Radiological features in paediatric bowel obstruction, Imaging in congenital bowel anomalies,

1. IMAGING OF PAEDIATRIC
INTESTINAL OBSTRUCTION
Present by:
Capt. Soe Moe Htoo
PG 2nd year (Radiology)

2. Contents
1. Neonatal bowel gas pattern
2. Developmental lesions of the intestinal tract
3. Types of IO
4. Common causes of IO in neonates
5. Clinical and radiological features of common lesions
6. Conclusion
2

3. Normal neonatal bowel gas pattern
Is there any abnormalities?
3

4. Normal neonatal bowel gas pattern
Swallowing begins immediately after birth:
• Gas in the stomach - few minutes
• Entire small bowel - within 3 hours of birth
• Sigmoid colon - after 8-9 hours
• Disruption of this common pattern is seen in obstruction or presence
of underlying illness such as brain damage, septicemia or
hypoglycemia.
4

5. Developmental lesions of the neonatal GI tract
1. Attributed to embryologic maldevelopment
2. Attributed to in utero vascular (ischemic) complication
3. Functional
4. Structural and Functional Combined
5

6. 1. Attributed to embryologic maldevelopment
• Esophageal atresia with or without fistula
• Antro-pyloric atresia
• Duodenal atresia
• Midgut malrotation with peritoneal bands
• Duplication or mesenteric cyst
• Anorectal atresia
6

7. 2. Attributed to in utero vascular (ischemic) complication
• Jejuno-ileal atresia
• Colonic atresia or stenosis
• Complicated meconium ileus
7

8. 3. Functional
• Meconium plug syndrome and its variants
• Megacystis-microcolon-intestinal hypoperistalsis
8

9. 4. Structural and Functional Combined
• Hypertrophic pyloric stenosis
• Midgut volvulus (complicating midgut malrotation)
• Uncomplicated meconium ileus
• Colonic aganglionosis
9

10. • 2 Types of intestinal obstructions:
(1) Upper IO
(2) Lower IO
• Obstructions occurring proximal to the mid-ileum  upper intestinal
obstructions.
• Involving distal ileum or colon  lower intestinal obstructions
10

11. Causes of Neonatal Intestinal Obstruction
High intestinal obstruction
• Gastric atresia
• Duodenal atresia
• Duodenal stenosis (with
annular pancreas)
• Duodenal web
• Malrotation
• Jejunal atresia and stenosis
Low intestinal obstruction
Small bowel involving
• Ileal atresia
• Meconium ileus
Large bowel involving
• Functional immaturity of the colon
• Hirschsprung disease
• Colonic atresia
• Anal atresia and anorectal
malformation
11

12. Oesophageal Atresia
• Due to abnormal division of foregut
• 1 in 3000 live births
• Early presentation(at birth) - drooling, vomiting, choking after feeding
• Late presentation - recurrent pneumonia
• Can occur with or without tracheoesophageal fistula
• Most common type  Oesophageal atresia with fistula (90%)
• Pure oesophageal atresia without fistula (10%)
12

13. Associations:
• VACTERL anomalies
1. Vertebral anomalies
2. Anorectal malformation
3. Cardiovascular malformations (VSD, PDA, right aortic arch)
4. Tracheal anomalies
5. Esophageal fistula
6. Renal anomalies
7. Limb anomalies
• Chromosomal (5-20%): Trisomy 18, 21,13
13
Oesophageal Atresia

14. Imaging features
Plain radiograph
• Dilated proximal oesophagus
• Coiled feeding tube within the blind ending upper pouch
• Gasless abdomen (indicates no distal fistula)
14
Oesophageal Atresia

15. Oesophageal atresia without fistula
15
Oesophageal Atresia

16. Hypertrophic Pyloric Stenosis
• Narrowing of the opening from the stomach to the first part of
duodenum
• Characterized by hypertrophy of the circular muscles
• 3/1000 live birth
• Male: Female (4:1)
• Most common cause for laparotomy before 1 year (esp. 3 weeks to 3
months)
• May have positive familial history
• Also occurs in adults d/t scarring from chronic peptic ulceration
16

17. 17
Pyloric Stenosis

18. Clinical Presentations
• Projectile non-bilious vomiting after feeding
• Stomach contractions: peristalsis across baby's upper abdomen soon
after feeding, but before vomiting
• Constipation
• Dehydration
• Hypertrophied pylorus can be palpated as an olive sized mass in the
right upper quadrant
18
Pyloric Stenosis

