Pediatrics GIT Flashcards
- Which of the following is most likely to be a feature of an enteric duplication cyst?
A. Multilocular nature
B. Hypoechoic internal layer
C. Echogenic outer layer
D. Layered echogenic debris within cyst
E. Dense calcification
D. Layered echogenic debris within cyst
Often an incidental finding on antenatal/postnatal US, most present in childhood. May become symptomatic due to compression effect on adjacent structures. Complications include ulceration, bleeding, volvulus and small bowel obstruction.
@# 35. Which is the most common location for enteric duplication cysts?
A. Ileum
B. Oesophagus
C. Colon
D. Jejunum
E. Stomach
A. Ileum
75% are abdominal. Synchronous lesions occur in 10-20%.
- Which is the most common type of transition between affected aganglionic and normal gangionic bowel in Hirschsprung’s disease?
A. Long segment
B. Short segment
C. Ultra short segment
D. Total intestinal aganglionosis
E. Total colonic
B. Short segment
Short segment accounts for 70-80%. Long segment accounts for 15-25%.
- Which of the following is the most common type of tracheoesophageal fistula (TOF)?
A. Oesophageal atresia and proximal atretic portion and location of fistulas
B. Pure oesophageal atresia without TOF
C. Isolated TOF (H type) without oesophageal atresia
D. Oesophageal atresia with proximal and distal TOF
E. Oesophageal atresia with proximal TOF and distal atretic portion
A. Oesophageal atresia and proximal atretic portion and location of fistulas
82% are of this type
- A 6-week-old boy with persistent non-bilious vomiting undergoes ultrasound of the abdomen. Which of the following is an ultrasound feature of pyloric stenosis?
A. Elongated pyloric channel > 16mm
B. Elongated pyloric channel > 12mm
C. Thickened pyloric muscle > 2mm
D. Increased pyloric diameter > 6mm
E. Increased pyloric diameter > 10mm
A. Elongated pyloric channel > 16mm
US features include gastric hyperperistalsis, failure to open pyloric channel or dynamic study and the echogenic mucosal layer may also look hypertrophied.
- Which is the most specific radiologic sign in the investigation of intususception in a 6-month-old?
A. Paucity of bowel gas in the right lower quadrant
B. Soft tissue mass in the right upper quadrant obscuring the liver
C. Non-visualisation of the air filled caecum
D. Soft tissue mass with concentric lucencies
E. Small bowel obstruction
D. Soft tissue mass with concentric lucencies
Target sign also seen on US as a mass with alternating rings of hyper and hypechogenicity in TS and layered or pseudokidney appearance on LS
- In biliary atresia on US:
A. The liver is almost always of abnormal echogenicity
B. GB is present in 75% of cases
C. Extrahepatic ducts are visible
D. An echogenic triangular cord sign represents a fibrotic remnant of the common duct
E. Lack of excretion of 99mT labelled studies into small bowel by 24 hours is diagnostic
D. An echogenic triangular cord sign represents a fibrotic remnant of the common duct
E is highly suggestive but not diagnostic. The gallbladder is present in 25% of cases. The liver may be enlarged but is usually of normal echogenicity.
- Which of the following occurs with Caroli’s disease to form Caroli’s syndrome?
A. Hepatosplenomegaly
B. Hepatic fibrosis
C. Portal hypertension
D. Cholangiocarcinoma
E. Renal cystic abnormalities
B. Hepatic fibrosis
Hepatosplenomegaly and portal hypertension are consequences. There is an increased risk of cholangiocarcinoma and renal cystic abnormalities.
- A 6-year-old girl with a large abdominal mass in the right upper quadrant and with an elevated AFP undergoes ultrasound assessment. This shows a 10cm mass in the right lobe of the liver, of heterogeneous echotexture, but predominantly solid. A spoke-wheel appearance is seen due to fibrous septa radiating from a central hub. Which is the most likely diagnosis?
A. Haemangioendothelioma
B. Hepatoblastoma
C. Mesenchymal hamartoma
D. Hepatocellular carcinoma
E. Metastasis from neuroblastoma
B. Hepatoblastoma
Haemangioendotheliomas have normal Alpha fetoprotein (AFP).
Mesenchymal hamartomas are usually more cystic.
47 Regarding the normal anatomy of the umbilical cord, there is:
(a) 1 umbilical artery, 1 umbilical vein
(b) 1 umbilical artery, 2 umbilical veins
(c) 2 umbilical arteries, 1 umbilical vein
(d) 2 umbilical arteries, 2 umbilical veins
(e) No ‘normal number’ as it is common to have different combinations of umbilical arteries/veins as an anatomical variant
(c) 2 umbilical arteries, 1 umbilical vein
A single UA is present in less than 1 % of all births. Single UA is more common with twins and diabetic mothers, and is associated with congenital anomalies.
(GIT) A child with a subacute history of vague abdominal pain is being investigated with ultrasound. Inflammatory markers are normal and there is no clinical indication of an appendicitis. During the study, an abnormality is detected in the right iliac fossa. Which of the following sonographic features favours a duplication cyst rather than a Meckel’s diverticulum?
A. Non-compressibility
B. Teardrop shape
C. A double layered wall
D. A greater degree of irregular mucosa
E. An elongated tubular shape
C. A double layered wall
An inflamed Meckel’s diverticulum can be difficult to distinguish from a duplication cyst in the terminal ileum. However, a characteristic double-layered wall is seen in duplication cysts, whereas the other features are more often found in an inflamed Meckel’s diverticulum.
3) A 2-day-old, full-term baby boy is found to have a palpable abdominal mass during a routine examination. He is otherwise well. A plain abdominal radiograph demonstrates a well-defined, dense mass containing multiple calcifications in the right lower quadrant. What is the most likely diagnosis?
a. neuroblastoma
b. duplication cyst
c. meconium peritonitis
d. meconium ileus
e. Hirschsprung’s disease
c. meconium peritonitis
Meconium peritonitis is a chemical peritonitis that occurs in utero following perforation of bowel as a result of bowel obstruction or ischaemia. Most commonly, the perforation seals off in utero, but the extruded meconium may be palpable as an abdominal mass, or may become calcified and therefore visible on plain film as a dense calcified mass or as calcific plaques throughout the peritoneal cavity. It may also be identified on ultrasound scan as echogenic material between bowel loops with a ‘snowstorm’ appearance. In other cases, active perforation is still present at birth, and the baby presents with clinical peritonitis.
Meconium ileus may result in abdominal calcifications in the neonate, but these are intramural in location. Hirschsprung’s disease and other causes of intestinal obstruction may be associated with intraluminal calcifications in the neonate. Neuroblastoma is frequently associated with calcification, but is suprarenal in location and usually symptomatic.
Duplication cysts are not usually associated with calcification.
8) A 5-year-old, previously well girl is found to have a palpable abdominal mass. Ultrasound scan demonstrates a 5 cm cystic lesion in the right upper quadrant. The wall of the lesion has an outer hypoechoic layer and an inner echogenic layer. The remainder of the abdomen appears normal. What is the most likely diagnosis?
a. Wilms’ tumour
b. ovarian cyst
c. pancreatic pseudocyst
d. duplication cyst
e. choledochal cyst
d. duplication cyst
Gastrointestinal duplication cysts account for 15% of paediatric abdominal masses. They most commonly arise from the small bowel and colon and, although usually asymptomatic, those that contain ectopic gastric or pancreatic tissue may present with ulceration or haemorrhage. Contrast studies are not useful for diagnosis, as most cysts do not communicate with the bowel lumen. Ultrasound scan is the most appropriate technique and demonstrates a simple anechoic cyst with a characteristic two-layered wall, representing the inner echogenic mucosa and the outer hypoechoic muscle. These appearances are characteristic of bowel wall, and help to distinguish a duplication cyst from other cystic lesions such as ovarian cyst, which are typically thin walled. Pancreatic pseudocyst is unlikely in the absence of previous episodes of pancreatitis.
