5 things i learned the hard way : gi imaging

Michael J. Callahan, M.D.

Department of Radiology

Boston Children’s Hospital

5 things I learned the

hard way : GI imaging

• Free air can be costly

• Not partial to small bowel

obstruction

• Read between the lines

• Bone to pick

• Contrast media, friend or foe?





obstruction


• Contrast media is my friend

• Contrast Media is my enemy



4-year-old girl with a cecal

perforation due to enteritis.

• Subphrenic air

• Falciform ligament sign

• Ligamentum teres sign

• Rigler’s sign

NEJM Radiologic Signs of Pneumoperitoneum

Ching-Hsing Lee, M.D.

N Engl J Med 2010

Signs

18 do male w CLD &

abdominal distention

Diagnosis ?

Diagnosis ?

1 d old male with

heterotaxy,

assess PICC

“Pseudo-pneumoperitoneum”

• Liver looks lucent

• Mimics free

intraperitoneal air

• Pt received 7 ml/kg

iodinated contrast in

cardiac cath lab

• peritoneal fluid is

dense due to third

space fluid loss with

contrast

Next day Diagnosis ?

Pseudo-pneumoperitoneum

• 5 ml/kg

iodinated

contrast media,

cath lab

• total body

opacification

Pseudo-pneumoperitoneum

• Peritoneum

looks lucent

relative to liver

• UVC misplaced,

eroded through

liver

• Fat-containing

TPN in peritoneal

cavity

• Respect the scout film


obstruction


• Contrast media, friend

• Contrast Media, foe



SBO

• Complete (high-grade)

• Incomplete (partial)

• Strangulated

• Closed loop

Radiographic Findings

of SBO

• Air-fluid levels of differential

height in the same small

bowel loop

• Mean small bowel air-fluid

width greater than or equal to

25 mm

• Dilated proximal Small bowel

• Collapsed Colon

SBO

• Dilated SMALL

BOWEL

• Air-Fluid levels

at multiple

levels

• Minimal gas in

the colon

“Normal” Air - Fluid levels

• Stomach

– Almost always (upright or decub)

• Small Bowel

– A few are usually acceptable

• Large Bowel

– Normally none

Diff Dx Pediatric SBO

“AIM” X 2

– Appendicitis

– Adhesions

– Internal hernia

– Intussusception

– Meckel’s

– Malrotation

IBD

Ingested

Foreign

Body

Adynamic Ileus

– “paralytic”

– can simulate mechanical obstruction

– Generally causes BOTH small and

large intestine to dilate

– CAN have AFLs

Caffey Edition, 2010 Part VII Small Intestine, Parker BR, pp. 1616 -

Ileus, Gastroenteritis

Caffey Edition, 2010 Part VII Small Intestine, Parker BR, pp. 1616 -

What is a “PSBO”?

• Mechanical Obstruction – blocked

lumen

• Functional / Neurogenic Obstruction

– Abnormal or absent peristalsis

– Called “ileus” in reference to small

bowel

• Colon ?

• 10 y.o. male w

Scoliosis

• “There is a mild

broad-based

dextroscoliosis of

the thoracolumbar

spine”

• “There is a

gastrostomy tube

in place, and a

partially

obstructive bowel

gas pattern”.

Colonic Air - Fluid levels

• Diarrhea

• Post operative

generalized

ileus

• Medications /

Laxatives

9 yo male w autism and

abdominal pain

12/11/16 early AM,

GoLytely therapy

12/11/16 KUB: “ multiple air-fluid

levels, concerning for evolving

small bowel obstruction

Referring clinician was

called: “Patient is

asymptomatic”



obstruction


• Contrast media, friend

• Contrast Media, foe



Trainee prelim read, “feeding

tube in the stomach”

5 yo male, w

septo-optic dysplasia

Chest radiograph obtained

hours later confirmed the

feeding tube to be in the

segmental left lower lobe

bronchus

Radiograph shows

endotracheal tube tip

overlying carina,

underinflated lungs, and

air-distended esophagus,

stomach and small bowel

Preterm male infant

Trainee prelim read, “ETT

in the right mainstem

bronchus, pull back 1 cm”

Esophageal intubation

Infant male, w ascites,

decreased urine output

3 days later, increasing abd girth

Infant male, w ascites,

decreased urine output



obstruction


• Bone to pick




9yo male, ESRD and

abdominal pain

9yo male, ESRD and

abdominal pain

AVN

3 month old female,

history of vomiting

3 month old female,

history of malrotation,

now vomiting

13 year-old girl with abdominal pain

13 year-old girl with abdominal pain

Weeks

later

SCFE



obstruction





Contrast Medium

• Substance

used to

enhance the

“contrast” of

structures or

fluids within

the body for

medical

imaging

MRCP

Juice is your

Friend !!!!!

Blueberry / Acai juice

GE Cor 3-D MRCP sequence

Nature’s Place Organic

Blueberry Juice

True Blue Blueberry

Juice Walgreen’s Distilled Water

A

AJ W

B

AJ W

Pre BBJ Post BBJ

CT: Is enteric

contrast necessary ?

CT

• Variable opinions on need of

enteric contrast media for

pediatric CT abdominal imaging

• Can be helpful in children w

paucity of retroperitoneal and

intraperitoneal fat, and increased

image noise

• 15-year-old female with left sided

abdominal pain, fever and

vomiting

US, 10/16/16

CT, 10/17/16

• Diff. Diagnosis: Mesenteric cyst

vs. LM

• Drainage by IR

• Ruptured, resulting in hypotension

and ICU stay

• Discharged w tumor markers sent

• Back to ED 10 days later,

abdominal pain

MRI, 11/2/16

• 11/7/17 OR

• Small Round Blue

Cell tumor

CT: Is enteric contrast

necessary ?

• Not always

• Can be helpful, but certainly not

mandatory

• Trauma, Appendicitis

• Can be helpful in children w

paucity of retroperitoneal and

intraperitoneal fat, and increased

image noise

Take Home Points



obstruction


• Bone to pick




5 things i learned the hard way : gi imaging

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