19. Associations:
• Turner syndrome
• Tracheo-esophageal fistula
• Esophageal atresia
• Trisomy 18
19
Pyloric Stenosis

20. Imaging Features
• USG is the first modality of choice
• Contrast evaluation if required
• Thickness of the muscle (most accurate criterion for the diagnosis)
20
Pyloric Stenosis

21. USG Method
• Stomach need well distension
• Antro-pyloric muscle is
measured in mid-longitudinal
plane.
21
Pyloric Stenosis

22. Ultrasonography
• Primary imaging method
• Sensitivity and specificity of approximately 100%
• USG confirmed hypertrophic pyloric stenosis when:
- pyloric muscle thickness (MT) > 4 mm &
- pyloric channel length (CL) > 15 mm
But,
• Linear relationship between Pyloric MT, CL Vs Patient age
• 3 mm MT (diagnostic for pyloric stenosis in younger patients)
22
Pyloric Stenosis

23. Hypertrophied muscular layer Abnormal elongation of the pyloric canal
23
Pyloric Stenosis

24. Infantile Hypertrophic Pyloric stenosis
24
Pyloric Stenosis

25. Axial oblique ultrasound shows thickened,
hypoechoic muscular wall and elongated pyloric
canal 25
Pyloric Stenosis

26. Pyloric Stenosis Vs Pylorospasm
• Sonographic measurements in pylorospasm may overlap with pyloric
stenosis.
• In pylorospasm, considerable variability in measurement or image
appearance with time during the study.
• Sonographic double-track sign (i.e., redundant mucosa in the
narrowed lumen, which creates 2 mucosal outlines) can be seen in
both pylorospasm and hypertrophic pyloric stenosis.
26
Pyloric Stenosis

27. Barium examination
• Performed if USG is inconclusive or gastro-oesophageal reflux is suspected.
• The hypertrophied muscle mass causes:
• Elongation and narrowing of pyloric canal (‘string sign’)
• Bulge in the distal antrum with streak of barium pointing towards
pyloric channel (‘beak sign’)
• The barium may outline crowded mucosal folds as parallel lines
(‘double/triple track sign’).
27
Pyloric Stenosis

28. Supine radiograph in an infant with vomiting
demonstrates caterpillar sign of active gastric
hyperperistalsis.
28
Pyloric Stenosis

29. Stomach shows double tracking in region of pyloric canal,
indentation on base of bulb and delayed gastric emptying.
29
Pyloric Stenosis

30. Upper gastrointestinal study from a child shows
the string sign
30
Pyloric Stenosis

31. Hypertrophic pyloric stenosis on an UGI exam.
Lateral view from an UGI exam demonstrates
elongation and narrowing of the pylorus,
consistent with the string sign (arrow).
31
Pyloric Stenosis

32. Tit sign - outpouching contrast on lesser curve by
distorted muscle in hypertrophic pyloric stenosis.
32
Pyloric Stenosis

33. TYPICAL UPPER GASTROINTESTINAL SERIAL IN A 2 YEARS OLD BOY WITH
HYPERTROPHIC PYLORIC STENOSIS.
33
Pyloric Stenosis

34. Duodenal Atresia
• 1 in 5,000-10,000 newborns
• No gender predilection
• one of the commonest causes of complete fetal bowel obstruction
• Proximal duodenal atresia – d/t failed bowel lumen recanalization in
early fetal life (late first trimester)
• Distal atresia – d/t secondary of ischemic episode
• 50% have history of polyhydramnios
34

35. Associations:
• Trisomy 21
• VACTERL association
• Malrotation
• Other intestinal atresias
• Annular pancreas
• Biliary anomalies
35
Duodenal Atresia

36. Imaging features:
• Double-bubble appearance - gas-filled distended stomach and
proximal duodenum (Non-specific)
• Dilatation of the duodenum is a sign of chronic obstruction
• Seen in duodenal atresia, duodenal web and annular pancreas
• In midgut volvulus, obstruction occurs acutely after birth, the
duodenum is not usually dilated
36
Duodenal Atresia

37. 37

38. Differential diagnosis of duodenal obstruction:
• Malrotation with Ladd bands and midgut volvulus - can be partial or
complete obstruction.
• Duodenal web - partial obstruction with small amount of distal bowel
gas
• Annular pancreas.
• Preduodenal portal vein
38
Duodenal Atresia

