To

Semina
r
Presented by :
Dr. M . Vijay kumar

1
 Case scenario
S/O Lipi Akhter, inborn, 30 minute old boy admitted in NICU
with the complaints of prematurity (31weeks), low birth
weight (1200gm) and respiratory distress soon after birth.
Mother having no h/o taking antenatal corticosteroid

On examination - Baby was cyanosed with 2L/min O₂, good

reflex activities, well perfused, euthermic, euglycaemic, R/R:
70 breaths/min, chest indrawing present, grunting audible
without stethoscope , bilateral poor air entry

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1. What is you provisional diagnosis?

➢ Respiratory Distress Syndrome

1. Single investigation you want do first ?

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Radiology in Newborn

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 Overview of presentation
➢Introduction
➢Radiographic examination
➢Chest radiograph
➢Chest x-ray of Common disease in Newborn
➢Position of Tubes and Catheters
➢Abdominal radiograph
➢Common disease in on plain abdominal X-ray
➢Contrast studies
➢Common disease in Newborn on Contrast X-
ray 5
 Introduction
➢Radiography is a great and useful tool for diagnosis of
Neonatal diseases
➢The x-ray is one of the most frequently requested
radiological examinations in neonatal intensive care
units

➢The corner stone of imaging is still conventional

radiography but ultrasound plays an important part

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 Radiographic examination
➢Chest radiograph
➢Abdominal radiograph
➢Babygram
➢Contrast study
➢Barium Contrast study
➢High-osmolality water soluble (HOWS) contrast study
➢Low-osmolality water soluble (LOWS) contrast study.
➢Radionuclide studies

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 Chest radiograph

➢Anteroposterior (A/P) view:

➢Identification of heart and lung disease

➢To see the position of ET tube & other lines

➢ Identifiction of air leak syndrome.

➢Cross-table lateral view:

➢To see the lung tube position - anteriorly or
posteriorly

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 Chest radiograph

➢Lateral decubitus view:

➢ For small pneumothorax or small fluid
collection

➢Upright view:

➢To see free air under the diaphragm

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 Indications of CXR
➢For initial diagnosis of the cause of respiratory distress

➢To Check the position of lines and tubes

➢Monitoring progression and responses to treatment

➢In case of respiratory deterioration

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 Normal CXR
➢Translucent

➢Air bronchogram can be present till 2nd generation of bronchi

in the retrocardiac area
➢Diaphragm- upto 6th rib anteriorly and 8th rib posteriorly

➢The normal cardiothoracic ratio can be as large as 60 percent

➢Residual lung fluid may give appearance of diffuse

opacification during first 4 hours of life

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Normal chest x-ray of a two-hour-old newborn
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Anatomical diagram of the anterior view of the lungs

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 Assessment of the Quality

➢Projection – PA or AP view
➢Breath : Inspiration or Expiration

➢Position

➢Rotation

➢Penetration/exposure

➢Artifact
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Projection

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 Penetration

➢Intervertebral disc can be seen through the heart

➢If you see them very clearly the film is over-penetrated

➢If you do not see them it is underpenetrated

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Good Penetration

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Under penetration Over penetration

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Rotation

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 Well-aligned

Heart size- normal

Heart size exaggerated Heart size- small

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 Inspiration or Expiration

Inspiratory Film Clues Expiratory Film Clues

•Diaphragm domes are • Diaphragms are very domed

rounded •3rd or 4th anterior rib crosses

•5th or 6th anterior rib the diaphragm

crosses the diaphragm on the • Lungs are white

frontal film
• Lungs are black

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 Evidences of hyperinflation

➢Lung expansion > 6 ribs

anteriorly, > 8 ribs posterioly
➢Flattening of diaphragms

➢Ribs are more horizontal

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Cardio-thoracic ratio

➢>50% is considered abnormal

in an adult; more than 60% in a
neonate.
➢AP views make heart appear
larger than it actually is

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 The thymus

➢The thymus is radiologically

characterized by a widening
of the upper mediastinum,
above the cardiac image

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 The thymus
Notch-sign- where the inferior border of the normal
thymus blends with the border of the cardiac silhouette

Wave-sign- corresponding to a gentle undulation on

the thymus surface produced by costal arcs
compression, more frequently to the left

Sail sign- resulting from a peculiar shape of the thymus

appearing like a normal anterior mediastinal sail
shaped structure, more frequently to the right

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Notch-sign

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 Ductus bump

A still open arterial canal

may be seen on a chest
x-ray as a convex
prominence to the left
of the spine, between
T3 and T4 vertebras

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Artifacts

skinfolds- projected
over the
cavity, thoracic
simulate and
pneumothorax may

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Chest x-ray findings of Common
disease in Newborn

