Case 1

These are 3 radiographs of different patients. These views are intended to show the variation in the bowel gas pattern in different patients. In early neonatal period visualisation of bowel depends on the ingested gas, and the time taken for the gas to reach the distal bowel. First radiograph shows only gaseous visualisation of stomach. Generally it takes nearly 24 hours for the bowel gas to reach the rectum. There is a large range of variation in the extent in the distribution, extent and pattern of bowel gas.

Case 2

What do you think as abnormal about this abdominal radiograph? There is no need to make a diagnosis in this case. However it is important to realise different patterns of bowel in children. This patient is loaded with the bowel contents. Extent of faecal loading varies greatly in children, depending on the bowel habit. Junk food contributes significantly as to the variation in bowel habits. Sometimes you can guess about the food ingested, like noodles or spaghetti !!!

Case 3

Any observation on this set of radiographs of the same patient? Finding is very subtle and visualised only on close scrutiny. Did you notice a small density in the right iliac fossa? Visualised density is an appendicular faecolith. Presence of appendicular calculi/colic provides additional support to the possible diagnosis of acute appendicitis in symptomatic patients. Of course, the logical sequence of examination should be ultrasound/CT depending on the need and availability.

Case 4

Chest radiograph of the 4-year-old, investigated for failure to thrive. The patient is a fussy eater who tends to take a long time for taking food. What are your observations on the chest radiographs? It is not easy to find clinching information on radiography in young patients. In this case lungs are clear. Cardiac shadow is somewhat prominent, probably due to additional component by the thymus. However right cardiac border should make you suspect something abnormal. On closer scrutiny you can appreciate a subtle double contour of the cardiac shadow, which is extending below the dome of diaphragm. This patient was investigated with a barium study. Provided images in 2 projections demonstrate grossly dilated oesophagus showing a smooth tapering. No irregularities noted. Stomach is visualised. On fluoroscopy, intermittent passage of the contrast into the stomach is observed. Observations are classical for achalasia cardia.

Case 5

This is a 3 month child presenting with altered bowel habits passing stools once in 4-5 days. Child had a distended abdomen. These are the set of plain radiography in supine, erect and the last one in the left is lateral projection. Bowel obstruction is one of the simple condition which can be diagnosed on plain radiographs. Distended bowel loops beyond the normal range will be the initial observation. Level of obstruction is often decided by the visualised dilated, most distal bowel loops. In this case you will see small and large bowel distension. In the left radiographs there is visualisation of gas almost reaching up to the level of rectum. Notice that there is large variation in the extent of bowel dilation in the 2 set of radiographs. Also the calibre of the visualised rectum is somewhat small, a finding highly suggestive of Hirschsprung’s disease.

Case 6

Frontal radiograph of by 1-month-old newborn is provided. Patient had a clinically obvious abnormality.

This diagnosis is not a challenge for a clinician, but an important observation for a radiologist. Based on the radiograph alone sometimes radiologist may miss this clinically obvious condition. This patient has bowel loops beyond the contour of the abdomen on the right side. Possibly, the patient has a hernia. Sonography is quite useful in suspected small hernias. CT examination is done for this patient and shows bowel herniation through the abdominal wall. Hernial opening is quite wide-mouthed. Deficiency of abdominal musculature could be one of the cause of such large herniation in the neonate. Multiple hernias may be associated with conditions like osteogenesis imperfecta, arterial tortuosity syndrome or Marfan syndrome.

Case 7

This child of 9 years presented with abdominal pain. The patient was previously treated for an abdominal condition. What are your observations in the present study. Plain abdominal radiograph is unremarkable. You might have noticed collections around the liver which is seen as scalloping of the liver margins. Also, it was noticed that such collections exist in the pelvis on either side of the uterus. There is various differential diagnoses in adults for such loculated multifocal collections. Since this is a child, these are likely to be due to inflammatory pathology like localised abscesses/peritoneal collections. This patient had a previous bacterial peritonitis, treated with antibiotics.

Case 8

This patient was investigated for recurrent abdominal pain and blood products in the stool. The method of investigation has undergone transformation over years. The present radiology practice does not include barium studies for such a clinical indication. However it is important to be familiar with earlier modes of investigation. For those who are unfamiliar with the nomenclature of this study, this is a barium meal follow through study in which examination is initiated with orally ingested barium and followed up till the transit of the contrast to the large bowel, at least up to the ileo-caecal junction. In this patient the upper GIT up to the proximal jejunum are normal. There is dilatation of the distal ileal loops which are significantly dilated at the level of the terminal ileum. The right lower radiographs are compression views of the ileo-caecal region. If you notice, there is a narrowing at the ileo-caecal junction with somewhat featureless appearance of distal small bowel loops. There is a stricture at the ileo-caecal junction. There is also asymmetrical outpouching at antimesenteric border (aneurysmal dilatation).   Patient was diagnosed to have Crohn’s disease with the stricture. Caecum is well distended and smooth in outline, excluding the possibility of ileo-caecal TB.

Case 9

These are the 4 views of the rectum and distal large bowel in a patient with the chronic constipation. These examinations are performed with the rectal tube without balloon. Notice that the calibre of rectum in relation to the sigmoid is somewhat small. Also, distal rectum is relatively smaller compared to the proximal rectum. Findings are classical for Hirschsprung’s disease. A left lower radiograph is a post evacuation radiograph. Notice that grossly dilated proximal rectum is contrasted against the smaller distal rectum.

Case 10

48-year-old male with lower abdominal pain, loss of weight. CT examination of this patient was performed for suspected ileo-caecal tuberculosis. Do have some observations and a diagnosis? Plain CT examination images demonstrate normal, visualised upper abdominal structures. Some suspicion is present regarding the bowel wall thickening in the region of right iliac fossa. Provided images do not allow to make this conclusion. Post-contrast images however do show wall thickening of the distal small bowel and proximal large bowel. An additional area of the distal small bowel shows focal thickening. There is fat stranding of adjacent mesentery with possible small nodes. These features may suggest the possibility of Crohn’s disease. Ileo-caecal tuberculosis is a close DD.

Case 11

73 year male with swallowing difficulty.

This 73-year-old male who was investigated for dysphagia. Examination demonstrates an extrinsic oesophageal impression which is on the right side and extending posteriorly. What you think the significance of this observation? In fact, there was no obstruction to the passage of contrast when the patient was swallowing. There were tertiary waves and the dysmotility in the lower oesophagus, probably due to presbyesophagus, due to aging. Diagnosis is extrinsic vascular compression due to aberrant right subclavian. Generally, in the frontal view, the impression is oblique towards the right side along the 11 o’clock position due to orientation of the traversing artery. The CT examination with contrast demonstrates left aortic arch with the aberrant right subclavian artery.

Case 12

Adult male with intermittent diarrhea and crampy abdomen.

