Investigation in Vomiting Children

By A.C. Maclennan
Glasgow, Scotand, UK
This article discusses how to investigate various surgical
causes of vomiting. Particular emphasis is placed on plain
radiographic, ultrasound, and contrast study findings. The
article touches upon nineteen different diseases, and encompasses diseases found in neonates to adolescents.
2003 Elsevier Inc. All rights reserved.

OMITING IS A common self-limiting symptom in

children, but occasionally heralds serious surgical
or life-threatening disease. This review is a practical
guide to the radiological findings in children who are
vomiting because of surgical disease. No test should be
performed before an experienced clinician assesses a
child. Tests are then carried out to confirm a suspected
diagnosis, eg, pyloric stenosis where a test feed is negative, or to exclude an unlikely, but potentially serious
diagnosis, eg, volvulus in a well baby with an episode of
bilious vomiting. Many of the pathologies discussed are
best investigated by old-fashioned plain radiographs,
ultrasound, and fluoroscopic examinations with watersoluble contrast or barium.1 Computed tomography
(CT), magnetic resonance imaging, and nuclear medicine
examinations have a lesser role.
THE VOMITING NEONATE

Many of the causes of vomiting reflect congenital

obstructions of the gastrointestinal tract.2,3 Some of
these, eg, duodenal atresia, may already have been suspected at the time of antenatal fetal ultrasound scans.

Fig 1. One-day-old child with vomiting and a single bubble

appearance due to gastric outlet obstruction confirmed at surgery.

Gastric Outlet Obstruction

Gastric outlet obstruction presents as a single bubble, which is the gas-filled stomach on an abdominal
radiograph (Fig 1). There is no gas distal to the stomach
and no further investigation is necessary.
Duodenal Atresia
Duodenal atresia presents as a double bubble, which
is the air-filled stomach and dilated duodenal bulb.
Proximal Jejunal Atresia
Proximal jejunal atresia presents as a triple bubble
because of air in the stomach, duodenal, and proximal
dilated jejunum.
From Royal Hospital for Sick Children Glasgow, Scotland, UK.
Address reprint requests to A.C. Maclennan, Royal Alexandre Hospital, Paisley PA2 9PN, Scotland, UK.
2003 Elsevier Inc. All rights reserved.
1055-8586/03/1204-0002$30.00/0
doi:10.1053/j.sempedsurg.2003.08.002
220

Distal Ileal Atresia

Radiographs show multiple air-filled loops of bowel.
There is no air in the rectum. A water-soluble contrast
enema may show a microcolon or normal-sized colon.
There is reflux into a short segment of small bowel,
which either terminates in a cigar butt or a small
nipple. Contrast will not pass any more proximally. Filling of the appendix should not be mistaken for smallbowel filling.
Meconium Ileus
Radiographs can show peritoneal calcification if there
has been a previous in utero perforation, abdominal
distension with absence of gas in the right iliac fossa due
to a meconium cyst, bubbly meconium in the right flank,
multiple dilated air-filled loops of small bowel proximal
to the ileus, and perforation (Fig 2). Water-soluble contrast enema shows a microcolon. The contrast then flows
around and through the thick meconium in the cecum

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

INVESTIGATION IN VOMITING CHILDREN

Fig 2. A 3 day-old baby with multiple dilated loops of gut and a

supine pneumoperitoneum. Perforation of a meconium ileus was
found at surgery.

221

Fig 3. High-resolution ultrasound shows a pylorus of 16-mm long

and individual muscle wall thickness of over 4 mm. Pyloric stenosis
was confirmed at surgery.

and proximal small bowel.1 The aim is to reflux watersoluble contrast proximal to the meconium obstruction
and into dilated air-filled loops of gut. The osmotic load
draws water into the gut lumen and may allow the baby
to pass the meconium without need for laparotomy.
Obviously, the baby must be well hydrated at the time of
the enema, which can be repeated several times. Inability
to reflux contrast into the air-filled dilated small bowel
loops proximal to the obstruction should raise the possibility of an associated volvulus, which will require laparotomy.
Hirschprungs Disease
Radiographs show multiple loops of air-filled dilated
gut and, occasionally, a perforation. There is usually no
gas in the rectum in the neonate with Hirschprungs
disease. There is often particular dilatation of the loop
immediately proximal to the transition zone.2 A barium
or water-soluble contrast enema, prior to any rectal
washout, is performed looking for a transition zone.4
This marks the level at which the affected colon widens

Fig 4. Six-week-old child with inconclusive pyloric ultrasound

shows sign of a pyloric tumor and free esophageal reflux. Tumor was
confirmed at surgery.

