GIT ANOMALIES

Dr Varun Bansal
Dept of Radio-Diagnosis
 Introduction

• Most Congenital Anomalies of the Gastrointestinal Tract

manifest early after birth while some may not present till
late childhood or adulthood.

• Various modalities used are:

1. Plain radiography
2. Ultrasound
3. Computed tomography
4. Magnetic Resonance Imaging
5. Radionucleotide imaging
Classification of developmental anomalies of
GIT

Structural
Attributed to embryologic maldevelopment
• Esophageal atresia with or without fistula
• Antro-pyloric atresia
• Antral diaphragm
• Duodenal atresia
• Duodenal stenosis
• Midgut malrotation with peritoneal bands
• Duplication or mesenteric cyst
• Anorectal atresia
Attributed to in-utero vascular (ischemic)
complication
• Jejuno-ileal atresia
• Colonic atresia or stenosis
• Complicated meconium ileus

Functional
• Meconium plug syndrome and its variants
• Megacystis-microcolon-intestinal hypoperistalsis

Structural and Functional Combined

• Hypertrophic pyloric stenosis
• Midgut volvulus
• Uncomplicated meconium ileus
• Colonic aganglionosis
 Esophageal Atresia
Tracheo-Esophageal fistula

ANTENATAL CLUES : Esophageal atresia

• Presence of polyhydramnios,
• Reduced intraluminal liquid in the fetal gut
• Inability to detect the fetal stomach on prenatal ultrasound

CHEST RADIOGRAPH:
• proximal esophageal pouch distended with air
• dilated proximal esophageal pouch with round distal margin and
coiled nasogastric tube within is diagnostic
• (on lateral): considerable anterior bowing and narrowing of the
trachea by the dilated blind esophageal pouch
• air in the stomach and the small bowel esophageal atresia with a
distal tracheo esophageal fistula.
• Absence  eliminates the possibility of a distal fistula.
 Frontal radiograph
of chest and
abdomen showing a
catheter in the
proximal pouch. The
abdomen is gasless.
(B) Lateral film
shows the tip of the
nasogastric tube at
the level of 4th
dorsal vertebra

CONTRAST STUDIES: Should be avoided, fear of aspiration

• isotonic nonionic contrast medium
• Though H-type fistulas can be at any level, most are at the thoracic inlet,
between C7 and T2 vertebral bodies
• best way to demonstrate H-type: Others can be bronchoscopy and endoscopy
• CT is an excellent non invasive investigation.
• EARLY COMPLICATIONS (i) leakage at the anastomotic site (ii) esophageal
stricture and (iii) recurrent fistula.
LATE COMPLICATIONS are dysmotility, gastroesophageal reflux, tracheomalacia,
rib fusion and scolosis
• TYPE A—Esophageal atresia without fistula (7.8%)
• TYPE B—Esophageal atresia with proximal fistula (0.8%)
• TYPE C—Esophageal atresia with distal fistula (85.8%)
• TYPE D—Esophageal atresia with fistula in both the pouches
(1.4%)
• TYPE E—H-type fistula without atresia (4.2%)
The plain radiographs for types A and B are similar as in case for
types C and D
H-type tracheoesophageal
fistula. The contrast study
demonstrates the
superiorly angulated
fistula (arrow) from
the oesophagus to the
trachea
 Microgastria
• fetal rotation of the stomach fails to occur
• accompanied by other congenital anomalies such as
malrotation, asplenia, renal, limb, vertebral and cardiac
anomalies (VACTERL syndrome).
• Prenatal ultrasound  mimic esophageal atresia due to failure
to visualize a distended stomach.
• UPPER GI STUDY:
• shows a small tubular stomach in the midline.
• esophagus is dilated and appears to take over the storage function
of the small capacity stomach.
• gastroesophageal junction is incompetent and GER is present.
• Associated esophageal dysmotility, secondary to its massive
dilatation.
CAUSES :
Gastric obstruction
• 1. Gastric atresia
• 2. Pyloric stenosis
• 3. Pyloric/ prepyloric membrane/ Antral web.

