Premature newborn with a rising lactate level

AXR and US of spontaneous intestinal perforation with dirty ascites — AXR AP (above left) shows a nasogastric tube projecting over the left upper quadrant of the abdomen. There is a collection of air in the mid-abdomen that does not appear to conform to being within bowel. There is no portal venous gas or pneumatosis intestinalis. Transverse US of the abdomen (above right) shows echogenic ascites in the abdomen surrounding the loops of bowel. AXR left lateral decubitus (below) shows a large amount of air between the abdominal wall and the liver. Subsequent placement of a surgical drain returned stool.

The diagnosis was spontaneous intestinal perforation resulting in pneumoperitoneum and complicated ascites.

Premature newborn now 1 month old with blood in their stools

AXR of necrotizing entercolitis — AXR AP (above) shows an extremely dilated bowel gas pattern with cuvilinear air in the wall of the entire colon. There is increased lucency in the center of the image just beneath the diaphragm. AXR left lateral decubitus (below) shows a small amount of air between the abdominal wall and the liver. There is also an extensive amount of branching air seen within the liver.

The diagnosis was necrotizing enterocolitis resulting in pneumatosis intestinalis, portal venous gas, and pneumoperitoneum.

Premature newborn with bloody stools

AXR of pneumatosis intestinalis of whole colon in necrotizing enterocolitis — AXR AP shows bubbly appearing air in the wall of the entire colon from the cecum to the sigmoid colon.

The diagnosis was pneumatosis intestinalis of the whole colon in a patient with necrotizing enterocolitis.

Premature newborn with increasing residuals

Radiograph of pneumatosis intestinalis in necrotizing enterocolitis — The diagnosis was pneumatosis intestinalis of the ascending colon and proximal transverse colon in a patient with necrotizing enterocolitis.

The diagnosis was pneumatosis intestinalis of the ascending colon and proximal transverse colon in a patient with necrotizing enterocolitis.

Newborn with bloody stools

AXR of pneumatosis intestinalis in necrotizing enterocolitis — AXR AP shows curvilinear appearing air in the wall of the descending colon.

The diagnosis was pneumatosis intestinalis of the descending colon in a patient with necrotizing enterocolitis.

Premature newborn after umbilical venous catheter placement

US of TPNoma due to umbilical venous catheter malposition — CXR AP (above) shows the tip of the umbilical venous catheter projecting over the left portal vein. Transverse (below left) and sagittal (below right) US of the left lobe of the liver obtained 4 months later shows hyperechoic branching lesions in the liver which are felt to be calcifications in the distal branches of the portal veins due to long term direct injection of total parenteral nutrition into the distal branches of the portal veins rather than into the inferior vena cava.

The diagnosis was TPNoma due to umbilical venous catheter malposition in the left portal vein.

Teenager who had a Nissen fundoplication 3 days ago who cannot swallow water or medications

Upper GI of Nissen fundoplication wrap that is too tight — AP image from an UpperGI exam taken 15 minutes after the first swallow of contrast shows most of the contrast is still in the distal esophagus and only a small amount of contrast is in the stomach due to very slow emptying of the esophagus through the Nissen fundoplication into the stomach.

The diagnosis was Nissen fundoplication malfunction in the form of the Nissen fundoplication being too tight.

School ager who had a Nissen fundoplication 5 years ago and is now retching

Upper GI of para Nissen herniation after Nissen fundoplication — AP (left) and lateral (right) images from an UpperGI exam show the impression of the Nissen fundoplication wrap on the superior border of the stomach beneath the diaphragm. However, part of the stomach has herniated through the Nissen fundoplication to a position above the diaphragm.

The diagnosis was Nissen fundoplication malfunction in the form of a para Nissen herniation.

Teenager after an inappropriate ingestion

AXR of a AA battery — AXR AP shows a radiopaque cylindrical object projecting over the stomach.

The diagnosis was gastrointestinal foreign body in the form of a AA battery.

Teenager seen to ingest three non-food objects

AXR of battery and lead pencil in the stomach — AXR AP shows two radiopaque cylindrical objects in the abdomen. There is a faintly radiopaque thin straight object coursing from the T12-L1 intervertebral disk space to the left and ending just above the superior most cylindrical object.

The diagnosis was gastrointestinal foreign body in the form of two AA batteries and a lead pencil.

Teenager who has eaten something they should not have eaten

AXR of ingested AA batteries in the stomach — AXR AP shows two radiopaque cylindrical objects in the abdomen in the region of the stomach.

The diagnosis was a gastrointestinal foreign body in the form of two AA batteries.

Preschooler who has eaten something they should not have eaten

AXR of rare earth construction magnets in the stomach — AXR AP (left) and AXR lateral (right) show 4 radiopaque linear objects that are joined together in the mid abdomen.

The diagnosis was gastrointestinal foreign body in the form of 4 rare earth construction set magnets that are joined together.

Toddler who has eaten something they should not have eaten

AXR of 3 coins in the stomach that are stuck together and mimicking a button battery — AXR AP shows a radiopaque foreign body in the fundus of the stomach which has a combination of beveled edges and step offs.

The diagnosis was gastrointestinal foreign body which was presumed to be a button battery but upon endoscopic removal was found to be a nickel and two smaller penny coins that were stuck together and mimicking a button battery.

