9 Nonskeletal Pediatric Imaging

Pediatric musculoskeletal imaging was covered in a special They also may occur without obvious cause. Febrile sei-
section at the end of Chapter 8. Congenital cardiac lesions zures usually occur between the ages of 6 months and 4
were covered in Chapter 5. Table 9-1 shows the appropri- years, and most are generalized tonic/clonic seizures.
ate imaging test for common pediatric problems. Imaging is recommended for children with new-onset sei-
zures who have experienced head trauma or partial sei-
zures and for those who have an abnormal neurologic
HEAD examination or an abnormal electroencephalogram.
Imaging is not necessary for uncomplicated febrile sei-
Imaging Techniques zures or in a patient with an obvious provoking cause.
MRI is the usual imaging modality of choice, although
Imaging of the fetal and infant brain can be done by using noncontrasted CT is used initially if intracranial hemor-
ultrasound as long as the fontanels remain open. Structures rhage or recent trauma is suspected. For those children
that can normally be visualized include the lateral ventri- with a history of seizures, imaging usually is done only if
cles, choroid plexus, thalamus, temporal lobes, and poste- the seizures are poorly controlled or are associated with a
rior fossa (Fig. 9-1). The two most common indications new neurologic deficit, or to follow up known abnormali-
for ultrasound of baby heads are (1) evaluation of ventricu- ties such as a tumor.
lar enlargement (hydrocephalus) and (2) hemorrhage
either within the parenchyma of the brain or within the
ventricles (Fig. 9-2). The major advantages of ultrasound NECK
in this application are that the imaging can be done in the
neonatal intensive care unit and that ionizing radiation is Croup and Epiglottitis
not used. This is important, because these studies are
repeated multiple times for continuing evaluation. If the Lateral soft tissue views of the neck are often done for
fontanels are closed, computed tomography (CT) is usually evaluation of the pediatric airway. This is important in
used for evaluation of suspected hydrocephalus or cases of suspected croup or epiglottitis. As you evaluate
hemorrhage. these lateral images, you should look to see that the child’s
Brain tumors in children are evaluated by CT or mag- neck has been extended. In a young child when the neck
netic resonance imaging (MRI). With MRI, sedation is is flexed, the trachea can buckle forward, causing the
necessary, and pediatric monitoring of respiration and appearance of a retropharyngeal mass. To avoid this arti-
other functions in a very high magnetic field is difficult. fact, simply extend the neck and lift the chin (Fig. 9-3).
CT scanning is easier to perform. About half of brain Acute epiglottitis usually occurs in older children
tumors in children are astrocytomas; medulloblastomas (between ages 2 years and 7 years) and most commonly is
(20%), ependymomas (10%), and craniopharyngiomas due to Haemophilus influenzae. This can be a life-threatening
(5% percent) are less common. disease, and the clinical findings are severe sore throat,
high fever, a muffled voice, and stridor. The patients often
can breathe more easily sitting up, and they drool because
Trauma they cannot swallow. This is a true pediatric emergency.
Because intubation can be necessary on very short notice,
Head trauma and the appropriate imaging studies are pre- a physician should accompany the child to the x-ray depart-
sented in Chapter 2 and also in Table 9-1. In general, ment. The lateral soft tissue view of the neck shows a
following significant acute head trauma of a child, a non- thickened epiglottis, often appearing bulbous (in the shape
contrasted CT scan is the procedure of choice. This will of a thumb) (Fig. 9-4). Remember that the normal epiglot-
reveal skull fractures, as well as evidence of bleeding. Sub- tis is a delicate, thin, curved structure. Other findings
acute injuries with neurologic or cognitive problems include ballooning of the hypopharynx and subglottic
usually will have a noncontrasted MRI. edema in about one fourth of cases.
Croup typically occurs in young children (between ages
6 months and 3 years), and it usually is caused by respira-
Childhood Seizures tory syncytial virus (RSV). The children often have a
brassy cough (like the barking of a seal) and inspiratory
Seizures may be provoked by infection, trauma, toxins, stridor. Occasionally the airway may have enough edema
metabolic abnormality, tumor, hypoxia, cerebrovascular that placement of an artificial airway is necessary. The
disease, cerebral malformation, or congenital abnormality. findings on the lateral view are marked ballooning of the
269
270    Chapter 9  |  Nonskeletal Pediatric Imaging

TABLE 9-1 Imaging of Pediatric Problems

SUSPECTED PROBLEMS IMAGING TEST OF CHOICE
Neonatal hydrocephalus or intracranial hemorrhage Cranial ultrasound
Uncomplicated febrile seizure No imaging needed
Seizure
  Neurologic deficit, partially unresponsive to therapy, MRI without contrast
new without obvious provoking factor
  Posttrauma
  Neonatal Noncontrast CT
US cranial
Ataxia MRI with and without contrast
Headache
  Isolated, no neurologic findings No imaging needed
  With neurologic signs CT without contrast or MRI
  Acute “thunderclap” headache CT without contrast
  Migraine without neurologic signs No imaging needed
Head injury
  Acute, mild, GCS > 13, without neurologic findings No imaging needed
  Acute, mild-moderate, <2 years of age CT without contrast
  Acute, penetrating, or moderate-severe CT without contrast
  Acute, suspected skull fracture CT without contrast
  Subacute, cognitive or neurologic findings MRI without contrast
Sinusitis
  Uncomplicated No imaging needed
  Recurrent, unresponsive, suspected complication CT without contrast
Croup or epiglottitis Lateral soft tissue view of neck
Suspected inhaled foreign body Inspiration/expiration or decubitus chest
Difficulty breathing Chest x-ray
Fever
  Without obvious source, no respiratory symptoms No imaging needed
  Neonatal or respiratory symptoms or increased WBC Chest x-ray
Esophageal atresia or tracheoesophageal fistula Lateral radiograph with soft feeding tube in place
Asthma
  Uncomplicated No imaging needed
  Poor response to therapy, complicated Chest x-ray
Suspected pneumonia Chest x-ray
Congenital heart disease or congestive heart failure Chest x-ray, echocardiogram
Gastroesophageal reflux Barium swallow or nuclear medicine reflux study
Vomiting (recurrent 0-3 mo of age) X-ray and UGI
Pyloric stenosis Ultrasound
Duodenal atresia, stenosis, or midgut volvulus Plain x-ray (use air as contrast)
Meconium ileus Plain x-ray and meglumine diatrizoate (Gastrografin) enema
Appendicitis CT with IV contrast or US (if experienced operator is available)
Intussusception Plain x-ray followed by reduction using air or Gastrografin enema
Necrotizing enterocolitis Plain x-ray of the abdomen and possible left lateral decubitus views (to look for free air)
Crohn’s disease CT with IV contrast or CT enterography
Hirschsprung’s disease Barium or Gastrografin enema
Biliary atresia or neonatal hepatitis Nuclear medicine hepatobiliary scan
Abdominal mass Plain x-ray of abdomen and ultrasound or CT
Meckel’s diverticulum Nuclear medicine Meckel’s scan
Urinary tract infection US kidneys and bladder
Hematuria
  Isolated US kidneys and bladder
  Painful or posttrauma CT without contrast
 Chapter 9  |  Nonskeletal Pediatric Imaging    271

