Drs. Neha Ray and Bradley Harris are interested in education and Pediatric Emergency Medicine. Follow along with the EMGuideWire.com team and Drs. Nikki Richardson, Mary Grady, and Michael Gibbs as they post these educational, self-guided radiology slides on Pediatric Emergency Medicine Radiology. This month’s topics include: - Bowel Obstruction - Malrotation - Hogkin’s Lymphoma - Pericardial cyst - Pneumothorax

1. Pediatric X-Rays of the Month
Neha Ray, MD & Bradley Harris, MD
Department of Emergency Medicine and Department of Pediatrics
Carolinas Medical Center & Levine Children’s Hospital
Michael Gibbs, MD, Faculty Editor
Nicholena Richardson, MD & Mary Grady, MD, Junior Faculty Editors
Chest X-Ray Mastery Project
October 2021

2. Process and Disclosures
This ongoing pediatric chest x-ray
interpretation series is proudly sponsored
by the Emergency Medicine Residency
Program and Pediatric Emergency Medicine
Fellowship at Carolinas Medical Center.
The goal is to promote widespread mastery
of CXR interpretation.
Cases are submitted by contributors from
many CMC departments, and now…
Tanzania and Brazil.
Ages have been changed to protect patient
confidentiality. No protected health
information (PHI) will be shared.
For more educational content, visit
EMGuidewire.com

3. Reading systematically…
A for airway
B for bones
C for cardiac silhouette
D for diaphragm
E for everything else
For more educational content, visit
EMGuidewire.com

4. Normal CXR
for your
reference

5. CASE 1 (REVIEW):
The patient is an otherwise healthy
12-year-old female presenting with
fever, vomiting, and abdominal pain
for the past 6 days. Seen in multiple
EDs with negative workup and
followed up with the PCP who
obtained the imaging to the right.
What do you see?

6. CASE 1 (REVIEW):
The patient is an otherwise healthy
12-year-old female presenting with
fever, vomiting, and abdominal
pain for the past 6 days. Seen in
multiple EDs with negative workup
and followed up with the PCP who
obtained the imaging to the right.
Impression: Bowel obstruction.
You can see the lateral XR view has
multiple air-fluid levels (circle) and
the AP shows dilated bowel loops
(arrow).

7. An Approach:
Gasses- What is the bowel gas
pattern and is there air outside
of the bowel?
Masses- Check the
intrabdominal organs.
Bones- Are there fractures,
lesions, or malalignment?
Stones- Calcifications or foreign
bodies?
Leads and Lines- Check the
tubes, lines, and drains.
Let’s talk about the
abdomen!
Normal KUB

8. CASE 2: 2-month-old male born full-
term presenting after an episode of
vomiting followed by a brief period
of cyanosis and unresponsiveness.
An abdominal ultrasound is ordered.
What do you see?

9. CASE 2: 2-month-old male born full-
term presenting after an episode of
vomiting followed a brief period of
cyanosis and unresponsiveness.
Gasses- elongated, organizing loops of
small bowel. No clear air outside of
bowel.
Masses- none
Bones- intact
Stones- none
Leads and Lines-NG tube in stomach (*),
leads overlying patient
Impression: Nonspecific appearance of
small bowel. Ddx: enteritis, ileus,
early NEC, developing SBO
*

10. CASE 2: 2-month-old male born full-
term presenting after an episode of
vomiting followed a brief period of
cyanosis and unresponsiveness.
The patient develops bloody stools with
a rising lactate. He is admitted to the
PICU. A GI series is obtained.
What do you see?

11. CASE 2: 2-month-old male born full-
term presenting after an episode of
vomiting followed a brief period of
cyanosis and unresponsiveness.
- The duodenal-jejunal junction lies to
the right of the lumbar spine below
the level of the duodenal bulb
- Contrast promptly enters more distal
loops of small bowel which are
primarily to the right of the spine
Impression: Malrotation without
volvulus at the time of the study.

