RADIO 250: ICC in Radiology and Nuclear Medicine

LEC 02: PEDIATRIC RADIOLOGY

Exam 01| Dr Gerardo Beltran | August 28, 2013
PART ONE

Evaluation involves lateral decubitus of the contralateral side of

area suspected (causing air to go up).

PEDIATRIC CHEST RADIOGRAPH

OUTLINE
I.
The Thymus
II.
Pneumothorax, Pneumoperitoneum, Pneumomediastinum
III.
Neonatal Respiratory Distress
A. Medical Causes
B. Surgical Causes
IV.
Diseases of the Pediatric Upper Airway
A. Acute Epiglottitis
B. Croup (Acute Laryngotracheobronchitis)
C. Retropharyngeal Abscess
V. Pulmonary Inflammatory Diseases:
A. Viral Pneumonia
B. Bacterial Pneumonia
C. Pneumatocoele
D. Pediatric Tuberculosis

Pneumothorax (lateral decubitus; Bilateral pneumothorax. Note

note the lucency).
areas of lucency without any lung
markings.

I. THE THYMUS

B. PNEUMOPERITONEUM

Normal CXR (Inspiratory)

Expiratory CXR

The air seen below the diaphragm and tends to cause its elevation
(outlined by dotted lines)
Note the liver (outlined by red arrows), which is located inferiorly.
In evaluation, one can also do a lateral decubitus radiograph.

C. PNEUMOMEDIASTINUM
3

Normal Thymic Tissue

Sail Sign of normal thymic tissue
Generally, a pediatric patient cannot follow instructions as much as
adults can. Therefore, the radiologist must make sure the
1
radiograph is taken during inspiration.
If the radiograph is taken during expiration, the diaphragm is
elevated, resulting to a large lucency filling the lower part of the
2
lung (upper right image).
Children have normal thymic tissue usually during the first 2 years,
3
sometimes up to five years of age.
The shape of the thymic shadow resembles the sail of a sailboat,
4
thus being termed the sail sign. Thymic tissue can be very large,
but pliable and adaptive to the mediastinal space without causing
shifting.
Cardiothymic shadow must be continuous, else, pathology may
present (ie air in mediastinum)

II. PNEUMOTHORAX, PNEUMOMEDIASTINUM,

PNEUMOPERITONEUM
Usually manifests as babies in distress
How does air enter the peritoneum?
o Air goes to the retroperitoneum through the 3 hiatus in the
diaphragm (aorta, IVC, esophagus)
o From the retroperitoneum, air could then go to the peritoneum

A. PNEUMOTHORAX
Seen as a radiolucent area devoid of lung markings, and which
highlights the border of visceral pleura.
The borders of the heart arent normally markedly delineated.
However, they are in pneumothorax due to the contrast of the
lucent air.

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It usually creates a pattern of lucency similar to an angels wings

(angel wing sign, outlined)
Thymus is displaced upward and laterally.
Also note the lucencies around the trachea and below the heart and
overlying the heart, which represent air that isnt supposed to be
there normally.

III. NEONATAL RESPIRATORY DISTRESS

MEDICAL CAUSES
Transient Tachypnea of the
Newborn
Meconium Aspiration Syndrome
Neonatal Pneumonia
Respiratory Distress Syndrome

SURGICAL CAUSES
Congenital Diaphragmatic Hernia
Congenital Cystic Adenomatoid
Malformation
Congenital Lobar Emphysema
Sequestration

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PEDIATRIC RADIOLOGY

A. MEDICAL CAUSES
TRANSIENT TACHYPENIA OF THE NEWBORN
Caused by delayed clearance of intrauterine pulmonary fluid.
Usually seen in babies delivered via caesarean section (since normal
delivery usually helps squeeze out the intrauterine pulmonary fluid)
Usually manifests immediately after delivery of the patient
But should clear up in 48-72 hours, otherwise one should consider
neonatal pneumonia
Findings is consistent with edema pattern with:
o Streaky pulmonary vessel markings (poor vascular definition)
o Blunted sulcus (minimal pleural effusion), with thickened fissures.
o Occasional alveolar edema.

MECONIUM ASPIRATION SYNDROME

Pathogenesis: aspirated meconium obstruction of bronchi

atelectasis (lung collapse) and hyperinflation
Best clue clinically: meconium stained baby
Radiograph shows multiple opacities.

