peds

1. ROLE OF RADIOLOGY IN PEDIATRIC
MEDICAL,SURGICAL AND SKELETAL
DISORDERS
Dr. Nitin Wadhwani
Prof. & HOD Radio-Diagnosis
Dr. D.Y Patil Medical College &Research Institute
Kolhapur

5. 1. Dilatation?
• When the bowel measures more than
the interpedicular width of L2, it is said
to be dilated.
• Massive dilatation is seen in complete
obstruction and is accompanied by fluid
levels on the dorsal decubitus
radiograph.
• However, fluid levels alone do not
necessarily correspond to dilatation,
but rather reflect abnormal peristalsis.
• An unchanging bowel gas pattern over
time indicates absence of peristalsis.
• On the left image the bowel is dilated
and the diameter exceeds L2
interpedicular width in a patient with
meconium ileus.
• On the image on the right there is
massive dilatation in a neonate with
jejunal atresia.

6. 2. Number of dilated loops?
• Up till three dilated small bowel
loops on an abdominal
radiograph generally indicate a
high obstruction.
The left image shows a case of
three dilated loops indicate a
low obstruction.
The image on the right is a case
of ileal atresia.

7. 3. Small bowel or colon?
• Since neonates do not have haustra
in the colon yet, it is often impossible
to discriminate between small bowel
and colon on an AP radiograph.
•
A dorsal decubitus radiograph may
help as colonic obstruction may
produce long fluid levels
•
Furthermore, the colon ascendens,
descendens and rectum are more
dorsally located structures.
To discriminate small bowel from
large bowel with certainty is only
possible with a colon enema.

8. 4. Air filled rectum?
• If sufficient time has gone by after birth, the rectum
will be filled with air.
Absence of rectal air indicates an obstruction.
• In Hirschsprung's disease there is usually no air in
the rectum or only a thin stripe of air.
• The image shows a neonate with dilated bowel
loops.
There is no air in the rectum.
This patient had a meconium ileus.

9. 5. Pneumatosis intestinalis?
Findings:
•What at first sight looks like granular feces in the bowel
(yellow arrow) is actually caused by gas in the bowel wall seen
en face.
•Air in the bowel wall is most easily recognized when seen in
profile as linear black lines that parallels the bowel lumen
(green arrows).
Pneumatosis intestinalis is defined as gas in the bowel wall.
In neonates it is seen in bowel wall ischemia in necrotizing
enterocolitis.
On the radiograph pneumatosis intestinalis resembles granular
feces, which is a normal finding in older children.
Neonates however do not have granular feces yet since they
only drink milk.
So what looks like granular feces in the bowel actually
represents intramural gas.
The air bubbles can be resorbed into the venous system
causing portal venous gas.
Pneumatosis intestinalis can lead to perforation seen as
pneumoperitoneum.

10. 6. Free air and ascites?
• Large amounts of free air can be seen on
the front radiograph under the diaphragms,
when visualizing both sides of the bowel
wall and outlining the falciform ligament.
• Small amounts of free air can only be
detected on the dorsal decubitus
radiograph.
• Ascites can only be suspected on a
radiograph when the amounts are large
enough to cause the bowel to float and
cluster in the center of the abdomen.
• The presence of both ascites, free air as
well as abdominal wall calcifications indicate
that there has been a perforation in utero
with meconium peritonitis.

11. Umbilical artery catheterization provides direct access to the
arterial system and allows accurate measurement of arterial
blood pressure, blood sampling and intravascular access for
fluids and medications.
The catheter should be passed through the umbilical artery and
enter the aorta via the internal iliac artery.
It should demonstrate the typical loop from the umbilicus inferiorly
into the internal iliac artery.
In order to avoid placement into aortic branches, the catheter
should be either in a high position above the celiac, mesenteric
and renal arteries or in a low position below the inferior
mesenteric artery:
•high position: T6-T9
•low position: L3-L5
The high position is advisable since it leads to less vascular
complications.

