importance of convectional imaging in pediatric age group with case studies

1. Paediatric Abdominal x-
ray-A key to diagnosis
DR. Devendra Kumar
Assistant professor
Radiology department

2. Objectives:-
 It is important for the pediatrician to know
 5% increase in the risk of developing a fatal cancer for every Sv of exposure.
 This estimation is actually going to be higher in children, estimated to be 15% especially in females.

3. Radiation risk
 The typical dose of radiation required for an abdominal x-ray (AXR) is
which is the equivalent approximate dose to
 In CT abdomen dependent on study and age
Radiation Dose to Children by Age at Diagnostic Examination Examination*
Dose (mSv) (by Age at Exposure [y])
0 1 5 10 15 adult
Chest AP 0.023 0.024 0.037 0.025 0.026 0.051
Abdomen
ap
0.077 0.197 0.355 0.509 0.897 2.295
CT
abdome
n
3.6 4.8 5.4 5.8 6.7 10.4

4. Views-
 AP Supine view -single, supine
abdominal radiograph is usually the most
common imaging study .
 Applies for all age group
 PA erect view standard view /upright
view for
.
Erect and supine view of radiograph in normal child

5. ADDITIONAL VIEWS
 Lateral decubitus (left sided down)-
free abdominal gases and rectal obstruction.
Upright radiographs and decubitus abdominal radiographs for detection of free air
have similar sensitivity
 Horizontal beam/cross table lateral radiograph-If decubitus or upright imaging
is difficult to obtain,
Supine position-for pneumoperitoneum
Prone (invertogram)-bowel obstruction (often used exclusively in characterizing
anal atresia)

6. A-lateral decubitus view of an infant with large free air between liver and abdominal wall
B- supine position, using a horizontal-beam technique. Air is demonstrated between the liver and
anterior abdominal wall (arrow).

8. A normal bowel gas pattern at two hours
following birth, demonstrating passage of
air into the stomach and proximal small
intestine. A paucity of gas in the right
hemi-abdomen is due to lack of gas filling
of the distal small bowel and should not be
confused with a right-sided abdominal mass
normal bowel gas pattern at 24 hours. Gas is seen filling
multiple intestinal loops throughout the abdomen, with the
appearance of “multiple polygons.” It is difficult to
differentiate small from large intestine on radiographs in the
newborn period.

9. Small vs large bowel
Small bowel randomly distributed,
gaseous foci scattered throughout
the abdomen. A normal small
bowel gas pattern varies from no
gas being visible to gas in three or
four variably shaped small
intestinal loops
Centrally located
Valvulae conniventes
large bowel
Peripheral located
Haustra
Mottled appearance due to
faeces

10. mass
Spleno
megaly

11. 1.Correct patient, date, hospital ID, right and left side markers.
2.Correct study
3.Check for clinical history and findings
3.Quality :-penetration(over/under) and exposure(density/contrast)
4.Xray- View
5.Ant. extrinsic object-tubes, lines or foreign body

12. Pattern of bowel gases
 A- Intraluminal (bowel gases)
 Extraluminal (free air )
 extraluminal within wall
 displaced air from their normal location
 B-bone (normal, loss of segment or lytic /sclerotic lesion)
 C-calcifications
 D-diaphragm
 E-extras (tubes , linings or foreign body)
 Solid organ

13. Case 1
 This is 13 yr. boy with history of 6
month abdominal pain and bloody
diarrhoea has loss considerable
amount of weight.
 On examination generalized
abdominal tenderness present
 Xray findings-
 Central dilated featureless loop of
bowel with dilated transverse
colon

14. Case 2
Six-month-old previously
premature baby with
marked bowel dilatation of
uncertain cause. A lateral
abdominal radiograph
shows the presence of an
umbilical hernia.

15. Case 3
5 month old infant showing air lucency in
right inguinal region without evidence of
dilated bowel loops or fluid levels
.Inguinal hernias are an important cause of
bowel obstruction in children.
The presence of gas-filled bowel below
the inguinal canal should be documented,
even in the absence of signs of
obstruction.
Also, when a bowel obstruction is
suspected in a child, it is important to try
to characterize the level of obstruction,
generally proximal versus distal

16. Case 4
supine view in a 4 yr. old child has
been shown radiopacity at midline
and left to peduncle within the
colon.

17. Dilated bowel loops (greater
than the combined height of
the L1 and L2 vertebral bodies,
including the intervening disk
space, or interpeduncular
distance )
Few bowel loops-proximal
obstruction
Multiple bowel loops-distal
obstruction
Multiple air fluid levels

18. Adynamic vs mechanical
obstruction
A. Erect view-The fluid levels tend to be long and are the same level on an erect view. Note gases
in both colon and small bowel loops
B. Erect view shows absent colon gas and multiple different air-fluid levels in the dilated small
bowel loop with a 'ladder' appearance

19. Case 5
Eight-month-old with
vomiting, marked abdominal
distension and almost in
cardio-respiratory collapse.
Plain abdominal radiographs
in the
(A) supine
(B) left lateral decubitus

20. Pneumoperitoneum-
extraluminal air
-perforated peptic
ulcers,
- inflammatory bowel
disease (IBD).
-Trauma, both
accidental and
nonaccidental, may
also result in
pneumoperitoneum.-
1.Upright
2.Lateral decubitus
Horizontal beam
cross table lateral
view preferred in
infants and young
children ,
for pseudo-riglers
sign

21. Case -6
This 3-month-old infant with dextrocardia and heterotaxy underwent
imaging for abdominal distension. B, The left-side-down decubitus view.
The patient was found to have a duodenal perforation at surgery.

22. Chronic constipation:-
can lead to serious sequelae such as
overflow incontinence, UTI, even toxic
megacolon and perforation.
Faecal loaded bowel in case of chronic
constipation
When a child undergoes abdominal radiography
for constipation, one must be certain to
assess sacral integrity.

23. child with ho
constipation shows
absence of the sacrum
Case 7

24. Six-year-old boy who swallowed a key. (A)
Initial abdominal radiograph shows the
presence of a linear metallic foreign body
in the left side of the abdomen. There was
some concern that this was a sharp object.
A repeat radiograph (B) confirms the object
to be a key which was subsequently passed
out naturally without intervention.
Case 8

25. Case 9-Hypertrophic
pyloric stenosis
Supine view demonstrates over distension
of the stomach and evidence of a
peristaltic wave (arrow) along the gastric
body. Note the relatively sparse bowel
gas.

26. Case 10
Supine view of 3yr old child illustrates the
presence of a faecolith in the right lower
quadrant (short arrows) and loss of the
right psoas outline (long arrows). Note
normal well-defined left psoas shadow
and a localized ileus with mildly dilated
loops of bowel