Necrotizing Enterocolitis x Ray findings

[Aymen Eshene]

Hello Dear 

I would like to share with you this photo for a 28 preterm baby aged now 30 days.

Commenting on a abdominal x ray a bit challenging for me and i want you kindly  to comment on this x ray.

please if you have an x ray at your PC OR Phone upload them and let us make this post a reference for NEC X rays.

X RAY S0 I0.BMP

[Hamed]

Hi Ayman,

Thanks for sharing the X-ray. To answer your concern, to comment on an X-ray abdomen in neonates use this guide in your comment

1)   Bowel loops distension:     (larger than width of  a vertebral body) 

2)   Bowel loop shape              (Polyhedral or Rounded and Sausage shape)

3)   Bowel wall thickening       (Thin or Thick)

4)   Gas distribution pattern  (In all the abdomen  or localized)

Then look for

5)   Pneumatosis intestinalis 

6)   Air in portal vein 

7)   Free air 

When you are suspecting a possibility of NEC take a cross-table lat view to better visualize free air and ascites.

Now try it on the X-ray you sent. 

 

 

 

[Schumz]

All of the above as @hamid. Bowel loops very distended. There is no NG tube in this radiograph! 

[Dr Ashish Jain]

Might as well look for the pre-sacral gas specifically .

[A.Sheta]

I would suggest a Lt lateral decubitus x-ray as there's a query translucency within the liver shadow which may reflect a ?pneumoperitoneum

[tarek]

I can appreciate dilated bowel loops small and large intestine

air up to rectum

Wall looks thin but either thin or thick can be presentvin NEC

No portal vein gas

No evidence of pneumatosis intestinalis

My suggestions:

check previous x ray to rule out dilated fixed loops

Check if the patient on CPAP how much flow and how much PEEP 

Is there is abdominal tenderness wall oedema dilated veins

Any other signs of feeding intolerance how much milk he is recieving and EBM or artificial

How much is platlets

Any metabolic acidosis

Next x ray do with lateral decubitus

Ultrasound abdomen for diagnosis of NEC is more sensitive than x ray but need some one who is expert

( take the patient as full and not x ray only)

If you going to start antibiotics i like tazocin +vancomycin

Involve pediasurgery to make them aware

 

 

 

[bimalc]

13 hours ago, tarek said:

Involve pediasurgery to make them aware

 

13 hours ago, tarek said:

If you going to start antibiotics i like tazocin +vancomycin

I will essentially agree with all your points (as I often do) but I think these two bear some comment.  As for the first, depending on your institutional culture there may be good reasons to NOT involve surgery since most NEC is medical. 1 is transport if surgery is not actually an option in your unit and the other is if your surgeons like to dictate medical management.

 

The antibiotic selection is very interesting as, yes, some variation probably reflects different susceptibility and pathogen patterns around the world, but I'm not aware of much data supporting any specific empiric regimen as 'superior'.  In my units, most of our medical NEC gets covered with Amp and Gent (plus Flagyl if the surgeons are involved).

Thus, I think the most interesting question now for us as a group is what our empiric abx selection is for NEC.  I'll go start a new thread on that and I welcome your perspectives there.

[tarek]

Thanks @bimalc

For your valuable comments

For antibiotics choice it differ from full term to preterm babies 

 NEC  has  not  been  shown  to  occur  in  germ-free  animals. While  bacterial  and  viral  pathogens  including  Escherichia  coli,  Klebsiella  spp, Clostridium  spp,  Staphylococcus  epidermidis,  rotavirus,  and  enterovirus  have  been implicated,  no  single  organism  has  been  consistently  associated  with  NEC.  Blood cultures  are  positive  in  only  20–30%  of  cases.  While  colonization  by  normal  gut flora  supports  the  intestinal  mucosa  through  toll-like  receptors,  pathological  bacteria  induce  inflammation  and  apoptosis  by  signaling  pathways  such  as  nuclear factor-κB.  The  growth  of  these  noncommensal  bacteria  may  also  result  in  endotoxin release, leading to mucosal damage.(Gomella)

This suggestion was mentioned in Gomella

  Antibiotic regimen  should  cover  pathogens  that  can  cause  late-onset  sepsis  in  premature infants.  Add  anaerobic  coverage  if  bowel  necrosis  or  perforation  is  suspected. Reasonable antibiotic regimens include a.  Vancomycin, gentamicin, and clindamycin (or metronidazole).

b.  Vancomycin and piperacillin/tazobactam.

c.  Vancomycin, gentamicin, and piperacillin/tazobactam.

d.  Term  infants  may  be  treated  with  ampicillin,  gentamicin,  and  clindamycin. 

[ali]

Hi,

There is a suggestion of tram lining within the most central bowel loop that would raise my suspicions of a pneumatosis.

How is the infant clinically presenting?

Many thanks

Alistair