Double contrast study of the large bowel is provided. Notice that some of the views are shown as it is obtained in the clinical setting. I am suggesting you look at fluid levels, which is an indication of a decubitus film. Do have a diagnosis? Young radiologists and trainee radiologists will find this radiograph not very helpful for making  a diagnosis, as this examination is no longer performed for the clinical condition. There are classical findings of ulcerative colitis, showing featureless large bowel (without haustrations), lead pipe colon (due to featureless and rigid bowel) and occasionally one can demonstrate multiple shallow ulcerations. One of the important features of ulcerative colitis is bowel changes in continuity from rectum. This feature helps to differentiate UC from Crohn’s disease which has areas of skip lesions.

Case 13

2 year old child suspected of gastro-esophageal reflux, investigated with barium meal.

Barium meal study and late film of the same region in a  2-year-old child is presented. Patient was investigated for exclusion of structural anomalies and possible G-E reflux. Patient did have severe reflux during the examination and also had a bout of coughing. Do have any observation or diagnosis? 

This is an interesting incident of barium aspiration. You can see that the patient did have some aspiration before. After reflux and bout of coughing it increased density-extent in the left lower lobe. Subsequent chest radiograph shows the extent of lesion in the left lung. Incidentally the density of this lesion is relatively high. There was very slow resolution of the lesion; hence the CT examination was done after few weeks. There are persistent lesions in the left lower lobe. HU of the lung density is high, indicating high-density content (barium). These findings can get organized, although most of the aspirated material is cleared through mucosal clearance.

Case 14

6 month old child with the persistent, projectile vomiting.

Erect and supine views of the abdomen are provided. Diagnosis must be somewhat simple. Dilated bowel loops with fluid levels of varying heights are demonstrated. This is an indication of a mechanical bowel obstruction. Observations are not always this simple in suspected bowel obstruction. Objective measurements of dilated bowel are not very useful criteria in a child. Also, the level of obstruction is not easy to guess. Effort should also be made to look for any obvious leading cause like intussusception or a duplication cyst (visible as soft tissue masses). It is also important to look for signs of bowel perforation.

Case 15

36-year-old female investigated for an observation on upper abdominal ultrasound. If you are familiar with cross sectional images of the abdomen, observations are very simple. There is a calcific lesion in the liver in segment 5/8. Density of the lesion is higher than that of a clear fluid. No significant contrast enhancement is noted. Did you observe anything on the scanogram? If you are facing an examiner, perhaps this would be a starting point. We can consider non-enhancing lesion with peripheral calcification like calcified hydatid cyst/chronic liver abscess etc.

Did you notice anything else in the study? There is an isodense lesion in the medial aspect of the spleen which shows homogeneous late contrast enhancement. This can be a haemangioma, granulomatous or neoplastic lesion. Unlike in the liver, splenic haemangiomas typically do not show intense peripheral/nodular enhancement.

• 40 y/ Male.

• Fever.

• K/c/o chronic pancreatitis.

• Status post Lateral pancreatico- jejunostomy done elsewhere.

• Now c/o persistent vague abdominal pain and pain in RIF.

• On USG done elsewhere appendix not visualized. No free fluid.

Case 16

Pre-and-post contrast-enhanced CT images in the axial plane are provided in a patient with a history of chronic pancreatitis and earlier surgery. The findings are very subtle in the form of mesocolic fat stranding in the region of the redundant sigmoid colon and adjacent RIF. Appendix is visualised and appears normal. In this context, one more diagnostic entity, epiploic appendagitis, can be considered. It can be primary due to torsion/ischaemia/inflammation or secondary to generalised inflammatory disease like diverticulitis, inflammatory bowel disease or inflammation of the adjacent organs. Generally, fat stranding in appendagitis will have a central hypodensity. Occasionally, mesenteric panniculitis can mimic this entity, but fat stranding tends to be more lobulated and may involve other areas in the mesentery. This patient was diagnosed with epiploic appendagitis and treated conservatively.

(Prepared in colloboration with Dr Shilpa Hegde)

Case 17

Axial plain and contrast  enhanced CT examination is provided with an additional coronal images. Generally, most abdominal imaging needs lot of time for scrutiny. Methodical imaging examination should be performed from lower thorax to the pelvis. You will be able to make relevant observations in this case if you are in active hospital based clinical practice. Obviously there is calcification in the region of the pancreatic head. Pancreas itself shows multiple cystic areas. Most of the distal pancreas appears to be a atropic. If you carefully observe there is a mass-effect in the region of pancreatic head and body with the irregular areas of enhancement. Also note that the common hepatic artery appears encased and occluded. There is thrombosis of the portal and splenic veins. And additionally there is mild splenomegaly, intrahepatic biliary dilation and irregular outline of the left adrenal. Minimal  ascites, located in RIF. Overall findings lead to following conclusion:

1. chronic calcific pancreatitis with the signs of chronic pancreatitis and collections.

2.  Evidence of a pancreatic malignancy is noted in the region of the pancreatic head and body with the encasement of the common hepatic artery,thrombosis of portal vein and possible adrenal metastasis.

(Prepared in colloboration with Dr Shilpa Hegde)

Case 18

Axial and reconstructed coronal contrast enhanced CT images are provided. Careful observation is needed in order to obtain accurate information. You might have noticed a hypodense subhepatic collection, confluent with the gallbladder fossa and peripancreatic region. There is presence of the peritoneal fluid as well.If you carefully note the proximal body of the pancreas shows linear hypodense, non-enhancing area. Following blunt trauma this patient had pancreatic fracture with rupture of the pancreatic duct, with the subsequent collection around the pancreas and subhepatic region. MRI examination may substantiate observation and occasionally add additional valuable information about the ductal anatomy. Subtle pancreatic duct injury is diagnosed with the contrast pancreatic done by ERCP.

(Prepared in colloboration with Dr Hemanth)

Case 19

Axial and contrast-enhanced CT images of the abdomen and pelvis are available. Making a diagnosis may not be very challenging in this case, as the size of the mass is huge and located in the retroperitoneal region, anterior to the kidneys. There are some areas of calcification on the left side of the mass. Predominant nature of the mass is fatty with the interspersed additional soft tissue component. Note the superior inferior extent. In most of the interface the lesion has a sharp margin. This is a large retroperitoneal liposarcoma. Differentiation between simple large lipoma, and liposarcoma is not always possible on imaging. Even sampling of tissue may not be representative thus histopathological reports can vary..

(Prepared in colloboration with Dr Shilpa Hegde)

Case 20

Two radiographs of a 6-month-old child is provided.