TABLE 9-1  Imaging of Pediatric Problems—cont’d

SUSPECTED PROBLEMS IMAGING TEST OF CHOICE
Rectal bleeding See text
Child abuse X-ray bone survey, CT head without contrast, CT abdomen if abdominal trauma
Hip dysplasia (<4 mo of age) US of hips
Limping child (0-5 yr) X-ray of affected extremity and hip
Osteomyelitis, cellulitis, or septic arthritis Plain x-ray, MRI, or three-phase nuclear medicine bone scan
CT, Computed tomography; GCS, Glasgow Coma Scale; IV, intravenous; MRI, magnetic resonance imaging; UGI, upper gastrointestinal x-ray examination; US, ultrasound;
WBC, white blood cell count.

Ant Post

Ant Post

LV
FL Sh
Th
LV
CP
TL

FIGURE 9-1  Ultrasound of normal neonatal head. A sagittal view

obtained through an open fontanel clearly shows the frontal lobe (FL),
lateral ventricle (LV), thalamus (Th), temporal lobe (TL), and choroid plexus
(CP). LV

pharynx and hypopharynx. On the anteroposterior (AP)

view the upper portion of the trachea is shaped like a
steeple (Fig. 9-5). The “steeple sign,” caused by subglottic
H
edema, is not pathognomonic, because it also can occur in
some children who have epiglottitis.

CHEST

Normal Anatomy and Imaging

One of the major differences between the normal chest of B
an adult or child and a neonate is the presence of the FIGURE 9-2  Ultrasound of abnormal neonatal head. A, Sagittal view of
thymus. It is routinely identified on chest x-rays from birth the brain in a neonate with hydrocephalus. A dilated lateral ventricle (LV)
to approximately age 2 years. The thymus is usually seen is seen as well as the shunt (Sh) catheter. B, Intraparenchymal hemorrhage.
as a widening of the soft tissues of the upper mediastinum, A sagittal view of the brain in a different infant shows a normal-sized lateral
although occasionally it may appear to project out into the ventricle but an area of increased echoes representing hemorrhage (H)
within the substance of the brain.
lung (the “sail sign”) (Fig. 9-6). Some people mistakenly
think that the sail sign is an indication that a pneumothorax
is present. This is not true.
Imaging of the chest in infants and children can be dif-
ficult because of their uncooperative nature, especially
272    Chapter 9  |  Nonskeletal Pediatric Imaging

Flexion Extension
A B
FIGURE 9-3  Pseudoretropharyngeal abscess. A, Lateral soft tissue view of the neck in a child with the neck slightly flexed shows the trachea (T) bowed
forward, which suggests that a retropharyngeal soft tissue mass is present (arrows). B, A lateral view taken a few minutes later of the same child with the
neck extended shows a normal prevertebral soft tissue pattern.

enough, hypoinflation of the chest is usually not a problem

in interpretation of pediatric chest x-rays.
Most children with pneumonias, bronchiolitis, or reac-
tive airway disease have hyperinflation. In most normal
young children the most superior portion of the hemidia-
phragm is at the level of the posterior eighth rib. If the
diaphragms are lower than this, hyperinflation should be
considered, and pathology may well be present. Rotation
of the patient can cause problems in interpretation. As
the patient is rotated to the left, the right cardiac border
Ph projects over the spine, and the right lower lobe pulmo-
nary vessels are indistinct and can mimic an infiltrate
(Fig. 9-7).
A favorite x-ray examination is the “babygram.” This is
E an AP view of both the chest and the abdomen. In extremely
small babies the x-ray exposure can be adequate to visualize
pulmonary vasculature, bowel gas, and skeletal structures.
Conversely, if you are interested only in the chest, a chest
T x-ray is what you should order to avoid unnecessary radia-
tion exposure.

Foreign Bodies
FIGURE 9-4  Epiglottitis. A lateral soft tissue view of the neck shows a
ballooned pharynx (Ph) with a swollen epiglottis (E) in the shape of a large Foreign bodies can be either aspirated or ingested. Most
thumbprint (arrows). foreign bodies consist of vegetable material (such as
peanuts) or plastic. Remember that vegetable and plastic
items are usually not visible on a plain x-ray. When a
when they are sick. In neonates, portable x-rays are usually foreign body is aspirated into a bronchus, two possibilities
obtained in the intensive care unit in a supine AP projec- exist. The first is that the object will become completely
tion. Somewhat older children can be placed in a holder impacted and will not allow air to pass during either inspi-
or restrained with Velcro straps while an image is obtained. ration or expiration. In this case the air distally will become
In most of these instances the image is taken randomly resorbed, and postobstructive atelectasis or a focal infil-
with respect to inspiration and expiration. Amazingly trate with associated volume loss will be found.
 Chapter 9  |  Nonskeletal Pediatric Imaging    273

R L

Ph

FIGURE 9-6  Normal thymic shadow. A posteroanterior view of the chest

shows a prominent thymic shadow (arrows). Sometimes referred to as the
sail sign, this is a normal finding.