12. • An umbilical vein catheter should pass through the umbilical
vein into the left portal vein.
Then through the ductus venosus into a hepatic vein and
the inferior vena cava(IVC).
• The tip should be positioned in the IVC at the level of the
diaphragm.
Several line malpositions are possible:
•Low position in the umbilical vein.
Not all medication can be administered through a line in this
position.
•Intrahepatic into the portal venous system, both right and left, or
even into the superior mesenteric or splenic vein.
This can cause thrombosis.
•Perforation of the portal vein can cause hemorrhage or abscess
formation in the liver.

13. Endotracheal tube
• The tip of an endotracheal tube should be in between
the thoracic aperture and 1 cm above the carina.
• The tip travels downward if the neck is flexed or upward
if the neck is extended.
• The most common malpositioning is in the right
mainstem bronchus, because of the shallower angle of
the right main bronchus.
• Here a good positioned tube in a patient with a
pneumothorax on the left.

14. Chest drainage tube
• Chest drainage tube are placed in case of
respiratory distress caused by pleural fluid or
pneumothorax in order to allow sufficient
expansion of the lung for ventilation.
• The tube should be positioned in the
midaxillary line via the 4th - 6th intercostal
space.
• The position should be apical anterior in
patients with a pneumothorax.
The findings are:
1.Endotracheal tube in good position.
2.Straight chest drain tube in good position.
Drainage however is not optimal.
3.Mediastinal shift to the right. There is however
no tension-pneumothorax, since the diaphragm
has a normal convex upper border.

15. Bone age assessment
• Bone age assessment is used to radiologically assess the biological and structural maturity of immature patients
from their hand and wrist x-ray appearances. It forms an important part of the diagnostic and management
pathway in children with growth and endocrine disorders. It is helpful in the diagnosis of various growth disorders
and can provide a prediction of final height for patients presenting with short stature.
• Bone age can also be used to monitor children on growth hormone therapy or those presenting in delayed or
advanced stages of puberty that may need treatment.
Methods
Assessment is performed with a radiograph of the non-dominant hand with a single DP view that includes the distal
radius and ulna and all the fingers. Appearances of the carpal bones, metacarpal, phalanges, radius, and ulna are
compared to standardised versions in one of two main atlases:
•Greulich and Pyle atlas presents a single standardised image for a range of ages of each gender
•Tanner-Whitehouse (TW) method involves the scoring of each carpal bone, the radius and ulna leading to a total
score, from which age can be estimated

17. • Bronchiolitis is a broad term that refers to any form of
inflammation of the bronchioles.
• It is often used in situations where the inflammation
primarily occurs in airways smaller than 2 mm
Bronchiolitis
• Usually not detected at chest radiography but may manifest
with non-specific findings such as ill-defined small or hazy
clustered nodules or areas of air trapping characterised by
hyperlucency and/or oligaemia.

18. Pneumothorax
• AP CXR (above) shows increased lucency in the left
hemithorax when compared to the right and a deep
sulcus sign is seen.
• There is mediastinal shift to the right implying
underlying tension.
• Right lateral decubitus CXR (below) shows a clear
pleural edge.
• Pneumothorax, refers to the presence of gas (often
air) in the pleural space.
• When this collection of gas is constantly enlarging with
resulting compression of mediastinal structures, it can
be life-threatening and is known as a tension
pneumothorax (if no tension is present it is a simple
pneumothorax).

19. PNEUMONIA
• Confluent airspace opacity in the right upper and mid-
zones consistent with infection.
• Pediatric patients do not usually present with confluent
airspace disease as a result of infection.
• Infection is usually viral and causes rather non-specific
findings, such as peribronchial thickening and patchy
airspace infiltrate.

20. AIRWAY FOREIGN BODIES IN CHILDREN
• A radiopaque foreign body was visualized in
the proximal esophagus at the thoracic inlet on
the chest and neck radiographs.
• The foreign body appeared to be metallic with
visualized concentric rings consistent with a
coin.

21. THANK YOU