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Approach to Pediatric Abdominal X-Rays, Exams of Anatomy

London South Bank University (LSBU)Anatomy

1. Develop a basic approach to interpreting pediatric abdominal x-rays. 2. Identify relevant anatomy on pediatric abdominal x-rays.

Typology: Exams

2021/2022

Uploaded on 09/12/2022

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Approach to Pediatric Abdominal X-Rays
Ben Pi, Dr. J. Jaremko
PedsCases
University of Alberta
Hello and welcome to a PedsCases’ podcast on a basic approach to interpreting pediatric
abdominal x-rays.
My name is Ben Pi and I am a medical student at the University of Alberta. This podcast
was developed with the help of Dr. Jacob Jaremko, a pediatric MSK radiologist at the
University Of Alberta Hospital, and the support of the PedsCases team.
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Approach to Pediatric Abdominal X-Rays

Ben Pi, Dr. J. Jaremko PedsCases University of Alberta

Hello and welcome to a PedsCases’ podcast on a basic approach to interpreting pediatric

abdominal x-rays.

My name is Ben Pi and I am a medical student at the University of Alberta. This podcast

was developed with the help of Dr. Jacob Jaremko, a pediatric MSK radiologist at the

University Of Alberta Hospital, and the support of the PedsCases team.

Learning Objectives

  1. Develop a basic approach to interpreting pediatric abdominal x-rays.
  2. Identify relevant anatomy on pediatric abdominal x-rays.
  3. Describe radiological findings of common abdominal pathologies

In the next 15 minutes, I hope to present one systematic approach to the interpretation of

abdominal X-rays, describe some of the relevant anatomy, and finally familiarize you with

some common abdominal pathologies.

Approach

  • Tubes, Lines, Other objects
  • Air: Intra-luminal (ex. bowel gas pattern), Extra-luminal (ex. Free air)
  • Solid Organs
  • Osseous and Soft tissue

Let us begin with an overview of the general approach when interpreting X-rays. I

personally like to think in 4 main sections: extrinsic objects such as tubes and lines, the air

pattern, the solid organs, and finally the bony and soft tissues structures.

Tubes and Lines

  • ETT = Endotracheal Tube
  • NGT = Nasogastric Tube
  • UVC = Umbilical Vein Catheter
  • UAC = Umbilical Artery Catheter
  • ECG = Electrocardiogram Lead

The first thing to comment on is the presence of extrinsic objects such as tubes, lines,

medical devices or other objects that are not intrinsic to the body. This XR shows some of

the common ones, such as ETT in the midline trachea, NGT descending midline and ending

in the gastric body, UAC and UVC entering at the umbilicus and traversing cranially. There

are certainly many more possibilities but we will not go into those details today.

Tubes, lines, others

  • Foreign Body

With the extrinsic and intrinsic structures in mind, let’s go over some pathologies and

practice our approach. Feel free to pause the video if you want to go over it by yourself and

then compare.

Case 1

  • A 2.5 year old female presents to your ER with a panicking mom

Case 1 is a 2.5 year old female who presents to the ER with a panicking mom.

Air

  • Pneumoperitoneum
  • Bowel Obstruction
  • Necrotizing Enterocolitis
  • Constipation
  • Duodenal Atresia

Thinking of the next major component in our approach, let’s look at some abnormal air

patterns. This is usually the area of the highest yield.

  • 2d old male with bilious vomiting, irritability, and lack of meconium passage

Case 2

Our next case is a 2d old male presenting with bilious vomiting, irritability, and lack of

meconium passage. This is his abdominal x-ray.

  • 1 month old ill-appearing premature infant with poor feeding, bloody diarrhea, abdominal distention, and failure to thrive.

Case 3

Our next case is a 1 month old ill-appearing premature infant with poor feeding, bloody

diarrhea, abdominal distention, and failure to thrive.

  • Necrotizing Enterocolitis
    • Pneumatosis Intestinalis (red)
    • Bowel loop distention
    • Portal venous air (not seen here)
    • Pneumoperitoneum (not seen here)

Case 3

We do not see any extrinsic lines and tubes are seen.

We do however see air that appears to be just beyond the lumen wall. This specific

appearance of gas within the bowel wall is called pneumatosis intestinalis, which is caused

by gas-producing bacteria in the bowel wall. This is seen with necrotizing enterocolitis, a

potentially deadly condition commonly associated with prematurity.

No free air is seen here, but pneumoperitoneum is not uncommon with NEC. Sometimes

you may also see gas in the hepatic veins in the RUQ.

Other organs, bones and soft tissue are unremarkable.

  • Constipation
    • Intraluminal fecal matter (yellow)
    • Complications include overflow incontinence, toxic megacolon, perforation, etc.

Case 4

No extrinsic lines or tubes are seen.

In this case, we still see bowel gas throughout the abdomen. In addition, there is

intraluminal solid matter, which is in keeping with fecal loading or constipation. No bowel

dilation or free air is seen.

Solid organs are within normal limits. No bony or soft tissue abnormalities.

Note that constipation is very common in the pediatric population, especially during times

of transition (ex. potty-training, starting school, moving, etc). They may end up in a cycle of

stool retention, holding behaviors and pain, which can lead to serious sequelae such as

overflow incontinence, UTI, even toxic megacolon and perforation.

  • 2mo old infant with significant abdominal distention, vomiting, and irritability

Case 5

Our next case is a sick appearing 2mo old infant with significant abdominal distention,

vomiting, and irritability.

Case 5 Companion Case

Here is another case with findings of pneumoperitoneum on the AP view (right), including

Football sign and Rigler’s sign. Notice the large pocket of air (lucency) at the top of the

abdomen on lateral view.

  • 4 year old female with bloating, nausea and vomiting Supine (^) Upright

Case 6

In this next case, we have a 4 year old female with bloating, nausea and vomiting. Here we

see 2 radiographs, an upright view, and a supine view.