DAVID SUTTON PICTURES THE PEDIATRIC ABDOMEN ONLY FOR STUDY PURPOSE

1. 28
THE PAEDIATRIC ABDOMEN
DAVID SUTTON

2. DAVID SUTTON PICTURES
DR. Muhammad Bin Zulfiqar
PGR-FCPS III SIMS/SHL

3. • Fig. 28.1 Barium aspiration. CXR in a 2-month-old boy
with congenital varicella and bulbar palsy
demonstrating high-density opacities throughout the
right lung secondary to aspiration during a barium
meal examination performed at 2 days of age.
Gastrostomy feeding was instituted.

4. • Fig. 28.2 Gadolinium-enhanced 3D MR angiogram in a
6-year-old girl following liver transplantation
demonstrating stenosis of the portal venous
anastomosis with poststenotic dilatation.

5. • Fig. 28.3 Oesophageal
atresia with tracheo-
oesophageal fistula. A
coiled nasogastric tube is
seen in the dilated
proximal oesophageal
pouch (top arrow). The
presence of distal air-filled
bowel implies an
associated
tracheoesophageal fistula.
Thirteen pairs of ribs are
noted, compatible with
VATER syndrome (lower
arrow).

6. • Fig. 28.4 Contrast oesophagram
demonstrating oblique track (arrows) of a
tracheo-oesophageal fistula with contrast
filling the tracheobronchial tree.

7. • Fig. 28.5 Double aortic arch. AP barium swallow
(A) demonstrating bilaterality are much reduced.
smooth extrinsic filling defects with a posterior
oesophageal impression on lateral image (B).
Axial T,-weighted MRI (C) confirming double
aortic arch.

8. • Fig. 28.6 Pyloric
stenosis. AXR
showing distended
gastric air bubble.

9. • Fig. 28.7 Pyloric stenosis. Longitudinal US
image (A) showing an elongated thickened
pylorus, muscle length 1 7 mm and width 3.8
mm. Transverse image (B) in another patient
with muscle width 6 mm. No transit of gastric
contents into the duodenum was observed.

10. • Fig. 28.8 Normal pylorus. Longitudinal US
section demonstrating an open pyloric canal
with transit of gastric contents observed on
dynamic imaging. Wall thickness
approximately 2 mm.

11. • Fig. 28.9 Pyloric stenosis. Barium meal
showing an elongated pyloric canal and
shouldering of the antrum due to the
hypertrophied pyloric muscle.

12. • Fig. 28.10 Duodenal atresia. Erect (A) and supine
(B) AXR demonstrating the 'double-bubble' sign.

13. • Fig. 28.11 Duodenal web. Barium meal
demonstrating a curvilinear filling defect or
'wind-sock diverticulum' in the second part of
the duodenum with proximal dilatation.

14. • Fig. 28.12 Malrotation and volvulus. AXR in a
12-month-old boy with bilious vomiting. The
stomach is distended with a relative paucity of
gas distally.

15. • Fig. 28.13 Malrotation. Contrast meal (A)
demonstrating abnormally low position of the
duodenojejunal junction (DJJ) (arrow). Further case
(B) demonstrating both inferior and medial
displacement of the DJJ (arrow). The normal DJJ should
lie to the left of the midline (over or lateral to the left
vertebral pedicle) at the level of the pylorus.

16. • Fig. 28.14 Midgut volvulus presenting as a classic
'corkscrew' appearance of the duodenum and
proximal jejunum on lateral view (A) and in a further
case as complete duodenal obstruction (B). The linear
filling defect is likely to represent the superior
mesenteric vessels and associated mesentery.

17. • Fig. 28.15 Contrast meal showing mild inferior
displacement of the duodenojejunal junction
(DJJ) in the presence of multiple dilated loops of
bowel. In this case the cause of obstruction was
an undiagnosed inguinal hernia. A repeat contrast
meal after surgery showed a normal DJJ location.

