaging of the Normal Male Urethra from the Neonate to the Elder: Radiologic Anatomy in Fluoroscopic Urethrography. ECR 2014/C-1524. [26] Katzberg, R. (1992) Chapter 5. Urography, Cyctography and Urethrrography. In: Katzberg, R.W., Ed., The Contrast Media Manual, Lippincott Williams and Wilkins, Philadelphia, 62-63. [27] Ki, H.C., Kim, S.O., Yoo, D.H. and Hwang, I.S. (2012) Abnormal Dimercaptosuccinic Acid Scan May Be Related to Persistence of Vesicoureteral Reflux in Children with Febrile Urinary Tract Infection. Korean Journal of Urology, 53, 716-720.
http://dx.doi.org/10.4111/kju.2012.53.10.716 [28] Tseng, M.H., Lin, W.J., Lo, W.T., Wang, S.R., Chu, M.L. and Wang, C.C. (2007) Does a Normal DMSA Obviate the Performance of Voiding Cystourethrography in Evaluation of Young Children after Their First Urinary Tract Infection? The Journal of Pediatrics, 150, 96-99.
http://dx.doi.org/10.1016/j.jpeds.2006.09.028
[1] Bartholomew, M. (2012) Essentials of Anatomy and Physiology. Person. [2] Marieb, E.N. and Hoehn, K. (2006) Human Anatomy and Physiology. 7th Edition, Person. [3] Armstrong, P., Wastie, M. and Rockall, A. (2012) Diagnostic Imaging. 6th Edition, Wiley-Blackwell. [4] Gross, G.W. and Lebowitz, R.L. (1981) Infection Does Not Cause Reflux. American Journal of Roentgenology, 137, 929-932.
http://dx.doi.org/10.2214/ajr.137.5.929 [5] Smellie, J.M. and Normand, I.C.S. (1975) Bacteriuria, Reflux and Renal Scarring. Archives of Disease in Childhood, 50, 581-558.
http://dx.doi.org/10.1136/adc.50.8.581 [6] Steinhardt, J.M., Kuhn, L.P. and Eisenberg, B. (1988) Ultrasound Screening of Healthy Infants for Urinary Tract Abnormalities. Pediatrics, 82, 609-612. [7] Elder, J.S., Peters, C.A., Arant, B.S., et al. (1997) Pediatric Vesicoureteral Reflux Guidelines: Panel Summary Report on the Management of Primary Vesicoureteral Reflux in Children. Journal of Urology, 157, 1846-1851.
http://dx.doi.org/10.1016/S0022-5347(01)64882-1 [8] Mattoo, T.K. (2011) Vesicoureteral Reflux and Reflux Nephropathy. Advances in Chronic Kidney Disease, 18, 348- 354.
http://dx.doi.org/10.1053/j.ackd.2011.07.006 [9] Ansari, M.S., Gulia, A., Srivastava, A. and Kapoor, R. (2010) Risk Factors for Progression to End-Stage Renal Disease in Children with Posterior Urethral Valves. Journal of Pediatric Urology, 6, 261-264.
http://dx.doi.org/10.1016/j.jpurol.2009.09.001 [10] Murawski, I.J. and Gupta, I.R. (2006) Vesicoureteric Reflux and Renal Malformations: A Developmental Problem. Clinical Genetics, 69, 105-117.
http://dx.doi.org/10.1111/j.1399-0004.2005.00562.x [11] Rubben, I., Goepel, M. and van Gool, J.D. (2011) Non-Neurogenic Bladder Dysfunction and Vesicoureteral Reflux in Children. Urologe A, 50, 551-556. [12] Berrocal, T., López-Pereira, P., Arjonilla, A. and Gutié, J. (2002) Anomalies of the Distal Ureter, Bladder, and Urethra in Children: Embryologic, Radiologic, and Pathologic Features. Radiographics, 22, 1139-1164. [13] Lebowitz, R.L., Olbing, H., Parkkulainen, K.V., Smellie, J.M. and Tamminen-Mobius, T.E. (1985) International System of Radiographic Grading of Vesicoureteric Reflux. Pediatric Radiology, 15, 105-109.