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 Respiratory distress syndrome (RDS)

➢Fine, diffuse reticulogranular pattern

➢Air bronchograms
➢Low lung volume
➢Ground glass opacities
➢Whiteout lung

➢These radiographic findings are usually present

shortly after birth but they also may appear after
12-24 hours

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Respiratory distress syndrome (RDS)

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 Radiological grading
Grade I: good lung expansion,
fine reticulogranular mottling
Grade II: mottling with air bronchogram

Grade III: diffuse mottling, heart

borders just discernible, prominent
air bronchogram

Grade IV: bilateral confluent

opacification (white out)
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Chest X Ray of RDS

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 Transient tachypnea of the newborn (TTN)

➢Symmetric perihilar and interstitial streaky infiltrates

➢Hyperinflation

➢Flattening of diaphragm

➢Prominence of the minor fissure

➢Small pleural effusion

➢Mild cardiomegaly

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TTN

Plain chest radiograph

reveals overaerated lungs
with radiating streaky
densities from the hilum
to the peripheral lungs
bilaterally. Right minor
fissure is accentuated

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TTN

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 Pneumonia
➢Diffuse alveolar or interstitial disease that is usually
asymmetric and localized
➢Pneumatoceles - staphylococcal pneumonia
➢Pleural effusions or empyema- bacterial
pneumonia
➢Group B streptococcal pneumonia can appear similar to
respiratory distress syndrome (RDS)

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Pneumonia

Diffuse increase in interstitial

lung markings is typical with
neonatal pneumonia

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Pneumonia

Staphylococcus aureus pneumonia.

Multifocal irregular opacities are
observed in both lungs with
cavitations (small arrows). Right
pleural effusion (long arrow) is
evident obliterating right
costophrenic sulcus

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 Meconium aspiration syndrome (MAS)

➢Bilateral, patchy, coarse infiltrates

➢Hyperinflation of the lungs

➢Flattened diaphragm

➢Increased incidence of pneumothorax

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Meconium aspiration syndrome (MAS).

Chest radiograph showing diffuse

coarse increase in lung markings
accompanied by hyperinflation,
typical for meconium aspiration
syndrome (MAS)

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 Bronchopulmonary dysplasia (BPD)

The radiographic appearance is highly variable-

➢Fine, hazy appearance of the lungs
➢Mildly coarsened lung markings
➢Coarse, cystic lung pattern

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Bronchopulmonary dysplasia (BPD)

Chest radiograph showing a

diffuse, moderately coarse
increase in lung density,
which in a 2-month-old
ventilated ex-preemie is most
consistent
with
bronchopulmonary dysplasia

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Bronchopulmonary dysplasia (BPD)

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Pneumopericardium

Air surrounds the heart,

including the inferior
border

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Pneumomediastinum

AP view. A hyperlucent rim of air is

present lateral to the cardiac border
and beneath the thymus, displacing
the thymus superiorly away from
the cardiacsilhouette (“angel wing
sign”)

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Tension pneumothorax

Left tension pneumothorax as shown

on an anteroposterior chest
radiograph in a ventilated infant on
day 2 of life. Note the accompanying
collapse of the left lung, depression of
the left diaphragm, and contralateral
shift of mediastinal structures

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Congenital Diaphragmatic Hernia

Herniation of bowel
loops into the
left
hemithorax,
shift of the heart
withand
mediastinum to the a
right side.

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Eventration of Diaphragm

Raised left dome of

diaphragm, with
defined diaphragmatic
the
left margin. well

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Cystic adenomatoid malformation

large air filled thin walled

cyst in the right lung with
herniation of the lung to
the contralateral side

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Esophageal atresia with distal TEF

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x-ray with contrast in the
upper esophagus showing
atresia

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Contrast esophagogram
showing an isolated
tracheoesophageal fistula
(H-type) with contrast
delineating
material the

trachea.
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Radiological findings of Common
Cardiac disease

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Boot shaped heart in TOF

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Egg on side in transposition of great artery

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Box shaped heart in ebstain anomaly

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 Position of Tubes and Catheters

➢ Endotracheal tubes (ETT)

➢ Nasogastric tubes (NGT)

➢Umbilical venous catheters

➢Umbilical arterial catheters

➢Central venous lines

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Naso/orogastric tube

Naso/orogastric tube

The naso/orogastric tube

tip should be in the mid-

stomach

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Endrotracheal tube

Normal position- Halfway

between the thoracic inlet
(Medial ends of clavicles)
and the carina (4th
thoracic vertebra)

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➢Endotracheal tube is
positioned in the oesophagus.
➢Chest radiograph shows
dilatation of the esophagus and
stomach, that are filled with air

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Right bronchus intubation
with atelectasis of the
entire left lung.

