Fetal Imaging of Gatrointestinal

Tract
Disorders
Maria A. Calvo-Garcia, MD, Beth M Kline-Fath, MD,
Leann E Linam, MD, Eva E. Rubio, MD.

Department of Radiology
Cincinnati Children’s Hospital Medical Center
University Hospital Cincinnati, Ohio
 Goals & Objectives
• To review the normal appearance of the
gastrointestinal tract utilizing fetal MRI.

• To display the spectrum of fetal GI anomalies

with the aid of MRI and with postnatal
radiologic and operative images.

• To test your knowledge with clinical cases.

 Sections of This Poster
„ This electronic poster has 3 sections.
„ Section 1 will briefly review the embryology,
physiology and the MRI anatomy of the fetal GI
tract.
„ Section 2 will review the assessment of fetal GI
pathologic processes.
„ Section 3 will give you clinical cases for you to
practice.
„ You can click on the section you want and skip the one you may
already know.
Sect. Sect. Sect.
1 2 3
 Background
„ US is the imaging modality of choice in
pregnancy.

„ US advantages:
„ Noninvasive and safe

„ Relatively low cost

„ Widely available

Sect. Sect. Sect.

1 2 3
 Background
„ Due to intrinsic US limitations and to the advances in
fetal medicine and surgery, fetal MRI has become a
clinically useful supplement to US.

„ Fetal MR has an emerging role in the diagnosis of fetal

GI tract anomalies.

„ Fetal MR shows specific and different signals of the

normal content of small and large bowel improving the
assessment of the GI tract anatomy.
 Anatomical/Physiological
Development of the Fetal GI Tract

„ In order to understand fetal bowel imaging we need to

know the anatomic and physiologic development of the
GI tract.

„ The anatomic development happens during the 1st

trimester.

„ The enzymatic and functional development happens

during the 2nd and 3rd trimesters.
 Anatomical/Physiological
Development of the Fetal GI Tract
„ By the end of the 5th
menstrual week the
primitive gut has formed.
It is a hollow tube
extending from the
bucopharyngeal
membrane to the cloaca.

„ It is made of 3 parts:
foregut, midgut and
hindgut.

http://sprojects.mmi.mcgill.ca/embryology/gi/pgm.htm
 Anatomical/Physiological
Development of the Fetal GI Tract
„ The bucopharyngeal membrane will rupture, the
tracheoesophageal septum will separate the
esophagus from the trachea. After a 90º rotation
the stomach will show its typical appearance by
the 10th menstrual week.

„ The midgut will grow in length and will undergo

a 270º counter clock rotation to assume the
adult configuration.
 Anatomical/Physiological
Development of the Fetal GI Tract
„ The caudal hindgut
connects with the
cloaca.
„ The urorectal septum
forms and by the 8th
menstrual week fuses
with the cloacal
8th menstrual week membrane, dividing
11-12th menstrual w
the cloaca into:
From: Gray SW et al. “Embryology for
surgeons”. WB Saunders, 1972
„ Urogenital sinus
„ and rectum
 Anatomical/Physiological
Development of the Fetal GI Tract
„ At the same time,
there is also caudal
retraction of the
cloacal membrane, so
the urogenital and
rectal membranes are
no longer part of the
8th menstrual week 11-12th menstrual w abdominal wall.
„ Urogenital and rectal
From: Gray SW et al. “Embryology for
surgeons”. WB Saunders, 1972 membranes, then,
open.
 Anatomical/Physiological
Development of the Fetal GI Tract
„ Intestinal peristalsis begins by 11 menstrual weeks
and fetal swallow starts shortly thereafter.

„ By 12 weeks, on US, the stomach can be identified as a

fluid filled structure in the LUQ.

„ The GI tract starts also its secretory function

(stomach, pancreas and small bowel) and absorption
(large bowel).
 Anatomical/Physiological
Development of the Fetal GI Tract
„ As a result of all these functions (swallowing, peristalsis,
absorption and secretion) meconium starts forming in
the small bowel around the 14th week.

