1. Necrotizing Enterocolitis
Case presentation
June 2016
Hidayatullah Hamidi
4th year radiology resident, FMIC, Kabul

2. Demographics/Clinical History
11 day old, late preterm (34-35 weeks) male neonate weighing 2300 gr was presented with fever, loose motion and poor sucking for three days.
The laboratory examinations were unremarkable.
The patient was admitted as presumed neonatal sepsis and IV antibiotic started.
On 4th day of admission he developed vomiting, bloody diarrhea and abdominal tenderness.

3. Imaging workup Extensive small echogenic foci in the intestinal walls
Trans-abdominal ultrasound with high frequency linear transducer
Extensive small echogenic foci in the intestinal walls

4. Imaging workup
Trans-abdominal ultrasound with high frequency linear transducer
Branching echogenic foci in the liver parenchyma extending to the liver edges

5. Imaging workup Mild to moderate free fluid in the peritoneal cavity
Trans-abdominal ultrasound with high frequency linear transducer
Mild to moderate free fluid in the peritoneal cavity

6. Imaging workup Rectal mural thickening
Trans-abdominal ultrasound with high frequency linear transducer
Rectal mural thickening

7. Imaging workup Plain abdominal radiograph
Linear lucencies in the bowel walls (Pneumatosis intestinalis)
Branching lucencies in the liver (portal venous gas)

8. DISCUSSION NEC is a severe disease of neonatal period.
Background
NEC is a severe disease of neonatal period.
Exact etiology is unknown however; few entities are believed as risk factors including low gestational age, low birth weight, congenital heart diseases, perinatal asphyxia, PDA, indomethacin therapy, prematurity and pulmonary disorders.
The pathologic process starts from mucosal injury proceeding to intestinal ischemia, necrosis, mural thinning and finally intestinal perforation in severe cases.

9. DISCUSSION
Clinical Perspective
Clinical diagnosis is challenging, as the presenting signs are often nonspecific.
Classic signs: Feeding intolerance, abdominal distention and bloody stools in the first two weeks of life.
Other signs include bilious vomiting, ileus and diarrhea.
Findings may soon progress to abdominal discoloration, bowel perforation, and peritonitis.
Systemic findings: lethargy, instability of blood pressure and temperature as well as apnea.
In severe cases the neonate will present with shock

10. DISCUSSION
Imaging Perspective
Plain abdominal radiography and abdominal ultrasound are the mainstay of imaging workup.
Supine, vertical beam and a horizontal beam radiograph are necessary for initial diagnosis.
Imaging findings: bowel distension; mural thickening, pneumatosis intestinalis (pathognomic sign), air in portal veins and free air and or fluid in the peritoneal cavity and Intramural gas
Advantage of ultrasound over radiograph: Real time ability for depicting bowel mural thickness, echogenicity, peristalsis, mural gas, perfusion and intra peritoneal fluid.

11. DISCUSSION
Outcome
Early diagnosis and prompt treatment are essential for favorable outcome.
Treatment consists of bowel rest, total parenteral nutrition, antibiotics therapy and adequate hydration.
Pneumoperitoneum is the indication for surgical intervention.

12. References
Kimura K, Loening-Baucke V (2000) Bilious vomiting in the newborn: rapid diagnosis of intestinal obstruction. American family physician 61(9): (PubMed )
Epelman M, Daneman A, Navarro OM, Morag I, Moore AM, Kim JH, et al (2007) Necrotizing Enterocolitis: Review of State-of-the-Art Imaging Findings with Pathologic Correlation. Radiographics 27(2): (PubMed )
Neu J, Walker WA (2011) Necrotizing enterocolitis. New England Journal of Medicine 364(3): (PubMed )
Buonomo C (1999) The radiology of necrotizing enterocolitis. Radiologic Clinics of North America 37(6): (PubMed )
KIRKS DR, O’BYRNE SA (1974) The value of the lateral abdominal roentgenogram in the diagnosis of neonatal hepatic portal venous gas (HPVG). American Journal of Roentgenology 122(1): (PubMed )
Shebrya NH, Amin SK, El-Shinnawy MA, Imam SS. (2012) Abdominal ultrasonography in preterm necrotizing enterocolitis. Is it superior to plain radiography? The Egyptian Journal of Radiology and Nuclear Medicine 43(3):
Kamali K, Say’yed Reza Hosseini Sy, Ardakani MRN, Farnoodi MR. (2015) Complementory Value of Sonography in Early Evaluation of Necrotizing Enterocolitis. Polish Journal of Radiology 80:317. (PubMed )

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