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➢The endotracheal tube (ETT) tip
is in the bronchus
intermedius.

RUL will also become

atelectatic along with all of left
lung

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Umbilical venous catheter

Normal- Venous umbilical

catheter localized in the
inferior vena cava at T8-T9
level

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Malpositioned
umbilical venous catheter
(UVC). The tip is
malpositioned in the region
of left upper pulmonary
vein across the patent
foramen ovale.

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Umbilical vein line
positioned in the periphery
of the liver through the
right portal vein.

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The umbilical vein line
is positioned in the
umbilical vein and not
deep enough.

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The umbilical arterial catheter

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The umbilical arterial catheter

Low UAC- The tip should be below

the third lumbar vertebra,
optimally between L3 and L4

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The umbilical arterial catheter

High-localization of arterial
umbilical catheter (arrow), the tip
should be between thoracic
vertebrae 6 and 9

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Malposition of umbilical artery line,
folded in the abdominal aorta.

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Deep position of umbilical
artery line, in aortic arch.

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Malposition of umbilical artery
line in left iliac artery.

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Abdominal radiographs

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 Viewes
1. AP view- best view for diagnosing

➢ Intestinal obstruction

2. Cross-table lateral view-

➢ Helps diagnose abdominal

perforation

3. Left lateral decubitus view- Best for diagnosis of

intestinal perforation

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Viewes

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Cross-table lateral view-
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Left lateral decubitus view

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 Normal Abdominal x-ray
Liver Gas in
stomach Splenic flexure
11th rib T12

Psoas margin
Left kidney

Hepatic flexure
Transverse colon

Iliac crest
Gas in sigmoid
Sacrum

Gas in caecum
SI joint

Bladder
Femoral head

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 What is normal?

• Stomach
– Almost always air in stomach
• Small bowel
– Usually small amount of air in
2 or 3 loops
• Large bowel
– Almost always air in rectum
and sigmoid

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 Normal Abdominal Gas Pattern

1. Air in the stomach- within 30 minutes after delivery.

2. Air in the small bowel- seen by 3–4 hours of age.

3.Air in the colon and rectum- seen by 6–8 hours of

age

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 Normal fluid levels
• Stomach
– Always (upright, decub)
• Small bowel
– Two or three levels
acceptable (upright, decub)
• Large bowel
– None normally

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 Large vs small bowel

• Large bowel
– Peripheral
– Haustral markings don’t extend from wall to wall

• Small bowel
– Central
– Valvulae conniventes extend across lumen

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 Differs from that of older children
➢A neonates has less fat- the outlines of organs such as
the kidneys and psoas muscles are not as well defined
➢No mucosal folds- cannot differentiate small bowel gas
from large bowel gas

➢The position of the bowel gas- helps us

to differentiate small bowel from large bowel

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Normal plain abdominal film of a newborn

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 Findings of Common disease in
Newborn on plain abdominal X-ray

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 Intestinal obstruction

➢Gaseous intestinal distention

➢Gas may be decreased or absent distal to the
obstruction.
➢Air-fluid levels are seen proximal to the
obstruction.

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 level of obstruction

•Duodenal atresia- if only stomach and loop of

intestine is dilated in the right upper quadrant then

duodenal atresia is likely.
•Jejunal atresia- Dilated loops confined to left upper

part of abdomen
•Ileal artresia- Many dilated loops

occupying mainly the right side of spine

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Small bowel obstruction

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Large bowel obstruction

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Duodenal atresia

Double bubble sign-

with gas filled distended
stomach
and duodenum with an
absence of distal gas

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Jejunal atresia

Plain abdominal radiograph of newborn

reveals dilated gastric bubble and massively
dilated duodenum and proximal jejunum with
gasless abdomen distal to level of obstruction;
these findings are consistent with jejunal
atresia.

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Ileal Atresia

Multiple air-fluid levels

proximal to the point of
obstruction, and absent
gas distal to the
obstruction

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Hirschsprung disease

➢Findings areprimarily
those a
of
obstruction
➢The affected bowel
bowel is of
smaller calibre variable
amounts of
colonic
distension are present

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Meconium Ileus
➢Dilated bowel loops
proximal to the impaction.
➢Classically, there is a paucity
or absence of air-fluid levels
and a "bubbly" appearance of
the distended intestinal loops
on radiographs.

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 Necrotizing Enterocolitis
➢Abnormal gas pattern, ileus

➢Bowel wall edema

➢Pneumatosisintestinalis

➢Fixed position loop

➢Portal venous gas

➢Pneumoperitonium

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Necrotizing Enterocolitis

distension of small bowel loops.