This is a  good training case for a student radiologist. Any diagnosis?  Many of you may be at loss as you may not accustomed to see plain radiography( that too abdomen) and subsequently make a diagnosis!!!!!. Two important observations in the first radiograph. The first is that of extensive spinal dysraphism, as shown with wide lumbar/sacral spinal canal. The second is a ‘coffee bean’ shaped bowel loops on left side of the abdomen. This is a redundant sigmoid colon. Patient did not have signs of bowel obstruction, making sigmoid volvulus less likely.  All these observations can be seen in spinal dysraphism. Patient had a large lumbosacral meningocoele and altered bowel habits. Subsequent radiograph, as you might have noticed has a V-P shunt. Is there at all?  Well, you might also discover that there is an ingested radio-opaque density (? battery cell) . Foreign body ingestion is a common problem with the mentally challanged patients. This patient had swallowed battery cell, a foreign body that should be closely followed, if necessary removed as poisonous  substance could leak in the bowel from this disintegrated button cells.

Case 21 

Patient investigated for recurrent right hypochondrial pain.

This is an example of the ERCP with the contrast study of the CBD. Lot of evolution has taken place in the endoscopes, previously bulky, rigid scopes have been replaced with the thinner, more flexible ones. Improvements in optics have revolutionized the diagnostic process and have added interventional options. In this case you can notice a small calculus in the distal CBD. During the technique most important precaution is to avoid air bubble introduction, which can be confused for a calculus.

Case 22 

18-month-old child, investigated for gastro-oesophageal reflux.

Frontal view of the lower oesophagus and stomach is provided. This patient had a free gastro-oesophageal reflux, seen is a continuous column of contrast from the stomach to the upper oesophagus. These observations are confirmed on fluoroscopy. Interestingly there is a small non-obstructive narrowing in the oesophagus, corresponding to the mucosal junction–the Z line. Position of the Z line shows the boundary between oesophageal and gastric mucosa. In this case there is a sliding hiatus hernia, below the Z line. Subsequent radiograph shows a label at the Z line and other anatomical landmarks of the gastro-oesophageal region.

Case 23

8 yr-old male with dysphagia and recurrent heartburn.

Barium examination of the oesophagus was performed with the tube in place.

These barium contrast based diagnoses were essential and routine in the past. Oesophagus shows a stricture in the middle third with minimal proximal dilation. Oesophagus distal to the stricture shows irregular lumen and a large outpouching posteriorly, representing an ulcer. Patient had repeated dilation in the past for the management of the stricture, probably contributing to injury and ulceration. Barrett’s oesophagus can appear similar on imaging with barium contrast examination.

Case 24.

1-month-old child with bouts of coughing while feeding.

This patient was investigated with a barium study. Barium esophagogram in the lateral projection is provided. This examination is a fluoroscopic examination under the supervision of the radiologist. Present practice does not involve barium; instead non-ionic water-soluble iso-osmolar contrast is used. (Iohexol or equivalent). Most important thing is to note any passage of contrast beyond the outlines of the oesophagus. Early phase examination is very important to establish the route of entry of contrast into the airways, whether it is a fistula or aspiration of the contrast from the upper airway. Did you notice the aspiration of contrast in the lung fields? In the past some of these examinations were performed in a prone radiography with the oesophageal tube in place.

Case 25

64 year old patient, known to have rheumatoid arthritis presenting with a recurrent left facial swelling and pain. Sonography outside had shown suspicion of a calculus in the parotid duct.

Plain radiography of the lower facial and views of the parotid sialogram are provided. No obvious calculus is appreciated on the plain radiography, small calculi overlying the bones are sometimes not observed on routine radiography. Sialography images demonstrate areas of focal dilatation of the main parotid duct with a saccular dilation of the branch ducts This observation, when bilateral, could be part of the autoimmune disease.(Sjogrens syndrome). However when localised to one side can be due to other aetiology like ductal calculi or recurrent sialectasis.

 (Case prepared in collaboration with Dr Vinay Belval.)

Case 28

20-year-old male who had a history of ingestion of corrosives. Patient had a oesophageal stricture and dilatation.

Non-contrast enhanced axial CT images and reconstructions provided. You might have noted that there is a abnormal contour and contents in the upper thoracic oesophagus. NGT seen. However oesophagus is seen as air containing structure; outline of the oesophagus is irregular with suspecion of dehiscence anteriorly. On close scrutiny you will note that there are subtle signs of pneumomediastinum. This is a complication of oesophageal dilatation. Patient had oesophageal dissection and pneumomediastinum. An important, potentially dangerous complication of dilatation of stricture.

(Case prepared in collaboration with Dr Vinay Belval.)

Case 27

32-year-old male, investigated for an abnormality in the sonography.

Plain and Contrast enhanced CT images are provided. This is just a sample of the routine imaging of the liver, only a single phase given. If you notice there is a hypodense lesion with intense peripheral enhancement in the early arterial phase. This lesion has to be followed in the portal as well as delayed phase in order to exclude a haemangioma. Generally small haemangioma gradually gets filled up from the periphery to the centre, nearly completely.  Occasionally a central scar or hypodense area may persist. This patient diagnosed as hemangioma, was followed-up.

Case 28

A 76-year-old lady, with sepsis, known uncontrolled diabetes presented with the acute abdomen.

Plain radiography when performed in an acute abdomen provides information mostly by showing characteristic patterns of bowel gas. Typically instances demonstrated are bowel obstruction, perforation and occasionally indirect signs of bowel infarction. You will notice that there is some degree of dilatation of the bowel loops in the central abdomen, large and small bowel loops. However there is a peculiar ‘speckled’ or bubbly appearance of the gas. Overall, the position of these loops  in the abdomen do not  change too much in location in the given images. This is an appearance of intestinal pneumatosis. This patient had mesenteric infarction due to SMA of thrombosis. There is a subtle amount of gas in the region of the liver, in the portal venous radicals. A finding may not be too obvious in the images.

Case 29

This 25-year-old lady presented with the abnormality of sonography. Clinically she is stable, does not have bowel symptoms.

This is a rare case from the imaging point of view as well as clinically. On scrutiny will notice that the right lobe of the liver is not seen, the left lobe is grossly enlarged, extending down like a mass. No focal lesions or obvious masses are noted. Outline of the visualised liver is smooth. There is mild enlargement of the spleen. The question is where is the right lobe of the liver? No history of surgery in this patient. This is one of the rare instances of  Agenesis of the right lobe of liver. Few cases are described, often in asymptomatic people. Detection is made on screening imaging for some other purpose. Notice that there are secondary changes in the bowel position, large bowel and loops of small bowel occupying the space of the right lobe liver. An interesting additional observation is that even the pancreatic head is migrated towards the right. Rotation of the mesentery due to bowel malposition is obvious in the form of a twist at the mesenteric root.                           

(Case worked in collaboration with one of my mentor, late Dr. Kailash Garg)

Case 30

3-year-old with a history of foreign body ingestion.

Wondering why I am trying to show you such an obvious abnormality. Is it very obvious? Presence of a foreign bodies was obvious, as the family brought the child in for ingestion of a coin. How many coins are seen? Looks like a single, but there are two coins, stacked together. Sometimes more than one coin is ingested and they travel together in packs. Generally ingested FB are passed spontaneously. Two important locations to be negotiated. Initially the pyloric sphincter, next is ileo-caecal junction. One should make sure that FB’s are followed up to ensure passage.

