Congenital anomalies of the gastrointestinal tract: A radiological review

Transcription

1 Congenital anomalies of the gastrointestinal tract: A radiological review Poster No.: C-1669 Congress: ECR 2010 Type: Educational Exhibit Topic: GI Tract Authors: S. P. Ramachandra, M. Bydder, N. Gurjar, M. Palaniappan, D Bakalinova ; Stoke on Trent/UK, Burton on Trent/UK Keywords: Gastrointestinal, Congenital, malformation DOI: /ecr2010/C-1669 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 95

2 Learning objectives 1. To demonstrate developmental pathologies of the gastrointestinal tract (GIT) in children. 2. To emphasise the various imaging modalities available for the evaluation of the alimentary tract. Background A wide spectrum of congenital anomalies affects the GIT and is a cause of significant morbidity in children. They can be categorised into anomalies of rotation, fixation or canalization or into upper and lower GIT as in this exhibit. Multi-modality imaging including plain films, contrast fluoroscope, ultrasound, CT, MRI and isotope studies are utilised in their diagnosis. Conventional radiography are widely performed and are most useful in the evaluation of upper GI Tract anomalies. They are often diagnostic in high GIT obstruction and can provide useful clues to determine subsequent appropriate diagnostic procedure. Upper GIT contrast fluoroscope must be performed in all cases with incomplete obstruction or when the surgery is to be delayed. Whereas, neonates with low intestinal obstruction undergo contrast enema examination which may be diagnostic and in some cases therapeutic. Ultrasound (US) imaging is the modality of choice and should be used for abdominal imaging prior to CT or MRI. CT, MRI and Isotope imaging have specific roles and are unsuitable for general screening. Imaging findings OR Procedure details Th Fully functional alimentary tract develops from primordial gut that develops at about 4 week of gestation through a complex but orderly series of events during the period of gestation. Failure of successful completion of any of these steps results in a predictable, often visible abnormalities on subsequent imaging. Page 2 of 95

3 Congenital anomalies of the Upper Gastrointestinal Tract 1.Oesophagus: Oesophageal Atresia and Tracheo-oesophageal Fistula (TOF): (Fig 1) on page 50 (fig 2) on page 51 It is characterised by incomplete formation of oesophagus or an abnormal communication between the oesophagus and the trachea. This is thought to be due to faulty separation of the primitive trachea and oesophagus. The following picture shows the classification of Oesophageal Atresia and Tracheooesophageal fistula. Fig.: Pictoral diagram of TOF and oesophageal atresia References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 3 of 95

4 Fig.: Oesophageal Artesia: Gas filled blind ending oesophageal pouch in the thoracic inlet with feeding tube within. Note the complete absence of gas within the abdomen (in types A and B) without distal tracheo oesophageal fistula Page 4 of 95

5 References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Of the above 5 types, Type C is the most common and presents in the newborn with drooling or inability to swallow. With Type E fistula, the diagnosis can be delayed for several years. The radiographic examination should include the abdomen. This reveals a blind ending proximal oesophagus that is distended with air. In types A and B there is absence of air in the abdomen. Inability to pass the radio-opaque feeding tube into stomach and this stays curled up in the proximal blind ending oesophageal pouch. Contrast examination (non-ionic water soluble or dilute barium) is necessary to demonstrate Type E TOF. The other rare congenital oesophageal anomalies include enteric cyst, neuroenteric cyst and oesophageal duplication. Disorders of Oesophago-gastric junction: (fig 3) on page 53 ( Fig 4) on page 55 Hiatus Hernia: It is of little clinical significance in the absence of gastro-oesophageal reflux. These can be assessed with Barium examination. Large hernias are uncommon but may be symptomatic. Paraoesophageal hernia is rare in children. Achalasia is failure of relaxation of lower oesophageal sphincter and is rare in children. Characteristic radiographic findings are distended oesophagus with air fluid level on upright chest x-ray. Dis-coordinated peristalsis is seen in the oesophagus in early cases. Ultimately atonic markedly distended oesophagus with residual food and characteristic beaking of distal oesophagus is seen. Page 5 of 95

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7 Fig.: Frontal view of barium oesophagogram demonstrates a large hiatal hernia (arrows). S= stomach, O= oesophagus. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 7 of 95

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9 Fig.: contrast study showing paraoesophgeal hiatus hernia (arrows) References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 9 of 95

