Teenager with an androgen excess who is without abdominal pain

MR of gallstone — Coronal HASTE (above) and axial T2 (below) MRI without contrast of the abdomen shows the gallbladder to contain over 20 small, round low-signal intensity objects. The gallbladder wall is not thickened.

The diagnosis was cholelithiasis without acute cholecystitis.

School ager with right lower quadrant pain

AXR of appendicolith — AXR AP shows an oval-shaped calcification in the right lower quadrant just above the right iliac crest at the level of the L4 vertebral body.

The diagnosis was acute appendicitis with an appendicolith within the appendix.

Infant with jaundice

Percutaneous cholangiogram of bile plug syndrome — AP image from a percutaneous cholangiogram shows a dilated intrahepatic biliary tree and a markedly dilated extrahepatic biliary tree containing large filling defects within it. In this case the cholangiogram was therapeutic as well as diagnostic.

The diagnosis was bile plug syndrome causing biliary obstruction.

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.

Newborn with bilious vomiting

Upper GI of malrotation with midgut volvulus — AP image from an upper GI shows complete obstruction of the duodenum at the junction of the second and third parts of the duodenum and associated massive gastroesophageal reflux. A final image taken 5 minutes later was unchanged.

The diagnosis was gastroesophageal reflux due to malrotation with midgut volvulus causing duodenal obstruction.

Newborn with bilious vomiting

AXR and upper GI of duodenal web — AXR AP (above) shows a double bubble sign with a dilated stomach to the left of the spine and a dilated duodenum to the right of the spine. Oblique images from an upper GI show a dilated duodenal bulb projecting over the vertebral bodies (lower right) and a small amount of contrast entering the second part of the duodenum (lower left).

The diagnosis was duodenal web.

Newborn with copious secretions in the delivery room

AXR of duodenal atresia — AXR AP shows a double bubble sign with a dilated stomach to the left of the spine and duodenum to the right of the spine with a small amount of distal bowel gas.

The diagnosis was duodenal atresia with air passing distally into the small bowel through the biliary tree and pancreatic ducts.

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.

School ager with abdominal pain

AXR and enema of sigmoid volvulus — AXR AP (above) shows the colon to be massively dilated throughout its length and there is a suggestion of a ‘bean’ sign in the middle of the abdomen. Early (below left) and later (below right) lateral images from an enema shows an inability to opacify the entire colon with contrast and the presence of a beak sign in the sigmoid colon.

The diagnosis was sigmoid 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.

School ager who fell out of a tree and has abdominal pain

CT of malrotation without midgut volvulus — Axial CT with contrast of the abdomen shows the unopacified small bowel on the right side of the abdomen and the colon on the left side of the abdomen.

The diagnosis was malrotation without midgut volvulus.

Newborn with non-bilious vomiting

Small bowel follow through of malrotation without midgut volvulus — Delayed AP image from an upper GI shows the ligament of Treitz to be over the right pedicle of the L2 verteral body and all of the jejunum to be on the right side of the abdomen.

The diagnosis was malrotation without midgut volvulus.

Infant with bilious vomiting

The diagnosis was malrotation with midgut volvulus.

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.

Infant with a right inguinal mass

US of inguinal hernia — Sagittal US of the scrotum (below) shows a loop of bowel superior to the right testicle within the right scrotal sac. Transverse US (above) best demonstrates the presence of a reactive hydrocele around the loop of bowel. The bowel was subsequently successfully reduced into the abdomen and repaired 3 days later.

The diagnosis was right inguinal hernia.

Preschooler with a bulge above the umbilicus

US of abdominal wall hernia — Transverse US of the midline abdominal wall just superior to the umbilicus shows echogenic omental fat herniating in the midline between the medial rectus muscles which are abnormally displaced to the lateral aspect of the image and which should normally be joined together in the midline.

The diagnosis was an abdominal wall hernia.

Infant with a blue belly button

AXR of umbilical hernia — AXR lateral shows mildly dilated loops of bowel from the stomach to the rectum, including a loop of bowel located anteriorly within the umbilicus.

The diagnosis was umbilical hernia.

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.

Infant with bilious vomiting for several days and a tender abdomen

AXR of small bowel obstruction due to malrotation with midgut volvulus — AXR supine shows multiple dilated loops of bowel with thickened walls.

The diagnosis was small bowel obstruction. In the operating room the patient was found to have malrotation with midgut volvulus. The small bowel was non-viable.

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.