Diagnostic imaging of acute abdomen
In gallstone ileus, plain abdominal radiographs reveal linear free gas in the right upper quadrant. This pattern corresponds to pneumobilia (pneumobilia), the presence of gas within the biliary tree, which typically indicates the formation of a bilioenteric fistula. Contrast-enhanced computed tomography allows the identification of classical signs of small bowel obstruction. Gas is also identified within the lumen of the common bile duct, and the cause of the obstruction is a gallstone with characteristic layered (laminar) calcification, located in the distal ileum.
In intussusception, a supine plain radiograph demonstrates a soft-tissue density mass in the upper abdomen. A pathognomonic crescentic gas collection forms around the invaginated portion of the bowel (the head of the intussusceptum). Barium enema is used for detailed visualization of massive intussusception. In adult patients with prolonged abdominal pain, this condition may be caused by a carcinoid tumor measuring approximately 10 mm in diameter, acting as the lead point of the intussusception.
Evaluation of skeletal injuries and pediatric trauma
The evaluation of pediatric radiographs requires careful analysis of the mechanism of injury. Most fractures are attributed to accidental trauma, the plausibility of which is verified by comparing the injury morphology, matching the radiological age of the fracture with the stated time of the event, and consulting age-specific epidemiological data.
During analysis, it is essential to differentiate normal variants from signs of unrecognized trauma and potential child abuse:
- Normal variant: physiological subperiosteal bone formation. In healthy infants (e.g., at 4 weeks of age), it appears as a smooth mineralized band separated from the cortical layer. It is located along the diaphysis of the tibia, and its thickness does not exceed 2 mm.
- Suspected child abuse: visualization of radiolucent, irregular lines with surrounding sclerosis (e.g., through the acromion processes). If follow-up radiographs at 6 weeks reveal healing on one side and no healing on the other, this indicates fractures of different ages resulting from previously unrecognized violence.
Additionally, skeletal changes such as angulated fractures and fragmentation must be differentiated from generalized bone disorders: rickets, Menkes syndrome, Schmid-type metaphyseal chondrodysplasia, and osteogenesis imperfecta.
Neuroimaging in pediatric traumatic brain injury
Traumatic brain injury remains a leading cause of morbidity and mortality in children under 2 years of age who have experienced abuse, with twins at an increased risk. Abusive head trauma (Abusive Head Trauma, AHT) occurs from forceful shaking, which may be accompanied by impact to the skull.
Clinical symptoms are often non-specific, ranging from apathy, pallor, and vomiting to seizures, cyanosis, shock, and respiratory failure. Hypoxic-ischemic injury may present with apnea and loss of consciousness. The primary "red flag" for the diagnostician is the dissociation (incongruity) between the reported history and the actual intracranial injuries.
The diagnostic imaging algorithm includes:
- First line: computed tomography (CT) of the head.
- Second line: MRI of the brain and spine, skeletal survey of all bones, and ophthalmoscopy.
Differentiating accidental from non-accidental trauma is extremely challenging. Retrospective data have not revealed a statistically significant difference in the patterns of subdural hematomas, presence of fractures, or retinal hemorrhages. However, perpetrator confessions indicate that the shaking is extremely violent, recurs in 55% of cases (averaging about 10 episodes), and the primary motive is the desire to "stop the infant's crying."
Radiological signs of salivary gland pathology
Sialography plays a key role in the diagnostic imaging of salivary duct pathologies. In sialodochitis, radiological examination reveals irregular dilation and stricture of ducts of various calibers. Notably, the severity of these changes on the sialogram does not correlate with the stage of the inflammatory process. The disease carries a favorable prognosis, though it is sometimes complicated by the formation of salivary stones.
Chronic interstitial sialadenitis develops in middle-aged and elderly individuals with equal frequency in men and women. It arises against the background of general somatic diseases (diabetes mellitus, gastritis, prostatitis) following a non-inflammatory sialadenosis stage. The parotid glands are primarily affected, clinically accompanied by their symmetric, painless or mildly painful swelling of soft consistency.
When evaluating pediatric trauma, remember the "Dissociation" rule: the primary warning sign (red flag) is a clear incongruity between the stated mechanism of injury and the actual radiological findings (fractures at different stages of healing, unexplained intracranial abnormalities).
Class and exam questions
How to distinguish normal subperiosteal bone formation from trauma in an infant?
Normally, this is a smooth mineralized band along the diaphysis up to 2 mm thick. In trauma, radiolucent, irregular lines with marginal sclerosis are identified at various stages of healing.
What are the radiographic findings in bowel intussusception?
A plain radiograph of the upper abdomen visualizes a soft-tissue mass, around the head of which a characteristic crescentic gas collection is identified.
What is the radiological presentation of sialodochitis, and does it depend on the stage of inflammation?
The sialogram demonstrates irregular dilation and stricture of ducts of various calibers. The severity of these radiological changes does not depend on the current stage of sialadenitis.
What conditions must be differentiated from pediatric fractures?
When fragmentation and angulated fractures are identified, the differential diagnosis includes rickets, copper deficiency (Menkes syndrome), Schmid metaphyseal chondrodysplasia, and osteogenesis imperfecta.
What else to study on this topic
- Criteria for the plausibility of the reported mechanism of accidental skeletal trauma in children.
- Differential diagnosis of angulated fractures versus generalized metabolic bone diseases.
- Clinical presentation and hypoxic-ischemic manifestations of brain injury in infants.
- The role of cytological examination of secretion smears in the diagnosis of sialodochitis.
- The pathogenetic transition chain from sialadenosis to chronic interstitial sialadenitis.
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