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11 Fig.: Frontal view of the oesophagogram demonstrates marked dilatation of the oesophagus with abrupt narrowing to a beak at the oesophagogastric junction (long arrow). References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Stomach and Duodenum: (fig5) on page 59 (Fig6) on page 59 The stomach malformations are not common as it undergoes little alteration in form during development. The Hypertrophic pyloric stenosis the only serious gastric disorder seen in infancy is not congenital. Fig.: Schematic diagram showing gastric atresia. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Complete gastric outlet obstruction is rare and is due to gastric atresia which is classified into 3 types (fig 5 on page 59). On imaging, when the obstruction is complete, no air is seen distal to stomach (Single bubble sign) (fig 4). In such cases further imaging not necessary and most patients are taken directly to surgery. Delayed presentation can be noted with partial gastric obstruction which may be due to an incomplete prepyloric membrane, annual pancreas, duplication cyst or antral stenosis. Radiography shows distended stomach with small amount of gas distal to stomach. Ultrasound and Barium studies are helpful to identify the defect. Page 11 of 95

12 Fig.: Gastric diaphragm: Abdominal X-ray demonstrating markedly distended stomach with very little gas in the distal bowel. Page 12 of 95

13 References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Hypertrophic pyloric stenosis (Fig 7) on page 60 (Fig 8) on page 61is another cause of partial gastric obstruction in early infancy and is considered acquired rather than congenital in origin. Plain films can be normal but usually show a distended stomach and paucity of gas in the small bowel. The ultrasound appearances are characteristic. Fig.: Hypertrophic pyloric stenosis showing elongated thickened pylorus indenting on fluid filled antrum on the longitudinal scan. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 13 of 95

14 Fig.: Hypertrophic pyloric stenosis: Contrast study demonstrates dilated stomach (star) with narrow and elongated pyloric channel (block arrow). References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 14 of 95

15 Fig.: Upper gastrointestinal barium study demonstrates dilated atonic stomach. There is no gastric outlet obstruction and barium is seen in the duodenum and proximal small bowel. Aganliosis of the stomach confirmed on biopsy. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 15 of 95

16 Fig.: Mesenteroaxial volvulus showing inverted distended stomach. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM The duodenal obstruction is more common than gastric obstruction. The vomiting is usually delayed until after the first feed and the abdominal distension is less obvious. The radiograph demonstrates double bubble sign (fig 5). The obstruction can be due to duodenal atresia, midgut volvulus or annual pancreas. When the obstruction is complete, there is no gas distal to duodenum and patient can be taken to surgery without further imaging. Page 16 of 95

17 Partial duodenal obstruction can be due to duodenal stenosis/ web, Ladd bands, midgut volvulus, annual pancreas, preduodenal portal vein and duplication cyst. Barium studies are needed to differentiate between volvulus and other causes. Cork screw appearance of the bowel around the SMA noted in midgut volvulus. US is useful to diagnose duplication cyst and cause for volvulus Page 17 of 95

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19 Fig.: Duodenal Atresia: Markedly distended stomach and duodenum - Double bubble sign. No gas seen in rest of the small bowel or large bowel. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Congenital Anomalies of Small Bowel and Colon: Obstructive Defects: High or upper intestinal obstructions occur proximal to the midileum and those involving distal ileum and colon are called low obstructions. This distinction is critical and can almost always be made on the plain film of the abdomen. Because in cases of complete high obstruction, plain radiograph is all that is required prior to surgery. In neonates with incomplete obstruction or in whom surgery is delayed, upper gastrointestinal series may be useful. Contrast enema examination may be therapeutic as well as diagnostic in neonates with low obstruction. High Intestinal Obstruction: Common causes for high obstruction include Atresia of jejunum or proximal ileum and peritoneal bands. Partial obstruction can be caused by jejunal stenosis, peritoneal bands, duplication cysts, malrotation and meckeles diverticulum. High obstruction caused bilious vomiting and abdominal distension. On plain film there are only a few dilated loops. Jejunal atresia is caused by ischaemic injury to developing gut. Two or three distended bowel loops seen on plain radiograph. Barium enema is often performed to exclude an associated distal atresia. In isolated jejunal atresia, the colon is of normal calibre. Page 19 of 95