GASTRIC ATRESIA --THREE TYPES:

a) Complete atresia with no connection between the stomach and
duodenum,
b) Complete atresia with a fibrous band connecting the stomach and
duodenum,
c) Gastric membrane or diaphragm
ON CHEST RADIOGRAPH:
1. “single bubble appearance”
2. marked dilatation of the stomach, proximal to the obstruction
3. absence of gas in the small bowel and colon
Pyloric Stenosis or Prepyloric Membrane or
Antral Web
• RADIOGRAPH:
• the stomach is dilated with varying degrees of distal air,
• the extent of which depends on the degree of obstruction.
• In incomplete obstruction, webs more common than stenosis.
• UGI BARIUM STUDIES:
• a web is seen as a thin, 2-3 mm, linear circumferential filling
defect traversing the barium column
• producing a reduction in the antral lumen,
• normal pyloric canal.
• ULTRASOUND:
• membrane may be visible if the stomach is filled with clear
fluid
• WEB  echogenic band extending centrally from the lesser
and greater curvatures in the prepyloric region.
• A mucus strand may be mistaken for an antral membrane.
• ENDOSCOPY:
• definitive diagnosis of antral web can be made.
 Congenital Hypertrophic Pyloric Stenosis
• Diagnosis made on appropriate history and palpation of
an ‘olive’ mass in the subhepatic region of an infant.
• Antral peristaltic waves can also be observed.

ON ULTRASONOGRAPHY:
• thickened echo-poor pyloric muscle and an elongated pyloric canal.
• two curved bundles of mixed but generally low reflectivity
• “doughnut appearance”, representing the reflective central mucosa and
submucosa surrounded by echopoor muscle
• pyloric canal length greater than 15 mm,
• muscle thickness greater than 3.0 mm
• transverse serosa-to-serosa diameter greater than 15 mm is consistent with HPS
• < 2 mm thick  unequivocally normal.
• 2 - 3 mm  abnormal but not specifically diagnostic for pyloric stenosis
• Longitudinal ultrasound image showing an elongated thickened pylorus seen as two curved
bundles of low reflectivity (m). The mucosal echoes are seen as central bright lines. gb –
gallbladder shows sludge within. Minimal fluid is present around the stomach. (B) Transverse
section shows the muscle thickness as an echo poor rim – “Bull’s eye” sign. serosa to serosa
measures 15 mm

“SHOULDER SIGN” – refers to an indentation upon the gastric antrum produced by

hypertrophy of the pyloric muscle
• “DOUBLE TRACT SIGN” – this refers to fluid, trapped in the mucosal folds in the center of an
elongated pyloric canal seen as two sonolucent streaks in the center
• “NIPPLE SIGN” is produced due to the evagination of redundant pyloric mucosa into the
distended portion of the antrum.
BARIUM STUDY:
if usg - inconclusive or gastro-oesophageal reflux

• hypertrophied muscle mass causes elongation and

narrowing of pyloric canal (‘STRING SIGN’)
• a bulge in the distal antrum with streak of barium pointing
towards pyloric channel (‘BEAK SIGN’).
•The barium may outline crowded mucosal folds as
parallel lines (‘DOUBLE/TRIPLE TRACK SIGN’)
Duodenal Atresia
INTRINSIC: Duodenal atresia, Duodenal
stenosis, Duodenal web or diaphragm
EXTRINSIC: Ladd’s bands, Midgut volvulus with
malrotation, Annular pancreas, Duplication,
Preduodenal portal vein

ABDOMINAL RADIOGRAPH: (usually

diagnostic)
1. Air is present in the stomach and proximal
duodenum but none distally
2. typical “double-bubble sign” represents air,
or air and fluid filled distended stomach and
duodenal bulb
 Further radiological study  preoperative diagnosis  distinguish
between a cause of partial obstruction - duodenal stenosis from
complete obstruction midgut volvulus.

• UGI STUDY:
• duodenal stenosis appears as dilatation of the duodenum proximal
to the point of obstruction with abrupt calibre change

DOUDENAL WEB:
• UGIE:
• diagnostic appearance  thin, convex, curvilinear defect extending for a variable
distance across the lumen of the duodenum.
• “wind sock” appearance seen in an adult or older child, intraluminal duodenal
diverticulum, not seen in newborns.

ANNULAR PANCREAS:
• RADIOGRAPHS: normal. MRI:
• UPPER GI STUDIES:
a persistent waist is seen, partially obstructing the second part of duodenum.
 Normal Physiology of Rotation.