Case 31

This is a 45-year-old male with a history of hypertension, recurrent headaches and sweating.

Plain and Contrast-enhanced images of the abdomen below the level of the kidneys are provided. I guess you have noticed a ‘cricket ball’ sized rounded homogeneous opacity, anterior to the retroperitoneal vascular structures. Anything unusual in the vascular structures? Well, this is a plain scan!! So we do see aortic calcification in this young patient. On IV contrast there is intense homogeneous enhancement of the mass with some vascular structures at the periphery. What would be the likely diagnosis in this patient? With all the clues, you  must be guessing at the right diagnosis, a pheochromocytoma arising from the sympathetic chain. Pheochromocytoma arises from chromaffin cells and secrete catecholamine.  Emergency tray should be really when you are investigating this patient with intravenous iodinated contrast.

Pheochromocytoma can be associated with the von Hippel-Lindau syndrome, multiple endocrine neoplasia type II and neurofibromatosis type I. 30% appear as part of hereditary syndrome. 98% of lesions are seen in the abdomen, mostly in the adrenals. Malignancy is slightly higher (35%) when the lesion is extra adrenal. Non- adrenal typical locations are retroperitoneal, arising from the sympathetic chain or in the organ of Zuckerkandl. Location adjacent to the urinary bladder is occasionally reported with classical clinical presentation.

Case 32

57-year-old lady with a history of irregular bowel habits and abdominal distension. 

Images of the contrast-enhanced abdomen are provided.

This is a case study for a student radiologist. Since representative, selected images are provided, you will be able to identify a soft tissue density in the right upper abdomen, just below the liver. Soft tissue structure has a signature for bowel origin, in the form of central gas and peripheral circumferential wall thickening. Some of the lower images indicate that the side is a sudden transition from area of narrowing to dilatation. There is some amount of fat stranding and thickening of the Mesocolon.. Also there is a dilatation of the large bowel proximal to the lesion and in the region of the splenic flexure. Now you must have arrived at the diagnosis. This is a case of a malignant stricture of the large bowel in the region of the proximal transverse colon.

Case 33

This is an 8-month-old child with direct hyperbilirubinemia. The child was in the NICU services for a long time on intravenous alimentation. Child had an ultrasound examination before.

Do you have some observations in the provided series? Samples of many images are selected for review. What is obvious in the images is a distended gallbladder with pericholecystic fluid. There is dilatation of the common bile duct and proximal intrahepatic ducts. Did you notice intraluminal abnormality in the distal CBD? Did you notice an echogenic (on US) slightly hyperdense( on CT) content in the distal CBD-  which is likely to be a calculus/inspissated bile in this patient. Pancreas however does not show evidence of pancreatitis. This appearance is a complication of long standing intravenous alimentation leading to biliary sludge or/and calculus.

Case 34

You are provided with the erect and supine views of abdomen and a sonographic examination of the upper abdomen. Erect views may not always be possible in a young child. Translateral views are alternative options, equally serve the-purpose well. The patient appears to have a distended stomach with air-fluid level. Level of obstruction is likely to be at distal pylorus. In a typical setting, a male child presents between 6-12 weeks with projectile vomiting. Ultrasound technique, when performed in this child needs some attention to detail. In our case we can see hypertrophic pyloric canal on sonographic examination. Criteria for muscle hypertrophy as discussed before. Single wall thickness more than 3 mm in the most sensitive parameter.

Case 35

Neonate with the feeding difficulty and congenital heart disease, was investigated with barium esophagogram. I am sure it is a simple observation to see a posterior impression of the oesophagus at the junction of the upper and middle third. Impression is extrinsic, smooth and looks like a vessel. Is it an aberrant subclavian, pulmonary sling? Or any other unusual vessel. Though I have not provided you the frontal view, impression was not linear. Pulmonary sling rarely has a posterior esophageal impression. This leaves a double aortic arch is a likely possibility. Ideally this patient needs a CT to evaluate airway compression as well.

Case 36

Images of the esophagram in a 4-year-old female are provided. There was a history of throat irritability/foreign body sensation. 

Pediatric imaging practice in a clinical setup always throws challenges. When you are well established in the field, with a sense of authority there are always testing times and lessons to be learned. In this case I did a fluoroscopic examination in a newly established fluoroscopic suit. They were all excited with the detail and options in the machine. While examining this patient, a radiolucent rounded filling defect was seen from the right wall of the upper oesophagus. Initially an impression of air bubbles was made as there were small bubbles seen around. However despite several swallowing attempts (you can understand how difficult it is to make the child drink barium) the filling defect was persistent. Although there was some movement of the defect, at no stage could the defect be moved out of the right wall of the oesophagus. So I considered the possibility of a polyp. I was fairly confident of the diagnosis. Patient was taken subsequently to a facility outside (UK) and the repeat barium study was normal. So the initial observation was probably an air bubble. I consider this is a great lesson, while giving a diagnosis or evaluating a case. Confident expression of your diagnosis does matter but a modest balanced expression of your impression while reporting is more important. I hope most of the senior radiologists are in agreement.

Case 37

The neonate with abdominal distension and failure to pass meconium is the clinical the presentation. Rather a typical presentation and clinical setting for meconium peritonitis. Neonate can be examined either with a plain radiograph or a sonography. On plain radiography will see abdominal distension, mostly in the flanks with the bowel loops located in the centre. Bowel gas may or may not reach the rectum. Areas of faint calcification are noted in the flanks and in relation to the bowel. This appearance is highly suggestive of meconium peritonitis. Sonographic evaluation also may collaborate this observation. Some areas which would be especially looked for calcification around the liver and in some of the spaces around the liver

Interestingly bowel dilatation may not be marked in meconeum ileus, even fluid levels may not be present. Speckeled appearance of bowel loops seen. Sonography may show the contents better than plain film. Also localised collection/ascitis may be detected.

Case 38

Preterm neonate, lethargic with abdominal distension. Serial abdominal radiographs are presented. In the given clinical context, careful scrutiny is required regarding the distribution of gas in the abdomen. In this context we are looking for early signs of necrotising enterocolitis. Initially mild distension of bowel loops may be the only sign. Subsequently one might note subtle thickening of the bowel wall. Intestinal pneumatosis is a subsequent sign, often seen in distal ileum in the region of right iliac fossa.

What are the observations of this  patient? I hope you noticed a slight bowel dilatation and wall thickening in the initial image. Any further observation subsequently? You will note that there is some band of radiolucency in the region of hepatic hilum. And if you further explore you will see diffuse radiolucency in the hepatic region. This is a sign of a subtle peritoneal air and air in the portal venous system. Distribution of these pockets are dynamic. In the peritoneal cavity they are in the anterior space in the supine position. Portal venous air initially passes through the portal vein subsequently goes to the periphery of the liver. This patient recovered well after medical management.