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21 Fig.: Jejunal Artesia with stomach and one loop of distended jejunum present. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Low intestinal obstruction: The obstruction is at the level of distal ileum or colon. The diffentials include ileal or colonic atresia, meconeum ileus or peritonitis, Hirschsprungs disease, functional immaturity of colon and anorectal malformations. Both ileal and colonic atresia demonstrate multiple dilated bowel loops and are difficult to distinguish on plain film examination. Contrast enema examination is necessary to determine the level of obstruction. In ileal atresia, the colon is in normal position but is minute in calibre - functional microcolon Meconium ileus is a presenting symptom of cystic fibrosis and results secondary to impaction of the meconeum in colon or ileum leading to mechanical obstruction. On plain film examination, there are several dilated bowel loops with relative lack of air fluid levels due to the presence of thick meconeum paste. Soap bubble / frothy appearance in right lower quadrant due to gas mixed with meconeum. Contrast enema examination shows a microcolon. Low intestinal obstruction: The obstruction is at the level of distal ileum or colon. The diffentials include ileal or colonic atresia, meconeum ileus or peritonitis, Hirschsprungs disease, functional immaturity of colon and anorectal malformations. Both ileal and colonic atresia demonstrate multiple dilated bowel loops and are difficult to distinguish on plain film examination. Contrast enema examination is necessary to determine the level of obstruction. In ileal atresia, the colon is in normal position but is minute in calibre - functional microcolon. Page 21 of 95

22 Fig.: Ileal atresia: Note the distal small bowel obstruction with several dilated small bowel loops Page 22 of 95

23 References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Meconium ileus is a presenting symptom of cystic fibrosis and results secondary to impaction of the meconeum in colon or ileum leading to mechanical obstruction. On plain film examination, there are several dilated bowel loops with relative lack of air fluid levels due to the presence of thick meconeum paste. Soap bubble / frothy appearance in right lower quadrant due to gas mixed with meconeum. Contrast enema examination shows a microcolon. Page 23 of 95

24 Fig.: Meconium ileus: Supine abdominal radiograph showing Multiple dilated loops of small bowel. Soap bubble appearance of meconium mixed with gas (arrow) noted Page 24 of 95

25 in Right side of abdomen. Note the absence of air fluid level despite distal intestinal obstruction. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 25 of 95

26 Fig.: Meconium Ileus: Water soluble contrast enema showing filling defects (arrow) within the distal ileum representing meconium and functional micro colon (unused). Page 26 of 95

27 References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 27 of 95

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29 Fig.: Microcolon: Barium enema examination demonstrating typical microcolon.this can be secondary to meconium ileus, ileal/ jejunal atresia or Hirschsprung disease. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Hirschsprungs diseaseis due to the absence of myeteretic ganglion cell in the colon. The length of the aganglionic segments varies but commonly involves a short segment in the rectosigmoid region (80%). The plain x-ray shows distended loops of bowel with air fluid level similar to the other caused of distal small bowel obstruction and gas is usually absent in rectum. Barium enema demonstrates the transition zone between the normal and abnormal bowel in the shape of an inverted cone - this is most characteristic, but st seen in 50% of neonates during 1 week of life (fig). Persistent corrugated appearance of aganglionic segment and marked barium retention on delayed films are other useful indicators. Functional immaturity of colon is seen particularly in premature neonates and is a spectrum of several findings notably small left colon syndrome and meconeum plug syndrome. The condition is both diagnosed and treated with barium enema examination. Barium demonstrates distended right colon and transverse colon with small left colon and calibre change at splenic flexure. Double contrast effect may be seen due to meconeum within the colon. Page 29 of 95

30 Fig.: Hirschsprung Disease: Barium enema examination showing transition zone with proximal dilatation of colon in short segment Hirschsprung disease. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 30 of 95

31 Fig.: Total colonic aganglionosis showing dilatation of the small bowel (arrow) proximal to transition zone. The large bowel is shortened with peculiar contours. There is marked regurgitation of barium into the dilated small bowel. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Malrotation: Page 31 of 95

32 The duodenojejunal and ileocolic segments rotate by 270 degrees in a counter clockwise direction around the omphalomesenteric vessels to cross beneath the vessels. Arrest in any of this sequence or gut rotation and fixation results in abnormal position of gut. The important anomalies are nonrotation, malrotation and reversed rotation. In nonrotation the midgut returns to peritoneal cavity without rotation. It is generally asymptomatic and incidental findings in older children and adults. The large intestine is on the left and small intestine on the right on barium examination. Abnormal peritoneal bands called Ladd's bands are part of the malrotation and cross anterior to the bowel loops and result in obstruction. The bowel is also poorly attached and floppy resulting in volvulus. Upper GI contrast study helps to determine the level of obstruction and may also show beaked duodenal deformity or cork screw appearance of the small bowel in the presence of volvulus. US examination shows reversed position of Superior mesenteric artery and vein positions, the artery being located to the right of the vein. However this only indicates the presence of malrotation but not volvulus. Also normal position of SMA and SMV does not exclude malrotation. Page 32 of 95