13) A newborn baby presents with coughing and choking during feeding. On examination, the baby is noted to drool excessively. Attempted passage of a feeding tube into the stomach is unsuccessful, and a chest radiograph shows the coiled feeding tube in the proximal oesophagus. An abdominal radiograph demonstrates gas within the stomach. What is the most likely diagnosis?
a. oesophageal atresia alone
b. oesophageal atresia and proximal tracheo-oesophageal fistula
c. oesophageal atresia and distal tracheo-oesophageal fistula
d. oesophageal atresia with proximal and distal tracheo-oesophageal 1fistulae
e. tracheo-oesophageal fistula without oesophageal atresia
c. oesophageal atresia and distal tracheo-oesophageal fistula
Oesophageal atresia is suspected when a newborn baby presents with drooling, and is confirmed on a chest radiograph by the presence of a gas-distended, proximal oesophageal pouch, or a coiled feeding tube within the pouch. Absence of gas in the abdomen on an abdominal radiograph implies oesophageal atresia either alone or with a proximal fistula. However, gas within the abdomen implies the presence of a distal tracheo-oesophageal fistula. Occasionally, there may be both proximal and distal tracheo-oesophageal fistulae, but this situation is rare, accounting for only 1% of patients, as opposed to around 80% with distal fistula alone. Oesophageal atresia and tracheo-oesophageal fistula may be part of the VACTERL association, which includes vertebral, anorectal, cardiovascular, tracheo-oesophageal fistula, renal and limb anomalies.
17) A 6-year-old girl is investigated for abdominal pain, jaundice and a palpable right upper quadrant mass. Ultrasound scan of the abdomen demonstrates a 5 cm cystic structure at the porta hepatis, which is separate from the normal gallbladder, and communicates with normal intrahepatic ducts. What is the most likely diagnosis?
a. biliary atresia
b. choledochal cyst
c. pancreatic pseudocyst
d. duodenal duplication cyst
e. pericholecystic abscess
b. choledochal cyst
Choledochal cyst is a congenital condition characterized by aneurysmal dilatation of the common bile duct, which in the majority of cases is associated with an anomalous junction of the common bile duct and pancreatic duct, allowing reflux of pancreatic enzymes into the common bile duct and resulting in weakening of the wall. The most common type (type I) is a localized dilatation of the common bile duct below the cystic duct. Communication with the common hepatic or intrahepatic ducts is demonstrated, and intrahepatic ducts are usually not dilated. Biliary atresia presents in the neonatal period with jaundice. Typical findings include an echogenic triangular structure at the porta, representing the atretic biliary plate, and a small or non-visualized gallbladder. Pancreatic pseudocyst and duodenal duplication cyst do not communicate with the biliary tree. A pericholecystic abscess would be unlikely in the presence of a normal gallbladder.
18) A 3-year-old boy presents with fever, skin rash and abdominal pain. On examination, he has a maculopapular rash on the extensor surfaces, erythema of the oral mucosa, palms and soles, and multiple enlarged cervical lymph nodes. He is tender in the right upper quadrant. Abdominal ultrasound scan demonstrates a markedly enlarged gallbladder with a thin wall and a positive sonographic Murphy’s sign is elicited. No gallstones are seen. What is the most likely diagnosis?
a. acute acalculous cholecystitis
b. acute gallbladder hydrops
c. choledochal cyst
d. acute calculous cholecystitis
e. emphysematous cholecystitis
b. acute gallbladder hydrops
Kawasaki’s syndrome is an acute multisystem vasculitis with a predilection for the coronary arteries, generally affecting children under 5 years of age. As well as skin, joint and cardiovascular manifestations, patients may develop acute hydrops of the gallbladder, probably caused by transient obstruction of the cystic duct. Ultrasound scan demonstrates a markedly enlarged and tender gallbladder with a thin wall. Acute acalculous cholecystitis may be seen in children in the high dependency or intensive care setting, especially with septicaemia and trauma, but it usually results in gallbladder wall thickening and less marked gallbladder dilatation. Choledochal cyst (aneurysmal dilatation of the common bile duct) is seen as a fusiform cyst beneath the porta hepatis separate from the gallbladder. Acute calculous cholecystitis is associated with gallstones within a thickened gallbladder wall.
Emphysematous cholecystitis usually occurs in adults over 50, and gas is seen as arc-like, high-level echoes outlining the gallbladder wall.
19) A 7-year-old boy who has recently arrived in the country from south-east Asia presents with colicky abdominal pain. Blood tests show eosinophilia. He undergoes small bowel follow-through examination, whichreveals multiple tubular filling defects in the small bowel averaging 20 cm in length, some of which contain a central, barium-filled canal. What is the most likely diagnosis?
a. ancylostomiasis (hookworm)
b. ascariasis (roundworm)
c. strongyloides infection
d. anisakiasis (herring worm disease)
e. taeniasis (tapeworm)
b. ascariasis (roundworm)
Ascariasis is the most common parasitic infection worldwide, predominantly affecting children aged 1–10 years.Worms mature in the small bowel and may be identified on plain films as tubular soft-tissue densities or on barium studies as linear or coiled filling defects of 15–35 cm in length. Barium ingested by the worms causes opacification of their central linear enteric canals. Patients may present with abdominal pain, appendicitis and haematemesis; occasionally, a bolus of worms may cause small bowel obstruction.
Tapeworms may also appear as linear filling defects, but are usually much longer, reaching many feet in length. In addition, tapeworms have no alimentary canal and do not ingest barium.
Hookworms measure 8–13 mm and cannot be visualized on barium studies.
Anisakiasis of the small intestine usually appears radiologically as bowel wall thickening and luminal narrowing.
Strongyloides infection may manifest as fold thickening and effacement, with a pipestem appearance of the jejunum in advanced cases.
27) What is the normal position of the duodenojejunal junction on frontal views during an upper gastrointestinal contrast examination?
a. to the left of the left pedicles of the vertebral body at the level of the duodenal bulb
b. to the left of the left pedicles below the level of the duodenal bulb
c. overlying the vertebral body at the level of the duodenal bulb
d. to the right of the right pedicles below the level of the duodenal bulb
e. to the right of the right pedicles above the level of the duodenal bulb
a. to the left of the left pedicles of the vertebral body at the level of the duodenal bulb
Intestinal malrotation is defined as a congenital abnormal position of the bowel within the peritoneal cavity, occurring as a result of disruption of the normal embryological process of gut rotation and fixation. It is associated with abnormal bowel fixation by mesenteric bands or lack of fixation of parts of the bowel, which may result in obstruction, volvulus and bowel necrosis. The position of the duodenojejunal junction (and by implication the ligament of Treitz) can help to identify the presence of malrotation and its type, and should be determined on every paediatric upper gastrointestinal contrast examination. The duodenojejunal junction normally lies to the left of the left-sided pedicles of the vertebral body, at the level of the duodenal bulb on frontal views.
Malrotation is associated with medial and inferior displacement of the duodenojejunal junction. Occasionally, the normal duodenojejunal junction may be displaced inferiorly by a distended stomach or dilated adjacent bowel segment, due to laxity of the peritoneal ligaments, which may mimic malrotation.
31) Regarding reduction of intussusception in children, which of these is a feature of hydrostatic reduction using barium, rather than pneumatic reduction using air?
a. lower intracolonic pressures
b. faster reduction
c. higher successful reduction rate
d. less contamination of the peritoneal cavity
e. lower radiation dose
a. lower intracolonic pressures
Compared with use of barium, pneumatic reduction of intussusception using air allows generation of higher intracolonic pressures, which is associated with faster and more effective reduction (70–90% success rate), and therefore less fluoroscopic time and lower radiation dose. If perforation does occur (around 1% of cases), the use of air results in smaller tears and less contamination of the peritoneal cavity. A potential complication of the pneumatic method is tension pneumoperitoneum, which may result in respiratory and haemodynamic compromise, requiring prompt needle puncture of the peritoneal cavity. Overall, pneumatic reduction is considered the optimal technique, and has replaced the use of barium in most centres. However, hydrostatic reduction with water-soluble contrast remains a viable alternative, but the contrast column needs to be elevated to a height of 150 cm to generate similar pressures.
39) A neonate with Down’s syndrome presents with persistent bilious vomiting within a few hours of birth. An abdominal radiograph demonstrates a dilated, gas-filled stomach and duodenal bulb, with a total absence of gas in the small and large bowel. What is the most likely diagnosis?
a. Hirschsprung’s disease
b. hypertrophic pyloric stenosis
c. duodenal atresia
d. duodenal duplication cyst
e. annular pancreas
c. duodenal atresia
Duodenal atresia is the commonest cause of congenital duodenal obstruction, and is often associated with Down’s syndrome and other congenital anomalies. Patients present soon after birth with persistent vomiting. The site of obstruction is usually distal to the ampulla of Vater, and a ‘double-bubble’ sign is seen on plain abdominal radiograph, representing gas within the duodenal bulb and stomach, but no gas is seen distally. Annular pancreas is also associated with Down’s syndrome, and may present neonatally with vomiting and the doublebubble sign, but obstruction is incomplete, with gas seen in the bowel distal to the stenosis. Hypertrophic pyloric stenosis usually presents with vomiting around 4–6 weeks of life, and a dilated duodenal bulb is not a feature. Duodenal duplication cyst may cause compression or displacement of the first and second parts of the duodenum, but rarely causes high-grade stenosis. The double-bubble sign is not a feature of Hirschsprung’s disease.
