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220to a meconium cyst, bubbly meconium in the right flank,multiple dilated air-filled loops of small bowel proximalto the ileus, and perforation (Fig 2). Water-soluble con-trast enema shows a microcolon. The contrast then flowsaround and through the thick meconium in the cecum

rom Royal Hospital for Sick Children Glasgow, Scotland, UK.ddress reprint requests to A.C. Maclennan, Royal Alexandre Hos-l, Paisley PA2 9PN, Scotland, UK.

2003 Elsevier Inc. All rights reserved.055-8586/03/1204-0002$30.00/0oi:10.1053/j.sempedsurg.2003.08.002Investigation in VBy A.C. M

Glasgow, S

is article discusses how to investigate various surgicalses of vomiting. Particular emphasis is placed on plainiographic, ultrasound, and contrast study findings. Theicle touches upon nineteen different diseases, and en-

passes diseases found in neonates to adolescents.003 Elsevier Inc. All rights reserved.

OMITING IS A common self-limiting symptom inchildren, but occasionally heralds serious surgical

life-threatening disease. This review is a practicalide to the radiological findings in children who aremiting because of surgical disease. No test should berformed before an experienced clinician assesses aild. Tests are then carried out to confirm a suspectedgnosis, eg, pyloric stenosis where a test feed is neg-ve, or to exclude an unlikely, but potentially seriousgnosis, eg, volvulus in a well baby with an episode ofious vomiting. Many of the pathologies discussed arest investigated by old-fashioned plain radiographs,rasound, and fluoroscopic examinations with water-uble contrast or barium.1 Computed tomographyT), magnetic resonance imaging, and nuclear medicineaminations have a lesser role.

THE VOMITING NEONATE

Many of the causes of vomiting reflect congenitalstructions of the gastrointestinal tract.2,3 Some ofse, eg, duodenal atresia, may already have been sus-

cted at the time of antenatal fetal ultrasound scans.

stric Outlet ObstructionGastric outlet obstruction presents as a single bub-, which is the gas-filled stomach on an abdominaliograph (Fig 1). There is no gas distal to the stomach

d no further investigation is necessary.

odenal AtresiaDuodenal atresia presents as a double bubble, whichthe air-filled stomach and dilated duodenal bulb.

oximal Jejunal AtresiaProximal jejunal atresia presents as a triple bubblecause of air in the stomach, duodenal, and proximalated jejunum.Seminarsiting Childrennnannd, UK

stal Ileal AtresiaRadiographs show multiple air-filled loops of bowel.ere is no air in the rectum. A water-soluble contrastema may show a microcolon or normal-sized colon.ere is reflux into a short segment of small bowel,ich either terminates in a cigar butt or a smallple. Contrast will not pass any more proximally. Fill-of the appendix should not be mistaken for small-

wel filling.

conium IleusRadiographs can show peritoneal calcification if theres been a previous in utero perforation, abdominal

ig 1. One-day-old child with vomiting and a single bubbleearance due to gastric outlet obstruction confirmed at surgery.tension with absence of gas in the right iliac fossa dueomaclecotaDi

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hadisin Pediatric Surgery, Vol 12, No 4 (November), 2003: pp 220-228

and proximal small bowel.1 The aim is to reflux water-soluble contrast proximal to the meconium obstructionand into dilated air-filled loops of gut. The osmotic loaddraws water into the gut lumen and may allow the babyto pass the meconium without need for laparotomy.Obviously, the baby must be well hydrated at the time ofthe enema, which can be repeated several times. Inabilityto reflux contrast into the air-filled dilated small bowelloops proximal to the obstruction should raise the possi-bility of an associated volvulus, which will require lap-arotomy.

Hirschprungs DiseaseRadiographs show multiple loops of air-filled dilated

gut and, occasionally, a perforation. There is usually nogas in the rectum in the neonate with Hirschprungsdisease. There is often particular dilatation of the loopimmediately proximal to the transition zone.2 A bariumor water-soluble contrast enema, prior to any rectalwashout, is performed looking for a transition zone.4This marks the level at which the affected colon widens

Fig 2. A 3 day-old baby with multiple dilated loops of gut and asupine pneumoperitoneum. Perforation of a meconium ileus wasfound at surgery.

Fig 3. High-resolution ultrasound shows a pylorus of 16-mm longand individual muscle wall thickness of over 4 mm. Pyloric stenosiswas confirmed at surgery.

Fig 4. Six-week-old child with inconclusive pyloric ultrasoundshows sign of a pyloric tumor and free esophageal reflux. Tumor wasconfirmed at surgery.

