Radiological observations during transpyloric tube feeding in infants of low birth weight. Perforation of the duodenum and variations in normal duodenal anatomy

Fluoroscopic Diagnosis of Malrotation: Technique, Challenges, and Trouble Shooting

A fluoroscopic upper gastrointestinal series is the most commonly used investigation for the diagnosis of malrotation and midgut volvulus. However, both false positive and false negative results can occur causing diagnostic confusion. Several physiologic states and pathologic conditions can mimic fluoroscopic appearance of malrotation. Proper fluoroscopic technique is essential to maximize diagnostic accuracy. In this pictorial essay, we discuss common diagnostic challenges in the diagnosis of malrotation and strategies radiologists can use to clarify the diagnosis in equivocal cases.

Exchange of an occluded nasojejunal tube facilitated by angioplasty balloon-induced rupture

We describe a method of exchanging a blocked nasojejunal (NJ) tube involving the use of a percutaneous transluminal angioplasty balloon to rupture the tube, followed by insertion of a guidewire through this rupture to create a guide for subsequent placement of a modified NJ tube. We used this technique in a child with a critical need for an NJ tube, in whom routine guidewire exchange was not feasible because of tube obstruction as well as the patient's anatomic abnormalities. This technique might also be useful for other patients in whom standard techniques are ineffective.

Duodenal perforation caused by a transpyloric tube in a critically ill infant

OBJECTIVE

We describe the case of a 2-mo-old infant who weighed 3.5 kg, had alveolar interstitial pneumopathy on mechanical ventilation, and developed a duodenal perforation due to a 6-Fr polyurethane transpyloric tube.

METHODS AND RESULTS

Abdominal ultrasound showed the tube to be within the intestinal lumen. Due to this diagnostic error, nutrition was administered through the tube and the patient developed severe peritonitis. Laparotomy showed a perforation due to the transpyloric tube at the level of the union of the second and third portions of the duodenum. The perforation was sutured but the patient developed new intestinal perforations with severe progressive intestinal damage, leading to multiorgan failure and death.

CONCLUSIONS

If there is a clinical suspicion of intestinal perforation secondary to insertion of a transpyloric tube, the position of the tube must be confirmed by radiographic and echographic techniques. In case of doubt, the tube should be withdrawn and endoscopic or contrast radiographic evaluation must be performed.

Disorders of intestinal rotation and fixation ("malrotation")

Malrotation with volvulus is one of the true surgical emergencies of childhood. Prompt radiological diagnosis is often paramount to achieving a good outcome. An understanding of the normal and anomalous development of the midgut provides a basis for understanding the pathophysiology and the clinical presentation of malrotation and malrotation complicated by volvulus. In this essay, the radiologic findings of malrotation and volvulus are reviewed and illustrated with particular attention to the child with equivocal imaging findings.

Intentional and unintentional abuse of infants and children

Intentional abuse of an infant is usually apparent. External injuries such as burns, bites, and bruises, as well as the skeletal changes of fractures, frequently multiple and in various stages of healing, are obviously intentionally inflicted, and are impossible accidental injuries for the nonambulatory young infant. Similar injuries in young children may be more difficult to evaluate because of their fear of and intimidation by the person who inflicted the injury. Fortunately, the high degree of suspicion regarding the nature of the injury permits the physician to make his accusations with legal protection in our judicial system. Every radiologist should be concerned with the responsibility of reporting to the referring physician the possibility of intentional trauma to infants and children. In Harris County, where Houston is located, there are 1,500 reports per month of child abuse; in other words, this approximates 18,000 cases a year in our community, and the radiologist is frequently the first physician to see evidence of the abused child. Not only is it a moral responsibility for the radiologist to report his suspicions, but in the state of Texas, as in other states, "any person having cause to believe that a child's physical and mental health, or welfare has been or may be adversely affected by abuse or neglect shall report" to the appropriate agency. A more recent amendment to this law is a penalty for failure to report. A person commits an offense if the person has cause to believe that a child's physical and mental health or welfare has been or may be adversely affected further by abuse or neglect and knowingly fails to report it. It is hoped that any radiologist recognizing either pathognomonic or suspicious signs of child abuse will have the conscience and courage to take a strong stand for the protection of the abused infant or child. Accidental injuries in older children may offer problems in diagnosis if there is no history available or if there is a denial of an injury. Some of these injuries may produce radiographic findings suggesting some form of metaphyseal or diaphyseal dysplasia. Iatrogenic injuries are frequently the result of physiologic or anatomical response to proper and lifesaving treatment. The most serious of these are found in the premature infant, who may suffer chronic lung disease or, more seriously, brain damage.(ABSTRACT TRUNCATED AT 400 WORDS)