Curr Treat Options Peds

DOI 10.1007/s40746-017-0089-5

General Surgery (D Carney, Section Editor)

Practical Approach to Imaging

of the Pediatric Acute
Abdomen
Joo Y. Cho, MD1,*
Craig Lillehei, MD2
Michael J. Callahan, MD1
Address
*,1
Department of Radiology, Boston Children’s Hospital and Harvard Medical
School, 300 Longwood Ave, Boston, MA, 02115, USA
Email: jooyupcho@gmail.com
2
Department of Surgery, Boston Children’s Hospital and Harvard Medical School,
300 Longwood Ave, Boston, MA, 02115, USA

* Springer International Publishing AG 2017

This article is part of the Topical Collection on General Surgery

Keywords Pediatric acute abdomen I Diagnostic imaging I Radiography I Fluoroscopy I Ultrasonography I Computed
tomography

Opinion statement
Infants and children commonly present to the emergency department (ED) with abdominal
pain, yet clinical evaluation of this condition remains extremely challenging due to
overlapping clinical symptoms and signs. Although many causes of abdominal pain are
self-limited, accurate and prompt diagnosis is important for proper triage and manage-
ment, particularly in the setting of emergent conditions such as midgut volvulus or acute
appendicitis. The utility of imaging with radiography and fluoroscopy is well established,
although there have been significant recent advances in cross-sectional medical imaging
for pediatric abdominal emergencies which allows for further applications of ultrasonog-
raphy (US), computed tomography (CT), and magnetic resonance imaging (MRI). Superior
diagnostic performance is often achieved using a combination of modalities, but a wide
variety of complex imaging protocols can hinder clinicians from requesting the most
appropriate imaging study. A close working relationship between radiologists and refer-
ring clinicians is encouraged to optimize the use of imaging services, particularly in the
setting of the acute abdomen. Emerging clinical decision support tools can further assist
clinicians to make appropriate imaging study requests.
 General Surgery (D Carney, Section Editor)

Introduction
Acute abdominal pain is a very common presenting
symptom to the pediatric emergency department [1].
According to the Centers for Disease Control and Pre-
vention, abdominal pain is the third leading cause of
emergency visits in children [2] and represents a broad
spectrum of medical and surgical conditions ranging
from self-limiting conditions to truly life-threatening
emergencies. Prompt diagnosis is important to mini-
mize patient discomfort and potential complications
from delayed treatment. However, clinical evaluation
can be challenging because of a significant overlap in
presentation of various disease processes. Localization
of pain is often non-specific, and gathering relevant
clinical history from a patient or parent can be extremely
challenging [1, 3]. One of the most important initial
clinical decisions is properly triaging surgical emergen-
cies from those clinical situations which are less severe,
and diagnostic imaging is often an essential component
of the initial clinical work-up [2, 4].
Imaging of the pediatric abdomen includes evalua-
tion of the solid viscera (liver, spleen, pancreas,
kidneys), hollow viscera (stomach, small intestine, large
intestine, and rectum), peritoneal cavity, and the retro-
peritoneum [5]. Proper choice of diagnostic imaging
depends entirely on the differential diagnosis. The pri-
mary role of imaging is to determine the etiology of the
abdominal pain and identify relevant complications [1,
4]. There are several imaging modalities available in
most radiology departments, including digital or com-
puted radiography (plain films), fluoroscopy, ultraso-
nography (US), computed tomography (CT), and mag-
netic resonance imaging (MRI).
Advances in imaging technology and imaging proto-
cols offer significant benefits for patient care, but such
complexity can create additional challenges for the or-
dering clinician. In an effort to guide both radiologists
and clinicians, the American College of Radiology
(ACR) established evidence-based guidelines and per-
formance parameters to help choose the most appropri-
ate imaging or treatment decisions. However, it should
be noted that a majority of these guidelines are princi-
pally designed for adult patients. More recently, the ACR
created ACR Select ™, which is a digitally consumable
version of the ACR Appropriateness Criteria ® (www.acr.
org), which can be incorporated into computerized or-
dering and electronic health record systems to help
healthcare providers order the most appropriate medical
imaging studies for a given clinical question. Several
other commercially available clinical decision support
(CDS) tools are available, including National decision
support company (NDSC), MedCPU© (www.medcpu.
com), MedCurrent (www.medcurrent.com), Medicalls
(www.medicalls.com), and Nuance (www.nuance.
com), although this technology does come with a finan-
cial cost.
We will review the current literature and accepted
practice for imaging of the pediatric acute abdomen with
an emphasis on the pros and cons of common diagnos-
tic imaging modalities. Salient imaging findings and
diagnostic strategies for several commonly encountered
acute pediatric surgical processes will also be reviewed.
The abdominal applications of pediatric nuclear medi-
cine imaging are an entirely separate discussion and will
not be addressed in this manuscript.

