Preschooler with cystic fibrosis and abdominal pain

AXR of distal intestinal obstruction syndrome / DIOS — AXR supine (above left) shows multiple dilated loops of small bowel with a stool-like mass in the mid-abdomen. AXR upright (above right) shows multiple air-fluid levels. AP image from an enema with high osmolar water soluble contrast (below) shows complete opacification of a normal appearing colon. The terminal ileum could not be refluxed and specifically the stool-like mass in the mid-abdomen could not be reached with contrast.

The diagnosis was small bowel obstruction due to distal intestinal obstruction syndrome in a patient with cystic fibrosis.

Toddler who swallowed an object

CXR of a coin in the stomach — CXR shows a round radiopaque foreign body in the antrum of the stomach.

The diagnosis was a coin as a gastrointestinal foreign body.

Teenager with chronic right lower quadrant pain

CT of Crohn disease — Coronal (left) and axial (right) CT with contrast of the abdomen shows wall thickening and mucosal hyperenhancement of the terminal ileum with separation of the bowel loops due to mesenteric infiltration of fat and prominent vasa recta (comb sign).

The diagnosis was Chron disease.

School ager who swallowed something

AXR of neodymium magnets — AXR shows two small round radiopaque foreign bodies that are attracted to each other.

The diagnosis was two rare earth magnets (neodymium magnets) as a gastrointestinal foreign body.

Infant with increased bowel sounds and decreased stooling

AXR of small bowel obstruction due to constipation — AXR shows multiple extremely dilated loops of small bowel and no rectal gas.

The diagnosis was distal small bowel obstruction due to constipation.

Infant status post surgery for bowel perforation

Upper GI of enterocutaneous fistula in necrotizing enterocolitis — AP image from an UGI exam (left) shows contrast opacifying the proximal jejunum. An image obtained a minute later (right) shows contrast entering the surgical drain in the left lower quadrant of the abdomen.

The diagnosis was enterocutaneous fistula after bowel perforation in a patient with necrotizing enterocolitis.

School ager with abdominal distension and generalized abdominal pain

AXR of constipation — AXR shows a marked amount of stool from the cecum to the rectum.

The diagnosis was constipation.

Newborn with choking while feeding

UGI of esophageal atresia with H-type tracheo-esophageal fistula — CXR (left) shows dextrocardia and diffuse lung infiltrates bilaterally. Oblique image from a pull-back esophagram performed with a nasogastric tube while injecting low-osmolar water soluble contrast in the distal esophagus (right) shows opacification of the trachea and bronchial tree via a fistula.

The diagnosis was aspiration pneumonia due to esophageal atresia with H-type tracheo-esophageal fistula.

School ager with recurrent abdominal pain

AXR of constipation — AXR shows a massive amount of stool from the cecum to the rectum.

The diagnosis was constipation.

Toddler with a lower abdominal midline mass

CT of colonic duplication — Axial CT with IV and oral contrast of the abdomen show a large midline mass which appears to contain air and stool (and no oral contrast) that extends from the lower abdomen (top) all the way to the rectum which it displaces posteriorly and to the right (bottom).

The diagnosis was colonic duplication.

Newborn with failure to pass meconium

Enema of colonic atresia — AXR (left) shows multiple dilated loops of bowel with an extremely dilated loop of bowel in the lower abdomen. AP (above right) and lateral (below right) images from an enema show a microcolon with contrast reaching the level of the cecum but not refluxing the terminal ileum, despite multiple attempts.

The diagnosis was colonic atresia.

Unjaundiced preschooler with vomiting and abdominal pain

CT and cholangiogram of choledochal cyst Type I — Axial (above left) and coronal (above right) CT without contrast of the abdomen show a large cystic lesion between the right kidney and pancreas with extensive surrounding inflammation. The gall bladder was normal. AP image from intraoperative cholangiogram (below) shows the lesion represents diffuse dilation of the common bile duct with free passage of contrast into the small bowel.

The diagnosis was choledochal cyst Type I.

Teenager with right lower quadrant pain and WBC=30,000

US of acute appendicitis with appendicolith — Sagittal US of the right lower quadrant (above) shows a dilated, non-compressible, blind ending tubular structure measuring 10 mm in diameter with an echogenic focus at its tip causing posterior shadowing. Transverse US of the cecum (below) shows it to be thickened in appearance.

The diagnosis was acute appendicitis with an appendicolith at the tip of the appendix. In the operating room, the inflammed appendix was adherent to an inflamed cecum.

