DIAGNOSTIC IMAGING OF GASTROINTESTINAL TRACT IN CHILDREN

1. DIAGNOSTIC IMAGING OF GASTROINTESTINAL TRACT IN CHILDREN

2. Differences in structure and function of gastrointestinal tract in children • Esophagus • - neonates and infants (< 1 year of life) • wider and with slower peristaltic movements • no visible mucosal folds in the first 6 months of life • transient gastro-esophageal reflux - physiology • toddlers and older children - as in adults • Stomach • - neonates and infants (< 1 year of life) • large stomach, its pyloric part is placed on the right side and distends backwards • no visible mucosal folds in the first 6 months of life

3. Differences in structure and function of gastrointestinal tract in children Bowel (duodenum, small and large bowel) - neonates and infants (< 1 year of life) duodenal bulb is small and round no visible mucosal folds in the first 6 months of life aerophagia (massive amount of air in small bowel) long large bowel with extra loop of sigma ileo-cecal valve insufficiency - physiology In toddlers and older children radiographic appearance and function of gastrointestinal tract is similar to adults

4. Abdominal Xrays – technical factors • The abdominal examination should includea minimum of three views: supine, prone,and erect.A lateraldecubitusview or a lateral ‘shootthrough’ film , with a horizontalbeam, is sufficient if the patient is too sick or unableto stand. • One can think of the air in the abdomen as contrast • medium; the purpose of obtaining three views is to • move air into different loops of bowel so that the • maximal quantity of bowel can be visualized.

5. The value of air as contrast medium by utilizing three views Supine roentgenograph in this 15-year-old girl withabdominal pain reveals multiple air-filled loops of bowelin the midabdomen but little gas within the rectum An erect film reveals that the base of the lungs is clear,and there is no free air under the diaphragm. There is gasin the hepatic flexure, transverse colon, and splenic flexure Prone examination reveals gas in the rectum (R),ascending (A), and descending (D) colon. The predominantpattern is that of colonic gas. The small bowel is notdistended, and there is no evidence of obstruction

6. Normal bowel gas pattern in a neonate 1st day 2nd day 12 hours 36 hours

7. ? Normal bowel pattern in a neonate. supine view - bowel loops display a polygonal pattern Abnormal gas pattern A supine film of a 4-year-old with a protuberant abdomen - large, homogeneous mass over the right and midabdomen.The bowel gas is pushed to the left. A sonographic examination confirmed the presence of a mesenteric cyst Ascites (secondary to urinary obstructionand posterior urethral valves). On this supine radiograph of a 2-day-old male infant the bowel gas is pushed to the center, and there is a grayness tothe flanks. The bowel loops float centrally instead of being displaced to one side by a mass

8. AbdominalXrays – technicalfactors • The film mustincludethe base of the lungs and • diaphragm as well as thepubic bone (on at least one of • the three films). • On every abdominal film, examine the chest as if you were actually reading a chest film.

9. Upright abdominal film in a 4-year-old with abdominal pain. Opacity in the medial left chest at T9–10 - a pneumonia. A 6-year-old with right lower quadrant pain. Opacity in the right medial region adjacent to T9–11 - also a pneumonia.

10. AbdominalXrays – technicalfactors • Look for signs offree intraperitoneal air • Look specifically for calcifications in all areas of • the abdomen. Stones in the gallbladder, urinary tract, • pancreas, or appendix may occur if there is stasis or • an inflammation. Benign and malignantneoplasmscan • calcify. • Assessthe size and amount of bowel distention

11. Perforation of a viscus and free intraperitoneal air. Supine abdominal film - a change in density of theliver in relation to the lateral abdominal wall. The entire abdomen is more lucent or blacker. There isair on each side of the falciform ligament. Decubitus film - a massive amountof air within the abdominal cavity.

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13. Calcifications within the abdomen gallstones meconium peritonitis appendicolith teratoma

14. Small bowel obstruction. (an incarcerated inguinal hernia) Erect film shows multiple air-fluid levels in a stepladderpattern Supine radiograph shows large, distended loops in the midabdomen On the prone film, gas has not successfully shifted intothe colon. The largest loops remain in the midabdomen.