„ It will slowly migrate from the small bowel to the colon

and rectum.

„ Visualization of meconium in the distal bowel depends

on adequate development and preservation of all these
functions throughout the pregnancy.
 Fetal GI Anatomy/Physiology
Fetal MRI
„ In the fetal setting there are 2
types of natural “contrast
media” that allow us to depict
the intestinal anatomy.
„ Amniotic fluid swallowed
by the fetus (Bright T2 SI)
„ Meconium (Bright T1
SI), produced by the
bowel.
„ The distribution of this T2
“contrast media” correlates T1
with fetal development.
 Fetal GI Anatomy/Physiology
Fetal MRI: Esophagus
29w GA

„ We will be able to
see intermittent
fluid distention of
segments of the
esophagus during
fetal swallowing.
T

21w GA
esophagus
 Fetal GI Anatomy/Physiology
Fetal MRI: Small Bowel

„ The fetal abdomen will

present a characteristic
spotty appearance prior
to 25 GW, as no
significant amniotic fluid
enters the fetal bowel
(except for the stomach).

21w GA
 Fetal GI Anatomy/Physiology
Fetal MRI: Small Bowel
„ Gastric emptying starts
around the 24 GW.
„ Increased swallowed AF
is noted by 25 GW

„ By 26-27 GW, fluid filled

small bowel loops
become apparent,
predominantly in the
LUQ.
26w GA
 Fetal GI Anatomy/Physiology
Fetal MRI: Small Bowel
„ By 26-27 GW
intermediate signal can
also be seen in the
jejunum (may reflect the
secretory activity of the
proximal bowel, liver and
pancreas)

26w GA
 Fetal GI Anatomy/Physiology
Fetal MRI: Small Bowel

„ Beyond 30 GW, longer ,

fluid filled jejunal loops
will be constantly
visualized with diameters
up to 7-8mm.
„ The bowel wall itself can
be visualized as well.

36w GA
 Progression of Small Bowel Signal
T2 WI

21w GA 26w GA 36w GA

„ The small bowel first contains meconium (initial spotty

abdomen) and then fills with ingested amniotic fluid.
 Fetal GI Anatomy/Physiology
Fetal MRI: Large Bowel
„ Meconium will be well
evaluated with T1WI
(bright signal).

„ It is hypointense on T2
WI.

„ It has intermediate signal T1 2D FIESTA

T2
on steady-state free
precession sequences
(2D FIESTA).
 Fetal GI Anatomy/Physiology
Fetal MRI: Large Bowel
„ After 20w we expect
to see meconium
filled rectum.

„ Meconium will fill

and distend the
rectum and colon in
a caudocranial
progression.
21 w
Fetal GI Anatomy/Physiology
Fetal MRI: Large Bowel

„ Around the 27 GW
the whole colon is
filled with meconium.

„ The cecum is position

at the level of the iliac
crest, as in the
newborn.

28w
 Fetal GI Anatomy/Physiology
Fetal MRI: Large Bowel
„ The maximum colon
diameter increases with
advancing age:
„ 3-4mm by 20w
„ 8-15mm at term.
„ Malas MA et al.. Early
Hum Dev 2004;78:1-13

„ We see also development

of colonic haustra after
25-26w, starting on the
right colon.
Meconium by 36w GA, T1 imaging
 Fetal GI Anatomy/Physiology
Fetal MRI: Large Bowel
„ The distance from the
bladder base/neck to the
rectal cul-de-sac
increases with the GA
(10mm or greater,
Saguintaah M, et al Ped
Radiol 2002).
„ Important in the
assessment of anorectal
malformations
 Fetal GI Anatomy/Physiology
Fetal MRI: Large Bowel
PERSISTENT CLOACA NORMAL PATIENT
FOR COMPARISON
 Assessment of Fetal GI Tract
Disorders

„ Proximal GI Disorders:

„ Esophageal atresia/TEF
„ Stomach malposition/ Abnormal stomach
size.
„ Duodenal obstruction.
 Assessment of Fetal GI Tract
Disorders
„ Small bowel disorders:
„ Bowel obstruction
„ Meconium peritonitis/meconium
pseudocyst
„ Intestinal cystic disease (also affecting
proximal and distal bowel, but less frequently):
„ Entericduplication cyst
„ Mesenteric/omental cyst (lymphatic
malformations)
 Assessment of Fetal GI Tract
Disorders

„ Large bowel abnormalities:

„ Colonic atresia

„ Anorectal malformations
„ Cloaca
 Fetal Imaging of GI Tract
Disorders

„ Proximal GI Disorders:

„ Esophageal atresia/TEF (tracheo-

esophageal fistula)
„ Stomach: malposition/Abnormal stomach
size
„ Duodenal obstruction
 Esophageal Atresia and/or TEF

„ It results from abnormal

development of the
tracheoesophageal
septum ( a process that
normally is completed by
8 weeks).

www.learningradiology.com/.../tefdiagram.jpg
 Esophageal Atresia and/or TEF
Diagnosis
„ Sonographic diagnosis of Esophageal Atresia (EA) with
or w/o TEF can be suspected based on:

„ Absent or small stomach, usually associated to poly

after 20w.
„ Polyhydramnios with IUGR

„ Proximal esophageal pouch: “the pouch sign”

(transient)
Direct visualization of upper esophageal
pouch on MRI. RT lung agenesis.

Transient distention of upper pouch!!!

 Postnatal
Prenatal (34w GA)
DOL#1

Esophageal atresia +TEF, RT lung agenesis+

segmentation vertebral anomaly.
 Fetal Imaging of GI Tract
Disorders

„ Proximal GI Disorders:

„ Esophageal atresia/TEF
„ Stomach: malposition/Abnormal stomach
size
„ Duodenal obstruction
 Abnormal Stomach Position

Intrathoracic stomach: LT CDH

Abnormal intraabdominal
position: situs anomaly.
 Abnormal Stomach Size
„ Enlarged stomach is characteristic of proximal
obstruction.
Enlarged Stomach and Polyhydramnios

Proximal Obstruction (Duodenal Atresia)

 Abnormal Stomach Size
„ Enlarged stomach is characteristic of proximal
obstruction.
„ Persistent small fluid distention of the stomach,
in the absence of adjacent mass, should raise
concern for:
„ Esophageal atresia/TEF (especially if
polyhydramnios after 20w).
 Small Stomach and Polyhydramnios

Esophageal Atresia and TEF w/o Direct Signs

Micrognathia.
 Abnormal Stomach Size
„ Enlarged stomach is characteristic of proximal
obstruction.
„ Persistent small fluid distention of the stomach,
in the absence of adjacent mass, should raise
concern for:
„ Esophageal atresia/TEF (especially if
polyhydramnios after 20w).
„ Congenital microgastria (typical normal amniotic
fluid in 3rd Trimester).
Small Stomach, Normal AF, Dilated Esophagus:
Congenital Microgastria (28w)

Dilated tortuous esophagus microgastria

Congenital Microgastria
DOL#1
 Congenital Microgastria: UGI

Very dilated tortuous esophagus, incompetent lower

esophageal sphincter (severe GER seen during the exam).
 Congenital Microgastria

Small sliding hiatal hernia, small midline

vertical stomach and malrotation.
 Congenital Microgastria
Pre and Postnatal Imaging Correlation
 Congenital Microgastria
Pre and Postnatal Imaging Correlation
 Congenital Microgastria
Pre and Postnatal Imaging Correlation

Microgastria Malrotation
Duodenal dilatation Duodenal stenosis (at surgery as well with annular
pancreas and preduodenal portal vein)
 Congenital Microgastria
„ It is a rare anomaly usually associated with other
malformations, especially VACTERL association,
asplenia (right –sided isomerism) malrotation,
congenital heart disease and musculoskeletal anomalies.
„ Due to arrested foregut development, the normal
rotation of the stomach does not occur. A small tubular
midline stomach remains with incompetent cardias and
dilated esophagus (GER).
„ Feeding difficulties: surgical management.
 Fetal Imaging of GI Tract
Disorders