39. 39

40. 40

41. Duodenal atresia
AXR of a newborn with bilious vomiting and abnormal antenatal ultrasound
showing polyhydramnios and dilated stomach
41
Duodenal Atresia

42. Duodenal Web
• Variant of duodenal stenosis
• Caused by a duodenal membrane
• In partial duodenal obstruction, upper GI contrast studies help to
distinguish between duodenal web and malrotation with Ladd bands
or midgut volvulus.
42

43. Imaging features:
• Plain radiograph: dilated gas filled stomach and duodenum 'double
bubble’ with small amount of distal bowel gas.
• 'Windsock' or 'dimple' appearance on upper GI contrast: representing
the web.
43
Duodenal Web

44. Duodenal web
AXR of a newborn with bilious vomiting.
44
Duodenal Web

45. 45

46. Intestinal Malrotation, Midgut volvulus
• Volvulus = Twisting
• 1:6000 live births
• Due to failure of complete rotation and fixation of the intestine
• (Some) entire life without symptoms
• 80-90%  present in the first year of life
• It predispose midgut volvulus and internal hernias
• Shortening and abnormal position of the mesenteric root  twist
bowel and develop midgut volvulus.
46

47. • Surgical emergency and early diagnosis is vital to prevent bowel
ischemia and potentially life threatening complications
• C/F - Feeding intolerance and bilious vomiting
47

48. Association:
• Ladd bands: abnormal fibrous peritoneal bands
• Internal hernia with mesenteric defect
• Cardiac isomerism
48
Malrotation

49. Imaging features:
Abdominal plain film:
Normal (or) Non-specific bowel gas pattern
Bowel distention and cut-off sign in complete obstruction
Upper GI contrast study:
• Abnormal positioned Duodenojejunal junction
• Corkscrew sign: proximal bowel twisted around the superior
mesenteric artery represents midgut volvulus.
49
Malrotation

50. 50

51. 51

52. 52

53. 53

54. 54

55. 55

56. Malrotation
5(a) markedly dilated stomach and duodenum similar to
'double bubble sign' but small amount of distal bowel gas.
5(b) Upper GI contrast study demonstrates obstruction at the
duodenum (arrow) due to malrotation and the presence of a
Ladd band.
5(c) AXR of another neonate presented with bilious vomiting.
Bowel gas pattern is non-specific.
5(d) Upper GI contrast study demonstrates abnormal position
DJ flexure over the spine and corkscrew sign (arrow head)
representing malrotation with midgut volvulus.
56
Malrotation

57. Jejunal Atresia
• More common than duodenal atresia
• Incidence 1 in 1,000 live births
• Arise form an ischemic event in utero and not infrequently involves
more than one segment (50%) of jejunum
57

58. Imaging Findings:
• Triple-bubble sign
 Double bubble sign + Third bubble (air filled dilated jejunum)
• No gas in the distal bowel
Differential Diagnosis of proximal obstruction:
Malrotation with midgut Volvulus
• Plain film confirms complete obstruction if there is no distal gas
• If there is small amount of distal gas  upper GI study (to distinguish
from malrotation/ volvulus)
58
Jejunal Atresia

59. • Several dilated proximal bowel loops in the
upper abdomen
• No distal bowel gas indicating complete
high obstruction due to Jejunal atresia
• Small amount of intra-abdominal
calcification (arrow) represents meconium
peritonitis due to in-utero perforation
secondary to the bowel obstruction
Newborn with abnormal antenatal ultrasound
suggesting bowel obstruction
59
Jejunal Atresia

60. Ileal atresia
• In-utero ischemic event resulting in single or multiple atresias
• Can associated with mesenteric defects
• Usually presents within first few days after birth
• Abdominal distension, bilious vomiting and failure to pass meconium
• May be diagnosed on antenatal ultrasound (with polyhydramios and
signs of bowel obstruction)
60

61. Imaging Findings:
• Numerous dilated bowel loops (indicating a low obstruction)
• Multiple air-fluid levels
• Calcifications (indicating meconium peritonitis in in-utero perforation)
• Microcolon and blind ending ileum on contrast enema
61
Ileal atresia

62. Differential Diagnosis of distal bowel obstruction:
• Meconium ileus
• Meconium plug and small left colon syndrome
• Total colonic Hirschsprung disease
• Colonic atresia
62
Ileal atresia

