Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

School ager with progressive abdominal distension and abdominal pain over the last month and new onset urinary retention

CT of constipation causing bladder outlet obstruction — Coronal (left) and sagittal (right) images from a CT with IV and oral contrast of the abdomen shows a hugely distended bladder whose dome nearly touches the inferior margin of the liver. There is a marked amount of stool throughout the colon, especially in the rectum where a fecaloma is pinching off the bladder neck and urethra.

The diagnosis was constipation causing bladder outlet obstruction.

Infant with urinary retention and constipation

Barium enema of presacral sacrococcygeal teratoma — Lateral image from a barium enema shows displacement of the rectum anteriorly by a presacral mass which is eroding into the rectum and causing the extravasation of a small amount of contrast from the rectum posteriorly.

The diagnosis was sacrococcygeal teratoma.

Toddler with recently noted urinary retention

IVP and CT of rhabdomyosarcoma of the bladder — AP image from the excretory phase of a vintage intravenous pyelogram (above) shows bilaterally normal appearing renal collecting systems and ureters. There is a multilobulated circumferential filling defect in the base of the badder. Axial CT with contrast of the abdomen shows the mass to almost complete fill the base of the bladder.

The diagnosis was rhabdomyosarcoma of the bladder.

Newborn with marked bilateral hydronephrosis on prenatal US

VCUG of posterior urethral valves — AP image from a voiding cystourethrogram (above) shows bilateral grade 5 vesicoureteral reflux, right greater than left, and a narrow pinecone-shaped bladder in the inferior midline aspect of the image. Lateral image of the urethra taken during the voiding phase of the voiding urethrogram (below) shows marked dilation of the posterior urethra and a thin lucent membrane at the transition zone where the urethra assumes a more normal caliber.

The diagnosis was posterior urethral valves.

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Newborn infant of a diabetic mother who has failed to pass meconium

Clinical image of meconium plug — Clinical image shows a contiguous plug of meconium that was expelled by the patient after a water-soluble contrast enema.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Toddler with an acutely enlarged and blue right scrotum

US of hydrocele — Transverse and sagittal US of the right scrotum (above) shows a large anechoic fluid collection around the right testicle and epididymis. Sagittal US of the left scrotum (below) for comparison shows no fluid collection around the normal appearing left testicle.

The diagnosis was a large right hydrocele.

School ager with an acutely enlarged right scrotum

US of hydrocele — Sagittal US of the left scrotum (above) is unremarkable while sagittal US of the right scrotum (below) shows a large anechoic fluid collection surrounding the right testicle.

The diagnosis was right hydrocele.

Toddler with right scrotal pain who had suffered non-accidental trauma

CT of testicular hematoma — Axial CT with contrast of the abdomen (above) shows a heterogenous appearance to the enlarged right testicle which is surrounded by an edematous scrotal sac. Sagittal US of the right scrotum (below) again shows the thickened edematous scrotal sac, the heterogenous testicle, and an anechoic fluid collection surrounding the testicle.

The diagnosis was testicular hematoma surrounded by a reactive hydrocele and a scrotal hematoma secondary to trauma.

Infant with enlarged left scrotum and elevated AFP

US of testicular yolk sac tumor — Transverse color doppler US of the scrotum (above) shows the left testicle is hypervascular and much larger in size than the right testicle. Sagittal US of the left testicle (below) shows the testicular enlargement is due to a large round mass in the superior aspect of the testicle that is discrete from the normal testicle inferiorly.

The diagnosis was yolk sac tumor of the testicle.

Infant with acute right groin swelling

US of inguinal hernia — Sagittal US of the right scrotum shows a normal appearing right testicle (to the right of the image) that is displaced inferiorly in the scrotal sac by a large mass composed of multiple tubular structures that demonstrated peristalsis on real-time imaging.

The diagnosis was inguinal hernia.

Preschooler with acute left scrotal pain

US of epidimo-orchitis — Sagittal and transverse greyscale US of the left testicle (above) show a heterogenous appearance of the left testicle. Sagittal color doppler US of the left testicle shows increased blood flow to the left testicle and there was also increased blood flow to the left epididymis (not pictured).

The diagnosis was left epididimo-orchitis.

Preschooler with acute onset of left scrotal pain

US of torsion of the appendix testis — Transverse (above) and sagittal (below) US of the left testicle shows a round, mixed echogenicity lesion superior and medial to the left testicle that had no flow on color and spectral doppler US. The left epididymis and left testicle were normal in appearance with normal appearing blood flow.

The diagnosis was torsion of the appendix testis on the left.

Teenager with acute left scrotal pain

US of testicular torsion — Sagittal color doppler US of the right testicle (above) shows the presence of color flow that had an arterial waveform on spectral doppler US. Sagittal color doppler US of the left testicle (below) shows the absence of color flow and no arterial waveforms could be found on spectral doppler US.

The diagnosis was left testicular torsion.

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Infant with non-bilious and bilious vomiting

Surgical image of Meckel's diverticulum — Surgical image shows shows multiple dilated loops of small bowel in the background with a sharp transition point seen in the center of the image in the terminal ileum where on its anti-mesenteric border a diverticulum is seen with an omphalomesenteric duct remnant coming off it. This remnant had been attached to the under surface of the umbilicus, serving as a fulcrum for a small bowel volvulus, resulting in a small bowel obstruction.

The diagnosis was Meckel’s diverticulum causing a small bowel volvulus and a small bowel obstruction.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Preschooler with emesis

CT of reflux nephropathy and VCUG of vesicoureteral reflux — Coronal CT with contrast of the abdomen (left) shows a normal appearing left kidney and a shrunken right kidney with diffuse loss of renal parenchyma and scarring. AP image from a voiding cystourethrogram (right) shows left grade II vesicoureteral reflux and right grade IV vesicoureteral reflux.

The diagnosis was bilateral vesicoureteral reflux resulting in right reflux nephropathy.

Infant with urinary tract infection

US of duplicated kidney with ectopic ureterocele and hydroureteropyonephrosis — Sagittal US of the right kidney (upper left) shows a duplicated renal collecting system with the upper pole replaced by a round structure filled with echogenic material. Sagittal US of the right upper pole ureter (upper right) shows a tortuous ureter filled with echogenic material. Transverse US of the bladder (lower left) shows a round structure in the right side of the bladder that has echogenic material in its inferior portion and anechoic material in its superior portion. Sagittal US of the right ureter and bladder (lower right) shows the tortuous right ureter filled with echogenic material on the left side of the image and the rounded structure with the fluid-fluid level in the right side of the bladder.

The diagnosis was acute pyelonephritis in a duplicated kidney with an ectopic ureterocele with hydroureteropyonephrosis throughout the upper pole of the right kidney and right upper pole ureter and ureterocele.

Infant with suspected congenital anomaly of the urinary tract

IVP of renal agenesis — AP image from the nephrogram phase of a vintage intravenous pyelogram shows a dense nephrogram in the right renal fossa representing the right kidney with contrast draining down the right ureter and filling the bladder. There is no nephrogram noted in the left renal fossa.

The diagnosis was agenesis of the left kidney.

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Newborn with vomiting and a double bubble sign on prenatal ultrasound

Surgical image of jejunal stenosis — Surgical image shows the two retractors outlining a markedly dilated duodenum in the center of the image. The proximal jejunum is markedly stenotic where it joins to the duodenum at the duodenal-jejunal junction in the center of the image. The more distal jejunum is normal in caliber.

The diagnosis was jejunal stenosis.

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.