9. CONTRAST STUDIES:
Should be avoided, fear of aspiration
• Nonionic isoosmolar contrast medium
• H-type fistulas are mostly at the thoracic inlet,
between C7 and T2 vertebral bodies
23. MALROTATION
Normal intestinal rotation
Two Processes involved :
Physiological midgut Herniation and Rotation : 6 wks -12 wks
Fixation of mesentery :12 wks -20 wks
24. 6 weeks -physiologic herniation
of the midgut through the
umbilical orifice (UO).
Superior mesenteric artery (SMA)
acts as the axis
prearterial segment
postarterial limb
29. INCOMPLETE ROTATION AND
MALFIXATION
Failure to complete the final 180-degree rotation.
Shortened mesenteric root -allows formation of elongated and mobile
segments of colon.
Midgut volvulus.
31. REVERSED INTESTINAL ROTATION –
Transverse colon lie behind the descending
duodenum and the superior mesenteric artery
cecum is can be medially placed
32. Midgut volvulus
Narrow mesentery
Suddenly presents with bilious vomiting
Ischemia and necrosis
Plain radiograph
33. corkscrew sign
tapering or beaking of the bowel in complete
obstruction
malrotated bowel configuration
Fluoroscopy: contrast study
34. Ultrasound
clockwise whirlpool sign
abnormal bowel
dilated duodenum proximal to obstruction
dilated fluid-filled loops of small bowel
free intra-abdominal fluid
35.
36. CT scan
whirlpool sign
malrotated bowel configuration
bowel obstruction
free fluid/free gas in advanced cases
37. Meckel’s Diverticulum
congenital intestinal diverticulum
omphalomesenteric duct fails to be completely obliterated
Present with obstruction or ulceration
Antimesenteric border
Litters hernia
38. Xray – non specific
SBFT with a large Meckel
diverticulum
44. Meconium peritonitis
Bowel perforates as a result of bowel
obstruction, such as atresias or meconium ileus
Meconium peritonitis and small bowel
obstruction is highly suggestive of atresia.
45. Low bowel obstruction
Difficult to differentiate on X-ray
Contrast enema is usually required
Water soluble contrast is preferred
52. Functional immaturity of colon
Meconium plug syndrome/ small left colon
syndrome
Immaturity of bowel innervation
Change in caliber in splenic flexure
53. Hirschsprung’s Disease
Absence of ganglion cells in bowel wall
Transition point found in the rectosigmoid (73%) >
descending colon (14%) > more proximal colon
(10%).
57. Anorectal Anomalies
Anal atresia: Vacterl association
range from a membranous separation to complete
absence of the anus.
RADIOGRAPH:
Invertogram
58. ULTRASOUND:
Delineating distance from the distal pouch to perineum
CYSTOGRAPHY:
Delineates associated fistulas between terminal bowel and urinary
tract.
CT & MRI
Modalities of choice
Help determine presence of puborectalis muscle, external sphincter
and rectal pouch.
60. fusiform manner and then
with preferential
growth of its dorsal wall
61. Mesenteric Cyst (Lymphangioma)
congenital malformation arising due to sequestration of lymphatic vessels.
SONOGRAPHY:
thin-walled unilocular or multilocular cystic lesion
useful to demonstrate the thin septations which may not be well seen on CT.
CT and MRI:
demonstrate variable characteristics of the cyst contents (usually water-to fat) depending
upon whether fluid is chylous, infected or haemorrhagic.
62. Megacystis-microcolon-intestinal
Hypoperistalsis Syndrome (Berdon Syndrome)
pseudoatresia.
functional small bowel obstruction with a microcolon,
malrotation and a large unobstructed bladder
UPPER GI CONTRAST STUDY:
hypomotility of small bowel with retrograde peristalsis.