18. • Fig. 28.16 Follow-through examination demonstrating
an abnormal high and medial caecal position (arrow).
Malrotation confirmed at surgery.

19. • Fig. 28.17 Transverse ultrasound images of
the normal superior mesenteric artery: vein
relationship (A) and a malrotated child (B) in
whom the SMV lies to the left of the SMA.

20. • Fig. 28.18 Ultrasound 'whirlpool' sign of
midgut volvulus. Twisting mesenteric vessels
with concentric rings of echogenic mesentery.

21. • Fig. 28.19 Chronic volvulus. Doppler
ultrasound showing large dilated mesenteric
veins in an 8-year-old girl with a long history
of intermittent abdominal pain. Barium meal
confirmed malrotation, and chronic volvulus
was found at laparotomy.

22. • Fig. 28.20 Neonatal
low gastrointestinal
obstruction. Multiple
loops of distended
air-filled bowel.

23. • Fig. 28.21 Meconium
ileus. AXR showing
loops of dilated bowel
with a ' bubbly'
appearance of
meconium mixed with
air in the right side of
the abdomen. Free air
is seen, indicating a
perforation.

24. • Fig. 28.22 Meconium ileus. Contrast enema
demonstrating a microcolon with reflux into
dilated distal ileum. Multiple filling defects of
inspissated meconium are seen within the distal
ileum (superimposed over the transverse colon)
and the colon.

25. • Fig. 28.23 Ileal atresia. Contrast enema with
microcolon and reflux into non-dilated distal
ileal segment with abrupt convex termination.
A few meconium plugs are present.

26. • Fig. 28.24 Hirschsprung's disease. An abrupt
transition zone is seen at the rectosigmoid
junction on this lateral rectal view from a
contrast enema performed on a 2-day-old boy
with failure to pass meconium. The rectum
was difficult to distend well and showed
irregular contractions.

27. • Fig. 28.25 Functional
immaturity (left colon
syndrome). Contrast enema in
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. The
patient established a regular
bowel habit over the following
week and was discharged
uneventfully.

28. • Fig. 28.26 Colonic atresia. AXR (A) showing disproportionate
dilatation of one bowel loop in a neonate with abdominal
distension and failure to pass meconium. Contrast enema (B)
showing a blind-ending colon with a convex distal border in the
splenic flexure. The dilated air-filled proximal colonic segment can
be seen. An isolated colonic atresia was confirmed at surgery.

29. Fig. 28.27 Anorectal atresia with urethral fistula.
Micturating cystogram (A) demonstrating fistula
from the distal rectal pouch to the posterior
urethra and distal loopogram (B) showing a fistula
to the anterior urethra in two newborn boys with
high anorectal malformations.

30. • Fig. 28.28 Perineal ultrasound documenting
an 8 mm rectoperineal distance consistent
with a low anorectal malformation.

31. • Fig. 28.29 Portal venous air. AXR (A) and
ultrasound (B) evidence of portal venous air
in a premature infant with necrotising
enterocolitis.

32. • Fig. 28.30 Free intraperitoneal air in
perforated necrotising enterocolitis
demonstrated by lucency over the entire
abdomen (football sign), subdiaphragmatic air
and outlining of both sides of the bowel wall
(Rigler's sign).

33. • Fig. 28.31 Necrotising enterocolitis. Supine AXR (A)
demonstrating extensive 'bubbly' pneumatosis in a 16-
day-old premature infant born at 28 weeks gestation.
No definite free air seen. However, lateral shoot-
through radiograph (B) shows a small triangle of free
air beneath the anterior abdominal wall (arrow). A
localised ileal perforation was found at laparotomy.

34. • Fig. 28.32 Left congenital diaphragmatic hernia with
associated mediastinal shift and pulmonary hypoplasia.
The tips of the arteriovenous (AV) ECMO lines are
positioned in the right atrium (radiodense dot distal to the
opaque portion of the catheter) and in the origin of the
right common carotid artery or aortic arch.

