A B D O M I N A L S I G N O F P E D I A T R I C A B N O R M A L I T I E S

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 PNEUMOPERITONIUM
B O WE L -R E LATE D S IGNS

• ​​Do u b l e Wa l l S i g n (Al s o K n o wn As R i g l e r S i g n Or B a s -re l i e f Si g n)

• Te l l t a l e Tri a ng l e Si g n (Al s o K no w n A s T h e Tri a ng l e S i gn O r Te l l t a l e Tr i a n g l e )

PE R I TONE AL L IGAME NT-R EL AT E D SI GNS

• Football sign

• F a l c i f orm l i g a me n t s i g n

• L a t e ra l u mb i l i c a l l i g a me n t s i g n (a l s o k n o wn a s i n ve rt e d " V" s i g n )

• Ur a c hu s s i g n

R IG HT UP P ER QUA DR ANT SIG NS

• C u p ol a s i g n

• F i s s ure fo r l i g a me n t u m t e re s s i g n

• He p a t i c e d g e s i g n

• L u c e nt l i v e r s i gn

• Mo ri s on p o u c h s i g n (d o g e c a p s i g n )

• P e ri p o rt a l fre e g a s s i g n

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 RIGLER SIGN
known as the double-wall sign, is a sign of
pneumoperitoneum seen on an abdominal
radiograph when gas is outlining both sides of
the bowel wall, i.e. gas within the bowel's
lumen and gas within the peritoneal cavity. It
is seen with large amounts of
pneumoperitoneum (>1000 mL).

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 TELLTALE TRIANGLE SIGN

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 FOOTBALL SIGN

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 FALCIFORM LIGAMENT SIGN

White arrow showing falciform ligament

Green arrow showing RIGLER SIGN

Red arrow showing LUCENT LIVER SIGN

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 CUPOLA SIGN
It refers to non-dependent gas that rises within
the abdominal cavity of the supine patient to
accumulate underneath the central tendon of
the diaphragm in the midline. It is seen as
lucency overlying the lower thoracic vertebral
bodies. The superior border is well defined, but
the inferior margin is not 1.

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CONTINUOUS DIAPHRAGM SIGN

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 INVERTED V SIGN
Free air outlining lateral umbilical ligaments,
coursing inferiorly and laterally from
umbilicus

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 DOGE CAP SIGN/MORISON POUCH

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 • Dilated pharyngeal pouch
ESOPHAGEA • Presence of air in the stomach and bowel in the setting of
L ATRESIA esophageal atresia implies that there is a distal fistula

• NGT/EGT Coiling

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Single Double Triple
pyloric duodenal jejunal
atresia atresia atresia
Bubble sign
ILEAL ATRESIA
In the postnatal period, an abdominal
radiograph will show air in the dilated
loops of proximal bowel.
 ILEAL ATRESIA
Fluoroscopy showing microcolon

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HYPERTROPHIC PYLORIC STENOSIS

• Abdominal x-ray findings are non-specific but may show

a distended stomach with minimal distal intestinal bowel
gas.
• Caterpilar sign
 FLUOROSCOPIC OF HPS

• An upper gastrointestinal series (barium meal) excludes other,

more serious causes of pathology, but the findings of an upper
gastrointestinal series infer, rather than directly visualize, the
hypertrophied muscle. On upper gastrointestinal fluoroscopy:
• Delayed gastric emptying
• Peristaltic waves (caterpillar sign)
• Elongated pylorus with a narrow lumen (string sign) which
may appear duplicated due to puckering of the mucosa
(double-track sign)
• The pylorus indents the contrast-filled antrum (shoulder sign)
and (tit sign) or base of the duodenal bulb (mushroom sign)
• The entrance to the pylorus may be beak-shaped (beak sign)

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The hypertrophied muscle is hypoechoic, and
the central mucosa is hyperechoic. Diagnostic
measurements include (mnemonic "number pi
"):
• Pyloric Muscle Thickness, I.E. Diame­ter Of A
Single Muscular Wall (Hypoechoic
Component) On A Transverse Image: >3 Mm
(Most Accurate 3)
• Length, I.E. Longitudinal Measurement: >15-
17 Mm
• Pyloric Volume: >1.5 Cm3
• Pyloric Transverse Diameter: >13 Mm
 ANAL ATRESIA
INVERTOGRAM

 > 2cm from metal piece High location

 < 2cm from metal piece Low location

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 NECROTIZING E NTEROCOLITIS

Supine view shows diffusely dilated bowels

with linear intramural gases (short arrows)
(pneumatosis cystoides intestinalis) and also
multiple linear and branching airs (long
arrows) in the liver (air-portogram).

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 BOWEL
OBSTRUCTION

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Step Ladder Sign
String of Pearls Sign
 small bowel obstruction Intussusception in
Coil Spring Sign barium follow through
Crescent Sign Intussusception
 intraluminar duodenal
diverticulum (arrows)
surrounded by narrow
Windsock Sign radiolucent line (arrow head)
Meconium Plug Syndrome
Meconium plug Radiograph
syndrome refers to a functional
colonic obstruction in a newborn May show multiple dilated bowel
due to an obstructing meconium loops which are a non-specific
plug. It is usually transient and finding. There may be a caliber
affects the left colon with change around the splenic flexure.
meconium plugging the bowel
distal to this segment. In this
situation, it is also termed
the small left colon syndrome.
 Fluoroscopy:
Contrast Edema
Contrast enema may
demonstrate a small caliber to
the left colon with multiple filling
defects within due to retained
meconium. The rectum is usually
normal in size, unlike
Hirschsprung disease. The use of
high osmolar ionic contrast
media for enema in a neonate or
infant is controversial due to the
risks associated with fluid shift 4.
 The enema can be both
diagnostic as well as therapeutic
and is usually accompanied by
the passage of meconium during
or after the procedure.
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Hirschsprung
Hirschsprung disease is
characterized by aganglionosis
(absence of ganglion cells) in the
distal colon and rectum. It is thought
to either occur from a failure of
neuroblasts in neural crest cells to
migrate into bowel segments or
degeneration of already migrated
neuroblasts. It affects cells both in
the myenteric and submucosal
plexuses . Hence, functional
obstruction develops as a result of a
spasm in the denervated colon. 
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• short segment disease: ~75% *
• rectal and distal sigmoid colonic involvement
only 
• long segment: ~15%
• typically extends to splenic flexure / 
transverse colon 
• total colonic aganglionosis: ~7.5% (range 2-
13%)
• also known as Zuezler-Wilson syndrome
• occasional extension of aganglionosis into
the small bowel
• ultrashort segment disease
• 3-4 cm of internal anal sphincter only
• controversial entity
Plain radiograph
Findings are primarily those of
a bowel obstruction. The
affected bowel is of smaller
caliber and thus depending on
the length of segment affected
variable amounts of colonic
distension are present.
In protracted cases, marked
dilatation can develop, which
may progress to enterocolitis
and perforation.

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 SHORT SEGMENT LONG SEGMENT

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 The rectosigmoid
ratio 
is a measurement of the diameter of
the rectum divided by that of the
sigmoid colon during contrast enema.
It is of particular use in the diagnosis
of Hirschsprung disease.

Normal children have a rectum that is

larger than the sigmoid (i.e.
rectosigmoid ratio >1). In fact the
rectum has the largest diameter of the
left side of the colon.
A rectosigmoid ratio (R/S) less than 1
suggests the diagnosis of short-
segment

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