Residents’ Section • Pat tern of the Month

Chang et al.
Gastrointestinal Tract Filling Defects in Pediatric Patients

Residents’ Section
Pattern of the Month
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Residents

Gastrointestinal Tract Filling

inRadiology Defects in Pediatric Patients
Patricia T. Chang1

D
iscrete gastrointestinal filling de- a “duodenal dimple,” which can occur when
Edward Y. Lee1 fects can result from develop- the tip of a nasogastric tube presses on the
Ricardo Restrepo 2 mental obstructive lesions of the contrast-filled web distally causing dimpling
Ronald L. Eisenberg 3 small intestine, neoplastic of the duodenal wall contour at the web at-
causes, infectious causes, or foreign body in- tachment sites. Treatment options include
Chang PT, Lee EY, Restrepo R, Eisenberg RL gestion (Table 1). Many pediatric patients surgical or endoscopic resection of the web
with gastrointestinal filling defects present or duodenoduodenostomy if there is a com-
with symptoms of bowel obstruction, includ- plete obstruction. The prognosis is usually
ing abdominal pain and distention, vomiting, excellent with treatment.
and obstipation. Radiography is often the ini-
tial imaging study, sometimes followed by Meckel Diverticulum
fluoroscopy, CT, or MRI. The combination of Meckel diverticulum is the most common
imaging, age of the patient, clinical history, congenital abnormality of the gastrointesti-
and laboratory data can usually permit sub- nal tract, occurring in approximately 2% of
stantial narrowing of the differential diagno- the population. Resulting from incomplete
sis and optimization of patient management. resorption of the omphalomesenteric (vitel-
line) duct, the embryonic communication be-
Congenital Causes tween the yolk sac and the developing midgut,
Duodenal Web
Duodenal web is a rare developmental TABLE 1: Filling Defects in the Bowel
anomaly caused by failure of the primitive in Children
foregut to recanalize between the ninth and Type
Keywords: gastrointestinal filling defects, 11th weeks of gestation. Associated anoma-
pediatric patients Congenital
lies include annular pancreas, midgut mal-
DOI:10.2214/AJR.13.12421 rotation, imperforate anus, and Down syn- Duodenal web
drome. Among the different types of duodenal Meckel diverticulum
Received December 13, 2013; accepted without revision webs are complete duodenal atresia (imperfo-
January 24, 2014. Meconium ileus
rate web), imperforate intraluminal duodenal
Choledochocele
1
Department of Radiology, Boston Children’s Hospital, diverticulum (windsock web), and perforat-
Harvard Medical School, Boston, MA. ed duodenal web (intraluminal duodenal di- Neoplastic
verticulum with either a central or eccentric Polyps
2
Department of Radiology, Miami Children’s Hospital, opening). Affected patients typically present
Miami, FL. Juvenile polyposis
early with feeding intolerance and bilious or
Gardner syndrome
3
Department of Radiology, Beth Israel Deaconess nonbilious vomiting. Later symptoms include
Medical Center, Harvard Medical School, 300 Brookline nausea, abdominal pain, progressive vomit- Bannayan-Riley-Ruvalcaba syndrome
Ave, Boston, MA 02215. Address correspondence to ing, and even acute pancreatitis. Lymphoma
R. L. Eisenberg (rleisenb@bidmc.harvard.edu).
On abdominal radiographs, severe ob- Infectious
WEB struction can lead to dilatation of the stom-
Parasitic infection
This is a web exclusive article. ach and proximal duodenum, producing the
classic double-bubble sign. On fluoroscopy, a Foreign Bodies
AJR 2014; 203:W3–W13 windsock deformity obstructing the duode- Radiopaque foreign bodies
0361–803X/14/2031–W3
num beyond the origin of the web can pro- Radiolucent foreign bodies
duce gradual ballooning of the duodenal dia-
Bezoars
© American Roentgen Ray Society phragm (Fig. 1). Another fluoroscopic sign is