33 Fig.: Malrotation: Contrast examination showing the Duodenojejunal flexure to the right side of the spine. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 33 of 95

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35 Fig.: Malrotation: Barium follow through examination demonstrates jejunal loops on the right side of the abdomen and there is no evidence of obstruction. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 35 of 95

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37 Fig.: Malrotation: Barium follow through examination of the same patient showing midline position of the high riding caecum. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Fig.: Malrotation: Ultrasound abdomen demonstrating SMA located to the right of SMV. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Duplication Cysts: By definition these contain muscular and mucosal layers. The most common location is around terminal ileum. They are usually spherical and noncommunicating. Symptoms depend on the size and location of the duplication cysts. Sometimes they are large enough to be palpable and can cause obstruction, intussusception or volvulus. Page 37 of 95

38 They can be seen on plain radiograph if they are large or have calcification in the wall. On US they are cystic echogenic mucosa and hypoechoic halo of muscularis. Fig.: Duplication cyst: US abdomen demonstrating anechoic clear cystic structure superior to the bladder. Echogenic inner lining (curved arrow) representing mucosal layer and outer hypoechoic halo (straight arrow) representing muscular layer noted. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 38 of 95

39 Fig.: Duplication cyst: Large enteric cyst in the central abdomen with rim calcification (arrows)(a rare finding) displacing stomach and bowel loops. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Meckels Diverticulum: Meckels diverticulum is persistence of omphalomesenteric duct and is seen in the terminal ileum along the antimesenteric border. The complications include intussusception and haemorrhage from the presence of ectopic gastric mucosa. The Meckels scan is >95% diagnostic Is the most common cause of intestinal obstruction in infant-toddler age ground and in majority no cause is found. More than 90% are iliocolic. Plain radiograph of abdomen can be normal. Paucity of colonic stool and gas with a visible soft tissue mass are suspicious for intussusception. Ultrasound is pathognomonic Page 39 of 95

40 with doughnut or target appearance with alternating hypo and hyper echoic layers with central hyper echoic layer representing mesentery. On longitudinal scan, pseudokidney appearance with central echogenicity and peripheral hypoechoic layer seen. Fig.: Intussusception: Supine plain film demonstrates a dilated loops of small intestine in the left upper abdomen (curved arrow) with a soft tissue mass (arrows) in the right upper quadrant. Page 40 of 95

41 References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Fig.: Intussusception: Barium enema demonstrates characteristic coiled spring appearance (arrows) of intussusception (ileocolic). Air enema is now used to reduce intussusception. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 41 of 95

42 Fig.: Intussusception due to Meckels Diverticulum: Post contrast CT, coronal reconstruction demonstrating Meckles diverticulum leading to ileocolic intussusception (arrow) and proximal small bowel obstruction. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 42 of 95

43 Fig.: Intussuception due to Meckels Diverticulum: Intussusception on US demonstrating doughnut / target sign. Short arrow = Intussuscipience, Long arrow = Mesenteric fat Star = central hypoechoic area proved to be Meckel diverticulum at surgery. Curved arrow = returning limb of intussusceptum. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Anorectal Malformation: This can be classified into Rectal atresia - where the anus is in normal position without fistula. Ectopic anus - This is due to failure of terminal bowel to descend normally. The site of arrest can be high or low in relation to the puborectalis sling. The Page 43 of 95

44 external sphincter is in normal position and the ectopic opening can be in the perineum, vestibule, vagina, urethra, bladder or cloaca. Imperforate anus Cloacal malformation. Cloacal extrophy. Page 44 of 95

45 Fig.: Anorectal malformation: Invertogram showing air within the blind ending hind gut pouch. No air seen within the rectum. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 45 of 95

46 Fig.: Anorectal malformation: Sacral agenesis (star) in the same patient with imperforated anus. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 46 of 95

47 Fig.: Anorectal malformation: Contrast injection through perineal opening demonstrates large communication between the vagina (V) & Rectum (R) (straight arrow) and Rectum and Bladder (B) (curved arrow). References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 47 of 95