35. • Fig. 28.33 Diaphragmatic eventration. PA (A) and
lateral (B) CXR demonstrating a focal bulge in the
anteromedial portion of the right
hemidiaphragm. Cardiomegaly and pulmonary
plethora are due to a ventricular septal defect.

36. • Fig. 28.34
Gastroschisis. Several
air-filled extra-
abdominal loops of
bowel are seen in this
infant of 26 weeks
gestation. A small left
congenital
diaphragmatic hernia
was also present.

37. • Fig. 28.35 Ingested coin. PA CXR (A) demonstrating a
coin impacted in the proximal oesophagus. Coins
lodged within the oesophagus are seen ' en face' on PA
CXR, whereas impaction within the trachea results in
'sideon‘ visualisation. Lateral cervical spine X-ray (B)
confirming oesophageal location of the foreign body.

38. • Fig. 28.36 Duplication cyst. Hypoechoic cyst
with double 'gut wall signature'. In this case
the adjacent segment of bowel can be seen
along the superior border of the cyst,
confirming its origin.

39. • Fig. 28.37 Oesophageal duplication cyst. CXR (A) on a 6-month-old infant
admitted to paediatric intensive care with upper airway obstruction showing
deviation of the nasogastric tube to the right and a possible right paratracheal
mass. AP (B) and lateral (C) views from contrast swallow showing smooth
extrinsic compression and posterolateral deviation of the proximal oesophagus
with narrowing and anterior bowing of the trachea. CT (D) confirmed the
presence of a prevertebral tubular cystic mass with oesophageal and tracheal
displacement. A proximal oesophageal duplication cyst was resected at
thoracotomy.

40. • Fig. 28.37 Oesophageal duplication cyst. CXR (A) on a 6-month-old infant
admitted to paediatric intensive care with upper airway obstruction
showing deviation of the nasogastric tube to the right and a possible right
paratracheal mass. AP (B) and lateral (C) views from contrast swallow
showing smooth extrinsic compression and posterolateral deviation of the
proximal oesophagus with narrowing and anterior bowing of the trachea.
CT (D) confirmed the presence of a prevertebral tubular cystic mass with
oesophageal and tracheal displacement. A proximal oesophageal
duplication cyst was resected at thoracotomy.

41. • Fig. 28.38 Mesenteric cyst. CT demonstrating
a large left-sided cystic abdominal mass with
compression of the left kidney. Ultrasound
showed multiple fine septations within the
cyst (not illustrated).

42. • Fig. 28.39 Appendicolith. Rounded calcific density
projected over the multiple fine septations within the
cyst (not illustrated). right iliac fossa in a 7-year-old boy
presenting with abdominal pain.

43. • Fig. 28.40 Acute appendicitis. Transverse
ultrasound image demonstrating a
hypoechoic tubular structure 7 mm (markers)
in diameter adjacent to the iliac vessels. It
was blind-ending and non-compressible.

44. • Fig. 28.41 Perforated appendicitis. Right iliac
fossa mixed echogenicity inflammatory mass.
A 6 mm echogenic focus with acoustic
shadowing consistent with an appendicolith
confirms the diagnosis.

45. • Fig. 28.42 CT pelvis (A) showing a large thick-
walled pelvic abscess containing an air-fluid level
in a 9-year-old girl presenting with a 10 day
history of ill-defined abdominal pain and
diarrhoea. An appendicolith was identified on a
more superior slice (B). The patient was managed
with percutaneous drainage and antibiotic
therapy

46. • Fig. 28.43 Acute appendicitis. CT pelvis in a 12-
year-old boy with a recent diagnosis of acute
leukaemia and a 2 day history of abdominal pain.
The appendix is identified medial to the iliac
vessels (arrow). It is thick walled and associated
with a small pocket of free fluid. An acutely
inflammed appendix was found at laparotomy.