63. Ileal atresia
7(a) Plain radiograph demonstrates multiple dilated bowel loops indicating a
distal obstruction
7(b) Contrast enema show a microcolon with a blind ending small distal ileum
representing ileal atresia.
AXR of a newborn with abdominal distension and feeding intolerance.
63
Ileal atresia

64. 64

65. Ileal atresia
(a) Multiple air-fluid levels occupying the entire abdominal cavity.
(b) Barium enema: numerous dilated, air-filled loops of bowel and a
small, unused colon (functional microcolon).
65
Ileal atresia

66. Colonic atresia
(a) Radiograph shows distended loops of bowel similar to those seen in low small bowel
obstruction.
(b) Barium enema: microcolon with complete obstruction to the retrograde flow of
barium in the transverse portion of the colon.
66

67. Meconium ileus
• Newborn bowel obstruction
• Secondary to thick tenacious meconium impacted in distal ileum
• Accounts for 20% of neonatal intestinal obstruction
• 50% of cases are complicated with perforation
• Usually managed conservatively with gastrograffin enema washout in
uncomplicated intestinal obstruction
67

68. Associations:
• Cystic fibrosis (almost all patients with meconium ileus have cystic
fibrosis and 15% of CF patients present with meconium ileus)
• Pancreatic duct stenosis/atresia
• Pancreatic insufficiency
68
Meconium ileus

69. Imaging features:
• 'Bubbly'/frothy appearance of intestinal contents (seen in the right
lower quadrant in 50-66%).
Contrast enema:
• Distal small bowel impacted with filling defects (meconium pellets)
• Microcolon
69
Meconium ileus

70. Meconium ileus
(a) Abdominal radiograph of a neonate who failed to pass meconium, showing distended gas filled bowel
loops and "soap bubble" appearance in the right lower abdomen representing the impacted
meconium in the distal ileum (arrow).
(b) Contrast enema examination demonstrates small-caliber colon "microcolon". Numerous filling defects
in the distal ileum represent the impacted meconium pellets. Note the multiple proximal dilated loops
of bowel.
70
Meconium ileus

71. Meconium ileus
(a) Abdominal scout radiograph shows marked distention of the small bowel and a
“soap bubble” appearance in the right side of the abdomen (arrows), a finding
suggestive of mottled air and feces.
(b) US image shows dilated, fluid-filled intestinal loops containing echogenic material
(calcified meconium) (arrows). Associated ileal atresia was seen at surgery. 71
Meconium ileus

72. Hirschsprung disease
• Most common cause of lower intestinal obstruction in neonates
• 1 in 5000 live births
• Male predominance (80%)
• Always begins in internal anal sphincter
• Extends proximally for a variable length of gut
72

73. Pathogenesis
73
Migratory failure of neural crest cells
Functional obstruction
Spasm of the affected segment of colon
Congenital absence of colonic ganglion
cells

74. Pathogenesis
74
Hirschsprung

75. Types of Hirschsprung disease:
1. Short segment disease (rectum and sigmoid) - 80%
2. Long segment disease (Rectum and sigmoid with the transition zone
above the rectosigmoid) - 15-25%
3. Total colonic Hirschsprung (entire colon) - <5 %
4. Total intestinal disease - very rare
5. Ultrashort segment (only ano-rectal junction) – very rare
6. Presence of skip lesions in Hirschsprung’s disease is extremely rare
75
Hirschsprung

76. Associations:
• Genitourinary anomalies (11%)
• Congenital cardiac disease (6%)
• Trisomy 21 (5%)
76
Hirschsprung

77. Clinical presentation
• Failure to pass meconium in 1st 24 hr. of life
• Abdominal distension, bilious vomiting, refusal to feed
Older children present late with
• Long standing history of constipation since birth
• Toxic Megacolon (Fever, abdominal distension, bilious vomiting,
explosive diarrhea, dehydration, shock)
• Spontaneous perforation (esp. in long segment)
77
Hirschsprung

78. • Definitive diagnosis - by full thickness rectal biopsy
• Contrast enema - usually demonstrates the transition zone
(but can be normal in ultrashort segment disease)
78
Hirschsprung

79. Imaging features:
• AXR: Multiple dilated bowel loops with lack of gas in the rectum
79
Hirschsprung

80. Barium enema
• Contrast agent should be prepared with normal saline
• Performed by inserting a straight tipped catheter just beyond the anal
sphincter
• Patient placed in lateral position
• Should infused barium slowly
• Rapid infusion can distend and mask the transition zone
• Diagnostic feature in short segment disease is funnel shaped
transition zone and reversal of the recto-sigmoid ratio.
80
Hirschsprung

