Necrotizing Enterocolitis Imaging

Necrotizing Enterocolitis Imaging

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Necrotizing enterocolitis (NEC) is a serious gastrointestinal disease of neonates. Its etiology is unknown. NEC is characterized by mucosal or transmucosal necrosis of part of the intestine. Infants born before term who are undersized and ill are most susceptible to NEC; the incidence of NEC is increasing because of the improved survival rate in the high-risk group of premature infants. [1, 2, 3, 4, 5, 6, 7]  (See the images below.)

Infants suspected of having NEC should undergo periodic radiography of the abdomen. In some centers, infants in whom NEC is highly suspected undergo routine frontal abdominal radiography every 4-6 hours.

Cross-table lateral examinations with a horizontal beam are useful for detecting subtle, early collections of free air, although some clinicians prefer to use lateral decubitus radiographs to detect free air (see the images below). In the presence of peritoneal adhesions, keeping the patient in the decubitus position for a prolonged period ensures that the air moves to the highest point.

Radiography is sufficient for an accurate diagnosis of NEC; the presence of air on a horizontal-beam radiograph is sufficient for diagnosing a bowel perforation.

Abdominal radiographs may demonstrate multiple dilated bowel loops that display little or no change in location and appearance with sequential studies. Pneumatosis intestinalis—gas in the bowel wall that displays a linear or bubbly pattern—is present in 50-75% of patients. (See the images below.)

Portal venous gas and gallbladder gas are indicative of serious disease. Pneumoperitoneum indicates a bowel perforation. (See the image below.)

Computed tomography (CT) scanning or a water-soluble enema examination may be used to demonstrate pneumatosis or a site of perforation. (See the image below.)

A high index of suspicion is essential for the diagnosis of NEC.

Small amounts of free air may not be easily visible on supine abdominal radiographs. Thickening of the bowel wall may not be easily observed in the presence of a dilated bowel.

The use of CT is not advocated for the diagnosis of NEC or for identifying the presence of free air. CT scanning or an examination with a water-soluble enema may be used to demonstrate pneumatosis or a site of perforation.

Ultrasonography of the abdomen characteristically shows thick-walled loops of bowel with hypomotility. Intraperitoneal fluid is often present.

In the presence of pneumatosis intestinalis, gas is seen in the portal venous circulation within the liver. [8]

Chung DH, Ethridge RT, Kim S, Owens-Stovall S, Hernandez A, Kelly DR, et al. Molecular mechanisms contributing to necrotizing enterocolitis. Ann Surg. 2001 Jun. 233(6):835-42. [Medline].

Claud EC, Walker WA. Hypothesis: inappropriate colonization of the premature intestine can cause neonatal necrotizing enterocolitis. FASEB J. 2001 Jun. 15(8):1398-403. [Medline].

Di Lorenzo M, Krantis A. Altered nitric oxide production in the premature gut may increase susceptibility to intestinal damage in necrotizing enterocolitis. J Pediatr Surg. 2001 May. 36(5):700-5. [Medline].

Jayakumar S, Patwardhan N. Characteristic Radiological findings in Preterm Infants with Missed Intestinal Perforation. J Neonatal Surg. 2014 Jul-Sep. 3 (3):27. [Medline].

Mehdi I, Al Bahrani B. Chemotherapy-induced neutropenic necrotizing enterocolitis: a review. J Pak Med Assoc. 2012 Jul. 62 (7):718-23. [Medline].

Urboniene A, Palepsaitis A, Uktveris R, Barauskas V. Doppler flowmetry of the superior mesenteric artery and portal vein: impact for the early prediction of necrotizing enterocolitis in neonates. Pediatr Surg Int. 2015 Nov. 31 (11):1061-6. [Medline].

Kamali K, Hosseini SR, Ardakani SM, Farnoodi MR. Complementory Value of Sonography in Early Evaluation of Necrotizing Enterocolitis. Pol J Radiol. 2015. 80:317-23. [Medline].

Saxena A, Galwa RP. Sonographic findings and outcome in necrotizing enterocolitis. Pediatr Radiol. 2007 Nov. 37(11):1180. [Medline].

Duro D, Kamin D, Duggan C. Overview of pediatric short bowel syndrome. J Pediatr Gastroenterol Nutr. 2008 Aug. 47 Suppl 1:S33-6. [Medline].

Heird WC, Gomez MR. Total parenteral nutrition in necrotizing enterocolitis. Clin Perinatol. 1994 Jun. 21(2):389-409. [Medline].

Panigrahi P. Necrotizing enterocolitis: a practical guide to its prevention and management. Paediatr Drugs. 2006. 8(3):151-65. [Medline].

Sodhi C, Richardson W, Gribar S, Hackam DJ. The development of animal models for the study of necrotizing enterocolitis. Dis Model Mech. 2008 Sep-Oct. 1(2-3):94-8. [Medline]. [Full Text].

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Beverly P Wood, MD, MSEd, PhD Professor Emerita of Radiology and Pediatrics, Division of Medical Education, Keck School of Medicine, University of Southern California; Professor of Radiology, Loma Linda University School of Medicine

Beverly P Wood, MD, MSEd, PhD is a member of the following medical societies: American Academy of Pediatrics, Association of University Radiologists, American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Radiological Society of North America, Society for Pediatric Radiology

Disclosure: Nothing to disclose.

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

David A Stringer, MBBS, FRCR, FRCPC Professor, National University of Singapore; Head, Diagnostic Imaging, KK Women’s and Children’s Hospital, Singapore

David A Stringer, MBBS, FRCR, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, Society for Pediatric Radiology, British Columbia Medical Association, European Society of Paediatric Radiology

Disclosure: Nothing to disclose.

John Karani, MBBS, FRCR Clinical Director of Radiology and Consultant Radiologist, Department of Radiology, King’s College Hospital, UK

John Karani, MBBS, FRCR is a member of the following medical societies: British Institute of Radiology, Radiological Society of North America, Royal College of Radiologists, Cardiovascular and Interventional Radiological Society of Europe, European Society of Radiology, European Society of Gastrointestinal and Abdominal Radiology, British Society of Interventional Radiology

Disclosure: Nothing to disclose.

Fredric A Hoffer, MD, FSIR Affiliate Professor of Radiology, University of Washington School of Medicine; Member, Quality Assurance Review Center

Fredric A Hoffer, MD, FSIR is a member of the following medical societies: Children’s Oncology Group, Radiological Society of North America, Society for Pediatric Radiology, Society of Interventional Radiology

Disclosure: Nothing to disclose.

Necrotizing Enterocolitis Imaging

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