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.

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.

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.

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.

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.

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.