Below we see the film of the same patient the next day. Note that
congestion has begun to clear up. BOOM parang walang nangyari

RESPIRATORY DISTRESS SYNDROME

Usually occurs in premature infants
Due to absence of surfactant (dipalmitoylphosphatidylcholine, yes
kailangan ko sabihin kasi biochem related haha) produced by Type 2
pneumocytes (o histo naman) which are not yet fully developed in
premature infants
Note that TTN, MAS, and neonatal pneumonia are all
hyperventilation states, while RDS is a hypoventilation state.
Since alveoli are hypoventilated (no air), you can easily see the air
inside the small airways thus appearing as air bronchogram on xray
(nagkaroon na ng interface kaya nagappear bigla).

NEONATAL PNEUMONIA
Is also characterized by pulmonary edema.
Usually in the setting of premature rupture of membrane and other
situations predisposing to infection.
Radiographic presentation is frequently nonspecific
One could see presence of the following:
o Reticulonodular densities similar to respiratory distress syndrome
o Patchy, asymetric infiltrates with hyperaeration similar to
meconium aspiration syndrome
Clinically, resolves beyond 48-72 hrs.

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PEDIATRIC RADIOLOGY

B. SURGICAL CAUSES
CONGENITAL DIAPHGRAGMATIC HERNIA (CDH)
Continuity between diaphragm and costal margin is disrupted
Capturing in the radiograph: Wait 24 hours for gas to fill alimentary
tube.
Clinically, would present with a scaphoid abdomen (vs CCAM)
Findings
o bubbly cystic structures in the thorax
o mediastinum is shifted to the other side
o trachea is found on the right
o check the abdomen: CCAM will have gas in the abdomen, CDH
will not

Findings:
o Diffuse symmetric reticulogranular densities
o Prominent central air bronchogram (white arrow)
o Generalized hypoventilation because of generalized atelectasis of
alveoli thus we see a smaller lung volume ( less air; less black
space)
This does not occur right away because even those who develop
RDS is born with surfactant.
th
RDS only starts to occue when surfactant is used up (approx 4 hour
nd
of life vs TTN which manifests as early as 2 hour of life)
Complications of RDS
1. Pulmonary Interstitial Edema (PIE) with pneumothorax
o Lucencies in lung that dont follow the normal findings
o Lung interstitium is full of air (white arrows) alveoli cannot
expand when ventilated lung becomes stiff (at about 28 days of
life)

CONGENITAL
(CCAM)

CYSTIC

ADENOMATOID

MALFORMATION

Most common congenital lung cyst in children

Considered a hamartoma of the lung
Types:
o Type I most frequent (2/3 of cases), contains a dominant cyst >
2 cm surrounded by multiple smaller cysts
o Type II (15-33%) uniform smaller cysts up to 2 cm
o Type III Least common (<10%), contains microscopic cysts that
are not grossly visible
The cyst will continue to expand until everything is moved to the
right.
Typical appearance is a single large cyst w/ smaller cysts (Type 1)

2. Bronchopulmonary Dysplasia
o Causes bubble-like pattern
rd th
o Manifests at 3 -4 week of life
o Can lead to a fibrotic pattern

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In image above, large arrow points to the large cyst while small
arrows point to the smaller cysts. Occasionally, fluid may also be
found inside (as seen below)

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PEDIATRIC RADIOLOGY
PULMONARY SEQUESTRATION
Presence of lung tissue with systemic arterial supply instead of a
pulmonary arterial supply
Veins draining blood supply may be systemic or pulmonary.
Can be intralobar or extralobar.
Best diagnosed with angiogram
Suspect in patients with recurrent pneumonia presenting on the
same spot because lungs receiving blood from systemic circulation
is more prone to infection
Usual findings include consolidation and opacities, mistaken as
pneumonia

Alternatively, a CT scan may also be done for better visualization

(see images below). Notice large cyst with smaller cysts:

CONGENITAL LOBAR EMPHYSEMA (CLE)

Presence of lucencies, which causes lung to be eventually filled with
air and increase in density.
Non cystic
43% in left upper lobe, 32% in right middle lobe and 20% in right
upper lobe.
In image below, note that right lung is pushing structures past the
midline.

Arrow points to a consolidation on the left lung.

Pulmonary sequestration looks like pneumonia on x-ray.

CT Angiogram: Note the descending aorta (long arrow) supplying the

sequestered lung (S) and the short arrows point to normal pulmonary
veins draining blood from the lungs to the left atrium.

3D Reconstruction: Long Arrow points to the descending aorta

supplying the sequestered lung (S).

In this CT (above), note the hyperinflated right lung with very

meager vascular markings.

