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Contrast-enhanced ultrasound (CEUS) findings in necrotizing enterocolitis (NEC) in a 39-day-old girl who was born at 26 weeks of gestation with abdominal distention and bloody stool. a, b Transverse gray-scale US (a) and corresponding CEUS (b) images are presented. Note a hyperenhancing linear adhesive band (thick solid arrow), limiting bowel motion under real-time evaluation. The band connects mildly hyperenhancing loops of bowel (dotted arrows). Additional irregular enhancing septae are noted within the moderate ascites (thin solid arrows)
Source publication
Ultrasound has proved to be a useful modality for enhancing the diagnostic accuracy of necrotizing enterocolitis and associated complications. The standard imaging algorithm for evaluating necrotizing enterocolitis includes radiographs and clinical symptoms, the combination of which constitutes the Bell criteria. Major limitations of using the Bell...
Similar publications
Infants with congenital heart disease are known to have higher rates of necrotizing enterocolitis (NEC) which is associated with poorer outcomes. Although the etiology is recognized as distinct from the premature neonatal population, there is not a universal consensus regarding etiology or specific risk factors. In this retrospective single-institu...
Citations
... Necrotizing enterocolitis (NEC) occurs in the neonatal intensive care population particularly in high-risk infants that are low-birth weight and/or have congenital heart disease [1][2][3]. The mortality rate of NEC ranges from 20 to 40% and increases to 50-64% if surgery is required [1,[4][5][6][7][8][9]. ...
Background
Bowel ultrasound is a useful diagnostic tool in the diagnosis and management of necrotizing enterocolitis (NEC) but can be time-consuming and requires technical expertise, particularly for assessing pneumatosis. Previous literature on sonographic evaluation of NEC has focused on a full bowel ultrasound protocol, but the utility of an abbreviated protocol primarily aimed at identifying high-risk sonographic findings without focused bowel assessment has not been well studied.
Objective
This study aims to describe the diagnostic accuracy of an abbreviated ultrasound protocol for identifying high-risk NEC findings.
Materials and methods
This is a retrospective, institutional review board-approved study. We identified all abbreviated NEC ultrasounds performed between January 2014 and August 2022 at our institution. Exams were reviewed for the presence of high-risk findings including pneumoperitoneum, fluid collections, and complex free fluid. Clinical outcome was categorized as poor or good depending on if emergent surgical intervention or death related to NEC occurred. The frequency of follow-up NEC ultrasounds was reviewed to determine if new findings affected outcome. Sensitivity, specificity, and positive and negative predictive values were generated to assess the performance of the abbreviated ultrasounds to identify high-risk findings.
Results
A total of 84 abbreviated abdominal ultrasounds were performed on 73 children. Median age at the time of ultrasound was 41 days (interquartile range (IQR) 53 days) and median gestational age was 35 weeks and 3 days (IQR 80 days), and 44/73 (60%) were male. Thirteen ultrasounds had at least one high-risk finding with nine (69%) resulting in a poor outcome, including seven surgical interventions and four deaths. Two patients had surgical intervention and died as a result of necrotizing enterocolitis. Ultrasounds without high-risk findings were not associated with poor clinical outcomes. Sensitivity, specificity, positive predictive value, and negative predictive value of the abbreviated NEC ultrasound were 100% (95% CI 60–100%), 95% (95% CI 86–98%), 69% (95% CI 39–90%), and 100% (95% CI 94–100%), respectively. Twelve abbreviated ultrasounds were followed by a second NEC ultrasound within 5 days. Five follow-up ultrasounds demonstrated new high- or low-risk findings, but the new findings did not correlate with a change in outcome as predicted by the initial ultrasound.
Conclusion
An abbreviated NEC ultrasound can be of clinical utility in predicting poor outcomes, particularly during non-business hours when resources are limited.
Graphical abstract
... After the body temperature had dropped, the heart rate continued to increase, and a grade III systolic murmur was heard in the precordial area. An abdominal ultrasound showed liver enlargement and peritoneal effusion, suggesting necrotizing enterocolitis (NEC) [13][14][15] (Figure 5), and a cardiac ultrasound showed a hyperechoic mass between the left coronary valve of the aorta and the aortic wall, suggesting a cardiac thrombus ( Figure 1A). Combined with an increased level of direct bilirubin (DBIL 29.3 µmol/L) and abnormal liver function (AST 923 U/L, ALT 71 U/L), the patient's ALB decreased from 38.3 to 25.1 g/L, and the myocardial enzymes were elevated (CK-MB117 U/L). ...