81. Rectosigmoid ratio
• Measurement of the diameter of the rectum divided by sigmoid colon
during contrast enema.
• Use in the diagnosis of Hirschsprung disease
• Normal children have a rectum that is larger than the sigmoid (i.e.
rectosigmoid ratio >1).
• A rectosigmoid ratio (R/S) less than 1 suggests the diagnosis of short-
segment Hirschsprung disease
81

82. 82

83. • Transition zone between the narrowed affected distal colon and the
dilated innervated proximal colon.
• Short segment: Rectum smaller than the sigmoid. Rectum in an
inverted cone shape.
• Long segment: Transition zone is above the recto-sigmoid junction.
• Total colonic Hirschsprung: Microcolon
• Normal rectum in 33%
• “Saw- tooth” appearance due to irregular spasm of the affected
segment
• Enterocolitis: thickened and ulcerated bowel wall
• 24 hr delayed films – Poor barium emptying through the colon
83
Hirschsprung

84. 84

85. Differential diagnosis of distal bowel obstruction:
• Meconium ileus
• Meconium plug and small left colon
• Ileal atresia
• Colonic atresia
85
Hirschsprung

86. Hirschsprung disease
(a) AXR of a newborn who failed to pass meconium, demonstrates multiple dilated loops of
bowel consistent with distal obstruction.
(b)(c) Lateral and AP views of contrast enema examination of the same neonate illustrating a
narrowed rectum compared to the sigmoid.
The rectum shows irregular contractions.
This is the classic 'inverted cone shape' rectum and 'saw-tooth’ appearance.
Rectal biopsy confirmed short segment Hirschsprung disease. 86
Hirschsprung

87. Hirschsprung disease.
9(d) Dilated transverse colon with the transition zone at the splenic flexure (arrow head)
corresponding to the lateral and AP barium enema contrast images
(e) and (f) (curved arrow). The descending and sigmoid colon is narrowed with spasm and the rectum
has a "saw-tooth appearance" due to abnormally contractions (black arrow).
Biopsy confirmed long segment Hirschsprung disease. 87

88. Hirschsprung disease in a 6-month-old infant with a history of chronic
constipation.
Frontal (a) and lateral (b) images from a barium enema study show the proximal
sigmoid colon and descending colon as greatly dilated compared with the distal
colon and rectum. 88
Hirschsprung

89. Hirschsprung disease
89

90. 90

91. Meconium Peritonitis
• Sterile chemical peritonitis
• Occurs 1 in 35,000 live births
• Secondary to intrauterine bowel perforation
• Associated with a mortality rate of up to 60%,
• When recognized early, a good clinical outcome can be achieved
• Bowel content leakage causes intense inflammation and dense fibrotic
tissue formation, subsequent peritoneal calcification (paracolic gutters
and below the diaphragm)
91

92. Association:
• Small bowel atresia
• Meconium ileus
• Viral infections (CMV, or HPV)
92
Meconium Peritonitis

93. Imaging features:
• Punctate/linear calcifications extending throughout the abdomen
(may extend into the male scrotum via a patent processus vaginalis)
• Bowel loop separation (secondary to intra-peritoneal fluid)
93
Meconium Peritonitis

94. Differential diagnosis of neonatal intra-abdominal calcification:
• Liver calcifications
• Intra-abdominal teratoma
• Congenital neuroblastoma
94
Meconium Peritonitis

95. Meconium Peritonitis
Multiple small scrotal calcifications representing
meconium peritonitis.
More calcifications in the right upper quadrant.
Intra-abdominal free air accumulating in upper
central abdomen (arrow head) representing the
"football sign", and free air extending into the
inguinal canal (arrow).
95

96. Football sign
• Seen in cases of massive pneumoperitoneum
• Abdominal cavity is outlined by gas from a perforated viscus
96
Rugby ball

97. Meconium peritonitis
- Linear and flocculent areas of calcification within the
peritoneal cavity (arrows)
- Scattered areas of calcification in the scrotum
97
Meconium Peritonitis

