Category: Gastrointestinal

Premature newborn after placement of a nasogastric tube

Upper GI of esophageal perforation caused by nasogastric tube
AXR AP (above left) shows the nasogastric tube to follow a rather straight course into the abdomen. There is increased lucency in the upper abdomen. Subsequent AXR decubitus (above right) shows free air between the abdominal wall and liver. AP view obtained 9 days later immediately after the injection of water soluble contrast through the nasogastric tube (below left) shows some contrast extravasating out of the esophagus into the mediastinum and some contrast entering the stomach. Lateral view obtained 15 minutes later (below right) shows contrast outlining the left pleural space.

The diagnosis was nasogastric tube malposition with the nasogastric tube causing esophageal perforation.

Newborn who is having difficulty handling their secretions

CXR of esophageal atresia without tracheo-esophageal fistula
CXR AP (above left) shows the chest to be unremarkable aside from a right sided aortic arch. However, there is no air seen within the gastrointestinal tract. CXR lateral (above right) shows the proximal esophagus behind the trachea to be very dilated. CXR obtained after placement of a nasogastric tube (below) shows the nasogastric tube to be looped within the proximal esophagus.

The diagnosis was esophageal atresia without tracheo-esophageal fistula.

Infant with bilious vomiting

Upper GI of malrotation with midgut volvulus
AP image from an upper GI exam shows the contrast filled stomach in the upper right of the image emptying into the duodenal bulb which is just to the right of the spine. The position of the duodenal-jejunal junction is not well defined and it may be in the right upper quadrant or in the left upper quadrant. In either case, it is well below the level of the duodenal bulb and therefore is malpositioned.

The diagnosis was malrotation with midgut volvulus.

Young adult with a gastrojejunostomy tube and chronic abdominal pain

CT of gastrojejunostomy tube causing duodenal-jejunal intussusception
Axial (above) CT with contrast of the abdomen shows a round soft tissue mass to the right of the vertebral body that has a target sign appearance and that has a jejunostomy tube coursing in the center of it. Coronal CT (below) shows the soft tissue mass to be long in length and to comprise the second and third parts of the duodenum and the proximal jejunum and to have the jejunostomy tube coursing throughout its length.

The diagnosis was gastrojejunostomy tube malfunction due to the formation of a duodenal-jejunal intussuception forming around the tip of the jejunostomy tube.

Preschooler with abdominal pain who yesterday was playing with a construction toy that utilizes rare earth magnets

AXR of rare earth magnets causing small bowel obstruction
AXR shows multiple round and cylindrical radiopaque objects in the lower abdomen that are all in close approximation to each other. There are multiple dilated loops of small bowel present.

The diagnosis was gastrointestinal foreign bodies in the form of 9 rare earth magnets which had stuck together in the small bowel causing small bowel obstruction and resulting several days later in small bowel necrosis and small bowel perforation.

Premature newborn after nasogastric tube placement

CXR of nasogastric tube placement into lung resulting in tension pneumothorax
Initial CXR AP (left) shows the course of the nasogastric tube to project over the right lung and the tip of the nasogastric tube projects over the liver and is probably in the right costophrenic sulcus. The remaining tubes and lines are in appropriate position. CXR AP obtained after removal of the nasogastric tube (right) shows a large amount of air in the right pleural space and there is mediastinal shift to the left.

Teenager who is having emesis during feeding through the jejunostomy port of his gastrojejunostomy tube

AXR of gastrojejunostomy tube malfunction due to migration of the tip of the jejunostomy tube back into the stomach
AXR taken after injection through the jejunostomy port of a newly placed gastrojejunostomy tube one month ago (above) shows the tip of the jejunostomy tube to be in the proximal jejunum. AXR taken today (below) shows that the tip of the jejunostomy tube has been pulled back into the antrum of the stomach.

The diagnosis was gastrojejunostomy tube malfunction due to migration of the tip of the jejunostomy tube back into the stomach.

Preschooler having difficulty with gastrojejunostomy feedings

AXR of gastrojejunostomy tube that has been pulled back into stomach
AP image obtained immediately after placement of a gastrojejunostomy tube and contrast injection through it (above) shows the tip of the gastrojejunostomy tube to be in good position in the proximal jejunum. AXR AP obtained 1 month later (below) shows the tip of the gastrojejunostomy tube to be in the stomach. A ventriculoperitoneal shunt is also present.

The diagnosis was gastrojejunostomy malfunction with pulling back of the jejunostomy tube tip out of the jejunum and into the stomach.

Toddler with new abdominal pain who also has had a long standing cough

Small bowel follow through of gastrointestinal tuberculosis of the terminal ileum
AP image from late in a small bowel follow through exam shows contrast exiting the small bowel and beginning to fill the cecum and ascending colon. The terminal ileum in the right lower quadrant is narrowed with only a thin string of contrast within it. The cecal pole is also somewhat narrowed in appearance.

The diagnosis was gastrointestinal tuberculosis involving the terminal ileum.