Radiography
Although there is no consensus on the most appropriate imaging test for the
evaluation of acute abdominal pain, an abdominal radiograph is commonly
the initial imaging study [2]. Clinicians may choose to request a single supine
view, supine and upright views, or include a decubitus view as part of the acute
abdominal series, depending on the clinical question to be answered. An
upright or decubitus view may be obtained if there is a concern for intraperi-
toneal free air or air-fluid levels. However, in a majority of cases, a single supine
radiograph will yield sufficient information, and absence of significant radio-
graphic findings on a single radiograph may be all that is necessary to appro-
priately triage a pediatric patient with abdominal pain [6].
 Practical Approach to Imaging of the Pediatric Acute Abdomen Cho et al.

Advantages of radiography include low cost, wide availability, portability,

rapid acquisition, lack of the need for sedation, and minimal exposure to
ionizing radiation. Abdominal radiography has been shown to be useful when
assessing for fecal burden, foreign body ingestion, small bowel obstruction, or
hollow viscous perforation [2, 7, 8]. Imaging findings on abdominal radiogra-
phy can help the radiologist determine if there is a need for additional cross-
sectional imaging [6]. However, despite the known advantages of abdominal
radiography, it generally has a lower sensitivity and specificity than US, CT, or
MRI for acute abdominal pathology. If there is strong clinical concern for acute
intra-abdominal pathology, cross-sectional imaging may be indicated despite a
normal abdominal radiograph.
Current ACR guideline supports abdominal radiography for initial assess-
ment of abdominal distension, suspected constipation, suspected necrotizing
enterocolitis, toxic megacolon, evaluation of certain medical devices, congenital
gastrointestinal abnormalities, and urinary tract calculi among others [8]
(Table 1).

Ultrasonography
US is an extremely powerful imaging modality in children, and the utility of
abdominal ultrasonography has been well documented in the pediatric litera-
ture. US is widely available, cost-effective, and often successful in visualizing
many of the causes of acute abdominal pain in children. Key advantages of US
include lack of ionizing radiation and an ability to perform focused, dynamic
evaluation at the site of maximum tenderness with graded-compression tech-
nique. Sedation is not necessary in the vast majority of cases. Advanced

Table 1. Summary of study indications for abdominal radiographs in pediatric patients [8]
Evaluation and follow-up of abdominal distension, non-obstructive ileus, or bowel obstruction
Assessment of fecal load and constipation in children
Assessment of necrotizing enterocolitis, especially in the premature infants
Assessment of congenital gastrointestinal abnormalities
Follow-up assessment of postoperative patients, including detection of retained surgical foreign bodies
Evaluation of urinary tract calculi and lithotripsy patients
Assessment of ingested or other introduced foreign bodies
A scout radiograph prior to a planned imaging study such as fluoroscopy
Assessment of pneumoperitoneum
Assessment of possible toxic megacolon
Evaluation of unstable patients after blunt abdominal trauma
Evaluation of a palpable abnormality (i.e. mass) in an infant or child
Localization of pancreatic duct stone prior to lithotripsy and endoscopic stone removal
Assessment of suspected retained video endoscopy capsule and determination of location of patency capsule
Evaluation of colon transit time using radiodense markers
 General Surgery (D Carney, Section Editor)

