School ager with recent recurrent pneumonias who underwent esophageal atresia repair 5 years ago

Upper GI of esophageal atresia with recurrent fistula — Lateral image from an upper GI exam shows a contrast filled esophagus (posteriorly) connecting to the trachea (anteriorly) through a superiorly oriented fistula (in the middle).

The diagnosis was recurrent fistula after repair of esophageal atresia.

School ager who choked while eating tacos who is status post esophageal atresia repair 12 years ago

Upper GI of esophageal atresia — AP image from an upper GI shows marked luminal narrowing at the esophageal anastomosis between the dilated proximal esophageal pouch and the distal esophagus with a large filling defect in the proximal pouch. At endoscopy a large piece of meat was removed from above the anastomosis and the anastomosis was successfully dilated.

The diagnosis was a stricture at the esophageal anastomosis after repair of esophageal atresia.

Toddler who cannot swallow solid foods who is status post esophageal atresia repair a year ago

AP image from an upper GI shows ~ 75% luminal narrowing at the esophageal anastomosis between the dilated proximal esophageal pouch and the distal esophagus. This narrowing was subsequently successfully treated with dilation.

The diagnosis was a stricture at the esophageal anastomosis after repair of esophageal atresia.

Newborn with difficulty handling secretions who subsequently developed tracheomalacia

CXR AP (left) shows a nasogastric tube that cannot be advanced further in the esophagus. Vintage upper GI lateral image (right) shows a dilated proximal esophageal pouch compressing the airway. In current practice, there is no indication for doing an upper GI with positive contrast material.

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

Infant with esophageal atresia without tracheo-esophageal fistula undergoing pre-operative imaging

AP image from an upper GI performed with a bougie dilator placed into the proximal esophageal pouch through the oropharynx and a bougie dilator placed through a gastrostomy tube site into the distal esophagus with both dilators held under tension shows a 2 cm gap between the proximal and distal esophageal segments.

The diagnosis was esophageal atresia with a long gap between the proximal and distal segments.

Infant with several episodes of aspiration pneumonia in the last year

CXR shows diffuse infiltrates in the right upper and lower lobes and hyperexpansion. An upper GI showed a fistula between the esophagus and trachea.

The diagnosis was esophageal atresia with H-type tracheo-esophageal fistula.

Infant with recurrent pneumonias

2 lateral images from an upper GI shows contrast in the esophagus as expected (posteriorly) and in the airway unexpectedly (anteriorly). An H-type fistula is clearly seen connecting the airway and the esophagus.

The diagnosis was esophageal atresia with H-type tracheo-esophageal fistula.

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.

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.

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.

Newborn with abdominal distension

AXR of pneumoperitoneum — Supine AXR shows increased lucency in the upper abdomen without clear demonstration of the football sign of the falciform ligament being outlined by free air.

The diagnosis was pneumoperitoneum.

Premature newborn on ventilator with abdominal distension

AXR of pneumoperitoneum — Cross-table lateral AXR shows a large amount of free air superiorly in the abdomen outlining some of the bowel loops and compressing the rest posteriorly.

The diagnosis was pneumoperitoneum.

Newborn with a distended abdomen

AXR of pneumoperitoneum — Left lateral decubitus AXR shows free air between the right abdominal wall and the liver.

The diagnosis was pneumoperitoneum.

Preschooler with abdominal pain

CXR of pneumoperitoneum — Upright CXR shows free air beneath the diaphragm.

The diagnosis was pneumoperitoneum.

Toddler with stridor

CXR and Upper GI of esophageal foreign body — Lateral spot films from an UGI show fixed narrowing of the trachea (left + middle) with an esophageal perforation / fistula arising from the anterior wall of the esophagus (right). Endoscopy done earlier in the day removed a set of plastic wheels from a toy car which was felt to have been present for a long time as the esophagus was ulcerated and edematous in the area of perforation.

The diagnosis was esophageal foreign body.