Case 49

Neonate with projectile vomiting. This case is one of the simplest conditions to diagnose on the radiology. It is important to enquire whether the vomitus is bile stained or not. Bilious vomiting indicates obstruction beyond the sphincter of Oddi, whereas non-bilious vomiting could be due to more proximal obstruction. Imaging provides more additional anatomical information. In our case we see classical double bubble stomach and proximal duodenum. The obstruction is expected beyond the first part of duodenum. Contrast studies demonstrate and confirm the observation. Technically an attempt should be made to document bowel beyond the obstruction. Sometimes delayed films help in documentation. Partial obstruction, duodenal atresia will allow some contrast to pass. In such an instance location of the fourth part of the duodenum is important to make sure that there is no associated malrotation.

Case 50

This child had a trauma during the war encounter as a collateral damage. He also underwent proximal transverse colostomy for a suspected colonic injury. Plain films of the upper abdomen show a radiopaque shadow of a bullet. As patient appeared to have a complaint related to gastrocolic reflux. Initially barium meal examination is performed. We can see some residual content in the stomach with a bubbly appearance. There is a passage of contrast to the duodenum and proximal small bowel. No clear diagnosis was possible with the study. 

Second contrast study was performed through the colostomy. Tube was passed into the proximal transverse colon. Along with opacification of transverse colon, passage of contrast is noted into the stomach–in the later phase adequately opacifying the stomach. This patient has a fistulous communication from transverse colon to the stomach, leading to the clinical symptoms.

Case 52

Young patient with abdominal distension and occasional vomiting is investigated with a contrast study of the gastrointestinal tract. (Barium meal follow through). Plain film evaluation of this patient gives some useful information. I hope that you have noticed dilated small bowel loops in the upper central abdomen. There is gaseous visualization of the large bowel, excluding total obstruction. Presently barium meal follow-through examination is not familiar to all radiologists, as the examination is less frequenty done. This is essentially a prolonged study performed after injesting barium suspension, followed by multiple views obtained during the examination under fluoroscopic guidance. Initially the stomach is evaluated, followed by the rest of the bowel at ½ -1 hr. intervals. In this patient the stomach and duodenum are normal. We also see near normal appearance of the jejunal loops which are located on the right side of the abdomen.

Subsequently we note dilatation of the ileal loops which are located on the left side of the abdomen and the lower abdomen. In the later phases of the study (examinations at one hour and 6 hours) reveal dilated small bowel with multiple persistent intraluminal filling defects. At 24-hour study there is contrast in the large bowel but small bowel dilatation and small bowel filling defects are persistent. This patient has a small bowel stricture with bezoar in the dilated distal small bowel. In partial, long standing small bowel obstruction, one may see such observations. Phytobezoar due to residual seeds and undigested plant products lead to intraluminal defects proximal to the site of obstruction. Trichobezoars are more frequent in the upper small bowel, especially in the stomach/ jejunum in patients with psychiatric issues.

 Case 53

Plain radiographs of the upper abdomen are provided. Patient had a history of suspected foreign body(FB) injection. In the context of ingested FB, this is a special instance wherein careful observation need to be made. Metallic foreign bodies are easy to detect. Other foreign bodies of varying densities may not be appreciated well on plain radiography. In this case we are seeing mottled diffusely scattered densities in the region of proximal stomach. Any guess as to the nature of these opacities? This patient had ingested iron(Fe) tablets, from his mother’s medicine cabinet. Ingested high dose of Fe, has a serious consequence as symptoms are very severe and there is a possibility of an iron toxicity.

Case 54

This is a child with a history related to gastro-esophageal reflux. Plain radiography at the two different instances are provided to start with. This is a good exercise for the residents. Make your comments ready. What are your observations on the plain radiographs? I hope you have noticed a tubular radiolucency extending from upper to lower mediastinum, bounded on the right side by azygo-oesophageal line. Yes, this is a dilated esophagus containing air. Amount of air in the esophagus can vary on plain radiography depending on the extent of distension of esophagus and peristalsis. For further evaluation a contrast study is necessary. Common causes of dilated esophagus in children are achalasia cardia, gastro-esophageal reflux, distal esophageal strictures, hiatus hernia and rarely a large esophageal diverticulum.  The patient underwent a contrast study, which showed relatively short, dilated esophagus showing narrowing at the gastro-esophageal junction. There is associated sliding hiatus hernia. Patient had stricture at the gastro-esophageal junction which was managed with the balloon dilatation.

Case 55

This patient is a term neonate with abdominal distension and passage of scanty meconium. To start with plain radiography of the abdomen and ultrasonography was performed. You have the plain radiography for evaluation. Chest examination is unremarkable. Bowel gas is conspicuously missing. No obvious areas of calcification noted. There is abdominal distension. This is a classic situation that typically benefits from sonography. In the sonographic image you have noted cystic spaces shown with what looks like a bowel wall pattern at the periphery. There were two fluid pockets One was at the left hypochondrium and the other was in the lower abdomen. You can also notice non-dilated echogenic small bowel in the abdomen. In day two and three the plain radiographs were repeated after NG tube insertion and minimal injection of air. You notice that there is a visualization of the stomach and part of the distended duodenum. Nasogastric tube is in the fundus. Appearance looked like duodenal atresia. Do notice anything else in the second follow-up radiograph? There is some opacification of the proximal small bowel but there is evidence of a pneumoperitoneum!!! I guess some of you may have overlooked this observation. Regarding pneumoperitoneum, you have 2 important signs; Continuous diaphragm sign and the falciform ligament sign in this patient.  Since there was no conclusive final diagnosis contrast examination of the upper GI T was performed. Contrast could not be passed beyond the distal stomach despite delayed films.

So, all together this is a very unusual context. There is certainly obstruction at the level of the duodenum. Pneumoperitoneum is probably due to perforation during the attempt to distend the stomach with air. Sonographic observations of cystic spaces in the lower abdomen do not explain a case of a duodenal atresia. Explore and suggest thoughts for a possible diagnosis?  This patient underwent surgery. Patient had duodenal atresia and multiple atresia in the small bowel. There were areas sequestrated fluid filled bowel in between probably leading to a observations of a cystic space in the sonography. This patient had hereditary multiple intraspinal atresia.

Case 56

Our Patient presented with failure to thrive, irritability and had somewhat tender limbs.  Another important manifestation is related to abnormal nutrition. In this patient we have multiple radiographs of the lower limbs and left upper limb. Please go through and conclude your observations. 

Do you have your impression on the bony abnormalities? This patient has radiographic appearance of the Rickets. There is osteopenia of the bones, bones appear to show tendency for injury as manifested by greenstick fractures involving the ulna and the right distal femur. Classical metaphyseal changes are noted in the distal radius and ulna, as demonstrated by metaphyseal widening, flaring and a slightly prominent zone of provisional calcification. Osteopenia related changes could be very severe due to associated pancreatic deficiency as well. You will note that the fibula is hardly visible due to severe osteopenia. Additionally, we have a radionuclide study of liver. What radionuclide study would recommend for this patient?

