53

Imaging
53.1. Plain Radiogaphs and Contrast Studies
Ghislaine Sayer, MRCP, DMRD, FRCR
Helen Carty, FRCR, FRCPI, FRCP, FRCPCH, FFRRCSI(Hon)
Alan Daneman, MD

Radiologic investigations are frequently required The plain lm is particularly useful in neo- pathology such as calci cation in the renal tracts
in the diagnosis of peiatric gastrointestinal dis- nates with obstruction, in whonm the distribution or biliary tree. It is diagnostically helpful when
ease.- Close cooperation between clinicians and of bowel gas is a clue to the level of obstruc- such calci cation is found. Other features that
radiologists is essential in selecting and interpret- tion, for example, differentiating esophageal may be suspected on the plain abdominal lm are
ing those tests, which will contribute meaningful from distal atresia. Associated ndings such as malrotation (easily missed on ultrasonography),
information to the diagnostic process. the bubbly appearance of gas in meconium ileus, impacted foreign bodies in a Meckel diverticu-
To avoid unnecessary repeat examinations, all calci cation following antenatal perforation, or lum, foreign bodies in the colon from compulsive
of the patient's previous imaging should be avail- gas in the bladder in a high anorectal malforma- pica, bezoars, and, rarely, duplication cysts seen
able for review. The motto should be do it once, tion may give further clues as to the cause of the as a mass or air- uid levels in a focal area of ileal
properly. To comply with radiation exposure reg- obstruction. In modern practice, ultrasonogra- dysgenesis, which is sometimes called a giant
ulations, each medical exposure should be justi- phy is often used in addition to the plain lm Meckel diverticulum.º
ed. The referring clinician is obliged to provide and can be particularly useful in the diagnosis
suf cient and accurate clinical information." of intussusception, hypertrophic pyloric stenosis, Technique
All radiologic modalities (including plain and appendicitis.
A supine lm is adequate in the majority of
lms, uoroscopy, ultrasonography, computed The role of the plain lm in chronic abdominal
cases. The lung bases and hernial ori ces must
tomography [CT], magnetic resonance imaging pain is less certain. Its main use here is to exclude
be included on the lm.6 The radiation dose can
[MRI], and radioisotope studies) have applica-
be reduced by the use of computed radiography,"
tions in pediatric gastroenterology. This chapter
the addition of extra ltration," and not using anti-
outlines the use of plain radiographs and contrast
scattergrids. ² Specialized pediatric departments
studies of the gastrointestinal tract.
consistently record lower doses than do gen-
Although not strictly a gastroenterologic
eral hospitals," not least because of familiarity
investigation, a plain chest radiograph is an
important part of the initial assessment of an ill
child. It should be remembered that erect chest
radiography is not possible in very young chil-
dren; therefore, the absence of free subdiaphrag-
matic air on the chest lm cannot always rule out
a perforation.
Children with chest infections do not expec-
torate but swallow sputum, subsequently present-
ing with vomiting. Abdominal pain, mimicking
appendicitis, may be the clinical presentation of
basal lung consolidation (Figure 1).

ABDOMINAL RADIOGRAPH

Indications
An abdominal radiograph is a useful starting
point in the investigation of acute abdominal
pain, although it may be unhelpful in up to half
of such cases. It is essential in suspected intesti-
nal obstruction or perforation.' Ingestion of for-
eign bodies does not necessitate an abdominal
radiograph unless the object is sharp or poten-
tially dangerous (e.g. batteries which may leak
Figure 2), although a chest lm is important to Figure I Abdominal radiograph of a child presenting with Figure 2 Foreign body ingestion: this patient had swal-
exclude aspiration. abdominal pain. There is right lower lobe consolidation. lowed a battery.
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 1420 Part VI/ Diagnosis of Gastrointestinal Disorders

with the unique challenges involved in gaining

the cooperation of children and their parents: get-
ting it right at the rst time avoids repeat lms
and unnecessary additional radiation.
Gonad shiclding should not be used in girls
because it may obscure important signs within
the pelvis.? Indeed, studics have shown that lead
shiclds are seldom appropriately placed to protect
the ovaries in any case.*
In adult practice, erect lms of the abdo-
men are sometimes performed to identify free
intraperitoncal air and to look for uid levels in
intestinal obstruction. The incidence of intestinal
perforation after the neonatal period is extremely
low in children. Free air in the neonate is usually
of large volume and easy to see on a supine lm.
Intestinal obstruction, after the neonatal period,
usually occurs only with intussusception, post-
operative adhesive obstruction, inguinal hernias,
and sepsis. In most instances, the diagnosis is
clinically obvious-hence the relatively limited
value of a routine additional erect or decubitus
lm. If the diagnosis of intestinal perforation is in
doubt, a lateral decubitus lm (or, in neonates, a
horizontal beam "shoot-through" with the patient (A)
supine) should clearly delincate free intraperi-
toneal gas, which will " oat" above dependent
uid levels in the peritoneal space.