STAGES OF INTESTINAL ROTATION:

(A), the duodenum has rotated 90 counter clockwise to lie to the right of the superior
mesenteric artery. The distal large bowel also rotates 90 counter clockwise. (B), the duodenum
has rotated another 90 counter clockwise, In (C) the duodenum has rotated its final 90 counter
clockwise with the duodenojejunal flexure lying to the left of the midline. The cecum continues
to rotate . In (D), the normally rotated bowel is depicted.
• NONROTATION –
• small bowel  right side and colon  left side.
• demonstrated incidentally on barium studies in older children or adults
• bowel is not very mobile and
• volvulus is not a common complication
• MALROTATION –
• final position between normal and complete nonrotation.
• shortened mesenteric root - narrow rather than a broad base that has a tendency
to twist on its axis
• bowel obstruction, lead to occlusion of the mesenteric vessels  if twist of
vessels
• twist of malfixed intestines around the short mesentery midgut volvulus.
• aberrant peritoneal bands (Ladd’s bands)  (extend from the malpositioned
cecum across the duodenum and attach to the hilum of the liver, posterior
peritoneum or abdominal wall)
• REVERSED INTESTINAL ROTATION –
• hepatic flexure and left transverse colon posterior in position.
• colon lie behind the descending duodenum and the superior mesenteric artery
• cecum is usually malrotated and medially placed and the small bowel is more
right-sided than normal. Obstructing bands & midgut volvulus
• PLAIN RADIOGRAPHS:
• feature of duodenal obstruction due to partially obstructing Ladd’s bands.
• duodenal bulb dilatation is less than that seen with duodenal atresia
• distal bowel obstruction (in case of volvulus).
• Bowel-wall thickening and pneumatosis  volvulus-induced ischemia.
• fluid-filled bowel loops associated with volvulus simulate an abdominal
mass
• normal abdominal film (only in nonrotation)
• UPPER GASTROINTESTINAL BARIUM :
• to document the location of ligament of Treitz and to evaluate for duodenal
obstruction.
• duodenojejunal junction is located lower and to the right of normal.
• on lateral views it is seen to lie behind the level of the stomach, with the fourth
part of the duodenum superimposed on the second part of duodenum (lost
in case of malrotation)
• abnormal position of the duodenojejunal flexure may be the only indication
• complete obstruction  a beaked tapering of the obstructed duodenum
• pathognomonic “corkscrew pattern” of the twisted duodenum and jejunum
 clockwise twisting around the superior mesenteric artery
• ULTRASOUND:
• distended proximal duodenum with a tapered end in front of the
spine is consistent
• peritoneal fluid and edematous bowel loops on the right.
• UGI series is mandatory
• COLOR DOPPLER US:
• demonstrates ‘whirlpool’ sign  clockwise spiralling of the
mesentery and superior mesenteric vein around the superior
mesenteric artery.
• Inversion of the mesenteric vessels or the “SMV rotation sign” (not
sensitive) also in situs inversus & abdominal masses.
• CT : (midgut volvulus)
• `whirl’ sign of small-bowel loops revolved around the SMA
• dilated, fluid-filled, obstructed stomach and proximal duodenum
• thick-walled loops of ischemic right-sided small bowel loops with
potential pneumatosis intestinalis and mesenteric edema
• free intraperitoneal fluid.
BARIUM MEAL FOLLOW THROUGH STUDY
(A) jejunal loops on the right side of the abdomen
(B) colon and cecum on the left side, with the ileum seen crossing the midline
from right to left – Non-rotation
 MIDGUT VOLVULUS. Narrow mesenteric attachment of
nonrotation (A) or incomplete rotation (B) may lead to midgut
volvulus (C)
LADD’S BANDS causing duodenal
compression in patients with
malrotation. The cecum is left
sided (A) and mid-line (B) in
position and has dense peritoneal
bands crossing over the
duodenum
MIDGUT MALROTATION WITH
LADD’S BANDS: Barium study
shows distended proximal
duodenum with tapering at the
level of obstruction indicative of
extrinsic compression. The small
intestine, distal to the usual site of
the ligament of Treitz lies below
the duodenum and to the right
• Upper GI barium study in two different patients showing
classic “corkscrew” appearance of the duodenum in
MIDGUT VOLVULUS
• Axial CECT of the abdomen showing characteristic
“whirlpool” sign of clockwise twisting of the SMV and
mesentery around the SMA
 Small Bowel Atresia