46) A 5-week-old boy presents with projectile vomiting. Examination of the abdomen is normal. He undergoes ultrasound scan of the abdomen, during which the following measurements are obtained: pyloric canal length of 18 mm, transverse pyloric diameter of 12 mm and pyloric muscle wall thickness of 3 mm. What is the most appropriate next step in management?
a. 24-hour pH probe monitoring
b. symptomatic management
c. pyloromyotomy
d. repeat ultrasound scan in 2–3 days
e. upper GI contrast examination
c. pyloromyotomy
Hypertrophic pyloric stenosis (HPS) is an idiopathic condition in which the circular muscle fibres of the pylorus undergo hypertrophy and hyperplasia, resulting in elongation and narrowing of the pyloric canal. Infants, often firstborn males, usually present at 4–6 weeks with projectile vomiting. If an experienced clinician can palpate an oliveshaped mass, no imaging is required. Otherwise, ultrasound scan is the imaging method of choice for diagnosis. Ultrasound findings include increased gastric peristalsis, failure of the pyloric canal to open, and elongated pylorus with thickened muscle. Pyloric canal length of >16 mm, transverse pyloric diameter of >11 mm and muscle wall thickness of >2.5 mm are indicative of HPS. The definitive treatment is pyloromyotomy.
47) A 2-day-old, full-term, male neonate presents with failure to pass meconium. A water-soluble contrast enema demonstrates a dilated sigmoid colon with a narrowed, poorly distensible rectum and a persistent corrugated appearance to the rectal mucosa. What is the most likely diagnosis?
a. colonic atresia
b. meconium ileus
c. imperforate anus
d. Hirschsprung’s disease
e. meconium plug syndrome
d. Hirschsprung’s disease
Hirschsprung’s disease is caused by an absence of parasympathetic ganglia in the muscle and submucosal layers of the distal colon, resulting in abnormal peristalsis and impaired evacuation of the colon. The rectum is virtually always involved, but the proximal extent of disease varies. Presentation is usually with failure to pass meconium by 48 hours. Characteristic features on contrast enema in the neonate include inversion of the rectosigmoid index (the normal neonatal rectum is of greater calibre than the sigmoid colon), tortuosity and corrugation of the narrowed aganglionic segment, and difficulty in obtaining good rectal distension. A discrete zone of transition is more commonly seen in older infants and children. Colonic atresia causes massive distension of the colon proximal to the area of stenosis, but is relatively rare. Meconium plug syndrome typically results in a dilated right and transverse colon with a transition point at the splenic flexure. Meconium ileus causes small bowel obstruction.
50) A 14-year-old girl is admitted following trauma and undergoes CT of the abdomen and pelvis. The large bowel is incidentally noted to lie on the left side of the abdomen, with the small intestine on the right. The superior mesenteric artery lies to the right of the superior mesenteric vein. What is the most likely diagnosis?
a. normal appearances
b. non-rotation
c. malrotation
d. reversed rotation
e. midgut volvulus
b. non-rotation
Non-rotation is an abnormality of bowel rotation in which the midgut loop returns to the peritoneal cavity without undergoing rotation. It is usually asymptomatic and is often found incidentally in older children or adults. The small bowel is located on the right side of the abdomen and the colon on the left side, and the small and large bowel have a common mesentery. The superior mesenteric vein lies to the left of the superior mesenteric artery, the reverse of the normal situation. In malrotation, the superior mesenteric vein tends to lie anterior to the superior mesenteric artery, and there is abnormal positioning of the duodenojejunal junction to the right and inferiorly, usually also with cephalad positioning of the caecum. Reversed rotation is rare, and results in the colon lying posterior to the superior mesenteric artery, with duodenum and jejunum in front of it. Midgut volvulus may complicate abnormalities of bowel rotation, resulting in torsion of the gut around the superior mesenteric artery due to a short mesenteric small bowel attachment. A clockwise ‘whirlpool’ sign may be seen on colour Doppler ultrasound scan, representing the superior mesenteric vein wrapping clockwise around the superior mesenteric artery.
57) A 6-year-old boy presents with lower gastrointestinal bleeding. He undergoes a [99mTc]-pertechnetate study, which demonstrates a small focal area of increased activity in the right lower quadrant 5 minutes after tracer injection, which increases in intensity with time paralleling the activity of the stomach. What is the most likely diagnosis?
a. Meckel’s diverticulum
b. appendicitis
c. duodenal duplication cyst
d. intussusception
e. peptic ulcer disease
a. Meckel’s diverticulum
Meckel’s diverticulum is a true diverticulum arising from the small bowel, usually 80–90 cm from the ileocaecal valve, representing failure of closure of the omphalomesenteric duct. Heterotopic gastric mucosa is present in 10–30% of diverticula, but is seen in 98% of those that present with bleeding. A [99mTc]-pertechnetate study demonstrates uptake in gastric mucosa within Meckel’s diverticulum, seen as a focal area of uptake, usually in the right lower quadrant with activity paralleling that of the stomach. Duodenal duplication cysts may contain heterotopic gastric mucosa, which may be a cause of a false-positive scan, but they often appear as larger areas of increased activity, and would be expected to be in the upper abdomen. Tracer uptake may be seen in inflammatory, obstructive and neoplastic conditions, including intussusception, peptic ulcer disease and appendicitis, but activity does not parallel that of the stomach.
60) A 2-year-old girl is admitted with abdominal pain and vomiting. No history of trauma is provided. On examination, she is tachycardic and has upper abdominal tenderness. Ultrasound scan of the abdomen demonstrates an echogenic intramural mass in the duodenum in keeping with an intramural haematoma. There is mild proximal dilatation of the duodenum and a small amount of free fluid within the abdomen. What is the most likely underlying cause?
a. duodenal diverticulum
b. haemophilia
c. pancreatitis
d. Henoch–Scho¨ nlein purpura
e. non-accidental injury
e. non-accidental injury
Duodenal intramural haematoma is usually traumatic, particularly following bicycle-handlebar accidents and lap-belt injuries. However, it isalso commonly seen in non-accidental injury, where the mechanism of injury is thought to be a blunt blow to the abdomen that compresses the duodenum against the vertebral column. Trauma to the duodenum may result in duodenal rupture, intramural tear or, most commonly, intramural haematoma. Ultrasound appearances are of an echogenic intramural mass that becomes progressively hypoechoic with maturation of the haematoma. There may be associated deformity or obstruction of the duodenum. CT may demonstrate free intraperitoneal fluid, though free air and frank perforation are uncommon. Spontaneous intramural haematoma may occur in Henoch–Scho¨ nlein purpura, but other features of the condition would be expected to be present. It may occur with anticoagulant therapy and blood dyscrasia, but haemophilia in females is extremely rare. Duodenal diverticula may cause gastrointestinal bleeding, but this is usually intraluminal rather than intramural. Duodenal intramural haematoma has been described in association with pancreatitis but is very rare.
58) A full-term baby boy born to a diabetic mother presents during the first day of life with abdominal distension and failure to pass meconium. Plain abdominal radiograph demonstrates a dilated, meconium-filled, proximal colon to the level of the splenic flexure, with an empty descending colon, sigmoid and rectum. Administration of a water-soluble enema results in passage of meconium, and the baby is discharged well 2 days later. What is the most likely diagnosis?
a. intussusception
b. Hirschsprung’s disease
c. meconium plug syndrome
d. meconium ileus
e. ileal atresia
c. meconium plug syndrome
Meconium plug syndrome is also known as small left colon syndrome and functional immaturity of the colon. It occurs most commonly in large infants and infants of diabetic mothers and is believed to be due to relativeimmaturity of bowel innervation. Characteristic features are of a dilated proximal colon with a calibre change at the splenic flexure and an empty descending colon. The functional obstruction is transient and usually self-limiting, and contrast enema may act as a stimulus for subsequent passage of (normal) meconium. Hirschsprung’s disease with a transition zone at the splenic flexure may mimic these findings, but the obstruction usually persists after contrast enema. Intussusception in this age group and at this site would be unusual. Meconium ileus and ileal atresia are causes of distal small bowel obstruction.