A R L

B
B
FIGURE 9-5  Croup. In a child with a “barking” cough a lateral soft tissue
view of the neck (A) demonstrates a markedly ballooned pharynx (Ph). FIGURE 9-7  Pseudoinfiltrate due to poor positioning. A, An anteropos-
B, An anteroposterior view of the neck shows a steeple-shaped trachea (T) terior view of the chest was obtained but is slightly rotated. This throws
(arrows) caused by subglottic edema. the heart shadow to the left and makes the right pulmonary vascularity
appear prominent, creating the impression of a right middle or lower lobe
infiltrate (arrows). B, A repeated view obtained on the same infant within
10 minutes shows that the chest is perfectly normal.
The second possibility is that the object is only incom-
pletely obstructing the bronchus. This occurs because
during inspiration the bronchus becomes larger in diam- x-ray may be normal. If the chest is normal, a ball-valve
eter, and air can pass around the object. During expiration phenomenon may still exist, and on the expiration view, air
the bronchus becomes narrower due to pressure in the will be trapped on the affected side, whereas the unaffected
lung, and the air distal to the object cannot escape. The lung will decrease in volume. When this happens, a resul-
object acts as a ball valve. Thus if you are suspicious of the tant shift of the mediastinum toward the normal unaffected
presence of an inhaled foreign body, be sure to order an side will be seen (Fig. 9-8).
inspiration and an expiration image. On the inspiration Swallowed objects may be caught within the esophagus.
image you may see postobstructive atelectasis, or the chest In children the objects that are large enough to remain in
274    Chapter 9  |  Nonskeletal Pediatric Imaging

R L R L

Expiration
A B
FIGURE 9-8  Foreign body in right main stem bronchus. A, An inspiration view of the chest looks essentially normal. B, An expiration view shows that
the left lung has decreased in volume (as expected) but that a shift of the heart to the left has occurred (arrows). The right lung remains hyperinflated due
to the inability of the air to escape the ball-valve phenomenon caused by the foreign body.

A B
FIGURE 9-9  Coin in the esophagus. A, A posteroanterior view of the chest demonstrates a quarter (arrow) that is lodged in the esophagus just at the
thoracic inlet. B, The lateral view also shows the coin behind the trachea in the esophagus (arrow).

the esophagus are typically coins. These may be lodged at tubes and catheters that are of specific interest in children
the level of the thoracic inlet, or they may sit in the esopha- are endotracheal tubes and umbilical artery and vein cath-
gus just above the level of the aortic arch (Fig. 9-9). eters. The tip of an endotracheal tube should be at least as
Another common foreign object that may lodge in either far down as the level of the medial clavicles or at the level
the hypopharynx or the esophagus is a fish bone or chicken of the vertebral body of T1 or T2. The endotracheal tube
bone. Chicken bones may be visualized on plain x-rays, but also should have its tip located 1 or 2 cm proximal to the
most fish bones are composed of cartilage and are essen- carina. If the carina cannot be easily visualized, you should
tially invisible. remember that on an AP or a posteroanterior (PA) chest
x-ray, a tube with its tip projecting over the vertebral body
of T5 is probably too low. Endotracheal tubes that are too
Tubes and Lines low usually will go down the right main stem bronchus,
because this is more vertical in orientation than the left
A discussion of central venous catheters, jugular catheters, main stem bronchus. Initially an endotracheal tube posi-
and pleural tubes has been included in Chapter 3. The tioned in the right main stem bronchus may demonstrate
 Chapter 9  |  Nonskeletal Pediatric Imaging    275

R L

RUL

C
FIGURE 9-10  Progressive right upper lobe atelectasis. A, A posteroanterior view of the chest demonstrates an endotracheal tube with the tip down
in the right main stem bronchus. This will often obstruct the right upper lobe bronchus. B, Early atelectasis of the right upper lobe occurs with resorption
of air, causing consolidation (arrows) and slight upward bowing of the minor fissure. C, As collapse of the right upper lobe becomes complete, the minor
fissure rotates upward and medially, and the completely collapsed right upper lobe (RUL) remains as a small density along the right paratracheal region.

a relatively normal-appearing lung. With time, however, one that goes down toward the pelvis and then toward the
selective obstruction of the right upper lobe bronchus will head is a UAC.
cause right upper lobe atelectasis with progressive collapse Another catheter that can sometimes be confusing is a
(Fig. 9-10) or generalized left lung collapse. ventriculoperitoneal shunt catheter. These shunts, which
Umbilical artery and vein catheters are easily differenti- are placed for relief of hydrocephalus, extend from the
ated on the lateral view of the abdomen and chest. The lateral ventricle of the brain down along the soft tissues of
umbilical artery catheter (UAC) proceeds inferiorly from the neck and anterior chest wall and then into the perito-
the umbilicus down into the pelvis and then turns and neal cavity (Fig. 9-12). Less commonly, the distal shunt tip
comes up the aorta (Fig. 9-11). Usually the tip of a UAC may be placed in the region of the right atrium.
is positioned at approximately the level of the vertebral
body of T8. If a UAC is advanced too far, it can proceed
up into the great vessels of the head and neck or go ante- Respiratory Disease in the Newborn
riorly in the aortic arch. An umbilical vein catheter (UVC)
also is best identified on the lateral view. It can be seen A number of entities can cause neonatal respiratory diffi-
progressing immediately superiorly from the umbilicus culty (Table 9-2). You should be able to recognize a con-
and then posteriorly along the liver and into the inferior genital diaphragmatic hernia, because it is a cause of
vena cava and right atrium. respiratory distress in the neonatal period, and it carries a
If both a UAC and a UVC are present on an AP view, mortality rate well in excess of 50%. Clinical manifesta-
it is not often easy to tell them apart, especially because tions are a scaphoid abdomen and bowel sounds in the
you will be seeing the portions of the catheters that are chest. Cyanosis due to pulmonary hypoplasia and pulmo-
inside and outside the baby. What you should do is imagine nary hypertension also may be present. These hernias
where the umbilicus should be. A catheter that goes straight occur more commonly on the left and will displace the
up and slightly to the right of the midline is a UVC, and heart and tracheal structures to the right. An opacity within
276    Chapter 9  |  Nonskeletal Pediatric Imaging

R L Ant

UAC

UAC

UVC

UVC

Ant

A B
FIGURE 9-11  Differentiation of umbilical artery from umbilical vein
catheters. A, On the anteroposterior view babygram, if you imagine the
position of the umbilicus (at the position of the “X”), the catheter that ini-
tially goes inferiorly and then turns and goes superiorly just to the left of
midline is the umbilical artery catheter (UAC) (black arrows). A catheter that
goes into the umbilical region and immediately progresses cephalad and
slightly to the right of the midline (white arrows) is the umbilical vein cath-
eter (UVC). B, A lateral view of the same infant demonstrates the inferior
and then the posterior and superior course of the umbilical artery catheter,
and the immediate superior course of the umbilical vein catheter progress-
ing toward the inferior portion of the liver.