12. CASE 2: 2-month-old male born full-
term presenting after an episode of
vomiting followed by a brief period
of cyanosis and unresponsiveness.
The patient is taken to the OR for ex-lap
with Ladd procedure. Intestinal ischemia
is noted concerning for intermittent
volvulus, but patient had improved
perfusion over case and no bowel
resection was required. His lactate
cleared post-operatively, and he was
eventually discharged home.
Final Dx: Malrotation with intermittent
volvulus

13. Malrotation and Midgut Volvulus
- During normal fetal development, the midgut undergoes a 270-
degree counter-clockwise turn. In incomplete rotation, fibrotic bands
known as Ladd’s bands form between the duodenum and
retroperitoneum connecting the cecum to the lateral abdominal wall
- A volvulus can occur around the narrow base of the mesentery
obstructing the jejunum and the branches of the SMA supplying the
midgut. This leads to obstruction and bowel gut ischemia
- Midgut volvulus usually presents with bilious vomiting and
abdominal distention and tenderness. You can also see
hematochezia with bowel ischemia.
- Plain films usually show paucity of gas and scattered air-fluid levels.
An upper GI series will demonstrate the duodenal-jejunal junction to
the right of the vertebral body.
- Treatment is surgical with a Ladd’s procedure. The Ladd’s bands are
lysed, opening the mesenteric pedicle to prevent recurrent volvulus.
Note: This does not restore normal anatomy!
- In the ED, all bilious emesis in a neonate is malrotation until proven
otherwise!
Image: Amboss
https://www.amboss.com/us/knowledge/Volvulus_and_intes
tinal_malrotation/
Source: Coste AH, Anand S, Nada H, et al. Midgut Volvulus. [Updated 2021 May 14]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK441962/

14. CASE 3: A 2-year-old male with
history of trisomy 21 and G-tube
dependence presents with vomiting
and diarrhea, for 2 days.
What do you see?

15. CASE 3: A 2-year-old male with
history of trisomy 21 and G-tube
dependence presents with vomiting
and diarrhea, for 2 days.
Impression: Dilated loops of small bowel
in the upper abdomen with air fluid
levels concerning for small bowel
obstruction or ileus.

16. CASE 3: A 2-year-old male with
history of trisomy 21 and G-tube
dependence presents with vomiting
and diarrhea, for 2 days.
Surgery is consulted. It was felt
additional imaging was needed. There
was concern for patient’s ability to be
still for an ultrasound, so a CT is
obtained.
What do you see?

17. CASE 3: A 2-year-old male with
history of trisomy 21 and G-tube
dependence presents with
vomiting and diarrhea, for 2 days.
Imaging shows contrast throughout
the small and large bowel into the
rectum. Appendix is normal. G-tube in
place.
Impression: No acute abdominal or
pelvic process
Final dx: Diarrheal illness
Remember the limitations of X-ray!

18. CASE 4: A 10-year-old presenting
with prolonged course of
vomiting/diarrhea, cough,
shortness of breath, and severe,
unintentional weight.
What do you see?

19. CASE 4: A 10-year-old presenting
with prolonged course of
vomiting/diarrhea, cough,
shortness of breath, and severe,
unintentional weight.
-Opacification of the right
hemithorax concerning for large
pleural effusion with left side
mediastinal shift due to mass
effect
-Aeration of right upper lobe but
displaced to the right
-Atelectasis of the left lower lung

20. CASE 4: A 10-year-old presenting
with prolonged course of
vomiting/diarrhea, cough,
shortness of breath, and severe,
unintentional weight.
-CT demonstrates extensive soft
tissue structures concerning for
nodal conglomerates
-Mass in right side blending into
atelectatic lung, measures up to
13x8x7 cm
-Leftward displacement of
cardiomediastinal structures due
to pleural effusion.
Final dx: Hodgkin’s Lymphoma

21. Mediastinal Masses:
Adults and Pediatrics
Further imaging such as CT or MRI
will likely be necessary for further
characterization.
Differential diagnosis is best led by
the location of the mass in the
mediastinum.
The mediastinum is divided by three
main categories: prevascular (blue),
visceral (yellow), and paravertebral
(green).
Thacker, Paul G. MD*; Mahani, Maryam G. MD†; Heider, Amer MD‡; Lee, Edward Y. MD, MPH§
Imaging Evaluation of Mediastinal Masses in Children and Adults, Journal of Thoracic Imaging: July
2015 - Volume 30 - Issue 4 - p 247-267 doi: 10.1097/RTI.0000000000000161