61) A 7-year-old boy is admitted with colicky abdominal pain and rectal bleeding. He is noted to have a purpuric skin rash on the extensor surfaces of his arms and legs. What are the most likely findings on CT of the abdomen?
a. multifocal bowel wall thickening
b. multiple small polyps in the colon
c. focal outpouching of the distal ileum
d. inflammatory changes at the terminal ileum
e. dilatation of the small bowel
a. multifocal bowel wall thickening
Henoch–Scho¨ nlein purpura is an acute systemic vasculitis that affects the skin, gastrointestinal tract, joints and kidneys. Children aged 3–10 years are predominantly affected, and may present with a purpuric rash on the extensor surfaces of the limbs, arthralgia and crampy abdominal pain with intestinal bleeding. Imaging demonstrates multifocal areas of bowel wall thickening due to intramural haemorrhage and oedema. Gastrointestinal complications include bowel infarction and perforation, as well as intussusception.
62) A 10-year-old boy is brought to accident and emergency after falling on his bike and sustaining a blunt abdominal injury by impacting the handlebars. CT shows free intraperitoneal fluid with a more focal collection of fluid at the mesenteric root. Additional findings of mesenteric stranding and focal bowel wall thickening are seen. There is diffuse homogeneous hyperattenuation of the pancreas, kidneys and bowel wall. What is the most likely underlying injury?
a. mesenteric rupture
b. bowel perforation
c. splenic rupture
d. renal contusion
e. pancreatic contusion
a. mesenteric rupture
The most common mechanism for traumatic mesenteric rupture is a road traffic collision, although such an injury can occur in children following any blunt abdominal trauma, with handlebar injuries and child abuse being well-recognized causes. Use of a lap belt makes children more prone to the injury. Bowel perforation, infarction and active haemorrhage are indications for immediate surgery and can be identified on CT. Most of the remaining cases are treated conservatively.
Free intraperitoneal air, extraluminal contrast or visible bowel wall defect is specific for perforation. Free fluid, haemorrhage and stranding are seen in perforation or mesenteric injury, with fluid at the root more likely to indicate the latter. Hyperattenuation of the pancreas, kidneys and bowel wall is a feature of hypoperfusion, along with small-calibre aorta and vena cava, and should not be mistaken for visceral injury.
69) Which of the following conditions is the most common underlying aetiology for intussusception in childhood?
a. viral gastroenteritis
b. Meckel’s diverticulum
c. Henoch–Scho¨ nlein purpura
d. duplication cyst
e. small bowel polyp
a. viral gastroenteritis
Most intussusceptions occur in childhood, usually between 6 months and 2 years of age. The vast majority are idiopathic or related to mucosal oedema and lymphoid hyperplasia following viral gastroenteritis. In the 5% of patients with a pathological lead point, causes include those listed above. Patients classically present with cramping abdominal pain, screaming episodes, ‘redcurrant jelly stools’ and a palpable abdominal mass. Most childhood intussusceptions are ileocolic. In contrast, a specific cause is identified in 80% of adult cases, and ileoileal intussceptions are more common than ileocolic.
72) An asymptomatic, 15-month-old girl is brought to the emergency department following witnessed ingestion of a hearing aid battery. A junior casualty officer asks for your advice about whether the patient requires imaging. What is the most appropriate imaging strategy?
a. reassurance that imaging is not indicated
b. patient to return for imaging if battery not passed within 48 hours
c. abdominal radiograph (and chest radiograph if abdominal radiograph negative)
d. ultrasound scan of the abdomen
e. patient to be referred straight for endoscopic removal
c. abdominal radiograph (and chest radiograph if abdominal radiograph negative)
Generally, in the case of ingested foreign bodies, a chest radiograph (including neck) at initial presentation is indicated. An abdominal radiograph is usually considered after 6 days only if there is doubt whether the foreign body has passed. However, if a sharp or potentially poisonous foreign body has been ingested, an abdominal radiograph is indicated at the time of presentation; a chest radiograph is indicated if the abdominal film is negative. Ingestion of disc batteries (small, coin-shaped batteries found in hearing aids, watches and calculators) may be associated with serious sequelae, particularly if the battery becomes lodged in the oesophagus, as is more likely with younger children and larger batteries. In this situation, leakage of alkaline material, and sodium hydroxide generated by electrolysis at the anode, can cause ulceration and perforation within a relatively short time. Radiography is indicated to locate the battery. If it lies within the oesophagus, emergency endoscopic removal is indicated. Batteries located beyond the oesophagus rarely require endoscopic removal, unless subsequent radiographs indicate delay in transit of the battery.
80) A 3-week-old baby boy born at full term presents with persistent jaundice. Clinical examination demonstrates hepatomegaly, and blood tests confirm hyperbilirubinaemia. He undergoes phenobarbital- augmented 99mTc-labelled IDA (iminodiacetic acid) cholescintigraphy, which demonstrates good hepatic activity within 5 minutes but no biliary clearance into the bowel on delayed images at 24 hours. What is the most likely diagnosis?
a. biliary atresia
b. neonatal hepatitis
c. cystic fibrosis
d. choledochal cyst
e. physiological jaundice
a. biliary atresia
Congenital biliary atresia is a destructive inflammatory process resulting in atresia of the bile ducts, which presents in neonates with persistent jaundice. Diagnosis is usually made with a combination of liver biopsy and hepatobiliary scintigraphy with a 99mTc-labelled iminodiacetic acid (IDA) analogue. Phenobarbital is given for 5 days prior to imaging to stimulate biliary secretion. Normal findings are of activity within the small bowel due to biliary excretion by 60 minutes, but in biliary atresia no biliary clearance is seen by 24 hours. Patients with non-obstructive causes of neonatal jaundice usually demonstrate biliary clearance into the bowel during the first 24 hours. Choledochal cyst usually presents in children, and cholescintigraphy may be used to confirm that the cystic structure is connected to the biliary system. The 99mTc-labelled IDA analogue will fill the cyst, and may show prolonged retention depending on the degree of obstruction. Cystic fibrosis may be associated with steatosis and biliary cirrhosis. Physiological jaundice resolves spontaneously within 2 weeks
86) A 2-year-old boy presents with jaundice, abdominal pain and precocious puberty. Ultrasound scan of the abdomen reveals a heterogeneous, hyperechoic, 10 cm mass with areas of coarse calcification in the right lobe of the liver. What is the most likely diagnosis?
a. hepatocellular carcinoma
b. hepatoblastoma
c. haemangioma
d. pyogenic abscess
e. choledochal cyst
b. hepatoblastoma
Hepatoblastoma is the commonest malignant liver tumour of early childhood, typically presenting before 3 years with pain, palpable mass, jaundice and weight loss, as well as precocious puberty due to hormone production. Tumours are typically large (average 10–12 cm) and appear to be heterogeneous with areas of calcification and necrosis. Metastases to the lung are common. Hepatocellular carcinoma is the second most common malignant liver tumour of children, but usually affects children over 5 years of age. Although it also commonly appears of heterogeneous echogenicity, calcifications are rare. Haemangiomas commonly appear hyperechoic on ultrasound scan and may contain calcifications, but are usually ,4 cm and are rarely seen in young children. Pyogenic abscess and choledochal cyst are typically hypoechoic lesions.
93) A 3-week-old girl presents with congestive cardiac failure and is found to have hepatomegaly on examination. Ultrasound scan of the abdomen shows an ill-defined, complex, heterogeneous, 5 cm mass in the right lobe of the liver containing multiple vascular channels on Doppler ultrasound scan. What is the most likely
diagnosis?
a. infantile haemangioendothelioma
b. hepatoblastoma
c. cavernous haemangioma
d. mesenchymal hamartoma
e. hepatocellular carcinoma
a. infantile haemangioendothelioma
Infantile haemangioendothelioma is the commonest benign hepatic tumour occurring in the first 6 months of life, consisting of multiple sinusoidal vascular channels with surrounding connective tissue stroma.
Patients typically present with an abdominal mass, or high-output cardiac failure secondary to arteriovenous shunting. Kasabach–Merritt syndrome (consumptive coagulopathy) is seen in 11% of patients. Typical CT features are of early peripheral enhancement and variable delayed central enhancement. Hepatoblastomas tend to occur in slightly older infants (peak 18–24 months) and congestive cardiac failure is not usually a feature. Mesenchymal hamartoma is a rare developmental liver tumour, which appears typically as a multiloculated cystic mass, but may appear solid and echogenic in infants due to innumerable microcysts.
However, these are generally hypovascular lesions. Hepatocellular carcinoma is more commonly seen in older children and adolescents. Cavernous haemangiomas are rarely seen in young children.
