Table Of ContentI
Contents
MEDICAL RADIOLOGY
Diagnostic Imaging
Editors:
A. L. Baert, Leuven
M. Knauth, Göttingen
K. Sartor, Heidelberg
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III
Contents
A. S. Devos · J. G. Blickman
(Eds.)
Radiological Imaging of the
Digestive Tract
in Infants and Children
With Contributions by
T. Berrocal · S. A. Connolly · G. del Pozzo · R. B. J. Glass · C. M. Hall · Y. L. Hoogeveen
M. Hiorns · R. M. Jiménez · J. S. Laméris · M. Meradji · E. Nijs · R. R. van Rijn
Foreword by
A. L. Baert
With 227 Figures in 500 Separate Illustrations, 43 in Color
123
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IV
Contents
Annick S. Devos,
MD
Erasmus MC
Sophia Children’s Hospital
Dr. Molewaterplein 40
P. O. Box 1738
3000 DR. Rotterdam
The Netherlands
Johan G. Blickman
, MD, PhD, FACR
Professor and Chairman, Department of Radiology
University Hospital Nijmegen
UMC Nijmegen-667
P. O. Box 9101
Geert Groteplein 10
6500 HB Nijmegen
The Netherlands
Medical Radiology · Diagnostic Imaging and Radiation Oncology
Series Editors:
A. L. Baert · L. W. Brady · H.-P. Heilmann · M. Knauth · M. Molls · C. Nieder · K. Sartor
Continuation of Handbuch der medizinischen Radiologie
Encyclopedia of Medical Radiology
Library of Congress Control Number: 2005935285
ISBN 978-3-540-40733-1 Springer Berlin Heidelberg New York
This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned,
specifi cally the rights of translation, reprinting, reuse of illustrations, recitations, broadcasting, reproduction on
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© Springer-Verlag Berlin Heidelberg 2008
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Medical Editor: Dr. Ute Heilmann, Heidelberg
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V
Contents
Foreword
Although conventional radiography and barium studies still play an important role
in radiological imaging of the digestive tract in infants and children, the new cross-
sectional methods based on ultrasound, CT and, to a lesser extent, MRI have gained
considerable importance in this radiological fi eld during recent years.
This volume provides a much needed update on our knowledge and insights on how
to provide optimal radiological care to infants and children with digestive malforma-
tions and acquired diseases of the digestive tract.
The editors, A. S. Devos and J. G. Blickman, are leading pediatric radiologists with
a special interest in pediatric digestive diseases. They have been assisted by a group
of internationally renowned experts. Together they have produced a well structured
work that, although concise in concept and contents, covers well our actual radiologi-
cal approach and management of diagnostic pediatric digestive problems.
I am confi dent that this outstanding volume will fi nd great interest from both
g eneral and specialised pediatric radiologists, as well as from radiologists in training,
neo natologists and pediatricians.
Leuven Albert L. Baert
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VII
Contents
Preface
For the general radiologist, pediatric radiology is not the most frequent part of his or
her daily practice. In particular, the pediatric chest and abdomen, relatively common
occurrences in a general radiology practice, are often cause for unease of approach and
interpretation.
Such unease arises both from a practical point of view, in that it can be physically
diffi cult to image the infant or young child, and from the differential diagnostic point
of view, the differential diagnosis often being different at varying ages.
This book is intended to provide the reader with a comprehensive review of all that
pertains to the pediatric gastrointestinal (GI) tract and the accessory digestive organs.
It is built up in a logical sequence, starting with pathology affecting the oesophagus
and culminating with pathology most often encountered at or near the rectum.
While primarily intended for general radiologists, both in training and in daily
practice, it also addresses those interested in GI tract imaging, such as pediatricians
or general practitioners, as well as trainees therein, of the pediatric and young adult
age group.
The book is by no means intended to be exhaustive, but certainly tries to give an up-
to-date approach to daily clinical diagnostic issues.
