SAM 1: Concerning secretin, what is 2014 SPR Postgraduate true? Course A. Administered as a bolus B. Contraindicated in cholelithiasis Module 3: Gastrointestinal C. Relaxes the sphincter of Oddi Moderators: Kassa Darge, MD/PhD and Jonathan Dillman, MD D. Causes gallbladder contraction

Washington DC E. Stimulates bicarbonate secretion

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Concerning secretin, what is true? SAM 2: What feature of chronic is seen in this secretin MRCP?

• A) is NOT correct – secretin must be slowly References A. Parenchymal calcification administered over one minute to avoid • Tirkes T, Sandrasegaran K, Sanyal R, Sherman and S, Schmidt CM, Cote GA, Akisik F. Secretin- B. Peripancreatic fluid collection • B) is NOT correct – the only relative enhanced MR cholangiopancreatography: contraindication to secretin use is acute spectrum of findings. Radiographics. 2013 Nov- C. Pancreatic parenchymal pancreatitis Dec;33(7):1889-906 edema • C) is NOT correct – secretin causes a transient • Tirkes T, Menias CO, Sandrasegaran K. MR increase in tone at the sphincter of Oddi which imaging techniques for . Radiol Clin D. Side branch dilation partly accounts for duct dilation North Am. 2012 May;50(3):379-93. • D) is NOT correct – secretin has no effect on • Delaney L, Applegate KE, Karmazyn B, Akisik E. stone gallbladder contraction MF, Jennings SG. MR • E) is correct – secretin stimulates cholangiopancreatography in children: bicarbonate secretion which, combined with feasibility, safety, and initial experience. Pediatr increased tone at the sphincter of Oddi Radiol. 2008 Jan;38(1):64-75. causes pancreatic duct dilation

1 SAM 3: 5 year old with pancreatitis. What is the most What feature of is likely diagnosis and etiology of the pancreatitis? seen in this secretin MRCP?

• A) is NOT correct – calcifications are not References A. Pancreas divisum visible • Tirkes T, Sandrasegaran K, Sanyal R, • B) is NOT correct – peripancreatic fluid Sherman S, Schmidt CM, Cote GA, Akisik F. B. Chronic pancreatitis collections are a finding of Secretin-enhanced MR and are not seen in this case cholangiopancreatography: spectrum of C. Choledochal Cyst Type • C) is NOT correct – parenchymal edema is a findings. Radiographics. 2013 Nov- finding of acute pancreatitis and is not seen Dec;33(7):1889-906 4a in this case • Tirkes T, Menias CO, Sandrasegaran K. MR • D) is correct – dilated side branches are imaging techniques for pancreas. Radiol Clin D. Choledocholithiasis visible in the head and body of the North Am. 2012 May;50(3):379-93. pancreas • E) is NOT correct – there is no filling defect in the pancreatic duct to suggest the presence of a pancreatic duct stone

5 year old with pancreatitis. What is the most 5 year old with pancreatitis. What is the most likely diagnosis and etiology of the pancreatitis likely diagnosis and etiology of the pancreatitis based on the image? based on the image?

Answer- Choice C is correct: The 3D reconstruction Figure B Choice D is not correct as well. There would be filling defects representing stones but there are no stones or debris from MRCP shows dilated intra and extrahepatic ducts in the ducts. No gallstones either. Keep in mind though bile stasis predisposes patients to develop sludge and which qualify as a Type 4A choldedochal cyst according stones in the bile ducts. to the Todani classification. There is mass effect on the pancreatic duct which is not uncommon and results in backwash of pancreatic fluid resulting in pancreatitis. References: Choice A is not correct as the pancreatic duct and CBD do • Mortele KF, Rocha T et al Multimodality Imaging of Pancreatic and Biliary Congenital Anomalies, Radiographics not separately insert, the definition of pancreas divisum. 2006 • Egbert ND, Bloom DA, Dillman JR. Magnetic resonance imaging of the pediatric pancreaticobiliary system. Choice B is not correct. A child with chronic pancreatitis will Magn Reson Imaging Clin N Am. 2013 Nov;21(4):681-96. have multiple episodes of pancreatitis in the past with a very • Rizzo RJ, Szucs RA et al. Congenital Abnormalities of the Pancreas and Biliary Tree in Adults abnormal appearing duct with undulations, irregularities, Chronic pancreatitis strictures and opacification of side branches (see Figure B).  Ductal dilatation