95) An 11-year-old boy presents with fever, vomiting and right lower quadrant pain. Ultrasound scan of the right lower quadrant demonstrates a blind-ending, compressible, fluid-filled, tubular structure measuring 4 mm in diameter, as well as enlarged mesenteric lymph nodes and several thickened loops of small bowel.
What is the most likely diagnosis?
a. acute appendicitis
b. mesenteric lymphadenitis
c. Crohn’s disease
d. Meckel’s diverticulum
e. enteric duplication cyst
b. mesenteric lymphadenitis
Mesenteric lymphadenitis is an inflammatory process affecting the mesenteric lymph nodes; it is most frequently caused by viral infection but also by Yersinia enterocolitica and other pathogens. It affects children and young adults, and clinically mimics acute appendicitis. Imaging findings are of enlarged mesenteric lymph nodes, and ileal and colonic wall thickening. The normal appendix must be visualized to differentiate it from acute appendicitis. Features of acute appendicitis on ultrasound scan are of a blind-ending, non-compressible, tubular, aperistaltic, fluidfilled structure measuring over 6 mm in diameter. Mesenteric lymph nodes may also be seen anterior to the right psoas muscle, but tend to be smaller and fewer than in mesenteric lymphadenitis. Thickened bowel wall may be seen on ultrasound scan in Crohn’s disease, but this would be less likely in this age group. Symptomatic Meckel’s diverticulum usually presents in younger children with gastrointestinal bleeding. Small bowel duplication cyst usually presents
100) A preterm male infant develops abdominal distension and blood-stained stools 2 days after birth. Plain abdominal radiograph shows distended and thickened bowel loops with curvilinear gas collections within the bowel wall. What is the most likely diagnosis?
a. necrotizing enterocolitis
b. Hirschsprung’s disease
c. meconium ileus
d. imperforate anus
e. viral gastroenteritis
a. necrotizing enterocolitis
Necrotizing enterocolitis is an acute inflammatory bowel condition seen predominantly in preterm infants. It usually presents 2–3 days after birth, with abdominal distension, vomiting and blood-stained stools. Plain film signs include distended small and large bowel, and bowel wall thickening, but the hallmark of the condition is pneumatosis intestinalis, seen in 80% of cases. This may be curvilinear (subserosal) or bubbly (submucosal) and may also be associated with portal venous gas. Hirschsprung’s disease is characterized by an aganglionic segment of distal colon, resulting in abnormal peristalsis and impaired evacuation of the colon. In this age group, it presents with failure to pass meconium, but is extremely rare in preterm infants. Meconium ileus and imperforate anus also present with failure to pass meconium. Pneumatosis intestinalis may be seen in association with mechanical obstruction resulting from these three conditions, but it is rare. It is not a feature of viral gastroenteritis.
(GIT) Which of the following may improve the detection of Meckel’s diverticulum on a [99mTc] pertechnetate study?
A. prior administration of cimetidine
B. prior administration of laxatives
C. prior administration of potassium perchlorate
D. maintenance of a full bladder
E. barium follow-through prior to study
A. prior administration of cimetidine
Cimetidine, a histamine H2-receptor antagonist, may be used to increase uptake of[99 mTc] pertechnetate by inhibiting its secretion from gastric mucosa. Pentagastrinand glucagon have also been used to improve visualization, by stimulating uptake anddecreasing peristalsis respectively. Procedures such as colonoscopy and use of laxativesshould be avoided prior to the scan, as they may cause mucosal irritation. Potassiumperchlorate should not be used to block thyroid uptake, as it also blocks uptake ofpertechnetate by the gastric mucosa. The patient normally fasts for 3–4 hours and voidsprior to the study, as a full stomach or bladder may obscure an adjacent Meckel’sdiverticulum. Barium studies should be avoided for 3–4 days prior to the study, asattenuation by the barium may hamper interpretation.
1 A 3 year old presents with entral epigastric pain. Blood tests reveal a raised amylase. Which of the following is the least likely cause?
(a) Choledochal cyst
(b) Cystic fibrosis
(c) Henoch-Schonlein purpura
(d) Non-accidental injury
(e) Rubella
(c) Henoch-Schonlein purpura
Trauma (including NAI) is one of the leading causes of pancreatitis in the paediatric population. Other causes include cystic fibrosis, hyperlipidaemia syndromes, drugs, viral, hyperparathyroidism, hypercalcaemia, idiopathic, Pearson syndrome (mitochondrial disorder), Schwachman-Diamond syndrome, and anatomical anomaly (pancreas divisum).
13 A 2 year old boy presents with haematochezia. He is in obvious distress on examination, but the bowel sounds are normal. AXR is unremarkable, and the paediatric team suspect a Meckel’s diverticulum. Your advice is sought regarding further investigation. Which of the following would be the most sensitive radiological investigation?
(a) Barium follow-through
(b) CT
(c) MRI
(d) 99mTc-pertechnatate scintigraphy
(e) Ultrasound
(d) 99mTc-pertechnatate scintigraphy
Pertechnatate studies are the most sensitive test (85%), although wireless capsule endoscopy has good potential. Pertechnatate is taken up by the ectopic gastric mucosa within the Meckel’s. False +ve results include AVM, haemangioma, UC, Crohn’s, appendicitis; false -ve results occur if the diverticulum contains no gastric mucosa.
17 An 8 month old boy presents with red-currant jelly stool and abdominal distension. US confirms an intussusception and the paediatric surgeons ask you to attempt fluo’roscopic reduction. Which of the following is a contraindication to fluoroscopic reduction?
(a) Age> 12 months
(b) Evidence of small bowel obstruction
(c) Free intra-peritoneal fluid
(d) Hypovolaemic shock
(e) US demonstrates fluid in the lumen around the Intussusceptum
(d) Hypovolaemic shock
Hypovolaemic shock suggests ischaemic bowel, which would require surgical intervention, furthermore reduction should not be attempted in a sick infant and the patient should be appropriately resuscitated before any attempts at reduction are made. Other contraindications include pneumoperitoneum and peritonitis. The remaining options are not absolute contra-indications, but their presence reduces the chances of successful therapeutic reduction. Small bowel obstruction implies ischaemia or the presence of a tight intussusception. Free intraperitoneal fluid or fluid in the lumen surrounding the intussusceptum suggests oedema or ischaemia of the bowel. An older age (> 12 months) suggests a pathological lead point may be the aetiology, in which case resection may be necessary.
18 A supine AXR is performed on a 4 day old neonate born at 32 weeks, who is noted to have increasing abdominal distension and appears clinically unwell. Which of the following features is an indication for urgent surgery?
(a) Air in the portal vein
(b) Adynamic ileus
(c) Pneumatosis intestalis
(d) Pneumobilia
(e) Pneumoperitoneum
(e) Pneumoperitoneum
NEC is the commonest GI emergency in premature infants. It is an infective/ ischaemic disorder of the neonatal gut in a compromised baby secondary to hypoxia. It typically presents at 2-3 days after birth and in 90% occurs before day 10. Treatment is normally conservative, surgery may be necessary due to perforation. Compared to adult patients, air in the portal system does not have such a grave prognosis. Late complications include intestinal strictures.
21 Antenatal US shows a RUQ cystic structure. A day 3 US shows an anechoic cyst with hyperechoic inner lining and a hypoechoic outer rim, causing superior-anterior displa_cement of the 1st and 2nd portion of the duodenum without bile duct dilation. What is the most likely diagnosis?
(a) Choledochal cyst
(b) Choledochocoele
(c) Duplication cyst
(d) Mesenteric lymphangioma
(e) Pancreatic pseudocyst
(c) Duplication cyst
These cysts appear anechoic, displace the proximal duodenum supero-anteriorly. There is a double capsule: inner mucosa! Lining (hyperechoic) and outer rim of bowel wall (hypoechoic), this ·can be identified as the ‘muscular rim’ sign described. Choledochal cysts have 5 subtypes (type V = Caroli’s disease). All bar type Ill involve the intrahepatic bile ducts. Choledochocoeles arise from the duodenal portion of CBD, but other features support a duplication cyst. In mesenteric lymphangioma there is a single wall.
24 A 3 week old boy presents with high output cardiac failure. On examination he has a mass within the right upper quadrant. CT shows a large heterogeneous mass with central areas of low density, occupying the entire left lobe of the liver. The mass enhances peripherally in the arterial phase. What is the most likely diagnosis?