Each author was asked to be exhaustive yet practical and, where possible, to try to
incorporate some aspects of “how I do it” in order to illustrate some of his or her per-
sonal approaches to each organ system.
In the course of writing this book, a number of things became obvious. The reader
should be aware that what the authors describe as state-of-the-art while writing their
chapters may already have become outdated, although in pediatric imaging in general
this is luckily not often the case.
Also, one must realize that the location of disease processes and approaches to diag-
nosis also vary, both between institutions but also whether one’s focus is the acute
patient or an analysis of the entire clinical question. Overlap between some parts of this
text are thus unavoidable. Examples include appendicitis and intussusception, but also
entities affecting multiple parts of the digestive tract.
To be asked by Prof. Albert Baert to take on this endeavour was a true honour. But
in the process he certainly showed me how to stay patient!
Also, and for me this is the real reason for being in academics, this endeavour was an
opportunity to encourage a promising ‘next-generation pediatric radiologist’ to take
the lead and ‘get one’s name in print’. Dr. Annick Devos did an outstanding job, even
while having a baby during the process.
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VIII
Preface
Both of us were lucky indeed to have our research associate, Dr. Yvonne
H oogeveen, to keep us on course and spend much time and effort on getting the
text in optimal shape. Without her, it would have been diffi cult, if not impos-
sible, to ensure the completion of this endeavour.
To complicate matters further, we had a number of potential and agreed
authors either dropping out due to illness or because of changes in employ-
ment situations precluding them from contributing. Nevertheless, the result is
a truly international effort that we are proud of.
For this we wish to thank the co-workers of Springer-Verlag, as they were
truly exemplary in their cooperation. Ursula Davis, in particular, deserves our
thanks.
Dr. Devos and I are extremely thankful to all the authors: you all are the
book! They were selected for their prominence in their specialty, and the list of
these authors represents a broad combination of experience, teaching ability
and stature.
Finally, it was a pleasure to contribute to better imaging in children, some-
thing that pediatric radiologists of course have made their aim in life, but also
should be aimed for by all radiologists in general.
Nijmegen Johan G. Blickman
It was a wonderful opportunity for me, and I agree wholeheartedly with the
above. Also, I want to thank Prof. Johan G. Blickman for giving me this oppor-
tunity and for the trust he had in me during our collaboration. Your enthusi-
asm is contagious and a source of motivation to persevere and at the same time
to remain patient!
Rotterdam Annick S. Devos
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IX
Contents
Contents
1 Imaging in Pediatric Gastrointestinal Emergencies
Teresa Berrocal and Gloria del Pozo . . . . . . . . . . . . . . . . . . . . . . . . 1
2 The Esophagus
Ronald B. J. Glass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3 Stomach
Els Nijs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109
4 Accessory Organs of Digestion
Rafael M. Jiménez, Susan Connolly, Johan G. Blickman,
and Yvonne L. Hoogeveen. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .133
5 The Small Bowel
Annick S. Devos, Morteza Meradji, and Johan G. Blickman . . . . . . . . . . . 167
6 The Colon
Melanie P. Hiorns and Christine M. Hall . . . . . . . . . . . . . . . . . . . . . . 193
7 Radiological Gastrointestinal Interventions in Childhood: A Review
Rick R. van Rijn and Johan S. Laméris . . . . . . . . . . . . . . . . . . . . . . . . .221
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243
List of Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
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1
Imaging in Pediatric Gastrointestinal Emergencies
1
Imaging in Pediatric Gastrointestinal Emergencies
Teresa Berrocal and Gloria del Pozo
1.1
CONTENTS
Gastrointestinal Emergencies in the
Neonate
1.1 Gastrointestinal Emergencies in the
Neonate 1
1.1.1
1.1.1 Neonatal Intestinal Obstruction 1
1.1.1.1 High Obstruction 2 Neonatal Intestinal Obstruction
1.1.1.2 Low Obstruction 14
1.1.2 Necrotizing Enterocolitis 29
Intestinal obstruction is the most common abdomi-
1.1.3 Pneumoperitoneum 34