2 SAM 4: Boy with Crohn’s disease Boy with Crohn’s disease and new buttock pain. What is the and new buttock pain. What is the diagnosis?

diagnosis? • Answer is B. Intersphincteric Abscess References • Rationales: The images show a peripherally- • Hammer MR, Dillman JR, Smith EA, Al- enhancing fluid collection located in the Hawary MM. Magnetic resonance imaging intersphincteric space, consistent with an of perianal and perineal Crohn disease in intersphincteric abscess. Such abscesses that children and adolescents. Magn Reson A. Skin Tag cross the midline are sometimes referred to as “horseshoe” abscesses. Imaging Clin N Am. 2013 Nov;21(4):813- B. Intersphincteric Abscess 28. • A supralevator abscess would be located above C. Transphincteric Fistula the levator ani musculature. Transphincteric • O'Malley RB, Al-Hawary MM, Kaza RK, fistulas are linear tracts that traverse both the Wasnik AP, Liu PS, Hussain HK. Rectal D. Extrasphincteric Fistula internal and external anal sphincter muscles, while imaging: part 2, Perianal fistula evaluation extrasphincteric fistulas extend from the high on pelvic MRI--what the radiologist needs E. Supralevator Abscess perirectal region through the levator ani to know. AJR Am J Roentgenol. 2012 musculature into the ischioanal fossa. Skin tags Jul;199(1):W43-53. appear as enhancing lobular polypoidal growths arising from the perianal skin surface.

SAM 5: 9 year old with failure to thrive and coffee SAM 5: 9 year old with failure to thrive and ground emesis. Touch the abnormality. coffee ground emesis. Touch the abnormality

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3 SAM 6: What is the abnormality in this 9 year old with failure to thrive and coffee ground emesis? 9 year old with failure to thrive and coffee ground emesis. What is the abnormality? A.Pancreas divisum • Answer-Correct Choice D : This spot image from the upper GI demonstrates an incomplete obstruction in the second portion of the duodenum. The basis of annular pancreas is B.Pancreatitis duodenal stenosis/obstruction. In the largest series to date, all children presented with duodenal obstruction (Zyromski et al), not pancreatitis as was once thought. There is also a higher association with other congenital anomalies. Embryologically there is an error in rotation and fusion of the pancreas C.Choledochal Cyst during the 4-9th weeks of gestation. The ventral pancreatic bud fuses to the duodenum –this then results in abnormal rotation of the ventral bud during the fusion with the dorsal analge. Eventually there D.Annular Pancreas is a partial or complete ring of pancreatic tissue around the second portion of the duodenum with or without inclusion of the pancreatic duct.

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9 year old with failure to thrive and coffee ground SAM 7: 6-year-old male. Which is the most emesis. What is the abnormality? likely mechanism of injury?

• Choice A is not correct as there is no bowel obstruction References associated with pancreas divisum. In fact the diagnosis • Mortele KF, Rocha T et al Multimodality A. Penetrating laceration can be made on MRCP not on upper GI examination. Imaging of Pancreatic and Biliary Congenital • Choice B is not correct and this diagnosis cannot be Anomalies, Radiographics 2006 B. Blunt injury from bicycle made based on this modality, but is best identified on US, • Egbert ND, Bloom DA, Dillman JR. handlebar MRI or CT. Pancreatitis alone will result in edema, Magnetic resonance imaging of the pediatric enlargement of the pancreas with mild dilatation of the pancreaticobiliary system. Magn Reson C. Diving into a shallow pool pancreatic duct with or without pancreatic fluid collections. Imaging Clin N Am. 2013 Nov;21(4):681-96. There is no associated duodenal obstruction with • Rizzo RJ, Szucs RA et al. Congenital D. Flank injury from karate kick pancreatitis Abnormalities of the Pancreas and Biliary • Choice C is not correct. are a form of Tree in Adults ductal ectasia and can result in mass effect on the head of the pancreas or result in upstream intrahepatic ductal dilatation, but they do not result in duodenal narrowing or obstruction.