„ Proximal GI Disorders:
„ Esophageal atresia/TEF
„ Stomach: malposition/ Abnormal stomach size

„ Duodenal obstruction
„ Intrinsic: atresia/stenosis

„ Obstructive midgut malrotation (band, volvulus)

„ Extrinsic: preduodenal portal vein, annular pancreas,

duodenal duplication, choledocal cyst.
 Duodenal Obstruction
Duodenal atresia
„ Duodenal atresia is usually a blind end atresia and less
likely a diaphragm or membrane that interrupts the
duodenal lumen

„ A previous cited explanation was failure of re-

vacuolization of the duodenal lumen from 8-10 weeks
of gestation. However other authors suggest that it is
result of vascular impairment during gut development.
 Duodenal Obstruction
Duodenal atresia
„ Polyhydramnios occurs in all cases of typical duodenal
atresia during 3rd T (if earlier, EA (esophageal atresia)
associated should be suspected).

„ Associated anomalies (Aprox 50% ):

„ Skeletal (vertebral/rib, sacral agenesis, radial
anomalies, talipes equinovarus)
„ GI: EA, jejuno-ileal atresia, biliary atresia, pancreatic
ductal atresia, ano-rectal atresia.
„ Cardiovascular, Genitourinary.
„ Chromosomal: T21 in 30-40%, although conversly
in T21 DA is seen in 5%)
Duodenal Atresia+ polyhydramnios
31w GA: Maternal IDDM and T 21
„ 1st day of life (31w
premature). T 21
„ Replogle in stomach.
„ Air in stomach and
duodenal bulb. Not in
other segments.
„ Prominent heart size
(Congenital Heart
Disease)
 Fetal Imaging of GI Tract
Disorders
„ Duodenal obstruction
„ Intrinsic

„ Obstructive midgut malrotation (band,

volvulus)

„ Extrinsic
„ Choledocal cyst
Choledocal Cyst: 21 w GA Referred as r/o
Duodenal Atresia
Choledocal Cyst: 21 w GA Referred as r/o
Duodenal Atresia

The stomach and duodenum drape over the cyst,

anteriorly. No biliary ductal dilatation.
Choledocal Cyst: Postnatal correlation

21w GA Postnatal: 1 ½ months of

age
Choledocal Cyst: Introperative Cholangiogram
 Assessment of Fetal GI Tract
Disorders
„ Small bowel disorders:
„ Bowel obstruction

„ Meconium peritonitis/meconium pseudocyst

„ Intestinal cystic disease (also affecting proximal

and distal bowel, but less frequently):
„ Entericduplication cyst
„ Mesenteric/omental cyst (lymphatic
malformations)
 Small Bowel Obstruction
Bowel Atresia
„ Jejuno-ileal atresia and stenosis usually result
from vascular impairment during embryologic
development
„ Sporadic
„ Secondary to a predisposing disorder such as
volvulus or gastroschisis.
„ Apple-peel atresia, which may be familial, probably
results from oclussion of a branch of the SMA. This
type can be associated to other malformations
(Congenital Heart Disease,…)
 Small Bowel Obstruction
Bowel Atresia
„ Type I: mucosal diaphragm
with intact wall (20%) III A is the most frequent type.
„ Type II: blind ends of bowel
connected by a fibrous band
(32%)
„ Type III A, blind ends of
bowel separated by a
mesenteric gap (48%)
„ Grosfeld added 2 additional
types:
„ Type III B, “apple peel” atresia
„ Type IV, multiple atresias

www.cincinnatichildrens.org
 Small Bowel Obstruction
Bowel Atresia

„ The sites of small bowel atresia are:

„ Proximal jejunum (31%)
„ Distal jejunum (20%)

„ Proximal ileum (13%)

„ Distal ileum (36%)

„ More than one site involved (6%).