Point-of-care critical ultrasound (POC-CUS) screening plays an increasingly important role in the treatment of critically ill infants. Without POC-CUS, the lives of many infants would not be saved in time and correctly. A premature infant with systemic multiple organ system dysfunction caused by fungal sepsis was treated and nursed under the guidance of POC-CUS monitoring, and the infant was ultimately cured. This premature infant had systemic multiple organ system dysfunction and disseminated intravascular coagulation (DIC) caused by fungal sepsis. In the hypercoagulable state of early-stage DIC, cardiac thrombosis could be found using ultrasound screening. For this case, right renal artery thrombosis was found via renal artery Doppler ultrasound examination. Due to the severity of this disease, ultrasound-guided peripherally inserted central catheter (PICC) insertion and ultrasound checks of the PICC tip’s position were performed, which ensured the success of this one-time catheterization and shortened the catheterization time. Lung ultrasound is used for the diagnosis and differential diagnosis of pulmonary diseases, and to guide the application of mechanical ventilation. Because the abdominal circumference of the patient’s markedly enlarged abdominal circumference, bloody stool, and absence of bowel sounds, abdominal ultrasonography was performed, which revealed a markedly enlarged liver, significant peritoneal effusion, and necrotizing enterocolitis. Guided by POC-CUS monitoring, we had the opportunity to implement timely and effective treatment that ultimately saved this critically ill patient’s life. The successful treatment of this newborn infant fully reflects the importance of carrying out POC-CUS screening.
... In 22 participants, bowel sounds when heard on auscultation did not correspond to visible bowel movement detection upon the use of US concurrently in the same set region. Direct visual observation of bowel movement is an accurate assessment of bowel peristalsis (12,15,16). This allows for the investigation of auscultated bowel sounds that were found FIGURE 3 Dot plot for each individual study participant (x-axis) showing the distribution of peristalsis (time in seconds) detected by the two methods (audio P and ultrasound P). ...
Introduction
Assessment of bowel health in ill preterm infants is essential to prevent and diagnose early potentially life-threatening intestinal conditions such as necrotizing enterocolitis. Auscultation of bowel sounds helps assess peristalsis and is an essential component of this assessment.
Aim
We aim to compare conventional bowel sound auscultation using acoustic recordings from an electronic stethoscope to real-time bowel motility visualized on point-of-care bowel ultrasound (US) in neonates with no known bowel disease.
Methods
This is a prospective observational cohort study in neonates on full enteral feeds with no known bowel disease. A 3M™ Littmann® Model 3200 electronic stethoscope was used to obtain a continuous 60-s recording of bowel sounds at a set region over the abdomen, with a concurrent recording of US using a 12l high-frequency Linear probe. The bowel sounds heard by the first investigator using the stethoscope were contemporaneously transferred for a computerized assessment of their electronic waveforms. The second investigator, blinded to the auscultation findings, obtained bowel US images using a 12l Linear US probe. All recordings were analyzed for bowel peristalsis (duration in seconds) by each of the two methods.
Results
We recruited 30 neonates (gestational age range 27–43 weeks) on full enteral feeds with no known bowel disease. The detection of bowel peristalsis (duration in seconds) by both methods (acoustic and US) was reported as a percentage of the total recording time for each participant. Comparing the time segments of bowel sound detection by digital stethoscope recording to that of the visual detection of bowel movements in US revealed a median time of peristalsis with US of 58%, compared to 88.3% with acoustic assessment ( p < 0.002). The median regression difference was 26.7% [95% confidence interval (CI) 5%–48%], demonstrating no correlation between the two methods.
Conclusion
Our study demonstrates disconcordance between the detection of bowel sounds by auscultation and the detection of bowel motility in real time using US in neonates on full enteral feeds and with no known bowel disease. Better innovative methods using artificial intelligence to characterize bowel sounds, integrating acoustic mapping with sonographic detection of bowel peristalsis, will allow us to develop continuous neonatal bowel sound monitoring devices.
... Dilated bowel loops, focal intramural gas, portal venous gas, fixed bowel loops, paucity of bowel gas and pneumoperitoneum can be seen on abdominal radiography ( Fig. 20.5a, b). With ultrasound, one can detect lack of peristalsis, bowel wall thickening or thinning, degree of bowel wall perfusion, intramural gas, ascites, and pneumoperitoneum [15,16]. ...
Age is a key factor in the differential diagnosis of gastrointestinal (GI) pathology in children. Imaging is crucial in a range of pediatric GI disorders. In term neonates, congenital anomalies of the GI tract causing obstruction are at the forefront: atresia, intestinal malrotation with or without midgut volvulus, Hirschsprung’s disease, meconium plug syndrome, and meconium ileus. In the premature neonate, necrotizing enterocolitis can be a life-threatening complication.