Interpretation Figure 3 Malrotation: abnormal distribution of bowel gas

with the small bowel lying to the right of the midline and
All abdominal radiographs should be reviewed the cecum clearly in the left iliac fossa.
in a systematic fashion. The following approach
will ensure that nothing is missed: 6. Identify both renal outlines, the liver, and the
spleen. Are there any unexplained masses?
1. Check the name, date, and left and right Renal outlines are poorly seen in children
markers. owing to the paucity of perirenal fat, but,
2. Identify the liver and stomach bubble to as a rule of thumb, the kidneys should cach
exclude situs inversus. measure about 3.5 vertebral bodies in length.
3. Check bowel gas distribution: masses or uid Liver size is poorly assessed on abdominal
collections will displace the bowel from its radiography. A Riedel lobe is a normal vari-
normal position. Identify, if possible, the ant that may extend to the right iliac fossa.
cecum in the right iliac fossa (Figure 3). Spleen size may be reliably assessed; if the
4. Look for any gas that does not lie within the tip of the spleen is seen below the ribs, it is
stomach or bowel; triangles, arcs, or straight likely to be enlarged (Figure 8).
lines of gas usually denote a perforation. 7. Look for any calci cations and decide on
The falciform ligament may be seen near the their location: renal tract, a mass lesion,
midline, outlined, or either side with free gas lymph nodes?
(Figures 4 and 5). Mottled or patchy areas 8. Check the corners of the lm (ie, lung bases
of gas may lie within an abscess. Retroperi- and hernial ori ces). Abdominal pain may
toneal air is notoriously dif cult to see on be referred from above the diaphragm, and
a plain lm but may be seen outlining the strangulated hernias are a common cause of
kidneys (Figures 6 and 7). bowel obstruction.
5. If distended bowel loops arepresent, identify 9. Examine the bones: vertebral anomalies are
(B) KEDA
the level to which they extend and the pres- a clue to congenitalanomalies such as tra-
ence of any distal gas. In general, the jejunum cheoesophageal stulae and renal and ano-
has a feathery pattern owing to the plenitude rectal mal formations (Figure 9). Check sites
of mucosal folds, whereas the ileum is more of tubes and lines (see below).
featureless. Haustral folds are present in the
colon. An important caveat in neonates is Figure 4 (A) Perforation in a neonate with meconium
that the colon has poorly developed haustral ileus. Gas outlines the liver and the falciform ligament
folds and can be mistaken for small bowel, l6 (large arrow) and distends the anks (so-called "football
Owing to the absence of a pelvic cavity in an sign"). Loops of bowel lled with granular-looking meco-
nium are seen (small arrows). (B) A more subtle example
infant, the sigmoid colon may lie on the right
of perforation: an abnormal gas lucency lies centrally in
side of the abdomen or even abut the liver. the abdomen (arrows). Again, the falciform ligament is
Assess the thickness of the bowel wall and clearly seen. (C) Decubitus lm of the baby in B. A hori-
the separation of bowel loops. zontal air-luid level is now visible (arrows). (C)
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 CHAPTER53.1 / Plain Radiographs and Contrast Studies 1421

L
Figure 7 Chest radiograph of the patient in Figure 6.
Figure 5 Perforation: crescents of air are seen bencath Air has tracked through the diaphragmatic hiatus into the
both hemidiaphragms. mediastinum (arrow).
Figure 9 Vertebral anomalies in a patient with an ano-
rectal malformation.
10. Identify the properitoneal fat lines, which Congenital Obstruction. The level of obstruc-
are normally convex medially beyond infant tion can usually be deduced from the plain lm.
age. Distention of these, particularly if cou- Esophageal atresia could be expected to produce Anorectal Anomalies. The diagnosis of ano-
pled with separation from bowel loops, may a gasless abdomen, but in practice, there is often rectal anomalies is clinical. However, a plain
indicate ascites (although this is much more a large amount of bowel gas present owing to a abdominal lm is required to assess the sacrum
easily identi ed on ultrasonography). Look tracheoesophageal stula distal to the esophageal for associated anomalies. A prone lateral "shoot-
for the psoas outline, which is rendered vis- atresia (Figure 10). Duodenal atresia produces the through" of the rectum will help to delineate the
ible by a fat plane. This may become obscured "double bubble" sign, with air in the distended level of the anorectal atresia, but meticulous tech-
in intra-abdominal sepsis, which is classically stomach and proximal duodenum (Figure 11). nique is essential. The baby should be laid prone
described with perforated appcndix. However, Jejunal obstruction produces several dilated with its bottom elevated for 30 minutes prior to
the psoas outline may be obscured in normal loops of small bowel in the left upper quadrant the lm being taken to allow air to rise to the
children owing to the rotation of the lm. (Figure 12). The more distal the obstruction, the most distal portion of the rectum. A radiopaque
more loops of distended bowel are seen. Distal marker should be placed on the skin at the anal
The following conditions have characteristic small bowel obstruction may be dif cult to dis- dimple. Rarely, there is air in the bladder owing
appearancesand may be diagnosed on plain lms: tinguish from large bowel obstruction. !" to a colovesical stula.

Igure 6 Retroperitoncal air following iatrogenic duo-

nal perforation. (Contrast in the colon is from a recent Figure 8 Splenomegaly in a patient with liver cirrhosis Figure 10 Gascous distention in a patient with a trachco-
luoroscopicexamination.) owing to cystic brosis. esophageal stula.
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 1422 Part VI / Diagnosis of Gastrointestinal Disorders

location, this may be a subtle nding, such as in

a subphrenic collection, in which the gas overlies
the dome of the liver, and may form a gas- uid
level. A localized ileus may cause a few loops of
distended bowel adjacent to the abscess.