• TYPE 1 —Membranous or web-like atresia, composed of mucosal and

submucosal elements with no interruption of the muscularis.
• TYPE 2 —Atresia with a solid fibrous cord connecting the atretic bowel ends, but
the mesentery is intact. All the three layers of the intestinal wall are interrupted.
• TYPE 3 —Complete absence of a segment of bowel (total atresia) as well as a
portion of the mesentery (V-shaped defect in the mesentry)
• TYPE 4 —The familial form of multiple atresias
• UNUSUAL FORMS OF ATRESIA : “Apple peel” or “Christmas tree” atresia
• PLAIN RADIOGRAPH:
• findings of small-bowel obstruction.
• Site  number & location of gas-filled loops of bowel.
• Proximal jejunal atresia  triple bubble sign,
• more distal atresia uniform dilatation & air-fluid levels.
• proximal loop just proximal to the site of atresia is distended
• if perforation meconium peritonitis .
• linear calcification under the free edge of the liver
Association of meconium peritonitis with small bowel
obstruction is virtually diagnostic of small bowel atresia.

• SONOGRAPHY:
• Ileal atresia  the bowel contents are echopoor
• Meconium ileus  dilated bowel loops are filled with echogenic
material
• CONTRAST ENEMA:
• further evaluation for low bowel obstruction to distinguish between a
large or distal small bowel obstruction
• Most common causes of neonatal distal small bowel obstruction
are ileal atresia and meconium ileus
• In cases of partial obstruction
little amount of distal gas is
usually present.
• In isolated proximal atresia of
the duodenum or jejunum, the
colon is of normal size- normal
caliber colon
• In ileal atresia, the colon has a
normal location but the caliber is
reduced (functional micro colon).

Small bowel atresia: Plain radiograph demonstrates

multiple dilated bowel loops and fluid levels. Peritoneal
calcifications are seen as a result of meconium
peritonitis.
 JEJUNAL ATRESIA.
(a) Supine radiograph
in a neonate with
associated esophageal
atresia shows three
dilated loops of bowel
(b) upright radiograph
obtained in a different
patient shown air-fluid
levels in the stomach
and the first part of the
small bowel. No distal
gas is seen.
 Ileal Atresia

( a ) Upright radiograph shown multiple air-fuild levels occupying the

entire abdominal cavity. ( b) Image from a barium enema study shows
numerous dilated, air-filled loops of bowel and a small, unused colon
(functional microcolon).
 Meconium ileus
• mimic of small bowel atresia clinically and on plain films
• ABDOMINAL RADIOGRAPH:
• distal bowel obstructive pattern with air-fluid levels.
• loops may vary in size, (finding seen less often in atresia)
• bubbly appearance in the right lower quadrant  air mixes with the
viscid meconium
• “soap bubble appearance” is not specific also seen ileal atresia, colonic
atresia, aganglionosis of the terminal ileum and meconium plug
syndrome.
• fewer air-fluid levels than patients with small-bowel atresias.
• Meconium peritonitis <-> peritoneal calcifications.
• localized perforation forms a meconium pseudocyst  peripheral
curvilinear calcifications
• ULTRASOUND:
• can detect abnormal bowel dilatation
• echogenic bowel contents in infants with meconium ileus.
• complications of meconium peritonitis or pseudocyst which is seen as
echogenic material lying outside the bowel loops, with or without
associated calcification.
(a) Abdominal scout radiograph shown marked distention of the small bowel and a
“soap bubble”appearance in the right side of the abdomen a finding suggestive of
mottled air and feces. (b) US image shown dilated, fluid-filled intestinal loops
containing echogenic material ( calcified meconium.
 • CONTRAST ENEMA:
• demonstrates a
microcolon with
inspissated
meconium pellets
identified in the
collapsed distal ileum
with dilated small
bowel proximal to the
obstruction

Water soluble contrast enema showing a

microcolon. Filling defects due to meconium
are seen in colon and distal ileum
 Megacystis-microcolon-intestinal
Hypoperistalsis Syndrome (Berdon Syndrome)

• pseudoatresia.
• functional small bowel obstruction with a microcolon,
malrotation and a large unobstructed bladder

• UPPER GI CONTRAST STUDY:

• hypomotility of small bowel with retrograde peristalsis.
 Meckel’s Diverticulum
• evaluation is difficult
• Routine and special radiological studies such as plain
abdominal radiograph, barium meal follow through,
arteriography and computed tomography are often
non-diagnostic & of limited diagnostic value.
• seldom recognized on a small bowel follow-through
study  no significant hold-up & small residue in
small neck.
• 99MTC (TECHNETIUM -99M PERTECHNETATE)
SCANNING:
• Done in suspected symptomatic patients.
Enteric Duplication Cyst
• uncommon & occur anywhere in the gastrointestinal tract.

