PEDIATRIC GI RADIOLOGY

I. Neonatal 3. DUODENAL ATRESIA

II. Upper GIT - Most common cause of congenital duodenal obstruction
III. Lower GIT - Failure of recannulation of duodenum typically occurs
IV. Hepatobiliary Tree in the region of the ampulla of Vater
- Incidence: 1 in 10,000 livebirths
NEONATAL - Associated disorders: Down syndrome (30%),
malrotation (20%), Heart Disease (20%), Renal
1. ESOPHAGEAL ATRESIA Anomalies, TEF, VACTERL anomalies
- Interruption of tubular esophagus - Radiographic Features:
- Incidence: 1 in 2,000 – 4,000  “Double Bubble” sign –
livebirths dilated stomach and
- Most common associated anomaly is duodenal bulb
TEF  Dilated stomach, no gas
- Common Radiographic Features: distal to proximal duodenum
 “Coiled NG Tube” in esophageal  No gas in the rest of small or
pouch large bowel
 Best view is LATERAL to
 If (+) bowel gas in abdomen,
visualize sacral area
there must be an associated TEF
(90% of cases of Esophageal
Atresia)
 Contrast collecting in proximal
esophageal pouch. (A contrast
study is rarely indicated. Air
injected through NGT can be
used as very safe, negative
contrast agent).

2. TRACHEOESOPHAGEAL FISTULA (TEF) 4. JEJUNAL-ILEAL ATRESIA

- three types: - Segmental atresia of the jejunum or the ileum
 A: esophageal - Associated with malrotation and volvulus (25%) and
atresia with distal cystic fibrosis (10%)
fistula - Patients present within the first days of life with
 B: esophageal vomiting or a distended abdomen
atresia without
fistula  Multiple distended loops of
 C: TEF without bowel
esophageal atresia
(H-type) – manifest with concomitant aspiration
pneumonia because food materials will go to the
trachea and eventually to the lungs
- Secondary to incomplete division of the trachea and
esophagus during organogenesis, resulting in an
abnormal connection between esophagus and trachea
- Incidence: 1 in 2,000-4,000 livebirths  Barium enema demonstrates unused microcolon in
- Sxs: coughing and choking during feeding, recurrent a patient with distal ileal atresia. Blurred picture,
pneumonia, and respiratory distress hindi rin maappreciate. What is important here is
- Radiographic Features: the barium enema demonstrating microcolon.
 Contrast was administered
through G tube into the 5. MECONIUM ILEUS
stomach - Caused by thick, tenacious meconium that adheres to
 Contrast refluxed into the the wall of the small bowel and causes obstruction
distal esophagus across the most often at the level of ileocecal valve in a neonate
TEF into the trachea and from - Almost all have cystic fibrosis (CF)
the trachea into the esophageal - 10-15% of CF patients present with meconium ileus
pouch - Treated nonsurgically with water-soluble enemas to
 Bronchial tree visualized upon relieve the obstruction or be treated surgically
administration of contrast - Complications:
 Ileal atresia and/or stenosis
  Volvulus 7. HIRSCHSPRUNG DISEASE
 Perforation - Aganglionosis of colon with absence of
 Meconium peritonitis (due to obstruction and parasympathetic ganglia in mucosal and submucosal
ischemia from tenacious meconium) layers of colon
- Radiographic Features: - Result of failure of normal cranial-caudal migration of
 Microcolon (unused colon) ganglion cells
 “Frothy” or “Soap-bubble” pattern of bowel gas - Most common transition site: rectosigmoid colon
(air mixed with meconium), often in RLQ - Total colonic aganglionosis is rare
 Dilated small bowel loops - Radiographic Features:
 Small bowel obstruction  Abnormal rectosigmoid ratio with rectum smaller
 Calcification due to meconium peritonitis (15%) than sigmoid due to denervation hyperspasticity
 Distal ileum packed with meconium and larger than (normally, rectum is larger than colon)
microcolon on contrast enema  “Transition Zone” – junction between proximally
normally innervated colon and the distal
aganglionic segment
 normally innervated proximal colon dilates
 In 33% of cases, there is normal-appearing rectum
 Small bowel obstruction
with dilated loops of bowel
and soap bubble bowel gas  Transition zone is near splenic
pattern in RLQ flexure

 Transition zone is mid-

 Area of rectosigmoid. On descending colon
Barium Enema, there is
microcolon.