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A.C. MACLENNAN

zone.5 Rectal biopsy is mandatory to confirm or exclude

the diagnosis.
Meconium Plug Syndrome
The plug is easily demonstrated as a large single filling
defect within the distal colon and rectosigmoid, on a
contrast enema. The plug may be aspirated back with the
contrast, or may then be spontaneously voided by the
baby because of the osmotic effect of contrast.
THE VOMITING BABY

Gastroesophageal Reflux

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

into normal colon. Rectosigmoid and colon affected by

Hirschprungs disease is of narrower caliber than normal
colon, and often shows fine mucosal irregularities due to
muscular incoordination. Total colonic Hirschprungs
poses a major problem for the radiologist. An enema can
miss whole colonic involvement, as there is no transition

Suspected reflux is the most common indication for a

barium swallow in our institution. It is an easy diagnosis
if there are multiple episodes of reflux filling the esophagus with barium. However, fluoroscopic diagnosis of
reflux is complicated by lack of an agreed method of
performing the barium swallow test. Multiple nonphysiological methods of provoking reflux exist, and there is
no agreed upon method of quantifying reflux. A barium
swallow is useful in confirming or excluding an esophageal stricture, hiatus hernia, or gastric outlet obstruction. The sensitivity for demonstrating reflux is about
50% compared to the gold standard of a 24-hour pH
probe study. The pH study is more invasive although it
does not have a radiation burden. A nuclear medicine
milk reflux scan allows physiological feeding and observation of a baby in order to document reflux over
several hours after a feed containing a nuclear medicine
tracer. It shows 60% to 80% sensitivity compared to
24-hour monitoring.6,7

Fig 6. High-resolution ultrasound of right flank

shows a typical intussusception, which was easily
reduced by air enema.

INVESTIGATION IN VOMITING CHILDREN

223

Malrotation and Volvulus

Malrotation or nonrotation causes abnormal fixation of
the gut within the abdominal cavity. It may be associated
with a short root of the mesentery, which runs from the
ligament of Treitz to the cecum. The risk of volvulus
increases as the base of the small bowel mesentery decreases. Unfortunately, with fluoroscopic imaging, the
bowel is visualized, not the mesentery and so the radiologist makes an informed guess about the mesenteric
position from the position of the gut. The most reliable
examination for confirming or excluding a malrotation is
a barium meal where the column of contrast is watched
during the first pass through duodenum and into jejunum.
A normal duodenojejunal flexure, which is the marker
for the ligament of Treitz, lies to the left of the spine at
or close to the level of pylorus (usually the second

Fig 7. Fourteen-month-old with a persistent filling defect immediately above the esophagogastric junction. A plastic ballpoint pencap was found at esophagoscopy.

Pyloric Stenosis
A positive test feed by an experienced clinician means
that imaging is unnecessary. Radiographs show a distended stomach, often with prominent peristaltic waves,
and traces of air in the remainder of the bowel. Ultrasound is both sensitive and specific at making the diagnosis of pyloric stenosis.8,9 A nasogastric tube is passed
into the stomach and the stomach washed out with warm
sterile water, and then filled with 30 to 60 mL of water.
The pylorus is directly visualized and the length and
diameter measured. Various sizes have been proposed
for diagnosis of pyloric stenosis.10,11 At our institution,
we diagnose pyloric stenosis when the pyloric length is
over 16 mm and the transverse diameter is over 10 mm12
(Fig 3). The normal transverse thickness of the pyloric
muscle is less than 2 mm. Over 4 mm is diagnostic of
pyloric stenosis. These measurements, however, are too
large for making a diagnosis of pyloric stenosis in a
neonate.13 Pyloric stenosis can also be diagnosed by a
barium meal that shows a shouldered pylorus and a
tramtrack sign of the elongated, and partly obstructed
pyloric channel (Fig 4).