AJR:203, July 2014 W3


Meckel diverticulum typically arises within 2
feet (61 cm) of the ileocecal valve on the an-
timesenteric border of the ileum. Most affect-
ed patients develop clinical symptoms before
age 2 years. Common complications include
bleeding (when the diverticulum contains ec-
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topic gastric mucosa), bowel obstruction, in-
flammation, and perforation.
Abdominal radiographs may be nonspe-
cific or rarely show a right lower quadrant
mass, displacement of bowel loops, and ob-
struction. Ultrasound may show a thick-
walled, mixed echogenicity tubular struc-
ture in the right lower quadrant. An inflamed
Meckel diverticulum can also present as a
cyst on ultrasound, but the mucosal layers
are more irregular than those typically found
in an intestinal duplication. On CT, a Meck-
el diverticulum can be found incidentally
originating from the ileum as a blind-end-
ing structure that may show contrast opaci-
fication. The findings of an inflamed Meckel
diverticulum can be similar to appendicitis,
with a thick-walled blind-ending structure
near the cecum associated with surround-
ing inflammatory changes. Therefore, it is
important to differentiate these entities by
documenting the presence of the normal ap-
pendix. Symptomatic Meckel diverticulum
commonly manifests as a small-bowel ob-
struction due to volvulus and internal hernia
around a mesodiverticular band, intussus-
ception, or incarceration of the diverticulum
in an umbilical or inguinal hernia. The CT
findings of a small-bowel obstruction caused
by Meckel diverticulum are nonspecific and
similar to those resulting from other entities
causing obstruction. If an intussusception
cannot be reduced, a small-bowel obstruc-
tion related to a Meckel diverticulum should
be considered (Fig. 2). The most specific test
for Meckel diverticulum is a 99mTc pertech-
netate scan, with accuracy of approximately
90%, in which the radionuclide accumulates
in the mucin-secreting cells of the ectopic
gastric mucosa in the diverticulum. Treat-
ment involves surgical resection with prima-
ry closure of the small intestine. An appen-
dectomy is also typically performed.
Meconium Ileus
Meconium ileus is a manifestation of in-
testinal and pancreatic dysfunction leading
to neonatal obstruction of the distal ileum
due to abnormally thick tenacious inspis-
sated intraluminal meconium. It is the earli-
est presenting illness in 10–20% of patients
with cystic fibrosis, which occurs in about
W4 AJR:203, July 2014
Chang et al.
90% of patients with meconium ileus. Mi-
crocolon results from distal bowel obstruc-
tion and failure of meconium to pass into the
colon. Complications of meconium ileus in-
clude segmental volvulus, atresia, necrosis,
and perforation with meconium peritonitis.
On abdominal radiographs, there is usual-
ly a nonspecific pattern of distal small-bowel
obstruction with a bubbly appearance of in-
testinal contents in the right lower quadrant
(Fig. 3A). Intramural calcifications can also
be seen as well as peritoneal calcification if
there is in utero perforation. A contrast en-
ema shows a microcolon and multiple filling
defects in the distal ileum from meconium
plugs (Fig. 3B). On ultrasound, there are di-
lated thick-walled loops of small bowel con-
taining heterogeneous meconium. Peritoneal
calcifications, echogenic ascites, and some-
times pseudocyst formation with in utero
perforation can also be identified. On fetal
MRI, high T1 signal intensity meconium can
be identified in the microcolon or obstructed
small-bowel loops.
Any patient presenting with meconium il-
eus should be tested for cystic fibrosis. Un-
complicated meconium ileus is treated with
serial hyperosmotic water-soluble enemas.
Surgery is typically reserved for patients
with decompensation, failed enemas, or per-
foration. In complicated meconium ileus,
surgery is the treatment of choice, which in-
volves resection of abnormal bowel, removal
of the meconium, and primary anastomosis
or temporary enterostomy.
Choledochocele
According to the Todani classification
system, a choledochocele is a type III chole-
dochal cyst that presents as dilatation of the
intraduodenal segment of the common bile
duct. Rare congenital malformations of the
intrahepatic biliary tree, choledochal cysts
primarily affect girls, are particularly preva-
lent in Japanese patients, and are thought to
be risk factors for the development of cholan-
giocarcinoma. The classic clinical symptoms
in pediatric patients are a triad of abdomi-
nal pain, palpable right upper quadrant mass,
and jaundice. Patients with choledochal cysts
also often present with recurrent cholangitis.
Ultrasound and MRCP are currently the
imaging modalities of choice for evaluating
