Infant with difficulty stooling

Enema in Hirschsprung disease — Lateral image from an enema shows that the rectum is narrower in diameter than the sigmoid colon. The recto-sigmoid ratio is < 1, thus there is recto-sigmoid inversion. The sigmoid colon is packed with stool.

The diagnosis was Hirschsprung disease.

Teenager with epigastric pain and lower abdominal pain

UGI of duodenal ulcer in Chron disease — AP spot image of the duodenum from an UGI exam shows a target sign with barium pooling centrally in a large ulceration surrounded by an edematous ring in the distal aspect of the duodenal bulb. There was also extensive inflammation of the terminal ileum shown later on the small bowel followthrough exam.

The diagnosis was a duodenal ulcer due to Crohn disease.

Newborn with a cystic right upper quadrant mass on prenatal US

US, HIDA scan, cholangiogram of choledochal cyst — Transverse (above left) and sagittal (below left) US of the liver shows an oval shaped cystic mass in the porta hepatis that is separate from the normal gallbladder. Anterior image of a HIDA scan obtained 40 minutes after radiotracer injection (above right) shows radiotracer localization in the liver, in a large oval mass medial to the liver, in the gallbladder which overlies the inferior and lateral border of the liver, and in the bowel. AP image from an intraoperative cholangiogram (below right) shows contrast being injected into the gallbladder which is flowing down the cystic duct and then filling an oval mass superior to the gallbladder. The contrast filled mass contains an air bubble and is partially obscured by a surgical retractor overlying it.

The diagnosis was choledochal cyst.

School ager after motor vehicle accident with abdominal pain

CT of hemoperitoneum due to splenic trauma — Axial CT with contrast of the abdomen shows the bladder in the center of the image partially filled with contrast and surrounded by a large amount of free fluid throughout the pelvis.

The diagnosis was splenic trauma with an extensive amount of hemoperitoneum.

School ager post appendectomy 3 months ago, now with abdominal pain and vomiting

AXR and upper GI and small bowel followthrough of small bowel obstruction due to adhesions — AXR supine (left) shows multiple dilated loops of small bowel and a paucity of gas in the colon. Image from an upper GI and small bowel follow through exam the next day (right) shows interval increasing dilation of the loops of small bowel. Contrast never reached the colon.

The diagnosis was distal small bowel obstruction due to adhesions.

Infant with bilious vomiting

Upper GI of normal position of ligament of Treitz — AP image from an upper GI exam shows a dilated air and contrast filled stomach and duodenum. The duodenal-jejunal junction is normally positioned at the level of the duodenal bulb and to the left of the spine at L1.

The diagnosis was normal bowel rotation.

Newborn with polyhydramnios on prenatal US and bilious vomiting

AXR and upper GI of jejunal web — AXR supine (above left) shows dilation of the stomach and duodenum and a loop of proximal jejunum with a decompressed small bowel gas pattern distally. This is more clearly shown on the upper GI exam (above right). AXR left lateral decubitus (below) shows a triple bubble sign with a dilated duodenum in the middle of the image with a dilated stomach proximal to it and a dilated jejunum distal to it.

The diagnosis was jejunal web.

Infant with 3 days of hematochezia and vomiting

AXR and air enema of intussusception — AXR supine (left) shows a round soft tissue mass in the mid transverse colon. AP image of an air enema (right) shows the round soft tissue mass to have been reduced to the level of the ileocecal valve, however it could not be reduced further.

The diagnosis was ileocolic intusssusception.

Newborn with vomiting

AXR of jejunal atresia — AXR supine (left) shows a dilated stomach in the left upper quadrant and a dilated duodenum in the right upper quadrant and a dilated loop of proximal jejunum inferiorly (triple bubble sign). There is no gas distally. AXR upright (right) shows air fluid levels in the stomach and duodenum and in the dilated loop of proximal jejunum.

The diagnosis was jejunal atresia.

Teenager with abdominal pain

AXR of appendicoliths — AXR supine shows two round radiopaque objects projecting over the right side of the middle and lower sacrum.

The diagnosis was appendicoliths in a patient with acute appendicitis.

Preschooler who fell out of a second story window and has right upper quadrant pain

CT of liver laceration — Axial CT with contrast of the abdomen shows two low density poorly circumscribed lesions in the right lobe of the liver.

The diagnosis was liver laceration.

Newborn with an anterior abdominal wall defect on prenatal US

CXR of omphalocele — CXR AP shows a large round sac-like object projecting over and beyond (and therefore outside of) the right side of the abdomen which contains multiple loops of bowel. The stomach is in the left upper quadrant of the abdomen.

The diagnosis was omphalocele.

Newborn with bilious vomiting

UGI of malrotation with intermittent midgut volvulus — AP image (above left) obtained early during an upper GI exam shows the duodenal bulb positioned over the spine and the second part of the duodenum to project to the left of the spine and to terminate in a beak with no contrast passing beyond this point. Lateral image (above right) confirms the complete duodenal obstruction. AP image (below) obtained 5 minutes later now shows the obstruction / midgut volvulus to be resolved as the ligament of Treitz is now positioned below the duodenal bulb and to the right of the spine. The proximal jejunum is on the right side of the abdomen.

