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Special Feature
Jan 2012

Picture of the Month—Quiz Case

Author Affiliations


Author Affiliations: Department of Emergency Medicine (Drs F. Balamuth and Goyal) and Division of Oncology (Dr N. Balamuth), The Children's Hospital of Philadelphia and The University of Pennsylvania School of Medicine, Philadelphia.

Arch Pediatr Adolesc Med. 2012;166(1):89. doi:10.1001/archpedi.166.1.89

A 9-month-old previously healthy infant presented to our emergency department with an episode of gagging with feeds. His parents reported that he had been well until the day of admission and had noted gagging with his dinner that evening, with 1 subsequent episode of nonbilious, nonbloody emesis. He had no fever, cough, rhinorrhea, respiratory distress, or excessive drooling. He had been gaining weight well, and there was no history of head trauma. The child had several toddler and preschool-aged siblings at home; thus, a concern for foreign body ingestion was raised.

On physical examination, the child was afebrile with stable vital signs. He was playful and interactive. No foreign body was noted on examination of the oropharynx, and no excessive drooling was noted. The neck was supple without lymphadenopathy. Lungs were clear to auscultation, with no cough, stridor, or wheeze. Cardiac examination was unremarkable. The abdomen was soft, without tenderness, distension, masses, or organomegaly. Genitourinary examination revealed a circumcised boy with bilaterally descended testes; no hernias were noted.

Because of the history of possible foreign body ingestion, chest and abdominal radiography were performed (Figure, A). Ultrasonography and computed tomographic (CT) scan were subsequently performed based on the results of the radiographs (Figure, B-D).

Image not available

Figure. A, The initial radiograph. B, An image from the patient's ultrasonography of the abdomen. C and D, Two representative saggital image slices from the computed tomographic scan of the abdomen.

What is your diagnosis?