Teenager with sickle cell disease and abdominal pain

AXR and CT of cholelithiasis due to sickle cell disease — AXR AP (left) shows faint calcifications in the right upper quadrant, just beneath the tip of the 12th rib and at the level of the L2 vertebral body which are better demonstrated on the coronal CT without contrast of the abdomen which demonstrates 5 calcifications within the gallbladder.

The diagnosis was cholelithiasis in a patient with sickle cell disease.

Teenager with an androgen excess who is without abdominal pain

MR of gallstone — Coronal HASTE (above) and axial T2 (below) MRI without contrast of the abdomen shows the gallbladder to contain over 20 small, round low-signal intensity objects. The gallbladder wall is not thickened.

The diagnosis was cholelithiasis without acute cholecystitis.

School ager with spinal dysraphism and a neurogenic bladder

AXR and US of bladder stone — AXR AP (above) shows two irregularly-shaped calcified objects projecting over the pelvis. Spinal dysraphism is noted in the sacrum. There is a cecostomy tube in the right lower quadrant. Sagittal US of the bladder (below) shows an echogenic mass within the inferior aspect of the bladder (to the right of the image) that has posterior shadowing.

The diagnosis was two bladder stones in a patient with neurogenic bladder.

School ager with right lower quadrant pain

AXR of appendicolith — AXR AP shows an oval-shaped calcification in the right lower quadrant just above the right iliac crest at the level of the L4 vertebral body.

The diagnosis was acute appendicitis with an appendicolith within the appendix.

Infant with constipation

AXR of adrenal hemorrhage — AXR shows large triangle-shaped calcifications projecting over the right adrenal gland at the level of T10 and the left adrenal gland at the level of T11. These were noted to resolve over several months.

The diagnosis was bilateral adrenal hemorrhage.

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Infant with 5 days of vomiting and abdominal distension who now has peritoneal signs and currant jelly stools

Surgical image of ileocolic intussusception — Surgical image shows an ileocolic intussusception extending into the mid ascending colon with a dusky terminal ileum (to the right) intussuscepting into the cecum (to the left). Note that the appendix (in the middle of the image) is intussuscepted with the ileum. The intussusception was reduced without great difficulty manually. No lead point was seen.

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Infant with jaundice

Percutaneous cholangiogram of bile plug syndrome — AP image from a percutaneous cholangiogram shows a dilated intrahepatic biliary tree and a markedly dilated extrahepatic biliary tree containing large filling defects within it. In this case the cholangiogram was therapeutic as well as diagnostic.

The diagnosis was bile plug syndrome causing biliary obstruction.

School ager with abdominal pain after trauma

CT and US of choledochal cyst — Axial CT with contrast of the abdomen (upper left) shows a large round low density structure inferior to the liver and separate from the gall bladder. Transverse and sagittal US of the liver show the round structure to be cystic and in communication with a dilated biliary tree. Delayed image (lower left) from a hepatobiliary scintigraphy exam shows concentration of radiotracer into the round structure which is slowly excreted into the bowel. AP image of an intraoperative cholangiogram (lower right) shows dilation of the intrahepatic and extrahepatic biliary tree with free flow of contrast into the bowel.

The diagnosis was choledochal cyst causing biliary obstruction.

Newborn with jaundice

hepatobiliary scintigraphy scan of biliary atresia — Immediate image (upper left) from a hepatobiliary scintigraphy exam performed after pre-treatment with phenobarbital shows good uptake of radiotracer in the liver with the 24 hour delayed image (upper right) showing no excretion of radiotracer into the bowel. Transverse US of the liver (lower left) shows the presence of a gallbladder. AP image of an intraoperative cholangiogram shows a dilated gallbladder (with some contrast extravasation outside of the gallbladder) and minimal visualization of the intrahepatic biliary tree and no visualization of the extrahepatic biliary tree.

The diagnosis was biliary atresia causing biliary obstruction.

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Newborn with a cystic abdominal mass on prenatal US

Surgical image of ileal duplication — Surgical images show the round mass arising from the mesenteric border of the ileum.

