Newborn with inability to handle secretions

CXR AP and Lateral shows a nasogastric tube that cannot be further advanced into the distal esophagus.

The diagnosis was esophageal atresia without tracheo-esophageal fistula.

Newborn with failure to pass a nasogastric tube and a distended abdomen

CXR | AXR shows a nasogastric tube in the proximal esophagus and a massively distended abdomen. Transverse US image of the upper abdomen (below) shows a dilated duodenal bulb (left) and a dilated stomach (right), a double-bubble sign.

The diagnosis was esophageal atresia without tracheo-esophageal fistula and duodenal atresia.

Newborn with difficulty handling secretions in whom a nasogastric tube could not be passed

AXR shows a gasless abdomen. Segmentation anomalies are noted in the sacrum suggesting the presence of VATER syndrome.

The diagnosis was esophageal atresia without tracheo-esophageal fistula.

Newborn with difficulty handling secretions

AP image from a vintage upper GI shows contrast that had been injected into a dilated proximal esophageal pouch (left) that was subsequently aspirated into the trachea (right).

The diagnosis was esophageal atresia without tracheo-esophageal fistula.

Newborn who can’t handle their secretions

CXR of esophageal atresia with distal fistula — CXR shows a nasogastric tube coiled within a dilated proximal esophagus. There is gas in the stomach.

The diagnosis was esophageal atresia with distal tracheo-esophageal fistula.

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Pediatric Imaging Pearl of the Week

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Premature newborn on ventilator with respiratory distress

CXR of pneumothorax — Supine CXR shows a large amount of air in the right pleural space with inversion of the right hemidiaphragm and mediastinal shift to the left. There is also evidence of pulmonary interstitial emphysema in the right lung.

The diagnosis was a right tension pneumothorax.

Preschooler status post left central line placement

CXR of pneumothorax — Supine CXR shows the left mediastinal and cardiac border is much more sharp in appearance than the right mediastinal and cardiac border.

The diagnosis was a left-sided pneumothorax which was confirmed on a right lateral decubitus radiograph.

School ager after trauma on an all terrain vehicle

CXR of pneumothorax — Supine CXR shows multiple left-sided rib fractures and the deep sulcus sign which is increased lucency in the left costophrenic angle. No definite pleural edge is seen.

The diagnosis was left-sided pneumothorax.

Newborn with respiratory distress

CXR of pneumothorax — Cross-table lateral CXR shows air collecting anteriorly in the thorax without a clear pleural edge. The thymus is also outlined by air.

The diagnosis was pneumothorax (side undetermined) with pneumomediastinum.

Newborn with respiratory distress

CXR of pneumothorax — Left lateral decubitus CXR shows a distinct left pleural edge with no lung markings superior to it and the left lung collapsing inferiorly.

The diagnosis was a left-sided pneumothorax.

Teenager with cystic fibrosis and chest pain

CXR of pneumothorax — Upright CXR shows a distinct right pleural edge with no lung markings lateral to it and the right lung collapsing inferiorly and medially.

The diagnosis was a right-sided pneumothorax.

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Infant with a persistently distended abdomen who had necrotizing enterocolitis 1 month ago

Enema of necrotizing enterocolitis — AP image from an enema shows two fixed strictures in the colon, the first at the junction of the sigmoid colon and descending colon, and the second at the splenic flexure.

The diagnosis was post necrotizing enterocolitis strictures.

Premature newborn with abdominal distension

The diagnosis was necrotizing enterocolitis.

Newborn with bloody stools

AXR of necrotizing enterocolitis — Supine AXR shows numerous branching linear lucencies throughout the liver consistent in appearance with portal venous gas.

The diagnosis was necrotizing enterocolitis.

Premature newborn with bloody stools

AXR of necrotizing enterocolitis — Supine AXR shows linear pneumatosis intestinalis involving several loops of bowel in the left lower quadrant of the abdomen.

The diagnosis was necrotizing enterocolitis.

Premature newborn with feeding intolerance

AXR of necrotizing enterocolitis — Supine AXR shows diffusely dilated loops of bowel throughout the abdomen. There is no evidence of pneumatosis intestinalis, portal venous gas, or free air.

The diagnosis was necrotizing enterocolitis.

Our DDX For This Week Is

Pediatric Imaging Pearl of the Week

The illustrated DDX can be found here.

Newborn with abdominal distension and fever

AXR of pneumoperitoneum — Supine (left) and upright (right) AXR show a central fixed air collection that does not appear to conform to bowel and does not demonstrate any of the classic signs of free air.

The diagnosis was pneumoperitoneum.

Infant with bloody stools and vomiting

AXR of pneumoperitoneum — Supine AXR obtained during an intussusception reduction shows air outlining both the inner and outer walls of the small bowel (Rigler’s sign).

The diagnosis was pneumoperitoneum.

Premature newborn with abdominal distension

AXR of pneumoperitoneum — Supine AXR shows increased lucency in the upper abdomen with clear demonstration of the football sign of the falciform ligament being outlined by free air.

The diagnosis was pneumoperitoneum.