Necrotizing Enterocolitis. The abdomi-

nal radiograph in the neonate with necrotizing
enterocolitis will display nonspeci c signs such
as widespread dilatation of bowel loops and sepa-
ration of loops. $ The radiologic hallmark, how-
ever, is intramural gas. This may be present at any
level from the esophagus to the rectum and may
be linear or bubbly in appearance (Figure 15).
Portal venous gas may be present and is no lon-
ger regarded as an ominous prognostic sign.l6,19
It must be differentiated from air in the biliary
tree, which tends to be more centrally located
(around the porta hepatis) and displays a branch-
Figure 11 "Double bubble sign in duodenal atresia. ing pattern. Portal venous gas occasionally may
be introduced via an umbilical vein catheter.
Acquired Bowel Obstruction. The plain lm in Figure 13 Small bowel obstruction. Note abscnce of gas Bowel Wall Thickening. Edematous, in amed
acquired obstruction typically shows dilated loops in the rectum.
bowel wall appears thickened, and loops lie
of bowel proximal to the obstruction (Figure 13). slightly separated from one another."Thumbprint-
If the obstruction is of recent onset, there may ing" occurs with ischemia and may also be due to
still be gas in the bowel distal to the obstruction. Ileus. In paralytic ileus, there is an absence
hemorrhage into the bowel wall, such as occurs in
Multiple uid levels within dilated loops form of peristalsis rather than mechanical obstruc-
hemolytic uremic syndrome, Henoch-Schonlein
a "ladder" pattern. In high-level obstruction, or tion. Therefore, both small and large bowels are
dilated (Figure 14). The individual loops tend to
purpura, or thrombocytopenia (Figure 16). Toxic
when the bowel is very full of uid, such as in megacolon, when the transverse colon is unduly
closed-loop obstruction, air-fuid levels may not be less distended than in mechanical obstruction,
dilated and in amed, is rare in children.
be present. Nasogastric suction may also alter the and uid levels are longer. Gas is seen as far
pattern of uid levels. as the rectum. Confusion may arise, however, in Hernias. Gas within the scrotal sac in boys (or
cases of prolonged mechanical obstruction, when below the inguinal ligament in girls) indicates a
ileus may ensue. Since sepsis is a common cause hernia; however, in strangulated hernias, the gas
of ileus in children, ultrasonography is supple- may be absent, but there will be asymmetry of
RT mentary to identify any intra-abdominal or pelvic the scrotal shadow (Figure 17). Umbilical hernias
collections. may cause unusual gas shadows on plain lms
owing to air interposed between the hernial sac
Intra-Abdominal Abscess. Large abscesses
and the anterior abdominal wall (Figure 18).
will be visible on the plain radiograph as mass
lesions with displacement of bowel loops. There Foreign Bodies. Incidental foreign bodies are fre-
is often gas within the abscess; depending on its quently seen in children, particularly in the colon.
Most will pass without incident. Swallowed den-
tal amalgam results in a characteristic pattern of
small akes distributed throughout the colon.

Figure 14 Postoperative ileus. Note the surgical clips and Figure 15 Necrotizing enterocolitis resulting in lincar gas
Figure 12 Jejunal atresia. several loops of dilated small bowel. lucencies within the thickened bowel wall (arrow).
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 CHAPTER53.1 / Plain Radiographs and Contrast Studies 1423

Figure 16 "Thumbprinting" of the colonic mucosa in Figure 18 Umbilical hernia.

a patient with Hirschsprung's disease and necrotizing
enterocolitis.
atrium is associated with an increased inci-
dence of intracardiac thrombus formation.? An
Tubes and Lines. The tip of a nasogastric tube umbilical artery catheter should lie between T6
should lie in the body of the stomach. and T10 (or L3-L5 if the low position is used)
An umbilical vein catheter should lie in the (Figures 19 and 20). The positions of lines will
right atrium"; a lateral lm may be required Figure 20 The umbilical artery catheter has been placed
vary in neonates with congenital diaphragmatic
to con rm this because malposition in the left too low.
hernias and may give clues as to the contents of
the hernia.2? Ventriculoperitoneal shunts should
terminate within the peritoneal cavity but may doubt as to the position of the line tip, a lateral
migrate upward as the child grows. If there is lm may be useful. If the tip is projected below
the costal margin on the frontal radiograph, a lat-
eral radiograph may show it to be super cial to
the liver, where it may pass in and out of the
peritoneal cavity, creating a valve effect, result-
ing in intermittent hydrocephalus.
Calci cation. Itis important to determine exactly
where calci cation on an abdominal radiograph is
and to decide on its cause. Adrenal calci cation
commonly follows neonatal adrenal hemorrhage
and is seen on either side of the vertebral column,
at the top of the renal outlines. Antenatal intesti-
nal perforation results in calci ed meconium in
the peritoneal cavity. Calci cation within a mass
lesion should always raise suspicion: neuroblas-
tomas commonly calcify, and calci cation is seen
rarely in Wilms tumor, hepatoblastoma, and liver
hemangioma (Figure 21).* In older children with
cystic brosis, pancreatic calci cation may be
seen extending across the midline at the Ll level.
Previous tuberculous infection may cause cal-
ci cation in mesenteric lymph nodes, liver, and
spleen; treatment of lymphoma with radiotherapy
may also result in lymph node calci cation. Feca-
liths are common incidental ndings, but their
presence should be reported because clective
appendectomy is indicated. Renal calci cation
should be differentiated into parenchymal versus
Figure 19 The umbilical vein catheter has been placed pelvic: medullary sponge kidney, renal papillary
FIgure 17 Small bowel obstruction owing to an inguinal too high; its tip lies in a neck vein. Note cndotracheal tube necrosis, and hyperparathyroidism are among the
hemia. There is gas in the scrotum (arrow). and nasogastric tube in a satisfactory position. causes of the former, whereas calci cation within
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 1424 Part VI / Diagnosis of Gastrointestinal Disorders