 Typically, hepatic scintigraphy studies can be considered into categories 1. For demonstrating hepatic parenchyma (technetium labelled sulphur colloid and a similar radiotracers) another group 2. For demonstrating hepatic excretion and biliary system (technetium labelled iminodiacetic acid (IDA) derivatives. In suspected biliary obstruction IDA derivatives are utilized. Generally, two phase examinations are performed, showing the herpetic distribution and the subsequent biliary–enteric drainage. Normally hepatic distribution is achieved by 5 minutes subsequently gallbladder opacification takes place by 10 minutes. By 30-40 minutes bowel activity is seen. Now he can look at the radionuclide study of our patient. You notice that there is uniform hepatic distribution of the radiotracer in the early phases. On follow up gallbladder is not visualized. And there is no bowel distribution of radiotracer even in the delayed phase. Such appearances can also be seen in the biliary atresia. Patient underwent surgery for biliary diversion. Per-operative cholangiography done through gallbladder shows hypoplasia of the intra and extrahepatic ducts. There was free passage of contrast to the bowel loops. Patient is diagnosed with Alagille syndrome.  Some of the associations of imaging importance in Alagille syndrome are cystic renal disease, echogenic kidneys, nephrocalcinosis, hypoplasia of the semicircular canals, coarctation of aorta, butterfly vertebra and pulmonary stenosis. Unlike biliary atresia, cord sign is not often seen in Alagille syndrome on sonography.

Case 60 : 52-yr-old male with right upper abdominal pain

Case 61 : 60-yr -old male with H/O loss of appetite and weight

Case 63

Barium swallow examination of a child in the lateral projection is provided. Dynamic evaluation of a process of process and passage of contrast through the upper oesophagus is an important element of evaluation. Further evaluation of the swallowing mechanism, videofluoroscopy recording and careful analysis is needed. In a routine barium swallow, general observations are made. In this case I wanted you to see the posterior esophageal impression. This impression is caused by the cricopharyngeus. It may be a transient impression or persistent one. When it is persistent it could be due to a band or a cricopharyngeal bar. Anterior impressions/irregularities are often due to the pharyngeal plexus of veins. If the outline is irregular, stricture needs to be evaluated. Cricopharyngeal impression is seen in up to 20% of the examinations and is often associated with gastro-oesophageal reflux (50%). Sometimes differentiation is made between cricopharyngeal bar (persistent impression) versus cricopharyngeal spasm. Spasm may be associated with conditions like myasthenia gravis, poliomyelitis and CVA.

Case 64

A 9-month-old child was diagnosed with a left diaphragmatic hernia. As for the previous protocol contrast study of the bowel was performed, barium enema as well as barium meal follow through. Perhaps these examinations are not very relevant, although quite interesting to go through. We notice the vertical orientation of the rectosigmoid and descending colon leading to the herniated large bowel in the left lower hemithorax. Lateral projection also provides an extremely vertically oriented distal large bowel. Also, we can observe large bowel loops coming out of the hernial sac after  looping in the thorax. In this case barium meal was performed earlier to see the extent of small bowel loops in the sac. It appears that only the terminal ileum is noted entering the sac. Also provided are the post-operative chest and abdominal radiographs. Notice that the left lung is hypoplastic, a common observation in large diaphragmatic hernias. Also observe the reorientation of the large bowel in the abdominal space. Do you have any additional observations in the postoperative abdomen? Hopefully notice that the bowel loops appear somewhat more distended and some of the bowel loops apparently are noted in the left inguinal region? Inguinal hernia. (This observation must be verified clinically)

Case 65

This is a child who had a diagnosis of a hypertrophic pyloric stenosis. Patient underwent pyloromyotomy. Patient had some persistent symptoms, hence sonography and a contrast study were performed. Not many will have an opportunity to investigate such patients as investigations are rarely indicated.. Only in very symptomatic patients contrast study may be indicated. In this patient the plain radiograph did reveal a distended stomach. Sonographic observations are of importance in learning postoperative changes in hypertrophic pyloric stenosis based on the sonography images. Do you think there is evidence of a pyloromyotomy?  If you carefully observe. You will notice that part of the pyloric ring is broken, posteriorly, showing an echogenic wedge-shaped area. In fact this observation constitutes indirect evidence of a pyloromyotomy . Subsequent contrast study revealed a free passage of contrast from stomach to the duodenum. Also, you notice that the pyloric canal is wider now. Patient improved spontaneously on follow-up.

Case 66

This is an adolescent girl with psychiatric issues. Some of the behavioural changes lead to ingestion of multiple foreign bodies.This clinical picture goes with Munchausen syndrome (factitious disorder imposed on self)  This patient had swallowed a coin, which was stuck at the gastroesophageal junction for a while and subsequently moved down. Search for the foreign body should include the whole abdomen up to the rectum. I have included a separate section on multiple varieties of foreign bodies. Usually toys and parts of the toy are the common cause of foreign bodies. Toddlers in the phase of teething often swallow foreign bodies. It is amazing to see the variety, as anything very significant to most striking examples are available. In the collection provided, I have ear-ring, jewellery, battery cell, metal rod and some tablets etc This is just a sample.

Case 67

I have 2 abdominal radiography examinations. Patient had no specific symptoms; examination was performed for non-specific colicky abdominal pain– not a real indication for radiography. But interestingly there is an observation. Do you think this radiograph is normal or abnormal? Do you appreciate a mass lesion in the location of the stomach?   Certainly, there is a rounded large soft tissue density in the region of the stomach. This is a gastric pseudo mass. Sometimes such pseudo masses are seen following ingestion of food or large amount of fluid. Noodles, banana, spaghetti, bread and similar bulky foods tend to cause such appearances. This child was provided with an ample meal to convince him for radiography!!!

Case 68

5-year-old child with abdominal pain and a vague mass. Mass was suspected on sonography. Sonography images are available in the sonography section. CT examination was needed to confirm and delineate the extent of abnormalities. You notice that the thoracic part of the examination appears normal. Thymus is somewhat large for its age, and shows a homogeneous appearance. Upper abdominal viscera appear normal. Gross bowel wall thickening is demonstrated in the mid abdomen involving the distal jejunal loops and ileal loops. There is an impression of a pseudo kidney in the central abdomen due to a grossly thickened bowel wall which compresses lumen. Patient had a biopsy of the lesion confirming Burkitt's lymphoma. There is a representative image following therapy (10 months) showing reduction in the extent of the lymphomatous mass.

Burkitt’s lymphoma in the B-cell lymphoma, can present with endemic (mostly in Africa presenting with the maxillary and mandibular lesions due to chromosome 8 translocation, involving the c-MYC oncogene) or sporadic forms. Patients are typically diagnosed between 5 and 9 years. Extranodal form of the disease often involves the distal ileum. Third form of Burkitt’s is known in patients with the immunocompromised status. All of them have similar histology, often showing a starry sky pattern.

