Patel Parth,  Shepp Kasey,  Aribindi Haritha,  Ibrahim Muaz

Final Pr. ID: Poster #: CR-011

The ingestions of magnetic foreign objects are a common occurrence in the pediatric population. The American Association of Poison Control has documented 95,700 incidents of foreign-body ingestion in the year 2011 alone with most cases occurring in children younger than 5 years of age. In this case, we present a two-year-old male who presented to the emergency department with a four-day history of bilious vomiting. Read More

Authors:  Patel Parth , Shepp Kasey , Aribindi Haritha , Ibrahim Muaz

Keywords:  jejuno-jejunal, fistula, small bowel obstruction

Rana Ricky,  Densley Ashton

Final Pr. ID: Poster #: CR-017

A 3-year-old male presents to the ED with two days of abdominal pain, cramping, anorexia, bilious emesis, RLQ tenderness on exam, and leukocytosis on CBC, refractory to trial of antiemetics, antipyretics, IV fluids, and analgesics. RLQ US and KUB showed an obstructive pattern. MRI demonstrated an inflamed RLQ fluid signal structure, suggesting appendicitis. CT identified a normal appendix and localized a RLQ transition point confirming high-grade SBO. After a trial of bowel rest, a repeat KUB revealed progression. Laparoscopy visualized a RLQ transition point coinciding with a twisted ileum segment due to a Meckel's diverticulum leadpoint. Segmental bowel resection and ileoileal anastomosis was performed. Hemorrhagic necrosis of a true diverticulum was confirmed histologically.
Meckel's is a common congenital GI anomaly, a vestigial structure from the embryologic omphalomesenteric duct. It has a prevalence of 2% and the complication rate is 6%, to include SBO such as in this case. Presentation is typically in the first 2 years of life. Meckel’s are true diverticula which have mucosal, muscularis, and serosal elements, unlike pseudodiverticula. The presence or absence of a muscularis propria layer cannot be determined on imaging alone, yet is evident on histology. Pseudodiverticula, which are more common along the mesenteric side, can originate anywhere in the GI tract.
Meckel's diverticulum has a narrow imaging differential. The appendix is another true diverticula in the right lower quadrant, although Meckel's originates from the distal ileum rather than the cecum. Diverticulosis often presents later with multiple pseudodiverticula in the left hemicolon. Enteric duplication cysts are another, albeit less common, fluid-filled formation located close to the colon. In contradistinction, communication with the intestinal lumen is unusual.
When a single diagnosis cannot be made and surgery is not warranted, a probabilistic presumptive diagnosis is often used in the absence of histology, particularly in cases where management is the same. Asymptomatic Meckel's diverticulum cases don't require treatment. In complicated yet stable patients, expectant management can be employed. If symptoms progress, surgical management may be needed for diagnosis and treatment.
This case highlights the essential role of imaging along with clinical context to differentiate Meckel's diverticulum from similar entities, in order to guide management. Read More

Authors:  Rana Ricky , Densley Ashton

Keywords:  Diverticulum, Obstruction, Meckel's Diverticulum

El Hawari Mohamad,  Joshi Akash,  Zarchan Adam,  Dobbs-desilet Debbie,  Ornelas Samuel

Final Pr. ID: Poster #: EDU-101

Congenital high airways obstruction sequence (CHAOS) refers to a relatively rare fetal anomaly caused by high airway obstruction (tracheal or laryngeal) caused by atresia or stenosis. Similar imaging findings can be seen with airway obstruction due to oropharyngeal or neck masses such as teratoma. Antenatal imagining findings include but not limited to dilated fluid filled trachea and proximal bronchi, bilateral enlarged echogenic lungs with relative small sized midline heart, flattening or eversion of the diaphragm, feta ascites and anasarca and polyhydramnios. The prognosis is overall poor, however it is improved after planning for delivery and performing EXIT procedure (ex utero intrapartum treatment) with tracheostomy.
We present a case of a 20-year-old female G1P0 at 25 weeks of gestation diagnosed with Congenital high airways obstruction sequence (CHAOS) with typical features on prenatal ultrasound and fetal MR. Delivery was planned and an EXIT procedure was performed and the newborn survived. Read More

Authors:  El Hawari Mohamad , Joshi Akash , Zarchan Adam , Dobbs-desilet Debbie , Ornelas Samuel