15. The most common GI tract problems diagnosed in neonatal period GASTROINTESTINAL TRACT OBSTRUCTIONS • Diagnosed just after birth in the delivery room • esophageal atresia – by placing soft catheter in theesophagus via nose • anal atresia – no visible anal orifice

16. The most common GI tract problems diagnosed in neonatal period GASTROINTESTINAL TRACT OBSTRUCTIONS • Diagnosed within the first day(s) of life: • duodenal atresia • bowel atresia • meconium peritonitis • meconium plug syndrome • malrotation • diaphragmatic hernias

17. neonates The most common GI tract problems diagnosed in neonatal period ACUTE ABDOMEN IN NEONATAL PERIOD • NEC • Hirschsprung disease • paralytic ileus • functional ileus due to prematurity – temporary poor intestinal function during the first few days of life (immaturity of neuronal plexuses)

18. The most common GI tract problems diagnosed in infants ACUTE ABDOMEN VOMITING • NEC • intussesception • paralitic ileus • pyloric stenosis • malrotation • GER • esophageal stricture due to abnormal blood vessel HIRSCHSPRUNG DISEASE

19. The most common GI tract problems diagnosed in toddlers and older children ABDOMINALGIA: due to GI tract diseases due to Urinary tract diseases liver and pancreas diseases other OTHER: caustic or thermal burns varices foreign bodies neoplasms achalasia ACUTE ABDOMEN: acute appendicitis intusussception paralytic ileus

20. Esophageal Atresia NEWBORNS • Most common abnormality app. 1:3000 live births • Usually associated with tracheoesophageal fistula (app. 95% of cases) • 50-70% of patients have associated anomalies (cardiovascular, urogenital, gastrointestinal, skeletal, VACTERL association in 25%) • Clinical findings: • excessive drooling / slavering • choking with feeding • accompanying respiratory distress resulting from aspiration

21. Esophageal Atresia Five main typesand additionally H-fistula (3)(fistula without atresia) The most common (75%) type - with distal fistla Visible air in the GI tract (stomach and bowel) is a proof of distal tracheoesophageal fistula

22. Esophageal Atresia air in GI tract - distal tracheoesophageal fistula Soft catheter in the proximal pouch of esophagus

24. ? Isolated EA or EA with a proximal fistula EA with a distal fistula

25. Esophageal Atresia VATER or VACTERL – a group of abnormalities

26. Esophageal Atresia 9 years old boy after surgical treatment - with clinical good effects

27. Duodenal Obstruction NEWBORNS • Causes of duodenal obstruction in the newborn: • intrinsic • duodenal atresia • duodenal stenosis • duodenal web or diaphragm or „wind-sock" deformity • extrinsic • Ladd’s (peritoneal) bands resulting from midgut malrotation • midgut volvulus complicating malrotation • annular pancreas • preduodenal portal vein • duplication • hematoma

28. Duodenalatresia App.50% of patients have other anomalies ( 20-30% Down syndrome, malrotation of small bowel, any other GI tract part atresia, congenital heart disease, biliary atresia, annular pancreas, renal anomalies, situs inversus, VACTERL anomaly) • Clinical findings: • Vomiting soon after birth, usually bilious (common postampullary level of obstruction) • Abdomen if often collapsed and scaphoid • Increased amount of amniotic fluid (polyhydramnios in prenatal period) – dilated stomach and proximalduodenum

29. Duodenalatresia Erect chest and abdomen radiograph – „double bubble”, no air in distal bowel

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31. Anorectal anomalies NEWBORNS • 1:5000 live births • Ecopic or imperforate anus • Anorectal atresia • Anal/anorectal stenosis 1: • Associated anomalies of: • lumbosacral spine • genitourinary sinus (rectourinary fistula in boys, rectovaginal fistula, hydromethrocolpos in girls, bladder or perineal fistula in both sexes) – imaging of urinarytract is obligated • bladder (neurogenic bladder)

32. Anorectal anomalies • Associated anomalies of: • VACTERL sequence occurs in around 45% of patients • OEIS complex (omphalocele, bladder exstrophy, • imperforate anus and sacral anomalies) in up to 5% • 2-8% patients have Down’s syndrome

33. Anorectal anomalies • The relationship to the puborectalis muscle dividesthe group of malformation into high and low. This classification has an important implications regarding surgical treatment as well as predicting continence • High anorectal malformations – supralevator – worse prognosis, greater risk of associated anomalies • Low anorectal malformations – infralevator – better prognosis, less operating procedures (one-step treatment)

34. Anorectal anomalies • Thedistinctionbetween high and lowlesionsisclinicalratherthanradiological. • In bothmale and femaleinfantswithlowlesions (therectumendsbelowthepuborectalissling), thereisusually a visibleperinealopening. Lowlesions do not have a communicationwiththe GU tract. • In bothmale and femalepatientswith high lesions, no visibleperinealfistulaispresent. Male patients will have a fistuloustractbetweentheatreticanorectum and theposteriorurethra (less common – fistula to thebladderoranteriorurethra). • Femalepatients – fistulas to vagina .