choledochal cysts in pediatric patients. Cho-
ledochoceles typically occur within the duo-
denal wall and protrude as a mass into the
duodenal lumen. Representing 4% of cho-
ledochal cysts, they may be lined with duo-
TABLE 2: Classification of Intestinal
Polyposis Syndromes
Classification
Hereditary
Familial multiple polyposis
Gardner syndrome
Peutz-Jeghers syndrome
Turcot syndrome
Nonhereditary
Cronkhite-Canada syndrome
Juvenile polyposis (occasionally hereditary)
denal mucosa, biliary mucosa, or both. On
MRCP, a choledochocele may appear as an
intramural filling defect exerting mass effect
on the duodenum (Fig. 4).
Surgical resection is the current manage-
ment of choice in pediatric choledochoceles,
especially those causing symptoms. Choled-
ochoceles less than 3 cm in diameter can be
excised endoscopically with sphincteroto-
my, whereas larger lesions are resected via a
transduodenal approach.
Neoplastic Causes
Polyps
Intestinal polyposis syndromes are rare
entities that can be classified as hereditary or
nonhereditary (Table 2). In the pediatric age
group, juvenile polyps are the most common
polypoid lesions in the colon. Findings sug-
gesting an intestinal polyposis syndrome in-
clude an alimentary tract polyp found in any
young patient, two or more polyps identified
in any patient, development of colon cancer
in a patient under 40 years old, and presence
of characteristic cutaneous manifestations
associated with some of these syndromes.
In familial juvenile polyposis syndrome,
hamartomatous polyps can affect the entire
gastrointestinal tract. This condition usually
presents in childhood, unlike the adult on-
set of syndromes with adenomatous polyps.
Patients with familial juvenile polyposis syn-
drome have an increased risk of developing
adenocarcinoma in the stomach as well as
colorectal cancer. In about 20% of patients,
germline mutations involved in transforming
growth factor β signaling have been identi-
fied. Barium enema or MRI can show multi-
ple pedunculated filling defects (Fig. 5).
Gardner syndrome is an autosomal domi-
nant subtype of familial adenomatous polypo-
sis. Caused by a mutation in the adenomatous
polyposis coli gene on chromosome 5q21, it is
 Gastrointestinal Tract Filling Defects in Pediatric Patients
characterized by adenomatous intestinal pol-
yps; multiple osteomas in the skull, maxillae,
and mandible; and multiple epidermoids and
desmoids. Nearly all adenomatous polyps un-
dergo malignant transformation if not treated.
Patients with Gardner syndrome also have a
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four times increased risk of developing pan-
creatic adenocarcinoma and a risk of hepato-
blastoma that is more than 800 times that of
the general population. On barium enema or
CT, Gardner syndrome appears as multiple
tiny polypoid filling defects that may be asso-
ciated with soft-tissue desmoids (Fig. 6).
Bannayan-Riley-Ruvalcaba syndrome is
a rare autosomal-dominant hamartomatous
disorder linked to mutations of the PTEN
gene. It is characterized by macrocephaly,
hamartomatous intestinal polyps, subcuta-
neous and visceral lipomas, and pigmented
macules involving the genitalia. Bannayan-
Riley-Ruvalcaba syndrome typically arises
in childhood, with delayed motor and intel-
lectual development. Mural polyps can be
seen on barium enema or CT (Fig. 7), al-
though no instance of colorectal or small-
bowel cancer has been reported.
Most patients with polyps detected by
barium enema should undergo colonoscopy
to excise the polyp and search for addition-
al neoplasms. Repeat colonoscopy should be
performed in 3 years for patients at high risk
for developing metachronous advanced ad-
enomas. Colonoscopic surveillance should
be considered for first-degree relatives of pa-
tients with adenomatous polyps.
Lymphoma
Lymphomas of the gastrointestinal tract
are the most common type of primary extra-
nodal lymphomas, representing 5–10% of all
non-Hodgkin lymphomas. Primary gastroin-
testinal lymphomas account for 1–4% of all
gastrointestinal tumors and represent about
15–20% of gastrointestinal lymphomas. Most
gastrointestinal lymphomas are located in the
stomach, with much fewer appearing in the
small bowel, colon, and rectum. The most
common signs and symptoms of lymphoma
involving the gastrointestinal tract in pediat-
ric patients include pain, weight loss, palpa-
ble mass, malabsorption, and diarrhea. Some
affected pediatric patients are asymptomatic,
whereas others may present with an acute ab-
domen due to obstruction or perforation.
The most common appearance of pediat-
ric gastrointestinal lymphoma on CT is an
infiltrating form, which produces a circum-
ferential sausage-shaped mass or aneurys-
AJR:203, July 2014 W5