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PEDIATRIC RADIOLOGY

IV. DISEASES OF THE PEDIATRIC UPPER AIRWAY

All of these pediatric airway diseases can present with stridor:
Epiglottitis
Croup
Retropharyngeal abscess
Foreign body obstruction
Vascular ring

A. ACUTE EPIGLOTTITIS

Swelling of the epiglottis

Usually bacterial (vs viral in croup)
Presents with thumb sign
Is considered a pediatric emergency.
Steeple Sign. Note the narrowing of the airway at level of larynx, a
result of inflammation.

C. RETROPHARYNGEAL ABSCESS
Opacities seen in the pharyngeal area, which may sometimes show
an air fluid level.
Can aspirate when the abscess ruptures

Acute epiglottitis: Pink Arrow, palatine tonsil enlargement; Red

Arrow: adenoid; Blue Arrow: aryepiglottic fold thickening; Green
Arrow: thumb sign caused by thickened and inflamed epiglottis.

Huge retropharyngeal abscess as demarcated by the red lines.

Arrows point to a positive thumb sign of Acute Epiglottitis

B. CROUP (ACUTE LARYNGOTRACHEOBRONCHITIS)

Edema of the larynx
Usually viral
Seen as steeple sign (from Sir: imagine the steeples at the side of
a usual Iglesia ni Cristo church)
Subglottic area is affected

A: Air-fluid level from a retropharyngeal abscess.

V. PULMONARY INFLAMMATORY DISEASE

Viral pneumonia
Bacterial pneumonia
Pneumatocoele
Tuberculosis

One can see peribronchial cuffing, dirty-looking hilum and

hyperinflation.
Clinical picture does not differ from bacterial pneumonia.
Note that fissures are the most sensitive structures to atelectasis
and shifts towards/ipsilateral to the collapsed lung

A. VIRAL PNEUMONIA

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PEDIATRIC RADIOLOGY

Initial x-ray consistent with pneumonia

Arrow points to a consolidation on the right upper lung field. Notice

also that the minor fissure is visible and is no longer horizontal.

B. BACTERIAL PNEUMONIA
Presents usually as focal lobar consolidation with air bronchogram
Presents as a triangular consolidation
A positive silhouette sign is the presence of obstruction of the
usual silhouette/shadow of adjacent structures, which means that
the pathology is at the same level as the structure

After 1 week. Note that the presence of pneumatocoele means that the
infection is already resolving.
Chest PA and lateral lung, bacterial pneumonia: Triangular Configuration of
lobar consolidation in bacterial pneumonia

D. TUBERCULOSIS
Presence of Gohns focus is part of criterion for diagnosis.
However, in some children, lymphadenopathy may be the only
presenting symptom.

Round Pneumonia. Some will not exhibit a lobar pattern and will thus show as
mass like.

C. PNUEMATOCOELES
As a result of pneumonia, air cysts develop
Appears when pneumonia is already resolving
Different from abscess because abscess appears on the onset of the
disease. The patient will appear very ill, and the radiograph will
show thick, irregular walls and sometimes, air fluid level.
Pediatric patient with Gohns focus. Leftmost arrow points to the granuloma
while the right arrow points to an enlarged lymph node

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PART TWO

PEDIATRIC RADIOLOGY

PEDIATRIC ABDOMINAL RADIOGRAPH

OUTLINE
I.
Esophageal Atresia
II.
Deudenal Atresia
III.
Jejuno-Ileal Atresia
IV.
Hirschsprung Disease
V.
Hypertrophic Pyloric Stenosis
VI.
Malrotation
VII. Appendicitis
VIII. Intussusception
IX.
Necrotizing Enterocolitis

I. ESOPHAGEAL ATRESIA
The classic sign of esophageal atresia(EA) is the coiled NG tube
sign, in which an NG tube inserted is found to coil in a radiograph
due to obstruction.
85% of esophageal atresia have tracheoesophageal atresia (TEF).In
radiograph, this type of esophageal atresia is determined by the
presence of air in the abdomen (meaning the trachea has a
connection to the more distal blind end of the atretic esophagus).

Multiple Bubbles seen on plain

radiograph

Barium enema microcolon

IV. HIRSCHSPRUNG DISEASE

Absence of parasympathetic ganglia in the mucosal and submucosal
layers of colon
Appears as transition zone on barium enema. There is abrupt
transition from dilated to spastic colon (the spastic part is the
pathologic aganglionic part that does not relax)
Most common transition zone is the rectosigmoid colon.2014

Coiled NG Tube Sign

Esophageal Atresia on Barium

Swallow

II. DUODENAL ATRESIA

The classic sign of duodenal atresia is the double bubble sign,
wherein the two bubbles are the dilated stomach and the dilated
duodenum.
Barium Enema showing transition zone.

