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Radiology in newborn collected by Dr. Saiful islam MD
1. To
Seminar
Presented by :
Dr. Sharmin Akhter (year-2)
Resident, PHO
Dr. Md Saiful Islam (year-4)
Resident, Neonatology ,BSMMU
1
2. S/O Lipi Akhter, inborn, 30 minute old boy admitted in NICU
with the complaints of prematurity (31weeks), low birth
weight (1200gm) and respiratory distress soon after birth.
Mother having no h/o taking antenatal corticosteroid
On examination - Baby was cyanosed with 2L/min Oâ, good
reflex activities, well perfused, euthermic, euglycaemic, R/R:
70 breaths/min, chest indrawing present, grunting audible
without stethoscope , bilateral poor air entry
Case scenario
2
3. 1. What is you provisional diagnosis?
ī Respiratory Distress Syndrome
1. Single investigation you want do first ?
3
5. Overview of presentation
ī Introduction
ī Radiographic examination
īChest radiograph
ī Chest x-ray of Common disease in Newborn
ī Position of Tubes and Catheters
īAbdominal radiograph
ī Common disease in on plain abdominal X-ray
īContrast studies
ī Common disease in Newborn on Contrast X-ray
5
6. Introduction
īRadiography is a great and useful tool for diagnosis of
Neonatal diseases
īThe x-ray is one of the most frequently requested
radiological examinations in neonatal intensive care
units
īThe corner stone of imaging is still conventional
radiography but ultrasound plays an important part
6
7. Radiographic examination
ī Chest radiograph
ī Abdominal radiograph
ī Babygram
ī Contrast study
īBarium Contrast study
īHigh-osmolality water soluble (HOWS) contrast study
īLow-osmolality water soluble (LOWS) contrast study.
ī Radionuclide studies
7
8. Chest radiograph
ī Anteroposterior (A/P) view:
īIdentification of heart and lung disease
īTo see the position of ET tube & other lines
ī Identifiction of air leak syndrome.
ī Cross-table lateral view:
īTo see the lung tube position - anteriorly or posteriorly
8
9. ī Lateral decubitus view:
ī For small pneumothorax or small fluid collection
ī Upright view:
ī To see free air under the diaphragm
Chest radiograph
9
13. Indications of CXR
īFor initial diagnosis of the cause of respiratory distress
īTo Check the position of lines and tubes
īMonitoring progression and responses to treatment
īIn case of respiratory deterioration
13
14. Normal CXR
īTranslucent
īAir bronchogram can be present till 2nd
generation of bronchi
in the retrocardiac area
īDiaphragm- upto 6th
rib anteriorly and 8th
rib posteriorly
īThe normal cardiothoracic ratio can be as large as 60 percent
īResidual lung fluid may give appearance of diffuse
opacification during first 4 hours of life
14
18. Assessment of the Quality
īProjection â PA or AP view
īBreath : Inspiration or Expiration
īPosition
īRotation
īPenetration/exposure
īArtifact
18
21. Penetration
īIntervertebral disc can be seen through the heart
īIf you see them very clearly the film is over-penetrated
īIf you do not see them it is underpenetrated
21
26. Inspiratory Film Clues
âĸ Diaphragm domes are
rounded
âĸ 5th or 6th anterior rib
crosses the diaphragm on the
frontal film
âĸ Lungs are black
Expiratory Film Clues
âĸ Diaphragms are very domed
âĸ 3rd or 4th anterior rib crosses
the diaphragm
âĸ Lungs are white
Inspiration or Expiration
26
27. Evidences of hyperinflation
īLung expansion > 6 ribs
anteriorly, > 8 ribs posterioly
īFlattening of diaphragms
īRibs are more horizontal
27
28. Cardio-thoracic ratio
ī >50% is considered abnormal
in an adult; more than 60% in a
neonate.
