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 bowel obstruction • 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 enteritis. • Subphrenic air • Falciform ligament sign • Ligamentum teres sign • Rigler’s sign NEJM Radiologic Signs of Pneumoperitoneum 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 • Peritoneum 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 – Appendicitis – Adhesions – Internal hernia Ingested IBD Foreign – Intussusception Body – Meckel’s – Malrotation Adynamic Ileus – “paralytic” – can simulate mechanical obstruction – Generally causes BOTH small and large intestine to dilate – CAN have AFLs Caffey Edition, 2010 Part VII Small Intestine, Parker BR, pp. 1616 - Ileus, Gastroenteritis 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 peristalsis – 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 • Diarrhea • Post operative generalized ileus • Medications / Laxatives 9 yo male w autism and abdominal pain 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, “feeding tube 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 esophagus, stomach and small bowel Esophageal intubation Infant male, w ascites, 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 vomiting 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? .