nal emergency in the neonatal period. It is almost
1.2 Gastrointestinal Emergencies in the Infant always the result of a congenital anomaly of the
and Young Child 35
gastrointestinal tract, which must be rectifi ed sur-
1.2.1 Intussusception 36
gically if the infant is to survive. Mortality in sur-
1.2.1.1 Diagnosis 36
1.2.1.2 Treatment 42 gically untreated patients is close to 100%, and the
1.2.1.3 Types of Enema Therapies 43 rate of survival is closely related to the time of sur-
1.2.2 Appendicitis 46 gical intervention (Hajivassiliou 2003). The most
1.2.2.1 Appendicitis Imaging 47
common clinical fi ndings are abdominal distension,
1.2.3 Small Bowel Obstruction 56
1.2.4 Midgut Volvulus 58 vomiting, and sometimes failure to pass meconium,
1.2.5 Meckel´s Diverticulum 59 depending on the level of the obstruction. These
1.2.6 Enteritis 60 fi ndings usually prompt the clinician to consult the
1.2.7 Infl ammatory Bowel Disease 61
radiologist, who must answer three major ques-
1.2.8 Schönlein-Henoch Purpura 62
tions: Is the obstruction present? What is the loca-
1.2.9 Mesenteric Lymphadenitis 63
1.2.10 Primary Fat Epiploic Lesions: tion of the obstruction? What is the aetiology? The
Right Segmentary Omental Infarction most valuable means of determining whether or not
Including Omental Torsion and Epiploic
obstruction is present is the plain abdominal radio-
Appendagitis 63
graph. Plain radiographs are often diagnostic. When
1.2.11 Peritonitis 66
1.2.12 Hepatobiliary Causes of Acute Abdominal not diagnostic, they may provide important clues
Pain 66 suggesting the subsequent most valuable diagnostic
1.2.13 Acute Pancreatitis 67 procedure (Singleton et al. 1977).
1.2.14 Renal Causes of Acute Abdominal Pain 68
Knowledge of the many variations in both the
1.2.15 Gynecological Causes of Acute Abdominal
distribution and quantity of intestinal air in infants
Pain 70
is useful in the interpretation of pathologic fi ndings.
References 73
In a healthy neonate, air can usually be identifi ed in
the stomach within minutes after birth, and reaches
T. Berrocal, MD, PhD the proximal portion of the small bowel during the
Pediatric Radiologist, Department of Radiology, Division fi rst 6 h of life. By 6–12 h the entire small bowel usu-
of Pediatric Radiology, University Hospital La Paz. Madrid. ally contains air, and after 12–24 h normal neonates
Spain
show rectosigmoid air in a plain abdominal radio-
G. del Pozo, MD, PhD
graph.
Associate Professor of Radiology, Pediatric Radiologist,
Department of Radiology, Pediatric Radiology section,
University Hospital 12 de Octubre, Madrid, Spain
2
T. Berrocal and G. del Pozo
When an intestinal obstruction is present, since 1.1.1.1
air proceeds distally in the gastrointestinal tract High Obstruction
until stopped at the obstruction, an abdominal
radiograph will show dilated air-fi lled loops proxi- 1.1.1.1.1
mal to the obstruction and no air distal to it. The Gastric Outlet Obstruction
number of dilated loops depends on the site of
obstruction: the lower the obstruction, the greater Complete obstruction involving the gastric outlet is
the number of dilated loops. Having established that a rare condition usually due to antral or pyloric atre-
an intestinal obstruction is present, the radiologist sia, although it may be caused by extrinsic pressure
should still determine the location of the obstruc- from congenital peritoneal bands or by annular pan-
tion and, if possible, the etiology. In order to arrive creatic tissue in the gastric wall. Antral or pyloric
at a useable differential diagnostic list of possible atresia accounts for less than 1% of all congenital
etiologies, neonatal obstructions can be classifi ed intestinal obstructions. The condition is thought
as high or low obstruction. High or upper intesti- to be due to localized vascular occlusion in fetal
nal obstructions are those that occur proximal to life (Okoye et al. 2000). It is usually produced by a
the mid-ileum and include obstructions involving membranous diaphragm in which only the mucosa
the stomach, duodenum, jejunum, and proximal is involved. An association with epidermolysis bul-
ileum. Obstructions that involve the distal ileum losa letalis has been described (Toma et al. 2002). It
or colon are called low intestinal obstructions. The is unknown whether the association is on the basis
distinction between high and low obstruction is of a causative effect on the antropyloric mucosa, or
also critical since children with high obstructions whether it is due to a genetic linkage (Dolan et al.
