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Abdominal US outperforms AR for NEC diagnosis

Belinda Chan, MD

Wed, 16/08/2023

A preterm infant presented with a new onset of emesis and bloody stool. This picture showed the infant with a distended, discolored abdomen, which may be the manifestation of a life-threatening intra-abdominal process. The differential diagnosis included necrotizing enterocolitis (NEC).

Image of a discolored abdomen of an infant.


The abdominal X-ray (AR) showed a non-specific dilated bowel gas pattern.

Abdominal X-ray of an infant.


Abdominal ultrasound (AUS) was obtained. The intestinal content spillage from the intestinal perforation was "caught on camera." It also showed abnormally dilated, echogenic intestines. These findings were undetectable by AR alone.

Abdominal ultrasound of an infant showing intestinal content spillage.


AUS also showed an extraluminal abscess and meconium collection. All these findings were consistent with NEC with intestinal perforation. This patient underwent emergent abdominal surgery for bowel resection and ileostomy.

Abdominal ultrasound of an infant showing extraluminal abscess and meconium collection. This case exemplifies the recent finding by Chen et al. that AUS (AUROC: 0.755, 95% CI 0.660–0.849) is better than AR (AUROC: 0.693, 95% CI 0.597–0.789) at predicting surgical NEC and the need for intestinal resection1. A recent meta-analysis had also identified several AUS findings that are associated with surgery or death in NEC2. The findings include focal fluid collection and dilated bowel (as seen in this case); other features are free air, no peristalsis, absent intestinal perfusion, complex ascites, abnormal bowel wall architecture2. References

1Chen, J., Mu, F., Gao, K. et al. Value of abdominal ultrasonography in predicting intestinal resection for premature infants with necrotizing enterocolitis. BMC Gastroenterol. 2022;22, 524.

2Cuna AC, Reddy N, Robinson AL, Chan SS. Bowel ultrasound for predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis. Pediatr Radiol. 2018;48(5):658-666. doi:10.1007/s00247-017-4056-x

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