Radiology of the vomiting child
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Radiology of the Vomiting Child. Steven T Welch, MD Children’s Mercy Hospital April 30, 2011. Vomiting/ Regurgitation in young children. Most common cause of vomiting and regurgitation in infants is gastroesophageal reflux .

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Radiology of the vomiting child

Radiology of the Vomiting Child

Steven T Welch, MD

Children’s Mercy Hospital

April 30, 2011


Vomiting regurgitation in young children

Vomiting/ Regurgitation in young children

  • Most common cause of vomiting and regurgitation in infants is gastroesophageal reflux.

  • These patients typically maintain normal weight and developmental milestones.


Natural history of infant regurgitation

Natural history of infant regurgitation

  • 47% of 1 month old infants had 1 or more daily episodes of vomiting/regurgitation, decreased to 29% at 4 mos, and 6% at 7 mos.

    • Miyazawa et al, “International Pediatrics”, 2002.

  • Spilling of feeds reached peak prevalence of 41% between 3 and 4 mosand decreased to less than 5% by 13 mos.

    • Martin et al, “Pediatrics”, 2002.


Radiology of the vomiting child

Reflux in esophagus

Stomach

Upper GI study


Vomiting regurgitation in young children1

Vomiting/ Regurgitation in young children

  • Most patients do NOT require imaging with an upper GI exam as this study defines anatomy, and reflux may or may not be seen.

  • In cases of persistent or severe regurgitation, pH probe monitoring may be helpful.

  • Imaging should be considered if there are airway symptoms or bloody or bilious emesis.


Radiology of the vomiting child

pH probe in esophagus


What test should be ordered for a child with bilious emesis

What test should be ordered for a child with bilious emesis?

  • Esophagram

  • Upper GI/small bowel follow-through

  • OPM (oropharyngeal motility)

  • Upper GI study


Vomiting regurgitation in young children2

Vomiting/ Regurgitation in young children

  • It is NOT necessary to order a small bowel follow-through examination to exclude malrotation because the pediatric upper GI examination includes imaging of the ligament of Treitz.


Newborn bilious emesis

Newborn Bilious Emesis

  • Bilious emesis in a newborn is an emergency which should be promptly evaluated with an upper GI examination to exclude malrotation and volvulus.

  • Patients should have an NG or OG tube placed to confirm the presence of bilious material as well as facilitating the UGI exam.


Radiology of the vomiting child

Supine abdomen

Left lateral decubitus view

stomach


Radiology of the vomiting child

Upper GI study

Left pedicle line

Duodenojejunal junction


Radiology of the vomiting child

Upper GI study

Volvulus


Radiology of the vomiting child

Normal duodenojejunal junction (ligament of Treitz)


Pyloric stenosis

Pyloric Stenosis

  • Common cause of early infantile intestinal obstruction.

  • Also known as Hypertrophic Pyloric Stenosis (HPS).

  • Multifactorial causes suggested including:

    • Hereditary

    • Exposure to macrolide antibiotics (erythromycin)

    • Abnormal myenteric plexus innervation

    • Infantile hypergastrinemia


Pyloric stenosis1

Pyloric Stenosis

  • 2-4 cases/ 1000 live births in U.S., male:female ratio 4:1

  • 95% diagnosed between 3 and 12 weeks of age.

  • Nonbilious emesis which becomes projectile.

  • May have a palpable “olive” on exam.


In cases of suspected pyloric stenosis the best radiology study to order is

In cases of suspected pyloric stenosis, the best radiology study to order is:

  • Upper GI study

  • KUB (abdXray)

  • Ultrasound

  • Computed tomography (CT)


Pyloric stenosis2

Pyloric Stenosis

  • A limited abdominal ultrasound is the diagnostic study of choice.

    • Highly sensitive and specific

    • No radiation

    • No sedation


Radiology of the vomiting child

Pyloric Ultrasound

Elongated pyloric channel

Thickened pyloric muscular wall


Pyloric stenosis3

Pyloric Stenosis

  • Individual wall thickness > 3mm

  • Elongated pyloric channel >18mm

  • Mucosal hypertrophy

  • Absence of fluid or gas in the pyloric channel during the US study.


Radiology of the vomiting child

Upper GI study

Elongated, narrow pyloric channel

Contrast filled stomach


Intussusception

Intussusception

  • Most common cause of intestinal obstruction in children aged 3 to 36 mos., 60% < 1 y.o., 80% < 2 y.o.

  • Majority are idiopathic.

  • Seasonal patterns associated with gastroenteritis, possibly due to hypertrophy of lymphoid tissue in the terminal ileum.

  • Increased incidence after some forms of rotavirus vaccine.