22. Mediastinal Masses:
Adults and Pediatrics
Prevascular (blue): Thymic
lesions/masses, germ cell tumors,
lymphadenopathy (infectious vs
lymphoma), intrathoracic goiter,
metastasis
Visceral (yellow): Foregut duplication
cysts, tracheal lesions, esophageal
masses, cardiac masses, aortic
aneurysms, lymphadenopathy
(infectious vs lymphoma), metastasis
Paravertebral (green): peripheral
nerve tumor, sympathetic ganglia
tumors, lateral thoracic
meningocele, extramedullary
hematopoiesis
Thacker, Paul G. MD*; Mahani, Maryam G. MD†; Heider, Amer MD‡; Lee, Edward Y. MD, MPH§
Imaging Evaluation of Mediastinal Masses in Children and Adults, Journal of Thoracic Imaging: July
2015 - Volume 30 - Issue 4 - p 247-267 doi: 10.1097/RTI.0000000000000161

23. Mediastinal Masses: Pediatric Differential
Wright CD. Mediastinal tumors and cysts in the pediatric population. Thorac Surg Clin. 2009
Feb;19(1):47-61, vi. doi: 10.1016/j.thorsurg.2008.09.014. PMID: 19288820.
Prevascular (blue)
1. Thymus
A. Thymic Hyperplasia
B. Thymic cysts
C. Thymoma
2. Lymphadenopathy
A. Infectious
lymphoma
B. Tumors
3. Germ cell tumor
A. Teratomas
B. Seminomas
C. Nonseminomatous
germ cell tumor
D. Hemangiomas
E. Lymphangiomas
Visceral (yellow)
1. Lymphadenopathy
A. Infectious lymphoma
B. Tumors
2. Tumors
A. Nerve tumors
B. Hemangiomas
3. Cysts
A. Esophageal
duplication cyst
B. Bronchogenic cyst
C. Pericardial cyst
Paravertebral (green)
1. Ganglion cell tumors
A. Neuroblastoma
B. Ganglioneuroma
C. Ganglioeuroblastoma
2. Other nerve tumors
A. Schwannoma
B. Neurofibroma
C. Paraganglioma
D. Meningocele

24. CASE 5: A 6-year-old female with
no significant PMH presents for
headache, vomiting, and diarrhea
for the past 1.5 months that has
acutely worsened in the last 2
weeks.
What do you see?

25. CASE 5: A 6-year-old female with
no significant PMH presents for
headache, vomiting, and diarrhea
for the past 1.5 months that has
acutely worsened in the last 2
weeks.
-Ovoid sharply demarcated mass,
presumed pleural in the left
parahilar region approx. 5x3.5 cm
-Ddx includes pericardial cyst vs
bronchogenic cyst
-Lucent lesion in the proximal left
humerus concerning for bone cyst
or non-ossifying fibroma

26. CASE 5: A A 6-year-old female
with no significant PMH presents
for headache, vomiting, and
diarrhea for the past 1.5 months
that has acutely worsened in the
last 2 weeks.
-CT demonstrates ovoid low-
density pericardial mass along the
lateral wall of the left ventricle
without anomalous vasculature
Final dx: pericardiac cyst and non-
ossifying fibroma of the left
humerus

27. CASE 6: A 14-year-old boy with no
PMH presenting for 1 week of URI
symptoms and two days of
shortness of breath and facial
swelling.
What do you see?

28. CASE 6: A 14-year-old boy with no
PMH presenting for 1 week of URI
symptoms and two days of
shortness of breath and facial
swelling.
-Large right pleural effusion with
low right lung volume
-Large rounded appearance of
mid to upper mediastinum
-Ddx: underlying mass, aneurysm,
prominent thymic tissue

29. CASE 6: A 14-year-old boy with no
PMH presenting for 1 week of URI
symptoms and two days of
shortness of breath and facial
swelling.
-CT demonstrates large soft tissue
attenuation mass throughout the
anterior mediastinum possibly
extending into the lower neck
-Mediastinal shift present
-Ddx: germ cell tumor, lymphoma,
thymic lesion
Final dx: T-lymphoblastic
lymphoma

30. CASE 7: A 12-day-old with no
PMH admitted for bronchiolitis
found to have atelectasis in the
RUL two days prior. Repeat CXR
obtained given lack of
improvement of respiratory
status.
What do you see?