Keywords:  Congenital High Airway Obstruction Sequence, Ultrasound, MRI

Hendi Aditi,  Harty Mary,  Grissom Leslie

Final Pr. ID: Poster #: SCI-061

Colonic volvulus in the pediatric population is very rare with 40% mortality making timely diagnosis imperative. Radiologists should operate with a high degree of clinical suspicion in patients with risk factors for large bowel volvulus. Recognition of colonic volvulus on plain film, contrast enema and CT is paramount to work-up and definitive management. This case series is the largest from any single institution and describes the clinical course and imaging findings in cases of volvulus, with the goal of familiarizing the radiologist with the appearance of this disease entity on several imaging modalities. Read More

Authors:  Hendi Aditi , Harty Mary , Grissom Leslie

Keywords:  Colonic Volvulus, Pediatric, Large Bowel Volvulus, Colonic Obstruction, Acute Abdomen

Kim Jane,  Shalaby-rana Eglal,  Krill Aaron,  Pohl Hans,  Majd Massoud

Final Pr. ID: Poster #: SCI-005

Lower moiety hydronephrosis/ureteropelvic junction (UPJ) obstruction is an uncommon configuration of duplex collecting systems. We sought to characterize its prevalence, appearance and behavior using diuresis renograms (DR). Read More

Authors:  Kim Jane , Shalaby-rana Eglal , Krill Aaron , Pohl Hans , Majd Massoud

Keywords:  Hydronephrosis, Ureteropelvic Junction Obstruction, Duplex collecting system

Burger Matthew,  Lindsay Aaron

Final Pr. ID: Poster #: EDU-011

Educational goals: Highlight epidemiology, clinical presentation, radiographic findings, and treatment for common neonatal obstructions considered high in the intestinal tract including malrotation with midgut volvulus, duodenal atresia, duodenal web, annular pancreas, and proximal jejunal atresia.

Malrotation with midgut volvulus occurs when abnormally rotated and fixated small bowel twists about the superior mesenteric artery. This often presents with bilious vomiting in the first month of life and requires emergent surgical repair. Abdominal radiographs may be normal or show distention of the stomach and proximal duodenum with some distal bowel gas seen. An upper GI fluoroscopy exam (UGI) demonstrates a spiral/corkscrew sign or abrupt beaking with small bowel malrotation. Duodenal atresia is usually the result of incomplete recanalization of the duodenum. This presents at birth with abdominal distention and bilious or non-bilious vomiting depending on the segment of duodenum affected. Treatment is surgical resection of the atresia and reanastomosis. Classically on radiograph there is a double bubble sign, which may be seen on an antenatal ultrasound. Duodenal web results from an incomplete diaphragm/web within the lumen which causes intermittent complete or partial obstruction. There may be mild symptoms, or it may present similarly to duodenal atresia. It usually presents after the first week of life but may present in any age. Treatment is usually surgical or endoscopic resection. Abdomen radiographs may show mild proximal dilation or a double bubble sign distal bowel gas. UGI classically shows a windsock sign or duodenal dimple sign. Annular pancreas results from incomplete rotation of the ventral pancreatic bud leading to pancreatic tissue encasing the descending duodenum. The presentation and age of onset varies, in neonates and children it causes similar symptoms of duodenal obstruction. Cross-sectional imaging shows the duct draining the pancreatic head encircling the duodenum. Symptomatic cases of annular pancreas are usually treated surgically to alleviate obstructive symptoms. Jejunal atresia results from a vascular injury in utero causing one or more areas of stenosis/atresia. Proximal jejunal atresia presents with abdominal distention and bilious emesis. Abdominal radiographs classically show a triple bubble sign. Treatment is surgical resection of the involved segments of bowel. Read More

Authors:  Burger Matthew , Lindsay Aaron

Keywords:  Bowel obstruction, Neonatal

Rajderkar Dhanashree,  Sharma Priya,  Verma Nupur

Final Pr. ID: Poster #: EDU-133

GI Emergencies and congenital malformation in the neonate are variable in their presentation and can be seen from the hypo-pharynx to the anus. The pediatric radiologist often plays a key role in diagnosis and planning of early surgical management. Read More

Authors:  Rajderkar Dhanashree , Sharma Priya , Verma Nupur

Keywords:  Congenital, GI malformations, Newborn bowel obstruction, New born GI emergencies, GI congenital emergencies

Shore Matthew,  Riedesel Erica

Final Pr. ID: Poster #: EDU-128

Hepatic sinusoidal obstruction syndrome (SOS) - previously termed hepatic veno-occlusive disease (VOD) - is a serious cause of acute liver failure in patients undergoing hematopoietic cell transplantation (HCT).

