0:02

Hello, and welcome to Noon Conference

0:04

hosted by MRI Online. In response to

0:07

changes happening around the world,

0:09

right now in the shutting down of in-person

0:10

events, we have decided to provide free daily

0:13

noon conferences to all radiologists worldwide.

0:17

Today we are joined by Dr. Jennifer Kucera.

0:20

Dr. Kucera is an associate professor of

0:22

radiology and associate program director

0:25

at the University of South Florida.

0:27

She is a pediatric radiologist and assistant

0:30

professor at Johns Hopkins All Children’s Hospital.

0:33

She has been awarded USF Teaching

0:35

awards six consecutive years.

0:38

She's a member of the SPR Fetal Imaging

0:40

Committee and SPR Postmortem Committee.

0:44

A reminder that there will be a Q and A session

0:46

at the end of this lecture, so please use the

0:48

Q and A feature to ask your questions, and we will

0:51

get to as many as we can before our time is up.

0:54

That being said, thank you all

0:55

for joining us today. Dr. Kucera,

0:57

I'll let you take it from here.

0:59

Good afternoon from sunny Tampa, Florida.

1:02

This morning, we're gonna talk about

1:03

pediatric gastrointestinal obstructions.

1:07

We're gonna start out by talking about neonatal bowel

1:09

obstructions, including upper and lower obstructions,

1:12

and also a related topic of necrotizing enterocolitis.

1:16

And then we'll move on to bowel

1:17

obstructions in the older child, including

1:19

my favorite mnemonic to remember them.

1:22

And we'll finish up with foreign body ingestion.

1:25

Okay, so our first patient is a baby with vomiting.

1:28

So when you have a baby with vomiting, there's

1:30

a few questions you should ask, and based off

1:33

of the answers to those questions, it should

1:35

help you form your differential diagnosis.

1:37

So first you wanna know, is it

1:39

bilious emesis, or non-bilious emesis?

1:42

If you're given a history of bilious emesis, you

1:44

should have a knee-jerk reaction that you

1:46

need to exclude malrotation with midgut volvulus.

1:50

If you get a history of projectile vomiting, the

1:53

first thing you'll think of is pyloric stenosis.

1:56

Other things in the differential include duodenal

1:59

atresia, stenosis or web, annular pancreas, jejunal

2:01

atresia, or just gastroesophageal reflux.

2:06

So here's the X-ray on our first patient.

2:09

And you see a very distended air-filled stomach,

2:13

as well as a distended air-filled duodenal bulb.

2:16

And the key to this X-ray is that

2:18

there is zero distal bowel gas.

2:21

So this is the classic double-bubble appearance,

2:24

and is consistent with duodenal atresia.

2:28

So there's nothing else really

2:29

in the differential here.

2:31

You don't need to do an upper GI to confirm.

2:34

If anything, you'll just squirt some

2:35

more air in through the NG tube to

2:38

distend the stomach and duodenal bulb.

2:40

This is another patient with duodenal atresia.

2:43

The double bubble's not quite as

2:45

impressive as in our first patient.

2:47

But similar findings of distended stomach,

2:49

distended duodenal bulb, and zero distal bowel gas.

2:53

Now remember that, um, this can be

2:56

associated with other anomalies, particularly

2:58

Down syndrome in about 30% of patients.

3:01

And in this patient here, you can

3:03

actually see there's a hemivertebral

3:04

body, which can be a sign of a syndrome.

3:08

Okay.

3:09

Now just for comparison, I wanna show

3:11

you what a duodenal web looks like.

3:13

So, stomach filled with contrast, proximal

3:16

duodenum is dilated, but we have a crescent-

3:19

shaped meniscus where we have an abrupt

3:21

transition in contrast going through.

3:24

Now also, you can see there's clearly distal

3:26

bowel gas here, unlike duodenal atresia.

3:31

Okay, the next case is another baby that's

3:34

vomiting, but this time it's bilious emesis.

3:37

So if you hear bilious emesis, the first

3:39

thing you have to do is an upper GI to

3:42

rule out malrotation with midgut volvulus.

3:45

Okay, so the X-ray on this

3:47

patient is kind of non-specific.

3:49

We see a little bit of distension of the stomach,

3:51

couple air-fluid levels in the proximal small

3:54

bowel, and a normal distal bowel gas pattern.

3:57

We move to upper GI, and we see contrast

4:01

in the stomach, contrast coming out of

4:03

the proximal duodenum, which is dilated.

4:06

And then we see an abrupt transition point,

4:08

where only a tiny trickle of contrast

4:12

goes through in a corkscrew pattern.

4:14

When you follow the duodenojejunal junction,

4:17

the normal duodenum should have a

4:18

C-shaped configuration, and the duodenojejunal

4:21

junction should be all the way to the left

4:23

of the spine, as high as the duodenal bulb.

4:27

Here you can see it starts to go in a C-

4:29

shaped configuration, but never makes it to

4:31

where it should be, and then the rest of the

4:33

bowel is on the wrong side of the abdomen.

4:36

So this is the classic appearance of

4:38

malrotation with midgut volvulus.

4:42

Okay, so abnormal position of

4:45

duodenojejunal junction.

4:46

We talked about abrupt transition point,

4:49

where only a tiny trickle of contrast goes

4:51

through, and corkscrew appearance of the

4:54

duodenum — malrotation with midgut volvulus.