mal dilatation on the antimesenteric border.
Other intestinal manifestations of childhood
lymphoma include a polypoid form produc-
ing a “target” lesion and a mesenteric form
that appears as multiple round masses en-
casing mesenteric vessels, a larger lobulated
heterogeneous mass with areas of necrosis
displacing small-bowel loops, or ill-defined
mesenteric fat infiltration. Intestinal lympho-
ma can also lead to intussusception due to
abnormal bowel motility, particularly in the
pediatric population (Fig. 8).
Burkitt lymphoma is a highly aggressive
form of non-Hodgkin lymphoma that, in the
pediatric population, may present as an ab-
dominal mass with gastrointestinal hemor-
rhage, abdominal pain, nausea, and intesti-
nal obstruction caused by direct compression
or intraluminal involvement. Up to 20% of
patients with primary abdominal Burkitt
lymphoma present with intussusception (Fig.
9). Treatment of intestinal lymphoma in-
volves chemotherapy. Surgical resection is
reserved for patients with lesions complicat-
ed by bleeding or perforation.
Infectious Causes
The gastrointestinal tract is the prima-
ry site of involvement by parasites during
their life cycle. Although mostly endemic
in underdeveloped or developing countries
in which sanitation is poor, parasitic infec-
tions are now more commonly encountered
in developed countries because of increased
immigration and travel. Common intestinal
parasitic infections include amebiasis, as-
cariasis, anisakiasis, strongyloidiasis, an-
cyclostomiasis, trichuriasis, and tapeworm
disease. Ascaris lumbricoides is one of the
most common parasitic infestations of the
gastrointestinal tract worldwide, giardiasis
is the most common protozoal disease in the
United States, and amebiasis infests 10% of
the world population. Common signs and
symptoms of a parasitic infection include
abdominal pain, diarrhea, nausea, vomit-
ing, weight loss, malabsorption, fever, and
gastrointestinal bleeding. Various parasitic
infections have predilections for different
locations in the body: ascariasis is typically
found in the small bowel, colon, common
bile duct, or pancreatic duct; giardiasis in
the duodenum and jejunum; and amebiasis
in the colon and liver.
Ascariasis produces linear filling defects
on sonographic and fluoroscopic imaging
(Fig. 10). Giardiasis appears as thickened
duodenal or jejunal folds on fluoroscop-
ic imaging, whereas amebiasis can present
as diffuse ulcerating colitis or as a liver ab-
scess on CT. Treatment regimens depend on
the type of parasitic infection. Ascariasis is
treated with antihelminthic chemotherapy
with mebendazole, albendazole, or pyran-
tel pamoate. Giardiasis is treated with ni-
tazoxanide or metronidazole, and amebiasis
is treated with metronidazole.
Foreign Bodies
Foreign body ingestion is common in chil-
dren, particularly those between 6 months
and 3 years old. If occurring in a child
younger than 6 months, foreign body inges-
tion should raise the suspicion of child ne-
glect. Most swallowed objects pass through
the gastrointestinal tract without difficulty. A
foreign body that has progressed beyond the
stomach rarely lodges in the rest of the ali-
mentary tract. However, foreign bodies larg-
er than 5 cm generally do not pass through
the pylorus. If one foreign body is identified,
the entire gastrointestinal tract from the na-
sopharynx to the anus should be examined
to search for additional foreign bodies (Fig.
11). Complications of foreign body inges-
tion include perforation, obstruction, fistula
or abscess formation, mediastinitis, peritoni-
tis, and intussusception. Expulsion of an in-
gested foreign body should be documented
either by checking the patient’s stool or with
follow-up radiography. Unless there is spon-
taneous expulsion, all ingested radiopaque
foreign bodies should be removed either en-
doscopically or by surgery.
Radiopaque Foreign Bodies
Radiopaque foreign bodies include most
metallic objects (except aluminum), lead,
mineral fragments (Fig. 12), and some med-
ical pills. Coin ingestion is common in chil-
dren (Fig. 13), although most cause no harm
and pass through the gastrointestinal tract in
a few days. However, if the coin enters the
airway or becomes impacted at the thoracic
inlet or the gastroesophageal junction, inter-
ventional therapy is warranted. Because of
their small size and resemblance to a dime,
disk (button) batteries are also commonly
ingested by children. These batteries contain
a variety of caustic and corrosive agents that
can lead to perforation and systemic toxicity
from heavy metal poisoning if the contain-
ers break. Batteries in the esophagus are es-
pecially dangerous and should be removed
immediately (Fig. 14). Another dangerous
scenario is the ingestion of multiple mag-