221INVESTIGATION IN VOMITING CHILDREN

into normal colon. Rectosigmoid and colon affected byHirschprungs disease is of narrower caliber than normalcolon, and often shows fine mucosal irregularities due tomuscular incoordination. Total colonic Hirschprungsposes a major problem for the radiologist. An enema canmiss whole colonic involvement, as there is no transition

zone.5 Rectal biopsy is mandatory to confirm or excludethe diagnosis.

Meconium Plug Syndrome

The plug is easily demonstrated as a large single fillingdefect within the distal colon and rectosigmoid, on acontrast enema. The plug may be aspirated back with thecontrast, or may then be spontaneously voided by thebaby because of the osmotic effect of contrast.

THE VOMITING BABY

Gastroesophageal RefluxSuspected reflux is the most common indication for a

barium swallow in our institution. It is an easy diagnosisif there are multiple episodes of reflux filling the esoph-agus with barium. However, fluoroscopic diagnosis ofreflux is complicated by lack of an agreed method ofperforming the barium swallow test. Multiple nonphysi-ological methods of provoking reflux exist, and there isno agreed upon method of quantifying reflux. A bariumswallow is useful in confirming or excluding an esoph-ageal stricture, hiatus hernia, or gastric outlet obstruc-tion. The sensitivity for demonstrating reflux is about50% compared to the gold standard of a 24-hour pHprobe study. The pH study is more invasive although itdoes not have a radiation burden. A nuclear medicinemilk reflux scan allows physiological feeding and ob-servation of a baby in order to document reflux overseveral hours after a feed containing a nuclear medicinetracer. It shows 60% to 80% sensitivity compared to24-hour monitoring.6,7

Fig 5. A 6-year-old boy with abdominal pain and vomiting. Bar-ium meal shows the corkscrew sign of a volvulus in the epigastrium.

Fig 6. High-resolution ultrasound of right flankshows a typical intussusception, which was easilyreduced by air enema.

222 A.C. MACLENNAN

Pyloric StenosisA positive test feed by an experienced clinician means

that imaging is unnecessary. Radiographs show a dis-tended stomach, often with prominent peristaltic waves,and traces of air in the remainder of the bowel. Ultra-sound is both sensitive and specific at making the diag-nosis of pyloric stenosis.8,9 A nasogastric tube is passedinto the stomach and the stomach washed out with warmsterile water, and then filled with 30 to 60 mL of water.The pylorus is directly visualized and the length anddiameter measured. Various sizes have been proposedfor diagnosis of pyloric stenosis.10,11 At our institution,we diagnose pyloric stenosis when the pyloric length isover 16 mm and the transverse diameter is over 10 mm12(Fig 3). The normal transverse thickness of the pyloricmuscle is less than 2 mm. Over 4 mm is diagnostic ofpyloric stenosis. These measurements, however, are toolarge for making a diagnosis of pyloric stenosis in aneonate.13 Pyloric stenosis can also be diagnosed by abarium meal that shows a shouldered pylorus and atramtrack sign of the elongated, and partly obstructedpyloric channel (Fig 4).

Malrotation and VolvulusMalrotation or nonrotation causes abnormal fixation of

the gut within the abdominal cavity. It may be associatedwith a short root of the mesentery, which runs from theligament of Treitz to the cecum. The risk of volvulusincreases as the base of the small bowel mesentery de-creases. Unfortunately, with fluoroscopic imaging, thebowel is visualized, not the mesentery and so the radi-ologist makes an informed guess about the mesentericposition from the position of the gut. The most reliableexamination for confirming or excluding a malrotation isa barium meal where the column of contrast is watchedduring the first pass through duodenum and into jejunum.A normal duodenojejunal flexure, which is the markerfor the ligament of Treitz, lies to the left of the spine ator close to the level of pylorus (usually the second

Fig 7. Fourteen-month-old with a persistent filling defect imme-diately above the esophagogastric junction. A plastic ballpoint pen-cap was found at esophagoscopy.

