Analysis of bowel perforation in necrotizing enterocolitis

Abstract

The most severe complication of necrotizing enterocolitis (NEC) is bowel perforation. Identification of neonates at high risk for perforation and optimization of radiologic imaging to identify bowel perforation are necessary to reduce the high mortality rate associated with this catastrophic event. One hundred and fifty-five cases of NEC were seen at our institution during a 5.5-year period. Nineteen (12%) progressed to perforation. A review of surgical findings, autopsy results and radiographs from these patients shows only 63% had radiographic evidence of free air in the peritoneal cavity at the time of perforation. Twenty-one percent had radiographic evidence of ascites but no pneumoperitoneum, and 16% had neither free air nor ascites. Thus purely radiographic criteria for bowel perforation in NEC are imprecise, and paracentesis is mandatory in NEC patients with ascites or clinical findings indicative of peritonitis. Timing of radiographic studies and site of bowel involvement are also important. Seventy-nine percent of perforations occurred by 30 h from confirmation of diagnosis (by clinical or radiographic criteria). Surgery or autopsy revealed involvement of the ileo-cecal region in 89% of cases with the actual site of perforation occurring in this area in 58% of patients.

Radiologists' Agreement When Using a 10-Point Scale to Report Abdominal Radiographic Findings of Necrotizing Enterocolitis in Neonates and Infants

“…Pneumoperitoneum is the only universally agreed on radiographic sign that mandates surgical intervention [19][20][21]. However, even this sign is present in only 50-75% of all neonates and infants with bowel perforation due to necrotizing enterocolitis [22][23][24]. Note-Substantial agreement between findings in study participants and reported findings at original clinical examination was also seen.…”

Necrotising Enterocolitis - epidemiology and imaging

“…More problematic, it is known to be missing in a great proportion of infants with perforated NEC. 31,75,37 The distribution of opinions on persistent loop on sequential radiographs and portal venous gas on AR as indications for surgery is similar to the equivocal results in the literature. 23,[56][57][58][59]79,199,204 Reported results on the potential of US to bridge the lack of sensitivity of AR for intestinal perforation and bowel necrosis are promising.…”

“…Especially in the extremely low birth weight infants, however, the sensitivity of radiographic signs is low, 26,39 PP is known to be missing in a great proportion of infants with perforated NEC. 31,37,75 Other signs, such as persistent/fixed loop and PVG are discussed. 23,46,56,57,59,79,204 Although PVG on AR has been associated with poor outcome, 56 it has also been suggested that not PVG, but severity of NEC, is associated with the need for surgical intervention.…”

“…The selection of articles may, however, not be complete. 40 1976 X Daneman 22 1978 X X X X X X Kogutt 41 1979 X Mata 48 1980 X X X Leonard 73 1982 X *Cikrit 74 1985 X Frey 75 1987 X X *Kennedy 76 1987 X Kosloske 56 1988 X X X Brill 77 1990 X Bömelburg 78 1992 X X X Rehan 43 1999 X X X X X X Molik 57 2001 X Tam 31 2002 X X X Faingold 70 2005 X Kim 60 2005 X Sharma 23 2005 X X X Coursey 50 2009 X X X X X X X Dördelman 24 2009 X X Bonhorst 34 2011 X Dilli 61 2011 X X X X Muchantef 53 2013 X X X X X X Silva 72 2013 X X X X Muller 79 2014 X * Abstracts only accessed US has been suggested to be used for: detection of PI, PVG, and intra-abdominal fluid and evaluation of bowel peristalsis, thickness, and perfusion of the bowel wall in neonates with mild symptoms and nonspecific plain film findings;…”

Clinical Importance of a Fixed Bowel Loop in the Treatment of Necrotizing Enterocolitis

“…Concerning these indications, two important caveats should be mentioned. Firstly, pneumoperitoneum is only detected by abdominal radiography in 50-75% of NEC patients with a bowel perforation [22,23]. This means that a significant number of patients are at risk of being unjustly treated conservatively.…”