functions such as color and spectral Doppler, cine recordings, harmonic imag-
ing, extended field-of-view imaging, and three-dimensional capabilities provide
highly relevant and useful information [5] in the setting of acute abdominal
pain. For these reasons, there has been expanding role of US in pediatric
imaging since late 2000s [3].
Although there are virtually no disadvantages to performing a US in a
pediatric patient with significant abdominal pain, the diagnostic performance
of US is extremely operator dependent. Sensitivity and specificity is decreased in
patients with higher body mass index (BMI). Furthermore, experienced pedi-
atric sonographers may not be available outside of major pediatric centers
limiting its utility for the primary evaluation of abdominal pain in infants and
children in certain settings.
At our institution, patients with abdominal pain and clinical suspicion for
acute appendicitis, intussusception, pyloric stenosis, obstructive uropathy,
nephrolithiasis, ovarian torsion, and pancreaticobiliary pathology are almost
exclusively initially evaluated with US. Diagnostic performance of US is signif-
icantly enhanced by direct involvement of our referring clinicians with focused
clinical history and differential diagnosis.
The ACR appropriateness criteria does not provide a detailed guideline for
the assessment of generalized abdominal pain in pediatric patients. However,
US typically ranks higher than CT, abdominal radiography, and MRI for chil-
dren presenting with localizing right lower quadrant pain and suspected acute
appendicitis [9] (Table 2).
Although not specifically addressed in this manuscript, contrast-enhanced
US is becoming an important adjunct to pediatric abdominal imaging and
shows significant promise for the evaluation of multiple pediatric abdominal
diagnoses, including acute abdominal pain.

Computed tomography
Computed tomography (CT) is a non-invasive imaging modality that
uses ionizing radiation and advanced computer technology to generate
detailed cross-sectional images of the body and is one of the most
important medical imaging advances of the twentieth century. Although
CT study generally exposes patients to a higher dose of ionizing radia-
tion than radiography, the benefits of a clinically indicated and appro-
priately performed CT will virtually always outweigh the small potential
risks [10, 11]. CT has been perceived as a modality that imparts high
levels of radiation exposure, although when utilizing modern CT tech-
nology, gonadal doses for CT enterography have been reported to be
lower than those for a typical upper gastrointestinal series with small
bowel follow through [12].
Advantages of CT include wide availability, lower operator dependence than
US, and extremely rapid image acquisition relative to US or MRI. CT is partic-
ularly useful in patients with uncertain abdominal pathology, multi-organ
disease, or when the extent of disease cannot fully be assessed by US. The need
for sedation for pediatric CT patients is far less compared to MRI, now used in
less than 2% of children younger than 4 years old [6].
CT is often used as an adjunct to US when sonographic assessment is
equivocal or there is a need for further anatomic detail, particularly in the
Table 2. American College of Radiology (ACR) appropriateness criteria ratings of imaging modalities for various abdominal conditions in pediatric and
pregnant patients [9]

ACR score -Abdominal ACR ACR ACR ACR ACR

radiograph score—upper score—contrast Score—Ultrasound score—CT score—MRI
GI enema with with and
contrast without
contrast
Bilious vomiting in 9 8 7 4 N/A N/A
neonate up to
1 week old
Bilious vomiting in 5 9 N/A 3 N/A N/A
infant 1 week to
3 months old
New onset 2 6 N/A 9 N/A N/A
non-bilious
vomiting
Intermittent 1 6 N/A 4 N/A N/A
non-bilious vom-
iting since birth
RLQ pain-suspected 6 N/A 2 8 7 5
appendicitisin
children
Acute 4 2 2 8 5 7
(non-localized)
abdominal pain
and fever or sus-
pected abdominal
abscess in a preg-
nant patient
Relative radiation 0.03–0.3 mSv 0.3–3 mSv 3–10 mSv 0 3–10 mSv 0
level (pediatric)
Practical Approach to Imaging of the Pediatric Acute Abdomen

ACR appropriateness criteria for imaging of bilious and non-bilious vomiting and RLQ pain in pediatric patients and acute abdominal pain in a pregnant patient. Rating scale: 1, 2, 3
usually not appropriate; 4, 5, 6 may be appropriate; 7, 8, 9 usually appropriate
N/A not applicable
Cho et al.
 General Surgery (D Carney, Section Editor)

setting of suspected acute appendicitis. CT is also useful when there is concern

for renal calculi and an equivocal US and can be performed at a fraction of the
dose for other clinical indications [13].
The perceived risk of ionizing radiation from CT has been intensely debated
in the past decade, and currently, there is no consensus on the true risk of low-
level exposure to ionizing radiation, especially below a certain threshold radi-
ation [6]. While it is important to recognize the risks of ionizing radiation and
unnecessary exposures in medical imaging in children should be avoided, the
potential benefits of appropriate and indicated CT far outweighs the theoretical
risks [11].
Given the small theoretical risks of ionizing radiation, pediatric radiologists
generally maintain a conservative approach and adhere to the ALARA (as low as
reasonably achievable) principle, which mandates appropriateness, justifica-
tion, and optimization of imaging, and strives to prevent unnecessary exposure
to ionizing radiation [5, 14] in any child.
The Image Gently® Campaign created by the Alliance for Radiation Safety in
Pediatric Imaging has been instrumental in educating and promoting awareness
of safety in pediatric imaging. Generalized protocols and a multitude of
resources are available on the Image Gently website (www.imagegently.org).
Pediatricians and surgeons are strongly encouraged to visit the website and
utilize the educational materials available for patients, parents, and clinicians.

