Pediatric Ascites

  • Etiology:
    — Simple ascites due to hydrops fetalis, liver failure
    — Complicated ascites due to bowel perforation, biliary tree laceration, lymphatic system laceration, intraperitoneal hemorrhage, infection, urinary tract obstruction and perforation
  • Imaging AXR: Centralization of bowel loops
  • Imaging US: Simple ascites is clear, complicated ascites is echogenic and may have septations
  • DDX: Abscess
  • Complications:
    — Can become septated or infected
    — Spontaneous bacterial peritonitis occurs in patients with underlying ascites
    — If large can cause respiratory distress
  • Treatment:
  • Clinical:

Radiology Cases of Ascites

Radiology Cases of Serous Ascites

CXR of Pentalogy of Cantrell
CXR and AXR shows the cardiac margin to be absent below the level of the diaphragm. The left lung is hyperlucent compared to the right. There is a paucity of bowel gas within the abdomen and centralization of bowel loops

Radiology Cases of Chylous Ascites

AXR of chylous ascites in child abuse
CXR AP (left) shows the lungs to be poorly expanded and clear but there are dense areas of callus along the lateral aspect of the right 3rd-5th ribs. Centralization of the loops of bowel were also incidentally noted and confirmed on a subsequent AXR AP (right).

Radiology Cases of Urine Ascites Due to Posterior Urethral Valves

VCUG of urine ascities
AXR scout image (left) shows centralization of mildly distended bowel loops. AP image obtained at the end of a voiding cystourethrogram (right) shows left Grade V vesicoureteral reflux. The overall density of the abdomen is increased in the interval due to contrast extravasation out of the renal collecting system and extravasated contrast is outlining loops of bowel and can be seen tracking up the right lateral aspect of the abdomen.

Radiology Cases of Urine Ascites Due to Urethral Atresia

US of urethral atresia resulting in cystic renal dysplasia, urine ascites and oligohydramnios
Sagittal US of the left kidney (above left) shows it to be small, echogenic, and to contain multiple cysts. Sagittal US of the right kidney (above right) shows it to have a similiar appearance. There is also a large amount of anechoic fluid around the right kidney which represents urine ascites. Transverse US of the bladder (below left) shows it to be thick walled. CXR AP (below right) shows a small bell-shaped chest with bilateral chest tubes present that were treating the bilateral pneumothoraces that were present at birth.

Radiology Cases of Urine Ascites Due to Intraperitoneal Bladder Rupture

VCUG of intraperitoneal bladder rupture
Lateral image from a voiding cystourethrogram during bladder filling (left) shows extravasation of contrast out of the base of the bladder into the peritoneum. AXR AP obtained after the exam (right) shows intraperitoneal contrast outlining the liver, spleen, and centralized loops of bowel.

Radiology Cases of Complicated Ascites Due to Bowel Perforation

AXR and US of spontaneous intestinal perforation with dirty ascites
AXR AP (above left) shows a nasogastric tube projecting over the left upper quadrant of the abdomen. There is a collection of air in the mid-abdomen that does not appear to conform to being within bowel. There is no portal venous gas or pneumatosis intestinalis. Transverse US of the abdomen (above right) shows echogenic ascites in the abdomen surrounding the loops of bowel. AXR left lateral decubitus (below) shows a large amount of air between the abdominal wall and the liver. Subsequent placement of a surgical drain returned stool.

Radiology Cases of Umbilical Venous Catheter Perforation of Vessel With Formation of TPNoma and TPN Ascites

CXR of umbilical venous catheter perforation causing TPNoma in liver and TPN ascites
AXR AP (above left) after line placement shows the tip of the umbilical venous catheter to be inferior to the cavo-atrial junction. The bowel gas pattern is normal. There is a moderate right pleural effusion. AXR AP obtained 1 day later (above right) shows developing mild centralization of the bowel loops and increase in the size of the right pleural effusion. The tip of the umbilical venous catheter now projects over the umbilical vein. AXR AP obtained 1 day later (below left) shows marked centralization of bowel loops. Sagittal US of the right side of the abdomen (below right) shows a large right pleural effusion (left side of image), a large amount of ascites (right side of image anteriorly) and a cystic lesion within the liver (right side of image posteriorly).