4:58

Okay, we have another case of yet another

5:01

baby that's vomiting with bilious emesis.

5:05

So we look at the X-ray.

5:06

The X-ray is basically normal, but

5:08

remember, no X-ray can exclude malrotation.

5:11

With midgut volvulus, you are

5:13

obligated to do the upper GI.

5:16

So we do the upper GI and we squirt

5:18

contrast in, and this is what we see.

5:20

We see contrast in the stomach, descending

5:22

duodenum, and then we see dilated duodenum here, and

5:26

we're not really seeing any contrast go through.

5:28

Let's look at a clip of this — what

5:30

it looks like in the fluoro room.

5:31

So no matter how long we wait,

5:33

no contrast is going through.

5:36

So this is also an example of

5:40

malrotation with midgut volvulus.

5:42

The thing that's different about this

5:44

compared to the last case is that the bowel

5:46

has twisted around itself so much that it has

5:49

caused a complete duodenal obstruction.

5:52

This is not as common of an imaging appearance

5:54

of malrotation with midgut volvulus, and I

5:57

feel oftentimes it confuses our surgeons.

5:59

So it's important that you understand that

6:02

this is also malrotation with midgut volvulus.

6:05

Now, you know, it can't be any type of atresia,

6:08

because you look over at the scout X-ray and there's

6:12

distal bowel gas, so it cannot be duodenal atresia.

6:18

Okay.

6:18

So I find residents often are confused

6:21

between the difference of malrotation

6:23

or malrotation with midgut volvulus.

6:25

So let's talk about that for a second.

6:27

So malrotation just means that there's abnormal

6:30

fixation of the small bowel mesentery, which means the

6:33

bowel is just not lined up how it's supposed to be.

6:36

The duodenum is not in the right spot, and

6:40

this predisposes patients to midgut volvulus.

6:43

But malrotation alone is not an obstruction.

6:46

Midgut volvulus is when you have malrotation and

6:49

then the bowel twists on the axis of the SMA.

6:53

That's when you get the corkscrew appearance

6:55

of the duodenum and proximal jejunum, or

6:57

that complete duodenal obstruction.

7:00

Now, this is a surgical emergency, can result

7:03

in ischemia and obstruction, and usually does

7:06

happen in the first three months of life.

7:11

Okay, so this is an example of malrotation,

7:13

but no volvulus, where you see that there's not

7:16

the normal C-shaped configuration of the

7:18

duodenum, but contrast goes through just fine.

7:22

There's no abrupt transition point.

7:24

And this patient, although the bowel is a

7:26

little dilated, the reason it is, is they

7:28

actually had an incarcerated inguinal hernia.

7:33

So we've alluded to this already, but the

7:35

criteria for a normal duodenojejunal junction is

7:39

that the duodenojejunal junction needs to be all

7:42

the way to the left of the spine and at the

7:44

same level or higher than the duodenal bulb.

7:47

If your duodenojejunal junction does not meet both of

7:50

those criteria, it's by definition malrotation.

7:55

Now I love this diagram and this

7:57

article by Charles Maxfield.

7:59

Um, so.

8:00

Let's take a look at it.

8:01

So normal duodenum should have a C-shaped

8:03

configuration, should come all the way to the

8:07

left of the spine, with the duodenojejunal

8:09

junction as high or higher than the duodenal bulb.

8:12

If you don't have both of those,

8:14

it by definition is malrotation.

8:17

So here's a picture of a regular old

8:19

malrotation where you don't have the

8:22

C-shaped configuration of the duodenum.

8:24

It does not come all the way to the left of

8:26

the spine, or as high as the duodenal bulb.

8:29

Now this one is pretty obvious malrotation, but even

8:31

if you have a C-shaped configuration, but it maybe

8:34

only goes to here, that would count as malrotation.

8:37

Volvulus is when you have malrotation, and then you

8:40

have an abrupt transition point with a corkscrew

8:44

appearance of trickle of contrast going through,

8:47

or where the whole duodenum twists off on itself,

8:50

and you have a complete duodenal obstruction.

8:55

Okay.

8:56

To fix this, they do the Ladd’s procedure, where they

8:59

put all the small bowel in the right side of the

9:01

abdomen, all the colon in the left side of the

9:03

abdomen, and then they usually resect the appendix,

9:07

because it sure would be confusing to try to diagnose

9:09

appendicitis if it were on the wrong side of the body.

9:15

Okay, our next patient is a baby with

9:17

projectile vomiting. So some bells should be

9:20

ringing when you hear projectile vomiting.

9:23

Let's look at the baby's X-ray.

9:25

So we have a pretty air-filled, distended stomach.

9:29

We have distal bowel gas, so when we hear projectile

9:33

vomiting, we're gonna proceed to ultrasound.

9:35

I.

9:36

So when we look at the ultrasound, here is a

9:39

fluid-filled stomach, and you can see the pylorus here.

9:44

Our MII tech is putting measurements on the pyloric

9:46

musculature here, which is measuring four millimeters,

9:49

and the pyloric channel, which is measuring 1.9 centimeters.

9:54

This is a picture of — this is a classic

9:57

imaging appearance of pyloric stenosis.

10:00

Now this is another patient

10:01

that also has pyloric stenosis.

10:03

This is an upper GI that shows the imaging features.