Fig 8.
Dilated esophagus and rat-tail narrowing of gastroesophageal junction in achalasia proven with subsequent manometery.

224

A.C. MACLENNAN

Fig 9. A 12-year-old boy with recurrent abdominal pain and vomiting shows
a large ulcer niche of duodenal cap on
double contrast barium meal. The ulcer
was confirmed by endoscopy.

lumbar vertebra). Most malrotations are obvious and

easily diagnosed. However, a number of variants of
normal duodenal anatomy overlap with subtle malrotations.14,15 These gray cases are best approached by
direct discussion between the radiologist and surgeon
about the appearances. A repeat barium meal or barium
enema to show cecal position, may be useful in deciding
how seriously to treat the appearances. Volvulus is due to
twisting of the midgut loop on the mesentery causing
venous then arterial ischemia of the gut. Radiographs
may show dilated gas-filled upper small bowel, or small
bowel lying in the right flank. Perforation is a grave sign.
A barium or contrast meal shows the corkscrew sign of
twisted bowel (Fig 5), or a complete cut-off at the level
of second or third part of duodenum. Ultrasound assessment of the position of the superior mesenteric artery and
vein is less reliable than a contrast meal for diagnosis of
malrotation and a normal ultrasound can occur with
malrotation.16,17
Intussusception
Radiographs may appear normal, show nonspecific
abnormality, or show a soft tissue mass in the right flank
and absence of paucity of colonic air.18 Small bowel
obstruction may be present but perforation is rare. A
normal air- and feces-containing cecum, on an abdominal radiograph, excludes the diagnosis. Ultrasound is
used to confirm the diagnosis and generally shows a
complex mass in the right flank or epigastrium19 (Fig 6).
Often individual bowel wall layers, lymph nodes, and
mesenteric fat are identified within the mass. There may
be trapped fluid within the intussusception or ascites.

Fig 10. Eleven-year-old boy with 5 days of vomiting and central

abdominal pain. There is small bowel obstruction and there is mass
effect by a soft tissue mass in pelvis causing deviation of the rectal
gas to the left side of pelvis. A perforated appendix and pelvic
abscess were found at surgery.

INVESTIGATION IN VOMITING CHILDREN

225

Fig 11. Contrast-enhanced CT of abdomen in moribund child 10 days postappendicectomy. There are multiple intraabdominal abscesses confirmed at subsequent
surgery.

Small bowel obstruction is shown by multiple hyperperistalsing dilated fluid-filled loops of small bowel. Ultrasound may also identify a pathological lead point.20 An
air or contrast enema can either be used to confirm the
diagnosis without ultrasound or to perform a reduction.
Ultrasound-guided reduction using Hartmanns solution
or saline is as effective as barium reduction and involves
no radiation exposure for patient or operator.21,22
THE VOMITING OLDER CHILD

Esophageal Stricture and Foreign Body

Strictures are seen as a thin, constricting ring
postesophageal atresia repair, a smooth mid or lower
third narrowing due to reflux esophagitis, or a long
irregular narrowing postcaustic ingestion. A foreign
body may impact on the stricture (Fig 7).
Achalasia
Achalasia does not cause vomiting, but does cause
regurgitation of undigested food and pulmonary complications due to aspiration. A chest radiograph may demonstrate areas of collapse or consolidation; a dilated
air-filled esophagus, an air fluid level in the esophagus,
or absence of the gastric air bubble. A barium swallow
shows disordered motility in early achalsia and a dilated
serpiginous esophagus containing food residue in established achalasia. The esophagus forms a smooth rattail stricture at the esophagogastric junction and one can
watch barium intermittently squirting into the stomach
during screening (Fig 8). Any shouldering, other stricture, or fixed polypoid intramural lesion is suspicious of
a superimposed carcinoma.

Fig 12. A 2-year-old boy with small bowel obstruction due to an

incerated right inguinal hernia.