63. • “DOUBLE TRACT SIGN” –
this refers to fluid, trapped in the
mucosal folds in the center of an
elongated pyloric canal seen as
two sonolucent streaks in the
center
Megacystis-microcolon //• Jejuno-ileal atresia // Colonic atresia or stenosis….I will be discussing the common disorders…
Esophageal atresia is the M/C congenital anomaly of esophagus >90 % have associated TEF
Trachea and oesophagus arise from the foregut. these structures are separated by a septum . Any anomaly in separation of these structures will lead to esophageal atresia with or without a trachea-oesphageal fistula…..Equal incidence in males and females….Isolated esophageal’tresia is more commonly aassociated with down,s syndrome..complte imaging is required to assess other associated anomalies
More than 80 %esophageal atresia and trachea is connected to the esophagus by a fistula …9-10 % have only esophageal atresia…6% ty no atresia only an abberent connection H type ( If small unlike others it may present later in childhood with episodes of choking coughing or cyanosis on feeding )
When there is a possibility of esophageal atresia
Presence atresia with a distal tracheo esophageal fistula.
Absence eliminates the possibility of a distal fistula
A feeding tube is coiled in the upper esophageal pouch (open arrows). Eleven ribs are present on the left and 12 on the right. Segmentation anomalies, including a
hemivertebra, are seen at the thoracolumbar level (solid arrow). The right hemithorax is opacified, and the mediastinal contents are shifted to the right because the right lung is agenetic.
USG of the fetus in the sagittal plane at the level of neck shows an anechoic pouch (anechoic, dilated, blind-ending proximal esophageal pouch) ..polyhydramnios
best way to demonstrate H-type: Others can be bronchoscopy and endoscopy
H-type tracheoesophageal fistula. The contrast agent injected into the upper esophagus fills the esophagus (E), the fistula (arrow), and the trachea (T).
Isoosmolar –iodixanol visipaque
All the stomach anomalies present with non billous vomiting
severe GOR megaoesophagus// VACTERL sequence, small bowel malrotation, upperlimb reduction defects and asplenia …The moderately dilated duodenum is in the normal position.
cause vomiting or failure to thrive in infants`…Antral web. Barium study demonstrates a thin, linear filling defect across the antrum (arrows).
Vomiting non billous …If not in this timeline and bilious malrotation is suspected//
Outllet function must be observed ,can be confused with pylorospasm (Passage of gastric contents into duodenum)
The pyloric length ( is abnormally elongated to more than 17 mm)//The stomach is distended with fluid
nonbilious vomiting shows gastric distention with relative paucity of gas distally A single streak of barium (the string sign,arrow) within the narrowed, elongated pyloric channel is seen…Pyloric stenosis. Barium meal showing an elongated pyloric canal and shouldering of the antrum due to the hypertrophied pyloric muscle
Due to incomplete recanalization//
Location : Just below the ampulla of vater Associated with :anomalies of pancreas, CBD and portal vein //
Air / aflevel is present in the stomach and proximal duodenum …Absence of distal air
patients also develop polyhydramnios - as was seen in this case.
is not complete; rather there is a diaphragm or membrane or web that causes duodenal stenosis
thin membrane or web can become stretched and propelled toward the distal duodenal lumen by constant peristalsis, creating the so-called windsock deformity//smoothly-marginated oval collection of barium with a thin lucent rim around it
Any Arrest in these processes lead to malrotation and malfixation of intestine
that the superior mesenteric artery (SMA) acts as the axis for midgut rotation/// (OMD) omphalomesenteric duct divides the`midgut into prearterial and postarterial limbs///The celiac axis (CA) is the major artery of the foregut; the inferior mesenteric artery (IMA) supplies the hindgut. CB, Cecal bud.
Liver enlarges and pushes pre-arterial segment down…..Midgut elongates predominantly prearterial ….postarterial segment occupies the left side of the umbilical hernia. Viewed from the front, this represents a 90-degree counterclockwise rotation……By the 12th week, the colon completes a 270-degree counterclockwise rotation.
Duodenojejunal juction (DJF) to the ileocaecal valve. It has a broad bse any defect in rotation or fixation acan cause a narrow mesentry which later causes volvulus.
demonstrated incidentally on barium studies in older children or adults ..bowel is not very mobile and volvulus is not a common complication …small bowel (prearterial ) right side and colon (post arterial) left side.