usually need little or no radiologic evaluation after 1993). The predominant symptom is vomiting within
plain radiograph, and the specifi c diagnosis is made the fi rst hours after birth, the vomits being free of
in the operating room. Newborns with low obstruc- bile. The absence of bile in the vomits indicates that
tions need a contrast enema, which usually pro- the obstruction is above the ampulla of Vater. A plain
vides a specifi c diagnosis and may be therapeutic radiograph of the abdomen shows distension of the
(Buonomo 1997). In general, plain radiographs in stomach proximal to the obstruction and absence
neonates with high obstruction reveal one, two, or a of air in the small bowel and colon, resulting in the
few dilated air-fi lled bowel loops, depending on the characteristic “single bubble” image (Rathaus et
level of the obstruction, while radiographs in low al. 1992) (Fig. 1.1). When a single bubble is observed,
obstructions show multiple dilated air-fi lled bowel examination with contrast material is unnecessary
loops. and most patients are taken directly to surgery. The
Disorders of the intestinal tract in the neonatal membranous atresia may perforate after birth, leav-
period usually present with abdominal distension ing variable degrees of stenosis. In these cases, plain
and dilatation of the bowel. However, not all intes- radiography will show distension of the stomach and
tinal dilatations represent obstruction. Infants some air in the small bowel depending upon the
with medical disorders such as sepsis, electrolyte degree of obstruction (Bell et al. 1977).
imbalance or necrotizing enterocolitis may pres- Pyloric stenosis may lead to obstruction of the
ent ileus characterized by uniform dilatation of the lumen and usually presents beyond the neonatal
bowel to the level of the rectum. Also, infants on period. However, it has been diagnosed in utero and
continuous positive airways pressure may swallow can be seen in the neonatal period after adminis-
an excessive amount of air and exhibit important tration of prostaglandin E to infants with ductus-
intestinal dilatation. This dilatation must be dis- dependent congenital heart disease. The stenosis
tinguished from mechanical obstruction, because is produced by central foveolar hyperplasia. On
the treatment is completely different. The differ- sonography, mucosal thickening often with pol-
entiation between these two categories can usually ypoid or lobular appearance is observed, different
be made on the basis of clinical history, laboratory from the muscular thickening observed in hyper-
tests, and appropriate radiographs (Hernanz- trophic pyloric stenosis (Peled et al. 1992; Babyn et
Schulman 1999). al. 1995) (Fig. 1.2).
3
Imaging in Pediatric Gastrointestinal Emergencies
a b
Fig. 1.1a,b. Pyloric atresia. Anteroposterior (a) and lateral (b) plain abdominal radiograph in a
newborn infant that shows distension of the stomach (st) and absence of air in the small bowel
and colon, resulting in the characteristic “single bubble” image
a b
Fig. 1.2a,b. Prostaglandin therapy-induced gastric outlet obstruction. Neonate with ductus-dependent
congenital heart disease treated with prostaglandin E to maintain ductus patency. a Longitudinal US scan
through the pyloric channel shows mucosal thickening (M), and a thin muscular layer (arrows), different
from the muscular thickening seen in hypertrophic pyloric stenosis. b Axial scan through the gastric an-
trum reveals markedly hypertrophic mucosa (arrows) and an undulating appearance. The thickness of the
muscular layer of the gastric wall is normal (arrowheads)