V. HYPERTROPHIC PYLORIC STENOSIS

In plain radiograph, it shows as single bubble sign.
In barium enema, it shows as mushroom sign.
In ultrasound, it is pyloric length of >14 mm(normal: 14), or pyloric
wall thickness of > 4 mm (normal: 4)

Double bubble sign

III. JEJUNO-ILEAL ATRESIA

Clinically, presents with infants who cannot pass meconium and
thus presents with vomiting
Radiographically, it has more bubbles than duodenal atresia, and
microcolon is seen on barium enema (since digestive materials
cannot pass through atretic small bowel).

Diagram showing the wall thickening on the pyloric stenosis

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PEDIATRIC RADIOLOGY

Single Bubble sign

Mushroom sign

Illustration of volvulus and the corkscrew appearance on barium enema.

VII. APPENDICITIS
Supposedly a clinical diagnosis
On x-ray, you will see dilated small bowels
On ultrasound, appendicolith can be seen, which may be the cause
of inflammation.
On CT scan, the appendix should be > 6 mm (normal: 6), also with
fat stranding (pericecally and periappendically2014), seen as
hyperdense compared to same area on other side.
CT scan can be used to rule in and rule out all of the ff;
ureterolithisis, choledocholithiasis, and appendicitis; thus, it is
useful especially for right lower quadrant pain

UTZ: pyloric length of >14 mm, or

pyloric wall thickness of > 4 mm

VI. MALROTATION
Attachment of small bowel instead of duodeno-jenunal junction to
cecum; can lead to midgut volvolus which compromises arterial
supply.2014 This results from failure of the small bowel (and SMA
artery to rotate in development).
Duodenum does not cross midline, thus the jejunum is not found on
the right but on the left.
Appears as corkscrew on barium enema.
Malrotation can result to volvulus, or the twisting of the bowels,
causing obstruction or cut-off of vascular supply.

Left: X-ray, dilated small bowels. Right: CT scan showing inflamed

appendix.

Above: Illustration and barium enema of malrotation

Left: Image showing that the
duodenum does not cross
midline thus jejunum is on the
right of the patient.

Ultrasound image of appendicitis

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PEDIATRIC RADIOLOGY
Supine radiograph

Cross-table lateral

PART THREE OTHER PEDIATRIC RADIOGRAPHS*

OUTLINE
I.
Renal
II.
Musculoskeletal
A.
Buckle Fracture
B.
Greenstick Fracture.

*Not Discussed

I. RENAL
CONGENITAL HYDRONEPHROSIS
Characterized by dilated pelvocalyces or the entire collecting system

CT Scan image of an inflammed appendix

VIII. INTUSSUSCEPTION
Obsruction secondary to invagination/prolapsed of an area of the
bowel into another.
Coil spring sign on barium enema
need to reduce in 4 years old; if >4 years, cannot reduce, surgery
needed2014
Currant jelly stools and abdominal pain are clinical signs.
The intussuception includes an intussuscipens (part of bowel in
which another bowel area has invaginated) and an intussusceptum
(part of bowel which invaginates).

Bilateral hydronephrosis. The pelvocalyceal system which present with

enlarged kidneys.

II. MUSCULOSKELETAL
The second most frequent radiographic study, after the chest film, is
that of the pediatric skeleton
The most common indication for such is trauma

BUCKLE FRACTURE
Also called torus fracture, in which a bone buckles upon itself and
does not disrupt adjacent bones.
Caused by presence of less porous bones in children.

GREENSTICK FRACTURE
Illustration of intussuception

Coil spring sign. The intussuceptum

forms a coil spring appearance at the
point of invagination into an
intussuscipens.

Due to pliable skeleton, it is also common to see in children the

presence of a fracture in which the bone snaps on one side while
bending on another.
This is called a greenstick fracture.

IX. NECROTIZING ENTEROCOLITIS

Currant jelly stools and abdominal pain
Mucosal damage seen due to intestinal ischemia and later necrosis.
2014:
Most common acquired GI emergency of premature infants
Infection and ischemia, commonly affecting the ileum and ascending
colon
Air in submucosal space can go up to veins and eventually lead to
pneumoperitoneum.
Frothy or soap-bubble bowel gas pattern, indicating a resultant
ileus.
Linear or crescent-shaped gas collections in the bowel wall
Worrisome signs: gas in portal venous system, ascites,
pneumoperitoneum

Buckle Fracture

Greenstick fracture

END OF TRANSCRIPTION
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