Infant having difficulties with tube feedings

AXR of feeding tube tip in stomach
AXR AP (above) shows a feeding tube that crosses to the right of the spine and then heads inferiorly before turning back to the left of the spine with its tip projecting in the left upper quadrant and this is also demonstrated on the pre-tube injection scout image (below left). Injection of contrast through the tube (below right) showed the tip was in the stomach.

The diagnosis was feeding tube malfunction with pulling back of the feeding tube tip out of the duodenum and into the stomach.

Preschooler with intermittent abdominal distension and abdominal pain who has a past history of necrotizing enterocolitis

CT and enema of colonic stricture after necrotizing enterocolitis
AXR (above left) shows an extremely dilated structure in the mid abdomen filled with air and small radiopaque objects. Axial CT without contrast of the abdomen (above right) shows the dilated structure to be a loop of bowel containing stool and radiopaque foreign bodies. AP image from an enema (below left) shows a dilated ascending colon, an extremely dilated transverse colon, and normal caliber of the descending colon and sigmoid colon. Oblique views of the splenic flexure (not provided) showed a very tight stricture there.

The diagnosis was a very tight stricture at the splenic flexure due to previous necrotizing enterocolitis. The radiopaque objects were a mixture of plant seeds and shells from nuts and various other ingested foreign bodies (below right) that could not make it past the stricture.

Newborn with failure to pass meconium and bilious vomiting

Enema of meconium plug syndrome
AP image from a contrast enema exam (left) shows a long filling defect in the colon within a normal caliber colon. The cecum was noted to be in the left mid abdomen. The terminal ileum was not refluxed. AP image from an upper GI exam (right) shows that while the duodenal jejunal junction projects over the left pedicle of the spine it is much lower in position than the duodenal bulb.

The diagnosis was malrotation without midgut volvulus in a patient with meconium plug syndrome.

Toddler with 4 days of abdominal pain and feculent vomiting

US and radiograph and air enema of ileocolic intussusception caused by Meckel diverticulum
Transverse US of the right lower quadrant (above) shows a round structure with a hyperechoic center and a hypoechoic rim (target sign). AXR supine (below left) shows multiple dilated loops of air-filled small bowel. Final AP image from an air enema exam (below right) shows an air filled colon with a large oval soft tissue mass in the cecum.

The diagnosis was an ileocolic intussusception resulting in a distal small bowel obstruction. The ileocolic intussusception could not reduced by air enema and at surgery the lead point for the ileocolic intussusception was found to be a Meckel diverticulum.

School ager with abdominal pain

CT and US of target sign and pseudokidney sign in ileocolic intussusception
Axial CT with contrast of the abdomen (above left) shows a mass involving the ascending colon which has a target sign appearance which on sagittal CT (above right) has a pseudokidney appearance. Transverse US of the ascending colon mass (below left) again demonstrates a target sign while the sagittal US of the mass (below right) again demonstrates a pseudokidney sign.

The diagnosis was ileocolic intussusception due to lymphoid hyperplasia with the lead point of the intussusception being mesenteric lymph nodes.

School ager with abdominal pain who just had a cardiac arrest

CT of Meckel diverticulum causing distal small obstruction due to small bowel volvulus around the Meckel diverticulum resulting in a closed loop obstruction and small bowel ischemia of the ileum and pneumatosis intestinalis from necrosis in the ileum
AXR AP (above left) shows multiple dilated loops of small bowel and a decomopressed colon. Coronal CT with contrast of the abdomen (above right) shows normal caliber and normal enhancement of the proximal jejunum loops in the left upper quadrant. The distal ileum loops in the right lower quadrant are dilated and do not enhance. There is pneumatosis intestinalis in the walls of the most lateral loop of ileum. Axial CT (below) again shows the pneumatosis in the walls of the most lateral loop of ileum on the right and again shows the difference in bowel wall enhancement between the normal jejunum on the left and the abnormal ileum on the right.

The diagnosis was Meckel diverticulum causing distal small obstruction due to small bowel volvulus around the Meckel diverticulum resulting in a closed loop obstruction and small bowel ischemia of the ileum and pneumatosis intestinalis from necrosis in the ileum.

Preschooler with recurrent abdominal pain

CT and US of recurrent ileocolic intussusception caused by juvenile polyps
Axial CT with contrast of the abdomen (above) at initial presentation shows a large round soft tissue mass in the region of the ascending colon that has alternating circles of soft tissue density and fat density which give it a target sign appearance. Transverse US of the abdomen obtained two weeks later (below) shows recurrence of a nearly identical appearing soft tissue mass in the region of the ascending colon that has alternating circles of decreased and increased echogenicity giving it a target sign appearance.

The diagnosis was initially ileocolic intussusception which had been reduced successfully but had recurred two weeks later and which again was reduced successfully. Surgical exploration subsequently revealed multiple juvenile polyps acting as the lead point for the recurrent ileocolic intussusception.