Small Bowel Obstruction
Jejunal Atresia (37w)
Small Bowel Obstruction
Jejunal Atresia (DOL#1)

The baby was born the next day, was transferred and got
surgery on DOL#1, w/o any further imaging!!!!
Type I Jejunal Atresia and Malrotation
 Small Bowel Obstruction
Gastroschisis/Volvulus
„ Gastroschisis with dilated eviscerated bowel
 Small Bowel Obstruction
Gastroschisis/Volvulus
„ Complicated gastroschisis. Dilated eviscerated bowel
w/o mechonium in rectum, supporting obstruction.
„ Atresia vs volvulus.
„ Dilated stomach due to obstruction or tight
anterior abdominal wall defect.

„ One week later the bowel was normal in caliber on

outside F/U US, and this specific event was considered
consistent with volvulus.

„ Possibly, as a result of that, however, bowel atresia was

found at birth.
 Assessment of Fetal GI Tract
Disorders

„ Small bowel disorders:

„ Bowel obstruction
„ Meconium peritonitis/meconium
pseudocyst
„ Intestinal cystic disease (also affecting proximal
and distal bowel, but less frequently):
„ Entericduplication cyst
„ Mesenteric/omental cyst (lymphatic
malformations)
 Meconium Peritonitis
„ Sterile chemical peritonitis results usually from
in utero bowel perforation in the setting of
obstruction.
„ It can also be seen in the setting of persistent
cloaca.
„ Idiopathic vascular impairment
(occlusion/thrombosis of mesenteric arteries)
and cocaine exposure are also potential
etiologies.
„ Iatrogenic.
 Meconium Peritonitis
„ Ascitis might be the only finding in the acute
phase.
„ Calcifications could be seen after 1-2weeks.
„ Overtime the inflammatory response may seal
the perforation spontaneously.
„ It can lead to meconium pseudocyst formation:
contained bowel perforation.
 Iatrogenic Meconium Peritonitis
TTTS with prior amnioreduction (20w GA)

„ Blood clot
surrounding
recipient’s body,
not seen on
prior US.
Iatrogenic Meconium Peritonitis
26w premature (recipient twin)
 Iatrogenic Meconium Peritonitis
26w premature (recipient twin)

No microcolon. Normal retrograde filling of the small bowel.

Sealed perforation. No surgery required.
 Assessment of Fetal GI Tract
Disorders

„ Small bowel disorders:

„ Bowel obstruction
„ Meconium peritonitis/meconium
pseudocyst
„ Intestinal cystic disease (also affecting proximal
and distal bowel, but less frequently):
„ Entericduplication cyst
„ Mesenteric/omental cyst (lymphatic
malformations)
 Meconium Pseudocyst
Bowel Atresia (ileal)
US at 27w
MR at 28w

Complex cyst
with fluid-
fluid level
Meconium Pseudocyst
Bowel Atresia (ileal)

Only meconium in distal

rectum!
 Fetal Imaging of GI Tract
Disorders

„ Small bowel disorders:

„ Bowel obstruction

„ Meconium peritonitis/meconium pseudocyst

„ Intestinal cystic disease:

„ Enteric duplication cyst

„ Mesenteric/omental cyst (lymphatic

malformations)
 Enteric Duplication Cyst
„ May develop anywhere along
the course of the digestive
tract although the stomach is
the least frequent site of
involvement.

„ Located on the mesenteric

side of the intestine, most
often in the ileum and do not
usually communicate with the
normal gut, unless tubular in Postnatal US: duodenal
type. duplication cyst
„ Spherical cysts>tubular.
Multiple cysts can be seen.
Small Ileal Duplication Cyst
 Fetal Imaging of GI Tract
Disorders

„ Small bowel disorders:

„ Bowel obstruction

„ Meconium peritonitis/meconium
pseudocyst
„ Intestinal cystic disease:

„ Enteric duplication cyst

„ Mesenteric/omental cyst (lymphatic

malformations)
 Mesenteric/Omental Cyst
(Lymphatic Malformations)
„ Mesenteric/omental cysts usually represent
abdominal lymphatic malformations.
„ The most common location is the small bowel
mesentery, followed by the large bowel mesentery ,
omentum and retroperitoneum.
„ Typically: large septated cystic mass with preferential
left location.
„ When the cyst is unilocular, the differential diagnosis
will include other abdominal cystic masses.
Mesenteric Cyst LUQ 31w GA (Vascular
Malformation, Lymphatic Type)
Several Episodes of Bilious Emesis Soon After
Birth. Proximal Obstruction.
DOL#1 (35w)
 Mesenteric Cyst LUQ (Vascular
Malformation, Lymphatic Type)

„ Complex cystic abdominal mass.

„ Proximal obstruction with bilious emesis.
„ Surgery on DOL#1: Example of complication of mesenteric
cyst, leading to volvulus/atresia. This happened after the MR
and prior to delivery . 180-270 degree torsion of the proximal
jejunum on the cyst pedicle with a focal area of atresia.
 Fetal Imaging of GI Tract
Disorders

„ Large bowel abnormalities:

„ Colonic atresia

„ Anorectal malformations
„ Cloaca
 Colonic Atresia

Dilated bowel (1st detected at 23w US). Echogenic content

and haustral pattern to level of expected distal transverse
colon. AFI was normal (18.7cm at 30w)
 30w GA with Colonic Atresia

Meconium has not reached the colon as a sign of obstruction.

There is, however, no proximal bowel dilatation or
polyhydramnios.
Colonic Atresia
 Colonic Atresia

„The hugely dilated segment has relatively bright T1 signal

(probably amniotic fluid mixed with meconium)
„Final diagnosis was transverse colonic atresia
 Colonic Atresia

„ Rare disease of ischemic mechanism.

„ AFI in colonic atresia could be normal.
„ Note also that in this case there was no proximal
bowel dilatation.
„ Increased mortality seems to be correlated with
surgical treatment performed after 72h of life
(Etensel et al. 2005). This highlights the interest
of prenatal diagnosis.
 Fetal Imaging of GI Tract
Disorders

„ Large bowel abnormalities:

„ Colonic atresia

„ Anorectal malformations
„ Cloaca
 Persistent Cloaca
„ Cloaca is defined as a
defect in which the
urinary tract, the vagina
and the rectum are fused,
creating a single
common channel.
„ It can lead to bladder
obstruction,
hydrometrocolpos or
colonic dilatation.
A. Pena, M Levitt. Seminars in
Neonatology 2003, 8;249-253
 Persistent Cloaca

„ Typically affects
females with an
incidence of 1/50,000
live births.

„ The perineum will

present a single
opening.
 Persistent Cloaca
„ It is thought to be due to
failure of the urorectal
septum to join the
cloacal membrane during
the 4th to 6th weeks of
embryonic development.

„ Patients with cloaca

present a wide anatomic
spectrum depending on
when the arrested
development happens.
 Persistent Cloaca
„ The length of the
common channel has
prognostic and
theraupetic implications.
„ Common channel <3 cm
(63%): associated urologic
defects in 59%
„ Common channel>3cm
(38%): 91% associated
urologic defects, complex
surgical repair, decreased A. Pena, M Levitt. Seminars in
potential for urinary Neonatology 2003, 8;249-253
control
 Persistent Cloaca
„ Prenatal diagnosis allows
time for
„ Parental counseling
„ Planning of the delivery at
a Tertiary Center
(equipped with neonatal
intensive care and
pediatric surgical and
urologic facilities)
„ Timely diagnosis of
cloacal anomalies and
associated complications
will improve the outcome.
 Persistent Cloaca
US Prenatal Diagnosis
„ Hydrocolpos can develop: This is not specific!!!!
„ Cystic pelvic mass, often septated in association with
oligohydramnios and impaired fetal growth.

