School ager with abdominal pain after trauma

CT and US of choledochal cyst
Axial CT with contrast of the abdomen (upper left) shows a large round low density structure inferior to the liver and separate from the gall bladder. Transverse and sagittal US of the liver show the round structure to be cystic and in communication with a dilated biliary tree. Delayed image (lower left) from a hepatobiliary scintigraphy exam shows concentration of radiotracer into the round structure which is slowly excreted into the bowel. AP image of an intraoperative cholangiogram (lower right) shows dilation of the intrahepatic and extrahepatic biliary tree with free flow of contrast into the bowel.

The diagnosis was choledochal cyst causing biliary obstruction.

Newborn with jaundice

hepatobiliary scintigraphy scan of biliary atresia
Immediate image (upper left) from a hepatobiliary scintigraphy exam performed after pre-treatment with phenobarbital shows good uptake of radiotracer in the liver with the 24 hour delayed image (upper right) showing no excretion of radiotracer into the bowel. Transverse US of the liver (lower left) shows the presence of a gallbladder. AP image of an intraoperative cholangiogram shows a dilated gallbladder (with some contrast extravasation outside of the gallbladder) and minimal visualization of the intrahepatic biliary tree and no visualization of the extrahepatic biliary tree.

The diagnosis was biliary atresia causing biliary obstruction.

Teenager on an aggressive weight-loss diet who has recently begun vomiting after meals

Upper GI of superior mesenteric artery syndrome
Delayed AP image from an upper GI shows a markedly dilated first and second part of the duodenum to the right of the spine with a marked narrowing and transition in duodenal caliber over the spine and only a small amount of contrast in the third part of the duodenum to the left of the spine. During the exam, marked to and fro peristaltic motion was noted in the first and second parts of the duodenum.

The diagnosis was superior mesenteric artery syndrome.

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.

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.

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.

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.

School ager with nausea and vomiting

CT of small bowel obstruction due to Meckel's diverticulum
AXR supine (upper left) and coronal CT with contrast of the abdomen (lower left) show multiple dilated loops of small bowel with thin walls throughout the abdomen. The lower axial CT (upper right) shows a small cystic structure in the midline with a thicker wall than the surrounding dilated bowel which is also seen on the midline sagittal CT (lower right) just beneath the umbilicus.

The diagnosis was distal small bowel obstruction due to Meckel’s diverticulum.