10:06

So we have stomach filled with contrast, and then

10:09

only a very tiny trickle of contrast is going

10:12

through the pylorus because of the thickened

10:15

pyloric musculature.

10:16

This is called the string sign, where only

10:18

a trickle of contrast goes through the

10:20

pylorus, and sort of the undulating appearance

10:24

of the stomach trying to contract against

10:26

the pylorus to push that contrast out.

10:28

This is called the caterpillar sign.

10:31

Okay, so pyloric stenosis occurs typically

10:35

between three weeks and three months of age.

10:38

And the pylorus should not empty

10:39

during real-time evaluation.

10:41

When you watch with the ultrasound

10:42

probe, the criteria we use is a muscle

10:46

thickness greater than three millimeters.

10:48

So we'd measure that like this on this

10:50

picture, or like this on this picture.

10:53

And the channel length has to

10:54

be at least 1.5 centimeters.

10:57

The only reason we care about the channel length

10:59

is it's kind of a double check to make sure that we

11:01

are not in pyloric spasm, because if the pylorus is

11:05

actively contracting, of course the muscle's going

11:07

to be all balled up on itself and falsely thickened.

11:11

So we want a nice elongated pyloric channel

11:14

to make sure we're not in pyloric spasm.

11:19

Okay, so, um, let's look at this clip of what you

11:22

would see of a normal pylorus while you're scanning.

11:25

So, stomach stuff in the stomach just

11:27

easily squirts through the pyloric channel.

11:30

Um, the actual pyloric musculature is kind of

11:33

hard to see here because it's not thickened.

11:35

So if you have a hard time seeing the pyloric

11:38

musculature, it's 'cause it's not thickened,

11:40

but fluid easily is going through there.

11:43

Okay, now let's look at what you'll

11:45

see real time with pyloric stenosis.

11:47

Stomach filled with stuff, thickened muscle.

11:49

You can see the stomach's trying to contract,

11:51

trying to push fluid through, but you don't see

11:52

that gush of fluid going through on ultrasound.

11:58

Okay, we're gonna move to lower obstructions now.

12:00

So our next patient is a baby

12:03

with failure to pass meconium.

12:07

So I want you to think about your

12:08

differential diagnosis for a baby that

12:10

hasn't passed meconium for a second.

12:15

So you should think of Hirschsprung’s,

12:17

meconium ileus,

12:18

ileal atresia, small left colon (which

12:21

used to be called meconium plug syndrome),

12:23

anal atresia, or anorectal malformation.

12:26

Either way, the next step should be enema.

12:30

Okay, so this is our baby.

12:31

We see several dilated loops of bowel,

12:33

compatible with a low obstruction.

12:39

When we do the enema on the lateral view, we can

12:43

see that the caliber of the rectum is definitely

12:47

way smaller than the caliber of the sigmoid.

12:50

And when we look on the AP view, you can see

12:52

that the transition point where the bowel

12:54

changes caliber is probably right about here.

12:57

This is classic appearance of Hirschsprung’s.

13:02

Now we talk a lot about the rectosigmoid

13:05

ratio, and I don't really like math.

13:08

I find it kind of confusing, so I just

13:11

like to remember the rectum should

13:13

be the biggest part of the colon.

13:14

So if anything down low is not

13:17

as big as up above, that's abnormal.

13:20

My residents stress, like where does rectum stop?

13:23

Where does sigmoid start?

13:24

It doesn't really matter if the bowel down

13:26

here is smaller than the bowel up here.

13:28

That's abnormal.

13:29

That's an abnormal rectosigmoid ratio.

13:33

Okay, this is the same baby.

13:34

Um, it's important when you do the enema to tell

13:37

the surgeon where you think the transition point is.

13:39

Because what they're gonna do is they're

13:40

gonna yank this much bowel out, and they're

13:44

going to do a transanal pull-through.

13:47

So they'll snip the bowel off where

13:49

they think the transition point is.

13:50

The pathologist will immediately look under the

13:53

microscope to see if ganglion cells are present.

13:56

If there are no ganglion cells, then

13:57

they have to yank more of the colon out.

14:00

Snip it off, and they have to keep doing

14:02

this till they find ganglion cells.

14:03

Otherwise, they're not really fixing the problem.

14:07

So Hirschsprung’s is related to an absence

14:09

of ganglion cells that innervate the colon.

14:12

The de-innervated colon spasms and

14:14

causes a functional obstruction, so the

14:16

affected portions of the colon are small.

14:18

And remember, this happens in a

14:20

contiguous fashion from the rectum.

14:23

Moving backwards, you'll look for the transition

14:26

zone, the abnormal rectosigmoid ratio, and

14:29

sometimes you'll see saw-tooth irregularity,

14:31

where the muscle is actually spasming.

14:33

And this also has a loose association with

14:35

Down syndrome, um, in about 5% of patients.

14:39

So this is another patient with Hirschsprung’s.

14:42

I like this picture 'cause I think this is a nice

14:44

example of the saw-tooth irregularity, or abnormal

14:47

contractions of the spasming de-innervated segment.

14:51

And then also, the rectosigmoid

14:53

ratio abnormality is not quite as

14:54

obvious as it was on the last patient.

14:57

However, I think we can all say that this bowel

15:00

here is clearly smaller than the bowel here.

15:04

So abnormal rectosigmoid ratio.