Fig 8. Dilated esophagus and rat-tail narrowing of gastro-esophageal junction in achalasia proven with subsequent manom-etery.


lumbar vertebra). Most malrotations are obvious andeasily diagnosed. However, a number of variants ofnormal duodenal anatomy overlap with subtle malrota-tions.14,15 These gray cases are best approached bydirect discussion between the radiologist and surgeonabout the appearances. A repeat barium meal or bariumenema to show cecal position, may be useful in decidinghow seriously to treat the appearances. Volvulus is due totwisting of the midgut loop on the mesentery causingvenous then arterial ischemia of the gut. Radiographsmay show dilated gas-filled upper small bowel, or smallbowel lying in the right flank. Perforation is a grave sign.A barium or contrast meal shows the corkscrew sign oftwisted bowel (Fig 5), or a complete cut-off at the levelof second or third part of duodenum. Ultrasound assess-ment of the position of the superior mesenteric artery andvein is less reliable than a contrast meal for diagnosis ofmalrotation and a normal ultrasound can occur withmalrotation.16,17

IntussusceptionRadiographs may appear normal, show nonspecific

abnormality, or show a soft tissue mass in the right flankand absence of paucity of colonic air.18 Small bowelobstruction may be present but perforation is rare. Anormal air- and feces-containing cecum, on an abdomi-nal radiograph, excludes the diagnosis. Ultrasound isused to confirm the diagnosis and generally shows acomplex mass in the right flank or epigastrium19 (Fig 6).Often individual bowel wall layers, lymph nodes, andmesenteric fat are identified within the mass. There maybe trapped fluid within the intussusception or ascites.

Fig 9. A 12-year-old boy with recur-rent abdominal pain and vomiting showsa large ulcer niche of duodenal cap ondouble contrast barium meal. The ulcerwas confirmed by endoscopy.

Fig 10. Eleven-year-old boy with 5 days of vomiting and centralabdominal pain. There is small bowel obstruction and there is masseffect by a soft tissue mass in pelvis causing deviation of the rectalgas to the left side of pelvis. A perforated appendix and pelvicabscess were found at surgery.

224 A.C. MACLENNAN

Small bowel obstruction is shown by multiple hyperperi-stalsing dilated fluid-filled loops of small bowel. Ultra-sound may also identify a pathological lead point.20 Anair or contrast enema can either be used to confirm thediagnosis without ultrasound or to perform a reduction.Ultrasound-guided reduction using Hartmanns solutionor saline is as effective as barium reduction and involvesno radiation exposure for patient or operator.21,22

THE VOMITING OLDER CHILD

Esophageal Stricture and Foreign BodyStrictures are seen as a thin, constricting ring

postesophageal atresia repair, a smooth mid or lowerthird narrowing due to reflux esophagitis, or a longirregular narrowing postcaustic ingestion. A foreignbody may impact on the stricture (Fig 7).Achalasia

Achalasia does not cause vomiting, but does causeregurgitation of undigested food and pulmonary compli-cations due to aspiration. A chest radiograph may dem-onstrate areas of collapse or consolidation; a dilatedair-filled esophagus, an air fluid level in the esophagus,or absence of the gastric air bubble. A barium swallowshows disordered motility in early achalsia and a dilatedserpiginous esophagus containing food residue in estab-lished achalasia. The esophagus forms a smooth rat-tail stricture at the esophagogastric junction and one canwatch barium intermittently squirting into the stomachduring screening (Fig 8). Any shouldering, other stric-ture, or fixed polypoid intramural lesion is suspicious ofa superimposed carcinoma.

Fig 11. Contrast-enhanced CT of abdo-men in moribund child 10 days postappen-dicectomy. There are multiple intraabdomi-nal abscesses confirmed at subsequentsurgery.

Fig 12. A 2-year-old boy with small bowel obstruction due to anincerated right inguinal hernia.


Duodenal UlcerA double-contrast barium meal using high-density

barium and spot views of the duodenal cap may showspasm untreatable by intravenous antispasmodics, an ul-cer niche if there is an acute ulcer, or scarring anddeformity if there is a healed ulcer (Fig 9). Endoscopy ismore sensitive than single-contrast barium studies fordiagnosis of both gastric and duodenal ulcers.23

AppendicitisRadiographic findings of appendicitis are generally

not helpful in early disease and include normal appear-ances, right lower quadrant haze, blurring of the rightpsoas shadow, obliteration of the right properitoneal fatline, as scoliosis convex to the left, a dilated loop ofsmall bowelsentinental loop sign or the colon cut-off sign of a dilated ascending colon with a sharplydefined lower margin (Fig 10). An appendicolith is seenin 10% to 15% of patients and clinches the diagnosis.Graded compression ultrasound demonstrates the in-flammed appendix as a tender, noncompressible, tubularstructure with 1 blind end and often a calcified appendi-colith at its base.24,25 There is often localized ascites,

hyperechoic mesenteric fat, and right iliac fossa lymph-adenopathy. Perforated appendicitis may form a complexmass of fluid, fat, and gut. Ultrasound can be falselynormal if there is only a distal tip appendicitis or if thereis a retrocecal appendicitis obscured by cecal gas. CT hasbeen used for diagnosing acute appendicitis.26 CT find-ings in appendicitis include an enlarged appendix, ap-pendicolith, tapered deformity of the colonthe arrow-head sign, stranding of adjacent fat, adjacent bowel wallthickening, and a complex mass if perforation occurs.27CT is also useful for delineating abscesses in postappen-dectomy patients presenting with fever and suspectedabscess (Fig 11).Small Bowel Obstruction: Hernias or Atresias

