eMedicine Specialties > Radiology > Pediatrics

Necrotizing Enterocolitis: Imaging

Author: Beverly P Wood, MD, MS, PhD, Professor, Departments of Radiology and Pediatrics, Division of Medical Education, Keck School of Medicine, University of Southern California
Contributor Information and Disclosures

Updated: Nov 10, 2008

Radiography

Technique
Infants suspected of having necrotizing enterocolitis (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. 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. (See Images 5-13 below.)

Image 5.

This radiograph shows free air secondary to bowel wall necrosis.


Image 6.


Left lateral decubitus radiograph shows free air.


Image 7.

Portal venous air is present in a patient with pneumatosis intestinalis.



Image 8.


The radiograph demonstrates multiple dilated loops in the large bowel and small bowel. Note the pneumatosis intestinalis with bubbly and linear gas collections in the bowel wall.


Image 9.

Increasing pneumatosis intestinalis is seen in this radiograph.


Image 10.


Anteroposterior image shows necrotizing enterocolitis with pneumatosis intestinalis.


Image 11.


Lateral abdominal image shows pneumatosis intestinalis.


Imaging findings
Radiography is sufficient for an accurate diagnosis of necrotizing enterocolitis; 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.

Portal venous gas and gallbladder gas are indicative of serious disease. Pneumoperitoneum indicates a bowel perforation.

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

Image 12.


Image obtained during examination with a water-soluble enema shows the pneumatosis well. This technique is not recommended.


Image 13.


In this radiograph, free air is observed over the liver that outlines the falciform ligament. This finding indicates perforation of the bowel, which necessitates surgical exploration and resection of necrotic bowel.


Imaging pearls

  • A high index of suspicion is essential for the diagnosis of necrotizing enterocolitis.
  • 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.

Computed Tomography

Imaging pearls

  • The use of CT is not advocated for the diagnosis of necrotizing enterocolitis 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.

Findings


Ultrasonography

Imaging findings

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.17

More on Necrotizing Enterocolitis

Overview: Necrotizing Enterocolitis
Imaging: Necrotizing Enterocolitis
Multimedia: Necrotizing Enterocolitis
References
Further Reading
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References

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

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

  3. 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. May 2001;36(5):700-5. [Medline].

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

  5. Hunter CJ, Upperman JS, Ford HR, Camerini V. Understanding the Susceptibility of the Premature Infant to Necrotizing Enterocolitis (NEC). Pediatr Res. Dec 10 2007;[Medline].

  6. Manogura AC, Turan O, Kush ML, Berg C, Bhide A, Turan S. Predictors of necrotizing enterocolitis in preterm growth-restricted neonates. Am J Obstet Gynecol. Jan 11 2008;[Medline].

  7. Buchheit JQ, Stewart DL. Clinical comparison of localized intestinal perforation and necrotizing enterocolitis in neonates. Pediatrics. Jan 1994;93(1):32-6. [Medline].

  8. Casey L, Lee KH, Rosychuk R, Turner J, Huynh HQ. 10-year review of pediatric intestinal failure: clinical factors associated with outcome. Nutr Clin Pract. Aug-Sep 2008;23(4):436-42. [Medline].

  9. Cakmak Celik F, Aygun C, Cetinoglu E. Does early enteral feeding of very low birth weight infants increase the risk of necrotizing enterocolitis?. Eur J Clin Nutr. Nov 28 2007;[Medline].

  10. Premji S, Chessell L. Continuous nasogastric milk feeding versus intermittent bolus milk feeding for premature infants less than 1500 grams. Cochrane Database Syst Rev. 2001;(1):CD001819. [Medline].

  11. Ververidis M, Kiely EM, Spitz L, Drake DP, Eaton S, Pierro A. The clinical significance of thrombocytopenia in neonates with necrotizing enterocolitis. J Pediatr Surg. May 2001;36(5):799-803. [Medline].

  12. Hunter CJ, Petrosyan M, Ford HR, Prasadarao NV. Enterobacter sakazakii: An Emerging Pathogen in Infants and Neonates. Surg Infect (Larchmt). Aug 7 2008;[Medline].

  13. Gagliardi L, Bellù R, Cardilli V, De Curtis M. Necrotising enterocolitis in very low birth weight infants in italy: incidence and non-nutritional risk factors. J Pediatr Gastroenterol Nutr. Aug 2008;47(2):206-10. [Medline].

  14. Bury RG, Tudehope D. Enteral antibiotics for preventing necrotizing enterocolitis in low birthweight or preterm infants. Cochrane Database Syst Rev. 2001;(1):CD000405. [Medline].

  15. Sigalet DL. Short bowel syndrome in infants and children: an overview. Semin Pediatr Surg. May 2001;10(2):49-55. [Medline].

  16. Ng E, Shah VS. Erythromycin for the prevention and treatment of feeding intolerance in preterm infants. Cochrane Database Syst Rev. Jul 16 2008;CD001815. [Medline].

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

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Further Reading

Evidence-based care guideline for necrotizing enterocolitis (NEC) among very low birth weight infants.
Cincinnati Children's Hospital Medical Center.  2005 Jul 14 (revised 2007 Feb).  12 pages.  NGC:005522
 

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Keywords

necrotizing enterocolitis, NEC, neonatal colitis, neonatal enteritis, necrotic appendicitis of the newborn, neonatal gastrointestinal disease, complication of prematurity

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Contributor Information and Disclosures

Author

Beverly P Wood, MD, MS, PhD, Professor, Departments of Radiology and Pediatrics, Division of Medical Education, Keck School of Medicine, University of Southern California
Beverly P Wood, MD, MS, PhD is a member of the following medical societies: American Academy of Pediatrics, American Association for Women Radiologists, American College of Radiology, American Institute of Ultrasound in Medicine, American Medical Association, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, and Society for Pediatric Radiology
Disclosure: Nothing to disclose.

Medical Editor

Fredric A Hoffer, MD, FAAP, FSIR, Professor of Radiology, University of Washington; Section Chief of Interventional Radiology, Department of Radiology, Seattle Children's Hospital and Regional Medical Center
Fredric A Hoffer, MD, FAAP, FSIR is a member of the following medical societies: American Academy of Pediatrics, Children's Oncology Group, Radiological Society of North America, Society for Pediatric Radiology, and Society of Interventional Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

David A Stringer, BSc, MBBS, FRCR, FRCPC, Professor, National University of Singapore; Head, Diagnostic Imaging, KK Women's and Children's Hospital, Singapore
David A Stringer, BSc, MBBS, FRCR, FRCPC is a member of the following medical societies: British Columbia Medical Association, Canadian Association of Radiologists, European Society of Paediatric Radiology, Ontario Medical Association, Radiological Society of North America, Royal College of Physicians and Surgeons of Canada, Royal College of Radiologists, and Society for Pediatric Radiology
Disclosure: None None None

CME Editor

Robert M Krasny, MD, Consulting Staff, Department of Radiology, The Angeles Clinic and Research Institute
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

John Karani, MBBS, FRCR, Consulting Staff, Department of Radiology, King's College Hospital, London
Disclosure: Nothing to disclose.

 
 
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