Paediatric Abdomen Radiology

Case 1

Esophageal atresia

Associated with VACTERL disorders. Most commonly associated with TEF. Infants present shortly after birth. Xray findings:

Coiled

NG tube. If there is bowel gas in the abdomen.. Associtated with TEF.

Tracheo-esophageal fistula

Sx:
Coughing,

and choking during feeding. Recurrent pneumonia. Respiratory distress.

Case 2

Duodenal atresia

Most common cause of congenital duodenal obstruction is duodenal atresia. Usually at the region of the ampulla of vater. Associated disorders: Down syndrome. malrotation., heart disease, renal anomalies, TEF, VACTERL. Sx: bilious vomiting in the first day of life.

X-ray findings:
Double

bubble sign (dilated stomach and duodenal bulb) No gas seen distally.

Case 3

Differential diagnosis
Meconium ileus. Meconium plug. Hirschsprungs disease

Meconium ileus

Caused by thick meconium that adheres to the small bowel wall causing obstruction, usually at the level of the ileocecal valve. Almost all patients with meconium ileus have cystic fibrosis 10-15% of CF patients present with meconium ileus. Small bowel obstruction, dilated small bowel loops, soap-bubble pattern of bowel gas (air mixed with meconium), often in the right lower quadratn. Microcolon (unused colon).

Meconium plug

Meconium is impacted in the colon, the colon remains normal in caliber. Often seen in infants of diabetic mothers. Contrast study shows meconium cast filling defect in the colon.

Hirschsprungs disease

Aganglionosis of the colon with absence of parasympathetic ganglia in mucosal and submucosal layers of colon. The most common transition site is the rectosigmoid colon. Early presentation with failure to pass meconium within 24 hours of life, or later presentation with constipation and paradoxical diarrhea.

Normally, the rectum is larger than the colon. There is an abnormal rectosigmoid ratio with the rectum smaller than the sigmoid. The TRANSITION ZONE is the junction between the proximal normally innervated colon and the distal aganglionic segment, the normally innervated proximal colon becomes dilated. 33% if cases normal-appearing rectum. 24 hour film in equivocal cases may either show delayed retention of contrast within the colon, contrast mixed with stool, or more obvious transition zone.

Case 4

Premature infant, second week of life, presented with bloody stools, diarrhea, bilious emesis, respiratory distress, abdominal distension.

Necrotizing enterocolitis

* most common acquired GIT emergency of premature infants. * X-ray findings: earliest sign and most common sign is gaseous bowel distention, pneumatosis intestinalis (diagnostic), linear or cystic air bubbles within the bowel wall. Air fluid levels. free intra peritoneal air if perforation. * usually affects the distal ileum and the ascending colon.

Case 5

New born infant presented with non-bilious projectile vomiting with a palpable mass in the epigastric region.

Hypertrophic pyloric stenosis

Pyloric stenosis present at the age of 3-6 weeks, usually in a first born male. Most common cause of gastric outlet obstruction. Pyloric length >14mm Pyloric muscle wall thickness > 4mm (most reliable criterion). Exaggerated peristaltic waves. Delayed or no gastric emptying of fluid into duodenum.

The string sign, narrowing of and elongated pyloric canal. The thickened and enlarged muscle mass on the doudenal bulb (apple core, mushroom). The shoulder sign caused by the impression of the hypertrophied muscle on the antrum.

Case 6

Malrotation

Malrotation is the failure of the normal rotation of the bowel resulting in suspension of the small bowel on a narrow vascular pedicle. The duodenal-juejunal junction expected location is to the left of the spine at the level of the duodenal bulb. Malposition of the cecum in the left side of the abdomen. Complications: obstruction and midgut volvulus which is a surgical emergency.

Midgut volvulus is a twisting of the small intestine around its vascular pedicle due to malrotation. Present within the first month of life with bilious vomiting, abdominal distension and shock. Complications include intestinal ischemia and necrosis in the distribution of the SMA. Radiological findings: spiral course of midgut loops (cork screw appearance).

Case 7

Intussusception

Intussusception occurs when a portion of the digestive tract becomes telescoped into the adjacent bowel segment. Most common between 3months and 2 years. The majority of cases are ileocolic. X-ray: soft tissue mass which is most seen in the upper quadrant effacing the adjacent hepatic contour, reduced air in the small intestine or a gasless abdomen.

Ultrasound: target or doughnut sign, with hypoechoic rim and hyperechoic central area (psuedo-kidney). Idiopathic ( following viral illness with hypertrophy of peyers pateches in terminal ileum) or pathologic leading point (tumour, inspissated feces CF, lymphoma. Presentation 3-24 months.

Treatment: reduction under fluoroscopic guidance using air enema (safer) or using Barium (risk of peritonitis if perforation occurs).

Complication of intussusception is bowel ischemia and perforation. Absolute contraindication for reduction: shock not corrected with IV fluids, established perforation with clinical signs of peritonitis.

Case 8

Pneumoperitoneum

X ray signs include: 1) football sign: central lucency with air outlining the falciform ligament in the right upper quadrant. 2) Riglers sign (wall sign): air on both sides of the bowel wall. 3) triangle sign: air between loops of bowel.