8. NECROTIZING ENTEROCOLITIS
- Most common acquired GI emergency of premature
6. MECONIUM PLUG SYNDROME infants
- Meconium obstruction of the colon, often seen in - Occurs less frequently in older children who are under
infants of diabetic mothers who received MgSO42 for great stress (eg congenital heart disease)
eclampsia - Relation to infection and ischemia, commonly affecting
- Meconium forms a cast of the colon, colon remains the ileum and ascending colon
normal in caliber - Usually presents during 1st or 2nd week of life with
- Patients present within the first 24 hours of life with bloody stools (50%), explosive diarrhea, bilious emesis,
abdominal distention, vomiting, failure to pass mild respiratory distress, generalized sepsis, abdominal
meconium distention, feeding difficulties.
- DDx: Hirschsprung Disease - Requires immature gut and time for gut to become
- Treatment: Water-soluble enemas colonized in order to develop
- Tx: Bowel rest and antibiotics & surgery for bowel
perforation
 Meconium cast filling defect in - Radiographic Features:
colon on barium enema.  Definitive finding: pneumatosis (gas in bowel wall)
 “Frothy” or “soap-bubble” gas pattern
 Linear or crescent-shaped gas collections in the
bowel wall may also be seen
 Unchanged bowel gas pattern over several films
indicating an ileus
  More worrisome signs: gas in portal venous system 2. HYPERTROPHIC PYLORIC STENOSIS
and ascites - thickening of the muscle of the pylorus resulting in
 Infants can have occult perforation without free obstruction
intraperitoneal air in the setting of gasless abdomen - Incidence: 3 in 1,000 livebirths
 Pneumoperitoneum used to be considered a - M:F ratio of 4-5:1
- Increased incidence with firstborn male children
surgical emergency. However, percutaneous drain
- S/Sx: nonbilious, projectile vomiting, palpable mass
may now be placed instead of surgery.
- Tx: Surgery
- Associated abnormalities: Esophageal atresia, TEF,
renal abnormalities, Turner’s syndrome, trisomy 18,
Rubella.
- Radiographic Features:
 Multiple dilated loops of bowel  “Single bubble” with air in distended stomach
with pneumatosis
 String Sign: elongated and narrowed pyloric canal
(2-4 cm in length when a small amount of barium
streaks through the pyloric canal).
 Diamond Sign: transient triangular tent-like
cleft/niche in the middle of pyloric canal

 “Single bubble” sign of dilated

stomach

 Extensive pneumatosis
throughout the abdomen

 Antral beaking: mass impression upon the antrum

with a streak of barium pointing toward the pyloric
canal
 Kirklin or Mushroom Sign: indentation of the
base of the bulb (occurring in 50%)
 Presence of multiple bubble-like
lucencies in the bowel wall
indicates pneumatosis (arrows)

 Upper GI study with barium

demonstrating “mushroom
sign”.

UPPER GIT
1. ESOPHAGEAL FOREIGN BODY
- Most swallowed FB especially the round ones pass  Outpouching along the lesser curvature because of
through the entire GIT successfully, but some lodge in antral peristalsis disruption
the esophagus, usually proximally at the thoracic inlet  Gastric distention with fluid and/or air
or at the level of aortic arch
- Most common FB is coin. Batteries can cause mucosal - Sonographic Features:
damage.  Hypoechoic ring of hypertrophic pyloric muscle
- Radiologic Features: around echogenic mucosa centrally on cross
 Coin lodged in the esophagus section
has its widest dimension in AP  Indentation of muscle mass on fluid-filled antrum
view on longitudinal section
 Coin in trachea has its widest  Pyloric length >14mm
dimension in lateral view  Pyloric muscle wall thickness >4mm (measured
from outer wall to mucosa)
  Caterpillar Sign: active gastric hyperperistaltic - Abnormal positioning of the duodenojejunal and
waves/ Exaggerated peristaltic waves ileocecal junctions results in a shortening of the
 Delayed or no gastric emptying of fluid into normally broad based mesenteric attachment
duodenum - Patients usually present within the first month of life
with bilious vomiting, abdominal distention, shock.
 Using linear probe (7-10 megaHertz) : Thick and
- Associated disorders: duodenal atresia (20%), Duodenal
elongated pyloric muscle
diaphragm, duodenal stenosis, annular pancreas
- Complications: intestinal ischemia and necrosis in the
distribution of the superior mesenteric artery
- Malrotation with midgut volvulus is a surgical
emergency
- Radiographic Features:
LOWER GIT
 Dilated air-filled duodenal bubble
1. MALROTATION
 “Double-bubble” sign; double bubble with a little
- Failure of the normal embryonic rotation of the bowel,
bit of distal gas
which results in suspension of the small bowel on a
 Gas in bowel loops distal to obstructed duodenum
narrow vascular pedicle
- Duodenal-jejunal junction does not reach its expected  Small bowel obstruction
location (normal: to the left of the spine at the level of  UGI: duodojejunal junction lower than duodenal
duodenal bulb) bubble and to the right of expected position; spiral
course of midgut loops; duodenal fold thickening;
- Abnormal: Duodenal-jejunal junction at the right of
malposition of cecum
spine adjacent to duodenal bulb
- Malposition of the cecum may result in its location in
the left side of the abdomen
- Complications include obstruction and midgut volvulus  Spiral course of small
- Most present at early age with bilious vomiting,, but bowel
symptoms can occur at any age
- Midgut volvulus is a surgical emergency, because it can
lead to bowel necrosis
- Ladd Bands are dense peritoneal bands, which cross
the duodenum from the malpositioned cecum to the 3. MECKEL’S DIVERTICULUM
hilum of the liver. They may cause partial obstruction - Persistence of omphalomesenteric duct
- Radiographic Features: - Incidence: 2-3% of the population
- Most common anomaly of GIT
 Duodenal-jejunal junction at the - Majority of patients will be under the age of ten, with
right of spine, most of the small M:F ratio of 3:1
bowel is on the right side of - Normally located within the last 6 feet of ileum with
abdomen 94% of cases on the antimesenteric border
- Rule of 2’s:
1) 2% of population
2) 2% of those with diverticulum will become
symptomatic
3) symptomatic usually before age 2
 Abnormal location of cecum: 4) located within 2 feet of ileocecal valve
midpelvis] 5) length of 2 inches
- Patients present with bleeding because of ectopic
gastric mucosa, focal inflammation, perforation, or
intussusception.
- Nuclear scintigraphy is most often used.
- How to differentiate small bowel from large bowel –
HAUSTRATIONS in large bowel
 Ladd Bands resulting in a
distended stomach with a small
amount of distal gas