Presentation may be acute small bowel symptoms, intussusception. Imaging pattern is that of a diffusely infiltrating bowel wall thickening. Occasionally aneurysmal dilatation of the small bowel is seen due to involvement of the sympathetic plexus. 

(Devita R, Towbin RB, Towbin AJ.  Burkitt lymphoma causing colocolonic intussusception.  Appl Radiol.  2019;48(1):48A-48C.) 

Case 69

This is a premature 30-week-old neonate who had respiratory distress syndrome and was managed with respiratory support and other supportive measures. Serial plain radiography and a contrast study are provided. This is one of the most challenging radiographs for interpretation. Correlation with the clinical evaluation is necessary for precise interpretation of each radiograph. In the initial chest-abdominal radiograph there is a lung hypoaeration with predominant opacification of the mid and lower zone lung fields. Abdominal examination is unremarkable. In the immediate follow-up. There is slight improvement in lung aeration. Bowel visualisation beyond the stomach is not seen. Patient had a significant gastric aspirate. Attempted a gaseous distension of the stomach resulted in severe dilatation of the oesophagus, leading to an extremely interesting radiograph showing hugely dilated central air-containing oesophagus.

Due to high suspicion of gastric outlet obstruction, contrast study of the stomach with water-soluble contrast was done. Contrast examination reveals an extremely bizarre looking stomach with multiple areas of contraction ending blindly in the region of mid duodenum with opacification of the biliary ducts!!!  Any guess what the situation?  

It is evident that this patient has a duodenal atresia distal to the ampulla of Vater. This explains why biliary ducts are visualised with contrast. Contrast could not be negotiated beyond duodenum. Aspiration of the contrast was performed after the study. A contrast study of large bowel was performed which demonstrated near normal unused large bowel: 

In the follow up period, the patient developed severe hypoxaemia and the required higher oxygen settings for maintenance. Radiograph at that stage revealed bilateral airspace opacities adjacent to the paracardiac regions. Resolution of the opacities was gradual with the bubbly appearance of the lung on the left side. Patient underwent a CT examination due to persistence of lung opacities. CT examination revealed focal lobar hyperinflation of the lung fields and bizarre interstitial emphysema of the lingula and some cavitary lesions in the right lower lobe. Also associated pleural fluid was noted on the left side with thickening of the oblique fissure

In the final analysis this neonate presents the following abnormalities. 

1 Patient had features of the surfactant deficiency with the moderate hypoaeration of lungs. 

2.Patient had a biliary atresia distal to the ampulla of water.  Patient developed a transient severe air distension of the oesophagus following attempted gaseous distension of the stomach. 

3, patient developed paracardiac bubbly opacities in the follow-up.? Acquired lobar hyperinflation/aspiration pneumonia.

 Findings of lobar hyperinflation was confirmed on CT. Patient also developed left-sided pleural fluid. Patient did not survive following attempted surgical reconstruction.

Case 72

Male Infant of 2 months old had a palpable lower abdominal swelling. Sonography and CT imaging was performed. Sonographic observations are simple, in the form of a unilocular cystic lesion in the right lumbar region, measuring approximately 4.5 x 3.5 cm. It extended from the lower pole of the kidney to the pelvis. There was a perceptible wall, not showing a typical layered appearance. Possibilities of the duplication cyst or an mesenteric cyst was entertained. CT examination showed a well-defined cystic lesion in the right lumbar region anterior to the colon. There was a perceptible uniformly enhancing wall. Secondary displacement of bowel loops was noted. Diagnosis of duplication cyst was made and was confirmed at surgery. 

Duplication cysts of the bowel are often seen before the age of 2 years. It might involve partial or complete doubling of the bowel. 80% cystic and tubular variety. They may be asymptomatic or can present with bowel obstruction or bleeding.

Case 73

This is another child 9-year with episodes of loose motions and multiple joint pains. You are provided with the contrast study of the small bowel, CT examination with oral and intravenous contrast and some MR examinations of the pelvis.

The findings on barium meal follow through are somewhat subtle in the form of the polypoidal mucosal pattern of the distal ileum. You will also notice reduction in the size of the terminal ileum (string sign) with a slightly oedematous ileocaecal valve. Additional findings are also present in the right colon and transverse colon which show abnormal mucosal relief pattern (pseudo-polyposis). Elevated position bowel loops in the pelvis are due to distended bladder. All these observations are demonstrated in the CT examination. Bowel wall changes appear circumferential. There is a mesenteric stranding in the region of the right iliac fossa. No obvious lymphadenopathy is noted. 

The reason for MR examination of the pelvis was recurrent hip pain. In this patient there are areas of abnormal metaphyseal T2 hyperintensity which subsequently show contrast enhancement. Findings are asymmetric. Similar findings are also noted adjacent to sacroiliac joints. The overall imaging appearances are indicative of Crohn’s disease with the areas of osteitis involving the sacrum and pelvic girdle. This combination is well established in Crohn’s disease.

Case 74

Male child with recurrent episodes of constipation and diarrhoea. Series of plain films and contrast study of the large bowel is provided.  Now that you have seen many conventional GI illustrations, I expect some diagnosis in this case. You have at least 3 series of plain radiographs supine and erect. I am sure you can make an observation of episodes of acute distal large-bowel obstruction. Anything special about the pattern? The transverse colon is hugely dilated and, in some images, shows abrupt cut-off of the air column at the splenic flexure. This is somewhat like the colon cut-off sign seen in patients with the toxic megacolon. What is the aetiology of bowel obstruction? 

The answer is available in the provided barium examination. Rectum, sigmoid and proximal descending colon are relatively ‘smaller’ compared to the proximal descending colon. Hugely dilated transverse colon which a tapered transitional shown in the subsequent images. Although there is an impression that the rectum is nearly normal in size, indeed a relatively small calibre of rectum and distal colon was noted in the initial phase of the study. This is a case of Hirschsprung’s disease with the transition zone in the mid descending colon. The Clue to the diagnosis lies in the early phase of the examination, stage at which somewhat narrow calibre is better shown. With progressive distension with barium slight increase in the calibre takes place in the involved areas. However gradual transition from narrow to dilated part will be visible in most instances. In borderline cases a biopsy will be confirmatory, as confirmed in our case.

Case 75

This child was involved in the road traffic accident along with the parents. This is a simple example to show visceral injury. This patient has hepatic contusions and subtle pulmonary contusions.  Pulmonary contusions are seen as subpleural alveolar shadowing, some of them evolve by cavitation. We see such changes at the right lung base. In the abdomen the liver shows a large area of hypodensity involving most of the right lobe. There is also minimal peritoneal fluid.  There is no evidence of hepatic laceration. This patient had an MR examination after 2 weeks. Quality of the study is suboptimal (early 2000) however it shows mildly enlarged liver with subtle enhancing areas in the subcapsular region of the right lobe of liver. No haematoma or any evidence of laceration noted. There is no residual peritoneal fluid.  Did you notice the T2-weighted axial MR images? Can you technically identify what is the likely basis behind this poor-quality image?