Figure 24 Computed tomographic scan ofappendicitis:

there is a fecalith (large arrow) and a rounded uid col.
lcction (small arrows) containing ecksofgas.

Intussusception. The plain lm may beentirely

normal in cases of intussusception. Thetypical
nding of a soft tissue mass indenting thecolon
(usually seen in the transverse colon) is seenin
only about 25% of patients (Figure 25)3 Les
speci c ndings include the absence of gasinthe
right upper quadrant (with failure to identifythe
cecum and the typical hepatic exure gaspatem)
and a vague right-sided mass. Varying degrees
Figure 21 Left-sided abdominal mass containing calci - of small bowel obstruction may bepresent,
cation (arrows). This was a neuroblastoma. depending on the time elapsed since theonset
of symptoms. Ultrasonography is sensitive inthe
Figure 22 Appendicitis: there is a fecalith in the right diagnosis of intussusception and should beper-
the lumen of the renal pelvis, ureters, or bladder iliac fossa (arrow). formed before proceeding to a contrast studyand
is likely to represent a true "stone." A transplant attempts at reduction.32
kidney may calcify owing to chronic rejection. In
signs include bowel wall edema and *thumb- Pitfalls for the Unwary. While assessingapedi-
older children, phleboliths within the pelvic veins
printing'"; in severe cases, intramural gas may be atric abdominal radiograph, the clinicianshould
are easily mistaken for ureteric stones. In general,
present. Secondary dilatation of the small bowel be aware of several "oddities" that maymasquer-
phleboliths are rounded with a slightly lucent
may occur: As with appendicitis, ultrasonogra- ade as pathology. Films taken on theintensive
center, whereas urinary tract calculi tend to be
phy and CT are playing an increasingly important care unit often include various tubes andequip-
more angular in shape. An intravenous urogram,
role in the diagnosis of typhlitis. It is particu- ment, which, in fact, lie outside thepatient.
possibly including an oblique lm of the bladder
larly important to distinguish this condition from The access hatch of an incubator may causea
area, may be required to show whether a calci c
appendicitis because surgical intervention is not
focus lies along the path of the ureter.
required in typhlitis unless complications (such
Appendicitis. A child with unequivocal clini- as perforation) occur.29,30
cal signs of appendicitis does not require imag-
ing. However, in cases where the diagnosis is
in doubt, radiologic input may be valuable.24,25
The plain abdominal lm is frequently normal in
appendicitis. In about 10% of cases, a calci ed
fecalith in the right iliac fossa will con rm the
diagnosis (Figure 22),' If the appendix is retro-
cecal, the fecalith may lie more superiorly and
may even mimic a gallstone. Other plain lm
ndings that have been described in appendici-
tis include a mass in the right iliac fossa with
displacement of bowel loops and possibly con-
taining gas (Figure 23), a localized ileus or even
complete small bowel obstruction, and blurring
of the peritoneal fat lines. In modern practice,
ultrasonography is the rst-line investigation in
suspected appendicitis and has the considerable
advantage of not using ionizing radiation. There
is also increasing evidence that CT in selected
cases can signi cantly reduce the rate of negative
appendectomies (Figure 24).27:2%

Typhlitis. This severe form of colitis is seen in

neutropenic and immunocompromised children.
The name strictly refers to cecal in ammation, Figure 23 Appendicitis: a rounded soft tissue density in
but the whole colon may be involved. Plain lm the right iliac fossa displaces bowel loops.
Figure 25 IntuSsusception.
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 CHAPTER53.1 / Plain Radiographs and Contrast Studies 1425

