Abd ped

Normal plain abdominal film of a newborn

After birth

shows gas in the stomach 10-15 minutes
gas in the proximal small bowel 30-60 minutes
gas in the distal small bowel within 6 hours
and gas in the colon and rectum within 24 hours

. Air in the dilated proximal esophagus (arrows)
S = stomach


Aspiration pneumonia in right upper lobe and left lower lobe
Note an NG tube in the dilated proximal esophagus
Esophageal Atresia and
Tracheoesophageal Fistula
When esophageal atresia is suspected in a child, the child should be
intubated using an NG tube and a chest film should be taken.
Abnormalities that may be seen are:
1. Air in a dilated esophagus proximal to the esophageal
atresia
2. The NG tube in the proximal esophagus It cannot be
passed into the stomach.
3. No air in the rest of the gastrointestinal tract, if the patient
has esophageal atresia without a tracheoesophageal fistula.
If a patient does have esophageal atresia with a
tracheoesophageal fistula, there will be more air in the rest of the
gastrointestinal tract than there is in normal children.
4. If the patient has aspiration pneumonia, there will be
pulmonary infiltration
Hypertrophic Pyloric Stenosis
The abnormalities seen in images in this
condition are
1. In a plain film, dilated stomach and less
gas in the rest of the gastrointestinal tract than
normal.
2. In ultrasonography, thickening of the
pylorus muscle.
3. In an upper GI series, string sign,
shoulder sign, beak sign, double tract sign, etc.

Duodenal atresia
The abnormalities seen in a plain
abdomen film of patients with this
condition are dilated stomach and dilated
duodenal bulb with no gas in the rest of
the gastrointestinal tract (double bubble
sign)

Jejunal atresia
The abnormalities seen in a plain
abdomen film of patients with this
condition are dilated stomach, dilated
duodenal bulb, and dilated proximal
jejunum with no gas in the rest of the
gastrointestinal tract (triple bubble sign).

Hirschsprung disease = megacolon kongenital
The abnormalities seen in images of patients with this disease are:
1. In a plain abdomen film (Figure 1),
- dilated small bowel and large bowel proximal to the aganglionic
segment.
- feces in dilated large bowel sometimes.
- no air or feces in the rectum.
. 2. Barium enema
- transition zone (Figure 2).
. - hyperspasticity of the aganglionic segment (Figure 3).
. - a rectosigmoid ratio less than 1.
. - the mucosal folds of the large bowel above the aganglionic segment
sometimes similar to mucosal folds of the jejunum (jejunization) (Figure 4).
. - delayed barium evacuation.


Figure 1. Dilated small bowel and large bowel without air/feces in the rectum


Figure 2. Transition zone (arrows)


Figure 3. Hyperspasticity of the rectum (arrow), transition zone, and
a rectosigmoid ratio less than 1. S = sigmoid, R = rectum



Figure 4. Jejunization (arrow)

Necrotizing Enterocolitis
The abnormalities seen in a plain abdomen film of patients
with this condition are:
1. Dilatation of bowel loops, particularly in the right lower
abdomen.
2. Thickening of the bowel wall.
3. Pneumatosis intestinalis
If there is gas in the subserosal layer, there will be linear
or curvilinear radiolucency in the bowel wall (Figure 1).
If there is gas in the submucosal layer, there will be
bubbly or cystic radiolucency in the bowel wall (Figure 2).
4. Gas in the portal vein (Figure 3).
5. Pneumoperitoneum when there is perforation of the
bowel (Figure 4).



Figure 1. Gas in the subserosal layer (arrows)


Figure 2. Gas in the submucosal layer (red arrows)
Note thickening of the bowel walls (blue arrows)


Figure 3. Gas in the portal vein, dilatation of bowel loops,
and Thickening of the bowel walls.


Figure 4. Pneumoperitoneum. Note falciform ligament (arrow)
and air in the left scrotal sac(S).

Diaphragmatic hernia
The abnormalities seen in a chest film and a plain
abdomen film of patients with a large diaphragmatic hernia
are:
1. Shift of the heart and mediastinum to
the opposite side.
2. Bowel loops in the hemithorax
3. Fewer bowel loops in the abdomen
than normal.
.



Intussusception

1. In a plain abdomen film:
- a soft tissue mass (Figure 1)
- dilated bowel loops or small bowel
obstruction (Figures 2 and 3)
- pneumoperitoneum in a patient with
Intussusception and bowel perforation.
Both supine and the upright or the left lateral
decubitus films should be taken in every patient
with suspected intussusception
2. In ultrasonography:
- On a longitudinal scan of the intussusception - a "pseudokidney"
sign (Figure 4) will be seen.
. - On a transverse scan of the intussusception - a "target" sign
(Figure 5) or "donut" sign will be seen.

3. Barium enema:
- Contraindications
1. peritonitis
2. pneumoperitoneum when seen in a plain abdomen film.
- A barium enema helps in diagnosis and treatment (reduction of
the intussusception) in these patients.

- The abnormalities seen in a barium enema (Figure 6) are:
1. obstruction of the barium at the site of intussusception
2. a cup-shaped filling defect at the site of obstruction
3. coiled spring appearance

Figure 1. Soft tissue mass (arrows)



Figure 3. Small bowel
obstruction and a soft tissue
mass (M)

Figure 4. Pseudokidney sign (arrows), RK = right kidney

Figure 5. Target sign (arrows)




Figure 6. A cup-shaped
filling defect (arrow) and
coiled spring appearance





Imaging of Children with Abdominal Masses
Types of imaging:
1. Plain abdomen film: In most cases we see only a soft tissue mass
where the mass palpated on physical examination is, and displacement of
bowel loops by the mass. However in some patients a plain abdomen film
may show more information such as fat or calcifications in patients with
teratomas, coarse calcifications in patients with hepatoblastomas, and
stippled calcifications in patients with neuroblastomas.
2. Ultrasonography: This can tell us whether the mass is solid or
cystic, and where the mass originated. However the complete mass may
not be seen because bowel gas may obscure some portion of it.
3. Computed Tomography: This can show how far the mass has
extended. However some tumors that often extend into the spinal canal
such as neuroblastomas may not be seen.
4. Magnetic Resonance Imaging: This is more expensive than
computed tomography and it takes longer time. It shows the extension of
the tumor completely, including extension into the spinal canal. It also
shows metastases to bone marrow.
5. Barium study: This is helpful in patients where it is suspected that
the mass originated in the gastrointestinal tact.