TABLE 9-2 X-ray Findings of Respiratory Distress FIGURE 9-12  Ventriculoperitoneal shunt for hydrocephalus. A, An
in the Newborn anteroposterior view of the chest shows a catheter coming down from the
cervical region and progressing across the chest (arrows), but not in a
pathway that would represent vascular or other mediastinal structures. 
LUNG
B, The lateral view of the chest shows the catheter progressing along the
ENTITY TIME VOLUME LUNG FINDINGS
anterior soft tissues down into the abdomen (arrows).
Diaphragmatic At birth Compressed Bowel in chest
hernia
Meconium At birth Increased Coarse, patchy the chest often has visible bowel or at least air-filled spaces
aspiration infiltrates
within it (Fig. 9-13).
Transient 0-2 days Normal or Homogeneous diffuse At birth, meconium aspiration can occur. Meconium is
tachypnea increased or linear infiltrates the term used for the first stool evacuated after birth, and
Hyaline 0-7 days Decreased* Granular infiltrates it is composed of mucus, epithelial cells, bile, and debris.
membrane In fetal distress, evacuation of meconium into the amniotic
disease fluid may occur. Only about 10% of the time does this
Neonatal Variable Variable Granular or patchy cause respiratory problems. At birth, as a result of this,
pneumonia infiltrates coarse patchy infiltrates and hyperinflation of the lungs
Pneumothorax Variable Decreased Lucent dark area at may be found, which clears in about 3 to 5 days. Pneumo-
lung edge† thorax or pneumomediastinum occurs in about 25% of
*Can be increased if the patient is on positive-pressure ventilation (PEEP).
cases.
†
Pneumothorax is much more common in children who are on PEEP. Another cause of respiratory distress within 48 hours of
Look carefully for a basilar, medial, or anterior pneumothorax, because the images birth is transient tachypnea of the newborn (TTN). Lung
are usually done supine.
volumes may be larger than normal, and there may be
linear or streaky opacities that usually clear within 2 days.
TTN is really a clinical and not a radiographic diagnosis;
it is due to delayed resorption of intrauterine pulmonary
liquid.
 Chapter 9  |  Nonskeletal Pediatric Imaging    277

R L R L

FIGURE 9-14  Pulmonary interstitial emphysema. This anteroposterior

view of the chest shows generalized opacification of both lungs in a child
with hyaline membrane disease. The arrows indicate linear air collections
that do not follow the normal branching bronchial pattern and represent
air in the interstitium. These patients often quickly progress to having a
pneumothorax.

FIGURE 9-13  Diaphragmatic hernia. This newborn had significant respi-

ratory difficulty. An anteroposterior view of the chest and abdomen dem-
onstrates opacification of the left hemithorax, with bowel loops pushing
up into the opacified left hemithorax. This condition carries a high fatality
rate and should be recognized immediately.

Hyaline membrane disease (HMD) is caused by surfac-

tant deficiency and results in low lung volumes (unless the
infant is intubated) and granular or ground-glass opacities
of both lungs. Any opacity in the lungs of a premature
infant should be considered to be HMD until another
cause is established. Air bronchograms are often present,
and, rarely, a pleural effusion is found. HMD typically
becomes radiographically apparent at 4 to 6 hours after
birth. A
With HMD or pneumonia, infants may need positive-
pressure ventilation. The complications of this respiratory
therapy include pulmonary interstitial emphysema (PIE)
and bronchopulmonary dysplasia (BPD). PIE refers to
accumulation of air outside of alveoli and in interstitial or
perivascular spaces. The imaging features include tortuous
linear lucencies that radiate outward from the hilum
and may extend all the way to the periphery of the lung.
If you look carefully, these do not resemble the pattern
of a typical bronchial tree but are more tortuous (Fig.
9-14). You should be able to recognize PIE, because it may
rapidly result in life-threatening complications, such as
pneumothorax, pneumomediastinum, or pneumopericar-
dium (Fig. 9-15).
Because the AP chest x-rays of newborns or neonates
are usually obtained with the infant in a supine position, a
B
pneumothorax may be difficult to appreciate. This is
because the air is usually located anteriorly (and not supe- FIGURE 9-15  Complications of hyaline membrane disease. A, Most
riorly or laterally) in the pleural space. You may be able to patients with hyaline membrane disease have low lung volume and bilat-
see lucencies either at the base of the lung or along the eral infiltrates. This patient is hyperinflated, with the diaphragms down to
the level of the posterior tenth ribs because of the need for positive-
medial aspect of the lung. Often a lateral projection taken pressure ventilation. B, A subsequent anteroposterior chest x-ray demon-
with the child lying on the back is necessary to show you strates development of a pneumopericardium, seen as a dark collection of
the (anterior) pneumothorax (Fig. 9-16). air surrounding the heart.
278    Chapter 9  |  Nonskeletal Pediatric Imaging

R L R L

Up

C
FIGURE 9-16  Pneumothorax on supine chest x-ray. A, In this infant a right chest tube has already been placed because a pneumothorax is present.
However, a lucency at the left lung base (small arrows) represents a loculated pneumothorax. Note in addition a deep sulcus sign (large arrow). B, An
anteroposterior view of the chest in another infant demonstrates a lucency or dark area overlying the medial aspect of the right lung and outlining the
right cardiac border (arrows). This represents an anterior medial right pneumothorax. C, A lateral view of the chest with this patient supine is the best way
to see an anterior pneumothorax. It will be seen as a dark collection of air in the retrosternal region and in the anterior costophrenic angle (arrows).

