Pediatric Imaging • Review Menashe et al. Errors on Abdominal Radiographs of Pediatric Patients Pediatric Imaging Review Pediatric Abdominal Radiographs: Common and Less Common Errors Sarah J. Menashe1 OBJECTIVE. Interpretation of abdominal radiographs of children benefits from a firm Ramesh S. Iyer knowledge of the congenital anomalies and pathologies unique to this patient population, lev- Marguerite T. Parisi eraged by a systematic approach. Interpretive errors place the patients and their families at Randolph K. Otto risk for a delay in diagnosis, unnecessary additional imaging, a potential increase in the radia- Edward Weinberger tion burden, and possible psychologic trauma. A. Luana Stanescu CONCLUSION. In this article, we describe the common and uncommon potential pit- falls in pediatric abdominal radiography, using several of our own interpretive errors as a Menashe SJ, Iyer RS, Parisi MT, Otto RK, framework while providing teaching points to help avoid these mistakes. Weinberger E, Stanescu AL he concept that medical errors Although peer review methods or scorecards contribute to patient morbidity are critically important as educational tools, T and mortality was widely sub- a more extended discussion of these tools is stantiated by the Institute of beyond the intended scope of this article. In- Medicine in 1999, when its report To Err Is stead, using a case-based approach, we of- Human: Building a Safer Health System was fer examples of some of our own “missed” published [1]. The numbers quoted at the cases to illustrate common and less common time seemed staggering, but they have con- errors that may occur, specifically when in- tinued to increase, with medical errors most terpreting abdominal radiographs of pediat- recently reported as the third leading cause ric patients. of death in the United States [2]. As in all fields of medicine, errors in ra- The Abdomen diology are often multifactorial, may be per- Causes of abdominal pathology in the ceptual (i.e., the finding was not seen), may pediatric population can differ significant- be caused by insufficient characterization ly from those in the adult population, and (i.e., the finding was identified but its signifi- they are further confounded by the inability cance was not appropriately recognized), or of a young patient to adequately communi- may represent a failure in communication cate or localize symptoms. Differential con- (i.e., the finding was accurately reported but siderations in the pediatric subset also vary Keywords: abdominal radiographs, errors, pediatric the appropriate channels of communication among age groups, where neonates, infants, for notifying the provider were not used), and young children can have distinctly dif- DOI:10.2214/AJR.17.17889 among many other causes [3, 4]. Growing ferent causes of abdominal pathology. Imag- awareness of imaging errors has led to an in- ing evaluation may consequently require any Received December 30, 2016; accepted January 18, 2017. creased focus on identifying, understanding, combination of advanced techniques, includ- Based on a presentation at the ARRS 2016 Annual and avoiding these mistakes, not only in the ing ultrasound, fluoroscopy, CT, and MRI. Meeting, Toronto, ON, Canada. radiology literature as a whole but, more re- Nevertheless, the most commonly performed cently, in pediatric radiology as well [3, 4–6]. initial examination remains the abdominal 1All authors: Department of Radiology, Seattle Children’s Hospital, University of Washington, 4800 Sand Point Way At our institution, as part of a rigorous radiograph. Despite its widespread use, par- NE, MA.7.220, Seattle, WA 98105. Address correspondence quality assurance program, we use various ticularly in the emergency department, the Downloaded from www.ajronline.org by 167.61.156.69 on 10/03/17 IP address 167.61.156.69. Copyright ARRS. For personal use only; all rights reserved to A. L. Stanescu ([email protected]). peer review strategies to identify such er- sensitivity and specificity of abdominal ra- rors and promote ongoing continuous educa- diography are quite variable [9–11]. Pitfalls AJR 2017; 209:417–429 tion and feedback [7, 8]. These strategies in- may arise because of difficulties in obtain- 0361–803X/17/2092–417 clude monthly peer review conferences and ing patient cooperation or because of the use peer review scorecards that assist in closing of an image acquisition technique that is in- © American Roentgen Ray Society the feedback loop to interpreting radiologists. adequate for the size of the patient’s body. AJR:209, August 2017 417 Menashe et al. Such pitfalls may occasionally ensnare even and a 1-week history of abdominal distention additional findings of bowel distention. The the most seasoned pediatric radiologist [7]. (Fig. 1). recognition and description of the hernia are Therefore, having a good command of com- Discussion—An abdominal mass identi- important because a delay in diagnosis can mon and less common pediatric abdominal fied in the first year of life is most commonly lead to an increased risk of incarceration