31. CASE 7: A 12-day-old with no
PMH admitted for bronchiolitis
found to have atelectasis in the
RUL two days prior. Repeat CXR
obtained given lack of
improvement of respiratory
status.
-Persistent mild RUL atelectasis
and reticular markings consistent
with bronchiolitis
-Normal cardiothymic silhouette
Remember the thymus! This is
the thymic "sail sign" and is
normal thymic shadow.

32. CASE 8: A 15-year-old female
admitted for COVID pneumonia
with acute respiratory failure.
Interpret this CXR.

33. CASE 8: A 15-year-old female
admitted for COVID pneumonia
with acute respiratory failure.
Dx: moderate right pneumothorax
without signs of tension
Patient was managed
conservatively. No chest tube was
required.

34. Pneumothorax is a leak of air into the
pleural space that causes collapse of the
lung.
Radiographically, a thin, sharply defined
linear density representing the visceral
pleura is the hallmark of pneumothorax.
Due to the gravity, the radiographic
appearance of pneumothorax depends
primarily on the positioning of the body.
Pneumothorax:
O'Connor AR, Morgan WE. Radiological review of pneumothorax. BMJ. 2005;330(7506):1493-
1497. doi:10.1136/bmj.330.7506.1493
Differentiating Pneumothorax from the Common Radiographic Skinfold Artifact
M. Obadah Kattea *and Omar Lababede
https://www.atsjournals.org/doi/10.1513/AnnalsATS.201412-576AS
Picture credits: <a href='https://www.freepik.com/vectors/people'>People vector created by
brgfx - www.freepik.com</a>

35. When mediastinal shifts accompany
it, it is called a tension
pneumothorax. This is a life-
threatening emergency that needs
urgent management.
Pneumothorax: tension
vs non-tension (simple)
When a mediastinal shifts accompanies a
pneumothorax, this suggests a tension
pneumothorax.
Tension pneumothorax occurs when the
air enters the pleural space but is unable
to exit.
Key CXR findings:
• Mediastinum shift
• Tracheal deviation to the contralateral
side
• Flattening of the hemidiaphragm on
the ipsilateral side
While these CXR findings suggest tension
PTX, remember that this this a clinical
diagnosis and REQUIRES tension
physiology to be present (hypotension,
tachycardia, hypoxia).
Jalota R, Sayad E. Tension Pneumothorax. [Updated 2021 Aug 11]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK559090/
Picture credits: left sided tension pneumothorax. Pictured originally used in article above.
Contributed by Wikimedia User: Karthik Easvur, (CC BY-SA 3.0
https://creativecommons.org/licenses/by-sa/3.0/).

36. CASE 9: A 6-month-old with PMH
of heart surgery presenting for 4
days of congestion, cough, and
increased work of breathing.
Initial vitals: HR 151, BP 125/70
Repeat vitals: HR 167, BP 60/32
What do you see?

37. CASE 9: A 6-month-old with PMH
of heart surgery presenting for 4
days of congestion, cough, and
increased work of breathing.
-Moderate right pneumothorax
with mediastinal shift to the left
-Post-sternotomy changes
Final Dx: tension pneumothorax
(radiographic signs, confirmed
with clinical presentation)

38. CASE 9: A 6-month-old with PMH
of heart surgery presenting for 4
days of congestion, cough, and
increased work of breathing.
A thoracostomy tube is placed with
resolution of the pneumothorax.

39. CASE 10 (from Nov 2019): A 5-
month-old full term infant with
history of congenital pulmonary
airway malformation s/p VATS 10
days prior presenting for
decreased oral intake found to
have mild increased work of
breathing and a RR of 42.
What do you see?

40. CASE 10 (from Nov 2019): A 5-
month-old full term infant with
history of congenital pulmonary
airway malformation s/p VATS 10
days prior presenting for
decreased oral intake found to
have mild increased work of
breathing and a RR of 42.
- Absent lung marking on right
- Leftward mediastinal shift
Final dx: pneumothorax with
radiographic signs of tension

41. CASE 11: A 16-year-old with no
PMH admitted for polytrauma
secondary to an MVC. Chest CT
demonstrated significant pleural
effusion and a chest tube was
placed.
What do you see?