48 Fig.: Anorectal Malformation: Loopogram of the rectum demonstrating fistulous tract of between rectum and urethra. There is retrograde filling of the bladder. R = Rectum B = Bladder Arrow = fistula References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 48 of 95

49 Fig.: Ectopic Anus: Ectopic anus: Perineal Ultrasound demonstrating meconium filled rectum (R) and the anal canal pointing anteriorly towards the vagina References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Page 49 of 95

50 Fig.: Anorectal Malformation,Imperforated anus: Perineal US demonstrating blind ending meconium filled distended rectum. The anal canal could not be seen. References: S. P. Ramachandra; Radiology, University hospital of Northstaffordshire, Stoke on Trent, UNITED KINGDOM Images for this section: Page 50 of 95

51 Fig. 1: Pictoral diagram of TOF and oesophageal atresia Page 51 of 95

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53 Fig. 2: Oesophageal Artesia: Gas filled blind ending oesophageal pouch in the thoracic inlet with feeding tube within. Note the complete absence of gas within the abdomen (in types A and B) without distal tracheo oesophageal fistula Page 53 of 95

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55 Fig. 3: Frontal view of barium oesophagogram demonstrates a large hiatal hernia (arrows). S= stomach, O= oesophagus. Page 55 of 95

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57 Fig. 4: contrast study showing paraoesophgeal hiatus hernia (arrows) Page 57 of 95

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59 Fig. 5: Frontal view of the oesophagogram demonstrates marked dilatation of the oesophagus with abrupt narrowing to a beak at the oesophagogastric junction (long arrow). Fig. 6: Schematic diagram showing gastric atresia. Page 59 of 95

60 Fig. 7: Gastric diaphragm: Abdominal X-ray demonstrating markedly distended stomach with very little gas in the distal bowel. Page 60 of 95

61 Fig. 8: Hypertrophic pyloric stenosis showing elongated thickened pylorus indenting on fluid filled antrum on the longitudinal scan. Page 61 of 95

62 Fig. 9: Hypertrophic pyloric stenosis: Contrast study demonstrates dilated stomach (star) with narrow and elongated pyloric channel (block arrow). Page 62 of 95

63 Fig. 10: Upper gastrointestinal barium study demonstrates dilated atonic stomach. There is no gastric outlet obstruction and barium is seen in the duodenum and proximal small bowel. Aganliosis of the stomach confirmed on biopsy. Page 63 of 95

64 Fig. 11: Mesenteroaxial volvulus showing inverted distended stomach. Page 64 of 95

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66 Fig. 12: Duodenal Atresia: Markedly distended stomach and duodenum - Double bubble sign. No gas seen in rest of the small bowel or large bowel. Fig. 13: Contrast Study showing annular pancreas causing incomplete obstruction of the 2nd part of the duodenum. Note the distended duodenum (D) and the transition point (arrow). Page 66 of 95

67 Fig. 14: SMA sydrome: Note the dilated duodenum (D) with abrupt calibre change at D2/3 portion caused by compressive effects of SMA Page 67 of 95

68 Fig. 15: SMA syndrome: CT scan of the same patient showing duodenal obstruction (long arrow) at the level of SMA (short arrows). Hydronephrosis of right kidney from different pathology. Page 68 of 95

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70 Fig. 16: Jejunal Artesia with stomach and one loop of distended jejunum present. Page 70 of 95

71 Fig. 17: Ileal atresia: Note the distal small bowel obstruction with several dilated small bowel loops Page 71 of 95

72 Fig. 18: Meconium ileus: Supine abdominal radiograph showing Multiple dilated loops of small bowel. Soap bubble appearance of meconium mixed with gas (arrow) noted in Right side of abdomen. Note the absence of air fluid level despite distal intestinal obstruction. Page 72 of 95

73 Fig. 19: Meconium Ileus: Water soluble contrast enema showing filling defects (arrow) within the distal ileum representing meconium and functional micro colon (unused). Page 73 of 95

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75 Fig. 20: Microcolon: Barium enema examination demonstrating typical microcolon.this can be secondary to meconium ileus, ileal/ jejunal atresia or Hirschsprung disease. Page 75 of 95

76 Fig. 21: Hirschsprung Disease: Barium enema examination showing transition zone with proximal dilatation of colon in short segment Hirschsprung disease. Fig. 22: Total colonic aganglionosis showing dilatation of the small bowel (arrow) proximal to transition zone. The large bowel is shortened with peculiar contours. There is marked regurgitation of barium into the dilated small bowel. Page 76 of 95