(a) Haemangioendothelioma
(b) Haemangiopericytoma
(c) Hamartoma
(d) Hepatoblastoma
(e) Hepatocellular carcinoma
(a) Haemangioendothelioma
Infantile haemangioendothelioma typically presents in neonates (85% are diagnosed at <j 6 months). 15% present with high output cardiac failure (AV shunts), consumption can lead to thrombocytopaenia/ DIC. Imaging characteristics are similar to adult haemangiomas. Haemangiopericytoma is a soft tissue sarcoma. Broadly speaking paediatric liver tumours present in ‘alphabetical order’ with age: haemangioendothelioma (neonates), hamartoma (15-22 months), hepatoblastoma (<3 years), and HCC (>3 years).
35 A 3 year old presents with abdominal pain and vomiting. The paediatric surgeons are concerned about possible malrotation and request a plain film in the first instance. What is the most common plain radiograph finding in malrotation?
(a) Bowel wall oedema
(b) Caecum located on left side
(c) Normal
(d) Small bowel obstruction
(e) SMA lying to right of the SMV
(c) Normal
The commonest plain film finding in malrotation is ‘normal appearances’, thus a ‘normal’ AXR cannot exclude malrotation. Other plain film findings of malrotation include ascites, bowel wall oedema (thumb-printing, due to SMV compression), evidence of ischaemic gut (due to SMA compression), duodenal obstruction (due to Ladd’s bands), SBO, right-sided small bowel, left-sided caecum/ colon.
37 A neonate has bile stained vomiting post feeding. The AXR shows a ‘double bubble’ sign? Which of the following conditions is the least likely underlying cause?
(a) Annular pancreas
(b) Duodenal atresia
(c) Ladd’s bands
(d) Pre-duodenal vein
(e) Pyloric stenosis
(e) Pyloric stenosis
The ‘double bubble’ sign describes gas within the proximal duodenum and stomach. There is often a gasless distal abdomen due to obstruction in the duodenum. Pyloric stenosis causes obstruction at the level of the pylorus. In this condition, the duodenum is usually gas-free if gas passes into the duodenum it will also freely pass more distally.
42 A pregnant mother with low α-FP, increased β-hCG and decreased unconjugated oestriol on screening is considered high risk for carrying a baby with Down’s syndrome. An 18 week anomaly US is arranged. Which of the following findings indicative of Down’s syndrome is least likely to be seen?
(a) Cystic hygroma
(b) Duodenal atresia
(c) Omphalocoele
(d) Increased nuchal thickness
(e) Short femur length
(b) Duodenal atresia
13-50% may not have any US-detectable anomalies. Duodenal atresia is present in 50%, but is not detected before 22 weeks. Nuchal thickness is increased in 40% to < 3 mm at 10-13 wks, 5 mm at 14- 18 wks; CHDs are present in 40%. Other US findings include hydrops, echogenic bowel, pyelectasis, hypoplasia of the 5th digit, and 11 pairs of ribs.
43 Regarding duplication cysts of the gastro-intestinal tract in neonates. Where is the commonest location?
(a) Duodenum
(b) Ileum
(c) Jejunum
(d) Oesophagus
(e) Stomach
(b) Ileum
15% of paediatric abdominal masses are duplication cysts, they can be found anywhere along the GI tract, commonest locations are: ileum (30-33%), oesophagus (17-20%), colon (13-20%), jejunum (10-13%), stomach (7%), pylorus (4%), duodenum (4-5%), ileocaecal junction (4%), rectum (4%).
(GIT) Regarding pancreas divisum, which of the following statements is true?
(a) The dorsal pancreas drains via the major papilla
(b) Pancreatic drainage is via the duct of Santorini
(c) The dorsal and ventral pancreas drain via the same channel
(d) The common bile duct and dorsal pancreas drain via the same channel
(e) The major papilla lies proximal to the minor papilla
(b) Pancreatic drainage is via the duct of Santorini
Dorsal and ventral pancreas drain separately in to the duodenum via the minor and major papillae respectively.
3 A neonate presents with vomiting, choking and drooling of secretions. An 8 Fr NG feeding tube cannot be passed into the stomach. What is the most likely diagnosis?
(a) Oesophageal agenesis with no distal oesophageal bud and no tracheal fistula
(b) Oesophageal atresia with a distal oesophageal bud, but no tracheal fistula
(c) Oesophageal atresia with a proximal tracheal fistula
(d) Oesophageal atresia with a distal tracheal fistula
(e) Oesophageal atresia with both proximal and distal tracheal fistula
(d) Oesophageal atresia with a distal tracheal fistula
The most common type of oesophageal atresia is that associated with a distal tracheal fistula (type C in the Gross classification, and referred to as ‘N’ shape), which accounts for 75-80% of cases. Pure atresia occurs in 10%, TOF in 10% (type E, and referred to as ‘H’ shape); other forms are rare. Oesophageal atresia with no distal oesophageal bud is very rare and is not classified within the Gross system.
7 Regarding fluoroscopically guided reduction for the treatment of intussusception in children. Which of the following is an advantage of hydrostatic barium over air reduction?
(a) It produces smaller tears if perforation occurs
(b) It is easier to confirm reduction across the ilea-caecal valve
(c) It is faster, thus less radiation dose
(d) It results in less contamination of the abdominal cavity if perforation occurs
(e) It delivers higher intracolic pressures
(b) It is easier to confirm reduction across the ilea-caecal valve
Fluoroscopy has the ‘rule of 3s’: 3 feet above the table (pressure 120 mmHg), a maximum of 3 attempts with 3 mins/ attempt and 3 mins between attempts. Air reduction is now used in most centres and answers (a), (c), (d) and (e) list its advantages. The only disadvantage of air reduction is confirmation of reduction across the ileo-caecal valve, especially when gas is present in the ileum. Although there is also a small risk of tension pneumoperitoneum with air reduction, any potential peritoneal ‘spill’ following perforation will be less than with barium reduction.
10 A screening antenatal US shows an abdominal wall .defect. The differential diagnosis is between gastroschisis and omphalocoele. Which additional feature confirms the diagnosis of gastrosch is?
(a) Associated herniation of the liver
(b) Central herniation into the umbilical cord
(c) Involvement of all 3 layers of the abdominal wall
(d) Multiple associated anomalies
(e) The presence of a covering membrane
(c) Involvement of all 3 layers of the abdominal wall
Gastroschisis is a defect involving all 3 layers of the abdominal wall, and is located to the right side of the cord in 90% of cases. There is normal insertion of the umbilical cord, and a lower incidence of associated anomalies. Omphalocoele is herniation of intra-abdominal contents into the base of the umbilical cord, any organs may herniate, but liver herniation is typical +/- bowel. Omphalocoeles have a covering membrane.
14 A 4 week old boy presents with a history of non-bilious vomiting and failure-to-thrive, but clinical examination is normal. Which of the following US features confirm the diagnosis of pyloric stenosis?
(a) Hyperechoic pyloric muscle
(b) Pyloric canal length of 13 mm
(c) Pyloric muscle wall thickness of 4 mm
(d) Reduced peristaltic waves within the antrum
(e) Transverse pyloric canal diameter of 10 mm
(c) Pyloric muscle wall thickness of 4 mm
Pyloric stenosis can be diagnosed clinically. US diagnostic criteria include: pyloric volume > 1.4 cm3, pyloric muscle wall thickness > 3 mm, pyloric canal length > 17 mm, pyloric transverse diameter > 13 mm when the pyloric channel is closed. In pyloric stenosis, a hypoechoic ring of hypertrophied muscle around the inner echogenic mucosa produces the ‘target sign’. Peristaltic waves are increased and hyperdynamic in an attempt to overcome the obstruction.
28 A 2 day old ex-premature boy on the neonatal unit with suspected necrotising enterocolitis has deteriorated, and the clinical team are worried about perforation. Which investigation should you recommend?
(a) Cross-table lateral AXR
(b) Erect CXR
(c) Left-side down decubitus AXR
(d) Right-side down decubitus AXR
(e) Supine AXR
(c) Left-side down decubitus AXR
Left-side down decubitus is the optimal view, it allows air to rise to the right lateral abdomen, which can then be seen between the liver edge and the abdominal wall; with right-side down films it is harder to detect free air due to presence of stomach/ splenic flexure. An erect CXR is likely to be impractical in a ventilated neonate. Signs on supine AXRs are often subtle (football sign, Rigler’s sign, or air around the falciform ligament). In a cross-table lateral it will be hard to differentiate free air and distended bowel (both rise centrally).
29 A neonate is noted to be jaundiced. Investigations are subsequently requested by the clinicians. Which of the following results is most supportive of the diagnosis of neonatal hepatitis over biliary atresia?