Magnetic resonance imaging

Although a majority of abdominal MRI studies are performed in patients to
follow-up or further characterize a known chronic disease including malignancy
or inflammatory bowel disease, there is mounting evidence supporting the role
of MRI for evaluation of acute pediatric abdominal emergencies [15•, 16, 17].
At our institution, the most common indication for an urgent abdominal MRI
in children is suspected acute appendicitis when US results are equivocal or
inconsistent with the clinical findings.
The benefits of MRI are well known. MRI has excellent soft tissue contrast
resolution, which allows assessment of subtle soft tissue abnormalities, and
there is no exposure to ionizing radiation. Unlike CT, oral or intravenous
contrast is usually not required for emergent abdominal MRI studies. Despite a
significantly longer scan time than CT, optimization of MR protocols can
significantly reduce the scan times. For example, our departmental appendicitis
MRI protocol has a scan time of approximately 17 min in a cooperative patient
(Table 3), allowing for these examinations to be added on to a busy MR
schedule. Other institutions have also developed a similar MRI appendicitis
protocol [18].
Despite its virtues, effective MRI in young children and developmentally
delayed individuals often requires sedation or anesthesia. Pediatric sedation is
very safe under expert hands, but the procedure does carry a small risk of acute
adverse events such as bradycardia, hypotension, respiratory depression, bron-
chospasm, hallucinations, aspiration, and hypothermia to list a few [19, 20],
especially in children with pre-existing cardiac or pulmonary conditions. The
theoretical deleterious neurodevelopmental effects of anesthetics have also
been described in certain animal models [21, 22]. There was a recently pub-
lished warning by the US Food and Drug Administration (FDA) that repeated or
 Practical Approach to Imaging of the Pediatric Acute Abdomen Cho et al.

Table 3. Example of MRI protocol for acute appendicitis

3T MRI required
Coil: body matrix and multichannel cardiac coil
Breath-hold preferred
Standard sequences:
3 plane localizer
HASTE T2 coronal
HASTE T2 axial
HASTE T2 fat suppression axial
HASTE T2 fat suppression coronal
Optional sequences:
VIBE coronal post-contrast
VIBE axial post-contrast
DWI axial

Standard sequences take approximately 17 min to complete in a cooperative patient

lengthy use of general anesthetic or sedation could in theory affect children’s

brain development and should be avoided when possible [23]. Further work is
needed to assess the neurocognitive effects of anesthetics on young children.
An MRI environment is loud, isolated, and sometimes claustrophobic,
which can be frightening for a young child or developmentally delayed indi-
vidual. It is important to remember that children are less apt to follow verbal
instructions and tend to react with greater stress and anxiety to the unfamiliar
environment, which further justifies shortening MRI scan times as much as
possible. Additional limitations of MRI include high cost and limited avail-
ability [24], especially in non-tertiary or smaller clinics.

Fluoroscopy
Fluoroscopy is an important modality in the setting of acute pediatric abdom-
inal pain. It is generally used when there is a suspicion for a primary gastroin-
testinal process, particularly in the acute setting. Fluoroscopic imaging also
provides guidance for urgent enteric tube placement and tube localization.
Notable strengths of fluoroscopy include dynamic, real-time evaluation of
certain abnormal enteric processes such as abnormal esophageal peristalsis or
small bowel stricture. In addition, clinically concerning areas can be further
assessed with various patient positioning, magnification, and compressive
paddles.
It is worth noting that like US, fluoroscopic evaluation of the pedi-
atric abdomen is operator dependent and requires well-rehearsed team-
work between the radiologist and the support staff. Like CT and radi-
ography, fluoroscopy utilizes ionizing radiation but doses can be kept to
a minimum with pulsed fluoroscopy technique, proper collimation, and
optimization of fluoroscopic machines. At our institution, routine gas-
trointestinal (i.e., upper gastrointestinal (UGI)) or genitourinary (i.e.,
 General Surgery (D Carney, Section Editor)