98. Bowel Perforation
• Can be from obstruction secondary to atresia, meconium ileus and
necotizing enterocolitis.
• Free air collects in the non-dependent portion of the abdomen
• Can seen on the supine abdominal radiograph as lucency over the
central abdomen, over the liver and outlining the falciform ligament.
• Lateral decubitus projection can be helpful in difficult cases, as the
free air will rise to the non-dependent areas.
98

99. Pneumoperitoneum.
(a) Lateral decubitus radiograph demonstrating the free air rising to the non
dependent area above the liver (curved arrow).
(b) Chest radiograph of a neonate showing the falciform ligament (arrow)
outlined by free air and therefore becomes visible
99

100. Necrotizing Enterocolitis (NEC)
• NEC is the most common gastrointestinal emergency in premature
low birth weight infants
• Combination of both bowel infection and ischemia
• Overall mortality of 20-30%.
• Most common affected site - ileum and right colon
• Breast-feeding  decreased NEC incidence
• Usually conservative treatment
• Surgery for perforation and complications
100

101. Predisposing Factors:
• Prematurity (50 - 80%)
• Patent ductus arteriosus
• Perinatal stress
• Infection
101
NEC

102. Imaging features:
• Persistent abnormally dilated bowel loops without change in position
• Bowel wall thickening
• Intramural gas
• Portal venous gas in up to 30%
• Pneumoperitoneum in perforation
• Post NEC stricture resulting in obstruction
102
NEC

103. Necrotizing enterocolitis
(a) Supine AXR of a premature neonate who developed severe NEC on 14th day of life,
demonstrating multiple dilated bowel loop with intramural gas (pneumatosis) (arrow) and portal
venous gas (branching linear lucencies in the liver extending to the periphery).
(b) The same infant developed bowel obstruction several weeks after the NEC episode.
(c) Contrast enema study demonstrates a focal stricture (curved arrow) with a localized perforation
at the site of previous NEC (short arrow). 103

104. Intussusception
• Invagination of one segment of bowel into another, leading to edema
and venous congestion within the bowel wall.
• Most common type - Ileocolic
• Majority - under 1 year of age, with a peak incidence between 5 and 9
months
• M:F (3:2)
104

105. 105
Intussusception

106. LEAD POINT
• A lead point is a lesion or variation in the intestine that is trapped by
peristalsis and dragged into a distal segment of the intestine, causing
intussusception.
• Meckel diverticulum
• Polyp
• Tumor
• Hematoma
• Vascular malformation
106
Intussusception

107. Intussusceptum (white arrow) and Intussuscipiens (black arrow)
107
Intussusception

108. Etiology
108
Intussusception

109. Etiology (Cont.)
Idiopathic
• Approximately 75 % of cases are idiopathic
• No clear disease trigger or pathological lead point
Influence of viral factors
• Has a seasonal variation, with peaks coinciding with seasonal viral
gastroenteritis.
• 30 % experience viral illness (URTI, otitis media, flu-like symptoms)
before the onset of intussusception.
109
Intussusception

110. 110
Viral infections
Stimulate lymphatic tissue in the intestinal
tract
Hypertrophy of Peyer patches in the
lymphoid-rich terminal ileum
Act as a lead point for ileocolic
intussusception

111. Presentation
• The classic triad of symptoms:
(1) intermittent colicky abdominal pain (about every 10-20 min)
(2) vomiting (rapidly becoming bile-stained)
(3) 'redcurrant jelly' stool
• Neurological symptoms (lethargy, hypotonia or sudden alterations of
consciousness)
111
Intussusception

112. Pathological process of intussusception
112
Intussusception

113. Imaging features:
Plain X-ray(Abd)
• Plain radiograph is normal in 25%.
• Small tissue mass and crescent of air around the intussuceptum in the
right abdomen.
• Small bowel obstruction
• Paucity of bowel gas distally
• Meniscus sign: Crescent of gas within colonic lumen that outlines the
apex of intussusceptum
113
Intussusception

114. 114
Intussusception

115. Meniscus sign
115
Intussusception

116. 116
Intussusception

117. Contrast Enema
1. Coil spring appearance:
- Trapping of barium between the edematous mucosal folds of
the returning limb of intussusceptum & wall of intussuscepian.
2. Meniscus sign:
- Convex intraluminal mass
NOTE: Barium enema is contraindicated in perforation.
117
Intussusception