BPD is thought to be the result of oxygen toxicity or viruses], rubella, cytomegalovirus, herpes simplex virus
barotrauma associated with respiratory therapy. BPD [TORCH]) or from perineal flora acquired as a result of
usually progresses as either HMD or neonatal pneumonia premature rupture of the membranes or while passing
is resolving. BPD is usually seen progressing from approxi- through the birth canal.
mately 1 week to 1 month of life. The lungs typically Children from several weeks to 1 year of age may have
become hyperinflated, although they may have diffuse a viral pneumonia caused either by RSV or by H. influen-
opacity with linear densities caused by fibrosis. Areas of zae. With these the early stage is bronchiolitis. About 15%
rounded lucency may appear within the lung. of children younger than 2 years will develop bronchiolitis
and will initially have rhinorrhea, sneezing, cough, and
low-grade fever followed by the rapid onset of tachypnea
Bronchiolitis, Reactive Airway Disease, and wheezing. Most cases occur during winter and early
and Pneumonia spring. These patients will not have infiltrates on the chest
x-ray, and hyperinflation is the only radiographic clue.
Neonatal pneumonia may result in a lung that is low in Bronchiolitis most commonly is due to RSV. As these viral
volume, normal, or hyperinflated. The lung opacities pneumonias progress, perihilar or peribronchial opacities
are typically granular, and the time course is variable. also may develop. This can be seen as peribronchial cuffing
Neonatal pneumonias are due to transplacental infection or hilar adenopathy. Again, many of these patients show
(from toxoplasmosis, other agents [congenital syphilis and associated hyperinflation. The peribronchial cuffing can be
 Chapter 9  |  Nonskeletal Pediatric Imaging    279

seen by looking for an outline of a bronchus in the region Cystic Fibrosis

of the hilum and noting that the bronchial wall is thicker
than a line traced by a fine lead pencil. Cystic fibrosis is caused by a dysfunction of the exocrine
As children get somewhat older (age 1 to 3 years), they glands producing thick mucus that accumulates in the
develop bacterial pneumonias during this period. Pneumo- lungs, causing bronchitis and recurrent pneumonias. It is
coccus is a common pathogen, whereas Staphylococcus aureus an autosomal recessive disorder and is the most common
and H. influenzae are usually seen during infancy. Bacterial lethal genetic disease affecting whites. Pulmonary findings
pneumonias typically cause alveolar infiltrates with lobar are present in essentially all cases by the time a child is age
or segmental consolidations, often with effusion. Staphy- 10 years or older. The most obvious finding is hyperinfla-
lococcal pneumonias may cause pneumothorax and also tion. Essentially the chest x-ray looks like that of an adult
may cavitate. Most of the bacterial pneumonias have with chronic obstructive pulmonary disease, with an
appearances similar to those already described for adults. increased AP diameter and flattening of the hemidia-
The two exceptions are the cavitating staphylococcal pneu- phragms. In addition, the lungs generally appear “dirty.”
monias and, occasionally, what is termed a round pneumo- Peribronchial thickening and bronchiectasis are found
nia. A round pneumonia is usually a bacterial pneumonia with many pulmonary markings at the lung bases (Fig.
in an early stage and later may develop into typical lobar 9-18). These are not lobar or segmental infiltrates.
consolidations (Fig. 9-17). Children with cystic fibrosis also are prone to a wide
variety of gastrointestinal (GI) problems, including meco-
nium ileus, meconium peritonitis, rectal prolapse, volvu-
Asthma lus, intussusception, pancreatitis, jaundice, and growth
failure or vitamin deficiencies. You should suspect cystic
Asthma is one of the most common pulmonary disorders fibrosis in any child with recurrent respiratory or GI
in children. Reversible airway obstruction can range from symptoms.
mild to life threatening. Asthma and wheezing (easy inspi-
ration and difficult expiration) should be differentiated
from stridor (difficult inspiration and easier expiration). PEDIATRIC ABDOMINAL IMAGING
The latter indicates an upper airway obstruction. The
initial workup of asthma includes history, physical exami- Congenital diaphragmatic hernia has already been men-
nation, and pulmonary function tests (particularly forced tioned, but you should be aware of a number of other
expiratory volume in 1 second [FEV1]). In young children congenital abnormalities of the bowel in neonates.
it is important to exclude inhaled foreign bodies, cystic
fibrosis, enlarged lymph nodes, or neoplasms obstructing
the bronchi. For patients with known asthma and a simple Esophageal Fistula
attack, a chest x-ray is not indicated. If there is suspicion
of a complicating factor (fever or pneumonia) or a poor Tracheoesophageal fistula (TEF) may be suspected in an
response to therapy, a chest x-ray is indicated. infant who has had polyhydramnios. This is usually clini-
cally apparent, because of excessive salivation; as soon as
an attempt is made to feed the child, aspiration, coughing,
and choking occur. Ninety-five percent of patients with a
TEF will have a blind-ending esophagus. The diagnosis is
R L usually made by passing a small, soft feeding tube down
the esophagus to the blind end and taking a lateral x-ray.
If necessary, air can be injected to help visualization. Instil-
lation of barium or other contrast material is rarely, if ever,
indicated. In those few patients with an “H-type” fistula
and a patent esophagus, it may take months to arrive at the
diagnosis, but the disorder should be suspected in a child
with recurrent pneumonias or chronic cough. You should
remember that 40% of patients with TEF have associated
cardiac and other GI anomalies. The VATER syndrome
describes the association among vertebral anomalies
(hemivertebra), anal atresia, tracheoesophageal fistula, and
radial limb dysplasia.