Single-contrast barium enema
Incomplete resorption of the dorsal mesentery that //twist of malfixed intestines around the short mesentery
extend from the malpositioned cecum across the duodenum and attach to the hilum of the liver, posterior peritoneum or abdominal wall
Malrotation demonstrated by barium enema
180 degrees clockwise
Fixation of mesentery does not occur and, as a result, the mesentery has a short root, which allows it to act as a pedicle (through which the SMA and SMV pass) around which volvulus can occur. //distended stomach and proximal duodenum with a tapered end
spiral appearance of the distal duodenum and proximal jejunum seen in midgut volvulus. //congenital malrotation of the midgut, the distal duodenum and proximal jejunum do not cross the midline and instead pass inferiorly
clockwise spiralling of the mesentery and superior mesenteric vessels.
CECT images through the upper abdomen revealed abnormal bowel position around the SMA, with a characteristic swirling pattern -this is consistent with Midgut Volvulus. //thick-walled loops of ischemic right-sided small bowel loops with potential pneumatosis intestinalis and mesenteric edema
apex of the physiologic herniation//wide spectrum of variation..May contain ectopic gastric tissue
//Fluoroscopy may demonstrate the narrowed neck blind-ending sac on the antimesenteric border.
It is actively accumulated and secreted by the mucoid cells of the gastric mucosa,[2] and therefore, technetate(VII) radiolabeled with Tc99m is injected into the body when looking for ectopic gastric tissue as is found in a Meckel's diverticulum with Meckel's scans
child presenting with billous vomiting// In contrast to duodenal atresia they are due to ..rather than failure of canalization //Supine radiograph in a neonate shows three dilated loops of bowel
The colon appears smaller callibre and unused,. //This colonic appearance depends upon gestational timing of inujry earlier will present with microcolon
Usually the perforation seals off and the bowel is intact at birth. Intraperitoneal meconium usually calcifies
Failure to pass meconium in 48 hrs ( safer if perforation is suspected // any contrast has a therapeutic benefit in meconium ileus and functional immaturity of colon.
(bile salts, bile acids, and debris from the intestinal mucosa) //granular/bubbly appearance of rlq
. Abdominal scout radiograph shown marked distention of the small bowel and a “soap bubble”appearance in the right side of the abdomen a finding suggestive of mottled air and meconium///The caliber of the colon is slightly diminished on contrast enema. As contrast material refluxes into the dilated and obstructed terminal ileum (I), it is diluted by the intraluminal meconium
) US image shown dilated, fluid-filled intestinal loops containing echogenic material ( calcified meconium.
and are contiguous with the small intestine wall// uncommon & occur anywhere in the gastrointestinal tract.//noncontrast CT hypodense rounded mass due to a jejenual duplication cyst.
Barium study shows extrinsic impression on the body of the stomach in a case of gastric duplication
Rarely the contents are reflective or contain septations secondary to hemorrhage or inspissated material within the lumen.
Contrast enema i n a newborn term infant showing a relatively small left colon, transition zone at the splenic flexure and a large coiled meconium plug which was dislodged from the splenic flexure to the hepatic flexure during colonic filling
always involves the anal canal and extends proximally for a variable distance.// upto splenic flexure//total colonic agangliosis//Palin radiograph shows markedly dilated colon, with no gas in the pelvis / rectum
Normally in neonates rectum is of a greater caliber// Barium enema shows an abrupt transition from the narrow caliber rectosigmoid (aganglionic) to the larger caliber more proximal sigmoid colon//
huge and disproportionately dilated loop of bowel//Image from a barium enema study demonstrates microcolon with complete obstruction to the retrograde flow of a barium enema study demonstrates microcolon with complete obstruction to the retrograde flow of barium in the transverse portion of the colon.
A coin/metal piece is placed over the expected anus and the baby is turned upside down (for a minimum 3 minutes
fourth week.. straight, hollow tube in the midsagittal plane