netic objects, which can attract each other
across the bowel walls and cause pressure
necrosis of the bowel wall and subsequent
perforation (Fig. 15). Children can also in-
gest marbles, which are not as dense as coins
or magnets (Fig. 16). Sharp metallic objects
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are likely to penetrate the bowel or esopha-
geal mucosal lining and cause significant in-
jury to the bowel wall or frank perforation,
which may not occur acutely or cause acute
symptoms (Fig. 17).
Radiolucent Foreign Bodies
Radiolucent foreign bodies include most
fish bones, wood, thorns, and plastics. The
diagnosis of foreign body ingestion can be
missed, especially if there is inadequate
history or the swallowed object is not ra-
diopaque. In selected cases, contrast-en-
hanced studies with barium impregnated
cotton balls may help in the diagnosis of for-
eign body ingestion such as fish or chicken
bones (Fig. 18). If there is an unusual opac-
ity or lucency seen on radiography, CT may
also be of value for further characterization
and confirmation before either endoscopic
or surgical removal.
Bezoars
Bezoars are aggregates of inedible or undi-
gested material, which are found most com-
monly in the stomach. They have also been
described in the esophagus and small and
large intestines, although colonic bezoars
are rare. Affected pediatric patients usual-
ly present with abdominal pain, nausea and
vomiting, and early satiety. Complications of
bezoars include obstruction, perforation, in-
tussusception, pancreatitis, and appendicitis.
Bezoars can be categorized into five ma-
jor subgroups according to the type of sub-
stance: Trichobezoars and phytobezoars are
the most common. Trichobezoars, which
are more common in adolescent girls and
patients with mental illness, can be com-
posed of hair fibers, carpet, or string. They
usually are at least partially contained with-
in the stomach, although they can extend
throughout the entire small bowel and cause
W6 AJR:203, July 2014
Chang et al.
obstruction (Rapunzel syndrome) (Fig. 19).
Phytobezoars, which are composed of poor-
ly digested fruit or vegetable material (per-
simmon, coconut fibers, celery, and banana
seeds), are more common after gastric sur-
gery. Lactobezoars are composed of undi-
gested milk precipitates and typically occur
in preterm infants fed with highly concen-
trated formula within the first few weeks
of life (Fig. 20). Risk factors include poor
gastric motility and dehydration. Pharmac-
obezoar is a complication of undissolved
medication pills (Fig. 21), most frequently
cholestyramine, sucralfate, enteric coated
aspirin, aluminum hydroxide antacids, and
such extended-release pills as nifedipine or
verapamil. Lithobezoar is the name given to
the ingestion of multiple foreign bodies as
well as to ingestion of such miscellaneous
substances as shellac, tar, dirt, and sand.
The imaging appearance of a bezoar de-
pends primarily on the types of ingested
materials, which can be radiolucent or radi-
opaque. In general, radiographs often show
increased opacities within the lumen, some-
times associated with dilated bowel loops
suggesting secondary bowel obstruction. On
ultrasound, they can be visualized as a hy-
perechoic intraluminal mass with marked
acoustic shadowing. On CT or fluoroscop-
ic imaging, the intraluminal mass can have
a mottled appearance and contain contrast
material or air bubbles. Treatment of bezoars
depends on the underlying ingested materi-
als but typically involves chemical dissolu-
tion or endoscopic or surgical removal.
Conclusion
Gastrointestinal filling defects can be
caused by numerous entities, from con-
genital lesions to foreign body ingestions.
Knowledge of the spectrum of causes is es-
sential for timely and appropriate manage-
ment of pediatric patients, particularly those
presenting with bowel obstruction. Recogni-
tion of characteristic imaging features is im-
portant because it can guide treatment and
may eliminate unnecessary invasive proce-
dures such as biopsy or surgery.
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 Gastrointestinal Tract Filling Defects in Pediatric Patients