Intussusception1

Intussusception

  • Pathologic lead point in some cases:

    • Meckel’sdiverticulum

    • Enteric duplication cyst

    • Lymphoma

    • Polyps

    • Henoch-Schonleinpurpura (intramural hemorrhage)


Intussusception2

Intussusception

  • Present with sudden onset of crampy, intermittent abdominal pain with drawing-up of legs and inconsolable crying.

  • May develop vomiting and currant-jelly stools.

  • Diagnostic work-up includes abdominal radiographs and ultrasound.

  • Treated with air enema reduction.


Why order plain x rays in suspected cases of intussusception

Why order plain x-rays in suspected cases of intussusception?

  • Look for obstruction.

  • Exclude free air.

  • May suggest an alternative diagnosis.

  • All of the above.


Radiology of the vomiting child

Supine abdomen X-ray

Left decubitus X-ray


Radiology of the vomiting child

Abdominal Ultrasound

Ileocolicintussusception


Radiology of the vomiting child

Air enema reduction


Intussusception3

Intussusception

  • Contraindications to enema reduction:

    • Pneumoperitoneum

    • Clinical peritonitis or unstable patient

  • Surgery required for incomplete reduction, free air, multiple recurrent episodes (possible lead point).

  • Incidental small bowel-small bowel intussusception which may be seen on US or CT is typically transient and asymptomatic.


Less common causes of obstruction

Less common causes of obstruction

Newborn presentation:

  • Meconiumileus

  • Small bowel atresia

  • Meconium plug (small left colon) syndrome

  • Hirschprung’s disease


Radiology of the vomiting child

Stomach

Multiple dilated bowel loops


Radiology of the vomiting child

Filling defects in terminal ileum on contrast enema


Radiology of the vomiting child

Meconiumileus


Radiology of the vomiting child

Upright Abdomen X-Ray

Supine Abdomen X-Ray


Radiology of the vomiting child

Delayed image from Upper GI study

Dilated distal small bowel loops


Radiology of the vomiting child

Ilealatresia


Radiology of the vomiting child

Multiple dilated bowel loops suggesting distal bowel pathology


Radiology of the vomiting child

Contrast Enema

Small left colon

Meconium plugs


Radiology of the vomiting child

Meconium Plug Syndrome


Radiology of the vomiting child

Multiple dilated bowel loops suggesting distal obstruction.


Radiology of the vomiting child

Lateral view from a contrast enema

Dilated sigmoid colon

Narrowed, irregular rectum


Radiology of the vomiting child

Hirschprung’s disease


Additional causes of obstruction

Additional causes of obstruction

  • Older infants and children:

    • Appendicitis

    • Adhesions

    • Incarcerated hernia

    • Meckel’sdiverticulum


Radiology of the vomiting child

Appendicolith


Appendix ultrasound

Appendix Ultrasound

Shadowing stone in dilated appendix


Appendix ultrasound1

Appendix Ultrasound

  • Ordered as a limited abdominal US.

  • Linear transducer with graded compression.

  • Non-compressible, blind-ending tubular structure, >6mm

  • Often surrounded by edema/inflammation.


Radiology of the vomiting child

Appendicitis CT

Stone within an inflamed appendix


Radiology of the vomiting child

Inguinal hernia noted on physical exam; Gas-filled bowel loops seen on X-Ray performed for vomiting.


Radiology of the vomiting child

Incarcerated Hernia


Radiology of the vomiting child

Abnormal fluid filled structure on Pelvis CT


Nuclear medicine meckel s scan tc99m pertechnetate

Nuclear Medicine Meckel’s Scan (Tc99m-Pertechnetate)

Meckel’sdiverticulum


Summary

Summary

  • Most vomiting/ regurgitation in infants is due to reflux and does not require imaging.


Summary1

Summary

  • Most vomiting/ regurgitation in infants is due to reflux and does not require imaging.

  • Bilious emesis is an emergency which should be evaluated by an upper GI study.


Summary2

Summary

  • Most vomiting/ regurgitation in infants is due to reflux and does not require imaging.

  • Bilious emesis is an emergency which should be evaluated by an upper GI study.

  • Ultrasound is an important tool in the diagnosis of pyloric stenosisand intussusception.


Summary3

Summary

  • Most vomiting/ regurgitation in infants is due to reflux and does not require imaging.

  • Bilious emesis is an emergency which should be evaluated by an upper GI study.

  • Ultrasound is an important tool in the diagnosis of pyloric stenosis and intussusception.

  • When in doubt about the imaging work-up, consult your radiology colleagues at CMH.


Thank you for your attention

Thank you for your attention


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