4 SAM 8: 12 year-old-male with upper abdominal 6-year-old male. Which is the most likely trauma. What is most suggestive of a pancreatic mechanism of injury? ductal injury? A. Non-visualization of the pancreatic duct • The answer is “B”. Blunt injury References: B. Free fluid in the pelvis from bicycle handlebar. • Lam JPH et al. Delayed presentation • Rationales: Bicycle accidents account of handlebar injuries in children. BMJ. C. Peripancreatic fluid collection for 5-14% of blunt abdominal trauma 2001 May26; 322(7297): 1288-1289. in children, and handlebar injuries • Gross JA et al. Handlebar Injury D. Free intraperitoneal air visualized account for 27% of blunt pancreatic Causing Pancreatic Contusion in a by ultrasound trauma in children. All other listed Pediatric Patient. Am J Roentgenol, mechanisms of pancreatic injury 2002; 179;222 would be substantially less likely to cause a pancreatic laceration.

SAM: 12 year-old-male with upper abdominal trauma. SAM 9: What would suggest a predominantly Which of the following is most suggestive of a fibrotic stricture? pancreatic ductal injury?

• The answer is “C”. Peripancreatic fluid collection References: A. Luminal narrowing • Rationale: Peripancreatic fluid collections in the • Sivit CJ et al. Imaging Children with setting of suspected pancreatic trauma are Abdominal TraumaAJR May 2009, B. Proximal bowel dilation suggestive of pancreatic ductal injury. Approximately Volume 192, Number 5 one half of focal fluid collections that develop after C. Hyperintense T2W signal in the pancreatic injury evolve into pseudocysts., and • Ruess L, Sivit CJ, Eichelberger MR, approximately one half of pseudocysts resolve Gotschall CS, Taylor GA. Blunt abdominal bowel wall spontaneously. Others require percutaneous trauma in children: impact of CT on drainage or surgical drainage. When pancreatic operative and nonoperative management. D. Lack of significant early post- ductal injury occurs, the duct distal to the injury often Am J Roentgenol. 1997;169:1011–1014. dilates (as seen in the provided image). Free fluid in contrast enhancement the pelvis may be present in patients with abdominal trauma, but this finding would be unlikely to be E. Persistent on multiple different related to pancreatic ductal injury. Free intraperitoneal air implies a hollow visceral injury. sequences

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5 Terminal ileum stricture (arrows) and small bowel dilation (*). What suggests the diagnosis of a predominantly fibrotic stricture in Crohn’s Recurrent pancreatitis. What is the abnormality? disease?

• A – incorrect – luminal narrowing could be seen References: with any type of stricture (inflammatory, fibrotic or mixed) • Zappa M, Stefanescu C, Cazals-Hatem D, et al. • B – incorrect – proximal bowel dilation can also be Which magnetic resonance imaging findings seen with any type of stricture accurately evaluate inflammation in small bowel • C – incorrect – hyperintense T2W signal in the Crohn’s disease? A retrospective comparison bowel wall indicates edema and is seen with with surgical pathological analysis. Inflamm active inflammation Bowel Dis 2011; 17: 984-993 • D – correct – lack of significant enhancement • Quencer KB, Nimkin K, Mino-Kenudson M, Gee indicates the absence of active inflammation, MS. Detecting active inflammation and fibrosis which would support a fibrotic stricture in pediatric Crohn’s disease: Prospective • E – incorrect – stricture from any etiology should evaluation with MR-E and CT-E. Abdoml persist on all sequences Imaging 2013; 38: 705-713

Recurrent pancreatitis. What is the Recurrent pancreatitis. Touch the abnormality. abnormality?

• A. Bayonete pancreas • B. Annular pancreas • C. Pancreas divisum • D. Ectopic pancreas

6 SAM: What best describes the finding in known Recurrent pancreatitis. What is the abnormality? Crohn’s disease?

A. Given the enhancement, this is a purely • Diagnosis: Pancreas Divisum inflammatory stricture. • Rationale: Pancreas divisum is the most common of the congenital anomalies B. Given the proximal bowel dilation, this is resulting from failure of fusion of the ventral a purely fibrotic stricture. and dorsal anlage of the pancreas. In those with recurrent pancreatitis, 12-26% of C. There is a stricture with evidence of patients have PDV. The main imaging inflammation, but underlying fibrosis feature of Pancreas divisum on MR is that could also be present. the main dorsal duct is in continuity with the duct of Santorini and drains into the major D. There is active inflammation without a papilla and the ventral duct (not stricture. communicating with dorsal duct) joins the CBD and drains into the minor papilla. E. The findings are likely due to adhesions from prior surgery.