mysterious circular lucency in the center of the

Table 1 Gastrointestinal Contrast Studies Performed in Children and Some of Their Indications
m. Similarly, the umbilical cord, particularly if
there is no clamp, may simulate a mass. The same Speech study/phonetics
effect can be produced by the penis scen end on. ldenti cation of palatal movement and choanal closure
The tip of the normal coccy may be misinter- Pre- and postsurgical repuir of cleft palate
pretedas abnormal calci cation within the pelvis. Specch problems with nasal escape
Nasal re ux of food
When assessing suspected intestinal obstruction,
Swallowing study
it is important to renmember that air seen in the
Oropharyngeal incoordination, mainly in children with neurologic impairment
rectum may have been introduced by digital rec- Contrast swallow
tal examination and therefore cannot be relied on Vascular rings and other extrinsic masses affecting swallowing
asa sign of patency of the distal bowel. Tracheoesophagcal stula (including follow-up postsurgical repair) (sce Figure 26)
Gastroesophageal re ux
Forcign body ingestion
CONTRAST STUDIES Strictures
Upper gastrointestinal study
INDICATIONS Usually follows contrast swallow
Demonstrates anatomy (eg, duodenojejunal exure) and motility
Contrast studies of the gastrointestinal tract, Pyloric stenosis (now largely replaced by ultrasonography)
when tailored speci cally to the clinical indica- Gastrostomy study
tions, can provide the clinician with anatomic Contrast instilled via gastrostomy tube
detail and functional information about motility Assesses gastric emptying and re ux
and gastric emptying. The spectrum of disease Small bowel studies
Assesses the bowel, which is not within reach of endoscopy
in children differs from that in adults; ulcers
Performed as follow through or enteroclysis (see below)
and tumors are rare, and congenital anomalies,
Crohn's discase
such as malrotation, are more frequent. Thus, the Small bowel strictures (traumatic/postsurgical)
emphasis is on anatomy and function rather than Dysmotility
mucosal detail, making a uoroscopic contrast Barium cncma
study a potentially more useful diagnostic tool Now rarely performed
than endoscopy in many cases. Contrast studies A limited study may be performed in severe constipation to exclude Hirschsprung's disease
Defecating proctography
are well tolerated by the vast majority of chil-
To assess pelvic oor dysfunction in obstructed defecation
dren, whereas endoscopy requires sedation or Fistulography/sinography
a general anesthetic. However, contrast studies Identi cation of tracks
of the esophagus, stomach and duodenum, and Water-soluble contrast enema
colon have largely been replaced by endoscopy Performed in nconates
in specialist pediatric units. Contrast studies of To identify cause of intestinal obstruction, eg, Hirschsprung's disease, mcconium ileus, meconium plug, intussusception
the small bowel now make up a larger propor-
tion of the work in a pediatric radiology depart-
ment, although ultrasonography and CT are often the clinician and the radiologist is of the utmost giving more detail about the track of a sinus or
complementary investigations in the diagnosis of importance to ensure that the appropriate test stula in three dimensions.
small bowel lesions (Table I and Figure 26). is performed. In some cases, CT may be used Contrast studies have been used in the past
As well as the conventional techniques listed in conjunction with uoroscopy, for example, for the investigation of the gallbladder and biliary
above, there is frequently the need for speci c tract in children. Ultrasonography is extremely
investigations in speci c circumstances: "loo- reliable in the diagnosis of biliary tract dilatation,
pograms" or sinograms, which are intended to choledochal cysts, and gallstones. More recently,
answer a particular clinical question, most often MRI has advanced to the point where magnetic
In surgical patients (Figure 27). It cannot be resonance cholangiopancreatography (MRCP)
Overemphasized that communication between can provide high-resolution images of the biliary
tree, gallbladder, and pancreatic duct, obviating
the need for invasive procedures such as percu-
taneous transhepatic cholangiography or endo-
scopic retrograde cholangiopancreatography.
MRCP has proved to be useful in the investigation
of acute pancreatitis, primary sclerosing cholan-
gitis, choledochal cyst, and congenital anomalies,
such as pancreas divisum." 0 New techniques
are continually being explored in this exciting
eld, and in the near future, virtual endoscopy
of the pancreatic and biliary ducts using data
from MRCP studies is likely to become routinely
available.37

Choice of Contrast
Barium sul fate is the traditional gastrointestinal
contrast medium of choice. It is cheap and read-
Figure ily available, and its high density provides excel-
20 Contrast swallow in a patient with H-type Figure 27 "Loopogram." Contrast has been introduced
Oesophagcal stula. Contrast is scen outlining the via the defunctioning stoma to demonstrate the level of lent contrast and de nition. It is not absorbed
racheaand bronchial tree. the anorectal atresia. by the gut and can, therefore, be used anywhere
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 1426 -Part VI/ Diagnosis of GastrointestinalDisorders

