Pearls and Pitfalls in Pediatric Imaging

Imaging description

An 11-year-old patient presented with diffuse abdominal pain. The medical history, clinical examination, and laboratory values did not reveal any abnormal findings. A fluoroscopic barium upper gastrointestinal (GI) study with small bowel follow through (SBFT) revealed multiple 2 mm nodules on the mucosal surface of the terminal ileum, deforming the thin barium-filled parallel folds that are seen in the contracted ileum (Fig. 49.1). These mucosal nodules are typical of benign enlarged lymphoid follicles, a frequent finding in children and adolescents. Additional examples are shown in (Figs. 49.2 and 49.3).

Importance

Lymphoid follicular hyperplasia of the intestinal tract represents a benign enlargement of the submucosal lymphoid follicles. It is a common condition in children and adolescents. The lesions may present in two forms, a focal or a diffuse type. In the more common focal type, an aggregate of benign lymphoid nodules is found in an isolated area, usually the terminal ileum. In the less common diffuse form, a multinodular pattern is found throughout much of the GI tract, especially the colon. The diffuse follicular hyperplasia may be seen in children with GI infections and/or bleeding and perhaps represents a lymphoid reaction to an unidentified infection. Especially when found in the colon, benign follicular hyperplasia has been confused with multiple polyposis, leading to unnecessary surgery or endoscopic resections. Follicular lymphoid hyperplasia of the appendix is associated with dilatation and thickening of the mucosa and can be mistaken for appendicitis or other pathology (Fig. 49.3). Absence of wall thickening, hyperemia, and periappendiceal inflammation help in making this distinction.