42. CASE 11: A 16-year-old with no
PMH admitted for polytrauma
secondary to an MVC. Chest CT
demonstrated significant pleural
effusion and a chest tube was
placed.
- Right thoracostomy tube in
basilar aspect of right lung
- Residual small right basilar
pneumothorax and pleural
effusion
Final dx: Residual pneumothorax
without signs of tension

43. CASE 12 (from May 2020): A 4-
year-old female admitted for
MRSA sepsis with ARDS from hip
septic arthritis and osteomyelitis.
Patient intubated and on
oscillator with acute episode of
desaturation which persisted
despite bagging.
What do you see?

44. CASE 12 (from May 2020): A 4-
year-old female admitted for
MRSA sepsis with ARDS from hip
septic arthritis and osteomyelitis.
Patient intubated and on
oscillator with acute episode of
desaturation which persisted
despite bagging.
-Left sided pneumothorax
-Rightward mediastinal shift
Dx: pneumothorax with
radiographic signs of tension

45. CASE 12 (from May 2020): A 4-
year-old female admitted for
MRSA sepsis with ARDS from hip
septic arthritis and osteomyelitis.
Patient intubated and on
oscillator with acute episode of
desaturation which persisted
despite bagging.
Vitals: HR 118, BP 70/42, SpO2
61% on 100% FiO2
Final Dx: tension pneumothorax

46. Tubes and Lines
Practice!
What tubes/lines do you see
and how is the positioning?

47. CASE 13: A 12-year-old female
presents in vasoplegic shock and
acute respiratory failure after a
calcium channel blocker overdose.
Describe the lines and tubes.

48. CASE 13: A 12-year-old female
presents in vasoplegic shock and
acute respiratory failure after a
calcium channel blocker overdose.
1. Right IJ dialysis catheter-
terminates over upper right
atrium
2. Endotracheal tube- terminates
over mid-tracheal near level of
the clavicles
3. Enteric tube (NG or OG)- enters
the stomach and terminates
outside field of image
4. Left arm PICC lines- terminates
in SVC
1
2
3
4

49. CASE 13: A 12-year-old female
presents in vasoplegic shock and
acute respiratory failure after a
calcium channel blocker overdose.
What’s changed?
What is marked?
*

50. CASE 13: A 12-year-old female
presents in vasoplegic shock and
acute respiratory failure after a
calcium channel blocker
overdose.
Patient was cannulated for veno-
venous ECMO. The ECMO cannula
courses over the SVC, right
atrium, and IVC, ending near the
retrohepatic IVC.
Also note the ETT tube
positioning near the carina. It
could be retracted 1 cm.
*

51. CASE 14: A 2-week-old male
presenting in cardiac arrest, ROSC
successfully obtained.
Describe the lines and tubes.

52. CASE 14: A 2-week-old male
presenting in cardiac arrest, ROSC
successfully obtained.
1. Endotracheal tube terminating
past the carina
2. Enteric tube (NG/OG)
terminating in stomach
Final dx: Right mainstem intubation
with partial atelectasis of right upper
lobe
1
2

53. CASE 14: A 2-year-old male
presenting after near drowning
episode with respiratory failure.
Describe the lines and tubes.

54. CASE 14: A 2-year-old male
presenting after near drowning
episode with respiratory failure.
1. Endotracheal tube 2cm above
the carina
2. Enteric tube (NG/OG) in
esophagus- needs to be
advanced about 20cm for
intragastric placement
1
2

55. CASE 14: A 2-year-old male
presenting after near drowning
episode with respiratory failure.
A KUB is obtained later during
hospitalization. Describe the lines
and tubes.

56. CASE 14: A 2-year-old male
presenting after near drowning
episode with respiratory failure.
1. OG tube terminating the in
stomach
2. Attempted nasoduodenal
feeding tube placement, but
also terminates in stomach
3. Right femoral central venous
access
4. Foley catheter
1
2
3
4

57. Summary of This
Month’s Diagnoses
• Bowel obstruction (review)
• Malrotation with intestinal volvulus
• Diarrheal illness with air-fluid levels
• Hodgkin’s lymphoma
• Pericardial cyst
• T lymphoblastic lymphoma
• Thymic shadow
• Tension and non-tension
pneumothoraxes
• Lines and Tubes with right mainstem
intubation
For more educational content, visit
EMGuidewire.com