interpretation of the pediatric abdominal radiograph - pedrad
TRANSCRIPT
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Interpretation of the Pediatric
Abdominal Radiograph – a basic
skill or a “lost art”?
Richard I. Markowitz, MD, FACR
Children’s Hospital of Philadelphia
Perelman School of Medicine
University of Pennsylvania
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Agenda
• Why do we do abdominal radiography?
• When is it most useful?
• What can we see?
• What does it mean?
• Which views are necessary?
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Why do we still perform abdominal
radiography?
• Advantages
– Inexpensive
– Ubiquitous
– Portable
– Overview
– Relatively low radiation (with appropriate
equipment and technique)
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Why do we still perform abdominal
radiography?
• Disadvantages
– Often non-specific or insensitive
– Wide range of variability
– Harder to interpret
– Limited tissue differentiation
– More radiation exposure than US or
MRI
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Common Clinical Indications
• Distention +
• Vomiting +
• Ingestion of foreign body +++
• Possibility of intestinal obstruction +++
• Possibility of bowel perforation ++
• Placement of lines or tubes +++
• Organomegaly?? +/-
• Mass???
• Bleeding???
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Approach to Radiographic Interpretation
• Be organized and methodical
• Look at lungs, bones, body habitus first
• ? Organomegaly, mass, large bladder
• Tubes and lines
• Calcification, contrast, or foreign material
• Bowel gas
– Dilatation
– Distribution
– Wall pattern
• Free air
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Does patient age matter?
What changes with age?
Age Organ/ Gas Disease
Body Size Pattern
__________________________________________________
• Neonate
• Infant
• Child
• Adolescent
based on Loomis, A
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Which one is abnormal?
Infant Child Young teen
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Full term newborns – lines and leads
Endotracheal tube
Umbilical venous Umbilical artery
External
temperature
lead
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What is wrong here?
Giant omphalocele
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Gastroschisis
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Neonate with abdominal distention
Ascites
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Newborn with bilious emesis and failure to
pass meconium
Ileal atresia
Water soluble contrast enema
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6 y.o. male with abdominal pain and vomiting
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CT
Abrupt transition mid small bowel
Small bowel obstruction related to
Persistent omphalomesenteric duct remnant
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Premature newborn with abdominal distension and
bloody stools
24 hours later
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Left side down decubitus views
Necrotizing enterocolitis
with bowel perforation
(free air)
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Premature newborn with distended abdomen
Free intraperitoneal air secondary to bowel perforation
(necrotizing enterocolitis)
Cross-table
lateral
Left side down
decubitus
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Continuous diaphragm sign
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Recent placement of gastrostomy tube
Free intraperitoneal air secondary to
leakage from gastrostomy tube site
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Pseudo pneumoperitoneum
6 month old female on
chronic high dose steroids
Increased retroperitoneal
fat deposition outlining
organs
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Two infants with necrotizing enterocolitis
courtesy M. Epelman, MD
Pneumotosis intestinalis Portal venous air
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Premature infant; NEC
Small bowel obstruction
secondary to necrotizing
enterocolitis
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Infant with abdominal distension
Gastro-enteritis
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18 y.o. female with Rett’s syndrome and
abdominal distension
“coffee bean“ sign of sigmoid volvulus
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Newborn with heart problem
Heterotaxy syndrome
asplenia/polysplenia
abnormal situs
discordant aortic arch, cardiac apex, stomach
transverse liver
“interrupted “ IVC with azygous continuation
congenital heart disease
malrotation
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Newborn with distended abdomen
Meconium peritonitis
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Are these “calcifications”?
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“Wet diaper” artifact
Water absorbed by sodium polyacrylate
granules in disposable diapers
Small “water balloons” surrounded by air
Seen only when diaper is wet
Not a problem on CT or MRI (cross sectional)
Can obscure findings on radiograph
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6 month old female with irritability
Neuroblastoma
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2 year old male with abdominal pain and “constipation”
Ileocolic intussusception
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1 month old with bilious vomiting
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Malrotation with midgut volvulus
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11 year old male with abdominal pain
Appendicolith
Retrocecal appendicitis
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6 year old male with abdominal pain
Right lower quadrant Color Doppler US
Acute appendicitis - uncomplicated
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14 year old male with abdominal pain and vomiting
Ruptured appendicitis
Abscess
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Sitz Mark test for constipation
(colonic transit time)
Capsule with 24 rings is ingested
Abdominal radiograph obtained
3 - 5 days later
Normal: No markers present after 5 days
What is this?
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15 y.o. female swallowed something
AAA battery in stomach
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Swallowed coin - where is it?
Erect radiograph
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Swallowed screw 2 days ago
Where is it now?
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18 month old with unexpected finding…
One martini too many?
courtesy M. Moore
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Chronically ill 12 year old
Splenomegaly secondary to
Chronic portal hypertension
Chronic liver failure
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4 year old male with fever, abdominal pain
and elevated white blood cell count
Findings?
Diagnosis?
Next step?
Right lower quadrant ultrasound
Normal appendix
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Let’s go back and look again…
Left lower lobe pneumonia
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Summary • Interpretation of the pediatric abdominal radiograph can be
difficult.
• Wide range of normal which changes with patient age.
• Worthwhile for many indications, but not always specific or
sensitive enough.
• Good start in many situations, but not needed to diagnose
pyloric stenosis, intussusception, midgut volvulus, etc.
• Use orderly approach - don’t forget the lungs or the bones.
• When in doubt – work it out!