The diagnosis was malrotation with midgut volvulus which was intermittent in nature. In the operating room, 360 degrees of midgut volvulus was present.

Toddler with crampy abdominal pain

Air enema of intussusception reduction — AXR (left) shows a paucity of air in the ascending colon. AP image from an air enema (above right) shows a soft tissue mass which was encountered at the hepatic flexure. Magnified view of the mass (below right) shows it to have a coiled-spring appearance.

The diagnosis was ileocolic intussusception which was successfully reduced on the fourth attempt.

Newborn who is vomiting with feeds

Enema of ileal atresia — AXR (left) shows multiple loops of dilated bowel suggesting a distal bowel obstruction. AP image from an enema (right) shows the colon to be small in caliber (a microcolon). Despite multiple attempts, the terminal ileum could not be refluxed with contrast.

The diagnosis was ileal atresia.

Newborn with a palpable abdominal mass

US of duodenal duplication cyst — AXR AP (above left) and AXR left lateral decubitus (below left) show a midline abdominal mass displacing the bowel inferiorly and to the left side of the abdomen. Transverse (above right) and sagittal (below right) US of the abdomen show a complex cystic mass in a subhepatic location. There was no suggestion of a hyperechoic inner layer of the cystic mass.

The diagnosis was duodenal duplication.

School ager with acute lymphoblastic leukemia and abdominal pain

CT of typhlitis — Axial CT with IV and oral contrast of the abdomen shows marked thickening of the wall of the cecum. The remainder of the colon was unremarkable.

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

School ager after motor vehicle accident

CT of liver laceration — Axial CT with contrast of the abdomen shows a low density triangular shaped lesion in the middle of the liver.

The diagnosis was liver laceration.

Premature newborn with past history of necrotizing colitis who is having difficulty stooling

Enema of post necrotizing enterocolitis stricture of the colon — AP image from an enema (left) shows a transition zone in the lower right of the image from a narrow sigmoid colon to a more dilated descending colon above it. Spot image from the enema (right) shows the narrowed colonic lumen filled with contrast connecting those two parts of the colon.

The diagnosis was a stricture of the descending colon after necrotizing enterocolitis.

Infant with projectile vomiting

Color US of Whirlpool sign of malrotation with midgut volvulus — Transverse color US of the upper abdomen in the midline (above) shows the mesenteric vessels swirling around themselves (Whirlpool sign). The superior mesenteric vein was above the superior mesenteric artery. Upper GI exam (below) shows the duodenal jejunal junction to be to the left of the spine but to be lower in position than the duodenal bulb and the proximal jejunum appears to spiral downwards away from it.

The diagnosis was malrotation with midgut volvulus.

Infant with 2 days of abdominal pain, vomiting, and currant jelly stools

AXR of small bowel obstruction due to ileocolic intussusception — AXR supine (above left) shows multiple dilated loops of small bowel and AXR upright (above right) shows multiple air-fluid levels. There is no air in the colon. AP image from an air enema (below) shows a soft tissue mass outlined by air in the hepatic flexure which was then easily reduced to the ileocecal valve on the first attempt but could not be reduced further on subsequent attempts. In the operating room the terminal ileum and cecum were found to be necrotic and were resected.

The diagnosis was small bowel obstruction caused by ileocolic intussusception.

Infant with projectile vomiting

AXR and US of hypertrophic pyloric stenosis — AXR AP (left) shows a hugely distended air-filled stomach with distal bowel gas. Sagittal US of a posteriorly positioned pylorus (right) shows the pyloric channel to be lengthened (25 mm) and the pyloric muscle to be thickened (4 mm). The anechoic gallbladder is positioned anteriorly to the pylorus.

The diagnosis was hypertrophic pyloric stenosis.

Teenager with fever of unknown origin

Small bowel follow through exam of Crohn disease of the terminal ileum — AXR from a small bowel follow through exam (left) shows diffuse narrowing of the terminal ileum and separation of the loops of terminal ileum due to mesenteric fat infiltration. Spot image of the terminal ileum (right) shows a nodular and cobblestone appearance to the narrowed loops of the terminal ileum.

The diagnosis was Crohn disease.

Newborn with absent anus and stool coming out of the vagina

US of low anorectal malformation — CXR AP (left) shows a hemivertebra at L1 causing spinal curvature convex left. Transverse US of the pelvis (above right) shows in the midline anteriorly an anechoic fluid-filled bladder with a round echogenic stool-filled rectum posterior to it while a transverse US of the perineum (below right) shows a very short distance between the calipers superiorly on the skin and inferiorly on the anterior wall of the rectum.

The diagnosis was low anorectal malformation and congenital scoliosis.

Infant with decreased stool output and fever

Enema of Hirshsprung enterocolitis — AXR AP (above) shows an obstructive bowel gas pattern with multiple dilated loops of small bowel. AP image from an enema (below left) shows the contour of the entire colon to have an irregular, serrated appearance. The terminal ileum was refluxed. Lateral image from the enema (below right) shows the diameter of the rectum to be less than the diameter of the sigmoid colon (recto-sigmoid inversion).

The diagnosis was Hirschsprung disease with concomitant Hirschsprung enterocolitis.