voiding cystourethrogram (VCUG)) studies expose the patients to ap-

proximately 0.1 to 0.3 mGy of radiation, which is considered a very low
dose [14], with minimal risk to the pediatric patient.
In the emergency setting, an upper gastrointestinal (UGI) series is almost
always indicated in pediatric patients presenting with acute abdominal pain
and bilious emesis, particularly newborns. A UGI has been shown to be 96%
sensitive in detecting malrotation and 79% sensitive in detecting midgut vol-
vulus [25].
Fluoroscopic-guided therapeutic air or hydrostatic reduction can also be
performed emergently to reduce an ileocolic intussusception once the diagno-
sis has been made with abdominal radiography or US. Most recently revised
ACR practice guidelines state that both air and hydrostatic intussusception
reductions are acceptable. There is variability among institutions regarding the
type of enema reduction used [26]. However, air enema has been shown to
reduce faster [26], and recently published meta-analysis showed that air enema
has superior success rate (82.7 versus 69.6%) and lower perforation rate (0.39
versus 0.43%) compared to liquid enema [27].
Fluoroscopic-guided contrast enema is indicated for other suspected causes
of congenital or acquired lower gastrointestinal tract obstruction, such as me-
conium ileus, small left colon syndrome, ileal or colonic atresia, or Hirsch-
sprung disease in infants and children. Further details on the exam preparation
and technique can be viewed in the ACR practice parameters for the perfor-
mance of pediatric contrast examination of the small bowel and pediatric
fluoroscopic contrast enema examinations.

Surgical acute abdomen examples

We will provide several common surgical causes of acute abdominal pain in
children. These conditions must be diagnosed promptly and accurately to
reduce the risk of potentially life-threatening complications. The following are
selected cases commonly encountered in the general pediatrics practice with
recommended imaging strategy.

Acute appendicitis
Acute appendicitis is the most common surgical emergency in childhood,
representing as much as 80% of pediatric abdominal emergencies [1]. This
condition accounts for approximately 84,000 hospitalizations per year in the
USA [28], which represents approximately a third of all admissions with ab-
dominal pain [29••]. Appendicitis is due to an obstruction of the appendiceal
lumen, which then leads to luminal distension, mural ischemia, inflammation,
and infection [12, 15•]. Patients usually present with acute onset abdominal
pain, nausea/vomiting, fever, and leukocytosis [1]. Definitive treatment most
often involves surgical intervention.

Imaging strategy and key findings

Although the clinical diagnosis of acute appendicitis is relatively common,
further assessment with US using graded compression is often requested in
patients with moderate to high risk of appendicitis based on initial clinical
 Practical Approach to Imaging of the Pediatric Acute Abdomen Cho et al.

assessment [29••]. There is no widespread agreement on the Bbest^ method of

diagnosis.
The normal appendix is a small compressible, blind-ending tubular struc-
ture. Finding a normal appendix by US can be challenging, especially if the
appendix is retrocecal or there are many obscuring bowel loops.
Common US findings of acute appendicitis include a non-compressible,
enlarged, and distended blind-ending tubular structure with diameter 97 mm
(measured from outer margin to outer margin). Additional primary and sec-
ondary signs may include mural hyperemia, obstructing appendicolith, and
surrounding hyperechogenic fat [30] (Fig. 1a, b). Accumulation of complex
right lower quadrant fluid without clear identification of an appendix, increased
periportal echogenicity, simple or complex periappendiceal fluid, and dilated
bowel loops are highly predictive of perforated appendicitis [31, 32].
Recently published data showed sensitivity and specificity of US for sus-
pected acute appendicitis as high as 97.1 and 94.8% [3] and accuracy of 96%
[33]. At our institution, the initial US results are combined with laboratory
values (white blood cell and neutrophil counts) for further risk stratification of
patients into low risk for appendicitis, moderate risk for appendicitis/high risk
for negative appendectomy, and high risk for appendicitis categories [29••].
MRI is considered after equivocal US in patients with moderate risk for
appendicitis/high risk for negative appendectomy group, but MRI is not per-
formed in patients with very low or very high clinical concern for appendicitis
(see diagram) at our institution (Fig. 2).
MRI has been shown to be highly accurate with sensitivity range of 94.4 to
100% and specificity of 96 to 100% [15•, 17, 34] with overall diagnostic
performance comparable to CT for equivocal appendicitis and appendiceal
perforation in pediatric patients [34]. CT is also a very rapid, accurate, and
reproducible modality for the evaluation of suspected acute appendicitis and is
commonly used in lieu of MRI at many pediatric institutions [35].