(a) Blood tests reveal a conjugated bilirubinaemia
(b) HIDA scintigraphy shows rapid hepatic tracer accumulation
(c) HIDA scintigraphy shows visualisation of tracer in bowel at 12 hours
(d) US shows no intra-hepatic duct dilatation
(e) US cannot visualise the gallbladder
(c) HIDA scintigraphy shows visualisation of tracer in bowel at 12 hours
Both conditions have conjugated hyperbilirubinaemia. The findings of a normal (> 1.5 cm) or enlarged gallbladder supports neonatal hepatitis, however, either finding can be present in BA as the GB can appear normal if the atresia is distal (in 20%). There is no intrahepatic duct dilatation in BA due to panductal sclerosis. In HIDA scintigraphy BA has good hepatic visualisation within 5 mins, but no excretion into the bowel, and no tracer uptake seen by 24 hours; in neonatal hepatitis there is slow and reduced uptake of the tracer by the liver, but bowel activity is seen by 24 hours.
30 Regarding enteric duplication cysts, which of the following is true?
(a) They are most commonly located in duodenum
(b) The majority communicates with the lumen
(c) There is usually calcification within the wall
(d) The majority are located on the anti-mesenteric side
(e) The capsule contains two walls
(e) The capsule contains two walls
Duplication cysts can be located anywhere along the GI tract, the most common location is the terminal ileum, followed by oesophagus, duodenum, colon, jejunum and stomach. They represent 15% of paediatric abdominal masses, and may be detected on antenatal US. Small bowel cysts are usually located on the mesenteric side of the bowel, oesophageal ones are typically intra-luminal. The cysts have a double capsule made of the bowel wall and mucosa, they are typically non-communicating and calcification is rare.
34 A 2 day old baby born to a diabetic mother presents with abdominal distension, never having opened the bowels. Water-soluble enema demonstrates a collapsed descending colon to the splenic flexure, with dilated proximal colon and small bowel. Following the study, copious amount of meconium are immediately passed. What is the most likely diagnosis?
(a) Hirschsprung’s disease
(b) Ileal atresia
(c) lmperforate anus (high malformation type)
(d) Meconium ileus
(e) Meconium plug syndrome
(e) Meconium plug syndrome
Meconium plug syndrome results from colonic inertia with subsequent inspissation of meconium. It typically presents in large babies, born to diabetic mothers, is not related to meconium ileus. Hirschsprung’s disease is the key differential diagnosis and can have similar radiological appearances. However, meconium is rarely passed following contrast examination and the given history of a diabetic mother is a leader to meconium plug syndrome.
35 What is the commonest presenting feature of a Meckel’s diverticulum?
(a) Obstruction
(b) Perforation
(c) Diverticulitis
(d) Volvulus
(e) Bleeding
(e) Bleeding
This is seen in over a quarter of cases. The remaining presentations are well-documented, but occur less commonly.
(GU) 47 Antenatal ultrasound at 22 weeks shows thick walled oedematous freely floating bowel loops outside the foetal abdomen. A 2 cm defect in the anterior abdominal wall is seen to the right of a normally inserted umbilical cord. Polyhydramnios but no foetal ascites is noted. No other congenital abnormality can be detected at this stage. What is the likely diagnosis?
(a) Gastroschisis
(b) Omphalocoele
(c) Limb-body wall complex
(d) Amniotic band syndrome
(e) Ectopia cordis
(a) Gastroschisis
This can be differentiated from omphalocoele by its location (right paraumbilical as opposed to midline), lack of covering membrane and relatively small defect size. It is also less commonly associated with other congenital defects. It is difficult to reliably diagnose this condition until at least 20 weeks gestation
50 A 2 week old baby presents with bilious vomiting. The surgical team request an upper GI Barium study looking for malrotation. Which of the following is the expected normal position of the duodenojejunal junction on the frontal view, making malrotation unlikely?
(a) Above the level of duodenal bulb, to the left of spine
(b) Above the level of duodenal bulb, to the right of spine
(c) At the level of duodenal bulb, to the right of spine
(d) Below the level of duodenal bulb, to the left of spine
(e) Below level of duodenal bulb, to right of spine
(a) Above the level of duodenal bulb, to the left of spine
Malrotation is the abnormal position of the bowel due to a narrow mesenteric attachment following arrest of rotation and fixation in utero. The normal DJJ is at the ligament of Treitz, to the left of the vertebral (usually L 1) pedicle at a level above or equal with the duodenal bulb on a true AP film. In malrotation, the mesentery is short, thus the DJJ does not reach the ligament of Treitz.
52 A 1 day old neonate has bile-stained vomiting. An AXR shows a dilated gas-filled stomach with air also within the duodenal bulb. No bowel gas seen distally. Which of the following is the more likely cause of these appearances?
(a) Annular pancreas
(b) Duodenal stenosis
(c) Meconium ileus
(d) Mid-gut volvulus
(e) Pyloric stenosis
(a) Annular pancreas
The ‘double bubble’ sign is described and implies obstruction at the level of the duodenum. Duodenal atresia (not stenosis) is thecommonest cause (30%) and is associated with Down’s. Annular pancreas is second commonest cause, others include: duodenal web/ diaphragm, pre-duodenal vein, midgut volvulus, and SMA syndrome..
65 A neonate presents at 48 hours with abdominal distension, bilious vomiting, and failure to pass meconium. The AXR shows multiple dilated loops of bowel, with a ‘soap bubble’ appearance in the RIF. Water soluble enema confirms microcolon and meconium is subsequently passed. What is the most likely underlying condition?
(a) Cystic fibrosis
(b) Duodenal atresia
(c) Hirschsprung’s disease
(d) Maternal diabetes
(e) Pancreatic duct atresia
(a) Cystic fibrosis
Meconium ileus is the initial presentation in 10-15% of CF neonates, but over 90% of infants presenting with meconium ileus have CF (atresia of the pancreas or pancreatic duct are other causes). The ‘soap bubble’ appearance may be seen in the RIF and represents gas mixed with meconium. A water soluble contrast enema aids diagnosis (shows an unused ‘micro’ colon) and treatment (if unsuccessful, surgery is required).
67 A 2 year old boy presents with rectal bleeding. He is not obviously in discomfort, there are no signs of obstruction and the AXR is normal. A Meckel’s diverticulum is suspected and a nuclear medicine study is arranged. Which of these pharmaceuticals should be avoided prior to image acquisition?
(a) Cimetidine
(b) Glucagon
(c) Pentagastrin
(d) Perchlorate
(e) Pertechnetate
(d) Perchlorate
Tc-99m pertechnetate is the radiotracer used; cimetidine, pentagastrin and glucagon have been shown to improve the sensitivity of the test. Pentagastrin enhances tracer uptake in gastric mucosa, cimetidine ‘traps’ pertechnetate within the Meckel’s, and glucagon reduces peristalsis, thus inhibits tracer washout. Potassium perchlorate given orally after the study protects the thyroid gland from accumulation of pertechnetate, however, if used prior to scanning it will block tracer uptake by gastric mucosa.
71 Regarding fluoroscopically-guided air reduction for the treatment of intussusception in a chiid. Which of the following is most likely to predict a successful outcome?
(a) 24 hour history of symptoms
(b) lntussusception seen in the sigmoid colon on US
(c) US demonstrates fluid in the lumen around the intussusceptum
(d) US shows blood flow in the intussusceptum
(e) The child is aged > 12 months
(d) US shows blood flow in the intussusceptum
Vascular flow is a good sign - ischaemia is unlikely. A left-sided lesion is more difficult to treat, but the majority are ileocolic (75-95%) or ileo-ileocolic (9%); colocolic lesions are very rare. A short history (< 24 hours) suggfusts there will be less oedema and the intussusception is less likely to have passed through to the left colon. An older age (> 12 months) suggests a pathological lead point may be the aetiology. lntussusception is idiopathic in 95% of paediatric cases.
75 A 4 day old boy has abdominal distension and has not opened his bowels. A contrast enema shows a narrow rectum and dilated descending colon. AXR after 24 hours shows contrast medium within the descending colon. What is the most likely diagnosis?
(a) Hirschsprung’s disease
(b) I leal atresia
(c) lmperforate anus (high malformation type)
(d) Meconium ileus
(e) Meconium plug syndrome
(a) Hirschsprung’s disease
Hirschsprung’s disease presents in neonates with abdominal distension and failure to pass meconium. Proximal obstruction +/- perforation can be seen on AXR. The rectum is always involved, but the proximal extent of disease varies. The normal colon will be dilated. If the transition point lies near the recto-sigmoid junction, the rectum: sigmoid diameter ratio will be less than 1 (normal is > 1 :1 ). Retention of contrast medium on a delayed 24 hours film is a classical feature, but definitive diagnosis-is-by-biopsy.
