1. Radiology of the Vomiting Child
Steven T Welch, MD
Children’s Mercy Hospital
April 30, 2011

2. 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.

3. 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 mos and decreased to less than 5% by 13 mos.
Martin et al, “Pediatrics”, 2002.

4. Reflux in esophagus
Stomach
Upper GI study

5. 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.

6. pH probe in esophagus

8. What test should be ordered for a child with bilious emesis?
Esophagram
Upper GI/small bowel follow-through
OPM (oropharyngeal motility)
Upper GI study

9. 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.

10. 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.

11. Left lateral decubitus view
Supine abdomen
Left lateral decubitus view
stomach

12. Upper GI study
Left pedicle line
Duodenojejunal junction

13. Upper GI study
Volvulus

14. Normal duodenojejunal junction (ligament of Treitz)

15. 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

16. 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.

17. In cases of suspected pyloric stenosis, the best radiology study to order is:
Upper GI study
KUB (abd Xray)
Ultrasound
Computed tomography (CT)

18. Pyloric Stenosis
A limited abdominal ultrasound is the diagnostic study of choice.
Highly sensitive and specific
No radiation
No sedation

19. Pyloric Ultrasound Elongated pyloric channel
Thickened pyloric muscular wall

20. 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.

21. Upper GI study Elongated, narrow pyloric channel
Contrast filled stomach

22. 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.

23. Intussusception Pathologic lead point in some cases:
Meckel’s diverticulum
Enteric duplication cyst
Lymphoma
Polyps
Henoch-Schonlein purpura (intramural hemorrhage)

24. 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.

25. 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.

26. Supine abdomen X-ray
Left decubitus X-ray

27. Ileocolic intussusception
Abdominal Ultrasound
Ileocolic intussusception

28. Air enema reduction

29. 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.

30. Less common causes of obstruction
Newborn presentation:
Meconium ileus
Small bowel atresia
Meconium plug (small left colon) syndrome
Hirschprung’s disease

31. Multiple dilated bowel loops
Stomach
Multiple dilated bowel loops

32. Filling defects in terminal ileum on contrast enema

33. Meconium ileus

34. Upright Abdomen X-Ray
Supine Abdomen X-Ray

35. Delayed image from Upper GI study Dilated distal small bowel loops

36. Ileal atresia

37. Multiple dilated bowel loops suggesting distal bowel pathology

38. Contrast Enema
Small left colon
Meconium plugs

39. Meconium Plug Syndrome

40. Multiple dilated bowel loops suggesting distal obstruction.

41. Narrowed, irregular rectum
Lateral view from a contrast enema
Dilated sigmoid colon
Narrowed, irregular rectum

42. Hirschprung’s disease

43. Additional causes of obstruction
Older infants and children:
Appendicitis
Adhesions
Incarcerated hernia
Meckel’s diverticulum

44. Appendicolith

45. Shadowing stone in dilated appendix
Appendix Ultrasound
Shadowing stone in dilated appendix

46. 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.

47. Appendicitis CT
Stone within an inflamed appendix

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

49. Incarcerated Hernia

50. Abnormal fluid filled structure on Pelvis CT

51. Nuclear Medicine Meckel’s Scan (Tc99m-Pertechnetate)
Meckel’s diverticulum

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

53. 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.

54. 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.

55. 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.

56. Thank you for your attention