A. Pena, M Levitt. Seminars in

Neonatology 2003, 8;249-253
 Persistent Cloaca
US Prenatal Diagnosis
„ Cloacal anomaly is being
reported as simulating
megacystis in the 1st
trimester. (Taipale P et al J Clin
Ultrasound 2004;32:419-422)

„ Fluid-debris level are

considered highly
suggestive (mucous,
descamated epithelium
and meconium).
 Persistent Cloaca
US Prenatal Diagnosis
„ Sometimes transient ascitis develops (urine scaping from
the cloaca via the fallopian tubes). Also not specific!
Placenta

Hydrocolpos Ascitis
„ Ambiguous genitalia, hydronephrosis and absent distention
of the urinary bladder are additional findings.
 Persistent Cloaca
US Prenatal Diagnosis
„ Presence of intraluminal calcifications in the
fetal abdomen (result of mixing of urine and
meconium) would be the most specific sign of
recto-urinary fistula
 Fetal MRI
Normal Anorectal Assessment
examples 28w: persistent cloaca with
long common channel

Distal
rectum!!!
29w
31w
38w
„ The rectal cul-de-sac will be expected to be higher than
in normal patients, especially with a high anorectal
malformation or in a cloaca with long common
channel.
 Fetal MRI
Anorectal Assessment

Mildly dilated
distal bowel with
fluid and
meconium
signal, also noted
within a bilobed
bladder

„ With imperforated anus with recto-urinary fistula and with

persistent cloaca we could see fluid in the distal bowel due to the
communication with the urinary system. (Saguintaah M, et al Ped
Radiol 2002). Mandell J et al J Pediatr Surg 1992;27:82-84.
 Clinical Cases

Sect. Sect. Sect.

1 2 3
 Case #1
„ Clinical history:
„ Dextrocardia (congenital heart disease),
polyhydramnios and persistently small
stomach.
„ Clinical concern for esophageal atresia.

„ GA: 27w
Case #1
 Case #1

„ Did you see the findings?

„ The next slide will review them and will give you
the diagnosis.
Esophageal Atresia with TEF: Direct Visualization
of Upper Esophageal Pouch on MRI

Transient distention
of upper pouch!!!

Minimal gastric distention

 Case #2

„ Clinical history:
„ 30 week gestation with polyhydramnios and
persistent gastric and duodenal distention.
„ Amniocentesis: Trisomy 21

„ Maternal diabetes.
Case #2
 Case #2

„ Same patient
close to the end
of the exam.
 Case #2

„ Do you have a diagnosis?

„ What happened close to the end of the exam?
„ On next slide we will review the findings.
Duodenal Atresia and Fetal Vomiting

Hyperperistaltic
gastroduodenal fluid dilatation.
Eventually decompressed!!!!!!
 Case #3

„ Clinical history:
„ 34w gestation with abnormal brain findings
on US. MRI was performed to better define.
We will be presenting images from the
abdominal assessment.
Case #3
 Case #3

„ Do you have a diagnosis?

„ Next slide will review the findings.
 Case #3

Fluid filled bowel on the right (small bowel)

 Case #3

Meconium filled bowel on the left (colon)

Example of Malrotation Undetected on US
 Case #4

„ Clinical history:
„ Dilated bowel 1st detected at 23w US.

„ Normal gastric distention and normal

amniotic fluid at 28w.
„ 28w GA at the time of fetal MRI
Case #4
Case #4
SAGITAL
 Case #4
„ Is there an obstructive pattern?
„ We will review the signs on the next slide.
 Obstructive Pattern Confirmed
SAGITAL

Bowel dilatation involving a few loops Minimal meconium in the

(proximal), with meconium. rectum, absent in the colon.
28w GA 35w newborn 1st day of life
 Contrast Enema DOL#1

Microcolon but contrast refluxed into large portion of nondilated

small bowel. The working diagnosis was jejunal atresia.
Final Diagnosis: Jejunal Atresia
 Jejunal Atresia

28w GA DOL#1
 Case #5
„ Clinical history:
„ Congenital heart disease (CHD).

„ LT Multicystic Dysplastic kidney (MCDK).

„ Normal amniotic fluid.