in the bowel. It remains the contrast medium the dose can be reduced further by using pulsed to fully distend the lower esophagus. A care.
of choice for small bowel studies and for dou- screening.40,4| A last-image-hold ("frame grab'") ful history is important: establish exactly what
ble-contrast enemas on the rare occasions that facility allows images to be recorded without a provokes the child's symptoms and try to repro.
these are done. However, if any of the following static exposure being made. Grids should not be duce these conditions as closely as possible dur.
contraindications exist, a water-soluble contrast used routinely. ing the study.
medium (see below) should be used: Video recordings should be made of all In children with feeding gastrostomies, the
gastrointestinal contrast studies. This allows parent or caregiver should be asked to replicate
• Suspected perforation (barium excites an
dynamic processes such as swallowing, gastro- the child's usual feeding process, usingcontrast
aggressive in ammatory response if allowed
esophageal re ux, or gastric transit to be viewed mixed with food. Again, the conditions thatpro-
to escape into the mediastinum or peritoneum).
in real time, or frame by frame. If an uncoopera- duce symptoms should be reproduced; forexam-
• Possibility of aspiration, for example, in neuro-
tive child has allowed only an incomplete study ple, if the patient habitually vomitsafter200mL
logically impaired children (although aspirated
to be performed, the video footage will often of food have been given, a study using only a
barium is usually well tolerated, serious respi-
contain suf cient information even if no static small volume of contrast will not behelpful.
ratory impairment can occur).
images have been recorded, thus obviating the The radiologist should take the opportunity
• Because barium is contraindicated, water-
need fora repeat study. during all upper gastrointestinal studies in chil.
soluble media are now the contrast of choice
dren to observe the passage of contrastaround
for neonates.
Speci c Techniques. the duodenal loop to the duodenojejunal exure.
• Barium may become inspissated in defunc-
An image of the correctly sited exure (to the
tioned bowel (eg, loopograms postsurgical Speech and Swallowing Studies. Speech and
left of the spinal column, at the level of Ll) will
resection), and there is a risk of impaction in swallowing dif culties frequently coexist in neu-
rule out 98% of cases of malrotation (Figure28).
Hirschprung's disease and cystic brosis. rologically impaired children. A multidisciplinary
In some centers, a contrast enema (rather than
Gastrogra n should not be used in the upper approach is essential in their management, and
an upper gastrointestinal study) is the investiga-
gastrointestinal tract because it is very hyperos- video uoroscopy swallowing studies should be
tion of choice to rule out malrotation;however,
molar and can precipitate pulmonary edema if carried out with the speech therapist. Video uo-
in 16% of children with malrotation, thececum
aspirated. It is used for therapeutic enemas in roscopy swallowing studies provide more detailed
is normally sited in the right iliac fossa.Further-
meconium ileus, where it draws uid into the and objective evidence of swallowing dysfunc-
more, the cecum may be displaced from theright
bowel lumen to aid disimpaction of the sticky tion than traditional bedside evaluation.36,42 The
iliac fossa in 15% of normal children.° Incases
meconium. However, it may cause dehydration aim is to assess the phases of swallowing and
of strong clinical suspicion of malrotation,where
by drawing excessive amounts of water into the to ensure that there is complete glottic closure
the duodenal position appears normal orequivo-
bowel, particularly in a vulnerable neonate, and without aspiration. Speci c observable problems
cal, it is logical to proceed to an enema studyto
great care should be taken to ensure adequate include poor tongue movements, delayed swal-
evaluate the cecal position.
uid replacement. The radiologist must inform low re ex, reduced laryngeal elevation, and silent
All radiologic studies for malrotation arelim-
the clinician that Gastrogra n has been used. spiration.37,4$ Aspiration is more likely to occur
ited by the fact that only the bowel is imaged,not
The iso-osmolar contrast agents are more with thin fuids; therefore, swallowing of thicker
the mesenteric xation, which is what actually
expensive than Gastrogra n but are safe if aspi- consistencies should be assessed rst, using, for
determines the malrotation. It is also well recog-
rated and have no effect on the peritoneum or example, bread or biscuits dipped in barium or
nized that the normal duodenum may be mark-
mediastinum. Perhaps surprisingly, there is no yogurt mixed with barium for infants who can-
edly mobile, especially in neonates, and thismay
evidence that iso-osmolar agents are any less not yet manage solids. Appropriate commercial
lead to further con fusion.7
effective in the treatment of meconium ileus than thickening agents are available. The result of
hyperosmolar media. these studies can be of vital importance in the Small Bowel Follow-Through. Most wouldagree
Double-contrast studies of the gastrointestinal future management of the child, for example, that the initial investigation of the smallbowel
tract are performed in adult practice and provide determining the safest position for feeding, which should be by follow-through, with enteroclysis
excellent mucosal detail. The technique uses a will help prevent long-term aspiration and mal- (see below) being reserved for selected diffcult
nutrition, 44,45 cases in which a follow-through study hasfailed
thin coating of barium to de ne the mucosa, com-
bined with distention of the viscus with air. With to make a diagnosis.$ In the follow-through
Upper Gastrointestinal Studies. Infants whose
the advent of endoscopy, double-contrast studies last feed has been withheld are usually quite will-
are now rarely required in children. ing to drink un avored barium or (amazingly!)
Air is now the medium of choice for intus- Omnipaque from a bottle. For older children,
susception reduction.8,3 It is introduced into the barium can be avored to make a relatively pleas-
colon at pressures of up to 120 mm Hg. Perfora- ant milkshake-style drink; Omnipaque is effec-
tion is a rare complication, but if it occurs, a large tively disguised in orange juice. To assess swal-
pneumoperitoneum will result, with respiratory lowing of solids, marshmallows can be soaked in
compromise. Accordingly, a large trochar should barium.
be available for immediate decompression of the Contrast swallows have historically been per-
peritoneum.$ formed mainly for the detection of gastroesopha-
geal re ux. However, the sensitivity of radiologic
Technique studies for re ux has been reported to be as low
General Considerations. A pediatric "barium" as 52%46; therefore, a negative study is of little
list presents a unique challenge. Flexibility and diagnostic value. Barium swallows continue to
ingenuity are essential so that each study is spe- be useful in the diagnosis of structural causes
ci cally tailored to the patient and the clinical of dysphagia, such as vascular rings, strictures
problem. following caustic ingestion, long-standing re ux
Steps should always be taken to minimize disease, or postsurgical repair of tracheoesopha-
geal stulae, as well as functional disorders such contrast
the radiation dose to children undergoing uoro-
as achalasia and globus hystericus. Views should Figure 28 Malrotation: upper gastrointestin
odenojejunal
scopic examinations. Digital uoroscopy deliv- study showing abnormal position of the
ers a lower dose than older cine lm systems, and always be taken in the supine oblique position exur which lies to the right of the midlinearrow).
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 CHAPTER53.1 / Plain Radiographs and Contrast Studies 1427