15:08

Saw-tooth contractions, Hirschsprung’s.

15:12

Okay, we have another baby

15:15

with failure to pass meconium.

15:21

Okay.

15:21

Similar X-ray to the last patient, where

15:24

we see multiple dilated loops of bowel,

15:26

compatible with a low obstruction.

15:28

We're gonna move on to do an enema.

15:34

Okay, so on the lateral view, you

15:37

can see that the bowel down low is

15:39

definitely bigger than the bowel up high.

15:41

So the rectosigmoid ratio is normal.

15:44

And as we squirt contrast in, we can see

15:46

that the whole caliber of the bowel is

15:48

very small, compatible with a microcolon.

15:52

We're gonna keep squirting contrast in, and we see

15:55

some filling defects within the bowel as we're

15:57

squirting contrast in, but we're able to

16:00

reflux contrast all the way into the small bowel.

16:04

We look closer, we can see more of these

16:06

filling defects, kind of terminal ileum.

16:09

So this is an example of meconium ileus.

16:14

This is what meconium looks like, um, in pathology.

16:19

So it's thick, sticky meconium that sort of makes

16:23

rock-like pellets that get stuck in the terminal ileum,

16:27

and don't allow anything to go through the colon.

16:30

Meconium ileus is a thing that's associated with

16:33

cystic fibrosis, and it's the presenting finding

16:35

in 10% of cystic fibrosis patients. And that thick,

16:39

sticky meconium gets stuck in the

16:40

distal ileum and causes an obstruction.

16:43

Once you do the enema, sometimes you can actually

16:45

relieve the obstruction by sort of sucking some of the

16:48

meconium out when it gets stuck with your contrast.

16:52

Okay, now this is a companion case.

16:54

This is a different patient also

16:56

with failure to pass meconium.

16:59

When we squirt contrast in, we see, um, a diffuse micro-

17:04

colon, which tells us there's disuse of the bowel.

17:08

Um, we see that there's dilated loops of

17:10

bowel that we're not filling, and no matter

17:12

how hard we squirt, we cannot squirt any

17:15

contrast back into the terminal ileum.

17:18

So this is an example of ileal atresia.

17:21

So there's actually an atresia of the distal ileum,

17:23

so the bowel's not connected. Nothing gets through,

17:26

the colon is disused, making it be a microcolon.

17:33

Okay, now this is another patient with failure

17:36

to pass meconium, and we see some mildly

17:40

distended loops of bowel throughout the colon,

17:43

because they haven't passed meconium.

17:45

Next step is an enema, so we'll do our enema,

17:51

and squirt contrast, and you see that the

17:53

rectosigmoid ratio is normal, and we see that the

17:57

colon on the left side of the body is

18:00

a little small.

18:01

It's not really a microcolon.

18:03

It's a little small, though.

18:05

And then there's a transition point kind of right

18:07

at the splenic flexure. Contrast goes through fine.

18:10

It gets refluxed into the small bowel, and this

18:13

is compatible with small left colon syndrome.

18:16

This used to be called meconium plug

18:18

syndrome, which was a bad name for this.

18:21

Or it can also be called

18:23

functional immaturity of the colon.

18:25

This is actually the number one diagnosis in babies

18:27

who fail to pass meconium, and basically it's just

18:31

you have ganglion cells, but they're immature.

18:34

And because they're immature, they cause a functional

18:36

obstruction, and this is a temporary thing.

18:39

As the ganglion cells mature, then

18:41

the colon starts working again.

18:43

You see this more often in babies of

18:45

diabetic mothers, or mothers who received

18:48

magnesium sulfate for eclampsia.

18:51

On imaging, you'll see filling defects, and most

18:54

commonly a transition point near the splenic flexure.

18:56

And often the baby will pass

18:57

meconium at the end of the exam.

19:01

Okay, so we're gonna do a practice question for those

19:04

of you that may be getting ready to take boards.

19:08

Okay.

19:09

Regarding colonic abnormalities in children,

19:12

which one of the following is correct?

19:15

A. Microcolon resolves on its own once

19:18

the obstruction has been relieved.

19:20

B. Colonic atresia is more common than ileal

19:24

atresia. C. Small left colon syndrome is part of

19:28

the VACTERL association. Or D. Meconium ileus presents

19:34

with a large plug in a normal-sized colon.

19:37

Okay, think about that for a second.

19:41

Okay, so the correct answer is microcolon resolves

19:44

on its own once the obstruction has been relieved.

19:48

Let's talk about why the other ones are not correct.

19:52

Okay.

19:53

B is not correct because

19:55

colonic atresia is super rare.

19:58

C is not correct because small left colon

20:00

is just associated with babies of moms with

20:03

diabetes, or who took magnesium sulfate.

20:06

Anal atresia is the one that's associated with VACTERL.

20:10

Okay.

20:10

And D. Meconium ileus presents with

20:13

a large plug in a normal-sized colon.

20:16

No, the colon is a microcolon because the

20:19

terminal ileum is essentially blocked off.

20:22

Nothing goes through, so it's a

20:24

disused colon, making it a microcolon.

20:30

Okay, our next patient is a two-week

20:32

old preemie with abdominal distension.

20:38

Okay, so when we look at these X-rays, we see

20:41

distended loops of bowel throughout the abdomen.