Intestinal malrotation and midgut volvulus

Intestinal malrotation refers to incomplete bowel rotation and abnormal fixa-
tion during embryologic development. These patients are at risk for midgut
volvulus, which results from twisting of narrow mesentery around the SMA axis,
causing bowel obstruction and ischemia [5]. Patients often present with bilious

Fig. 1. a Six-year-old male presenting with peri-umbilical pain migrating to the right lower quadrant. Grayscale ultrasound shows a
distended, blind-ending, and hyperemic tubular structure (arrows) measuring 1.8 cm in diameter, consistent with acute appendi-
citis. There is increased echogenicity in the surrounding fat, consistent with inflammation. There is no sonographic evidence of an
obstructing appendicolith. b Color Doppler shows mural hyperemia in this abnormally distended appendix.
 General Surgery (D Carney, Section Editor)

Fig. 2. A clinical algorithm for assessment and triage of patients with suspected acute appendicitis [29].

emesis, abdominal pain and distension, and failure to thrive [36]. Once the
diagnosis is made, treatment is almost always surgical. They may also have
peritoneal bands (Ladd’s bands) of the abnormally positioned cecum in the
right upper quadrant causing proximal duodenal obstruction.

Imaging strategy and key findings

Conventional approach to infants and children presenting with abdominal
pain and bilious vomiting starts with abdominal radiography, followed by
either an urgent UGI or contrast enema, depending on the level of obstruction
suggested by the abdominal radiography. It is important to note that abdom-
inal radiographs can be entirely normal in patients with malrotation.
Midgut volvulus is an upper gastrointestinal emergency, and a UGI must be
performed promptly if the diagnosis is suspected. Delay in diagnosis may result
in further ischemic bowel injury. Barium sulfate is typically administered for an
UGI, but water-soluble contrast can alternatively be considered in premature
infants [37].
In a normal UGI study, both the second and fourth portions of the duode-
num course posteriorly in the retroperitoneum and a normal DJJ should be
positioned to the left of the spine at a similar level to the pylorus (Fig. 3).
Proximal jejunal bowel loops are usually located in the left abdomen but can
also normally be positioned in the right abdomen in patients with documented
normal position of the duodenum and DJJ [30].
Malrotation generally results in an abnormal location of duodenal-
jejunal junction and associated cecal malposition in 80% of patients [30].
 Practical Approach to Imaging of the Pediatric Acute Abdomen Cho et al.

Fig. 3. Twelve-year-old male with chronic non-bloody and non-bilious vomiting. A frontal view of fluoroscopic UGI shows normally
positioned duodenojejunal junction (arrow) to the left of the vertebral column at the level of the duodenal bulb (arrowhead).

The DJJ is usually abnormally positioned below the pylorus and often to
the right of the spine or in the midline on an UGI series. A so-called
corkscrew appearance of bowel or abrupt cut off of contrast column may
be seen in patients with superimposed volvulus and represents a surgical
emergency requiring urgent exploration in an effort to salvage potentially
compromised bowel (Fig. 4).
Although midgut malrotation or midgut volvulus has not been com-
monly diagnosed by US, this modality has been shown to be a useful
adjunct to diagnosis of midgut volvulus with sensitivity and specificity of
89 and 92%, respectively [25]. Reversal or aberrant superior mesenteric
vein/superior mesenteric artery (SMV/SMA) axis has been shown to be
predictive and diagnostic of midgut volvulus [38].

Fig. 4. Four-day-old male with bilious emesis. Fluoroscopic upper GI series with barium sulfate shows malpositioned duodenal
jejunal junction to the right of the spinal column with cork-screw configuration of the proximal jejunum (arrow), consistent with
malrotation and midgut volvulus.
 General Surgery (D Carney, Section Editor)

Ileocolic intussusception
Idiopathic ileocolic intussusception is the most common cause of small bowel
obstruction in young children and occurs when the distal ileum
(intussusceptum) invaginates into the cecum (intussuscipiens). Idiopathic
ileocolic intussusception occurs most commonly between the ages of 3 months
to 3 years [6, 30]. Incidence is about 56 per 100,000 children, and it is slightly
more common in girls. Patients usually present with intermittent colicky ab-
dominal pain, vomiting, and currant jelly bloody stool [5, 6]. The cause of
intussusception is unknown in more than 90% of the cases, but approximately
5–6% cases are associated with a pathologic lead point such as Meckel’s
diverticulum, intestinal polyp, enteric duplication cyst, lymphoma, or other
space occupying lesions [5, 39].