technique, the child drinks about 500 mL of Achalasia. Video uoroscopy in achalasia shows
dilute barium after a 6-hour fast. An immediate abnormal motility and failure of relaxation of
supine lm is taken, followed by prone lms (the the lower esophageal sphincter. The esophagus
prone position separates bowel loops) at intervals becomes dilated in long-standing cases and may
until the ileocecal junction has been visualized. be lled with food debris. The narrowed lower
The ms should be carefully examined as they esophageal sphincter has a characteristic "rat-
are done, and uoroscopy should be performed tail" appearance."
to clarify any doubtful areas, for example, to
Hiatal Hernia andGastroesophagealReftux. If
con n xation or separation of bowel loops.
the gastroesophageal junction lies above the
The terminal ileum should always be screened to
diaphragm, a hiatal hernia is present. The sig-
ensure that under lling is not misinterpreted as
ni cance of hiatal hernia in re ux disease has
a stricture. If the colon is loaded with feces, the
yet to be cstablished.>" A small amount of re ux
passageof barium will be slowed; this may often
is a normal nding in children. A clinical his-
be overcome by giving the child a meal once con-
tory of repeated vomiting, failure to thrive, and
trast has reached the ileum.
recurrent chest infections (owing to aspiration)
Enteroclysis. Enteroclysis (or small bowel are clues that signi cant re ux is present. If the
enema)involves introduction of contrast directly gastroesophageal junction is widened and the
into the proximal jejunum via a long, wide-bore esophagus appears "baggy," signi cant re ux is
oro- or nasojejunal tube. A bolus of dilute barium likely to be present. Any contrast re uxing above
isused, followed by water or methylcellulose for the gastroesophageal junction should be noted,
a double-contrast effect, and is monitored with as well as the level to which it ascends and the
uoroscopy throughout the small bowel. The frequency of episodes during the study. Failure
technique is more sensitive than follow-through to demonstrate re ux on video uoroscopy does
studies, particularly for the demonstration of not exclude the diagnosis (see under "Technique"
polyps, but is often poorly tolerated by children. above). In chronic re ux disease, an esophageal
Intubation may be dif cult, and if the tube is too stricture may develop, which is usually smooth
proximal, barium will re ux into the stomach and and tapering in appearance. Figure 29 Contrast study demonstrating duodenal atresia.
result in vomiting.
Duodenal Obstruction. Complete duodenal
Peroral Pneumocolon. This technique is supple- atresia is usually diagnosed on the plain lm, tion" of the ileum) (Figure 31). Transient intus-
mentary to a small bowel follow-through study. which typically shows the "double bubble" sign. susceptions may be seen during the small bowel
Once barium has reached the terminal ileum, air Partial duodenal obstruction may be due to con- study.5.3$ There is an increased risk of small
is insuf ated per rectum to distend the colon and genital webs, annular pancreas, Ladd bands, or bowel lymphoma, so any mass should be treated
terminal ileum. This gives good mucosal detail of a preduodenal portal vein. A web may appear as with suspicion.
the terminal ileum but is relatively more invasive. a linear lling defect within the duodenum, and Crohn's Disease. Crohn's disease may affect
the dilated, barium- lled distal duodenum with a any part of the gastrointestinal tract. In the small
CharacteristicAppearances of Selected Condi-
convex end has been described as a "wind sock." bowel, the terminal ileum is the most commonly
tions on Contrast Studies. The reader is referred
Other causes of partial duodenal obstruction are affected region; however, up to 20% of children
to the individual chapters for a more complete
dif cult to distinguish from webs on barium stud- with small bowel Crohn's disease will have a nor-
discussion of these conditions.
ies (Figures 29 and 30). Cross-sectional imaging mal terminal ileum on imaging. "$4 More typi-
Vascular Rings. The lateral view of the esoph- will be helpful in demonstrating pancreatic and cally, there is a segment of narrowed, rigid bowel
agus during a contrast swallow can predict the portal vein anomalies.'* However, pragmatically, with mucosal nodularity or "cobblestoning" and
type of vascular anomaly in most cases. The plain this is not done in neonates because these chil-
chestradiograph will provide additional informa- dren require surgery.
tion about the aortic arch and tracheal position. In
Malrotation and Volvulus. As discussed under
modern practice, the de nitive diagnosis is usu- FRRVE- 1
"Technique" above, contrast studies are not infal-
ally made by MRI.
lible in the diagnosis of malrotation. The major
There are four patterns of esophageal and/or
life-threatening complication of malrotation is
tracheal compression on the contrast swallow;
volvulus of the small bowel around the superior
these correspond to four major vascular anoma-
mesenteric artery. If this is present, the contrast
lies. A double aortic arch causes posterior esoph-
study may demonstrate a corkscrew or "twisted
ageal compression together with anterior trachcal
ribbon" appearance ofthe duodenum and jejunum,
compression. (A similar pattern occurs with a
with thickened mucosal folds owing to edema of
right-sided arch in combination with a left duc-
the bowel wall. Classically, the contrast termi-
tus arteriosus and aberrant left subclavian artery.)
nates in a "bird's beak" at the point of obstruc-
Compressionof the trachea by a prominent innom-
tion.2: however, the obstruction may be rounded
inate artery causes an anterior impression on the
and appear to be similar to duodenal atresia. "
trachea but a normal esophagus. Aberrant right
Subclavian artery (the most common anomaly of Malabsorption. Malabsorption attributable to
the aortic arch) results in a posterior impression any cause characteristically results in nonspeci c
on the esophagus with a normal trachca. Finally, a changes in the small bowel contrast study: frag-
posterior impression on the trachea, coupled with mentation of the barium column, occulation of
anterior compression of the esophagus, is caused barium, and mild dilatation of the small bowel.
Figure 30 Partial duodenal obstruction, owing in this case
by an aberrant left pulmonary artery, arising from Celiac discase is classically described as causing lo compression by the superior mesenteric artery. There is
the right pulmonary artery and passing between a featureless, smooth jcjunum with an increase in dilatation of the duodenum proximal to the obstruction
the trachea and esophagus. 17,,49 mucosal folds in the ileum (so-called iejuniza- (arrow).
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 1428 Part VI / Diagnosis of Gastrointestinal Disorders