īAP views make heart appear
larger than it actually is
28
29. The thymus
īThe thymus is radiologically
characterized by a widening
of the upper mediastinum,
above the cardiac image
29
30. Notch-sign- where the inferior border of the normal
thymus blends with the border of the cardiac silhouette
Wave-sign- corresponding to a gentle undulation on
the thymus surface produced by costal arcs
compression, more frequently to the left
Sail sign- resulting from a peculiar shape of the thymus
appearing like a normal anterior mediastinal sail
shaped structure, more frequently to the right
The thymus
30
32. A still open arterial canal
may be seen on a chest
x-ray as a convex
prominence to the left
of the spine, between
T3 and T4 vertebras
Ductus bump
32
35. Respiratory distress syndrome (RDS)
īFine, diffuse reticulogranular pattern
īAir bronchograms
īLow lung volume
īGround glass opacities
īWhiteout lung
īThese radiographic findings are usually present
shortly after birth but they also may appear after
12-24 hours
35
40. Transient tachypnea of the newborn (TTN)
īSymmetric perihilar and interstitial streaky infiltrates
īHyperinflation
īFlattening of diaphragm
īProminence of the minor fissure
īSmall pleural effusion
īMild cardiomegaly
40
41. TTN
Plain chest radiograph
reveals overaerated lungs
with radiating streaky
densities from the hilum
to the peripheral lungs
bilaterally. Right minor
fissure is accentuated
41
43. Pneumonia
īDiffuse alveolar or interstitial disease that is usually
asymmetric and localized
īPneumatoceles - staphylococcal pneumonia
īPleural effusions or empyema- bacterial pneumonia
īGroup B streptococcal pneumonia can appear similar to
respiratory distress syndrome (RDS)
43
44. Diffuse increase in interstitial
lung markings is typical with
neonatal pneumonia
Pneumonia
44
45. Staphylococcus aureus pneumonia.
Multifocal irregular opacities are
observed in both lungs with
cavitations (small arrows). Right
pleural effusion (long arrow) is
evident obliterating right
costophrenic sulcus
Pneumonia
45
47. Meconium aspiration syndrome (MAS)
īBilateral, patchy, coarse infiltrates
īHyperinflation of the lungs
īFlattened diaphragm
īIncreased incidence of pneumothorax
47
48. Meconium aspiration syndrome (MAS).
Chest radiograph showing diffuse
coarse increase in lung markings
accompanied by hyperinflation,
typical for meconium aspiration
syndrome (MAS)
48
49. Bronchopulmonary dysplasia (BPD)
The radiographic appearance is highly variable-
īFine, hazy appearance of the lungs
īMildly coarsened lung markings
īCoarse, cystic lung pattern
49
50. Bronchopulmonary dysplasia (BPD)
Chest radiograph showing a
diffuse, moderately coarse
increase in lung density,
which in a 2-month-old
ventilated ex-preemie is most
consistent with
bronchopulmonary dysplasia
50
53. Air surrounds the heart,
including the inferior
border
Pneumopericardium
53
54. AP view. A hyperlucent rim of air is
present lateral to the cardiac border
and beneath the thymus, displacing
the thymus superiorly away from
the cardiacsilhouette (âangel wing
signâ)
Pneumomediastinum
54
55. Left tension pneumothorax as shown
on an anteroposterior chest
radiograph in a ventilated infant on
day 2 of life. Note the accompanying
collapse of the left lung, depression of
the left diaphragm, and contralateral
shift of mediastinal structures
Tension pneumothorax
55
68. Normal position- Halfway
between the thoracic inlet
(Medial ends of clavicles)
and the carina (4th
thoracic vertebra)
Endrotracheal tube
68
69. īEndotracheal tube is
positioned in the oesophagus.
īChest radiograph shows
dilatation of the esophagus and
stomach, that are filled with air
69
86. Viewes
1. AP view- best view for diagnosing
ī Intestinal obstruction
2. Cross-table lateral view-
ī Helps diagnose abdominal perforation
3. Left lateral decubitus view- Best for diagnosis of
intestinal perforation
86
90. Normal Abdominal x-ray
11th
rib
Hepatic flexure
Gas in
stomach
T12
Gas in caecum
Iliac crest
Femoral head
SI joint
Gas in sigmoid
Transverse colon
Splenic flexure
Psoas margin
Sacrum
Left kidney
Liver
Bladder
90
91. Gas pattern
âĸ Stomach
â Almost always air in stomach
âĸ Small bowel
â Usually small amount of air in
2 or 3 loops
âĸ Large bowel
â Almost always air in rectum
and sigmoid
What is normal?
91
92. Normal Abdominal Gas Pattern
1. Air in the stomach- within 30 minutes after delivery.
2. Air in the small bowel- seen by 3â4 hours of age.
3. Air in the colon and rectum- seen by 6â8 hours of
age
92
93. Normal fluid levels
âĸ Stomach
â Always (upright, decub)
âĸ Small bowel
â Two or three levels
acceptable (upright, decub)
âĸ Large bowel
â None normally
93
94. Large vs small bowel
âĸ Large bowel
â Peripheral
â Haustral markings donât extend from wall to wall
âĸ Small bowel
â Central
â Valvulae conniventes extend across lumen
94
96. Differs from that of older children
ī A neonates has less fat- the outlines of organs such as
the kidneys and psoas muscles are not as well defined
īNo mucosal folds- cannot differentiate small bowel gas
from large bowel gas
īThe position of the bowel gas- helps us to
differentiate small bowel from large bowel
96
99. Intestinal obstruction
īGaseous intestinal distention
īGas may be decreased or absent distal to the
obstruction.