20:45

And if you look, you should

20:47

see air within the bowel wall.

20:50

So you see this lucent, ring-like structure.

20:53

Here, here, here, here.

20:55

You can see it on the AP view.

20:58

This is very extensive.

21:00

Diffuse pneumatosis.

21:03

This is what it looks like in the operating room.

21:05

You can actually see these little bubbles of

21:07

air actually within the bowel wall, and this

21:12

is necrotizing enterocolitis in a preemie.

21:16

So let's talk about necrotizing enterocolitis.

21:18

This occurs in premature infants, usually

21:21

about one to three weeks after birth.

21:23

Mortality rate somewhere between 20 and 30%.

21:27

And necrotizing enterocolitis most

21:28

commonly affects the ileum and right colon.

21:31

So things you'll look for on X-ray — you'll

21:33

look for focal, fixed, dilated loops of bowel.

21:36

You'll look for featureless, widely separated bowel

21:39

loops, pneumatosis, portal venous gas, or free air.

21:44

And in survivors of necrotizing

21:47

enterocolitis, you can get strictures.

21:49

And interestingly, those are

21:51

most commonly in the left colon.

21:54

Okay, so this is another baby with necrotizing

21:57

enterocolitis, and I wanted to show you by

21:59

what I mean by fixed, dilated loops of bowel.

22:03

So this is their X-ray at 14 weeks. You can

22:05

see there's sort of space between bowel that

22:08

tells you there's edema in the bowel wall.

22:10

And when you look at the X-ray the next day,

22:12

it looks almost the same pattern, and the

22:14

next day it's almost the same bowel pattern.

22:17

So that's sick bowel.

22:19

Now this baby,

22:22

had an abnormal appearing belly, and although I don't

22:24

see babies' bellies all that often, even I know this

22:28

is abnormal. And when they took this baby to the

22:31

OR, all of this bowel was dead bowel — so not good.

22:40

Okay.

22:41

Now that we've talked a lot about bowel

22:43

obstructions in the neonatal period, I wanna move

22:46

outside of the neonatal period and talk about

22:48

bowel obstructions in children and older babies.

22:52

So this is my favorite mnemonic in probably

22:55

all of radiology for the differential.

22:58

It's A-I-I-M-M — AIM.

23:02

So adhesions, appendicitis, intussusception,

23:06

incarcerated inguinal hernia, mal-

23:09

rotation with volvulus, and Meckel diverticulum.

23:16

So now let's look at some kids and older babies

23:19

and talk about those cases. So our first

23:23

patient is a 2-year-old with crampy abdominal pain.

23:29

Okay, this is the kid's X-ray, and we see some mildly

23:33

dilated loops of bowel in the left upper abdomen.

23:36

And if you look closely, you can kind

23:39

of make out that there's a soft tissue

23:41

mass in the right upper quadrant.

23:44

There's kind of a lack of distal

23:46

bowel gas, so this soft tissue mass

23:49

to me is suspicious for an intussusception.

23:53

Let's look on ultrasound, which is the gold standard.

23:57

So when we do an ultrasound, we see this ovoid bowel-

24:01

within-bowel structure in the right upper quadrant.

24:04

We put flow on it. There's still

24:06

preserved blood flow, so that's good.

24:08

And we, um, check the size of this thing, and

24:11

we see it measures 3.2 centimeters in diameter,

24:15

which tells you it's an ileocolic intussusception.

24:19

Okay?

24:19

So ileocolic intussusceptions most commonly happen

24:22

between three months and three years of age.

24:26

You get telescoping of bowel, usually

24:28

related to lymphoid hyperplasia.

24:31

And as we mentioned, ileocolic

24:32

intussusceptions are usually bigger than

24:34

three centimeters in diameter.

24:36

Now you can get transient small bowel, small-

24:39

bowel intussusceptions, and those are usually less

24:41

than two centimeters, but between two and

24:43

three centimeters is kind of the gray zone.

24:46

Often what we will do —

24:47

if we can't tell the difference,

24:49

we'll follow it up in an hour.

24:51

If it has gone away, it was

24:53

almost for sure a small-bowel,

24:55

small-bowel intussusception.

24:56

If it's still there, then we

24:58

may proceed to a reduction.

25:00

So how do you treat an ileocolic intussusception?

25:05

You do an air reduction enema.

25:08

Board-style question: you wanna keep your

25:11

pressures less than 120 millimeters of

25:14

mercury, and there's a 1% perforation rate.

25:19

Okay, so here's an example.

25:20

So we have the rectal tube

25:22

in the rectum.

25:23

We squirt air in under pressure.

25:25

So you see air going in the sigmoid,

25:28

left colon, transverse colon.

25:30

We get to the hepatic flexure, and

25:32

then you see this filling defect.

25:34

That's the intussusceptum.

25:36

That's the thing we saw on the X-ray.

25:38

So we squirt some more air in,

25:41

and we see the intussusceptum backs out a little bit.

25:44

It's getting a little bit smaller as we

25:45

continue, and then all of a sudden we

25:48

have a gush of air into the small bowel.

25:51

That's how you know you have fixed

25:53

the ileocolic intussusception.

25:56

Now, sometimes it can be tricky to tell if

25:58

you have dilated loops of small bowel to

26:00

begin with, so you can always do a bedside

26:04

ultrasound while you're still on the fluoroscopy

26:06

table if you wanna make sure you fixed it.

