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Home , Ileus, Peritoneal fluid, Pneumoperitoneum

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 • Read between the lines • Bone to pick • Contrast media, friend or foe?

5 things I learned the hard way : GI imaging

• Free air can be costly • Not partial to small bowel obstruction • Read between the lines • Contrast media is my friend • Contrast Media is my enemy

Signs 4-year-old girl with a cecal perforation due to .

• Subphrenic air

• Falciform ligament sign

• Ligamentum teres sign

• Rigler’s sign

NEJM Radiologic Signs of Ching-Hsing Lee, M.D. N Engl J Med 2010

18 do male w CLD & Diagnosis ? abdominal distention

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

Diagnosis ? Next day Pseudo-pneumoperitoneum

• 5 ml/kg iodinated contrast media, cath lab

• total body opacification

Pseudo-pneumoperitoneum

• looks lucent relative to liver • UVC misplaced, eroded through liver • Fat-containing TPN in peritoneal cavity

5 things I learned the hard way : GI imaging

• Respect the scout film • Not partial to small bowel obstruction • Read between the lines • 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 – – Adhesions – Internal Ingested IBD Foreign – Intussusception Body – Meckel’s – Malrotation

Adynamic

– “paralytic” – can simulate mechanical obstruction – Generally causes BOTH small and to dilate – CAN have AFLs

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

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 – 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

•

• Post operative generalized ileus

• / Laxatives

9 yo male w autism and

12/11/16 KUB: “ multiple air-fluid levels, concerning for evolving small bowel obstruction

Referring clinician was called: “Patient is asymptomatic”

12/11/16 early AM, GoLytely therapy 5 things I learned the hard way : GI imaging

• Respect the scout film • Not partial to small bowel obstruction • Read between the lines • Contrast media, friend • Contrast Media, foe

5 yo male, w septo-optic dysplasia

Trainee prelim read, “ in the stomach”

Chest radiograph obtained hours later confirmed the feeding tube to be in the segmental left lower lobe bronchus Preterm male infant

Trainee prelim read, “ETT in the right mainstem bronchus, pull back 1 cm”

Radiograph shows endotracheal tube tip overlying carina, underinflated lungs, and air-distended , stomach and small bowel

Esophageal intubation

Infant male, w , decreased urine output

3 days later, increasing abd girth Infant male, w ascites, decreased urine output Infant male, w ascites, decreased urine output 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?

9yo male, ESRD and abdominal pain 9yo male, ESRD and abdominal pain

AVN 3 month old female, history of 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 5 things I learned the hard way : GI imaging

• Respect the scout film • Not partial to small bowel obstruction • Read between the lines • Contrast media, friend or foe?

Contrast Medium

• Substance used to enhance the “contrast” of structures or fluids within the body for medical imaging

MRCP MRCP Juice is your Friend !!!!!

Blueberry / Acai juice GE Cor 3-D MRCP sequence

Nature’s Place Organic True Blue Blueberry Walgreen’s Distilled Water Blueberry Juice Juice A

AJ W

B

AJ W A

B 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 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 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?