Pediatric Radiology

Pediatric Radiology Indian Medical PG Question 1: A 5-month old child rushed into hospital with complaint of colicky pain, bilious vomiting and red current jelly like appearance of stools. On examination, there was a sausage shaped mass in the right lumbar region. Which of the following is the preferred modality that is used as both diagnostic and therapeutic?

• A. Air enema (Correct Answer)
• B. MRI
• C. Anoscopy
• D. Barium enema

Pediatric Radiology Explanation: ***Air enema*** - An **air enema** can be both diagnostic and therapeutic for **intussusception**, using air pressure to reduce the telescoping bowel segment. - The classic triad of **colicky pain, bilious vomiting, and red currant jelly stools** strongly suggests intussusception, and an air enema is often the first-line intervention. *MRI* - **MRI** is not typically used for the initial diagnosis or treatment of pediatric intussusception due to its long imaging times and need for sedation. - While it can provide detailed anatomical information, it is not a **therapeutic** modality for this condition. *Anoscopy* - **Anoscopy** is a procedure used to visualize the anal canal and distal rectum, primarily for conditions like hemorrhoids or anal fissures. - It is **not suitable** for diagnosing or treating intussusception, which involves a more proximal bowel obstruction. *Barium enema* - A **barium enema** can be diagnostic and therapeutic for intussusception, using barium solution to reduce the intussusception. - However, **air enema** is generally preferred due to a lower risk of perforation and easier interpretation of reduction, making it the more common choice.

Pediatric Radiology Indian Medical PG Question 2: A child of 2 years having a respiratory rate of 46 per minute shall be classified by a health worker as

• A. no pneumonia, cough or cold
• B. severe pneumonia
• C. very severe disease
• D. pneumonia (Correct Answer)

Pediatric Radiology Explanation: ***Correct: Pneumonia*** - A respiratory rate of **46 breaths per minute** in a 2-year-old child falls within the criteria for **fast breathing**. According to World Health Organization (WHO) IMCI guidelines, fast breathing is defined as a respiratory rate ≥ 50 breaths/minute for children aged 2 months to 12 months, and **≥ 40 breaths/minute for children aged 12 months to 5 years**. - Fast breathing alone (without chest indrawing or danger signs) is the **key clinical sign** for classifying a child with cough or difficulty breathing as having **pneumonia**. - This is based on the **WHO IMCI classification** used by health workers for management of childhood illness. *Incorrect: No pneumonia, cough or cold* - This classification would be made if the child's respiratory rate was **within the normal range** for their age (< 40 breaths per minute for age 1-5 years) and if there were no other signs of pneumonia or severe disease. - A respiratory rate of 46 breaths per minute in a 2-year-old is **above the normal limit** and meets the criteria for fast breathing. *Incorrect: Severe pneumonia* - Severe pneumonia is classified by the presence of **chest indrawing** in addition to cough or difficult breathing, without danger signs. - While the child has fast breathing, the question does not mention **chest indrawing**, which is required for this classification. *Incorrect: Very severe disease* - Very severe disease is classified when there are **danger signs** present: inability to drink or breastfeed, persistent vomiting, convulsions, lethargy or unconsciousness, or stridor in a calm child. - The question only mentions elevated respiratory rate without any **danger signs**, so this classification does not apply.

Pediatric Radiology Indian Medical PG Question 3: A healthy appearing 8-year-old boy is evaluated for an abdominal mass, felt by his mother during a bath. What is the most likely diagnosis?

• A. Wilms' tumor (Correct Answer)
• B. Hodgkin's lymphoma
• C. Embryonal rhabdomyosarcoma
• D. Stage 4 neuroblastoma

Pediatric Radiology Explanation: ***Wilms' tumor*** - **Wilms' tumor**, or **nephroblastoma**, is the most common primary renal malignancy in children, typically presenting as an asymptomatic abdominal mass. - The peak incidence is between ages 2 and 5, but it can occur up to 8 years old; a **palpable abdominal mass** is the classic presentation. *Hodgkin's lymphoma* - Hodgkin's lymphoma usually presents with **lymphadenopathy** (enlarged lymph nodes), often in the neck or supraclavicular region, along with systemic symptoms like fever and weight loss. - While it can occur in childhood, an isolated abdominal mass without other typical signs makes it less likely. *Embryonal rhabdomyosarcoma* - **Rhabdomyosarcoma** is a soft tissue sarcoma and can occur in various locations, but an isolated abdominal mass in an 8-year-old is less commonly embryonal rhabdomyosarcoma without other localizing symptoms. - It usually presents with symptoms related to the primary site, such as a painful mass, swelling, or organ dysfunction if it invades structures. *Stage 4 neuroblastoma* - **Neuroblastoma** typically presents in infants and young children, often with an abdominal mass but also with signs of metastasis (e.g., bone pain, periorbital ecchymosis, opsoclonus-myoclonus syndrome). - While it can manifest as an abdominal mass, the "healthy appearing" aspect makes stage 4 less likely, as advanced neuroblastoma often causes systemic symptoms.

