School ager with nausea and vomiting

CT of small bowel obstruction due to Meckel's diverticulum — AXR supine (upper left) and coronal CT with contrast of the abdomen (lower left) show multiple dilated loops of small bowel with thin walls throughout the abdomen. The lower axial CT (upper right) shows a small cystic structure in the midline with a thicker wall than the surrounding dilated bowel which is also seen on the midline sagittal CT (lower right) just beneath the umbilicus.

The diagnosis was distal small bowel obstruction due to Meckel diverticulum.

Former premature newborn who is now several months old who is vomiting

AXR of small bowel obstruction due to inguinal hernia — AXR supine shows massively dilated loops of bowel filling the abdomen with a loop of bowel noted in each of the scrotal sacs.

The diagnosis was distal small bowel obstruction due to bilateral inguinal hernias.

Infant with abdominal pain and currant jelly stools and peritonitis

AXR of small bowel obstruction due to intussusception — AXR supine (left) shows decompressed loops of bowel (presumed jejunum) in the left upper quadrant and multiple dilated loops of bowel (presumed ileum) in the right lower quadrant. AXR upright (right) shows multiple air-fluid levels.

The diagnosis was distal small bowel obstruction with the patient going directly to the operating room due to the peritonitis where an ileocolic intussusception was encountered and reduced.

Infant who had congenital diaphragmatic hernia repair months ago, now with vomiting

SBFT of small bowel obstruction due to abdominal adhesions — AXR supine (left) shows several dilated loops of bowel in the left upper quadrant. Upper GI and small bowel follow through delayed image (right) shows contrast filling several dilated loops of jejunum with no contrast passing distally into the colon.

The diagnosis was proximal small bowel obstruction. In the operating room, the obstruction was found to be due to abdominal adhesions in the proximal jejunum.

Preschooler with abdominal pain, diarrhea, emesis

AXR of small bowel obstruction due to perforated appendicitis — AXR supine (left) shows multiple dilated loops of small bowel that have air fluid levels on the AXR upright (right). There is also a suggestion of a soft tissue mass in the right lower quadrant which is displacing the bowel loops medially.

The diagnosis was distal small bowel obstruction due to perforated appendicitis.

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View the illustrated DDX of small bowel obstruction

Teenager with paraplegia who uses an appendicovesicostomy for self-catheterization who now has abdominal distension and no stool for one week

Surgical image of cecal volvulus — Surgical image shows an extremely distended cecum twisted around the pateint’s appendicovesicostomy tract. The distal ileum was also extremely dilated.

The diagnosis was cecal volvulus.

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Toddler with long-standing vomiting after eating

Upper GI of aspiration due to gastroesophageal reflux — Upper GI exam shows a markedly distended stomach with marked gastroesophageal reflux rising to the level of the oropharynx and entering into the trachea clearly outlining the trachea to the right of the esophagus on the AP image (left) and anterior to the esophagus on the lateral image (right).

The diagnosis was aspiration secondary to gastroesophageal reflux due to gastric outlet obstruction.

Preschooler with long-standing vomiting after eating

AXR of gastroparesis — AXR upright shows an extremely distended stomach with an air-fluid level within it that is displacing the transverse colon inferiorly.

The diagnosis was gastroparesis.

Teenager with long hair and long-standing early satiety when eating

AXR and Upper GI of trichobezoar — AXR AP (left) shows radio-opaque material filling and distending the midline stomach which is displacing the transverse colon inferiorly. AP image from an upper GI exam (right) shows a thin coat of barium outlining a large cast of material within the distended stomach. Endoscopy showed the stomach to be full of hair.

The diagnosis was trichobezoar.

School ager with protein calorie malnutrition who has just rapidly eaten the equivalent of 3 large meals

AXR of gastric distension — AXR AP taken immediately after ingesting 3 large meals shows an extremely distended stomach along with a moderate amount of stool throughout the colon. An AXR obtained the next day showed the stomach to be completely empty, thus ruling out gastric motility problems.

The diagnosis was acute gastric distension from overeating, mimicing a bezoar or gastroparesis.

Infant with vomiting in a patient with ductal-dependent congenital heart disease

Upper GI and US of Prostaglandin E induced gastritis — AP image from an upper GI exam (above) shows persistent narrowing of the pyloric channel. Transverse US of the pylorus (below) shows marked thickening of the central hyperechoic pyloric mucosa and a normal thin appearance of the peripheral hypoechoic pyloric muscle which measures 1.2 mm thick.

The diagnosis was prostaglandin E induced gastritis.