Imaging strategy and key findings

At our institution, supine and upright abdominal radiographs are requested in
certain patients with severe abdominal pain, particularly if there is a strong
suspicion for intussusception. The presence of a soft tissue mass in the right
abdomen may raise concern for intussusception, often precipitating further
evaluation with US [6] (Fig. 5a).
At our institution, US is almost always performed as the initial imaging
evaluation for patients with clinical or radiographic concern for intussuscep-
tion. An ileocolic intussusception can appear as a Btarget^ or Bdoughnut^ sign
on US (Fig. 5b), with intussuscipiens representing the hypoechoic outer wall,
intussusceptum as internal hypoechoic ring, and hyperechoic mesenteric fat in-
between [30]. In the sagittal plane, the intussusception will resemble a kidney,
the so-called pseudo kidney sign with centrally positioned hyperechoic mes-
enteric fat and multiple layers of outer hypoechoic bowel walls [30] (Fig. 6).
Identification of a lead point or trapped fluid within the intussusceptum have
been shown to be associated with lower reduction rate [40].
Once the diagnosis of intussusception is made, urgent fluoroscopic air (or
hydrostatic) reduction is performed to reduce the intussusception (Fig. 7a–d).
Many intussusception reductions are performed at pediatric institutions. When

Fig. 5. a Thirty-month-old male presenting with episodic abdominal pain for 2 days. Upright abdominal radiograph shows a soft
tissue mass (arrow) in the right lower abdomen, suspicious for intussusception. There is no intraperitoneal free air or evidence of
bowel obstruction. b Transverse grayscale ultrasound of the intussusception shows concentrically alternating hypoechogenic and
hyperechogenic rings representing intussuscipiens, intussusceptum, and mesenteric fat, collectively known as the Btarget sign.^
 Practical Approach to Imaging of the Pediatric Acute Abdomen Cho et al.

Fig. 6. Three-year-old male with colicky abdominal pain. A longitudinally oriented abdominal ultrasound shows an intussusception
(white arrow) resembling an appearance of a normal kidney (dark arrow); the so-called pseudo kidney sign.

performing an air contrast reduction, insufflation pressure should not exceed

120 mmHg when the child is at rest [6]. Presence of peritonitis or pneumo-
peritoneum are the two absolute contraindications to the procedure [6].

Fig. 7. a, b, c, d Sixteen-month-old previously healthy male presents with intermittent abdominal pain due to ileocolic
intussusception. Series of fluoroscopic images (a–d) during air enema reduction (patient prone) shows gradually reducing
intussusception (white arrows) from the transverse colon to cecum. The reduction is complete once air in the small bowel is seen
(dark arrow).
 General Surgery (D Carney, Section Editor)

According to the literature, the success rate of reduction is 82.7 and 69.6% with
perforation rates of 0.39 and 0.43% for the air and hydrostatic techniques,
respectively [27].

Hypertrophic pyloric stenosis

Hypertrophic pyloric stenosis is the most common cause of bowel obstruction
in infants G6 months of age with incidence of 2 to 5 per 1000 births in
European descendants and 0.7 per 1000 births in African American or Asian
descendants [5]. It occurs 2.5 to 5.5 times more commonly in males and in first-
born infants [30]. Although appropriate diagnostic and surgical management
has improved over the years, the etiology of pyloric muscular hypertrophy
remains unknown. Patients commonly present with acute onset, or gradually
worsening non-bilious projectile vomiting over a course of days to weeks,
resulting in weight loss, dehydration, and hypochloremic metabolic alkalosis.
Treatment is fluid resuscitation, electrolyte repletion, and surgical pyloromyot-
omy. Both open and laparoscopic surgical interventions have been shown to be
equally effective and safe [41].

Imaging strategy and key findings

The role of US for the diagnosis of pyloric stenosis is well established
and regarded as the Bgold-standard,^ offering a rapid, non-invasive, and
accurate diagnosis [42, 43]. A normal pyloric channel is small and thin
when visualized with a fluid-filled gastric antrum in close proximity to
the duodenal bulb. An abnormally thickened and elongated pyloric
muscle measures 93 mm in single-wall thickness with pyloric channel
length of 15 mm or longer (Fig. 8). Caution should be taken when
evaluating for pyloric stenosis because early pyloric hypertrophy that
does not yet meet the measurement criteria for pyloric stenosis can be
symptomatic. As with many other ultrasonographic studies, the tech-
nique is operator dependent and should be performed by an experi-
enced sonographer. It is also important to continuously assess the
pylorus over a period of time to exclude potential mimickers such as
pylorospasm or collapsed gastric antrum (Fig. 9a, b).