77 Fig. 23: Malrotation: Contrast examination showing the Duodenojejunal flexure to the right side of the spine. Page 77 of 95

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79 Fig. 24: Malrotation: Barium follow through examination demonstrates jejunal loops on the right side of the abdomen and there is no evidence of obstruction. Page 79 of 95

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81 Fig. 25: Malrotation: Barium follow through examination of the same patient showing midline position of the high riding caecum. Fig. 26: Duplication cyst: US abdomen demonstrating anechoic clear cystic structure superior to the bladder. Echogenic inner lining (curved arrow) representing mucosal layer and outer hypoechoic halo (straight arrow) representing muscular layer noted. Page 81 of 95

82 Fig. 27: Duplication cyst: Large enteric cyst in the central abdomen with rim calcification (arrows)(a rare finding) displacing stomach and bowel loops. Page 82 of 95

83 Fig. 28: Malrotation: Ultrasound abdomen demonstrating SMA located to the right of SMV. Page 83 of 95

84 Fig. 29: Intussusception: Supine plain film demonstrates a dilated loops of small intestine in the left upper abdomen (curved arrow) with a soft tissue mass (arrows) in the right upper quadrant. Page 84 of 95

85 Fig. 30: Intussusception: Barium enema demonstrates characteristic coiled spring appearance (arrows) of intussusception (ileocolic). Air enema is now used to reduce intussusception. Page 85 of 95

86 Fig. 31: Intussuception due to Meckels Diverticulum: Intussusception on US demonstrating doughnut / target sign. Short arrow = Intussuscipience, Long arrow = Mesenteric fat Star = central hypoechoic area proved to be Meckel diverticulum at surgery. Curved arrow = returning limb of intussusceptum. Page 86 of 95

87 Fig. 32: Intussusception due to Meckels Diverticulum: Post contrast CT, coronal reconstruction demonstrating Meckles diverticulum leading to ileocolic intussusception (arrow) and proximal small bowel obstruction. Page 87 of 95

88 Fig. 33: Anorectal malformation: Sacral agenesis (star) in the same patient with imperforated anus. Page 88 of 95

89 Fig. 34: Anorectal Malformation: Loopogram of the rectum demonstrating fistulous tract of between rectum and urethra. There is retrograde filling of the bladder. R = Rectum B = Bladder Arrow = fistula Page 89 of 95

90 Fig. 35: Anorectal malformation: Contrast injection through perineal opening demonstrates large communication between the vagina (V) & Rectum (R) (straight arrow) and Rectum and Bladder (B) (curved arrow). Page 90 of 95

91 Fig. 36: Anorectal malformation: Invertogram showing air within the blind ending hind gut pouch. No air seen within the rectum. Page 91 of 95

92 Fig. 37: Anorectal Malformation,Imperforated anus: Perineal US demonstrating blind ending meconium filled distended rectum. The anal canal could not be seen. Page 92 of 95

93 Fig. 38: Ectopic Anus: Ectopic anus: Perineal Ultrasound demonstrating meconium filled rectum (R) and the anal canal pointing anteriorly towards the vagina Page 93 of 95

94 Conclusion 1. A good understanding of the GIT embryology is required for the interpretation of congenital GIT anomalies. 2. It is important to understand the typical age and mode of presentation of these anomalies and their complications. 3. Conventional plain films and fluoroscopic contrast examinations continue to be the major modalities of imaging to obtain adequate information. Personal Information References 1) Cumming WA. Esophageal Atresia and tracheo-esophageal fistula Radiol Clin North Am 1975; 13: ) Teresa Berrocal T, Torres I, Gutiérrez J, Prieto C, Hoyo M L D, Lamas M Congenital Anomalies of the Upper Gastrointestinal Tract Radiographics July : ) Buonomo C Neonatal gastrointestinal emergencies. Radiol Clin North Am 1997 ; 35: ) Berrocal T, Lamas M, Gutierrez J, Torres I, Prieto C, Hoyo M L D. Page 94 of 95

95 Congenital anomalies of the small intestine, Colon, and rectum. Radiographics 1999; 19: ) Swischuk L E Imaging of the Newborn, Infant, and Young Child th 4 edition 1997, Williams & Wilkins 6) Silverman F N, Kuhn J P Caffey`s Pediatric X-ray Diagnosis an integrated imaging approach. th 9 Edition, 1992, Mosby. Page 95 of 95