Fig. 1—Duodenal web in 20-day-old infant with

new vomiting.
A, Upper gastrointestinal series image shows pooling
of oral contrast material in dilated proximal duodenum
(PD), with web causing abrupt obstruction.
B, Delayed image shows eventual passage of
contrast material through elongated stenotic
segment (windsock diverticulum) (arrow).
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A B

Fig. 2—Meckel
diverticulum in 5-year-old
boy with abdominal pain.
A, Ultrasound image
shows layers of alternating
echogenicity, consistent
with intussusception
(arrow). Meckel
diverticulum serves as
lead point and there is
surrounding free fluid (F).
B, Contrast-enhanced
axial CT image shows
Meckel diverticulum
(arrow) as intussusceptum
containing fat.

A B

Fig. 3—Meconium ileus in newborn infant with

failure to pass meconium.
A, Frontal abdominal radiograph shows
numerous dilated bowel loops, consistent with
distal obstruction.
B, Contrast enema image shows microcolon, with
distal ileal filling defects (arrows) representing
meconium pellets.
A B

AJR:203, July 2014 W7

 Chang et al.

Fig. 4—Choledochocele in 12-year-old girl with

intermittent episodes of upper abdominal pain.
Coronal thin-slab MRCP image shows cystic
dilatation of distal common bile duct and intramural
mass (arrow), which causes mass effect on
duodenum. GB = gall bladder.
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Fig. 5—Juvenile polyposis in 10-year-old boy with rectal bleeding.

A, Air-contrast barium enema image shows multiple pedunculated colonic filling
defects (arrows).
B, Axial T2-weighted MR image of abdomen shows pedunculated polyp (arrow)
in rectum.
A

W8 AJR:203, July 2014

 Gastrointestinal Tract Filling Defects in Pediatric Patients
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A B
Fig. 6—Gardner syndrome in 21-year-old man with upper gastrointestinal bleeding, anorexia, and weight loss.
A, Contrast-enhanced axial CT image shows multiple tiny polyps (arrows) projecting from gastric wall.
B, Coned image shows soft-tissue desmoid (arrow), additional manifestation of Gardner syndrome.

Fig. 7—Bannayan-Riley-Ruvalcaba syndrome in 7-year-old boy with
macrocephaly, dolichocephaly, cutis marmorata, and penile lentigines. Virtual
colonoscopy CT image shows several mural polyps (asterisks).
Fig. 8—Intestinal lymphoma in 8-year-old boy who
presented with signs of bowel obstruction. Contrast-
enhanced coronal CT image shows concentric
layers of hyper- and hypodense tissue representing
intussusception (arrow) caused by a leading point
related to neoplastic process.