Pediatric Radiology Indian Medical PG Question 4: A child presented with blunt abdominal trauma, the first investigation to be done is -

• A. USG (Correct Answer)
• B. CT Scan
• C. Complete Hemogram
• D. Abdominal X-ray

Pediatric Radiology Explanation: ***USG*** - An **ultrasound (USG)** is the **first-line imaging investigation** for blunt abdominal trauma in children due to its **non-invasive nature**, lack of radiation exposure, and rapid bedside availability. - **FAST (Focused Assessment with Sonography for Trauma)** effectively identifies the presence of **free fluid** (indicating internal bleeding/hemoperitoneum) and can assess solid organ injuries, particularly the **spleen and liver**. - It is the **preferred initial investigation in hemodynamically stable pediatric patients**. *CT Scan* - A **CT scan** is more sensitive and provides detailed anatomical information but involves significant **radiation exposure**, which is a major concern in children. - It is usually reserved for cases where USG is inconclusive, there is a **high clinical suspicion of severe injury**, or when determining the need for surgical intervention in hemodynamically stable patients. *Complete Hemogram* - A **complete hemogram** assesses blood components like hemoglobin and hematocrit, which are crucial for evaluating blood loss, but it is a **laboratory test, not an imaging investigation**. - While important for initial assessment and serial monitoring, it doesn't provide immediate information about the **location, type, or extent of internal abdominal injuries**. *Abdominal X-ray* - An **abdominal X-ray** has limited utility in blunt abdominal trauma as it is primarily useful for detecting **hollow viscus perforation (free air)** or bony fractures. - It does not effectively visualize soft tissue injuries, fluid collections, or solid organ damage, making it unsuitable as the primary diagnostic tool in blunt abdominal trauma.

Pediatric Radiology Indian Medical PG Question 5: What is the investigation of choice for an 8-year-old child presenting with an acute abdomen?

• A. USG (Correct Answer)
• B. CT Scan
• C. X-ray
• D. MRI

Pediatric Radiology Explanation: ***USG*** - An **ultrasound (USG)** is the preferred initial imaging modality in pediatric acute abdomen due to its **lack of ionizing radiation**, ease of use, and ability to visualize common causes like appendicitis and intussusception. - It is particularly useful for assessing **fluid collections**, inflammation, and obstruction in a non-invasive manner suitable for children. *CT Scan* - While it offers detailed anatomical views, **CT scans** involve significant **ionizing radiation**, which is a concern in children due to increased lifetime cancer risk. - It is typically reserved for cases where **USG is inconclusive** or if there is a high suspicion of conditions not well visualized by ultrasound. *X-ray* - **X-rays** provide limited information for soft tissue pathologies and are primarily useful for detecting **bowel obstruction (air-fluid levels)** or **free air** (perforation). - They lack the resolution to diagnose many common causes of acute abdomen in children, such as appendicitis or intussusception. *MRI* - **MRI** provides excellent soft tissue contrast without ionizing radiation but often requires **sedation** in young children due to the long scan times and need for stillness. - It is less readily available and more expensive than USG, making it a less practical first-line investigation for an acute presentation.