Newborn with direct hyperbilirubinemia

Hepatobiliary scan of biliary atresia — Transverse US of the liver (above) at the level of the main portal vein shows the liver and intrahepatic and extrahepatic biliary tree to be unremarkable. The gall bladder (not shown) was small and collapsed, although the patient had been fasting for 12 hours before the exam. Serial images from a hepatobiliary scan performed after pretreatment with phenobarbital obtained up to 5 minutes after the injection of radiotracer (below left) show prompt uptake of radiotracer by the liver but no excretion of radiotracer into the biliary tree, gall bladder, or bowel. Delayed image obtained at 24 hours after injection of radiotracer (below right) again fails to show excretion of radiotracer into the biliary tree, gall bladder, or bowel.

The diagnosis was biliary atresia.

Newborn with failure to pass meconium

AXR of anorectal malformation — AXR (above) shows multiple dilated loops of bowel within the abdomen that are progressively more dilated as they near the rectum. Prone cross-table lateral radiograph of the abdomen obtained after 10 minutes in the prone position (below) with a radio-opaque BB on the anus shows a short distance between the anus and the gas in the rectum.

The diagnosis was a low anorectal malformation.

School ager with intermittent abdominal pain

UGI and SBFT of lymphoid hyperplasia — Spot images from an upper GI small bowel follow through show multiple round filling defects, which represent pseudopolyps, throughout the terminal ileum which is normal in caliber.

The diagnosis was lymphoid hyperplasia.

Preschooler with abdominal pain

CT and US of acute cholecystitis — Axial (above left) and sagittal (above right) CT with contrast of the abdomen shows an enlarged gallbladder with diffuse wall thickening and pericholecystic fluid. Transverse (below left) and sagittal (below right) US of the abdomen again shows gallbladder wall thickening and pericholecystic fluid and a large amount of sludge in the gall bladder.

The diagnosis was acute cholecystitis.

Teenager with vomiting after posterior spinal fusion 1 week ago

UGI of superior mesenteric artery syndrome — AP image from an upper GI exam shows extremely dilated first and second portions of the duodenum. There was continuous to and fro motion of contrast in the duodenum and over 15 minutes no contrast passed across the spine and through the duodenal C-loop.

The diagnosis was superior mesenteric artery syndrome.

Preschooler who is being treated for Wilms tumor and is immune suppressed and is septic

US of candidial microabscesses in spleen — Transverse (left) and sagittal (right) US images of the spleen show multiple, round anechoic lesions within the spleen.

The diagnosis was candidial microabscesses in the spleen.

Preschooler with colicky abdominal pain

US of pancreatitis caused by pancreatic duct stone — Transverse US of the pancreatic head (above) shows just to the right of midline a round echogenic lesion with posterior shadowing in the center of the pancreatic head while transverse US of the pancreatic body (below) shows a dilated pancreatic duct throughout the body of the pancreas.

The diagnosis was a large stone in the pancreatic head portion of the pancreatic duct causing pancreatic duct obstruction and pancreatitis.

Teenager with intractable back pain

US of pancreatoblastoma — Transverse US of the abdomen shows a large solid mass in the pancreatic head encasing the hypoechoic portal-mesentero venous junction in the center of the image.

The diagnosis was pancreatoblastoma.

School ager with right lower quadrant pain and elevated white blood cell count

CT of omental infarction — Axial CT with contrast of the abdomen shows diffuse mesenteric fat stranding which is most prominent along the right side of the abdomen. The appendix (not pictured) measured 7-8 mm in diameter and was considered via measurement to be indeterminate for acute appendicitis.

The diagnosis was omental infarction which was seen along with a normal appendix in the operating room.

Infant with vomiting and failure to thrive

Upper GI of organoaxial volvulus — AP image from an upper GI shows rotation of the stomach along its long axis with reversal of the greater and lesser curvatures of the stomach.

The diagnosis was organoaxial gastric volvulus.

Teenager with an incidentally noted paraspinal mass on a CXR

Upper GI of organoaxial gastric volvulus and hiatal hernia — Early AP (above left) and later AP (above right) and lateral (below) images from an upper GI shows rotation of the stomach along its long axis with reversal of the greater and lesser curvatures of the stomach. The stomach is also noted to have slid through the esophageal hiatus into the chest.

The diagnosis was organoaxial gastric volvulus in a patient with a hiatal hernia.

Infant with cough and vomiting

Upper GI of organoaxial gastric volvulus — Early AP (above left) and later AP (above right) and lateral (below) images from an upper GI shows rotation of the stomach along its long axis with reversal of the greater and lesser curvatures of the stomach.

The diagnosis was organoaxial gastric volvulus.