What best describes the finding in known Crohn’s SAM: 15 year-old boy with disease? Crohn’s proctitis and pelvic pain. What is the most likely diagnosis? • A – incorrect – while the enhancement is evidence of References inflammation, many strictures have components of both • Adler J, Stidham RW, Higgins PDR. Bringing inflammation and fibrosis and enhancement does not the inflamed and fibrotic bowel into focus: exclude a fibrotic component Imaging in inflammatory bowel disease. J A. Cutaneous Crohn’s Disease • B – incorrect – all types of strictures (inflammatory, Gastroenterol Hepatol 2009; 5: 705-715 fibrotic and mixed) will cause proximal dilation • Adler J, Swanson SD, Schmiedlin-Ren P, et B. Ischioanal Abscess • C - correct – many strictures that have findings of al. Magnetization transfer helps detect active inflammation also have histologic evidence of intestinal fibrosis in an animal model of Crohn C. Transphincteric Fistula fibrosis disease. Radiology 2011; 259: 127-135 • D – incorrect – the proximal bowel dilation and clinical • Zappa M, Stefanescu C, Cazals-Hatem D, et D. Intersphincteric Fistula presentation of bowel obstruction both indicate a al. Which magnetic resonance imaging E. Supralevator Fistulous Disease stricture findings accurately evaluate inflammation in small bowel Crohn’s disease? A retrospective • E – incorrect – adhesions would not cause the bowel comparison with surgical pathological wall thickening and hyper-enhancement indicative of analysis. Inflamm Bowel Dis 2011; 17: 984- active inflammation 993

7 In this 15 year-old boy with proctitis due to Crohn’s disease and SAM: Pelvic axial T2 in an 8-year-old male with treated anal pelvic pain, what is the most likely diagnosis? stricture. What is the presacral mass (arrow)?

• Answer is E. Supralevator Fistulous Disease References: A. Posterior urethral • The images show supralevator T2-weighted • Hammer MR, Dillman JR, Smith EA, Al- diverticulum signal hyperintensity and enhancement that is Hawary MM. Magnetic resonance imaging most likely due to supralevator fistulous of perianal and perineal Crohn disease in B. Anterior meningocele disease. children and adolescents. Magn Reson • Visualized skin appears normal without Imaging Clin N Am. 2013 Nov;21(4):813- C. Duplicated thickening or hyperenhancement. No peripherally-enhancing fluid collection is present 28. D. Sacrococcygeal in the ischioanal fossa. Transphincteric fistulas • O'Malley RB, Al-Hawary MM, Kaza RK, teratoma are linear tracts that traverse both the internal Wasnik AP, Liu PS, Hussain HK. Rectal and external anal sphincter muscles, while imaging: part 2, Perianal fistula evaluation E. Stool intersphincteric fistulas course through the on pelvic MRI--what the radiologist needs intersphincteric plane. to know. AJR Am J Roentgenol. 2012 Jul;199(1):W43-53.

Pelvic axial T2 in an 8-year-old male with treated anal stricture. SAM: 5-year-old male with repaired . What is What is the presacral mass (arrow)? the cystic mass posterior to the bladder? • The answer is D. • The MRI shows a heterogeneous presacral mass. Anorectal malformations (ARM) are associated with presacral masses such as sacrococcygeal teratomas and anterior meningoceles. • Option A is NOT correct. A posterior urethral diverticum is one of the most common urologic A. Posterior urethral diverticulum complications in postoperative ARM patients. Patients with anal strictures are often treated non- operatively. The diverticum is the result of the incomplete resection of the distal rectum. When B. Anterior meningocele present, they occur between the bladder and the rectum, not posterior to the rectum. • Option B is NOT correct. Anterior meningoceles are the most common presacral mass in patients with C. Post-operative seroma ARM. They are cystic lesions that are uniformaly bright on T2-W images. In addition, the meningocele should be connected to the spinal canal. D. Sacrococcygeal teratoma • Option C is NOT correct. A duplicated colon can occur; however, they have an appearance more E. Ectopic ureter similar to bowel. • Option D is correct. Sacrococcygeal teratoma is the most common tumor in patients with ARM. It is often mixed cystic and solid with a heterogeneous appearance on MRI. • Option E is NOT correct. Stool should be within the colon. References: • Podberesky DJ, Towbin AJ, Eltomey MA, Levitt MA. Magnetic resonance imaging of anorectal malformations. Magn Reson Imaging Clin N Am. 2013;21:791-812. • Bischoff A, Levitt MA, Peña A. Update on the management of anorectal malformations. Pediatr Surg Int. 2013;29:899-904.