Acute Gastroenteritis

The usual clinical presentation is acute onset of diarrhea,

vomiting, or both. Dehydration is the major complication.
FIGURE 9-17  Round pneumonia. A posteroanterior view of the chest Acute gastroenteritis is usually due to viruses (Rotavirus or
demonstrates a rounded density in the right lower lobe (arrows). Usually Norwalk virus). In extremely ill patients a stool culture or
this will progress to a standard lobar consolidation of a typical pneumonia. toxin assay is indicated. If the patient has abdominal pain
280    Chapter 9  |  Nonskeletal Pediatric Imaging

R L

T11

A B
FIGURE 9-18  Cystic fibrosis. A, The posteroanterior view of the chest in this young teenager demonstrates marked hyperinflation, with the hemidia-
phragms being flattened and pushed down to the level of the posterior eleventh ribs. Diffuse bronchial thickening throughout both lungs is shown. 
B, The lateral view of the chest shows an increase in anteroposterior diameter (double-ended arrow) and flattening of the hemidiaphragms. These findings
in an adult would normally be associated with chronic obstructive pulmonary disease, but in a teenager or child they are almost certainly due to cystic
fibrosis.

or distention, the differential diagnosis includes appendi- approximate level of obstruction in the bowel is typically
citis, intussusception, or bowel obstruction. In these cir- determined on the plain radiograph by seeing how far
cumstances a plain and upright radiograph of the abdomen bowel gas has progressed through the GI tract. If gas is
or a CT scan may be helpful. These are discussed in more seen only in the stomach or the stomach and duodenum
detail in Chapter 6. For simple gastroenteritis no imaging (the double bubble sign), a proximal obstruction is likely.
studies are indicated. Duodenal atresia or midgut volvulus should be suspected
in a birth with polyhydramnios and an infant who has bile-
stained vomiting. Duodenal atresia is the most common
Bowel Obstruction cause of the double bubble sign, with annular pancreas
being the next most common. Duodenal bands, webs, and
Air should normally be seen in the abdomen of the neonate midgut volvulus are less frequent. Duodenal atresia has
in the following temporal progression: in the stomach 2 been associated with Down syndrome. Midgut volvulus,
hours after birth, in the small bowel at 6 hours, and in the although less common, is important to consider, because a
rectum by 24 hours. Hypertrophic pyloric stenosis is the high mortality rate occurs without intervention. A midgut
second most common GI condition requiring surgery in volvulus occurs when the small bowel and proximal colon
the first 2 months of life. Pyloric stenosis is more common rotate about the axis of the superior mesenteric artery; this
in male infants and should be suspected if a maternal or can cause arterial compromise and gangrene.
sibling history of the condition exists. The typical clinical If air is seen beyond the duodenum but not into the
symptom is nonbilious vomiting during the second to distal small bowel or colon, you should think of midlevel
fourth week of life. A palpable olive-shaped mass may be lesions. Atresias can occur in the jejunum and ileum. With
found to the right of the umbilicus. A plain x-ray of the any of these entities, even with x-ray contrast studies, it is
abdomen will show a stomach that is dilated to more than not possible to tell with certainty either the site of or the
7 cm, and peristaltic waves can sometimes be seen, giving length of the atresia or even to differentiate an atresia from
the stomach a caterpillar appearance. The diagnosis is con- a midgut volvulus. As a result, most pediatric surgeons are
firmed by using abdominal ultrasound to visualize the content with the plain x-ray findings before proceeding to
thickened pyloric muscle. The pyloric muscle should not surgery. Occasionally some will request a barium enema to
be more than 4 mm in thickness (mucosa to outside wall) look for a microcolon before surgery.
or greater than 18 mm in length (Fig. 9-19). If gas is seen throughout most of the abdomen of a
Duodenal atresias, midgut volvulus, and pyloric stenosis neonate but not in the region of the rectum, a distal small
are apparent because they produce obstruction and vomit- bowel or colon obstruction should be suspected. This may
ing. Under these circumstances consult the radiologist be the result of either a meconium ileus or Hirschsprung’s
as to what imaging procedure would be best. The disease. A note of caution should be entered here relative
 Chapter 9  |  Nonskeletal Pediatric Imaging    281

A
R

Pyloric M
canal
M

B
FIGURE 9-19  Pyloric stenosis. A, A KUB (kidneys, ureters, bladder)
image of the abdomen shows a markedly dilated, gas-filled stomach. B, A
transverse ultrasound study of the upper abdomen shows the thickened
pyloric muscle (M) on both sides of the pyloric canal (arrows).
B
FIGURE 9-20  Meconium ileus. A, An anteroposterior view of the
to the appearance of bowel gas in a neonate or very young abdomen demonstrates dilated bowel. In a child of this age, it is not pos-
sible to differentiate the colon from the small bowel. However, no gas is
child. Gas in the small bowel and colon look exactly the seen within the rectum. B, A meglumine diatrizoate (Gastrografin) enema
same, and you should not allow yourself to think that you has been performed, and the colon is noted to be very small (a microco-
can tell the difference. Rather, differential diagnoses are lon). Intraluminal defects are seen in the colon at the level of the ileocecal
made on the basis of whether gas is seen in the proximal valve, because usually obstruction at this level results from the thick tena-
or distal “bowel.” cious meconium adhering to small bowel.
Meconium ileus is seen in 50% of patients with cystic
fibrosis. On an enema performed with water-soluble con-
trast, the colon is seen to be very small (microcolon), telescoping into colon. Forty percent of patients are ini-
because it was unused during fetal life (Fig. 9-20). tially seen between ages 3 months and 18 months, most
Hirschsprung’s disease is due to the absence of neural cells with pain and vomiting. A lesser number have an associ-
in the distal segment of the colon; these children are seen ated abdominal mass or rectal bleeding. Intussusception is
in the first 6 weeks of life with obstruction or constipation. rarely seen in neonates. Clinically the children have an
This disorder should be suspected in any infant who fails acute onset of colicky pain, and they may cry, draw up their
to pass meconium in the first 24 hours of life. In about knees, and vomit. Sometimes a sausage-shaped mass can
75% of patients the abnormal segment is restricted to the be felt in the upper abdomen. Radiographically, plain
rectosigmoid colon. On a barium enema a narrowed x-rays are often normal. If the intussusception has occurred
segment may be identified (Fig. 9-21). within 24 hours before the patient is seen, a radiologist has
Intussusception is invagination of a segment of bowel a good chance of reducing it with a water-soluble contrast
into more distal bowel and usually occurs with ileum enema. Currently, however, most radiologists prefer to
282    Chapter 9  |  Nonskeletal Pediatric Imaging

FIGURE 9-23  Necrotizing enterocolitis. This represents the most

common gastrointestinal emergency in premature infants. A plain x-ray of
the abdomen of this 5-day-old infant shows abnormal collections of air
FIGURE 9-21  Hirschsprung’s disease. This abnormality is due to an within the bowel wall (arrows).
absence of myenteric plexus cells in the distal colon. A barium enema
demonstrates a narrowed segment in the rectum (arrows) and a markedly
dilated sigmoid and descending colon.

