Teenager with abdominal pain

BE of ulcerative colitis — AXR AP from a barium enema (left) shows the loss of haustral markings in the colon (lead pipe sign). The magnified view (right) suggests the presence of multiple fine mucosal ulcerations.

The diagnosis was ulcerative colitis.

Teenager with abdominal pain

The diagnosis was ulcerative colitis.

Teenager with poorly controlled inflammatory bowel disease

CT of Crohn's disease with fistula and abscess — Axial CT with contrast of the abdomen shows a thick-walled mass that is filled with air and oral contrast that is located medial to the oral contrast-filled thickened ascending colon and above the right psoas muscle. An extensive amount of inflammatory change is seen in the mesenteric fat in the right lower quadrant.

The diagnosis was Crohn disease with a fistula to an abscess above the right psoas muscle.

Teenager with abdominal pain

Small bowel follow through of Crohn's disease — AXR AP from a small bowel follow through shows bowel fold thickening in the proximal ileum in the left lower quadrant and bowel lumenal narrowing in the mid ileum in the midline that continues to the terminal ileum in the right lower quadrant.

The diagnosis was Crohn disease.

School ager status with acute lymphocytic leukemia and abdominal pain

CT and US of typhlitis — AXR AP (above left) is unremarkable. Axial CT with contrast of the abdomen (above right) shows moderate thickening of the cecum. Transverse and sagittal US of the cecum (below) shows a moderately thickened cecum lying above the right psoas muscle.

The diagnosis was typhlitis in a patient with acute lymphocytic leukemia.

School ager with abdominal pain, diarrhea, and vomiting

AXR and CT and US of pseudomembranous colitis — AXR AP (above left) shows thickening of the haustra of the transverse colon (thumb printing). Axial CT with contrast of the abdomen (above right) shows diffuse thickening of the colon which is markedly thickened in the ascending colon compared to the descending colon. An accordion sign is demonstrated in the ascending colon. Sagittal (below left) and transverse (below right) US of the cecum show a diffusely thickened cecum.

The diagnosis was pseudomembranous colitis.

Teenager status post bone marrow transplant with abdominal pain

Small bowel follow through of graft versus host disease — AXR AP from a small bowel follow through shows mild thickening of the small bowel folds in the distal jejunum and proximal ileum in the middle of the image.

The diagnosis was graft versus host disease.

Preschooler status post bone marrow transplant with abdominal pain

AXR of pneumatosis intestinalis in graft versus host disease — AXR AP shows diffuse pneumatosis intestinalis of the colon from the cecum to the rectum.

The diagnosis was graft versus host disease.

Newborn with a distended abdomen

AXR of complicated meconium ileus / meconium peritonitis — AXR shows displacement of much of the bowel to the left lower quadrant of the abdomen. Faint cresenteric calcifications are seen arcing upwards and downwards on the right side of the abdomen while an oval-shaped calcified object is seen on the left side of the abdomen at the level of the L1 and L2 vertebral bodies. Nodular appearing calcifications are scattered throughout the abdomen.

The diagnosis was complicated meconium ileus. A large meconium pseudocyst was encountered in the operating room.

Teenager with sickle cell disease and abdominal pain

AXR and CT of cholelithiasis due to sickle cell disease — AXR AP (left) shows faint calcifications in the right upper quadrant, just beneath the tip of the 12th rib and at the level of the L2 vertebral body which are better demonstrated on the coronal CT without contrast of the abdomen which demonstrates 5 calcifications within the gallbladder.

The diagnosis was cholelithiasis in a patient with sickle cell disease.

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.