• distal ileum (35%) > distal esophagus (20%) > stomach (9%)
> duodenum > jejunum.

• PLAIN RADIOGRAPHS:
• demonstrate a mass lesion in chest (esophageal duplication)
• bowel gas pattern may suggest an obstruction, particularly with
duodenal or ileal duplications
• mural calcifications

• CONTRAST STUDIES:
• filled with barium suspension
• May not demonstrated in this manner.
• reveals extrinsic compression of the bowel or an obstruction
 Barium study shows extrinsic impression on the body of the stomach with
effacement of the mucosa in AP and lateral views in a case of gastric duplication
• ULTRASONOGRAPHY:
• Well defined, unilocular anechoic mass with good through
transmission
• Rarely the contents are reflective or contain septations secondary to
hemorrhage or inspissated material within the lumen.
• highly reflective mucosa and a surrounding echo poor muscular wall
 identified in the dependent portion of the cyst.
• double layered appearance (“gut wall signature”) is specific &
exclude other cystic masses - mesenteric or omental cyst,
choledochal cyst, ovarian cyst, pancreatic pseudocyst or abscess
• RADIONUCLIDE STUDIES:
• useful in patients where the enteric duplications have gastric
mucosa.
• Free pertechnetate is taken up and secreted by gastric mucosa,
• CT & MRI:
• useful in further characterizing the nature when the diagnosis is
unclear,
• seen as well-marginated, smooth walled masses of fluid
attenuation/signal not showing any contrast enhancement.
 CECT images of esophageal and gastric duplications of the two patients of the
showing sharply marginated, non-enhancing, homogeneous mass of water
attenuation in the (A) posterior mediastinum and (B) along the greater curvature of
stomach.
 Mesenteric Cyst (Lymphangioma)
• congenital malformation arising due to sequestration of
lymphatic vessels.
• seen in the mesentery and less often in omentum and
retroperitoneum.
• SONOGRAPHY:
• thin-walled unilocular or multilocular cystic lesion
• useful to demonstrate the thin septations which may not be well
seen on CT.
• CT and MRI:
• demonstrate variable characteristics of the cyst contents (usually
water-to fat) depending upon whether fluid is chylous, infected or
haemorrhagic.
• RARELY, A MESENTERIC LYMPHANGIOMA MAY CONTAIN
CALCIFICATION MIMICKING A MESENTERIC TERATOMA
 Colonic obstruction
• ANATOMICAL TYPE:
• atresia of the colon,
• anorectal atresia, and
• ANATOMICAL TYPE WITH A FUNCTIONAL ELEMENT:
• aganglionosis or Hirschsprung’s disease.
• FUNCTIONAL OBSTRUCTION:
• meconium plug,
• neonatal small left colon syndrome
 Colonic Atresia
• TYPE I: represents a diaphragmatic occlusion,
• TYPE II: represents a complete atresia with a blind, solid cord extending
between the two ends of atretic segment;
• TYPE III: represents a complete atresia with complete separation and an
associated V-shaped mesenteric defect.
• PRENATAL SONOGRAPHY:
• demonstrate dilatation of the colon proximal to the atresia.
• PLAIN RADIOGRAPH:
• distal obstruction with multiple air-fluid levels (nonspecific)
• huge and disproportionately dilated loop of bowel (highly suggestive)
• “soap-bubble” appearance of retained meconium
• dilatation of the proximal colon up to the level of the atresia, unless multiple atresias are
present.
• CONTRAST ENEMA:
• microcolon, distal to the atresia with obstruction to the retrograde flow of barium at the site
of atresia.
• hook or question-mark appearance at the site
• colon is often non-fixed or malpositioned in the midline.
• distal colon segment may perforate into the peritoneal cavity  blind end is covered with
only mucosa.
 Colon Atresia

Distended loops of bowel similar to those seen in low small bowel obstruction.
Image from a barium enema study demonstrates microcolon with complete
obstruction to the retrograde flow of a barium enema study demonstrates
microcolon with complete obstruction to the retrograde flow of barium in the
transverse portion of the colon.
 Hirschsprung’s Disease
(Aganglionosis of the colon)