(GIT) A one-month-old baby girl with a persistent productive cough developed progressively worsening respiratory distress. She had a chest radiograph which showed clear lungs. Linear gas shadows were visible projected over the central liver. What is the most likely diagnosis?
a) Respiratory distress syndrome
b) Bronchopneumonia
c) Tracheoesophageal fistula
d) Congenital tracheobiliary fistula
e) Pulmonary emboli
Answer D: Congenital tracheobiliary fistula
The finding of pneumobilia is key to thinking of the diagnosis.
(GIT) 3. A neonate is diagnosed with congenital tracheoesophageal (TE) fistula. A plain film demonstrates a gasless abdomen.Which type of TE fistula is associated with this finding?
a. Type B
b. Type C
c. Type D
d. Type E
e. None of the above
- a. Type B
Congenital TE fistula and oesophageal atresia occur in approximately 1 in 4000 live births. They are divided into five subtypes, A to E. Type C is the most common, comprising 75% of all types and involves oesophageal atresia with a distal TE fistula. Type D involves oesophageal atresia with both proximal and distal TE fistula, and type E is a TE fistula without oesophageal atresia. Therefore types C to E do not typically present with gasless abdomen. Type B is oesophageal atresia with a proximal TE fistula; there is no communication between the trachea and the distal oesophagus, and therefore a gasless abdomen is typical. Type A is oesophageal atresia without TE fistula and therefore may also present with a gasless abdomen, but is not a listed option.
- A neonate is found to have hypotonic abdominal wall musculature, and further investigations reveal bowel malrotation and cryptorchidism. Which of the following conditions is most likely?
a. Prune belly syndrome
b. Zellweger syndrome
c. Wolman disease
d. Meckel–Gruber syndrome
e. Wunderlich syndrome
- a. Prune belly syndrome
Prune belly syndrome is a non-hereditary disorder occurring in males with a triad of abdominal wall muscular hypoplasia, bilateral cryptorchidism and distended nonobstructed ureters. Other associations include malrotation of the gastro-intestinal tract, intestinal atresia, cystic renal dysplasia, vesico–ureteric reflux, pulmonary hypoplasia and cardiac anomalies (including PDA, tetralogy of Fallot and VSD).
- A premature neonate presents with bilious vomiting in the first few days of life. A plain abdominal X-ray shows prominent gas-fluid levels in the duodenal bulb and in the gastric fundus. There is absence of gas in the remainder of the small and large bowel. Which one of the following diagnoses is most likely?
a. Choledochal cyst
b. Annular pancreas
c. Duodenal atresia
d. Duodenal duplication cyst
e. Ladd bands
- c. Duodenal atresia
Duodenal atresia typically presents in the first few days of life with bilious vomiting, and is caused by failure of recanalisation of the duodenal lumen in the fetus. It is associated with Down’s syndrome, congenital heart disease and other gastro-intestinal disorders such as malrotation, annular pancreas and biliary atresia. The characteristic feature on abdominal X-ray is the double-bubble sign with dilatation of the stomach and duodenal cap.
- A young boy presents with abdominal pain and vomiting. Ultrasound of the abdomen confirms ileocolic intussusception. Which one of the following features is associated with a good chance of successful hydrostatic reduction?
a. Symptom history of greater than 48 hours
b. Small bowel obstruction
c. Presence of blood flow within the intussusceptum
d. Passage of blood per rectum
e. Age less than three months
- c. Presence of blood flow within the intussusceptum
The following criteria are associated with a lower rate of successful enema reduction: age less than three months or greater than five years, long duration of symptoms, passage of blood per rectum, significant dehydration, obstruction of the small intestine and visualization of the dissection sign during enema therapy.
(GIT) 36. A six week old child has an ultrasound scan of the abdomen performed for non-bilious projectile vomiting. Which one of the following features would support a diagnosis of infantile pylorospasm over a diagnosis of hypertrophic pyloric stenosis?
a. Pyloric muscle wall thickness of 2mm
b. Pyloric canal length of 19mm
c. Target sign
d. Antral nipple sign
e. Transverse pyloric diameter of 14mm
- a. Pyloric muscle wall thickness of 2mm
Hypertrophic pyloric stenosis presents between four and six weeks of life with non-bilious vomiting, typically in first-born males. A palpable olive-shaped mass is a sign with reported sensitivity of up to 80%, but ultrasound is the most frequently used imaging modality. Typical ultrasound features include the target sign (central hyperechoic mucosa with surrounding hypoechoic pyloric muscle), the nipple sign (pyloric mucosa indenting the gastric antrum), pyloric canal length >16 mm, transverse pyloric diameter >13mm and pyloric muscle wall thickness >3 mm. Pyloric stenosis can be difficult to differentiate radiologically from infantile pylorospasm. Typically with pylorospasm the appearances change with time, and so if the pyloric muscle thickness is measured at less than 3mm this makes infantile pylorospasm the more likely diagnosis.
- An abdominal CT in a neonate with major congenital abnormalities demonstrates a large central liver and absence of spleen. Which of the following features is likely on chest CT?
a. Absence of the minor fissure on the right
b. Hyparterial bronchus on the right
c. Presence of three lobes on the left
d. Tubular appendages bilaterally
e. Absence of SVC
- c. Presence of three lobes on the left
The neonate has heterotaxy with right atrial isomerism, which is associated with bilateral trilobed lungs, and both atrial appendages are short and broad-based. It is also usually associated with bilateral SVC and bilateral eparterial bronchus.
- A three year old boy is referred for a Tc-99m pertechnetate scan following recurrent painless gastro-intestinal bleeds. A Meckel’s diverticulum is suspected. Which one of the following may give a false negative result?
a. Recent barium investigation
b. Intussusception
c. Urinary tract obstruction
d. Acute appendicitis
e. Anterior myelomeningocoele
- a. Recent barium investigation
Prior to adolescence a Tc-99m pertechnetate scan has a high pick-up rate for a Meckel’s diverticulum. This declines with increasing age as the test relies on the presence of ectopic gastric mucosa, which is less likely to be present in someone asymptomatic throughout childhood. A false negative result is most commonly due to insufficient mass of ectopic gastric mucosa within the Meckel’s diverticulum, but may also be seen with barium from recent investigation attenuating the gamma radiation, and dilution of intraluminal activity due to rapid bowel transit.
- At a routine 20-week obstetric ultrasound scan, polyhydramnios with multiple foci of scattered calcifications are found throughout the fetal abdomen in between bowel loops. Which one of the following is most likely to be the underlying cause?
a. Mesenteric ischaemia
b. Meconium peritonitis
c. Meconium plug syndrome
d. Necrotising enterocolitis
e. Gastroschisis
- b. Meconium peritonitis
These features are typical of meconium peritonitis. This is a chemical peritonitis secondary to bowel perforation in utero. The intraperitoneal meconium characteristically calcifies within 24 hours of perforation. Other features seen on ultrasound include fetal ascites,polyhydramnios and bowel dilatation.
- A neonate presents with abdominal distension, vomiting and failure to pass meconium. A water-soluble contrast enema is performed and shows a narrow rectum with a cone-shaped transition zone to a dilated, more proximal bowel. Which one of the following is the most likely diagnosis?
a. Colonic atresia
b. Hirschsprung’s disease
c. Meconium ileus
d. Cystic fibrosis
e. Functional immaturity of the colon
- b. Hirschsprung’s disease
These features are typical of Hirschsprung’s disease. This is caused by absence of parasympathetic ganglion cells in the bowel wall. Meconium ileus typically shows an empty microcolon on water-soluble enema and colonic atresia shows a distal microcolon with obstruction at the point of atresia. Functional immaturity of the colon typically shows microcolon distal to the splenic flexure with an abrupt transition to mildly dilated proximal colon
9 An infant is born with an abdominal wall defect and exteriorised bowel loops. Which additional finding would suggest a diagnosis of gastroschisis rather than omphalocoele?
a Herniated liver
b Ascites
C Bowel loops covered by peritoneum
d Right paraumbilical abdominal wall defect
e Bladder exstrophy
9 Answer D: Right paraumbilical abdominal wall defect
26 A neonate presents with progressive respiratory distress. Which of the following plain film findings is suggestive of a tracheo-oesophageal fistula without oesophageal atresia?
a Abdomen distended by bowel gas
b Gasless abdomen
C Nasogastric tube coiled within the pharynx
d Air distended proximal oesophagus
e Displaced trachea
a Abdomen distended by bowel gas
