SONOWORLD : Necrotizing enterocolitis

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Abdomen » Gastrointestinal

Necrotizing enterocolitis with dilatated bowel loops, intramural gas, peritoneal fluid and small dots of portal venous gas

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Author(s) :

Taco Geertsma, MD

Presentation 6 days old premature female infant with abdominal distension and bloody stools

Caption: Image of the right lower abdomen

Description: The arrow points to a bowel loop with hyperechoic intramural gasbubbles. Next to it is a normal fluid filled small bowel loop with a normal thin wall

Caption: Image of the right lower abdomen

Description: The arrows point to a small amount of free peritoneal fluid on both sides of the bowel loop with intramural gas

Caption: Image of the right lower abdomen

Description: The arrows point to small hyperechoic foci representing small air bubbles in the peritoneal fluid

Caption: Image of the right lower abdomen with color doppler

Description: The arrows point to a small bowel loop with increased vascularity of the wall

Caption: Image of the central abdomen

Description: There are dilatated small bowel loops

Caption: Image of the right liver lobe

Description: There are tiny hyperechoic foci representing small bubbles of portal venous gas

Caption: Image of the left liver lobe

Description: The arrows point to tiny hyperechoic foci representing small bubbles of portal venous gas

Caption: Plain abominal film

Description: The arrows point to intramural gas or pneumatosis intestinalis

Final Diagnosis Necrotizing enterocolitis with dilatated bowel loops, intramural gas, peritoneal fluid and small dots of portal venous gas

Discussion

Necrotizing enterocolitis is typically seen in premature infants, and the time of its onset is generally inversely proportional to the gestational age of the baby at birth. Clinical symptoms found in cases of necrotizing enterocolitis are feeding intolerance, increased, abdominal distension and bloody stools. Complications can be intestinal perforation and peritonitis. The most common area of the bowel affected by necrotizing enterocolitis is near the ileocecal valve.

The cause of the disease is unknown

The diagnosis is usually suspected clinically but often requires the aid of diagnostic imaging modalities such as plain x ray films of the abdomen and or ultrasound. to confirm the diagnosis and to evaluate the severity of the disease. Initial radiological signs of necrotizing enterocolitis are dilated bowel loops or a "fixed loop" (unaltered gas-filled loop of bowel). The most pathognomonic X ray finding in necrotizing enterocolitis is pneumatosis intestinalis. Other findings include portal venous gas and pneumoperitoneum .

Ultrasound can be very useful because it can detect signs and complications of necrotizing enterocolitis before they are evident on x ray films. Especially air in the bowel wall and portal venous gas can be picked up by ultrasound in a very early stage. Free peritoneal fluid although non specific is seen easily with ultrasound.

In patients suspected of having a necrotizing enterocolitis, or when there is evidence of a necrotizing enterocolitis, frequent monitoring is indicated to detect complications in an early stage. This is usually done with plain X ray films. Since ultrasound can pick up signs of complication in an early stage, when it is available can be added to the monitoring scheme.

Treatment consists primarily of supportive medical care. When the disease does not respond to medical treatment alone, or when the bowel perforates, surgery to resect the dead bowel is generally required.

The prognosis of patients that can be treated conservatively is usually good. The prognosis of patients that require surgery are less favorable. Late complications include short bowel syndrome.

For more cases of bowel wall pathology in children see www.ultrasoundcases.info

Case References

Epelman M, Daneman A, Navarro OM, Morag I, Moore AM, Kim JH, Faingold R, Taylor G, Gerstle JT.Necrotizing enterocolitis: review of state-of-the-art imaging findings with pathologic correlation.Radiographics. 2007 Mar-Apr;27(2):285-305. Review

Silva CT, Daneman A, Navarro OM, Moore AM, Moineddin R, Gerstle JT, Mittal A, Brindle M, Epelman M.Correlation of sonographic findings and outcome in necrotizing enterocolitis.Pediatr Radiol. 2007 Mar;37(3):274-82. Epub 2007 Jan 16.

Follow Up Patient was referred to a neonatal intensive care unit and treated without surgery. No further compications developed and the child is now doing fine

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