„ GA at the time of US and MRI: 26w

Case #5

Bladder
Case #5
 Case #5
„ The MRI shows an additional finding, not
suspected on US. Did you see it?.
„ On the next slides we will review the findings.
 Case #5
„ 3v cord. Mildly distended bladder. No
hydrocolpos. Normal AF.
Case #5

„Normal RK, MCD LK

„No bowel dilatation identified.

The rectal cul-de-sac is high, at the level of the bladder neck and not
beyond, as expected in normal patients.
High T2 signal in the distal bowel is suggesting abnormal fluid content
(communication with urinary system is suspected!!!)
 FSPGR SSFSE
(T1)

NORMAL PATIENT
FOR COMPARISON
Working diagnosis should be 2D
ano-rectal malformation, most FSPGR SSFSE FIESTA
(T1)
likely cloaca.
US: DOL#1
bladder

Distal bowel

No hydrocolpos
 3 month old status post diverting
colostomy. Cloacagram
Distal bowel
Distal bowel

Bladder

Müllerian
Bladder remnant
Müllerian Common
remnant Common channel channel

Catheters in mucous fistula, and through the common

channel in the bladder and distal rectum
 3 month old status post diverting
colostomy. Cloacagram

Distal bowel

Bladder

Müllerian
remnant
Common channel

Cloaca with relatively long common channel

(3.5cm)
 Case #6
„ Clinical history:
„ Cystic abdomino-pelvic mass first detected at
12 weeks.
„ Female fetus.

„ Rule out cloaca.

„ 20 w 5d GA at the time of this work up.

Case #6
Case #6
Case #6
 Case #6
„ 1. Is this cyst a hydrocolpos or enlarged bladder?
„ 2. Is the rectum filled with meconium as we
would expect in a normal 20 w gestation?
„ 3. Are you concern about cloaca, or would you
consider another differential diagnosis?
„ 4. The answers will be reviewed in the next
slides.
 Case #6

Bladder

1. A normal bladder is identified.

The cyst is not extending posterior to the
bladder as expected for hydrocolpos
 Case #6: Hepatic Cyst

2. Normal meconium Differential diagnosis was hepatic cyst,

mesenteric/omental cyst, ovarian cyst.
3. No concern for cloaca
Final diagnosis: Hepatic cyst
 Case #7
„ Clinical history:
„ Bladder outlet obstruction since 11w GA.
„ Bilateral hydronephrosis.
„ 2 vessel cord.
„ Normal amniotic fluid.
„ Congenital heart disease.
„ Clubfeet.
„ Female fetus.
„ MRI performed at 28w GA.
Ano-rectal assessment:
Is the rectal cul-de-sac
normally located?
 POSTNATAL VCUG
(baby has a single
perineal opening)
SAG

Distal
bowel

Do you have now a

bladder diagnosis?
 POSTNATAL
VCUG

Cloaca with long

common channel
Can you summarize the
findings on this baby with
an acronym?
 V A

TE

R
Segmentation
anomaly L
(scoliosis)

Ano-rectal
malformation

Heart
disease Esophageal
atresia-TEF

Renal and limb

anomalies
„ MRI, when indicated, in combination with US
is helping prenatal care:

„ Improving counseling of the patient

„ Guiding management.

„ Helping clinicians to be prepared for critically

ill neonates.
„ References :
„ Couture D (2008): “Fetal Gastrointestinal Tract: US and MR”. In:
Gastrointestinal Tract Sonography in Fetuses and Children. Springer-
Verlag, pp 1-84.

„ Brugger PC, Prayer D. Fetal abdominal magnetic resonance imaging. EJR

(2006) 57:278-293.

„ Veyrac C, et al. MRI of the fetal GI tract abnormalities. Abdom Imaging

(2004) 29:411-420.

„ Saguintaah M, et al. MRI of the fetal Gastrointestinal tract. Pediatric

Radiol (2002) 32:395-404.

„ Warne S. et al. Prenatal diagnosis of cloacal anomalies. BJU International

(2002), 89:78-81.