8 5-year-old male with repaired imperforate anus. What is the SAM: Upper abdomen US in 9 year old girl with sickle cell cystic mass posterior to the bladder? disease, gallstones, and now upper abdominal pain. Which is most correct regarding the superior mesenteric artery and vein? • The answer is A. • The MRI shows a cystic mass arising from the posterior aspect of the bladder. The mass has a fluid/fluid level. • Option A is correct. A posterior urethral diverticum is one of the most common urologic complications in postoperative ARM patients. The diverticum is the result of the incomplete resection of the distal rectum. A. A normal relationship excludes malrotation. Patients with posterior urethral diverticulum are at increased risk to develop urinary calculi, recurrent urinary tract infections, and even malignancy. B. A normal relationship is present in “non-rotation” • Option B is NOT correct. Anterior meningoceles are the most common presacral mass in patients with ARM. They are cystic lesions that are uniformaly bright on T2-W images. In addition, the meningocele should be connected to the C.Inversion of the relationship is never a normal spinal canal, not the bladder. finding. • Option C is NOT correct. Post-opertative seromas can occur but should not have a direct connection to the bladder. • Option D is NOT correct. Sacrococcygeal teratoma are the most common tumor in patients with ARM. They are D.Inversion of the relationship is present in “non- typically mixed cystic and solid with a heterogeneous appearance on MRI. They do not connect to the bladder. • Option E is NOT correct. Ectopic ureters connect to the bladder but course superiorly towards the kidney. This rotation” collection courses inferiorly towards the base of the pelvis. References: E. Inversion of the relationship indicates the • Podberesky DJ, Towbin AJ, Eltomey MA, Levitt MA. Magnetic resonance imaging of anorectal malformations. Magn Reson Imaging Clin N Am. 2013;21:791-812. presence of volvulus • Bischoff A, Levitt MA, Peña A. Update on the management of anorectal malformations. Pediatr Surg Int. 2013;29:899-904. • Alam S, Lawal TA, Peña A, Sheldon C, Levitt MA. Acquired posterior urethral diverticulum following surgery for anorectal malformations. J Pediatr Surg. 2011;46:1231-5.

Upper abdomen transverse US in a 9 year old girl with sickle cell disease, gallstones, and now upper abdominal pain. Which is SAM: 1 year old boy with vomiting. Diagnosis? most correct regarding the superior mesenteric artery and vein?

• Answer is D. References A. Intussusception • The sonographic image illustrates inversion of the • Loyer E, Eggli KD (1989) Sonographic evaluation superior mesenteric artery and vein relationship – the of superior mesenteric vascular relationship in B. Inflammatory bowel disease vein is anterior and to the left of the artery. It is present malrotation. Pediatr Radiol 19:173-175 C. Midgut malrotation and volvulus in most cases of malrotation including patients with so- • Weinberger E, Winters WD, Liddell RM et al (1992) D. Inflamed Meckel’s diverticulum called “nonrotation.” Sonographic diagnosis of in • Option A is not correct. A normal relationship does not infants: importance of the relative positions of the E. Solid neoplasm of pancreas exclude malrotation. superior mesenteric vein and artery. AJR Am J • Option B is not correct. A normal relationship is not Roentgenol 159:825-828 usually present in “non-rotation” • Strouse PJ (2000) Disorders of intestinal rotation • Option C is not correct. Inversion of the relationship and fixation (“malrotation”). Pediatr Radiol 34:837- may be present with normal rotation. 851 • Option E is not correct. Inversion does not indicate the presence of a midgut volvulus. • Orzech N, Navarro OM, Langer JC. (2006) Is ultrasonography a good screening test for intestinal malrotation? Pediatr Surg 41(5):1005-9.