47. • Fig. 28.44 Henoch-Schönlein purpura.
Ultrasound (A), barium follow-through (B)
and CT abdomen (C) demonstrating jejunal
bowel wall thickening in a 5-year-old boy.
Thickening of the valvulae conniventes can
also be seen on the barium study.

48. • Fig. 28.45 Graft-versus-host disease. CT
abdomen demonstrating extensive thickening of
the bowel wall, abnormal mucosal enhancement
and mesenteric stranding in pancolitis due to
GVHD after bone marrow transplantation.

49. • Fig. 28.46 Juvenile
polyp. Barium enema
demonstrating a
pedunculated polyp in
the descending colon
(arrow).

50. • Fig. 28.47 Colitis. Ultrasound demonstrating
thick-walled ascending colon, in this case due
to Crohn's disease. Doppler examination
showed hyperaemia of the bowel wall.

51. • Fig. 28.48 Gadolinium-enhanced fat saturated
T 1 -weighted axial MRI pelvis showing diffuse
mucosal enhancement and bowel wall
thickening of the rectosigmoid colon in
Crohn's disease.

52. • Fig. 28.49 Intussusception. Paucity of bowel gas
in the right iliac fossa and a soft-tissue mass
(arrows) strongly suggest intussusception in this
11-month old child. However, in many cases,
AXR shows no definite abnormality.

53. • Fig. 28.50 Intussusception. Transverse
ultrasound showing multiple hypoechoic
concentric rings, central echogenic mesentery
and a few small trapped lymph nodes.

54. • Fig. 28.51 Pathological lead point. Composite
ultrasound image showing a cystic mass at the
head of an intussusception in a 3-month-old
boy. A duodenal duplication cyst was found at
laparotomy.

55. • Fig. 28.52 Air enema demonstrating a large
ileocaecal soft-tissue mass outlined by air. The
length of the mass suggests an ileoileocolic
intussusception. Radiological reduction was
successful.

56. • Fig. 28.53 Transverse (A) and longitudinal (B)
ultrasound images demonstrating a small
bowel intussusception around the tip of a
gastrojejunostomy feeding tube.

57. • Fig. 28.54 Bilateral Wilms' tumours. CT
showing bilateral large low attenuation renal
masses filling the abdomen of this 5-month-
old girl.

58. • Fig. 28.55 Wilms' tumour. Ultrasound (A) demonstrates a
large heterogenous mass arising from the left kidney
containing multiple low echogenicity areas of haemorrhage
or necrosis. CT (B, C) demonstrates the ' claw sign' with
renal parenchyma stretched around the mass, confirming
its renal origin. The tumour displaces the retroperitoneal
vessels without encasing them. The left renal vein lies over
the anteromedial aspect of the mass. Small retroperitoneal
lymph nodes are present.

59. • Fig. 28.55 Wilms' tumour. Ultrasound (A) demonstrates a
large heterogenous mass arising from the left kidney
containing multiple low echogenicity areas of haemorrhage
or necrosis. CT (B, C) demonstrates the ' claw sign' with
renal parenchyma stretched around the mass, confirming
its renal origin. The tumour displaces the retroperitoneal
vessels without encasing them. The left renal vein lies over
the anteromedial aspect of the mass. Small retroperitoneal
lymph nodes are present.

60. • Fig. 28.56 Non-Hodgkin's lymphoma of the kidneys.
Longitudinal renal ultrasound (A) in a 5-year-old boy
showing multiple isoechoic masses in a 17 cm kidney. Axial
T,-weighted (B) and coronal STIR MRI (C) confirming gross
enlargement of both kidneys with complete loss of normal
renal architecture. Differential diagnoses include
lymphoma, leukaemia and nephroblastomatosis. Biopsy
yielded non-Hodgkin's lymphoma.