Pediatric Radiology Indian Medical PG Question 6: A 3-month-old child presents with indrawing of the chest and a respiratory rate of 52 breaths per minute. This condition can be classified as:

• A. SIRS
• B. Respiratory distress (Correct Answer)
• C. Tachypnoea
• D. ARDS

Pediatric Radiology Explanation: ***Respiratory distress*** - **Indrawing of the chest** is a classic sign of increased work of breathing, indicating the child is struggling to oxygenate. - A respiratory rate of **52 breaths per minute in a 3-month-old** is significantly elevated and, combined with indrawing, points to respiratory distress. - According to **WHO IMCI guidelines**, chest indrawing in a child with fast breathing is classified as **pneumonia/respiratory distress** requiring immediate treatment. *SIRS* - **Systemic Inflammatory Response Syndrome (SIRS)** criteria are typically more comprehensive and include fever or hypothermia, tachycardia, tachypnea, and abnormal white blood cell count. - While tachypnea is present, the other defining features of SIRS are not fully met by the information provided, nor does indrawing directly classify as SIRS. *Tachypnoea* - **Tachypnoea** refers specifically to an elevated respiratory rate, which is present (52 breaths per minute). - However, the presence of **chest indrawing** indicates more than just rapid breathing; it signifies significant respiratory effort and compromise. - The classification must capture both the elevated rate and the increased work of breathing. *ARDS* - **Acute Respiratory Distress Syndrome (ARDS)** is a severe form of lung injury characterized by widespread inflammation, hypoxemia, and bilateral infiltrates on chest imaging. - While respiratory distress is a feature of ARDS, the given information is insufficient to diagnose ARDS, which requires specific criteria relating to oxygenation and radiological findings.

Pediatric Radiology Indian Medical PG Question 7: Investigation of choice for the diagnosis of congenital hypertrophic pyloric stenosis is:

• A. USG (Correct Answer)
• B. Barium meal
• C. Barium meal follow through
• D. CT scan with contrast

Pediatric Radiology Explanation: ***USG*** - **Ultrasound** is the preferred initial imaging modality due to its non-invasiveness, lack of radiation, and high accuracy in visualizing the thickened pyloric muscle. - The classic ultrasound findings include a **pyloric muscle thickness** of ≥ 4 mm and a **pyloric channel length** of ≥ 14 mm. *Barium meal* - While a barium meal can show findings like the "string sign" or "shoulder sign," it involves **radiation exposure** and is generally considered a second-line investigation. - Its diagnostic accuracy is good, but it is less convenient and riskier than ultrasound for this condition. *Barium meal follow through* - This procedure tracks barium through the entire gastrointestinal tract, which is **excessive and unnecessary** for diagnosing pyloric stenosis, which is a localized obstruction. - It also involves significant **radiation exposure** and a prolonged examination time. *CT scan with contrast* - A **CT scan** involves significant **radiation exposure** and is not typically used for diagnosing congenital hypertrophic pyloric stenosis. - It is also less sensitive than ultrasound for visualizing the specific soft tissue changes in the pyloric muscle.

Pediatric Radiology Indian Medical PG Question 8: The X-ray of the patient shows?

• A. Rickets
• B. Hemarthrosis
• C. Scurvy (Correct Answer)
• D. Sun burst appearance

Pediatric Radiology Explanation: ***Scurvy*** - The X-ray images display classical findings of scurvy, including a **dense metaphyseal line** (white line of Frankel), **lucent zone beneath the metaphysis** (Trümmerfeld zone), and **epiphyseal separation** due to capillary fragility. - The findings are particularly evident at the distal ends of the femur and proximal tibia, consistent with **subperiosteal hemorrhages** and impaired osteoid formation characteristic of **vitamin C deficiency**. *Rickets* - Rickets is characterized by **widening, cupping, and fraying of the metaphyses**, often accompanied by **growth plate widening** and bowing of long bones due to defective mineralization of bone matrix. - These features are not the predominant findings in the provided X-rays, which show distinct abnormalities related to hemorrhage and bone fragility. *Hemarthrosis* - Hemarthrosis refers to bleeding into a joint space, often characterized by **joint effusions** and possibly **bone erosions** if chronic, typically seen in conditions like hemophilia. - While subperiosteal hemorrhages are present in scurvy, the X-ray findings are broader than just intra-articular bleeding and include specific metaphyseal changes. *Sun burst appearance* - A "sunburst appearance" is a classic radiographic finding often associated with aggressive **bone tumors** like **osteosarcoma**, indicating **spiculated periosteal reaction** extending perpendicularly from the bone cortex. - This pattern is absent in the provided X-rays, which show signs of metabolic bone disease rather than a primary bone tumor.