Hepatic injury is uncommon in children, occurring in less than 8-10% in large paediatric series of general trauma. Most common associated injury is head trauma. A classification provided above (radiopedia) provides some idea regarding the basis of analysis and measure of severity of the injury as provided on the basis of the classification system.

Exibit 76 

Search for the foreign body should include the esophagus and whole abdomen up to the rectum. I have included this separate section to show multiple varieties of foreign bodies. Usually toys and 'parts of the toy' are the common cause of foreign bodies in children. Toddlers in the phase of teething often swallow foreign bodies. It is amazing to see the variety, as anything very common  to most rare examples are available. In the collection provided, I have examples of ear-ring, jewellery, battery cell, metal rod and some Fe tablets etc. This is just a sample.

Case 82

Middle-aged female with recurrent abdominal pain and irregular bowel habits. Plain radiography of the abdomen, erect and supine and axial images of the upper abdomen and the 3D MIP images of the hepatobiliary-tree are provided.

In this case you will notice observations of a classic disease of the pancreas and its plain film and MR correlation. Important things to note on the plain radiography is the presence of calcification and its location. In this case calcification is dense and oriented transversely/obliquely in the orientation of the pancreas. Other things to note in this context is to see any bowel related  abnormality in the form of an ileus. If the stomach is visualised one should look for any obvious compression or displacement. Then of course we had to look for any evidence of pleural fluid. In the nutshell, we are looking for evidence of acute inflmmatory episodes in a context of chronic calcific pancreatitis.

MRI images are provided here as they show very classic observations. Pancreatic ductal dilatation, calcification-calculi within the dilated pancreatic duct and pancreatic atrophy is evidenced. You will also notice biliary calculi. What about the structure between the dilated pancreatic duct and the gallbladder? On close scrutiny you will see that this is a dilated fluid containing duodenum. Fluid level is evident in T1-weighted images. In this case we do not see evidence of acute inflammation. MRCP images display the ductal anatomy of the biliary ducts and pancreatic ducts

Case 85

A 13-year-old female is investigated for a suspected liver enlargement. MRI examination of the upper abdomen is provided. Diagnosis of this entity is not very difficult if you're aware of the condition. Multiple scattered hepatic lesions are shown, demonstrating bright T2 signals. If you carefully observe the images some of the liver images demonstrate fluid-fluid levels. Anything else do you observe to make a diagnosis? There are a few lesions with similar morphology in the paraspinal muscles. In the T1 images most of the lesions are isointense except for the right lobe lesion showing hyperintense signals. Overall findings are indicative of haemangiomatosis of the liver

Morphologically two types of hepatic hemangiomatosis are seen - diffuse and nodular form. Nodular type shows involvement of the entire liver with discrete multiple hemangiomas. Diffuse type is more common in infants. In nodular involvement small discrete and coalescent nodules measuring <5 mm showing peripheral discontinuous enhancement during the arterial phase with filling in during portal venous and delayed phase is seen. Rarely, hepatic hemangiomatosis is seen adjacent to a giant cavernous hemangioma in the liver parenchyma ( Bansal K, Sureka B, Bharathy KG, Bihari C, Arora A. Diffuse hepatic hemangiomatosis. Astrocyte 2014;1:246-9)

Our Patient belongs to the category of Multifocal hepatic hemangioma (MHH). Condition represents a benign hepatic tumor that is commonly diagnosed in children with multiple cutaneous infantile hemangiomas (IH) .  Multifocal and diffuse HHs are true IHs, undergoing parallel phases of growth and involution to cutaneous lesions. Radiographically, multifocal HHs (MHHs) are individual lesions separated by normal intervening liver parenchyma whereas diffuse HHs are characterized by extensive replacement of the hepatic parenchyma with innumerable lesions. Symptomatic patients are traditionally treated with steroids these patients also respond well to therapy with propranolol. (Ji, Y. et al. Clinical features and management of multifocal hepatic hemangiomas in children: a retrospective study. Sci. Rep. 6, 31744; doi: 10.1038/srep31744 (2016).

Multiple cutaneous IHs associated with MHHs in a 1-month-old girl.

(A) Multiple IHs on the face and trunk. This patient also had additional lesions on the extremities. (B) T2-weighted axial MRI of the liver showed lesions were hyperintense with intervening areas of normal hepatic parenchyma.      (Ji, Y. et al. Clinical features and management of multifocal hepatic hemangiomas in children: a retrospective study. Sci. Rep. 6, 31744; doi: 10.1038/srep31744 (2016).

Case 86

12-year-old patient was incidentally found to have a lesion on the sonography. Followed up with an MR examination. This case represents a single typical cystic lesion in the liver, located in the subcapsular location of segment 7 of the right lobe. This is a unilocular simple cyst, although location is slightly atypical. Simple hepatic cysts are seen in 2-7% of the population, showing the slight predilection for the female. Growth is generally slow and insidious. Not known to have malignant potential or biliary communication. Cysts have imperceptible wall and the content is serous. On the LI-RADS classification system, a simple cyst is given a designation of LR1 or LR2.. Multiple cysts are noted in polycystic renal disease, polycystic liver disease and on the nipple Linda disease. (Radiopedia) 

Case 87

This is a contrast study of the upper GI in a patient with a history of projectile vomiting. Observation on this barium meal study is straightforward. Stomach is distended. There is good visualization of the pylorus, duodenal and proximal duodenal loop. Orientation of the proximal duodenum is normal, whereas the transverse part of the duodenum shows an abnormal spiral curve, showing right-sided orientation of the proximal jejunal loops. This constitutes a typical corkscrews appearance of a midgut volvulus. All pediatric radiologists are familiar with this common condition. Contrast study is a definitive procedure, although some of the indirect signs can be obtained with ultrasound and CT by observing the vascular anatomy of the mesenteric root. In contrast study duodenal and duodenal jejunal flexure should be at the same level in the frontal view. In the lateral view duodenal jejunal flexure should overlie the spine, indicating a proper fixation of a duodenal jejunal flexure. Note that in our patient, transverse duodenum shows an anterior curve, rather than going to the location of the duodenal jejunal flexure. There are delayed films in this example showing gastric stasis as well as abnormal location of the right colon.

Case 88 : 65-yr-female with loose stools and bilious vomiting

Case 89 : 34-yr-old female with post LSCS abdominal distension.

Case 90 : 27-yr-old male with H/O upper abdominal blunt injury

Case 91 : 57-yr-old female with pain abdomen. Mass felt on clinical examination.

Case 92 : 26 yr-old male with acuate abdominal pain.