Abdominal radiograph and acute imaging decisions

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Target exams

Red flags

• A child with suspected midgut volvulus from malrotation in whom the imaging pathway is delayed, because the bowel can infarct within hours and bilious vomiting in an infant is an upper gastrointestinal contrast study or surgical emergency until proven otherwise
• A child with a suspected perforation whose abdominal radiograph is misread as normal because free air is easily missed on a single supine film, which is why an erect chest or a left lateral decubitus view is added when perforation is genuinely suspected
• A child who has ingested a button battery in whom no radiograph is obtained, because a battery lodged in the oesophagus can perforate into the aorta or the trachea within hours and the imaging is the only way to localise it
• A computed tomography scan performed without applying the ALARA principle, because the radiation dose carries a small but real lifetime cancer risk that is higher in the young child, and a single unnecessary scan is never trivial
• An abdominal radiograph requested for non-specific abdominal pain in a well child, because the yield is very low, it rarely changes management, and it adds radiation without answering the clinical question that ultrasound answers better
• A constipated child investigated with an abdominal radiograph as the first or the only test, because functional constipation is a clinical diagnosis and the guidelines state that the radiograph is not needed to confirm it

Life stages

Care settings

Clinical exam formats

Board mappings

• States that the abdominal radiograph has a narrow but specific role in suspected perforation, obstruction, the ingested foreign body or button battery, and that it has a very low yield in non-specific abdominal pain in a well child
• Explains the ALARA principle that the lowest radiation dose that answers the clinical question should be used, and that children are more radiation-sensitive than adults because of their longer remaining lifespan and faster-dividing tissues
• Recognises that ultrasound is the first-line imaging for appendicitis, intussusception, and pyloric stenosis because it uses no ionising radiation
• Applies a clinical pathway that uses ultrasound first for suspected appendicitis, with computed tomography reserved for the equivocal or unstable child after radiology discussion
• Selects the upper gastrointestinal contrast study for suspected malrotation with midgut volvulus, and recognises that bilious vomiting in an infant is a surgical emergency until proven otherwise
• Reads the abdominal radiograph for the signs of perforation (free air, Rigler sign), obstruction (dilated loops, air-fluid levels, stepladder), intussusception (target sign), and neonatal necrotising enterocolitis (pneumatosis intestinalis, portal venous gas)
• The indications and the low yield of the abdominal radiograph, and the guideline statement that functional constipation is a clinical diagnosis that does not require a radiograph to confirm
• The ALARA principle, the Pearce 2012 evidence linking childhood computed tomography to a small increase in leukaemia and brain tumour risk, and the Image Gently campaign
• The ultrasound-first imaging pathway for appendicitis using the pARC risk calculator and the ACR Appropriateness Criteria, with computed tomography as the second-line modality
• Discusses the acute abdominal imaging decision with the family, explaining the reason for the chosen modality, the radiation considerations, and the expected next step
• Reads the abdominal radiograph and the ultrasound at the bedside in the acute setting and integrates the findings with the clinical picture
• Coordinates the imaging pathway with the radiologist, the surgeon, and the retrieving team for the unstable child with an acute abdomen
• Level 1: Recognises when an abdominal radiograph is indicated and when it is not, and states the ALARA principle
• Level 2: Applies the ultrasound-first pathway for appendicitis and intussusception and reads the key radiographic signs of perforation and obstruction
• Level 3: Leads the imaging decision for the complex or unstable child and teaches the radiation-aware practice to the team
• The indications for the abdominal radiograph and the contraindication of relying on it for non-specific abdominal pain or functional constipation
• The radiation-risk evidence of Pearce 2012 and the ALARA and Image Gently principles that follow from it
• The imaging modality selection for the common acute paediatric abdominal presentations: appendicitis, intussusception, malrotation and volvulus, necrotising enterocolitis, and the ingested button battery
• Discussion of the imaging decision for a child with acute abdominal pain in a structured oral, choosing ultrasound first and reserving computed tomography for the equivocal or unstable case
• Interpretation of an abdominal radiograph demonstrating free air, bowel obstruction, or a foreign body, with the clinical reasoning that follows
• Communication of the radiation considerations and the imaging plan to the family in a way that informs without alarming
• The American College of Radiology Appropriateness Criteria for suspected appendicitis in the child, which recommend ultrasound as the first imaging study
• The ALARA principle and the Image Gently campaign for radiation-aware paediatric imaging
• The clinical diagnosis of functional constipation by the NASPGHAN and ESPGHAN criteria, which do not require an abdominal radiograph
• Selects the appropriate imaging modality for the acute paediatric abdomen using the lowest-dose option that answers the question
• Recognises the surgical emergencies of midgut volvulus, intussusception with peritonitis, and the ingested button battery, and the imaging each requires
• Counsels the family on the radiation dose and the benefit of the study, and documents the clinical justification for every computed tomography scan
• The Canadian approach to the acute paediatric abdomen with ultrasound-first pathways and the careful, guideline-driven use of computed tomography
• The radiation-risk awareness and the ALARA principle applied across the imaging decisions in the paediatric emergency department
• The recognition of the neonatal abdominal emergencies of necrotising enterocolitis and malrotation and the imaging pathway for each