Necrotizing Enterocolitis
R L
Necrotizing enterocolitis is the most common GI emer-
gency in premature infants. It usually develops within the
first week after birth but can be seen up to 2 months after
birth. Clinical signs are abdominal tenderness, rectal
St bleeding, and a septic shock–like appearance. The earliest
SF radiographic sign is air within the wall of the bowel (pneu-
matosis) or a bubbly appearance of the bowel. Another
early finding is small bowel dilatation due to an adynamic
ileus (Fig. 9-23). Common complications and indications
for surgery include free air within the peritoneal cavity,
M which indicates a bowel perforation. Gas in the portal vein
also may be identified. In contrast with adults, in whom
this condition generally portends a fatal outcome, the
outcome in children with portal venous air is not so bad.
DC On a supine view if a large amount of free air is noted
within the peritoneal cavity, the air will outline the falci-
form ligament of the liver (the “football sign”) (Fig. 9-24).
This is a fairly subtle sign; a large amount of air may be
FIGURE 9-22  Intussusception. This 3-year-old had colicky abdominal present in the peritoneal cavity, and on a supine image you
pain and rectal bleeding. Invagination of a segment of bowel into more
distal bowel can be seen. Ileocolic and ileoileocolic intussusceptions rep- may easily overlook it. For this reason, a left lateral decu-
resent 90% of occurrences. Here an image has been obtained while the bitus view, which will show air over the lateral margin of
radiologist is reducing the intussusception with air. Air is seen in the distal the liver, is often recommended.
colon (DC) and the splenic flexure (SF), and the mass (M) representing the
leading portion of the intussuscepted segment is clearly identified. St,
Stomach.
Meckel’s Diverticulum

reduce intussusception simply by using air (Fig. 9-22). If Meckel’s diverticulum is a vestigial remnant of the ompha-
this fails, surgery is necessary. Reduction by a radiologist lomesenteric duct, and it may contain gastric mucosa.
should not be attempted if clinical signs of peritonitis or Clinical signs are painless rectal bleeding and occasionally
shock are found. Other relatively common lesions to bear intestinal obstruction. Meckel’s diverticulum follows what
in mind when it looks as though there is a proximal bowel is known as the rule of twos. It occurs in 2% of the popula-
obstruction in a child who is 6 to 30 months of age are an tion, it usually is first seen before age 2 years, and the
incarcerated inguinal hernia and appendicitis. diverticulum is usually located in the ileum within 2 feet
 Chapter 9  |  Nonskeletal Pediatric Imaging    283

Ant

5 min 10 15

H
St

20 25 R Lat
FIGURE 9-25  Meckel’s diverticulum. In this 2-year-old child with unex-
plained rectal bleeding, a nuclear medicine study was performed using
radioactive material that concentrates in gastric mucosa (technetium 99m
pertechnetate). Sequential 5-minute images of the abdomen are obtained.
On the 20-minute image, the heart (H), stomach (St), and bladder (B) are
A clearly seen, as well as an ectopic focus of activity (arrow) representing a
Meckel’s diverticulum.
R

Up
Neonatal Jaundice

In some infants who are 2 to 3 weeks old, jaundice may

develop. The usual diagnostic dilemma is whether the
Liver infant has neonatal hepatitis or biliary atresia. The imaging
test of choice is a nuclear medicine hepatobiliary scan.
This involves giving a small amount of radioactive tracer
Air that is concentrated by the liver and then excreted via the
biliary system. If any excretion into the small bowel is
detected on the images, biliary atresia is excluded. Occa-
sionally in patients with severe hepatitis, follow-up images
are needed at 24 hours after injection, to be certain of the
diagnosis.

Abdominal Masses

Abdominal masses in children are usually initially worked

B up by clinical examination and a plain x-ray of the abdo-
men. The differential diagnosis of an abdominal mass
FIGURE 9-24  Complications of necrotizing enterocolitis. A, A supine varies with the child’s age. A mass in the abdomen of a
abdominal x-ray of the abdomen demonstrates diffuse mottled air child of any age most likely arises from the kidneys. In a
throughout the bowel wall and shows air within the portal venous system
(short arrows) as well. The falciform ligament is outlined by free air (long
neonate, 55% of masses are renal in origin (hydronephro-
arrows) anteriorly in the peritoneal cavity. To the uninitiated, the amount sis or multicystic dysplastic kidney), and the remainder are
of free air is difficult to appreciate. B, A left lateral decubitus view obtained usually GI duplications, cysts, and hemangioendothelio-
in the same patient immediately afterward demonstrates a very large mas of the liver.
amount of free air overlying the surface of the liver. If a mass appears to be in the flank in an older infant or
child, Wilms’ tumor, neuroblastoma, and hydronephrosis
account for about 80% of the lesions. Other possibilities
of the ileocecal valve. If gastric mucosa is present in the include abscesses, cysts, and hepatoblastomas. Neuroblas-
diverticulum, ulceration and hemorrhage may result. In tomas have calcification approximately 90% of the time
patients with rectal bleeding before age 2 years, Meckel’s (Fig. 9-26) and are usually seen in patients younger than 2
diverticulum should be considered. The imaging study of years. They appear as masses external to the kidney and
choice is a nuclear medicine scan done with technetium tend to displace the kidney rather than deform it. Because
pertechnetate. This concentrates in the normal and ectopic neuroblastomas arise from neural tissue, they also are rela-
gastric mucosa and allows identification of Meckel’s diver- tively common in the region of the adrenal glands, along
ticulum (Fig. 9-25). the sympathetic chain, and in the posterior mediastinum
284    Chapter 9  |  Nonskeletal Pediatric Imaging

