Teenager who fell off a horse with abdominal pain

CT of bladder trauma / bladder perforation — Axial CT with contrast of the abdomen shows bilateral pubic rami fracture (above) with a Foley catheter in the center of the bladder and contrast extravasating out of the bladder into the perivesical space (below).

The diagnosis was extraperitoneal bladder perforation.

Teenager who crashed their all terrain vehicle with abdominal pain

CT of renal trauma / renal laceration and ureteral trauma / ureteral transection and splenic trauma / splenic laceration — Axial and coronal CT with contrast of the abdomen immediate phase (above) shows low density in the superior and inferior poles of the left kidney and fluid in the left perirenal and pararenal spaces. There is also a large area of low density in the spleen. Delayed phase CT images (below) show extravasation of urine out of the ureter into the left pararenal space.

The diagnosis was left renal laceration with ureteral transection and splenic laceration.

School ager who fell out of a tree with hematuria

CT of renal trauma / renal laceration — Axial CT with contrast of the abdomen shows areas of low density in the anterior and lateral aspects of the left kidney with associated left perirenal and pararenal high density fluid collections.

The diagnosis was left renal laceration with perirenal and pararenal hematomas.

Preschooler who fell 20 feet out a window with abdominal pain

CT of adrenal trauma / adrenal laceration and liver trauma / liver laceration — Axial CT with contrast of the abdomen shows a large amount of fluid in the region of the right adrenal gland and areas of low density in the middle and posterior aspects of the right lobe of the liver.

The diagnosis was right adrenal hemorrhage and liver laceration.

School ager who fell off their scooter 4 days ago and has increasing abdominal pain

CT of pancreatic trauma / pancreatic laceration — Axial CT with contrast of the abdomen shows a linear low density just anterior to the portal vein at the junction of the pancreatic head and pancreatic body. There is a large amount of peripancreatic fluid.

The diagnosis was pancreatic laceration / transection.

Teenager in a motor vehicle accident with abdominal pain

CT and US of pancreatic trauma / traumatic pancreatitis — Axial CT with contrast of the abdomen (above) shows an enlarged pancreatic head with some mild intrahepatic biliary dilation and non-visualization of the common bile duct. Transverse US of the pancreas obtained a day later (below) shows an enlarged hypoechoic pancreatic head.

The diagnosis was pancreatitis causing common bile duct obstruction.

School ager status post handlebar injury and abdominal pain

CT of inhomogenous enhancement of the spleen and liver laceration — Axial CT with contrast of the abdomen shows a stellate area of low density in the right lobe of the liver. The spleen does not have a laceration, instead it demonstrates inhomogenous opacification due to the image being obtained in the arterial phase – note how dense the contrast in the aorta is.

The diagnosis was inhomogenous enhancement of the spleen and a liver laceration.

School ager in a motor vehicle accident with abdominal pain

CT of splenic trauma / splenic laceration — Axial CT with contrast of the abdomen shows multiple areas of low density in the spleen, a perisplenic fluid collection, and a large amount of free fluid in the pelvis

The diagnosis was splenic laceration with hemoperitoneum.

School ager in a motor vehicle accident with abdominal pain

CT of periportal halo — Axial CT with contrast of the abdomen shows no laceration in the liver and linear low density surrounding the portal venous system.

The diagnosis was periportal halo.

School ager in a motor vehicle accident with abdominal pain

CT of liver trauma / liver laceration — Axial CT with contrast of the abdomen shows an area of low density in the right lobe of the liver and a large amount of free fluid in the pelvis.

The diagnosis was liver laceration with hemoperitoneum.

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Pediatric Imaging Pearl of the Week

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School ager with diminished femoral pulses

CXR of coarctation of aorta — CXR AP shows a 3 sign in the region of the aortic arch and bilateral rib notching.

The diagnosis was coarctation of the aorta.

School ager with dyspnea

CXR of pericardial effusion — CXR AP shows normal pulmonary vasculature and an enlarged water bottle-shaped heart.

The diagnosis was pericardial effusion. 375cc of chylous fluid were drained out of the pericardium.

Newborn with cyanosis

CXR of Ebstein anomaly — CXR AP shows decreased pulmonary vascularity and a huge box-shaped heart.

The diagnosis was Ebstein anomaly.

Preschooler with cyanosis

CXR of tetralogy of Fallot — CXR AP shows decreased pulmonary blood flow and an upturned cardiac apex resulting in a boot-shaped heart.

The diagnosis was tetralogy of Fallot.

School ager with dyspnea

CXR and angiogram of partial anomalous pulmonary venous return — CXR AP (above) shows a hypoplastic right lung, AP arterial (left) and venous (right) phases of a pulmonary artery angiogram show a right pulmonary (scimitar) vein draining into the inferior vena cava.

The diagnosis was partial anomalous pulmonary venous return.

Infant with cyanosis

CXR and angiogram of total anomalous pulmonary venous return — CXR AP (above) shows increased pulmonary blood flow and a snowman-shaped heart, AP angiogram venous phase (below) shows dilated superior vena cava on right and left vertical vein on left.

The diagnosis was total anomalous pulmonary venous return – supradiaphragmatic.

Infant with cyanosis

CXR of transposition of the great arteries — CXR AP shows increased pulmonary blood flow and an egg on a string-shaped heart.

The diagnosis was transposition of the great arteries.

Our DDX For This Week Is

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Newborn with new abdominal distension with a patent ductus arteriosus who is receiving indomethacin to close it

AXR of pneumoperitoneum — Right lateral decubitus radiograph of the abdomen shows a large amount of free air within the abdomen.

The diagnosis was indomethacin-induced bowel perforation.

Infant with hypoplastic left heart syndrome on prostaglandin E to keep their ductus arteriosus patent who is continuously vomiting with feeds

UGI and US of prostaglandin E induced gastritis — Two lateral images from an upper GI (above) show persistent narrowing of the pylorus causing relative gastric outlet obstruction. Sagittal (left below) and transverse (right below) US of the pylorus shows the central echogenic gastric mucosa to be thickened and the pyloric muscle outside of it to be normal in diameter. The patient was also noted to be malrotated.

The diagnosis was prostaglandin E induced gastritis.

Infant with tracheomalacia and concern for vascular ring

CT of calcified ligamentum arteriosum — Axial CT with contrast of the chest shows a linear crescent-shaped calcification just to the left of the trachea which appears to join the main pulmonary artery to the descending aorta. An outside institution misinterpreted this calcification as a fish bone perforating out of the esophagus and transferred the patient emergently to our institution.

Infant with a murmur

CXR of patent ductus arteriosus ductus diverticulum — CXR AP shows mild cardiomegaly and pulmonary vascular congestion along with an extra soft tissue mass just to the left of the spine near the presumed position of the ductus arteriosus.

The diagnosis was a ductus diverticulum in a patient with patent ductus arteriosus.