Radiographs show multiple dilated air-filled smallbowel loops or a string of pearls sign of small amountsof air within the gut and fluid-filling of the remainder ofgut. A gas-filled loop of gut may be seen in scrotum,confirming an inguinal hernia (Fig 12). Ultrasound maybe used to confirm an inguinal hernia in boys or girls

Fig 13. Left renal calculus in a 13-year-old boy with vomiting anda proven urinary tract infection.

Fig 14. An 11-year-old girl with 3 days of abdominal pain andvomiting. The supine radiograph shows a scoliosis to the left and asoft tissue mass, which is partly calcified, in the right side of pelvis.

226 A.C. MACLENNAN

showing the gut and mesenteric fat or ovaries and fallo-pian tubes.28 CT can be used to look for the transitionzone from proximal dilated gut to collapsed gut indicat-ing the site of obstruction.29,30

Renal ColicRadiographs usually show a radio opaque stone either

within the renal pelvis or in the line of ureters (Fig 13).Ultrasound, which should be performed first,31 may alsoshow stone as a hyperintense area within the renal pelviswith posterior shadowing. There may be hydronephrosisdue to obstruction by a ureteric stone. Unenhanced CT isthe most sensitive method for diagnosing a stone, show-ing a renal stone as a dense area within the kidney,possibly hydronephrosis, and stranding of the perirenalfat. A ureteric stone is identified as a dense focus in theline of ureter, possibly with hydronephrosis, hydroureter,circumferential thickening of the ureteric wall andstranding of the periureteric fat.32

PancreatitisRadiographs are generally not helpful. Calcification

due to chronic pancreatitis is rare. A sentinental loop of

dilated air-filled small bowel due to local ileus may bepresent. Cross-section imaging is used to stage the se-verity of pancreatitis and assess complications. Contrast-enhanced CT scan obtaining images in the arterial phaseis the best method for showing the presence and assess-ing the percentage of pancreatic necrosis, and showingabscesses.33 Arterial phase CT is also best for demon-strating arterial pseudoaneurysms, although delayed CTis necessary for showing venous occlusion or stenosis.Pseudocysts can be followed either by ultrasound orCT.34

Ovarian Torsion

Radiographs can mimic appendicitis or may be diag-nostic if there is calcification in a torsion of an ovariandermoid (Fig 14). Ultrasound shows a pelvic or adnexalmass that is either cystic or solid35 (Fig 15). A tortedovary is several times larger than normal. Doppler im-aging may show the mass to be avascular. Ultrasound,CT, or magnetic resonance imaging may all show mul-tiple peripheral cysts within the mass due to dilatedfollicles.36

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Fig 15. The same child as in Fig 14.Ultrasound shows a large cystic mass.This was torsion of a hemorrhagic der-moid cyst at surgery.


comparative study with radiography and 24-h pH monitoring. PediatrRadiol 31:737-741, 2001

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17. Dufour D, Delaet MH, Dassonville M, et al: Midgut malrotation,the reliability of sonographic diagnosis. Pediatr Radiol 22:21-23, 1992

18. Sargent MA, Babyn PS, Alton DJ: Plain radiography in sus-pected intussusception: a reassessment. Pediatr Radiol 24:17-20, 1994

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25. Sivit CJ, Siegel MJ, Applegate KE, et al: When appendicitis issuspected in children. Radiographics 21:247-262, 2001

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228 A.C. MACLENNAN

Investigation in Vomiting ChildrenTHE VOMITING NEONATETHE VOMITING BABYGastric Outlet ObstructionDuodenal AtresiaProximal Jejunal AtresiaDistal Ileal AtresiaMeconium IleusHirschprungs DiseaseGastroesophageal RefluxPyloric StenosisIntussusception

THE VOMITING OLDER CHILDEsophageal Stricture and Foreign BodyAchalasiaDuodenal UlcerAppendicitisSmall Bowel Obstruction: Hernias or AtresiasRenal ColicPancreatitisOvarian Torsion

REFERENCES

vomiting children

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