Correct answer is: Necrotising enterocolitis with perforation
Discussion
Image 1 and video 1 demonstrate thickened bowel loops and complex fluid throughout the abdomen. In video 1 and image 2, a bubble of free peritoneal gas is present anteriorly along the liver margin causing a strong reverberation artifact. In image 3, a cluster of echogenic foci representing gas is shown within the bowel wall, representing pneumatosis intestinalis. The overall appearance is that of necrotizing enterocolitis (NEC) with a perforation leading to the presence of intraperitoneal air.
NEC is a devastating intestinal disease of the neonate typically associated with prematurity. The condition is characterized by mucosal injury (due to severe prematurity, altered microbiome, food protein allergy, hypoxic injury and other causes) triggering a cascade of bacterial translocation (from the lumen into the bowel wall), acute inflammation, altered permeability, ischaemia, dysmotility, necrosis and perforation.
The clinical diagnosis of NEC is difficult. Abdominal X-ray and ultrasound aid in the identification of anatomical features of NEC. High-resolution ultrasound with the use of high-frequency ultra-broadband linear transducers provides unprecedented image resolution and allows the practitioner to distinguish minor gut changes in the inflammatory phase from more significant complications in the ischaemic phase and perforation. The typical features of NEC on ultrasound include bowel wall thickening, hyperemia (in the acute inflammatory phase), simple free fluid, bowel wall thinning (in the ischaemic phase), presence of gas within the bowel wall (pneumatosis), bowel dysmotility, portal venous gas, complex fluid and free peritoneal air (pneumoperitoneum). The presence of peritoneal air signals bowel perforation. It is important to keep in mind that more than one segment of the bowel may be affected by NEC and the involvement may vary in severity.
The neonate in this case study underwent laparotomy, confirming NEC with perforation.
Conflicts of Interest
The authors declare no conflict of interest
References
- Alexander KM, Chan SS, Opfer E, Cuna A, Fraser JD, Sharif S, et al. Implementation of bowel ultrasound practice for the diagnosis and management of necrotising enterocolitis. Archives of Disease in Childhood – Fetal and Neonatal Edition. 2021 Jan 1;106(1):96–103.
- Esposito F, Mamone R, Serafino MD, Mercogliano C, Vitale V, Vallone G, et al. Diagnostic imaging features of necrotizing enterocolitis: a narrative review. Quantitative Imaging in Medicine and Surgery. 2017 Jun;7(3):33644–33344.
- Chen S, Hu Y, Liu Q, Li X, Wang H, Wang K, et al. Application of abdominal sonography in diagnosis of infants with necrotizing enterocolitis. Medicine. 2019 Jul;98(28):e16202.
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