AJR:203, July 2014 W9

 Chang et al.
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A B
Fig. 9—Gastric Burkitt lymphoma in 4-year-old boy with intermittent abdominal pain, anorexia, weight loss, constipation, and irritability.
A, Contrast-enhanced axial CT image shows eccentric thickening (asterisks) of gastric wall.
B, Contrast-enhanced axial CT image shows small-bowel intussusception (asterisks) due to lead point from lymphoma.

A B
Fig. 10—Ascariasis in 7-year-old boy from Turkey with abdominal pain and vomiting for 3 days.
A, Ultrasound image shows cylindric structures (arrows) in small-bowel lumen.
B, Small bowel follow-through image shows serpiginous filling defect (arrow) within small bowel, compatible with ascaris infestation.

W10 AJR:203, July 2014

 Gastrointestinal Tract Filling Defects in Pediatric Patients

Fig. 11—Foreign body

ingestion in 15-month-old
girl with neck swelling
and fever.
A, Frontal chest
radiograph reveals subtle
incompletely imaged
foreign body (arrow).
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B, Lateral radiograph of
neck clearly shows foreign
body (arrow) within
cervical esophagus. This
illustrates importance of
obtaining radiographic
series “from mouth
to anus” in cases of
suspected ingested
foreign bodies.

A B

A B
Fig. 13—Coin ingestion in 20-month-old girl with history of gagging.
A, Frontal chest radiograph reveals coin (arrow) lodged in upper esophagus with characteristic en
face appearance.
B, Lateral chest radiograph confirms anatomic location of coin (arrow) within esophagus just behind trachea.

Fig. 12—Rock ingestion in 2-year-old boy. Frontal

chest radiograph shows multiple irregular radiopaque
foreign bodies (arrow) in esophagus.

Fig. 14—Battery ingestion in 7-year-old girl with

developmental delay who swallowed battery
(unwitnessed).
A, Frontal chest radiograph shows radiopaque
battery (arrow), which was initially thought to
represent overlying object outside of patient. Note
secondary right pleural effusion.
B, Image from repeat study obtained because of
patient’s worsening symptoms shows interval
insertion of right chest tube due to development
of hydropneumothorax caused by esophageal
and pleural erosion related to corrosive effects of
ingested battery (arrow).
A B

AJR:203, July 2014 W11

 Chang et al.
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Fig. 15—Magnet ingestion in 9-year-old girl with
abdominal pain. Frontal abdominal radiograph
shows multiple radiopaque foreign bodies (arrow)
clustered together and dilated loops of proximal
small bowel (asterisks).
Fig. 16—Marble ingestion in 5-year-old boy. Frontal Fig. 17—Safety pin ingestion in 6-month-old boy.
abdominal radiograph shows round radiopaque Coned image from frontal radiograph of neck shows
foreign body (arrow) overlying stomach. Note that open safety pin in esophageal lumen.
marble is not as dense as coin or magnet.

Fig. 18—Chicken bone ingestion in 13-year-old boy

with foreign body sensation in his throat after eating.
A, Frontal radiograph of neck shows no definite
radiopaque foreign body.
B, Lateral radiograph from barium swallow reveals
chicken bone (arrow) within esophagus, which was
not seen on frontal view.

A B

W12 AJR:203, July 2014

 Gastrointestinal Tract Filling Defects in Pediatric Patients
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Fig. 19—Trichobezoar in 18-year-old woman who has anorexia nervosa.
Contrast-enhanced axial CT image of abdomen shows filling defect (asterisk) in
stomach.
Fig. 20—Lactobezoar in 35-week-old infant girl with
history of continuous feedings with maltodextrin-
enriched infant formula who presented with food
intolerance. Image from upper gastrointestinal series
shows large filling defect (asterisk) in gastric lumen.

Fig. 21—Pharmacobezoar in 18-year-old woman with history of ingestion of

multiple iron pills. Axial CT image shows massively dilated stomach filled with
numerous undissolved pills.

AJR:203, July 2014 W13