Complex Fluid Collection on Abdominal Ultrasound Indicates Need for Surgery in Neonates with Necrotizing Enterocolitis

Abstract

The aim of this study was to determine whether a correlation exists between the sonographic findings and the clinical outcomes, defined as surgery or death, in neonates with radiographically and/or histopathologically confirmed necrotizing enterocolitis (NEC). In this retrospective study, the case notes of 58 patients admitted to Karolinska University Hospital, Stockholm, Sweden, with radiographically confirmed NEC from September 2010 to August 2013, were reviewed. We included all newborns who underwent both plain abdominal radiographs and an abdominal ultrasound on the same day. The images were reviewed retrospectively. Patients' characteristics, clinical data, and histopathological data were recorded from the case notes. We excluded newborns who developed free gas before surgery. Abdominal ultrasound images were reviewed for free intraperitoneal gas, peritoneal fluid, pneumatosis intestinalis, portal gas, bowel vascularity, bowel wall thickness, and peristalsis. We correlated the sonographic features with the clinical outcomes; defined as the need for surgery or death. Overall, 25 neonates were included. Out of these, 11 patients underwent surgery and 5 patients died. The sonographic finding of complex fluid collection was statistically significant, predicting severe NEC that needed surgery. No other sonographic features were related to the need for surgery or death. Complex fluid collection shown with abdominal ultrasound appears to be strongly correlated to the need for surgery in newborn infants with severe NEC.

Bowel ultrasound for predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis

“…Of these, 11 articles reporting on 748 infants met eligibility criteria and were included in our final analysis (Fig. 1 ) [ 13 – 23 ]. The characteristics of the included studies are summarized in Table 1 .…”

“…Five studies assessed the association of increased bowel perfusion using color Doppler with NEC outcomes, although increased perfusion was variably defined. Two studies [ 15 , 20 ] objectively defined increased perfusion as having more than nine dots of color Doppler signal per square centimeter; another two studies [ 16 , 23 ] used more subjective criteria based on patterns of flow and one study [ 18 ] did not provide a clear definition for increased perfusion. No studies evaluated bowel perfusion using Doppler waveforms.…”

Necrotising Enterocolitis - epidemiology and imaging

“…[62][63][64][65][66][67] Complex ascites (focal or echoic fluid) has been associated with intestinal gangrene, perforation, the need for surgery, or otherwise poor outcome. 39,42,68,69 PP detected with US may also predict poor outcome, as well as a combination of three or more of: increased wall echogenicity, absent perfusion, PVG, bowel wall thinning, bowel wall thickening, free fluid with echoes or PI. 39 Absent perfusion detected with doppler, in combination with various other signs, has been associated with bowel necrosis 70,71 and the finding of a dilated, elongated intestinal loop on AR, 72 which has in turn been associated with poor outcome.…”

“…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. 23 Ultrasonographic signs that may indicate intestinal necrosis and need for surgery include localized and/or turbid fluid 53,68,72 and absent perfusion with reduced peristalsis. 71 Clinical indications for surgical intervention include deterioration in spite of maximal medical treatment, abdominal erythema or a palpable abdominal mass.…”

“…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. 53,68,71,72 There is no contradiction between the reports on the ability of some radiographic and ultrasonographic findings, other than PP, to predict the need for surgery 59 and the effect of timing surgery according to a combination of metabolic parameters (MD7) on outcome. 206,246 Both may contribute to the improvement of NEC surveillance.…”