Pediatric Radiology Indian Medical PG Question 9: Parameningeal Rhabdomyosarcoma is best diagnosed by:

• A. MRI (Correct Answer)
• B. CT Scan
• C. SPECT
• D. PET

Pediatric Radiology Explanation: ***MRI*** - **Magnetic Resonance Imaging (MRI)** provides excellent soft tissue contrast, which is crucial for visualizing the extent of **parameningeal rhabdomyosarcoma** and its relationship to critical structures like the **meninges**, **brainstem**, and **cranial nerves**. - It is superior for detecting **intracranial extension**, **bone erosion**, and assessing response to treatment, making it the preferred imaging modality for diagnosis and staging. *CT Scan* - **Computed Tomography (CT) scans** are good for evaluating bone involvement and calcifications but offer less detailed soft tissue resolution compared to MRI. - While it can identify large masses, it may miss subtle extensions or involvement of the **meninges** that are readily seen on MRI. *SPECT* - **Single-Photon Emission Computed Tomography (SPECT)** is a nuclear medicine imaging technique primarily used to assess organ function and blood flow, often in cardiology or neurology for functional studies. - It provides limited anatomical detail for the precise localization and characterization of soft tissue tumors like **rhabdomyosarcoma**. *PET* - **Positron Emission Tomography (PET) scans** are excellent for detecting metabolically active tumors, assessing disease burden, and identifying distant metastases, especially when combined with CT (**PET/CT**). - However, while useful for staging and follow-up, it does not provide the high-resolution anatomical detail of the primary tumor's local extent and its relationship to adjacent structures as effectively as **MRI**.

Pediatric Radiology Indian Medical PG Question 10: A chest X-ray shows the following appearance. Identify the pathology:

• A. Pericardial effusion
• B. Boot shaped heart
• C. Egg on side appearance (Correct Answer)
• D. Normal-sized heart

Pediatric Radiology Explanation: ***Egg on side appearance*** - The image illustrates a classic "egg on side" or **"egg-on-a-string" appearance**, which is a radiological sign of **transposition of the great arteries (TGA)**. - This appearance is due to the narrow vascular pedicle (aorta and pulmonary artery are superimposed) and the **enlarged, egg-shaped cardiac silhouette** as a result of ventricular hypertrophy and right atrial enlargement. *Pericardial effusion* - **Pericardial effusion** would typically manifest as a **globular or "water-bottle" heart shape** on chest X-ray due to fluid accumulation around the heart. - This appearance is characterized by a widened cardiac silhouette with sharply defined borders, which is not clearly visible here. *Boot shaped heart* - A **"boot-shaped" heart**, also known as a **coeur en sabot**, is characteristic of **tetralogy of Fallot**. - This shape is caused by **right ventricular hypertrophy** with an upturned cardiac apex, and often an accompanying concave pulmonary artery segment, which is not seen in this image. *Normal-sized heart* - The cardiac silhouette in the image is clearly **enlarged and distinctly abnormal** in shape, indicating it is not a normal-sized heart. - A **normal-sized heart** would have a cardiothoracic ratio of less than 0.5 and distinct great vessel outlines.

Pediatric Radiology Flashcard 1 of 10

Question: Which is the neuroimaging modality of choice for etiological evaluation of seizures in a neonate?_____

Answer: MRI

Pediatric Radiology Flashcard 2 of 10

Question: X-rays of the skull reveal enlarged sella and intersutural (wormian) bones in children with Congenital _____

Answer: hypothyroidism

Pediatric Radiology Flashcard 3 of 10

Question: _____ on chest x-ray is suggestive of neonatal respiratory distress syndrome.

Answer: Air bronchogram

Pediatric Radiology Flashcard 4 of 10

Question: _____, fraying, and splaying are the metaphyseal radiological features seen in rickets.

Answer: Cupping

Pediatric Radiology Flashcard 5 of 10

Question: The X-ray of choice to determine the skeletal age of a 12 to 14 year-old boy is X-ray of the _____ and hip.

Answer: elbow

Pediatric Radiology Flashcard 6 of 10

Question: What is a feature of child abuse on MRI?_____

Answer: Sub-epiphyseal micro-fracture

Pediatric Radiology Flashcard 7 of 10

Question: Contrast enema shows an empty microcolon in case of _____

Answer: Meconium ileus

Pediatric Radiology Flashcard 8 of 10

Question: Target sign on USG Abdomen is suggestive of _____.

Answer: intussusception

Pediatric Radiology Flashcard 9 of 10

Question: The given barium enema is suggestive of _____ disease

Answer: Hirschsprung

Pediatric Radiology Flashcard 10 of 10

Question: The given USG shows _____ sign and _____ sign in congenital hypertrophic pyloric stenosis

Answer: cervix