9 SAM: Cumulative effective dose (CED) above 50 mSv has 1 year old boy with vomiting. Diagnosis? been associated with an increased cancer risk. About what fraction of inflammatory bowel disease patients undergoing • Answer is C. The sonogram demonstrates a “mass” with a References concentric ring appearance which is most in keeping with a • Chao HC, Kong MS, Chen JY et al imaging will exceed 50 mSv? volvulus of the midgut associated with malrotation. (2000) Sonographic features related to • Option C is correct. The sonographic appearance is volvulus in neonatal intestinal due to the and vessels coiled around malrotation. J Ultrasound Med 19:371- the superior mesenteric artery in the centre. 376 •A. 3% • Option A is not correct. The mass of an intussusception • Shimanuki Y, Aihara T, Takano H et al does not have a vessel in the centre. There is more (1996) Clockwise whirlpool sign at color •B. 6% echogenic mesenteric fat between the layers of an Doppler US: an objective and definite intussusception. •C. 9% sign of midgut volvulus. Radiology • Option B is not correct. Inflammation of the bowel wall 199:261-264 causes thickening of the wall and increased echogenicity • D. 12% but does not have this concentric ring appearance. • Yoo SJ, Park KW, Cho SY et al (1999) • Option D is not correct. Although Meckel’s diverticulum can Definitive diagnosis of intestinal volvulus • E. 24% present as a mass it is seldom in the upper abdomen and if in utero. Ultrasound Obstet Gynecol inflamed may often surrounding echogenic fat. 13:200-203 • Option E is not correct. Pancreatic neoplasms are rare in • Strouse PJ (2000) Disorders of intestinal infants and do not have a concentric ring appearance. rotation and fixation (“malrotation”). Pediatr Radiol 34:837-851

SAM: Cumulative effective dose (CED) above 50 mSv has SAM: Children have higher risk of cancer development from been associated with an increased cancer risk. About what ionizing radiation than adults. Patients with inflammatory bowel fraction of inflammatory bowel disease patients undergoing disease are at even higher cancer risk because: imaging will exceed 50 mSv?

A. Inherently higher risk of cancer development • Answer is B. 6% References • Fuchs Y, Markowitz J, Weinstein T, Kohn N, from the disease itself • In retrospective studies it was found that the Choi-Rosen J, Levine J. Pediatric CED was >50 mSv in approximately 6% of inflammatory bowel disease and imaging- B. Repetitive diagnostic studies due to patients with inflammatory bowel disease related radiation: are we increasing the recurrence of the disease undergoing imaging studies. likelihood of malignancy? JPGN (2011) 52: 280-285 C. Medications used to treat the inflammatory • Huang JS, Tobin A, Harvey L, Nelson TR. Diagnostic medical radiation in pediatric bowel disease patients with inflammatory bowel disease. JPGN (2011) 53: 502–506 D. A and B E. A, B and C

10 Children have higher risk of cancer development from ionizing 15-year-old with pancreatic laceration from radiation than adults. Patients with inflammatory bowel disease bicycle handlebar injury. What are the salient are at even higher cancer risk because: imaging findings?

• Answer is E. A, B, and C. References • Sauer CG. Radiation exposure in children • All the above factors are additional factors with inflammatory bowel disease. Curr Opin A. Normal proximal pancreatic segment and that increase the risk of cancer in patients Pediatr (2012): 24:621–626 fatty infiltration of the distal segment with inflammatory bowel disease undergoing • Fuchs Y, Markowitz J, Weinstein T, Kohn N, B. Fatty infiltration of the proximal pancreatic imaging studies. Choi-Rosen J, Levine J. Pediatric inflammatory bowel disease and imaging- segment and normal distal segment related radiation: are we increasing the C. Normal proximal pancreatic segment and likelihood of malignancy? JPGN (2011) 52: 280-285 pancreatitis of the distal segment • Huang JS, Tobin A, Harvey L, Nelson TR. D. Pancreatitis of the proximal pancreatic Diagnostic medical radiation in pediatric patients with inflammatory bowel disease. segment and normal distal segment JPGN (2011) 53: 502–506

Axial T2 HASTE

15-year-old female with pancreatic laceration Crohn’s disease and intermittent partial bowel obstruction. from bicycle handlebar injury. What are the Touch the stricture. salient imaging findings?

