12 - paediatric abdomen radiology

8/2/2019 12 - Paediatric Abdomen Radiology

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Paediatric Abdomen

Radiology


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Case 1


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Esophageal atresia


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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.


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Tracheo-esophageal fistula

Sx:

Coughing, and choking during feeding.

Recurrent pneumonia.

Respiratory distress.


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Case 2


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Duodenal atresia


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Most common cause of congenital duodenalobstruction 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.


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X-ray findings:

Double bubble sign (dilated stomach and

duodenal bulb)No gas seen distally.


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Case 3


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Differential diagnosis

Meconium ileus.

Meconium plug.

Hirschsprungs disease


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Meconium ileus


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Caused by thick meconium that adheres to the smallbowel wall causing obstruction, usually at the level of theileocecal valve.

Almost all patients with meconium ileus have cysticfibrosis

10-15% of CF patients present with meconium ileus.

Small bowel obstruction, dilated small bowel loops,

soap-bubble pattern of bowel gas (air mixed withmeconium), often in the right lower quadratn.

Microcolon (unused colon).


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Meconium plug


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Meconium is impacted in the colon, thecolon remains normal in caliber.

Often seen in infants of diabetic mothers.

Contrast study shows meconium castfilling defect in the colon.


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Hirschsprungs

disease


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Aganglionosis of the colon with absence ofparasympathetic 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 withconstipation and paradoxical diarrhea.


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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 theproximal normally innervated colon and the distalaganglionic segment, the normally innervated proximalcolon becomes dilated.

33% if cases normal-appearing rectum.

24 hour film in equivocal cases may either show delayedretention of contrast within the colon, contrast mixed withstool, or more obvious transition zone.


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Case 4


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Premature infant, second week of life,presented with bloody stools, diarrhea,

bilious emesis, respiratory distress,abdominal distension.


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Necrotizing

enterocolitis


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* most common acquired GIT emergency ofpremature infants.

* X-ray findings: earliest sign and most commonsign is gaseous bowel distention, pneumatosisintestinalis (diagnostic), linear or cystic airbubbles within the bowel wall. Air fluid levels.free intra peritoneal air if perforation.

* usually affects the distal ileum and theascending colon.


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Case 5


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New born infant presented with non-biliousprojectile vomiting with a palpable mass in

the epigastric region.


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Hypertrophic pyloric

stenosis


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Pyloric stenosis present at the age of 3-6 weeks, usuallyin 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.


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The string sign, narrowing of andelongated pyloric canal.

The thickened and enlarged muscle masson the doudenal bulb (apple core,mushroom).

The shoulder sign caused by theimpression of the hypertrophied muscle onthe antrum.


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Case 6


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Malrotation


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Malrotation is the failure of the normal rotation ofthe bowel resulting in suspension of the smallbowel on a narrow vascular pedicle.

The duodenal-juejunal junction expectedlocation is to the left of the spine at the level ofthe duodenal bulb.

Malposition of the cecum in the left side of the

abdomen. Complications: obstruction and midgut volvuluswhich is a surgical emergency.


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Midgut volvulus is a twisting of the smallintestine around its vascular pedicle due tomalrotation.

Present within the first month of life with biliousvomiting, abdominal distension and shock.

Complications include intestinal ischemia andnecrosis in the distribution of the SMA.

Radiological findings: spiral course of midgutloops (cork screw appearance).


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Case 7


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Intussusception


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Intussusception occurs when a portion of thedigestive tract becomes telescoped into theadjacent bowel segment. Most common

between 3months and 2 years. The majority ofcases are ileocolic.

X-ray: soft tissue mass which is most seen in theupper quadrant effacing the adjacent hepatic

contour, reduced air in the small intestine or agasless abdomen.


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Ultrasound: target or doughnut sign, withhypoechoic rim and hyperechoic central

area (psuedo-kidney). Idiopathic ( following viral illness with

hypertrophy of peyers pateches interminal ileum) or pathologic leading point

(tumour, inspissated feces CF, lymphoma. Presentation 3-24 months.


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Treatment: reduction under fluoroscopicguidance using air enema (safer) or using

Barium (risk of peritonitis if perforationoccurs).


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Complication of intussusception is bowelischemia and perforation.

Absolute contraindication for reduction:shock not corrected with IV fluids,established perforation with clinical signs

of peritonitis.


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Case 8


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Pneumoperitoneum


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X ray signs include:

1) football sign: central lucency with air outlining

the falciform ligament in the right upperquadrant.

2) Riglers sign (wall sign): air on both sides of

the bowel wall.

3) triangle sign: air between loops of bowel.


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12 - paediatric abdomen radiology

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