http://dx.doi.org/10.1007/BF02388714 [14] Lim, R. (2009) Vesicoureteral Reflux and Urinary Tract Infection: Evolving Practices and Current Controversies in Pediatric Imaging. American Journal of Roentgenology, 192, 1197-1208.
http://dx.doi.org/10.2214/AJR.08.2187 [15] http://www.radiologyinfo.org/en/photocat/gallery2.cfm?pid=1&pg=voidcysto [16] Howard, R.G., Roebuck, D.J., Yeung, P.A., Chan, K.W. and Metreweli, C. (2001) Vesicoureteric Reflux and Renal Scarring in Chinese Children. The British Journal of Radiology, 74, 331-334.
http://dx.doi.org/10.1259/bjr.74.880.740331 [17] Lee, J.H., Kim, M.K. and Park, S.E. (2012) Is a Routine Voiding Cystourethrogram Necessary in Children after the First Febrile Urinary Tract Infection? Acta Paediatrica, 101, e105-e109.
http://dx.doi.org/10.1111/j.1651-2227.2011.02507.x [18] Easton, S. (2008) An Introduction to Radiography. Churchill Livingstone, London. [19] Perisinakis, K., Raissaki, M., Damilakis, J., Stratakis, J., Neratzoulakis, J. and Gourtsoyiannis, N (2006) Fluoroscopy-Controlled Voiding Cystourethrography in Infants and children: Are the Radiation Risks Trivial? European Radiology, 16, 846-851.
http://dx.doi.org/10.1007/s00330-005-0072-6 [20] International Atomic Energy Agency (IAEA) (2006) Nuclear Medicine Resources Manual. IAEA, Vienna, 517. [21] Riccabona, M. and Fotter, R. (2004) Urinary Tract Infection in Infants and Children: An Update with Special Regard to the Changing Role of Reflux. European Radiology, 14, L78-L88.
http://dx.doi.org/10.1007/s00330-003-2030-5 [22] Elder, J.S., Peters, C.A., Arant Jr., B.S., et al. (1997) Pediatric Vesicoureteral Reflux Guidelines Panel Summary Report on the Management of Primary Vesicoureteral Reflux in Children. The Journal of Urology, 157, 1846-1851.
http://dx.doi.org/10.1016/S0022-5347(01)64882-1 [23] Gearhart, J.G., Rink, R.C. and Mouriquan, P.D.E. (2009) Pediatric Urology. 2nd Edition, Elsevier Health Sciences, Amsterdam. [24] Jequier, S. and Jequier, J.C. (1989) Reliability of Voiding Cystourethrography to Detect Reflux. American Journal of Roentgenology, 153, 807-810.
http://dx.doi.org/10.2214/ajr.153.4.807 [25] Charsoula, A. (2014) Imaging of the Normal Male Urethra from the Neonate to the Elder: Radiologic Anatomy in Fluoroscopic Urethrography. ECR 2014/C-1524. [26] Katzberg, R. (1992) Chapter 5. Urography, Cyctography and Urethrrography. In: Katzberg, R.W., Ed., The Contrast Media Manual, Lippincott Williams and Wilkins, Philadelphia, 62-63. [27] Ki, H.C., Kim, S.O., Yoo, D.H. and Hwang, I.S. (2012) Abnormal Dimercaptosuccinic Acid Scan May Be Related to Persistence of Vesicoureteral Reflux in Children with Febrile Urinary Tract Infection. Korean Journal of Urology, 53, 716-720.
http://dx.doi.org/10.4111/kju.2012.53.10.716 [28] Tseng, M.H., Lin, W.J., Lo, W.T., Wang, S.R., Chu, M.L. and Wang, C.C. (2007) Does a Normal DMSA Obviate the Performance of Voiding Cystourethrography in Evaluation of Young Children after Their First Urinary Tract Infection? The Journal of Pediatrics, 150, 96-99.
http://dx.doi.org/10.1016/j.jpeds.2006.09.028