Dykie Adam,  Katzman Philip,  Chaturvedi Apeksha

Final Pr. ID: Poster #: EDU-037

Wilms tumors, also known as nephroblastomas, are overwhelmingly the most common renal tumors in children. While radiologists are abundantly familiar with the imaging appearances of these tumors, their knowledge of underlying histologic features, prognostic variables, and treatment approaches may not be equally robust. Histologically typically triphasic and containing differing proportions of blastemal, epithelial, and stromal components, the prognosis of individual subtypes differs. The “teratoid” variant of Wilms tumor contains components of differentiated tissues such as muscle, bone, cartilage, and fat. Focal and diffuse anaplasia are important histological features with diffuse anaplasia recognized as the most important prognostically unfavorable feature. In addition, there is an intermediate category of “nuclear unrest” which carries some but not all features of anaplasia. Clinical approaches differ between the two major renal tumor clinical research groups: the International Society of Paediatric Oncology (SIOP) Renal Tumor Study Group and the Children's Oncology Group (COG) Renal Tumor Group. This exhibit uses a case-based template of radiologic-pathologic correlation of different Wilms subtypes encountered at our institution, outlining treatment for individual tumor subtypes. We discuss differential diagnoses which may overlap with Wilms tumor on imaging, including nephrogenic rests, mesoblastic nephroma, malignant rhabdoid tumor of the kidney, clear cell sarcoma, and pediatric cystic nephroma (as a mimic of cystic Wilms tumor). We review Wilms tumor classification with known syndromic associations. We provide information on staging through the National Wilms Tumor Study system covering imaging and post-surgical findings. The ultimate goal is to make radiologists more effective members of the interdisciplinary tumor boards through enhancing a holistic understanding of Wilms tumor. Read More

Authors:  Dykie Adam , Katzman Philip , Chaturvedi Apeksha

Keywords:  Wilm's Tumor, Kidneys, Abdominal Imaging

Mannuru Sravani,  Hui Jessica,  Lai Lillian

Final Pr. ID: Poster #: EDU-018

Extralobar pulmonary sequestration (EPS) and cystic neuroblastoma (CN) are rare pediatric thoracoabdominal masses with distinct yet sometimes overlapping imaging features, posing diagnostic challenges for radiologists. Accurate differentiation is crucial for guiding clinical management and preventing unnecessary interventions. This review focuses on comparing the imaging characteristics of EPS and CN, with emphasis on key features that aid in distinguishing between these entities. EPS typically presents as a well-defined, homogenous mass located near the lower lobes of the lung, often with systemic arterial supply visualized on contrast-enhanced imaging. It may exhibit smooth margins and is commonly identified in neonates and infants. Conversely, cystic neuroblastoma, while rarer, typically manifests as a retroperitoneal mass, often arising from the adrenal gland, with a more complex appearance, including cystic and solid components. Calcifications, which are frequently seen in neuroblastoma, may provide a critical clue for diagnosis, while the absence of systemic arterial supply differentiates it from EPS. Pitfalls arise from the potential overlap in appearance, such as fluid-filled or cystic components within both lesions, which may lead to confusion. Additionally, both lesions may be incidentally discovered on prenatal or early postnatal imaging, necessitating careful evaluation of ancillary features such as vascular supply, location, and internal characteristics to ensure accurate diagnosis. This review offers radiology residents, fellows, and attending radiologists a comprehensive comparison of EPS and CN imaging findings, with a focus on avoiding common diagnostic traps. Understanding these key differences enhances diagnostic confidence, promotes appropriate management, and improves outcomes for pediatric patients. Read More

Authors:  Mannuru Sravani , Hui Jessica , Lai Lillian

Keywords:  Pediatric Radiology, Abdominal Imaging, Chest

Podury Ruchika,  Dagar Saloni,  Weiss Danielle,  Amodio John,  Blumfield Einat,  Levin Terry

Final Pr. ID: Poster #: EDU-035

Intraluminal post bulbar duodenal masses in children may be solid or cystic, congenital, neoplastic or post traumatic. The aim of this educational exhibit is to present the imaging findings of these duodenal masses using fluoroscopy, ultrasonography, computed tomography and magnetic resonance imaging and discuss the role of imaging. In addition, the clinical implications of these entities will be discussed. The cases will include: duodenal duplication cyst, duodenal web, choledochocele, duodenal hematoma, and duodenal adenoma. Read More

Authors:  Podury Ruchika , Dagar Saloni , Weiss Danielle , Amodio John , Blumfield Einat , Levin Terry

