Category: Gastrointestinal

Infant who has just undergone a gastrostomy tube replacement which was technically difficult

Gastrostomy tube injection of gastromy tube malposition outside of stomach
AP image from a gastrostomy tube injection done with water soluble contrast (left) shows none of the injected contrast conforming to the lumenal contour of the stomach. AXR taken 15 minutes later (right) shows the extravasated contrast diffusing throughout the peritoneum and outlining loops of bowel and being excreted in the bladder.

The diagnosis was malposition of the gastrostomy tube replacement outside of the stomach.

Infant with vomiting after gastrostomy tube placement a week ago

Enema and gastrostomy tube injection showing gastrostomy tube that was placed through colon into stomach
AP image during an enema shows a fixed lumenal caliber change or filling defect caused by the gastrostomy tube balloon in the mid transverse colon. Early lateral image during gastrostomy tube injection with water soluble contrast (above right) shows the gastrostomy balloon and tip within the stomach. Later lateral image during gastrostomy tube injection (below right) shows contrast refluxing back from the stomach along the gastrostomy tube tract into the colon which is anterior to the stomach.

The diagnosis was initial malposition of the gastrostomy tube through the colon and then into the stomach.

Newborn with esophageal atresia with abdominal distension after gastrostomy tube placement 1 week ago

AXR of pneumoperitoneum due gastrostomy tube malposition causing gastric perforation
Supine AXR (left) shows a gastrostomy tube projecting appropriately over the stomach with a triangular lucency superior to the stomach. Left lateral decubitus AXR (above right) again shows the triangular lucency superior to the stomach but does not show air between the abdominal wall and liver. Cross-lateral AXR (below right) shows air between the anterior abdominal wall and liver.

The diagnosis was pneumoperitoneum due to gastric perforation after gastrostomy placement. In the operating room the patient was found to have ischemic necrosis of the greater curvature of the stomach.

Preschooler with superior mesenteric artery syndrome who had a feeding tube placed into the third part of the duodenum 1 day ago that is now not working. AXR (not available) showed the tip had migrated into the right upper quadrant of the abdomen

US of feeding tube tip in main portal vein
Transverse US of the liver shows the echogenic tip of a feeding tube to be in the main portal vein in the center of the image. Note the posterior shadowing from the tip extending inferiorly from it.

The diagnosis was feeding tube malfunction due to migration of the feeding tube tip out of the duodenum into the main portal vein. In the operating room the feeding tube was seen to have eroded into the superior mesenteric vein and then into the main portal vein and it was removed without complication.

Infant after feeding tube placement

AXR of feeding tube in mainstem bronchus, lung and pleural space with tension pneumothorax
AXR obtained immediately after feeding tube placement (left) shows a feeding tube going down the left mainstem bronchus and then turning up into the lung and increased lucency in the left costophrenic angle presumably due to the feeding tube entering the left pleural space. AXR obtained a minute later after feeding tube repositioning (right) shows the tip of the feeding tube in the antrum of the stomach and a large left pleural air collection with mediastinal shift to the right.

The diagnosis was feeding tube malfunction due to placement of the feeding tube through the airway into the lung and pleural space causing a tension pneumothorax.

Preschooler with right hip pain for 2 weeks

CT of perforated appendicitis
AP radiograph of the right femur was unremarkable. Coronal STIR MRI of the right hip and femur was unremarkable aside from incidental bright pelvic free fluid noted just above the bladder. Coronal 2D reconstruction from a CT with IV and oral contrast of the abdomen shows a large complex fluid collection containing air and a central calcification in the right lower quadrant which was lying next to the psoas muscle.

The diagnosis was perforated appendicitis with an abscess containing an appendicolith.

Teenager who crashed their all terrain vehicle with abdominal pain

CT of renal trauma / renal laceration and ureteral trauma / ureteral transection and splenic trauma / splenic laceration
Axial and coronal CT with contrast of the abdomen immediate phase (above) shows low density in the superior and inferior poles of the left kidney and fluid in the left perirenal and pararenal spaces. There is also a large area of low density in the spleen. Delayed phase CT images (below) show extravasation of urine out of the ureter into the left pararenal space.

The diagnosis was left renal laceration with ureteral transection and splenic laceration.

School ager status post handlebar injury and abdominal pain

CT of inhomogenous enhancement of the spleen and liver laceration
Axial CT with contrast of the abdomen shows a stellate area of low density in the right lobe of the liver. The spleen does not have a laceration, instead it demonstrates inhomogenous opacification due to the image being obtained in the arterial phase – note how dense the contrast in the aorta is.

The diagnosis was inhomogenous enhancement of the spleen and a liver laceration.