26:13

Okay, our next patient is a 10-year-old

26:15

with right lower quadrant pain.

26:23

Okay, so we're doing an ultrasound of the

26:25

right lower quadrant 'cause we're peds,

26:27

and we like to do ultrasound before CT.

26:30

And we see a dilated tubular

26:32

structure in the right lower quadrant.

26:34

The diameter measures greater than six millimeters.

26:37

There's hyperemia when we put flow on.

26:40

And then I want you to look at all

26:41

this white stuff around the appendix.

26:44

That's inflammation.

26:46

That's the equivalent of fat stranding on CT.

26:49

Now, if we push on this with the ultrasound probe,

26:51

it's not gonna be compressible, and the patient

26:54

will have pain right when we push over that area.

26:56

So this is consistent with appendicitis.

26:59

We're gonna look for free fluid,

27:00

make sure there's no abscess.

27:03

We also can sometimes see an appendicolith on

27:05

ultrasound, which this patient does not have.

27:09

Okay, this is a different patient. I'm sure by now

27:11

you've all seen CT examples of appendicitis,

27:14

but you see the dilated appendix,

27:16

the wall is a little hyperenhancing.

27:18

There's a little fluid around it.

27:20

And also, um, you see an appendicolith.

27:27

So on ultrasound, you look for the

27:29

dilated, non-compressible appendix.

27:32

You are looking for the surrounding echogenic

27:34

inflamed fat, pain when scanning over the

27:37

appendix, possibly an appendicolith, possibly

27:39

hyperemia, possibly free fluid or abscess.

27:44

Okay, this is another companion case, similar

27:47

symptoms of right lower quadrant pain, and you see

27:50

inflammatory change in the right lower quadrant.

27:52

This tubular, dilated, peripherally

27:54

enhancing structure, which is the appendix.

27:57

And I show this video just to remind you that

28:00

um, there are different causes of appendicitis.

28:03

And while you may be eating your lunch,

28:05

I wanted you to see this cute little

28:06

worm climbing around on the appendix.

28:08

So this is pinworm appendicitis.

28:11

Um, so now that you're woken up, we can

28:14

continue on with the rest of our lecture.

28:19

Okay?

28:21

Next case is a 4-year-old with lower abdominal pain.

28:26

Okay, so on these images,

28:32

see a dilated tubular structure

28:35

in the left lower quadrant.

28:37

It's peripherally enhancing.

28:39

You can see it here on the axial images.

28:41

There's stranding around.

28:43

It kind of looks like an appendix on these pictures,

28:46

but I assure you when we scroll through, we actually

28:48

found a normal appendix in the right lower quadrant.

28:51

We also see some dilated small

28:52

bowel loops here as well.

28:54

Okay, now I'm gonna show you another patient with

28:56

a different presentation from the same thing.

29:00

Okay.

29:00

This is a different patient.

29:02

This is a Meckel scan study, and we see

29:06

uptake in the stomach, which is normal.

29:09

And then we see uptake here in the

29:11

right abdomen, which is not normal,

29:14

and it persists throughout the exam.

29:16

It's just as avid as the stomach.

29:18

So this is something with ectopic gastric mucosa.

29:23

So both of these patients — this patient and

29:26

this patient — they both have Meckel diverticuli.

29:30

So a Meckel diverticulum can cause bleeding if it

29:34

has ectopic gastric mucosa, and it will show up on

29:37

our Meckel scan study if it has ectopic gastric mucosa.

29:41

A Meckel diverticulum can also become inflamed,

29:44

like Meckel diverticulitis, like our patient on CT.

29:47

It can cause an obstruction or serve

29:50

as a lead point for an intussusception.

29:55

Our next patient is a baby with a distended abdomen.

30:04

Okay.

30:06

So on these radiographs, I see dilated loops of

30:09

bowel with air-fluid levels on the decubitus view.

30:13

And you can see that there's an air-filled loop of

30:15

bowel extending down into the right inguinal region.

30:19

So this is an obstruction from

30:21

an incarcerated inguinal hernia.

30:30

Okay, and we're gonna finish

30:32

up with foreign body ingestion.

30:36

Now, one of my co-fellows took this X-ray when I

30:38

was a fellow at Cincinnati Children’s, and I think

30:40

it's kind of cute to look to see sort of what

30:43

some of the different things look like on X-ray.

30:48

Alright, so our first case

30:51

is a kid swallowed something.

30:53

So.

30:56

So we have an abdominal X-ray, and we see

30:59

a rounded radiopaque structure over the

31:01

upper abdomen, probably over the stomach.

31:04

And when we look at it closely, we

31:06

can see that there's a beveled edge

31:08

or a ring-within-a-ring appearance.

31:12

This is a classic appearance of a button battery.

31:16

So if you zoom in, I want you

31:17

guys to put this in your memory.

31:20

So button batteries are found in

31:22

cameras, watches, hearing aids, toys.

31:26

They, um, have a beveled edge where you see

31:28

those two circular edges, and they're bad.

31:31

They can develop corrosive holes, and there's

31:34

different complications that can happen.

31:36

Because of that, you can have esophageal perforation

31:39

or a fistula between the esophagus and trachea, or

31:43

aorta, and it requires emergent endoscopic removal.

31:48

Let's look at this patient.