35. Anorectal anomalies • Thetraditionalradiologicalapproach – theinvertedlateralradiograph • a radioopaque marker isplacedovertheanaldimple • and thedistancebetweenthethepouch of rectal • gas and the marker ismeasured > 15 MM • Transperineal US, MRI • Plainradiographs – to demonstrateintravesical air • (implying a high lesionwith a rectovesicalorrectourethralfistulain a boy) orcalcifiedintraluminalmeconium

36. Anorectal anomalies Recto-urethral fistula „invertogram”

38. MR 12 MM RECTUM SACRUM

39. Meconium ileus /meconium plug syndome NEWBORNS • Mostly in cystic fibrosis (in 20-30% of CF affected children) • Thick meconium lasts in the jejunum, terminal ileum is packed with dried pellets resembling rabbit droppings – causing ileus • Complications (50%) – meconium peritonitis due to perforation, bowel atresia, stenosis, volvulus • Plain roentgenogram – meconium masses on the right side of abdomen, small mount of air in the colon, no fluid-air levels; • Colonography – microcolon – secondary to failure of small bowel contents to pass into the colon • Hypertonic CM colonography has the diagnostic and therapeutic function (fluid moves from the intercellular space into the colonic lumen, softens the meconium stool)

40. Meconium ileus /meconium plug syndome/ Microcolon in meconium plug syndrome Intraluminal meconium plugs

41. NEWBORNS Meconium peritonitis • Is the effect of GI tract perforation in the fetal period • Meconium passes from the bowel to peritoneal cavity and causes chemical peritonitis. Clinical findings in the neonate • ileus • malrotation • calcifications in peritoneum

42. Meconium peritonitis Calcifications on the right side of abdomen, some dilated loops of bowel, abdominal distension

43. NEWBORNS Necrotizing enterocolitis • Mostly in premature neonates (1-3 in 1000 live births) • Due to bowel ischemia in respiratory distress of premature, decreased mucus production, diminished immune response of premature baby – break-down of intestinal mucosal barrier • Clinical diagnosis should be established because rentgenografic signs are late and suggest the complications (bowel distention, bowel intramural gas pneumatosis intestinalis, portal venous gas, pnemoperitoneum) • USG – free fluid in the peritoneal cavity may be a early symptom of NEC • Complications – bowel perforation, peritonitis, bowel stenosis

44. Necrotizing enterocolitis Free air in peritoneal cavity – bowel perforation Airless bowel loopsPHYSIOLOGYIN THE FIRST DAY OF LIFE

45. Necrotizing enterocolitis Pneumatosis intestinalis

46. The specyfice common GI tract problems diagnosed in infants ACUTE ABDOMEN VOMITING • NEC • intussesception • paralitic ileus • pyloric stenosis • malrotation • GER • esophageal stricture due to abnormal blood vessel HIRSCHSPRUNG DISEASE

47. INFANTS Pyloric stenosis (pyloric muscle hypertrophy) • The most common cause of gastric outlet obstruction app. 1: 500 infants • Usually 3 to 6 weeks with range 1 week to 3 months • Positive family history in 5% of cases • 80-85% affected children are males • Etiology is not known • Hypertrophy of circular muscle and mucosa of the pylorus • Clinical findings: • Vomiting, initially mild (often early in life) • As the relative degree of obstruction increases, vomiting progress rapidly • Dehydration and inadequate body weight • 5% of patients are mildly jaundiced

48. Pyloric stenosis (pyloric muscle hypertrophy)

49. INFANTS Intussusception • Invagination or telescoping of one portion of intestine into the contiguous distal segment • Peak of incidence 2 months to 3 years – • Idiopathic intussusception is the most common cause of small intestine obstruction in the infancy and toddler age group • The possible lead point is hypertrophy of Peyer’s patches or reactive lymphoid hyperplasia of the terminal ileum • In newborns and older children/adults intussusception should alert one to possibility of pathologic lead point (lymphoma) • 2/3 of affected children are boys • 90% intussuscepions are ileocolic, ileoileic and colocolic are uncommon

50. Intussusception