colon or even stomach. In long-standing discase,

cccentric scarring occurs, resulting in "pseudo-
sacculations" on the antimesenteric border of the
bowel. CT and ultrasonography have an impor-
tant supplementary role in delineating thickened
bowel loops and in ammatory masses.3 In dif -
cult cases, an isotope-labeled white cell scan may
be required to identify an intra-abdominal site of
in ammation.
Crohn's discase of the colon can be demon-
strated on a double-contrast barium enema; how-
ever, these are rarely performed in modern pediat-
ric practice because endoscopy is the mainstay of
diagnosis for in ammatory diseases of the colon.
The colon is usually asymmetrically involved (in
contrast to ulcerative colitis), with predominantly
the right colon being affected and less commonly
the rectum." In early Crohn's colitis, there may
be discrete aphthae (ulcers with a smooth raised
edge); these later coalesce to form linear ulcer-
ation and may penetrate the bowel wall to form
Figure 34 Contrast enema in meconium ileus. Note
sinuses or stulae. As in the small bowel, skip meconium within the terminal ileum.
lesions are characteristic, and pseudosacculations
may occur.
of small intestinal secretions reaching the colon
Intussusception. Intussusception may be in fetal life.17.56 However, in practice, the colon is
Figure 31 Small bowel meal in celiac disease. The jeju-
ileoileal, ileocolic, or ileoileocolic (in which an seldom examined radiologically.
num is mildly dilated, smooth, and relatively featureless.
ileoileal intussusception then invaginates into the
Meconium Plug. In meconium plug syndrome,
colon). In all of these cases, the intussusceptum
there is functional immaturity of the colon. A
deep ulcers (Figure 32). If the stricture is tight, will be seen as a lling defect indenting the col-
contrast enema will demonstrate the meconium
the proximal portion of bowel may be dilated. umn of contrast or air (Figure 33). Following suc-
in a normal-caliber colon. A caliber change at or
Several sections of bowel may be affected, with cessful reduction, a residual lling defect is often
proximal to the splenic exure, with the descend-
the intervening areas appearing normal ("skip seen in the cecum: this is the edematous ileocecal
valve5,17 ing colon being narrowed, is known as small left
lesions"). Fistulae may occur between adjacent
loops of small bowel or between small bowel and colon syndrome but is a variant of meconium
Meconium Ileus. A contrast enema in meco- plug syndrome. A therapeutic enema with water-
nium ileus will show a microcolon, and contrast soluble contrast medium will aid the passage of
re uxing into the terminal ileum will outline meconium. !7
inspissated meconium (Figure 34). The colon is
also of very small caliber in distal ileal atresia Hirschsprung Disease. The characteristic indi-
but tends to be of near normal caliber in proximal cator of Hirschsprung's disease is a transitional
ileal or jejunal atresia owing to a larger quantity zone between the proximal, dilated (normal)
bowel and the distal, small-caliber agangli-
onic segment (Figure 35). Irregular "sawtooth"

Figure 32 Crohn's discase. There are several long stric-

tures of the small bowel with "cobblestoning" and "rose- Figure 33 Contrast enema in intussusception. The intus-
Figure 35 Contrast enema in Hirschsprung's diseas
thon" ulcers (arrows). susceptum shows as a lling defect (arrows).
showing sharp caliber change at the transitional zone.
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 CHAPTER53.1 / Plain Radiographs and Contrast Studies 1429

contractionsin the aganglionic segment may be |1. HufAon AP, Doyle SM, Carty HM. Digital radiography in 36. van Heurn-Nijsten EW, Snoep G, Kootstra G, et al. Pre-
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