Hepatic SOS results from injury to the hepatic venous endothelium during intensive myelopablative chemotherapy or radiation therapy prior to HCT. Endothelial injury eventually leads to fibrous obliteration of the terminal hepatic venules with sinusoidal obstruction, hepatocyte necrosis, and hemorrhage, typically seen in the first 3-6 weeks post-transplant.

Early identification of this disease process is critical given high incidence of multi-organ failure and significant morbidity and mortality. Ultrasound is extremely valuable in accurate early diagnosis as imaging findings often precede clinical signs of disease. Spectrum of findings on gray-scale ultrasound includes hepatomegaly, heterogeneous hepatic parenchymal echotexture, ascites, and gallbladder wall thickening. Findings on Doppler ultrasound - increased mean hepatic artery resistive index (RI) and decreased or reversed portal venous flow - are highly sensitivie for hepatic SOS.

In this education exhibit we will review the epidemiology and pathophysiology of hepatic sinusoidal obstruction syndreom (SOS) and discuss imaging findings that aid in accurate diagnosis. Special attention will be given to Doppler ultrasound findings and additional diagnostic information provided by B-flow Doppler ultrasound. Read More

Authors:  Shore Matthew , Riedesel Erica

Keywords:  Hepatic Sinusoidal Obstruction Syndrome, Doppler Ultrasound, B-flow Ultrasound, Educational Exhibit

Ahn Ju Hee,  Westberry Andrew

Final Pr. ID: Poster #: EDU-036

Gastric outlet obstruction in neonates and infants is an uncommon condition that results in nausea, non-bilious vomiting, and abdominal distension. Comprehension of the disease entities of obstructed gastric outlet can help radiologists make accurate diagnoses and guide management. The purpose of this educational exhibition is to provide a review of radiographic findings of the differential diagnosis of gastric outlet obstruction and its clinical manifestations. Read More

Authors:  Ahn Ju Hee , Westberry Andrew

Keywords:  gastric outlet obstruction, neonates, congenital and acquired

Tan Timothy Shao Ern,  Tan Eelin

Final Pr. ID: Poster #: EDU-034

Bowel obstruction in newborns are divided into high and low obstruction. High obstruction occurs before the proximal jejunum and comprise congenital causes including: atresia of the esophagus, stomach, duodenum or jejunum, duodenal stenosis from annular pancreas, duodenal web, malrotation without or without midgut volvulus and congenital abdominopelvic cysts or masses. Low obstruction occurs distal to the proximal jejunum and consist of congenital causes such as ileal and colonic atresia, anorectal malformation, Hirschsprung’s diseasem, congenital abdominopelvic cysts or masses. Other causes include meconium ileus or functional immaturity of the colon.

Bowel obstruction in older neonates and children includes congenital causes such as Meckel’s diverticulum, malrotation, congenital hernia as well as inflammatory conditions such as appendicitis and Inflammatory bowel disease. Other causes include hypertrophic pyloric stenosis, intussusception, adhesions, sigmoid volvulus and ingested foreign bodies.

Plain radiographs are often the first-line imaging modality for neonates and children presenting with suspected gastrointestinal pathology. A comprehensive radiographic approach along with sound knowledge of the common causes and imaging features of bowel obstruction in the various pediatric demographics will help facilitate timely and appropriate management and also prevent unnecessary further investigations. Additionally, differentiating between high and low bowel obstruction will help guide the next step in management.

The purpose of this education exhibit are to:
1. Review normal and abnormal bowel gas pattern on plain radiographs and associated intepretation pitfalls in newborns, older neonates and children.
2. Familiarise radiologists with common causes and radiographic features of bowel obstruction in newborns, older neonates and children. Illustrative cases for the above conditions will be shown. Relevant further investigations are also discussed. Read More

Authors:  Tan Timothy Shao Ern , Tan Eelin

Keywords:  Obstruction, Neonate, Meconium

Saguintaah Magali,  Taleb Arrada Ikram,  Prodhomme Olivier,  Bolivar Perrin Julie,  David Stephanie,  Sevette Nancy,  Couture Alain,  Baud Catherine

Final Pr. ID: Poster #: EDU-067

To review the imaging appearances of neonatal bowel obstruction, focusing on the sonographic findings.
To describe the etiologies and the indication for other imaging modalities Read More

Authors:  Saguintaah Magali , Taleb Arrada Ikram , Prodhomme Olivier , Bolivar Perrin Julie , David Stephanie , Sevette Nancy , Couture Alain , Baud Catherine