Intussusception is the most common cause of obstruction in infants and young children. Inflammatory bowel disease is the main focus in older children and adolescents. Appendicitis can occur at any age although most frequently in children older than 5 years of age. The distal ileum is where GI tract duplication cysts are most frequently situated. They are usually detected on prenatal ultrasound and sometimes only later in life when causing obstruction.
Different imaging modalities can be used to image the GI tract. Plain films, ultrasound, and contrast studies are the principal imaging tools. CT and MRI are problem solvers and are used in a specific context, such as trauma, inflammatory bowel disease (IBD), diseases of the biliary tree, and tumoral pathology.
... If abdominal radiographs are often ambiguous for pneumatosis, over other findings, then better radiologic diagnostic tools are needed. Tools such as grayscale, Doppler, and contrastenhanced ultrasound or other novel modalities may serve to enhance early diagnostic capabilities [30,31]. Once a diagnosis is made, treatment should proceed rapidly. ...
This study investigated whether delayed receipt of antibiotics in infants with necrotizing enterocolitis (NEC) is associated with disease severity. In this retrospective, single-center cohort study of infants diagnosed with NEC over 4 years, we compared the timing of antibiotic administration in infants (time order placed to time of receipt) in medical and surgical NEC. Cases were independently reviewed, then various clinical factors were compared. Of 46 suspected cases, 25 were confirmed by a panel of radiologists with good interrater reliability (ICC 0.657; p < 0.001). Delays in antibiotic receipt were 1.7× greater in surgical than medical NEC cases (p = 0.049). Every hour after order entry increased the adjusted odds of surgical NEC by 2.4 (1.08-5.23; p = 0.032). Delayed antibiotic receipt was more common in infants with surgical than medical NEC. Larger studies will be needed to investigate if optimizing antibiotic expediency could improve intestinal outcomes.
... The reported incidence rate of NEC is 1-5% of all neonatal intensive care unit (NICU) admissions [1][2][3]. Low birth weight is a significant risk factor, and infants weighing 500-1,500 g have a 7-10% chance of developing NEC [1,2,4]. NEC also occurs in term infants, particularly in the setting of congenital heart disease. ...
... Clinical exam findings are also nonspecific and include abdominal distension, abdominal wall discoloration, abdominal wall erythema, crepitus and induration, abdominal tenderness to palpation, temperature and blood pressure instability, apnea and septic shock [1,5,13]. Laboratory findings include metabolic acidosis, thrombocytopenia, increased platelet activating factor, interleukin imbalance and increased levels of tumor necrosis factor alpha [4]. Several studies have reported that fecal calprotectin, a marker of intestinal inflammation, is significantly elevated in infants with NEC at the time of diagnosis [14]. ...
... Risk factors for NEC include very low birth weight, prematurity, formula feeding, hypoxic-ischemic insult, congenital heart disease, infection and microbial dysbiosis [4,14]. Feeding might also play a role, with literature showing that immediate enteral feeding can reduce the risk of NEC in preterm infants and that there is a dose-dependent reduction of NEC in infants who are fed breastmilk [11]. ...
Necrotizing enterocolitis (NEC) is a common condition in the neonatal intensive care unit that continues to present challenges in terms of diagnosis and management. Traditionally NEC has been diagnosed and managed by clinical and radiographic findings, but US has shown promise in characterizing and prognosticating NEC. In this manuscript we review the abdominal US technique for NEC, the clinical significance of individual sonographic findings of NEC, and how US can be integrated in the clinical decision process for diagnosing and managing NEC. We also discuss the potential value-added role of a limited abdominal US protocol that focuses on the sonographic findings most indicative of a poor prognosis to include pneumoperitoneum, complex free fluid and focal fluid collections.
... US has become fundamental for evaluating early changes in peristalsis, abdominal wall integrity, presence of intramural or portal gas, blood flow, and free fluid/gas in the peritoneal cavity (Fig. 8) [25]. Pneumatosis and portal venous gas can be detected earlier by US as hyperechoic foci with dirty shadowing than by radiographs. ...
Background
Abdominal emergencies in neonates require surgical management in almost all cases and complications may include bowel perforation, sepsis, shock, and even death. Radiological imaging has become a very important aid in the clinical setting as it shortens time to diagnosis.
Objective
The objective of this review is to discuss the more prevalent neonatal gastrointestinal emergencies, review appropriate imaging options, and illustrate common radiological presentations of these entities.
Conclusion
Despite advancements in imaging techniques, it is important to keep in mind that neonates have a higher susceptibility to the adverse effects of ionizing radiation, and therefore radiography and ultrasonography remain the main diagnostic modalities for ruling out the diseases with the worst prognosis. Other modalities (fluoroscopy, computed tomography, and magnetic resonance imaging) may have limited use in very specific conditions. All providers in an emergency department should be familiar with the basic radiological findings that may indicate a gastrointestinal emergency, especially in health institutions that do not have 24-h radiologist coverage.