Fig. 8. Seventy-six-day-old female full-term infant presenting from outside hospital with non-bilious vomiting over the course of
2 weeks. Grayscale ultrasound shows abnormally thickened pyloric muscle measuring 4 mm (arrowheads) and pyloric channel length
of 19 mm, which did not allow passage of echogenic glucose. Ultrasound findings were diagnostic of hypertrophic pyloric stenosis.
 Practical Approach to Imaging of the Pediatric Acute Abdomen Cho et al.

Fig. 9. a Eighty-four-day-old female infant presenting with vomiting and diarrhea. Grayscale ultrasound shows partially collapsed
gastric antrum mimicking a borderline abnormal pylorus with single wall thickness of 2 mm and channel length of 10 mm. b
Continuous monitoring with grayscale ultrasound shows opening of the pylorus and passage of echogenic air and glucose solution
in to the proximal duodenum.

Conclusion
Acute abdominal pain is a common presenting symptom in pediatric emer-
gency department. While a majority of cases may be self-limited, truly life-
threatening conditions must be diagnosed quickly and treated expeditiously.
Imaging often provides an important role in the diagnosis and treatment in
these patients. Rapid and effective imaging requires communication and col-
laboration between pediatric radiologists, general pediatricians, surgeons, and
emergency medicine physicians. Increased access to online clinical decision
support tools has the potential to further promote appropriate imaging, in-
crease the effectiveness of imaging, and decrease costs [44].

Key points
Abdominal radiographs are useful for excluding bowel obstruction or intraper-
itoneal free air, although sensitivity and specificity are generally lower than
cross-sectional imaging. Additional diagnostic imaging is advised in patients
with high clinical suspicion for abdominal pathology.
US is extremely useful for the initial assessment of pediatric abdominal pain and
will continue to define its role in pediatric imaging. Key benefits of US include
wide availability, relatively lower cost, lack of ionizing radiation, and ability to
perform focused evaluation. Sedation is also not needed in vast majority of
cases. However, it is important to note that the technique is operator dependent
and experienced pediatric sonographers may not always be available.
CT is a rapid and widely available imaging tool for pediatric patients, especially
when other imaging modalities cannot sufficiently depict pathology. There has
been a substantial decrease in the need for sedation/anesthesia for CT in young
children and developmentally delayed individuals in recent years, further add-
ing to the utility of CT in these patients. In addition, advancing technology and
refinement in the imaging protocols continue to lower the radiation dose for
CT. While being mindful to avoid unnecessary exposure to ionizing radiation in
 General Surgery (D Carney, Section Editor)

medical imaging, the potential benefits of a clinically indicated CT generally far

outweighs the small theoretical risks.
There is growing interest in the application of MRI in pediatric emergency, and
there is extensive literature supporting the utility of MRI for further assessment
of suspected acute appendicitis. The major benefit of MRI is its exceedingly
superior soft tissue contrast resolution, and we anticipate further application of
MRI in pediatric emergency setting. Notably, there remain lingering issues of
availability, high cost, prolonged scanning time, and need for sedation in
certain pediatric patients.
Fluoroscopy has been essential to pediatric imaging for many years with
both diagnostic and therapeutic applications. In an emergency setting,
fluoroscopy is used to diagnose causes of upper gastrointestinal obstruc-
tion including midgut volvulus and perform therapeutic enemas to
reduce ileocolic intussusception. Key benefits of fluoroscopy include
real-time imaging and ability to perform a focused examination with
dynamic evaluation of bowel. However, it is worth noting that fluoro-
scopic procedures are operator dependent and require well-rehearsed
teamwork between the radiologist and the support staff.
Decision support tools such as ACR select, ACR-SPR practice parameter guide-
lines, and other online resources described in this manuscript have been devel-
oped to support both radiologists and clinicians choose the most appropriate
imaging study.

Compliance with Ethical Standards

Conflict of Interest
Joo Y. Cho declares that he has no conflict of interest. Craig Lillehei declares that he has no conflict of interest.
Michael J. Callahan declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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