Keywords:  neonatal bowel obstruction, ultrasonography

Rubio Eva,  Blask Anna,  Bulas Dorothy,  Badillo Andrea

Final Pr. ID: Poster #: SCI-060

Differentiating levels of small bowel obstruction in the fetus and predicting the outcome remain challenging. Our goal is to characterize imaging details which suggest the level of obstruction or a potentially complex postnatal course. Read More

Authors:  Rubio Eva , Blask Anna , Bulas Dorothy , Badillo Andrea

Keywords:  jejunal, ileal, obstruction

Reddivalla Naresh,  Opfer Erin,  Robinson Amie,  Reid Kimberly,  Chan Sherwin

Final Pr. ID: Poster #: SCI-053

Sinusoidal obstruction syndrome (SOS) is a potentially fatal disease affecting children following bone marrow transplantation (BMT). SOS diagnosis is clinical because traditional ultrasound has poor sensitivity and specificity with portal vein flow reversal occurring well after the disease is clinically evident. Ultrasound elastography is a newer technology that measures liver stiffness, which should increase in SOS due to passive hepatic congestion. Our hypothesis is that quantitative shear wave ultrasound elastography will be more accurate in detecting this disease compared with conventional ultrasound parameters. Read More

Authors:  Reddivalla Naresh , Opfer Erin , Robinson Amie , Reid Kimberly , Chan Sherwin

Keywords:  Sinusoidal Obstruction Syndrome, Veno-Occlusive Disease, Ultrasound Elastography

Castro Denise,  Silva Cecília,  Paranhos Isabela,  Lira Andréa,  Fonseca Josélia,  Ribeiro Rafaela

Final Pr. ID: Poster #: CR-045

A 10-year-old girl presented with 18-hour history of crampy periumbilical pain, associated with three episodes of non-bilious vomiting and anorexia over the past few days. She denied fever and had a normal bowel movement one day before admission. She had no medical history and was not on any medication. Her social development and school performance were both unremarkable. On physical examination, the abdomen was distended, tender in the periumbilical area, with normal bowel sounds and no peritoneal signs.
The abdominal radiograph showed air-fluid levels with distended small bowel loops and a large heterogeneous mass conforming to the shape of the stomach and a possible distended loop with mottled gas pattern in the mid pelvis, to the left of the midline. Six hours later, while in the hospital, the patient developed bilious vomiting and a computed tomography (CT) showed a mottled air-containing large mass within the stomach and a second smaller similar appearing mass within a segment of small bowel in the left lower quadrant, with diffuse distension of small bowel loops and multiple air-fluid levels proximal to it, in keeping with small bowel obstruction (SBO). The patient admitted to trichotillomania and trichophagia and a patch of alopecia was noted in the left parietal scalp. She was sent to the operating room where a supraumbilical vertical midline incision was made and a large obstructing trichobezoar completely filling the gastric lumen was removed through a transverse gastrotomy. The small bowel was inspected and a palpable, obstructing smaller trichobezoar was removed from the jejunum, approximately 1 meter from the pylorus.
Trichobezoars form after the ingestion of large amounts of hair, often over many years. Although trichotillomania affects about 1% of the population, only one third have trichophagia and just 1% of these individuals eat enough hair to require surgical intervention, making trichobezoars very uncommon in clinical practice. They are usually single and seen in the stomach, but in 5% of cases more then one bezoar is found. SBO occurs in fewer than 10% of patients with trichobezoar.
Plain radiographs are usually the initial imaging tool for diagnosis of SBO. CT can be helpful in determining the presence of obstruction in clinically suspected cases with equivocal plain radiographs, and determining the site and cause of obstruction, including trichobezoars. Read More

Authors:  Castro Denise , Silva Cecília , Paranhos Isabela , Lira Andréa , Fonseca Josélia , Ribeiro Rafaela

Keywords:  trichobezoar, small bowel obstruction, simultaneous, synchronous, bezoar

Goldman-yassen Adam,  Kurian Jessica,  Blumfield Einat,  Levin Terry

Final Pr. ID: Poster #: EDU-018

Common causes of bowel obstruction (BO) in infants and children include appendicitis, adhesions, intussusception, inguinal hernia, midgut volvulus, and Meckel's diverticulum, for which the mnemonic "AIM” is used. We present uncommon causes of BO in infants and children and review the clinical presentation, imaging findings, and surgical diagnoses. Read More