31:49

This is another patient, and you can see again

31:52

there's a button battery in their upper esophagus.

31:55

And if you look, the inferior margin of the

31:58

button battery has an irregular contour, and the

32:02

upper margin of it also has an irregular contour.

32:08

This patient had the button battery in their

32:10

esophagus for a while, and they actually

32:13

developed a fistula between their trachea

32:16

and esophagus from the button battery.

32:18

So here you can see we're squirting

32:20

contrast in the esophagus.

32:22

You can see an abnormal connection

32:23

between the esophagus and the trachea.

32:26

The trachea is outlined with contrast.

32:30

And on this image you can see the whole

32:32

tracheobronchial tree lighting up.

32:34

I also saw during fellowship a case of erosion through

32:39

the esophagus into the aorta from a button battery.

32:42

So it's a big deal.

32:43

You need to call this result if you see it.

32:46

Okay, now this is another patient.

32:49

Companion case, and here we see a rounded

32:52

radiopaque foreign body over the thoracic inlet.

32:55

You see it projecting over the

32:56

esophagus on the lateral view.

32:59

Now this turned out to be a coin, but I would urge

33:02

you not to say that you see a coin in the esophagus.

33:07

If you see a button battery or a beveled edge,

33:09

you wanna definitely call it a button battery.

33:11

If, unless you see a president's head on the

33:14

x-ray, I would just call this a rounded radiopaque

33:18

foreign body, because not all button batteries

33:20

have the most obvious beveled edges, and

33:22

you can't a hundred percent exclude that here,

33:26

although it's unlikely given the appearance.

33:30

Okay, we have another patient

33:32

that's swallowed something.

33:36

Okay, so we have an x-ray from yesterday,

33:39

followed by an x-ray from today.

33:42

And on yesterday's x-ray, we see

33:43

these two rounded adherent structures

33:47

present over the right upper quadrant.

33:49

And today we can see they have

33:51

migrated to the left lower quadrant.

33:53

There might be some mild distension to the

33:55

bowel, but, um, the important thing here is that—

34:00

these things have migrated.

34:01

So these are two adherent magnets.

34:04

So if you swallow two magnets and they're already

34:07

stuck together before you swallow them, and that's

34:09

all you swallow, it's not that big of a deal.

34:14

But if you swallow a magnet, drink some water,

34:17

swallow another magnet, drink some water, and they

34:21

go in opposite loops of bowel, they can actually

34:24

cause the two bowel loops to stick together

34:26

and they can cause obstruction or perforation.

34:29

So you wanna check for fixed position on

34:31

x-ray versus free-moving position on x-rays.

34:34

So the fact that these changed positions

34:37

significantly, that tells me they're stuck to each

34:39

other, but there's no loop of bowel in between.

34:45

Okay, now here's another patient, a companion case.

34:49

Okay, so this is the yesterday's

34:50

x-ray and we see these two adherent

34:54

structures in the right hemiabdomen.

34:56

Also, you see a couple thumbtacks.

34:58

So, um, patient likes to eat things, I guess.

35:03

But if you look at today's x-ray,

35:06

these guys have not really moved.

35:09

Much.

35:10

I think the thumbtacks the kid either pooped

35:12

out or they removed them by colonoscopy.

35:14

But these two adherent magnets have not moved.

35:18

And now there's a focal dilated bowel loop.

35:21

And these turned out to

35:23

be in opposite bowel loops.

35:25

They attracted each other, they caused a

35:26

closed-loop obstruction of the small bowel.

35:29

And when they went to the OR, they actually

35:32

found multiple microperforations from the bowel

35:35

loop, from the magnets through the bowel loops.

35:41

Okay.

35:43

And finally, case three.

35:45

This is a teenager with a palpable epigastric mass.

35:53

Okay.

35:53

This is her x-ray, so we see she does have an IUD.

35:58

You have some mild gaseous distension of bowel loops,

36:00

non-obstructive pattern, but the thing that kind

36:02

of jumps out to me is that the stomach is distended

36:06

and it sort of has some mottled lucency in it.

36:09

And I think the colon is almost kind of

36:11

pushed down a little bit by the stomach here.

36:14

So she came to me for an upper GI,

36:19

so I did the upper GI and—

36:23

throughout the whole study there was this filling

36:25

defect in the stomach and you can see as you kind

36:28

of wait, some contrast sort of gets in little

36:34

pockets within this thing in the stomach,

36:37

but there's always kind of a filling defect here.

36:41

I had my suspicions what this was.

36:43

I asked the patient a few key questions,

36:46

such as, one, do you eat anything unusual?

36:49

Like lots of celery, carrots, things

36:53

with lots of fiber, cotton balls?

36:55

She said, no, and I said, number—

36:58

my other question is, do you by chance eat your hair?

37:01

And she said, yes.

37:02

I just can't stop eating my hair.

37:05

So this is a trichobezoar, a hairball.

37:09

Let's look at it on some other imaging modalities.

37:10

Let's look at it on some other imaging modalities.

37:13

So here's—

37:14

this is actually a CT and you

37:17

can see very distended stomach duodenum.

37:21

This is actually a couple months later, and

37:23

you can see there's little, uh, pockets

37:25

of air within the junk in her stomach.

37:29

Okay, so they tried to remove this via endoscopy.

37:32

So here's the pictures from the endoscopy.