Pancreatitis of distal • C. Normal proximal pancreatic segment and pancreatic segment pancreatitis of the distal segment • Explanation: Axial T2 images show normal signal of the gland proximal to the laceration. The distal pancreatic segment is enlarged and demonstrates heterogeneous intrasubstance increased signal, as well as surrounding free fluid and abnormal fluid signal in the anterior pararenal space, consistent with pancreatitis. Pancreatic duct is dilated in the distal pancreatic segment Normal proximal pancreatic segment

11 Based on the illustration, indicate which numbered tract is a Crohn’s disease and intermittent partial bowel obstruction. transphincteric fistula? Touch the stricture.

A. 1 B. 2 C. 3 D. 4

8-year-old female with repaired anorectal malformation and Based on the illustration, indicate which numbered tract is a fecal incontinence. What is in the red oval? transphincteric fistula? • Answer is B. 2 • Rationale: The illustration shows four types of fistula tracts. “2” represents a transphincteric fistula, crossing both the internal and external sphincter muscles. “1” represents an intersphincteric fistula coursing through the intersphincteric plane, while “3” represents a A. Levator muscle suprasphincteric fistula which extends superiorly through the intersphincteric space before passing B. Ischiorectal fossa through the levator ani musculature and extending into the ischioanal fossa. “4” represents an extrasphincteric C.Mesenteric fat fistula which extends from the high perirectal region D.Space of Retzius through the levator ani musculature into the ischioanal fossa. References: • Hammer MR, Dillman JR, Smith EA, Al-Hawary MM. Magnetic resonance imaging of perianal and perineal Crohn disease in children and adolescents. Magn Reson Imaging Clin N Am. 2013 Nov;21(4):813-28. • O'Malley RB, Al-Hawary MM, Kaza RK, Wasnik AP, Liu PS, Hussain HK. Rectal imaging: part 2, Perianal fistula evaluation on pelvic MRI--what the radiologist needs to know. AJR Am J Roentgenol. 2012 Jul;199(1):W43- 53. 2014 SPR PG Course

12 8-year-old female with repaired anorectal malformation and Transverse ultrasound image of upper abdomen in a neonate fecal incontinence. Red oval shows mesenteric fat. with vomiting. Touch the abnormality.

• Answer C.

• Discussion: A pull-through with attached mesenteric fat indicates that the rectum was resected and the sigmoid colon was pulled through. This causes a loss of the normal rectal reservoir and can lead to fecal incontinence.

Reference • Podberesky DJ, Towbin AJ, Eltomey MA, Levitt MA. Magnetic resonance imaging of anorectal malformations. Magn Reson Imaging Clin N Am. 2013;21:791- 812.

Transverse ultrasound of the upper abdomen in a neonate with 14 year old with chronic pancreatitis; vomiting. Touch the abnormality on this image? identify on the MRI the pancreatic duct stricture that prompted subsequent • Finding: The color Doppler image depicts the whirlpool sign of a midgut volvulus. • Explanation: The color Doppler image shows ERCP. flow in the mesenteric veins which are coiled around the superior mesenteric artery which is present in the centre of the whirlpool. The volvulus has caused obstruction to the duodenum which is dilated with fluid to the right of the whirlpool and the stomach is distended with fluid anterior to the whirlpool.

13 14 year old with chronic pancreatitis; 14 year old patient with chronic identify on the MRI the pancreatic duct pancreatitis, identify on the MRI the stricture that prompted subsequent pancreatic duct stricture that prompted ERCP. subsequent ERCP.

Finding to be made: Focal stricture of the main pancreatic duct at the level of the pancreatic head.

Explanation: There are several findings of chronic pancreatitis in this case including dilation and irregularity of the main pancreatic duct and dilation of side branch ducts. The focal change in caliber at the level of the pancreatic head reflects a stricture that was subsequently dilated endoscopically.

14