2. MIDGUT VOLVULUS
- Twisting of small intestine around its vascular pedicle
due to malrotation
4. APPENDICITIS
- Obstruction of the appendiceal lumen resulting in
distention of the appendix, superimposed infection, - Rule of 3:
ischemia, eventually perforation 1) 3 meters height of contrast material put cannula in
- Incidence: 7-12% of Western world population, anus; contrast is suspended
occuring in all ages 2) 3 feet (I don’t know kung 3 meters ba or 3 feet...)
- Sxs: fever (56%), nausea and vomiting (40%), RLQ 3) 3 attempts
pain-McBurney sign (72%), leukocytosis (88%)
- In 20-30% of patients, however, classic S/Sx are not - Barium enema reduce intussusception. Visualize cecum
present and ileacecal area
- Perforation is a serious complication - If in
- Tx: Surgical removal of the appendix

 Small bowel obstruction with an

appendicolith faintly visualized
in RLQ

third attempt – not yet reduced – proceed to SURGERY

 1- Soft tissue mass (intussusceptum outline by
barium in hepatic flexure)
 2- Soft tissue mass (intussusceptum outline by
barium reduced to ileocecal valve)
 3- Complete reduction with reflux of contrast into
distal small bowel

 UTZ: Dilated appendix with - Ultrasound:

the calcified appendicolith.  Pseudo-kidney sign:
 Calcified appendicolith in alternating signs of
CT Scan (I did not include hyper- and
the picture, blurred kasi). hypoechogenicity
indicate the telescoped
bowel

5. INTUSSUSCEPTION
- Telescoping of one portion of the bowel into another - Air enema:
- Idiopathic incidences maybe seen following viral illness  Pre-reduction scout
with hypertrophy of Peyer’s patches in the terminal film: Demonstration
ileum of intussusception in
- Age of presentation is usually 3-24 months hepatic flexure
- Pathologic intussusception is associated with a lead A. Reduced to
point such as tumor, inspissated feces (cystic fibrosis) ileocecal valve
or lymphoma, often in older child >2. B. Completely
- If <2 y/o : inflammatory - affecting Peyer’s patches reduced with air
- If >2 y/o : tumor, lymphoma refluxed into
- Sx: crampy abdominal pain, bloody stools, vomiting small bowel
- Tx: fluoroscopically guided reduction with air or fluid
enema or surgery if unreducible
- Air enema is first performed followed by surgery if this If air in cecum
method is unsuccessful visualized :
successful reduction

6. COLONIC ATRESIA
- Rare; likely secondary to in utero ischemic event
- Tx: surgical
- Radiographic Features:
  Abdominal film: distal obstruction often with
“frothy” appearance of air mixed with meconium
in RLQ
 Enema: small caliber distal unused colon; no filling
proximal to atretic segment

 Large cystic lesion in location of common bile duct

 Multiple dilated loops of
bowel with frothy
appearance in RLQ

 Microcolon with abrupt

cutoff in mid-transverse
colon

LIVER AND BILIARY TREE

1. NEONATAL HEPATITIS
- Inflammation of neonatal liver
- Radiographic Features:
 Normal/decreased hepatic tracer accumulation
 Prolonged clearance of tracer from blood pool
 Bowel activity faint/delayed usually by 24 hours
 Gallbladder may not be visualized
- Ultrasound:
 Absence of gallbladder is suggestive; 20% of
patients have a small or normal gallbladder.
Normal hepatic parenchyma, normal intrahepatic
bile ducts
 Hepatobiliary scintigraphy: normal radiotracer
uptake by liver, no excretion into GIT

2. CHOLEDOCHAL CYST
4 Types
Type I Dilatation of the extrahepatic ducts (80%) of
the cases
Type II Eccentric diverticulum
Type III (Choledochocele): Focal dilatation near the
sphincter that extends into the duodenal wall
Type IV Multiple
dilatations