Paediatric Practice Cases
I am grateful for people for donating these paeds cases. Management and approach to paeds cases is slightly different i.e. infection. It is also recommended that you spend a bit of time revising tubes and lines.
I hope these cases are of benefit.
Abdominal radiograph of a neonate. There is evidence of free air with riglers, falciform and football sign all evident. No pneumatosis. No air in the portal vein. Normal appearance of the bony skeleton. No gross solid organ lesions identified. In summary, perforation but the cause is unclear. This is a surgical emergency and needs urgent referral to a surgeon.
Analysis, a common cause of perforation is NEC, but this is not a case of this. There are lots of the classic features of perforation. In teaching people automatically say NEC, but this is more associated with preterm and has more features such as air in the bowel.
Plain film radiograph of a skeletally immature child demonstrating excess bowing of the tibia. No acute bony injury. Growth plates are unfused. Normal cortex. No lytic bony changes. Most likely diagnosis is Blounts disease but a differential diagnosis is excess bowing associated with age. This requires orthopaedic referral.
What are the features of Blounts disease on imaging?
- Medial beaking of the epiphysis
- Widened irregular medial physis
- Irregular ossification
- Medial slope of the epiphysis and metaphysis in varus
How is the disease classified? Severity is affected by tibiofemoral angle
‘Baby gram’ including the chest and abdomen. ETT and NG tube appropriately positioned. There is a granular appearance of the lungs. This is suggestive of inflammatory lung disease. Lucency is projected over the liver. A few bowel loops including the stomach are distended. The appearance is in keeping with perforation of a hollow viscous. No pneumatosis. No air in the portal vein. This is a surgical emergency and the patient will need to be referred for urgent management.
Analysis. The chest, tubes and lines, free air. Lots of things to talk about. My suggestion is that even if you saw the perforation quickly. Be systematic. Start with tubes and lines, for example the ETT might be in the wrong position, then look at the chest, there could be an easy pneumothorax that you miss in a case like this. I have suggested a structured prose the approaching this case.
Abdominal radiograph of a baby. Small and large bowel loops are dilated. There is evidence of air within bowel loop walls. No radiological evidence of perforation. No bony abnormality. In a child this is most likely to be secondary to NEC. This is a surgical emergency and requires urgent management.
What is NEC? This is a disease process which is transmural. There is mucosal oedema and haemorrhage. As the disease progresses there is transmural necrosis and ulceration. This results in subserosal gas collections.
How is this management? This depends on perforation. If there is no perforation the management is supportive. If there is perforation then the patient will require surgical intervention. Even if the child recovers there is a risk of future adhesions so will need to be followed up.
What is the cause? The exact cause is unknown, but there is an association with preterm birth.
Abdominal radiograph of a child. The NG tube is appropriately positioned but there is evidence of dilated small and large bowel loops. No radiological evidence of ischamia or perforation. However, there are two groin hernias which contain bowel loops. This is the likely cause of the obstruction. No bony abnormalities. The patient will need urgent review by the surgical team
Analysis, hernias are a possibility for cause of obstruction in children and adults. Remember, no radiological evidence of ischaemia does not exclude this. This requires clinical correlation.
Radiograph of the chest and abdomen in a child. Tubes and lines appear appropriately positioned. There is a large density in the chest which contains locules of air. This likely represents a large hernia with significant portion of the abdomen within the chest. No evidence of perforation. No free fluid.
Analysis. The examiner might ask about Morgagni and bochdalek hernias and the association of these conditions.
CXR of a child demonstrates an NG tube coiling in the upper oesophagus. Appearance in keeping with oesophageal atresia. No gastric or duodenal bubble is appreciated. No focal active lung lesions. No bony abnormalities appreciated. This condition is associated with VACTERL and if not know already the patient will require a work up to assess for this.
CXR of a child demonstrates a fracture of the right mid shaft of the clavicle. No additional bony injury is identified. No lung lesions. No pneumothorax visible. The mediastinum is normal in appearance.
Analysis. The key with childhood bony injury is look for evidence of healed fracture. The clavicle fracture is apparent but please look for evidence of healed fractures of different ages. This could be a sign of NAI. It is useful to know the UK guidance on NAI.
CXR of a child with the NG tube positioned in the stomach which is located on the right hand side. The liver outline is on the left. The heart is on the right. No focal lung lesions. No bony abnormalities appreciated. The image features are in keeping with situs inversus with dextrocardia. However, I would recommend that the clinician listen to the heart to ensure it is on the right side to make sure this is not a radiological department error.
Analysis. The examiner may combine this with a case of kartegeners syndrome, so look for evidence of bronchiectasis or consolidation or effusion.
Chest Radiograph of a child demonstrates a umbilical vein catheter in the correct position and right upper lobe collapse. There is also evidence of a left sided pneumothorax with minor flattening of the left hemidiaphragm suggestive of underlying tension. No rib fractures. No bony abnormalities. No mediastinal shift. A clear cause for the pneumothorax has not been identified.
Analysis 1. Please be comfortable with paediatric tubes and lines before the exam. 2. Collapse in a child is more likely to be due to infection or foreign body. Please double check for a foreign body causing the collapse. The pneumothorax may require a drain as there is an element of tension. The mistake in paeds cases is to recommend a drain in a child when there is no tension
Abdominal radiograph of a neonate demonstrates dilated large bowel and normal calibre small bowel. The point of calibre change is in the rectum. No free air. No free fluid. No pneumatosis. No evidence of a hernia. Appearances in keeping with mechanical obstruction. The most likely cause is Hirschsprungs disease. If not known this will need to be referred to the surgical team for assessment.
Analysis, a differential for dilated bowel in a neonate is NEC. This requires correlation with assessment parameters. Look for evidence of NEC in plain film as well.
I am grateful to Dr Abhijit Vipul for the donation of this case
Baby gram including chest and abdomen. NG tube, ETT and abdominal line appropriately positioned. Stomach bubble in left lower quadrant. There is air space shadowing in the left lung with air bronchograms. Appearance in keeping with inflammatory process. The right lung appears clear. Normal mediastinum. No bony lesions. Recommend treating the patient with clinical follow up.
Analysis. Always say clinical follow up for Chest infection in a child. If the child does not improve or gets worse recommend follow up CXR. DO NOT ROUTINELY RECOMMEND A CXR FOLLOW. THIS IS DIFFERENT TO ADULT MEDICINE
Baby gram including the chest and abdomen. ETT appropriately positioned. No focal active lung lesions. There is evidence of dilated large bowel loops with air in the bowel wall. No free air is demonstrated. The appearance is in keeping with NEC without perforation.
Analysis. Please be comfortable with the complications and severity of NEC and management options.
Chest Radiograph of a neonate, NG tube appropriately positioned. This demonstrates hyperinflated lungs, with diffuse patchy infiltrates. No consolidation, effusion or pneumothorax. Appearances most in keeping with meconium aspiration syndrome. This is most likely because the lungs are hyperinflated indicating air trapping.
What are the associations of MAS
No air bronchograms with MAS. Instead there is patchy opacities indicating meconium.
Associations include pneumothorax and pleural effusions. This usually occurs in term or late babies.