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Necrotizing Enterocolitis

Pneumatosis intestinalis is
the classic radiographic
finding in NEC

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Necrotizing Enterocolitis

Portal venous gas (arrow)

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Necrotizing Enterocolitis

NEC with perforation 112

GIT perforation

Area of lucency over the right

hemi-diaphragm obliterating
the normal opacity of the liver
in a neonate with perforation

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 Contrast studies
Types of Contrast agent
1. Iodinate
d 1
Ionic
2 Non-
ionic
2. Barium
3. Air
4. Carbon
dioxide 114
 Barium contrast studies

Barium sulfate-
➢Inert compound
➢Water-insoluble
➢Not absorbed from the GI tract

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 Barium contrast studies
Indications
➢GI tract imaging
➢Barium swallow -used to study the pharynx and
esophagus
➢Barium meal- used to study the lower esophagus,
stomach and duodenum
➢Barium follow through - used to study the small
intestine
➢Barium enema- used to study the large intestine and
rectum
➢Suspected H-type TEF
➢Suspected esophageal perforation
➢Suspected gastroesophageal reflux (GER). 116
 High-osmolality water-soluble (HOWS)
contrast studies

➢Formerly widely employed in imaging

➢HOWS contrast agents have been replaced by LOWS

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 Low-osmolality water-soluble (LOWS)
contrast agents.

Advantages-
a. Do not cause fluid shifts.

b. If bowel perforation is present- nontoxic to the peritoneal

cavity

c. If aspirated, there is limited irritation to the lungs.

d. Limited absorption from the normal intestinal tract

Disadvantages- higher cost than barium.

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Commonly used contrast agents

Omnipaque – Iohexol
Iopamiro- iopamidol
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 Preparation for radiologic studies
Neonatal study Preparation
Upper GI series NPO for 1-2 hours for neonate & infants upto 2 year

Contrast enema No preparation needed for evaluation of bowel

obstruction or to rule out Hirschsprung disease

HIDA(Hepatobiliary) Oral phenobarbitone (5 mg/kg /day) for 5 days prior

scan to examination

Voiding No preparation
cystourethrogram
(VCUG)

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Findings of Common disease in
Newborn on Contrast X-ray

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Congenital hypertrophic pyloric stenosis

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Congenital hypertrophic pyloric stenosis

String sign
Shoulder sign
Double-track sign

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Duodenal atresia

Upper GI contrast study demonstrates

dilated stomach and proximal duodenum
without further passage of contrast in
newborn with duodenal atresia.
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Jejunal atresia

Plain abdominal radiograph of newborn

reveals dilated gastric bubble and
massively dilated and
proximal
duodenum jejunum with gasless abdomen
distal to level of obstruction; these
findings are consistent
with atresia. jejunal

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Jejunal atresia

Upper GI contrast study demonstrates

dilated stomach duodenum, with
enlarged
and upper jejunum and lack of
passage of contrast agent to distal small
bowel; these findings are consistent with
high jejunal atresia.

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Ileal Atresia

Multiple air-fluid levels

proximal to the point of
obstruction, and absent
gas distal to the
obstruction

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Ileal atresia

Lower GI contrast study in

newborn ileal atresia
demonstrates
with microcolon with
dilated non-contrast-enhanced
stomach and proximal small
bowel.

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Malrotation with volvulus

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Malrotation without midgut volvulus

malrotation
without midgut.
Note the small bowel
in the right
abdomen.

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Malrotation with midgut volvulus

The abdominal plain film

is usually nonspecific
but
might demonstrate
gasless
evidence of duodenal
a
obstructionabdomen
with
a double-bubble sign.
or

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Malrotation with midgut volvulus

Corkscrew sign in a
patient with intestinal
malrotation with volvulus

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Meconium Ileus
➢Dilated bowel loops
proximal to the impaction.
➢Classically, there is a paucity
or absence of air-fluid levels
and a "bubbly" appearance of
the distended intestinal loops
on radiographs.

133
Gastrografin enema study shows filling
defects in the terminal ileum and
cecum. Also note the microcolon
(transverse and descending colon).

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Hirschsprung disease

➢Findings areprimarily
those a
of
obstruction
➢The affected bowel
bowel is of
smaller calibre variable
amounts of
colonic
distension are present

135
Hirschsprung disease

Barium enema showing

reduced caliber of the rectum,
followed by a transition zone
to an enlarged-caliber sigmoid.

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Invertogram

Baby held upside down for

3-5 minutes and then lateral
X-ray is taken

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Invertogram

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Cross Table Prone Lateral X-Ray

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 Invertogram
➢Low- When a rectal pouch that is below the I
line

➢Intermediate- If the rectum ends below the P–C

line, but not below the I line

➢High- when pouch ends above the P–C line

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