(Fig. 9-27). Wilms’ tumor begins within the kidney, and Appendicitis
on an intravenous pyelogram it will be seen as a mass
within the kidney, deforming the normal collecting system In cases of suspected appendicitis in adults, CT scan of the
(Fig. 9-28). Wilms’ tumors are bilateral 10% of the time abdomen and pelvis with intravenous contrast is the pro-
and are rarely calcified. The average age of presentation is cedure of choice. Although graded-compression ultra-
2 years to 3 years, which is older than the usual age for sound can be used, the accuracy is quite dependent
neuroblastomas. upon the skill of the operator. Obviously the appeal of

R L
R L

FIGURE 9-28  Wilms’ tumor. On this intravenous pyelogram the collect-

ing system of the right kidney is identified along the lateral border of L1,
L2, and L3. The collecting system of the left kidney (arrow) has been dis-
FIGURE 9-26  Retroperitoneal neuroblastoma. On this intravenous placed inferiorly by a mass (M), and the collecting system has been dis-
pyelogram the left kidney appears to be functioning well (white arrows). torted, suggesting that the mass is intrarenal in origin. This is a common
On the right, no functional kidney is identified, but the multiple scattered way of differentiating an intraparenchymal Wilms’ tumor from an extrare-
tiny amorphous calcifications (arrows) are often seen with this tumor. nal neuroblastoma.

R L

R Ant L

St

M
Sp

A B
FIGURE 9-27  Posterior mediastinal neuroblastoma. A, A posteroanterior view of the chest demonstrates a rounded retrocardiac mass (arrows). B, On
a transverse computed tomography scan, the liver (L), spleen (Sp), and stomach (St) are seen, with a mass (M) in the left paraspinous region.
 Chapter 9  |  Nonskeletal Pediatric Imaging    285

ultrasound for children is that no ionizing radiation is used. with no risk for a contrast reaction. If only information
Published studies show that for children, CT scanning has about the degree of dilatation of the collecting system is
minimally better sensitivity and specificity than ultrasound. desired, ultrasound is the test of choice.
Often CT scanning is done because of unavailability of an Ureterovesicular reflux is due to maldevelopment of the
experienced ultrasound operator. In cases of children with flap valve that is created as the ureter crosses obliquely
atypical presentation, ultrasound is sometimes done first through the bladder wall. Less commonly, it can be due to
and if negative or equivocal, it may be followed with a ectopic insertion of a ureter when ureteral duplication is
CT scan. found or to a ureterocele. On a contrast study any visible
reflux of urine from the bladder into a ureter is abnormal.
If severe, it is surgically repaired because of the increased
Rectal Bleeding risk for infection. The most common imaging method is
a cystogram. A catheter is placed, contrast is put into the
Rectal bleeding in children should be classified as dark or bladder, and the radiologist looks for contrast in the
bright red and painless or painful. Dark red blood usually ureters. This involves a relatively high radiation dose to
indicates upper GI origin, and the differential diagnosis the child’s gonads, but the anatomic resolution is good. If
includes foreign body, varices, peptic ulcer, and bowel repeated evaluations of reflux are necessary, a nuclear med-
duplication. Painful dark or bright rectal bleeding is associ- icine cystogram can provide good quantitative information
ated with volvulus, mesenteric thrombosis, and Meckel’s with a much lower dose.
diverticulum. Bright red painless bleeding may be due to Multicystic dysplastic kidney is a unilateral process
a polyp, neoplasm, colitis, or sigmoid intussusception. resulting from a severe UPJ obstruction in utero. As a
Painful bright red bleeding is most commonly due to an result, no functional renal parenchyma is present, and the
anal fissure, hemorrhoids, or rectal prolapse; for these, no kidney is represented by a large number of noncommuni-
imaging studies are usually needed. Rectal bleeding in cating cysts. Calcification may be present, with absent or
young children can also be due to an allergy to formula. only very small renal vessels. A retrograde pyelogram
The workup of any rectal bleeding should begin with a shows a blind-ending ureter. Surgery is not immediately
rectal examination. If an obvious cause is not identified and necessary. Another congenital condition is called multi-
particularly if associated pain, vomiting, guarding, rebound, locular cystic nephroma, which has large cystic areas. Cal-
or abdominal distention is present, a surgical consultation cifications in this entity are rare.
should be obtained. The imaging workup depends on Neonatal or infantile polycystic disease is not initially
which of the causes is thought to be most likely, although seen with a dominant abdominal mass. Each has ectasia of
either endoscopy or a plain x-ray of the abdomen with an renal tubules, but no obvious cysts are visible by imaging
air or barium enema is often obtained. methods. Ultrasound is the test of choice in the neonatal
form; most tubules are ectatic, and death usually occurs in
months or years. Little associated hepatic fibrosis develops.
Urinary Abnormalities In the infantile form about 20% of the tubules are ectatic,
and symptoms do not appear for 3 to 6 months. Moderate
Two relatively common urinary problems in children are hepatic fibrosis is seen. In the juvenile form fewer tubules
hydronephrosis and ureterovesicular reflux. The most are ectatic, and symptoms appear at age 1 to 5 years. The
common cause of hydronephrosis in a child is an obstruc- liver fibrosis is severe in this form, and death results from
tion at the junction of the lower portion of the renal pelvis portal hypertension.
and the upper ureter (ureteropelvic junction [UPJ]). The
entity is bilateral in 20% of cases. The initial imaging test
Suggested Textbooks and Website on the Topic
of choice is a CT scan with intravenous contrast. Although Alliance for Radiation Safety in Pediatric Imaging: Radiation protection
the dilated collecting system can be visualized with ultra- of children during imaging. Image Gently Campaign. Available at:
sound, usually not enough anatomic detail of the ureter is http://www.pedrad.org/associations/5364/ig. Accessed March 11,
found, and no information about renal function is pro- 2013.
Donnelly LF, Pediatric Imaging: The Fundamentals. Philadelphia,
vided. Postoperative follow-up functional studies in these Elsevier Health Sciences, 2009.
children are usually done with a nuclear medicine furose- Slovis TL: Caffey’s Pediatric Diagnostic Imaging, 11th ed. Philadelphia,
mide (Lasix) renogram, because the radiation dose is lower Elsevier Health Sciences, 2007.