61. • Fig. 28.56 Non-Hodgkin's lymphoma of the kidneys. Longitudinal
renal ultrasound (A) in a 5-year-old boy showing multiple isoechoic
masses in a 17 cm kidney. Axial T,-weighted (B) and coronal STIR
MRI (C) confirming gross enlargement of both kidneys with
complete loss of normal renal architecture. Differential diagnoses
include lymphoma, leukaemia and nephroblastomatosis. Biopsy
yielded non-Hodgkin's lymphoma.

62. • Fig. 28.57 Angiomyolipoma. Longitudinal
ultrasound showing a well-circumscribed
echogenic mass in the upper pole of the right
kidney.

63. • Fig. 28.58 Tuberous sclerosis. The architecture of both
kidneys is distorted by multiple fat-containing
angiomyolipoma. This CT was performed on a 15-year-
old girl with tuberous sclerosis admitted with acute
abdominal pain following haemorrhage into one of the
right-sided lesions. Oedematous changes in the right
abdominal wall followed removal of a percutaneous
drain.

64. • Fig. 28.59 Neonatal adrenal haemorrhage.
Ultrasound of a right adrenal haemorrhage
on day 2 (A) and day 10 (B) of life. Decrease in
size of the mass, often with cystic change (not
shown in this example) confirms the nature of
the lesion.

67. • Fig. 28.61 Ultrasound of a normal neonatal right
adrenal gland (A) showing the 'stripe' of hypoechoic
cortex and hyperechoic medulla. Enlarged and
echogenic oedematous left adrenal gland due to
asphyxia (B). Enlarged 'speckled' adrenal with
lobulated outline typical of congenital adrenal
hyperplasia (C). Densely calcified enlarged adrenal
gland in Wolman's disease (D).

68. • Fig. 28.61 Ultrasound of a normal neonatal
right adrenal gland (A) showing the 'stripe'
of hypoechoic cortex and hyperechoic
medulla. Enlarged and echogenic
oedematous left adrenal gland due to
asphyxia (B). Enlarged 'speckled' adrenal
with lobulated outline typical of congenital
adrenal hyperplasia (C). Densely calcified
enlarged adrenal gland in Wolman's disease
(D).

69. Fig. 28.62 Hepatoblastoma. Unenhanced (A)
and enhanced (B) CT abdomen showing a
large low-attenuation mass in the left lobe of
the liver with small central calcific foci and
heterogenous enhancement. delineated on
ultrasound, CT or MRI and strongly suggest
malignancy

70. • Fig. 28.64 Hepatic cyst. CT abdomen
demonstrating a congenital hepatic cyst
within the right lobe.

71. Fig. 28.63 Haemangioendotheliosis. Ultrasound (A) showing
an ill defined, almost isoechoic mass with multiple vascular
channels in the right lobe of the liver in a newborn infant
with congestive cardiac failure. Axial T,-weighted (B) and T2
-weighted (C) MRI showing lesions within the right and left
lobes (low signal on T1 , high signal on T 2 ) with tortuous
dilated feeding vessels arising from the coeliac axis. Sagital
2D TOF MRA (D) showing large calibre proximal abdominal
aorta with a reduction in calibre below the origins of the
dilated coeliac axis and superior mesenteric artery.

72. • Fig. 28.63 Haemangioendotheliosis. Ultrasound (A) showing an ill
defined, almost isoechoic mass with multiple vascular channels in
the right lobe of the liver in a newborn infant with congestive
cardiac failure. Axial T,-weighted (B) and T2 -weighted (C) MRI
showing lesions within the right and left lobes (low signal on T1 ,
high signal on T 2 ) with tortuous dilated feeding vessels arising
from the coeliac axis. Sagital 2D TOF MRA (D) showing large calibre
proximal abdominal aorta with a reduction in calibre below the
origins of the dilated coeliac axis and superior mesenteric artery.