226

A.C. MACLENNAN

hyperechoic mesenteric fat, and right iliac fossa lymphadenopathy. Perforated appendicitis may form a complex
mass of fluid, fat, and gut. Ultrasound can be falsely
normal if there is only a distal tip appendicitis or if there
is a retrocecal appendicitis obscured by cecal gas. CT has
been used for diagnosing acute appendicitis.26 CT findings in appendicitis include an enlarged appendix, appendicolith, tapered deformity of the colonthe arrowhead sign, stranding of adjacent fat, adjacent bowel wall
thickening, and a complex mass if perforation occurs.27
CT is also useful for delineating abscesses in postappendectomy patients presenting with fever and suspected
abscess (Fig 11).
Small Bowel Obstruction: Hernias or Atresias
Radiographs show multiple dilated air-filled small
bowel loops or a string of pearls sign of small amounts
of air within the gut and fluid-filling of the remainder of
gut. A gas-filled loop of gut may be seen in scrotum,
confirming an inguinal hernia (Fig 12). Ultrasound may
be used to confirm an inguinal hernia in boys or girls

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

Duodenal Ulcer
A double-contrast barium meal using high-density
barium and spot views of the duodenal cap may show
spasm untreatable by intravenous antispasmodics, an ulcer niche if there is an acute ulcer, or scarring and
deformity if there is a healed ulcer (Fig 9). Endoscopy is
more sensitive than single-contrast barium studies for
diagnosis of both gastric and duodenal ulcers.23
Appendicitis
Radiographic findings of appendicitis are generally
not helpful in early disease and include normal appearances, right lower quadrant haze, blurring of the right
psoas shadow, obliteration of the right properitoneal fat
line, as scoliosis convex to the left, a dilated loop of
small bowelsentinental loop sign or the colon cutoff sign of a dilated ascending colon with a sharply
defined lower margin (Fig 10). An appendicolith is seen
in 10% to 15% of patients and clinches the diagnosis.
Graded compression ultrasound demonstrates the inflammed appendix as a tender, noncompressible, tubular
structure with 1 blind end and often a calcified appendicolith at its base.24,25 There is often localized ascites,

Fig 14. An 11-year-old girl with 3 days of abdominal pain and

vomiting. The supine radiograph shows a scoliosis to the left and a
soft tissue mass, which is partly calcified, in the right side of pelvis.

INVESTIGATION IN VOMITING CHILDREN

227

Fig 15. The same child as in Fig 14.

Ultrasound shows a large cystic mass.
This was torsion of a hemorrhagic dermoid cyst at surgery.

showing the gut and mesenteric fat or ovaries and fallopian tubes.28 CT can be used to look for the transition
zone from proximal dilated gut to collapsed gut indicating the site of obstruction.29,30
Renal Colic
Radiographs 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 also
show stone as a hyperintense area within the renal pelvis
with posterior shadowing. There may be hydronephrosis
due to obstruction by a ureteric stone. Unenhanced CT is
the most sensitive method for diagnosing a stone, showing a renal stone as a dense area within the kidney,
possibly hydronephrosis, and stranding of the perirenal
fat. A ureteric stone is identified as a dense focus in the
line of ureter, possibly with hydronephrosis, hydroureter,
circumferential thickening of the ureteric wall and
stranding of the periureteric fat.32
Pancreatitis
Radiographs 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 be

present. Cross-section imaging is used to stage the severity of pancreatitis and assess complications. Contrastenhanced CT scan obtaining images in the arterial phase
is the best method for showing the presence and assessing the percentage of pancreatic necrosis, and showing
abscesses.33 Arterial phase CT is also best for demonstrating arterial pseudoaneurysms, although delayed CT
is necessary for showing venous occlusion or stenosis.
Pseudocysts can be followed either by ultrasound or
CT.34
Ovarian Torsion
Radiographs can mimic appendicitis or may be diagnostic if there is calcification in a torsion of an ovarian
dermoid (Fig 14). Ultrasound shows a pelvic or adnexal
mass that is either cystic or solid35 (Fig 15). A torted
ovary is several times larger than normal. Doppler imaging may show the mass to be avascular. Ultrasound,
CT, or magnetic resonance imaging may all show multiple peripheral cysts within the mass due to dilated
follicles.36

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