with pathologies and their associated imaging of renal origin and has benign causes, such as obstruction and perforation [12]. findings is essential when assessing abdomi- hydronephrosis or multicystic dysplastic kid- Evaluation of bowel obstruction in chil- nal radiographs. ney, which are usually detected on prenatal ul- dren can be difficult because bowel loop size trasound. During the ensuing decade of life, can vary depending on the age of the child; Technique and Approach however, primary tumors of the kidney be- for example, a normally distended bowel Historically, both supine and upright views come more common in children, with Wilms loop in a toddler could represent significant of the abdomen were routinely acquired in the tumor reported to be the most common ab- bowel dilatation in a premature infant. In setting of acute abdominal symptoms. Recent dominal malignancy in childhood [15], fol- 1980, Edwards [22] proposed using fixed heightened awareness of radiation and its po- lowed by neuroblastoma. Clear cell sarcoma bony landmarks to allow more accurate as- tential long-term consequences has caused ra- of the kidney, historically known as bone me- sessment of bowel dilatation, regardless of diologists and clinicians alike to rethink the tastasizing renal tumor of infancy, represents patient size. Bowel loops were considered necessity of obtaining multiple views in all less than 4–5% of primary renal tumors and to be normal in diameter when measuring clinical contexts. For example, a single supine typically occurs before the age of 4 years. less than the combined height of the L1 and anteroposterior abdominal radiograph is often Commonly presenting as an abdominal mass L2 vertebral bodies, including the interven- all that is necessary to characterize suspect- and often indistinguishable from Wilms tu- ing disk space. Once dilated bowel loops are ed constipation, which is a common cause of mor on imaging, clear cell sarcoma is more identified, one should search for clues to their pediatric abdominal pain. If obstruction, per- aggressive and is associated with higher mor- underlying cause, starting first with wheth- foration, or some other pathology is suspect- tality and relapse rates [16]. er the obstruction is proximal (indicated by ed, additional projections may be appropriate, Although an overall paucity of bowel gas the presence of few loops present) or distal and they may include left lateral decubitus or or gasless abdomen has been reported in as- (indicated by the presence of multiple loops). cross-table lateral projections, for young chil- sociation with intubation in neonates [17], Bowel obstructions in pediatric patients may dren, or more conventional supine and upright observation of decreased or displaced bowel be secondary to a number of causes, includ- views, for older pediatric patients [12]. An an- gas in an infant or child should prompt care- ing adhesions, appendicitis, intussusception, teroposterior image should include the lung ful scrutiny of the adjacent soft tissues for inguinal hernia, malrotation with midgut bases and the diaphragm superiorly, extend to any abnormality. volvulus and Meckel diverticulum (easily re- the inferior pubic rami inferiorly, and encom- Teaching point—Abdominal radiographs membered using the mnemonic AAIIMM), pass both abdominal walls along the lateral that show persistent displacement of bowel among numerous other causes [23–25]. edge. A thorough interpretation algorithm in- loops on multiple views should raise the con- Teaching point—Inguinal hernias are an cludes careful scrutiny of the bowel gas pat- cern for the presence of an abdominal mass. important cause of bowel obstruction in chil- tern, assessment for the presence of abdomi- dren. The presence of gas-filled bowel below nal calcifications or mass effect, solid-organ Case 2 the inguinal canal should be documented, evaluation, identification of extraluminal col- Case 2 involved a 4-week-old boy (born even in the absence of signs of obstruction. lections of gas or fluid, and attention to osse- prematurely at 27 weeks of gestation) with a Also, when a bowel obstruction is suspected ous structures [10, 12]. history of heart block requiring a pacemaker in a child, it is important to try to character- and respiratory failure. The patient presented ize the level of obstruction, generally proxi- Bowel Gas Pattern with increased fussiness (Fig. 2). mal versus distal. There is significant heterogeneity in the Discussion—In infants and children, in- normal bowel gas pattern seen among adults guinal hernias are one of the most common Case 3 and children alike, in part related to the vari- reasons for surgery. This is especially true Case 3 involved a 21-year-old woman with ability of air and the fluid-filled small bow- for premature infants, for whom both the in- a history of acute lymphoblastic leukemia el. Additional variation will be present in cidence and risk of an incarcerated hernia is after bone marrow transplantation who pre- healthy neonates on the first day of life, when the highest [18–20].