The diagnosis was ileal duplication.

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Teenager on an aggressive weight-loss diet who has recently begun vomiting after meals

Upper GI of superior mesenteric artery syndrome — Delayed AP image from an upper GI shows a markedly dilated first and second part of the duodenum to the right of the spine with a marked narrowing and transition in duodenal caliber over the spine and only a small amount of contrast in the third part of the duodenum to the left of the spine. During the exam, marked to and fro peristaltic motion was noted in the first and second parts of the duodenum.

The diagnosis was superior mesenteric artery syndrome.

Newborn with bilious vomiting

Upper GI of malrotation with midgut volvulus — AP image from an upper GI shows complete obstruction of the duodenum at the junction of the second and third parts of the duodenum and associated massive gastroesophageal reflux. A final image taken 5 minutes later was unchanged.

The diagnosis was gastroesophageal reflux due to malrotation with midgut volvulus causing duodenal obstruction.

Newborn with bilious vomiting

AXR and upper GI of duodenal web — AXR AP (above) shows a double bubble sign with a dilated stomach to the left of the spine and a dilated duodenum to the right of the spine. Oblique images from an upper GI show a dilated duodenal bulb projecting over the vertebral bodies (lower right) and a small amount of contrast entering the second part of the duodenum (lower left).

The diagnosis was duodenal web.

Newborn with copious secretions in the delivery room

AXR of duodenal atresia — AXR AP shows a double bubble sign with a dilated stomach to the left of the spine and duodenum to the right of the spine with a small amount of distal bowel gas.

The diagnosis was duodenal atresia with air passing distally into the small bowel through the biliary tree and pancreatic ducts.

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Infant with respiratory distress, anemia, and an abdominal mass

Surgical image of inflammatory myofibroblastic tumor — Surgical image shows a mass with a large number of collateral blood vessels that was intimately associated to the terminal ileum and cecum with the appendix draped across the mass.

The diagnosis was inflammatory myofibroblastic tumor.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Teenager with abdominal pain

CT of small bowel volvulus around mesenteric cyst — Two contiguous axial images from a CT with contrast of the abdomen show a whirlpool sign of swirling of the mesenteric vessels (above left) around a round low density structure just to the left of the spine (above right). Another axial image from the same exam (below left) shows a normal relationship of the superior mesenteric vein to the right of the superior mesenteric artery although both appear to be shifted to the left. AP image from a subsequent upper GI (below right) shows normal position of the ligament of Treitz in the left upper quadrant.

The diagnosis was small bowel volvulus around a mesenteric cyst. There was no evidence of malrotation or midgut volvulus.

School ager with abdominal pain

AXR and enema of sigmoid volvulus — AXR AP (above) shows the colon to be massively dilated throughout its length and there is a suggestion of a ‘bean’ sign in the middle of the abdomen. Early (below left) and later (below right) lateral images from an enema shows an inability to opacify the entire colon with contrast and the presence of a beak sign in the sigmoid colon.

The diagnosis was sigmoid volvulus.

Teenager with chronic abdominal pain

Upper GI of malrotation with chronic midgut volvulus — AP image from a small bowel follow through exam (below) shows the small bowel on the right side of the abdomen and the colon on the left side of the abdomen. Close examination of the upper GI portion of the exam (above) beyond the abnormal position of the ligament of Treitz shows a thickened appearance of the folds throughout the duodenum (above left) and proximal jejunum (above right) but there was no evidence of spiraling of the bowel or obstruction.

The diagnosis on the upper GI was malrotation without midgut volvulus. In the operating room the patient was found to have malrotation with chronic midgut volvulus with chronically dilated lymphatic and mesenteric venous systems which were the cause of the thickened appearance of the small bowel folds.

School ager who fell out of a tree and has abdominal pain

CT of malrotation without midgut volvulus — Axial CT with contrast of the abdomen shows the unopacified small bowel on the right side of the abdomen and the colon on the left side of the abdomen.

The diagnosis was malrotation without midgut volvulus.