Preschooler with a history of a foreign body ingestion

Radiograph of a button battery in the stomach — AXR AP (left) shows a round radiopaque object in the region of the pylorus of the stomach that has a lucent halo around it. Zoomed up image of the object (right) better shows the lucent halo.

The diagnosis was gastrointestinal foreign body in the form of a button battery.

Toddler who is choking on something

CXR of button battery ingestion in a patient with a Morgagni hernia — CXR AP (above left) shows a round radiopaque object with a halo of lucency around it in the neck and there is a dense opacity in the medial aspect of the right lower lobe. CXR lateral (above right) shows the round object to be in the esophagus posterior to the airway and there is a loop of bowel coursing up from the abdomen to the chest anterior to the heart. Axial (below left) and sagittal (below right) CT without contrast of the chest shows the loop of bowel anterior and medial in location in the right chest to have haustra and therefore to be colon.

The diagnosis was a gastrointestinal foreign body in the form of a button battery in the esophagus in a patient who also had a Morgagni hernia.

Teenager with abdominal pain

US and MRI of focal nodular hyperplasia — Transverse US of the liver (above left) shows a round hyperechoic lesion in the liver. Coronal T2 MRI without contrast of the abdomen (above right) shows the lesion in the right lobe of the liver to have slightly increased signal intensity aside from the center of the lesion which has high signal intensity. Axial T1 MRI with contrast of the abdomen obtained in early phase imaging (below left) shows near uniform enhancement of the lesion aside from the center of the lesion while delayed phase imaging (below right) shows delayed stellate-like enhancement of the center of the lesion while the rest of the lesion is now isointense to liver.

The diagnosis was focal nodular hyperplasia.

School ager with cystic fibrosis and abdominal pain

CT of cystic fibrosis causing liver cirrhosis and pancreatic insufficiency — Coronal CT with contrast of the abdomen (above) shows a marked nodular contour to the liver and multiple dilated veins around the spleen. Coronal CT with contrast of the abdomen (below) shows diffuse fatty replacement of the pancreas.

The diagnosis was cystic fibrosis causing cirrhosis of the liver and esophageal varices and cystic fibrosis causing pancreatic insufficiency.

Newborn with difficulty feeding

Upper GI of congenital esophageal stenosis — CXR (left) shows a dilated air-filled structure just to the right of the spine. AP (middle) and lateral (right) images from an upper GI exam show two fixed focal areas of narrowing in the distal esophagus causing dilation of the esophagus proximal to those areas of narrowing.

The diagnosis was congenital esophageal stenosis.

Teenager with chronic neurologic impairment who has fever and constipation

CT of stercoral colitis — Axial CT with contrast of the abdomen (above) shows marked diffuse wall thickening and mucosal enhancement of the transverse colon. Wall thickening and mucosal enhancement is also present but less pronounced in the descending colon on the coronal CT (below left) and rectum (below right). The colon is filled with a marked amount of stool from the cecum to the rectum.

The diagnosis was a marked amount of chronic constipation resulting in stercoral colitis.

Toddler who was seen to swallow something

AXR of gastrointestinal foreign body in the form of ingested rare earth magnets — AXR AP shows 13 small round radiopaque objects that are joined together in a chain.

The diagnosis was gastrointestinal foreign body in the form of a chain of rare earth magnets.

Immune suppressed patient with odynophagia

UpperGI of candida esophagitis — AP images from an UpperGI show multiple longitudinally oriented lesions in the under-distended esophagus which are separated by normal mucosa and small round ulcers.

The diagnosis was candida esophagitis.

Preschooler with anemia and a palpable epigastric mass

CT of trichobezoar — Coronal (above) and axial (below) CT with contrast of the abdomen show the stomach distended by a large mass that has a swirled appearance and that fills the entire stomach and the duodenal bulb.

The diagnosis was trichobezoar that after removal was found to have caused a gastric ulcer which eroded into the liver.

Teenager with no history of esophageal surgery who is having repeated food bolus impactions in the esophagus

CT and upper GI of eosinophilic esophagitis — Axial CT without contrast of the chest (above) shows posterior to the trachea a dilated proximal esophagus due to food being impacted within it. AP (below left) and lateral (below right) images from an upper GI exam after the food bolus was removed from the esophagus show multiple ring-like narrowings encircling the proximal esophagus. The remainder of the esophagus was unremarkable.

The diagnosis was eosinophilic esophagitis.

Infant with failure to thrive

AXR and upper GI of annular pancreas — Left lateral decubitus AXR (above left) shows an air filled duodenal bulb and an air filled stomach (double bubble sign) with some distal bowel gas. Transverse US of the pylorus (below left) shows from left to right a fluid filled duodenal bulb, normal pylorus, and fluid filled stomach (double bubble sign). AP image from an upper GI exam (below right) shows a distended stomach and duodenal bulb with the remainder of the duodenal C-loop having a normal caliber.

The diagnosis was annular pancreas.https://pediatricimaging.org/diseases/annular-pancreas/

Teenager with substernal dysphagia

Upper GI of achalasia — Three lateral images from an upper GI exam shows dilation of the proximal esophagus which narrows to a beak distally which never opens up. A barium pill would not pass through the distal esophagus into the stomach.

The diagnosis was achalasia.