Plain Abdnominal Radiographs in Neonatal Intestinal Perforation
Plain Abdnominal Radiographs in Neonatal Intestinal Perforation
Introduction: The recognition of neonatal intestinal perforation relies on identification of free gas in the peritoneum on plain abdominal radiographs and the associated clinical signs. The neonatal bowel takes several hours to fill with gas, potentially obscuring one of the radiological signs of bowel perforation in the neonate.
Case Presentation: We describe the case of a male, Caucasian neonate, born prematurely at 35 weeks of gestation, who was suspected before birth to be at risk of intestinal perforation, based on antenatal ultrasound signs of bowel obstruction. However, the diagnosis of intestinal perforation after birth was initially delayed because the first abdominal radiograph, requested by the neonatal team, was taken too early in the clinical progression of the neonate's condition. As a consequence, this delayed referral to the paediatric surgical team and definitive management.
Conclusion: This case illustrates how consideration of the timing of abdominal radiographs in suspected intestinal perforation in the neonate may avoid misinterpretation of radiographic signs, thereby avoiding delays in referral and treatment in the crucial first few hours of life.
Abdominal distension with bile-stained vomiting in a neonate can potentially represent bowel obstruction. Neonatal bowel obstruction can be complicated by intestinal perforation, hence the necessity for early surgical referral in cases of neonatal bowel obstruction. Intestinal perforation may occur before birth. The preliminary imaging modality of choice to diagnose suspected bowel obstruction and intestinal perforation in a neonate is a plain supine abdominal radiograph. Accurate diagnosis often relies on recognition of abnormal gas patterns within the abdomen. However, the passage of gas through the neonatal intestine takes a number of hours after birth.
Peritoneal calcification is indicative of in utero bowel perforation, which can be associated with postnatal meconium peritonitis. Meconium peritonitis can be treated operatively or non-operatively, since in utero bowel perforations may heal spontaneously. A recent meta-analysis of the literature has helped to clarify the features of meconium peritonitis that are associated with a need for operative management. Cases of meconium peritonitis were divided into four prognostic groups based on ultrasonographic criteria. Children with isolated intra-abdominal calcification had an excellent prognosis, normally avoiding surgery. The presence of one of ascites, pseudocyst or bowel dilatation had a good prognosis but an increased risk of surgery (52% required laparotomy). Having two or more of these features placed the neonate at higher risk of surgery (80% required laparotomy), whilst having all of these features was associated with the worst prognosis, this group being the only one associated with a risk of death in this study (6%). Intestinal perforation, in contrast, is associated with a higher risk of death, usually requiring early surgical intervention.
Abstract and Introduction
Abstract
Introduction: The recognition of neonatal intestinal perforation relies on identification of free gas in the peritoneum on plain abdominal radiographs and the associated clinical signs. The neonatal bowel takes several hours to fill with gas, potentially obscuring one of the radiological signs of bowel perforation in the neonate.
Case Presentation: We describe the case of a male, Caucasian neonate, born prematurely at 35 weeks of gestation, who was suspected before birth to be at risk of intestinal perforation, based on antenatal ultrasound signs of bowel obstruction. However, the diagnosis of intestinal perforation after birth was initially delayed because the first abdominal radiograph, requested by the neonatal team, was taken too early in the clinical progression of the neonate's condition. As a consequence, this delayed referral to the paediatric surgical team and definitive management.
Conclusion: This case illustrates how consideration of the timing of abdominal radiographs in suspected intestinal perforation in the neonate may avoid misinterpretation of radiographic signs, thereby avoiding delays in referral and treatment in the crucial first few hours of life.
Introduction
Abdominal distension with bile-stained vomiting in a neonate can potentially represent bowel obstruction. Neonatal bowel obstruction can be complicated by intestinal perforation, hence the necessity for early surgical referral in cases of neonatal bowel obstruction. Intestinal perforation may occur before birth. The preliminary imaging modality of choice to diagnose suspected bowel obstruction and intestinal perforation in a neonate is a plain supine abdominal radiograph. Accurate diagnosis often relies on recognition of abnormal gas patterns within the abdomen. However, the passage of gas through the neonatal intestine takes a number of hours after birth.
Peritoneal calcification is indicative of in utero bowel perforation, which can be associated with postnatal meconium peritonitis. Meconium peritonitis can be treated operatively or non-operatively, since in utero bowel perforations may heal spontaneously. A recent meta-analysis of the literature has helped to clarify the features of meconium peritonitis that are associated with a need for operative management. Cases of meconium peritonitis were divided into four prognostic groups based on ultrasonographic criteria. Children with isolated intra-abdominal calcification had an excellent prognosis, normally avoiding surgery. The presence of one of ascites, pseudocyst or bowel dilatation had a good prognosis but an increased risk of surgery (52% required laparotomy). Having two or more of these features placed the neonate at higher risk of surgery (80% required laparotomy), whilst having all of these features was associated with the worst prognosis, this group being the only one associated with a risk of death in this study (6%). Intestinal perforation, in contrast, is associated with a higher risk of death, usually requiring early surgical intervention.