Infant with vomiting

Upper GI and US of hypertrophic pyloric stenosis — Lateral images from an upper GI exam (above) show delayed passage of barium out of the stomach due to a thickened and elongated pylorus. A tram track sign of barium in the pyloric channel was seen (upper left) along with pyloric muscle shouldering on the antrum along with a pyloric beak (upper right). Sagittal (lower left) and transverse (lower right) US of the pylorus shows marked thickening of the peripheral hypoechoic pyloric muscle which measures 4.5 mm thick, as compared to the thin central hyperechoic pyloric mucosa. Elongation of the pyloric channel was also noted, measuring 25 mm in length.

The diagnosis was hypertrophic pyloric stenosis.

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View the illustrated DDX of gastric outlet obstruction

Newborn with an abnormal fetal echo

CT of interrupted aortic arch — Axial CT with contrast of the heart (above), obtained in a venous phase, shows discontinuity of the ascending and descending aorta while the sagittal image (below right) shows a dilated patent ductus arteriosus reconstituting the descending aorta and the coronal image (below left) shows dextrocardia.

The diagnosis was interrupted aortic arch supplied by a patent ductus arteriosus in a patient with dextrocardia.

School ager with bilateral scrotal pain and a skin rash

US of epididymitis secondary in Henoch-Schonlein Purpura — Transverse color doppler US of the scrotum shows enlargement and hypervascularity of the bilateral crescent shaped epididymides when compared to their respective round testicles, to which they are lateral in position.

The diagnosis was bilateral epididymitis in a patient with Henoch-Schonlein Purpura

School ager with abdominal pain who is now unresponsive

CT of pseudoaneurysm in Ehlers-Danlos Syndrome — Axial CT with contrast of the abdomen shows an intimal flap in the superior mesenteric artery and a large retroperitoneal hematoma.

The diagnosis was spontaneous dissection with a bleeding pseudoaneurysm of the superior mesenteric artery in a patient with Ehlers-Danlos syndrome.

Infant who had undergone emergency thoracotomy for cardiac massage during a cardiac arrest 6 months before and now has a lump under the left arm

CXR of pulmonary herniation — CXR AP in inspiration (above) shows the left 5th intercostal space at the side of the previous thoracotomy to be deformed. CXR AP in expiration (below) shows interval development of a cystic structure in the soft tissues of the left chest wall.

The diagnosis was pulmonary herniation through the left 5th intercostal space secondary to incorrectly repaired thoracotomy incision.

School ager with hypercoagulable state with respiratory distress

CXR, VQ scan, angiogram of pulmonary embolism / pulmonary embolus / PE — CXR AP (above) shows a large wedge shaped infiltrate in the right lower lobe and a right pleural effusion. Ventilation image from a V/Q scan (middle left) shows normal ventilation to both lungs. Perfusion image from a V/Q scan (middle right) shows essentially no perfusion to the right lung. PA image from a pulmonary angiogram shows a near complete lack of blood flow to the right lung.

The diagnosis was right pulmonary embolism.

School ager with hypoxia who has Eisenmenger syndrome due to a ventricular septal defect and a brain abscess

CXR and CT of septic emboli in the lungs / septic pulmonary emboli — CXR AP (above) shows prominence of the central pulmonary arteries and multiple round lesions of varying size throughout both lungs which on the axial CT with contrast of the chest (below) are shown to have indistinct margins.

The diagnosis was septic emboli in the lungs in a patient with Eisenmenger syndrome.

Infant with cough and decreased left ventricular ejection fraction

CXR and CT of anomalous left coronary artery from the pulmonary artery / ALCAPA — CXR AP (above) shows the left hemithorax is completely opacified with no mediastinal shift to the left and the pulmonary vascularity is congested. Axial CT with contrast of the chest (below) shows an extremely dilated left ventricle causing compression of the left mainstem bronchus and complete collapse of the left lung.

The diagnosis was anomalous left coronary artery from the pulmonary artery causing ischemic cardiomyopathy.

Young adult with recurrent pulmonary infections

Gross pathological image of bronchial atresia — Gross pathological image of a sectioned right middle lobe shows a dilated mucous filled airway (in white) distal to a focal area of an atretic bronchus.

The diagnosis was bronchial atresia.

Newborn with grunting

CXR of persistent pulmonary hypertension — CXR AP shows cardiomegaly and increased pulmonary blood flow.

The diagnosis was persistent pulmonary hypertension.

School ager with dyspnea

Angiogram of pulmonary ateriovenous malformation — CXR AP (upper left) shows an ill-defined mass in the right hilum. AP image from a selective injection of the right pulmonary artery from a pulmonary angiogram (upper right) shows a tangle of dilated arterial vessels comprising the mass. Arterial phase (lower left) and venous phase (lower right) AP images from a pulmonary angiogram demonstrate the early arterial appearance of the lesion and then its venous drainage back into the left atrium.

The diagnosis was pulmonary arteriovenous malformation.