• majority of cases , the aganglionic segment is limited to

the rectosigmoid region (short segment aganglionosis).
• always involves the anus and internal sphincter and
extends proximally for a variable distance.
• transition point found in the rectosigmoid (73%) >
descending colon (14%) > more proximal colon (10%).
• RADIOGRAPHIC FEATURES:
• features of distal bowel obstruction.
• a dilated colon proximal to the distal and smaller aganglionic segment
typical finding
• small gas-filled rectum can be seen (in prone film).
• absence of rectal gas is not specific as also seen in infants sepsis and
necrotizing enterocolitis.
• bowel pattern may appear normal.
• pneumoperitoneum may be seen in patients with long segment or total
colonic disease secondary to colonic perforation
• CONTRAST ENEMA:
• directed towards identifying the transition zone  the most specific (where
the normalsized, distal aganglionic bowel changes in caliber to join the
proximal ganglionic bowel)
• funnel-shaped and it is an important diagnostic feature
• FLUOROSCOPIC VISUALIZATION:
• irregular saw-toothed mucosal pattern  disordered contractions in the
aganglionic colon
• straight transverse bands in the involved segment of colon  represent areas
of persistent spasm
• Rectosigmoid index
• This compares the ratio of the rectal diameter to the sigmoid diameter
• abnormal if the sigmoid colon is more dilated than the rectum
• (R/S index <1)  abnormal.
• Other:
• Immediate postevacuation film  collapsed distal aganglionic segment.
• Delayed radiographs (24 hours)  prolonged retention of barium (strong
indicator) when enema findings - inconclusive
• colon that is shortened with flexures pulled down and rounded in
appearance (question mark colon)
• true microcolon appearance is rare
• Confirmation:
• suction biopsy  taken 2 cm above the dentate line,
as below this line  the normal anus shows relative hypoganglionosis.
CONTRAST ENEMA CAN BE SAFELY PERFORMED 24 HOURS AFTER A
SUCTION BIOPSY, THOUGH IDEALLY THE ENEMA SHOULD PRECEDE A
BIOPSY.
• IN EQUIVOCAL CASES,
• ANORECTAL MANOMETRY:
• relies on anal sphincter reflex relaxation in response to distention
of the rectum
• Absent in patients with Hirschsprung’s disease.

• ENTERECOLITIS IS A MAJOR CAUSE OF DEATH &

ENEMA IS CONTRAINDICATED IN THESE PATIENTS.
Plain X-ray abdomen showing
a dilated proximal sigmoid
colon with a smaller distal
sigmoid with relatively little
rectal gas in a neonate
Barium enema shows an
abrupt transition from the
narrow caliber rectosigmoid
(aganglionic) to the larger
caliber more proximal sigmoid
colon
 Meconium plug syndrome

(a) BARIUM ENEMA study

shown a normal-sized rectum
and colon with inspissated
meconium filling defects. (b)
Gross specimen shown the
colon and the typical
appearance of an evacuated
plug.
Anorectal Anomalies
• ATRESIA: rectal atresia, imperforate anus
• FISTULA: perineum, vestibule, vagina, urethra,
bladder.
• RADIOGRAPH:
• Low small bowel or colonic obstruction
• Prone shoot though radiographdetermine the
level of atresia and assessment of the sacrum.
• M-line  horizontally through the junction of the
lower third and upper two third of the ischium
level of the puborectal muscle
• Classify lesion: high, intermediate or low.
• ULTRASOUND:
• Delineating distance from the distal pouch to perineum
• <10 mmlowsimple perineal anoplasty
• >15mm  high  diversion & colostomy

• CYSTOGRAPHY:
• Delineates associated fistulas between terminal bowel and urinary tract.

• CT & MRI
• Modalities of choice
• Help determine presence of puborectal muscle, ext sphincter and rectal
pouch.
IMPERFORATE ANUS: Lateral voiding cystogram demonstrates an air-filled distal rectal
pouch ending blindly below the “M” line. low lesion. No fistula is opening the terminal
bowel.
ECTOPIC ANUS - Voiding cystogram demonstrates a recto-urethral fistula.
 References:
• Grainger & Allison's Diagnostic Radiology: Textbook of
Medical Imaging, 6th edition
• Gore & Levine textbook of gastrointestinal radiology, 2nd
edition.
• Textbook of radiology and imaging - David Sutton.
• Diagnostic Radiology Paediatric Imaging.
AIIMS_MAMC_PGI series.
• Gupta A: Imaging of Congenital Anomalies of the
Gastrointestinal Tract.Indian Journal of Pediatrics, Volume
72—May, 2005
• Berrocal: Congenital anomalies of Small Intesine, colon and
rectum. Radiographics 1999;19:1219-1236.
• Berrocal: Congenital anomalies of Upper gastrointestinal tract.
Radiographics 1999;19:855-872
Thank you.