118. COIL SPRING SIGN
118
Intussusception

119. Barium enema showed filling defect with crab's
claw sign at the mid transverse colon
119
Intussusception

120. Ultrasound
• Up to 100% accuracy for the diagnosis of intussusception
• portable, noninvasive, and without radiation
• Characteristic finding>>>>3- to 5-cm diameter mass, typical target or
doughnut sign found just deep to the anterior abdominal wall on the
right side can detect a possible pathologic lead point with higher
frequency (66%) than contrast (40%) or air enema (11%)
• “Target” appearance multiple concentric rings and central mesenteric
fat in the transverse plane.
• “Pseudo-kidney“ appearance: On longitudinal images,
intussusception often shows peripheral hypoechoic bowel with
central increased echoes.
120
Intussusception

121. Warning signs of necrosis on US
• absence of blood flow on Doppler a thick peripheral hypoechoic rim
• free intraperitoneal fluid
• fluid trapped within the intussusceptum,
• enlarged lymph nodes dragged with the mesentery into the
intussusception
121
Intussusception

122. • Measurement of intussusception assist in differentiating between
ileocolic and small bowel-small bowel intussusception
• Small bowel-small bowel intussusception is smaller, typically self-
limiting, and does not require intervention.
• Ultrasound findings such as intussuscepted lymph nodes and
interloop fluid indicate increased difficulty in an attempt at reduction
122
Intussusception

123. Target sign
123

124. • In ileocolic type, the patient should undergo reduction via air or
contrast enema to prevent complications (bowel wall ischemia or
necrosis, perforation, and shock)
• Surgery for patients in whom reduction is unsuccessful or have
contraindications to fluoroscopic reduction (e.g. free air, peritonitis,
or signs of shock).
124
Intussusception

125. Non-surgical Reduction
• Pneumatic or hydrostatic reduction may be performed
• In both procedures, an enema tube is placed in the patient’s rectum
• In pneumatic reduction, air is pumped manually through the tube
into the colon, pushing the intussusceptum through the ileocecal
valve.
• A pressure of 120 mm Hg or less should be maintained
• If the patient engages in a Valsalva maneuver, the pressure may
intermittently increase
• When the mass is no longer seen and air enters the distal small
bowel, the reduction is considered successful.
• At the end of the procedure, post reduction image must be taken.
(to check +/-pneumoperitoneum)
125
Intussusception

126. • In hydrostatic reduction, water-soluble isotonic or LOCM is hung 3
feet above the table and allowed to flow freely into the colon.
• When the intussusceptum reduces, contrast is seen in distal small
bowel loops.
• Advantages of the pneumatic technique:
• Faster reduction
• Decreased radiation, and
• Air rather than contrast entering the peritoneal cavity (in cases of perforation)
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Intussusception

127. Intussusception
Distal SBO with a soft tissue mass in the right lower
quadrant representing an ileocolic intussusception.
Note the absence of gas in the colon and rectum.
127
Intussusception

128. Intussusception on ultrasound
(A) Transverse and (B) longitudinal gray-scale US images
- characteristic of intussusception with a target and “pseudokidney”
appearance, respectively.
- Lymph nodes can be seen with the intussusceptum on the
transverse image (arrow) 128
Intussusception

129. CT and MRI
• Are not routinely used
• Intussusception found incidentally on imaging performed for
another suspected diagnosis
• target or doughnut sign
129
Intussusception

130. Inguinal Hernia
• Herniation of the intra-abdominal structures
• Due to failure of closure of processus vaginalis
• Usually reducible and asymptomatic
• But can be irreducible  distal bowel obstruction
• 60% of hernias occur on the right side
• Premature infants are at increased risk for inguinal hernia, with
incidence rates of 2% in females and 7-30% in males.
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131. Imaging features:
• Low obstructive bowel pattern
• Bowel gas in the scrotum or inguinal canal
• Widening of the scrotal shadowing on one side
131
Inguinal Hernia

132. Inguinoscrotal hernia
AXR of neonate demonstrating loops of bowel in the left
inguinal region extending down to the scrotum.
132
Inguinal Hernia

133. Conclusion
• Plain radiograph of a neonate provides a useful initial imaging tool to guide
appropriate further imaging, conservative or surgical management.
• Abnormal bowel gas pattern on plain radiography can be diagnostic of a specific
bowel pathology (e.g. in case of duodenal and jejunal atresia) without further
investigations required.
• However, in majority of the cases contrast study will be required to reach a final
diagnosis.
• It is important for radiologists to have a good understanding of normal and
abnormal bowel gas patterns and the potential differential diagnosis.
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134. THANK YOU
134