īAir-fluid levels are seen proximal to the
obstruction.
99
100. level of obstruction
âĸDuodenal atresia- if only stomach and loop of
intestine is dilated in the right upper quadrant then
duodenal atresia is likely.
âĸ Jejunal atresia- Dilated loops confined to left upper
part of abdomen
âĸ Ileal artresia- Many dilated loops occupying
mainly the right side of spine
100
104. Plain abdominal radiograph of newborn
reveals dilated gastric bubble and massively
dilated duodenum and proximal jejunum with
gasless abdomen distal to level of obstruction;
these findings are consistent with jejunal
atresia.
Jejunal atresia
104
106. Hirschsprung disease
īFindings are primarily
those of a bowel
obstruction
īThe affected bowel is of
smaller calibre variable
amounts of colonic
distension are present
106
107. Meconium Ileus
īDilated bowel loops
proximal to the impaction.
īClassically, there is a paucity
or absence of air-fluid levels
and a "bubbly" appearance of
the distended intestinal loops
on radiographs.
107
108. Necrotizing Enterocolitis
īAbnormal gas pattern, ileus
īBowel wall edema
īPneumatosisintestinalis
īFixed position loop
īPortal venous gas
īPneumoperitonium
108
116. Barium contrast studies
Indications
īGI tract imaging
īBarium swallow -used to study the pharynx and
esophagus
īBarium meal- used to study the lower esophagus,
stomach and duodenum
īBarium follow through - used to study the small intestine
īBarium enema- used to study the large intestine and
rectum
īSuspected H-type TEF
īSuspected esophageal perforation
īSuspected gastroesophageal reflux (GER).
116
118. Low-osmolality water-soluble (LOWS)
contrast agents.
Advantages-
a. Do not cause fluid shifts.
b. If bowel perforation is present- nontoxic to the peritoneal
cavity
c. If aspirated, there is limited irritation to the lungs.
d. Limited absorption from the normal intestinal tract
Disadvantages- higher cost than barium.
118
120. Preparation for radiologic studies
Neonatal study Preparation
Upper GI series NPO for 1-2 hours for neonate & infants upto 2 year
Contrast enema No preparation needed for evaluation of bowel
obstruction or to rule out Hirschsprung disease
HIDA(Hepatobiliary)
scan
Oral phenobarbitone (5 mg/kg /day) for 5 days prior
to examination
Voiding
cystourethrogram
(VCUG)
No preparation
120
124. Duodenal atresia
Upper GI contrast study demonstrates
dilated stomach and proximal duodenum
without further passage of contrast in
newborn with duodenal atresia.
124
125. Plain abdominal radiograph of newborn
reveals dilated gastric bubble and
massively dilated duodenum and
proximal jejunum with gasless abdomen
distal to level of obstruction; these
findings are consistent with jejunal
atresia.
Jejunal atresia
125
126. Upper GI contrast study demonstrates
dilated stomach and duodenum, with
enlarged upper jejunum and lack of
passage of contrast agent to distal small
bowel; these findings are consistent with
high jejunal atresia.
Jejunal atresia
126
128. Lower GI contrast study in
newborn with ileal atresia
demonstrates microcolon with
dilated non-contrast-enhanced
stomach and proximal small
bowel.
Ileal atresia
128
131. The abdominal plain film
is usually nonspecific but
might demonstrate a
gasless abdomen or
evidence of duodenal
obstruction with a
double-bubble sign.
Malrotation with midgut volvulus
131
132. Corkscrew sign in a
patient with intestinal
malrotation with volvulus
Malrotation with midgut volvulus
132
133. Meconium Ileus
īDilated bowel loops
proximal to the impaction.
īClassically, there is a paucity
or absence of air-fluid levels
and a "bubbly" appearance of
the distended intestinal loops
on radiographs.
133
134. Gastrografin enema study shows filling
defects in the terminal ileum and
cecum. Also note the microcolon
(transverse and descending colon).
134
135. Hirschsprung disease
īFindings are primarily
those of a bowel
obstruction
īThe affected bowel is of
smaller calibre variable
amounts of colonic
distension are present
135
136. Barium enema showing
reduced caliber of the rectum,
followed by a transition zone
to an enlarged-caliber sigmoid.
Hirschsprung disease
136
137. Baby held upside down for
3-5 minutes and then lateral
X-ray is taken
Invertogram
137
142. īLow- When a rectal pouch that is below the I line
īIntermediate- If the rectum ends below the PâC
line, but not below the I line
ī High- when pouch ends above the PâC line
Invertogram
142