Keywords:  Duodenum, Abdominal Imaging, Pediatric Imaging

Kumar Tushar,  Elhussein Wala,  Kim Helen Hr

Final Pr. ID: Poster #: EDU-040

Sinusoidal obstruction syndrome (SOS), also known as veno-occlusive disease (VOD), is a potentially life-threatening hepatic complication that occurs primarily following hematopoietic stem cell transplantation (HSCT). It is characterized by obstruction of hepatic sinusoids and venules due to accumulation of cellular debris and red blood cells, leading to impaired hepatic outflow. The incidence in pediatric patients can be as high as 40%, resulting from toxic injury or activation of liver sinusoidal endothelial cells (LSECs). Common etiologic factors include myeloablative conditioning regimens for HSCT, chemotherapeutic agents such as oxaliplatin, and total body irradiation. SOS/VOD is classified into acute (80%, within 21 days post-HSCT) and late-onset forms (20%, beyond 21 days). Histopathologically, late-phase SOS shows peri-sinusoidal fibrosis and hepatocyte atrophy in addition to sinusoidal obstruction. Clinically, the disease manifests with painful hepatomegaly, conjugated hyperbilirubinemia, and rapid weight gain or ascites. While the modified Seattle and Baltimore criteria are traditionally used for adults, the European Society for Blood and Marrow Transplantation (EBMT) 2019 criteria have been specifically developed for the pediatric population, incorporating both clinical and radiologic parameters. Ultrasonography remains the first-line imaging modality, including gray-scale, color Doppler, and spectral analysis. Ultrasound elastography can detect SOS as early as 2–12 days before clinical criteria are met by quantifying increased hepatic stiffness due to portal hypertension; a ≥ 30% rise in stiffness from baseline has demonstrated high sensitivity and specificity. Characteristic sonographic findings include hepatomegaly, gallbladder wall thickening, increased portal vein diameter, ascites, paraumbilical vein visualization with altered flow, reduced portal venous velocity, and elevated hepatic artery resistive index—imaging parameters that are incorporated into the newer Hok-US scoring system (maximum 14 points). Additionally, MR elastography and hepatobiliary MRI using Eovist have shown promise for early, noninvasive detection. Early diagnosis is critical, as severe SOS carries mortality rates up to 80%, and the only approved therapy remains defibrotide, emphasizing the need for vigilant imaging surveillance and prompt management. Read More

Authors:  Kumar Tushar , Elhussein Wala , Kim Helen Hr

Keywords:  Abdominal Imaging, Venoocclusive Disease, Sinusoidal Obstruction Syndrome

Mannava Sindhu,  Chen Paula,  Marine Megan,  Cromeens Barrett,  Karmazyn Boaz

Final Pr. ID: Poster #: SCI-020

Neonatal bowel obstruction (NBO) is the first presentation of cystic fibrosis (CF) in approximately 15–20% of cases and is most commonly due to meconium ileus (MI) in this cohort. Contrast enema (CE) is a diagnostic tool which can help discern NBO etiology with variable accuracy. CE can also be a therapeutic tool in cases of simple MI. In this study, we describe our experience with CE in diagnosis and management of meconium ileus and other pathologies causing bowel obstruction in these patients. Read More

Authors:  Mannava Sindhu , Chen Paula , Marine Megan , Cromeens Barrett , Karmazyn Boaz

Keywords:  Abdominal Imaging, Contrast Enema, Obstruction

Ro Esther,  Schooler Gary,  Morin Cara,  Khanna Geetika,  Towbin Alexander

Final Pr. ID: Poster #: EDU-029

The American College of Radiology Pediatric LI-RADS Working Group was formed in 2017 with the task of advancing the imaging work up, diagnosis, and management of pediatric liver tumors, particularly pediatric hepatic malignancies. This exhibit will present how the Pediatric LI-RADS Working Group is working towards this goal by means of advocacy, education, and research. In regard to advocacy, the Working Group is a strong proponent for the standardization of imaging practice for pediatric liver tumors. Based on expert interpretation of the literature, the Working Group established consensus imaging recommendations for children with a known or suspected liver neoplasm. This exhibit will highlight the key recommendations for choosing imaging modality and protocol for the work up of a pediatric liver tumor. Education is another major component of the Working Group’s mission. The group has presented at meetings and published manuscripts on various topics. Topics include age and indication-based imaging strategies for pediatric liver tumors and liver masses in children with predisposition syndromes. This exhibit will touch on the major teaching points of these papers. Lastly, this exhibit will present the research conducted by the Pediatric LI-RADS Working Group. Their research studied the utility of applying adult LI-RADS criteria to children. Another study analyzed the imaging features of hepatocellular carcinoma in children with and without an underlying predisposition. To summarize, through discussion of the major accomplishments of the Pediatric LI-RADS Working Group, this exhibit will provide insight, education, and resources for the radiologist interpreting pediatric liver tumors. Read More