73. • Fig. 28.65 Hepatic arteriovenous malformation.
Ultrasound of the liver showing dilated portal
venous and hepatic arterial vessels. Doppler
spectral traces confirmed arterialisation of the
portal venous system due to arteriovenous
shunting. There was no associated soft-tissue
mass.

74. • Fig. 28.66 Target lesion. Ultrasound showing a
small target lesion with hypoechoic rim in the left
lobe of the liver. Several other hepatic lesions
were identified in this immunosuppressed patient
and are highly suspicious for fungal infection in
this clinical setting.

75. • Fig. 28.67 Ruptured choledochal cyst. This 2-
year-old girl presented with clinical signs of
peritonitis and echogenic ascites documented on
ultrasound. CT abdomen shows a right upper
quadrant cyst with a 'tail' directed towards the
head of the pancreas and ascites. Laparotomy
confirmed the diagnosis.

76. Fig. 28.68 Fusiform dilatation of the common
hepatic and common bile ducts in a type 1 B
choledochal cyst (A) and a large saccular type 2
choledochal cyst showing connection to the
common bile duct (B).

77. Fig. 28.69 Gallstones. Multiple calculi within a
collapsed gallbladder in a 13-year-old girl with
sickle-cell anaemia.

78. • Fig. 28.70 Acalculous cholecystitis.
Ultrasound demonstrating grossly thickened
gallbladder wall in an 8-year-old girl admitted
to paediatric intensive care with pneumonia
and septicaemia

79. • Fig. 28.71 Pancreatic pseudocyst. CT
abdomen (A) showing two large pseudocysts
anterior to the body of the pancreas. This 3-
year-old boy had sustained a laceration to the
neck of the pancreas 9 days earlier (B)
following a fall from a shopping trolley.

80. • Fig. 28.72 Solid papillary tumour of the pancreas. CT
abdomen with a large low-attenuation mass in the
region of the tail of the pancreas in a 16- year-old girl.
Ultrasound demonstrated both solid and cystic
components to the mass (not illustrated).

81. • Fig. 28.73 Polysplenia. Two spleens were
identified on ultrasound in this newborn
infant with left isomerism.

82. • Fig. 28.74 Wandering spleen. CT abdomen in a 4-year-
old boy with acute abdominal pain demonstrating a
low-attenuation mass in the pelvis. No spleen
identified in the left upper quadrant. The echogenicity
of the mass was similar to splenic tissue on ultrasound
(not illustrated) but no Doppler flow was obtained,
consistent with an infarcted wandering spleen.

83. • Fig. 28.75 Multiple small hypoechoic lesions
within the spleen may be due to infections
(fungal disease, granulomatous disease, bacterial
microabscesses), diffuse infiltrative
lymphocytosis syndrome in HIV-infected children
(case illustrated), extramedullary haematopoesis
or, rarely, metastases.

84. • Fig. 28.76 Prostatic rhabdomyosarcoma. Sagittal
fat-saturated T 2 - weighted MRI in a 4-year-old
boy demonstrating a large prerectal pelvic mass
displacing the bladder anteriorly.

85. • Fig. 28.77 Type II sacrococcygeal teratoma. CT
pelvis (A) in a newborn girl showing a
presacral mass with a large external
component (B) containing soft tissue, cystic,
fat and calcific elements.

86. • Fig. 28.78 Ovarian cyst. Ultrasound of the pelvis
in a 4-week-old girl demonstrating an ovarian
cyst containing mobile debris. A crescent of
ovarian tissue is seen laterally and confirms the
origin of the cyst.

87. • Fig. 28.79 Mature ovarian teratoma in an 11-
year-old girl. CT demonstrating a large mixed
solid/cystic mass arising from the pelvis and
containing fat and calcification.

88. • Fig. 28.80 Torted ovary. This infant girl presented with
a tender left inguinal lump. Ultrasound showed a
hypoechoic mass with peripheral cysts and absent
Doppler flow. Surgical exploration revealed a torted left
ovary that had herniated into the inguinal region.