Background:
Bowel ultrasound (US) is one of the methods used to enhance diagnostic accuracy of necrotizing enterocolitis (NEC) and its associated complications in premature newborns.
Aim:
To explore the diagnostic accuracy of BUS in extremely low birth weight (ELBW) infants with NEC.
Methods:
A single-center retrospective case-control study included 84 extremely low birth weight (ELBW) infants. The infants were divided into three groups: Group 1 -infants with NEC (n = 26); Group 2 -infants with feeding problems (n = 28); Group 3 -control group (n = 30).
Results:
The specific BUS findings in premature newborns with NEC (stage 3) included bowel wall thinning, complex (echogenic) ascites, and pneumoperitoneum, p < 0.05. The diagnostic effectiveness of these sonographic signs was 96.8% (sensitivity 75.0% and specificity 97.6%), p < 0.05. These findings with high specificity were associated with the need for surgical intervention, poor outcomes, or increased mortality. Stage 2 NEC which did not require surgery showed impaired differentiation of the bowel wall layers, absent or decreased bowel peristalsis, pneumatosis intestinalis, portal venous gas, or simple ascites, with a diagnostic accuracy of 82.9% (sensitivity 55.6%, specificity 91.4%, p < 0.05).
Conclusions:
BUS can be used as an adjunct to abdominal radiography to aid in the diagnosis of infants with suspected NEC by providing more detailed evaluation of the intestine.
Objective:
The aim of this study was to identify the state of surgical treatment of neonatal necrotizing enterocolitis (NEC) in China.
Methods:
A total of 246 delegates (88.0% senior surgeons) completed a survey sent by the Neonatal Surgery Group of the Pediatric Surgery Branch of the Chinese Medical Association in 2022. Five centers were eliminated due to lack of experience.
Results:
Generally, 38.2% of surgeons work in centers where more than 20 cases of surgical NEC are treated per year. A total of 81.3% of surgeons reported the use of ultrasonography; the most used biomarkers were white blood cell count (95.9%), C-reactive protein (93.8%), and procalcitonin (76.3%). Most surgeons (80.9%) used a combination of two (67.2%) antibiotics or single (29.5%) antibiotic for a treatment period of 7-14 days, and most used antibiotics were carbapenems (73.9%), penicillin and cephalosporins (56.0%). Patients are issued the fasting order for 5-7 days by nearly half surgeons (49.8%) for conservative treatment. 70.1% of surgeons deemed that the most difficult decision was to evaluate the optimal timing of surgery. Most surgeons (76.3%) performed diagnostic aspiration of peritoneal fluid. Laparoscopy was performed for the diagnosis and/or treatment of NEC by 40.2% of surgeons. A total of 53.5% of surgeons reported being able to identify localized intestinal necrosis preoperatively. Surgeons relied the most on pneumoperitoneum (94.2%) and failure of conservative treatment (88.8%) to evaluate the surgical indications. At laparotomy, surgical treatments vary according to NEC severity. Infants are fasted for 5-7 days by 55.2% of surgeons postoperatively. Most surgeons (91.7%) followed up with patients with NEC after discharge for up to 5 years (53.8%).
Conclusions:
The most difficult aspect of surgical NEC is evaluating the timing of surgery, and surgeons in the children's specialized hospitals are experienced. The treatment of NEC totalis is controversial, and the indications for laparoscopy need to be further clarified. More multicenter prospective studies are needed to develop surgical guidelines in the future.
Background
Necrotizing enterocolitis (NEC) is a severe inflammatory bowel disease that may lead to perforation, causing high morbidity and mortality in preterm infants. Abdominal ultrasound (AUS) has been shown to provide benefits in diagnosing and managing NEC in recent years.
Objective
This study focused on the utility of AUS in the diagnosis and evaluation of surgical NEC.
Patients and methods
In this retrospective study, available data of the patients diagnosed from January 2019 to June 2022 were reviewed. The sensitivity and specificity of AUS in diagnosing a perforation were analyzed. Typical cases for the application of AUS in monitoring and evaluating the progression, complications, and sequela of NEC were described.
Results
There were 69 neonates diagnosed with NEC and examined by AUS, of whom eight patients developed a perforation. AUS was used for diagnosing a perforation in eight patients with key features of pneumoperitoneum and/or complex ascites, allowing us to find four locations of perforation, with a sensitivity and specificity of 100%.
Conclusion
AUS plays an important role in diagnosing and evaluating surgical NEC in newborn infants, with good sensitivity and specificity.