Authors:  Ro Esther , Schooler Gary , Morin Cara , Khanna Geetika , Towbin Alexander

Keywords:  Liver Tumor, Malignancy, Abdominal Imaging

Priya Sarv,  Nagpal Prashant

Final Pr. ID: Poster #: CR-030

Pediatric polyarteritis nodosa (PAN) is a rare systemic vasculitis affecting medium-sized arteries, leading to inflammation and organ damage. It often involves the skin, kidneys, and gastrointestinal tract, with symptoms such as fever, abdominal pain, and hypertension. Early diagnosis and treatment are essential to managing this condition. This report discusses renal imaging findings in two pediatric patients with PAN.

A 10-year-old male presented with abdominal pain, nausea, and acute renal failure. A left renal biopsy revealed medium vessel arteritis, raising suspicion for polyarteritis nodosa. Renal Doppler ultrasound showed normal renal arteries but increased echogenicity of the kidneys. CTA demonstrated patent renal arteries without beading, but bilateral cortical hypoenhancement was observed, indicating cortical necrosis consistent with vasculitis. MRA further confirmed the suspicion of PAN by revealing minimal contrast blushing and nodularity at the corticomedullary junction, suggestive of microaneurysms. Imaging played a key role in confirming the diagnosis of PAN in this patient.

A 16-year-old male presented with a six-month history of abdominal pain, fatigue, weight loss, chills, and hypertension. Laboratory results showed elevated inflammatory markers. MRA of the chest, abdomen, and pelvis revealed numerous bilateral arterial enhancing foci within the renal parenchyma, measuring 2 to 5 mm, suggestive of microaneurysms. A renal biopsy confirmed secondary focal segmental glomerulosclerosis.

CT and MR imaging are essential for diagnosing pediatric polyarteritis nodosa by identifying key vascular abnormalities such as microaneurysms and ischemic damage. These imaging techniques not only confirm the diagnosis but also guide timely intervention, improving the management of this rare condition in pediatric patients. Read More

Authors:  Priya Sarv , Nagpal Prashant

Keywords:  Renovascular Hypertension, Vasculitis, Abdominal Imaging

Zawin Joan,  Buyukkaya Ayla

Final Pr. ID: Poster #: CR-016

Case Report
Duodenum inversum is an uncommon congenital anomaly, in which the duodenum ascends to the level of the duodenal bulb, then passes posteriorly before crossing the midline above the pancreas.
This condition is thought to result from the persistence of the dorsal mesentery, leading to increased mobility of the duodenum. It is frequently associated with fixation or positional anomalies of the right kidney, pancreas, and transverse mesocolon.
Diagnosis is typically made via upper gastrointestinal (GI) series or laparoscopy, but may be delayed or overlooked if the configuration of the proximal duodenum is not carefully evaluated.
Although often asymptomatic, when symptoms such as vomiting, abdominal pain, or signs of obstruction are present, accurate diagnosis through imaging is essential for appropriate management. Awareness of this condition can help differentiate it from disorders such as malrotation, duodenal obstruction, or superior mesenteric artery (SMA) syndrome, and prevent potential complications associated with misinterpretation of imaging findings.
Associated conditions can include pancreatitis, gallbladder disease, duodenal ulcer, and, more rarely, gastric ulcer. Many of these symptoms are believed to result from stasis within the duodenal loop.
We present the case of a 1-year-old child with a history of hypoxic ischemic encephalopathy, who underwent upper GI imaging for evaluation of vomiting that had worsened over the past two weeks. On imaging, the first and second portions of the duodenum appeared normal. However, the third portion of the duodenum did not cross the midline, as would be expected. Instead, it ascended on the right side of the spine, posterior and parallel to the descending duodenum, reaching the level of the duodenal bulb. It then completed a transverse course to the left upper abdomen, where the duodenojejunal junction was appropriately located on the left side of the spine, at the level of the duodenal bulb findings consistent with duodenum inversum.
Treatment is primarily medical in the absence of obstruction. In cases where obstruction is attributed to SMA syndrome, transpyloric feeding is considered. Surgical intervention is reserved for cases of obstruction caused by fibrotic bands, in which a partial Ladd’s procedure may be performed. Read More