Authors:  Goldman-yassen Adam , Kurian Jessica , Blumfield Einat , Levin Terry

Keywords:  Obstruction, Volvulus

Rafferty Bridget,  Thakrar Pooja

Final Pr. ID: Poster #: CR-010

Orbeez Water Beads, marketed as "nontoxic sensory toys for kids ages 5 and up," arrive as pinhead-sized microbeads ("seeds") which must be soaked in water for several hours to achieve full size of 7-8 mm (1,2,4). The water beads and other similar products, such as gel beads, water orbs, and gel balls, are available in multiple colors and finishes, including "shimmer" and glow in the dark (1). Their small size and bright colors give these water beads the appearance of candy, and they are easily ingested. If ingested as seeds, the beads will expand in the gastrointestinal tract, where they have been found to grow well beyond their purported full size of 8 mm to as much as 40 mm, causing bowel obstruction (3).
Detecting water beads on imaging is a challenge for the pediatric radiologist, but localization of the beads before intervention can aid the surgeon or gastroenterologist in their retrieval attempts. Radiographs are poor detectors of their thin membranes and majority fluid composition. If there is a high index of suspicion for ingestion, CT is often second-line for detection of the fluid-filled orbs and evaluation of intestinal obstruction. However, in the pediatric population, in whom keeping radiation exposure to the lowest reasonably achievable levels is paramount, ultrasound (US) is a valuable tool for diagnosis of bowel obstruction. US demonstrates equal sensitivity and increased specificity in comparison to radiography. In addition, US is an excellent tool for identifying the beads themselves, which appear as well-circumscribed, rounded, anechoic structures within the bowel lumen. Importantly, US is readily available, is easy to use, and obviates exposure to radiation in young children.
We present a case of ingested water beads diagnosed by US to demonstrate the utility of US in identifying both the beads and potential bowel obstruction in young children.
References:
1. https://www.spinmaster.com/en-US/brands/orbeez/
2. https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Water-Beads-Harmful.aspx
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808832/
4. https://www.amazon.com/Blaster-Splatter-Electric-Automatic-Manual/dp/B09YBYR2T7 Read More

Authors:  Rafferty Bridget , Thakrar Pooja

Keywords:  ultrasound, ingestion, obstruction

Epps Caleb,  Cassady Christopher,  Ketwaroo Pamela

Final Pr. ID: Poster #: CR-004

A 33-year-old presented for fetal MRI at 22 weeks 2 days gestation following pre-natal ultrasound that demonstrated findings suspicious for congenital high airway obstruction syndrome (CHAOS). Findings were characteristic of CHAOS and included focal narrowing of the cervical trachea, pulmonary hyperexpansion, tracheobronchomegaly, everted hemi-diaphragms, and abdominal free fluid. However, follow-up MRI at 27 weeks 3 days gestation showed decreased pulmonary hyper-expansion and abdominal free fluid. Diagnosis of atypical congenital high airway obstruction (aCHAOS) was suggested. Further improvement was noted on fetal MR at 31 weeks 2 days gestation and the diagnosis of aCHAOS was reinforced.

CHAOS represents a rare, life-threatening fetal airway anomaly characterized by complete or incomplete obstruction of the upper airway. Prenatal imaging findings of classic CHAOS have been well described and include hyperexpanded lungs with everted diaphragms, tracheobronchomegaly, and hydrops. Our experience at quaternary referral centers is that this applies to a particular subset of patients with complete laryngotracheal obstruction without a pathway of fluid egress, and that there is a spectrum of more subtle but equally critical large airway obstructions. This can be in the form of either incomplete large airway obstruction or complete large airway obstruction with a decompression route such as coexisting tracheoesophageal fistula.

Accurate characterization by fetal imaging has increased in importance as treatment options have expanded, including fetal airway management and ex utero intrapartum treatment (EXIT). There is a paucity of literature regarding the characterization of CHAOS variants and their natural history. However, improved understanding is important as it is unknown whether outcomes between classic CHAOS and aCHAOS may differ. Findings on prenatal imaging of aCHAOS are more subtle, and the diagnosis requires nuance and a high index of suspicion. Close follow up is required in fetal life, as a lack of proper preparation risks near-certain neonatal death. Diagnoses that mimic aCHAOS, such as bilateral congenital lung malformation, should be considered and excluded. We present the current case along with companion cases to expand the spectrum of prenatal imaging appearances in congenital large airway obstruction. Read More

Authors:  Epps Caleb , Cassady Christopher , Ketwaroo Pamela

Keywords:  Congenital High Airway Obstruction Syndrome, Atypical CHAOS, Fetal MR