37:34

You see strands of hair, and often they,

37:37

this is like all matted together, and they

37:39

can't just pull it out via endoscopy.

37:42

So this patient actually had to go to the OR. They

37:45

delivered her stomach, and then they opened it up.

37:49

And here is the world's largest

37:52

hairball, and I think this is really—

37:56

interesting, because she was a blonde

38:00

and changed her hair color to brown.

38:02

So two different hair colors

38:06

in one hairball, trichobezoar.

38:12

Okay.

38:12

At this point, um, we're gonna stop,

38:15

and I'm gonna take any questions.

38:17

You can use the Q and A function to ask questions.

38:25

And I see Omar got the answer.

38:27

Bezoar, correct.

38:28

Awesome job, Omar.

38:31

Okay.

38:32

Um, the first question is, how do you measure

38:35

the rectosigmoid ratio in Hirschsprung's disease?

38:41

And that is always measured on the lateral view,

38:45

and I measure that on one of my very early filling—

38:50

views.

38:50

So I measure the rectum, and then I measure

38:55

the sigmoid, and it's just a ratio.

38:58

So rectosigmoid ratio—it's rectum

39:01

divided by sigmoid, and some PACS systems

39:03

won't measure in actual centimeters.

39:05

It'll measure in pixels.

39:06

It doesn't matter, since it's the ratio.

39:10

Okay.

39:11

Um, I see a question from TJ asking to

39:16

discuss the orientation of foreign bodies

39:18

in the trachea versus the esophagus.

39:20

And I have seen that kind of

39:22

question appear on certain tests.

39:24

So, um, if you have a foreign body in the esophagus,

39:29

it's gonna be oriented vertically, up and down.

39:33

And you'll see that on the lateral view,

39:34

like the patients we looked at—the coin

39:36

or foreign body was oriented up and down.

39:40

Um, if it's in the trachea,

39:42

it'll be flat in the trachea.

39:44

So you would just see the little edge on the AP view.

39:49

Okay.

39:49

Let's see.

39:50

Next question.

39:51

Do you inflate the balloon for

39:53

pneumatic reduction of intussusception?

39:56

Yes, absolutely.

39:58

So when you do an intussusception reduction,

40:00

you have to maintain consistent pressures.

40:03

So we inflate a balloon.

40:05

We also, um, tape the butt cheeks closed with—

40:09

I mean, with duct tape, as crazy as

40:11

it sounds, because if you get any leak

40:13

of air out from the intussusception

40:16

reduction, then it's not going to work.

40:21

Okay.

40:22

Next question.

40:23

If you have a perforation during pneumatic

40:25

reduction of intussusception, where do you

40:27

stick the needle into the abdomen to decompress

40:30

tension pneumoperitoneum?

40:33

Okay.

40:33

So I am lucky enough that I have never had—

40:38

perforation yet, although there's nothing

40:40

you can really do to prevent it other

40:42

than maintain the appropriate pressures.

40:44

But if you're getting tension pneumoperitoneum,

40:46

you're gonna have so much air in the abdomen

40:48

that you can kind of stick it anywhere.

40:50

But what I—I certainly wouldn't stick it where

40:52

the liver is, but I would probably go for right

40:54

lower quadrant, um, just like you're doing—

40:57

um,

40:59

paracentesis in someone with a lot of

41:01

ascites, but you stick it in just a little

41:03

bit and you'll hear the air come out.

41:04

So you don't have to stick it in that

41:06

far, since air rises up to the surface.

41:11

Okay.

41:12

Let's see.

41:14

Okay, I'm gonna do this one.

41:15

How can you differentiate between,

41:18

uh, pylorospasm and hypertrophic

41:21

pyloric stenosis on ultrasound and, um—

41:27

we kind of talked about that a little bit. So

41:29

you have to look at the muscle thickness first.

41:32

So if the muscle is thicker than three millimeters,

41:35

you're gonna start thinking about pyloric stenosis

41:39

to make sure that it's true pyloric stenosis,

41:43

and not just muscle spasm or pylorospasm.

41:48

Then you're gonna use the channel length.

41:50

To make sure the channel is nice and

41:53

elongated and not all balled up on itself.

41:56

So the channel length basically is your

41:58

double check to tell you that it's true

42:01

pyloric stenosis, not just pylorospasm.

42:07

I think that that is, um, we

42:12

are done with our questions now.

42:15

Um, if there's any other questions that were not

42:18

answered, um, because of time constraints,

42:21

this is my email address, jra2@jmi.edu.

42:27

You're welcome to email me any questions, and I

42:29

can go into more details, um, regarding those.

42:33

So thank you all for joining, and I hope you all

42:37

have a great rest of the day and a great 2021.

42:42

All right, as we bring this to a close,

42:44

I want to thank Dr. Kucera for this lecture.

42:46

And thanks to all of you for

42:47

participating in our noon conference.

42:50

Uh, a reminder that this conference is

42:51

available on demand on MRIonline.com, in

42:55

addition to all previous noon conferences.

42:57

Be sure to join us again on Wednesday for a lecture

43:00

from Dr. Vickis Agarwal on image-guided spine biopsy.

43:05

You can register for that at MRIonline.com and follow

43:08

us on social media at The MRI Online for updates

43:12

and reminders on upcoming noon conferences.

43:15

Thanks again, and have a great day.