Authors:  Zawin Joan , Buyukkaya Ayla

Keywords:  Abdominal Imaging, Duodenum, Upper GI Study

Mannuru Sravani,  Hui Jessica,  Lai Lillian

Final Pr. ID: Poster #: EDU-089

Pediatric adrenal masses are rare but significant findings in clinical radiology, requiring careful evaluation due to their varied etiologies ranging from benign lesions to malignant tumors. For radiology residents, fellows, and attending radiologists, a systematic approach is essential for accurate diagnosis and management. This review highlights key imaging pearls and common pitfalls associated with pediatric adrenal lesions. The "pearls" include recognizing age-specific differentials, the importance of correlating clinical and biochemical findings, and the utility of advanced imaging techniques such as MRI for tissue characterization. Neuroblastoma, the most common malignant pediatric adrenal tumor, should be distinguished from benign entities like adrenal hemorrhage or hyperplasia based on imaging characteristics such as calcification, organ displacement, and vascular encasement. In contrast, pitfalls often arise from misinterpreting normal anatomic variations or failing to account for the dynamic nature of some lesions, such as hemorrhage or pheochromocytoma, which may change in size or appearance over time. Furthermore, the overlap in imaging features between benign and malignant lesions can lead to diagnostic uncertainty. This review emphasizes the need for a multidisciplinary approach, incorporating clinical, laboratory, and imaging data to avoid misdiagnosis and unnecessary interventions. Understanding the pearls and pitfalls of pediatric adrenal mass imaging will aid radiologists in providing more accurate and timely diagnoses, ultimately improving patient outcomes. Read More

Authors:  Mannuru Sravani , Hui Jessica , Lai Lillian

Keywords:  Abdominal Imaging, Adrenal, Pediatric Imaging

Van Antwerp Emily,  Makris Joseph

Final Pr. ID: Poster #: CR-024

Inspissated bile syndrome (IBS) is a rare pediatric condition, with an estimated incidence of 1 in 175,000 live births. It results from the thickening or "inspissation" of bile, often leading to biliary obstruction, cholestasis, and pale or acholic stools. While IBS is typically associated with predisposing factors such as prematurity, sepsis, total parenteral nutrition, or certain medications, it can occur without identifiable risk factors, as seen in this case. Early recognition and treatment are critical in preventing more serious complications such as liver dysfunction or cirrhosis. We report the case of a 4-week-old full-term infant (born at 40 weeks’ gestation) presenting with acholic (white) stools and mild jaundice. Initial laboratory tests showed a total bilirubin level of 5.0 mg/dL (3.9 direct), gamma-glutamyl transferase (GGT) of 352 U/L, alkaline phosphatase (ALP) of 586 U/L, and mildly elevated liver function tests. An abdominal ultrasound demonstrated intra- and extrahepatic biliary dilatation, with echogenic material obstructing the distal common bile duct just proximal to the ampulla, findings highly suggestive of inspissated bile syndrome. The patient was started on ursodiol 40 mg twice daily, a bile acid that promotes bile flow and decreases the viscosity of bile. A follow-up MRCP performed 10 days later showed complete resolution of the biliary obstruction and no evidence of intra- or extrahepatic dilation. This case highlights not only the rarity of IBS but also its ability to present in the absence of typical risk factors such as prematurity, malabsorption disorders, or prolonged total parenteral nutrition. Additionally, it underscores the essential role of imaging modalities such as ultrasound and MRCP in diagnosing biliary obstruction and guiding appropriate management. IBS should be considered in the differential diagnosis for any neonate presenting with jaundice and acholic stools, as timely diagnosis and medical management can lead to full recovery and prevent more serious hepatobiliary complications. Read More

