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.

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View the illustrated DDX of volvulus

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.

Newborn with non-bilious vomiting

Small bowel follow through of malrotation without midgut volvulus — Delayed AP image from an upper GI shows the ligament of Treitz to be over the right pedicle of the L2 verteral body and all of the jejunum to be on the right side of the abdomen.

The diagnosis was malrotation without midgut volvulus.

Infant with bilious vomiting

Upper GI of malrotation with midgut volvulus — AP image from an upper GI (left) shows the ligament of Treitz projecting over the right pedicle of the L2 vertebral body and to be lower in position than the duodenal bulb that projects over the right pedicle of the L1 vertebral body. The spiral appearance of the proximal jejunum is best appreciated on the lateral image (right).

The diagnosis was malrotation with midgut volvulus.

Preschooler with vomiting

AXR and upper GI of mesenteroaxial gastric volvulus — AXR AP (above left) shows a distended air-filled stomach which on the AXR upright (above right) has a large air-fluid level within it. AP image from an upper GI (below) shows that by following the course of the feeding tube the stomach appears to be upside down with the pylorus of the stomach located superiorly to the gastroesophageal junction and the tip of the feeding tube to be in the second part of the duodenum.

The diagnosis was mesentero-axial gastric volvulus.

Teenager with paraplegia who uses an appendicovesicostomy for self-catheterization who now has abdominal distension and no stool for one week

Enema of cecal volvulus — AXR AP taken immediately after an enema shows multiple dilated loops of air-filled small bowel with no reflux of contrast into the terminal ileum. The ascending colon ends in a beak which points to a dilated air-filled cecum in the right lower quadrant.

The diagnosis was distal small bowel obstruction caused by cecal volvulus.

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Infant with vomiting and a palpable olive

Surgical image of hypertrophic pyloric stenosis — Surgical image shows delivery of the pylorus which is thickened, firm and blanched as opposed to its normal small, soft and pink consistency.

The diagnosis was hypertrophic pyloric stenosis.

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View the illustrated DDX of hernias

Infant with a right inguinal mass

US of inguinal hernia — Sagittal US of the scrotum (below) shows a loop of bowel superior to the right testicle within the right scrotal sac. Transverse US (above) best demonstrates the presence of a reactive hydrocele around the loop of bowel. The bowel was subsequently successfully reduced into the abdomen and repaired 3 days later.

The diagnosis was right inguinal hernia.

Preschooler with a bulge above the umbilicus

US of abdominal wall hernia — Transverse US of the midline abdominal wall just superior to the umbilicus shows echogenic omental fat herniating in the midline between the medial rectus muscles which are abnormally displaced to the lateral aspect of the image and which should normally be joined together in the midline.

The diagnosis was an abdominal wall hernia.

Infant with a blue belly button

AXR of umbilical hernia — AXR lateral shows mildly dilated loops of bowel from the stomach to the rectum, including a loop of bowel located anteriorly within the umbilicus.

The diagnosis was umbilical hernia.

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Newborn with polyhydramnios and a double bubble sign on prenatal US

Surgical image of duodenal atresia — Surgical image shows a massive fluid filled stomach (on the left) and duodenal bulb (on the right) which was found to contain over 400 cc of fluid.

The diagnosis was duodenal atresia.

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View the illustrated DDX of intussusception

Toddler with abdominal pain

US of transient small bowel intussusception — Transverse greyscale US (upper left) of the left lower quadrant of the abdomen shows a soft tissue mass demonstrating a target sign measuring less than 2 cm in diameter which on transverse color doppler US (upper right) shows normal vascularity. Sagittal greyscale US of the area shows a pseudokidney sign (below). A repeat US 15 minutes later showed the mass was gone.

The diagnosis was transient small bowel-small bowel intussusception.

School ager with abdominal pain

CT of Meckel's diverticulum causing small bowel obstructin — Axial (above), coronal (lower left) and sagittal (lower right) CT with contrast of the abdomen shows multiple dilated loops of small bowel and a soft tissue mass in the right upper quadrant just beneath the gall bladder that shows the target sign on the sagittal image and the pseudokidney sign on the transverse and coronal images. The soft tissue mass was still present on an US performed 1 hour later.

The diagnosis was small bowel obstruction due to an ileal-ileal intussusception caused by Burkitt lymphoma.

Toddler with colicky abdominal pain

US of intussusception — XR supine (upper left) shows a non-obstructive bowel gas pattern but suggests a soft tissue mass in the right lower quadrant. Transverse US of the right lower quadrant (upper middle) shows a soft tissue mass with a target sign measuring 3 cm in diameter while the longitudinal US (upper right) shows a pseudokidney sign. AP spot image from an air enema (bottom) shows a soft tissue mass being encountered in the cecum.

The diagnosis was ileocolic intussusception which was successfully reduced.

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Newborn with failure to pass meconium

Surgical image of ileal atresia — Surgical image shows a massively dilated distal ileum (to the left of the image) than then dramatically narrows in the center of the image.

The diagnosis was ileal atresia.

Pediatric Imaging Pearl of the Week

View the illustrated DDX of small bowel obstruction