Authors:  Van Antwerp Emily , Makris Joseph

Keywords:  Biliary, Abdominal Imaging, Abdominal Ultrasound

Ocal Selin,  Lee Jason,  Alizadeh Houman

Final Pr. ID: Poster #: CR-019

This case elucidates a 20mo male with history of chronic granulomatous disease (CGD) who presented with PO intolerance, recurrent emesis, fussiness, and abdominal pain. The patient was diagnosed with CGD at age 11mo after developing upper extremity cellulitis from Serratia marescens. Just 1 month before this presentation, he underwent colonoscopy/endoscopy for persistent anorexia and fussiness after clean-out for severe constipation and was found with ulcerative pancolitis. Initiation of vendolizumab was recommended; just a few days before his first dose, he developed increased vomiting, lethargy, and PO refusal. Ten days after symptom onset (5 days after first venolizumab dose) he presented to the emergency department. Initial abdominal radiograph was largely unrevealing with clinical suspicion for constipation. However, subsequent upper GI series revealed a diffusely narrowed and elongated pyloric channel with mild delay in gastric emptying, suspicious for pyloric stenosis. Follow-up ultrasound depicted increased pyloric length with mucosal and muscularis thickening consistent with pyloric stenosis in the setting of CGD. An ensuing CT of the abdomen demonstrated segmental circumferential proximal jejunal wall thickening compatible with chronic granulomatous disease enteropathy. Pyloric stenosis, which typically presents in the first 2 months of life, is an unusual finding in a child of age 20mo. Though pulmonary infections are the most commonly affected organ system in CGD, the gastrointestinal (GI) manifestations—beyond just hepatic abscesses, which occur in 25-50% of patients—are infrequently discussed. The patient presented here exhibits predominantly GI-related effects. Granulomatous inflammation can affect any part of the GI tract and may mimic Crohn's disease via bowel wall thickening, luminal narrowing, fistulation, or mucosal cobblestone/skip lesions. Gastric antral wall thickening is estimated in 16% of CGD patients, and more commonly reported upper GI study findings in patients with CGD include delayed gastric emptying, circumferential antral narrowing, gastric fold thickening, or esophageal strictures with dysmotility. Though gastric outlet obstruction from antral or diffuse gastric wall thickening has been described, there are no other prior reports of pyloric stenosis due to CGD. From this case, we posit that CGD should be considered as a causative etiology for older infants/children with new radiological findings of pyloric stenosis. Read More

Authors:  Ocal Selin , Lee Jason , Alizadeh Houman

Keywords:  Pyloric Stenosis, Abdominal Imaging, Upper GI Series

Cheeseman George,  Torikai Hideyuki,  Smith Leah,  Walls Robert,  Patrie James,  Ahn Ju Hee

Final Pr. ID: Poster #: SCI-019

Pediatric acute appendicitis is the most common surgically treated disease in the United States. Evaluation via ultrasonography is recommended as the most appropriate initial modality to diagnose acute appendicitis in the pediatric population by the American College of Radiology. However, nonvisualization of the appendix creates diagnostic challenges leading to additional imaging and laboratory studies as well as costs. The purpose of this study is to determine the value of identifying the ileocecal valve as a reliable initial landmark for identification of the appendix via ultrasonography. Read More

Authors:  Cheeseman George , Torikai Hideyuki , Smith Leah , Walls Robert , Patrie James , Ahn Ju Hee

Keywords:  Appendix, Ultrasonography, Abdominal Imaging

Ng Evonne,  Dawani Anuradha

Final Pr. ID: Poster #: CR-022

Enteric Duplication cysts (EDCs) are uncommon congenital anomalies of the alimentary tract. These can arise from anywhere along the gut including the foregut, midgut and hindgut duplications with most common location being ileum. Majority of the EDCs are symptomatic within the first 2 years of life and early surgery is the treatment of choice for symptomatic EDCs. Radiologically, gut signature sign is pathognomonic on the ultrasound for the more common (80%) cystic/spherical EDCs. However, the less common (20%) tubular subtype can be difficult to interpret on imaging and mimics other pathologies. We present an atypical case of a long tubular duplication cyst in an infant that posed imaging diagnostic challenge.
An 8 week old female child presented with fresh red blood in stools, intermittent drawing up of legs and tachycardia with low dropping haemoglobin levels. Intussusception was suspected clinically and ultrasound was initially performed which showed a grossly dilated (up to 4 cm diameter) small bowel loop in left abdomen with mild wall thickening and hyperemia. Rest of the bowel was normal. Incidentally, gall bladder duplication was noted. Subsequently, CT was also performed to delineate the full extent of the abnormality which demonstrated similar findings of a very long segment of dilated jejunal loop with features of enteritis and possibility of congenital segmental intestinal dilatation was considered. Surgery revealed that the dilated bowel loop was in fact a tubular EDC intimately associated with a long segment of jejunum approx. 45 cm in length and complete resection with end to end anastomosis was done.
Our case highlights that the tubular subtype of enteric duplications cysts is a rare entity that poses a diagnostic challenge and must be included as plausible differential diagnosis in the appropriate clinical setting and supporting imaging features. Read More

Authors:  Ng Evonne , Dawani Anuradha

Keywords:  Abdominal Imaging, Bowel, Enteric Cyst