VOL.
No.
123,
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BENIGN
FORM
OF
JOHN
By
A.
NECROTIZING
RICHMOND, LOS
M.D., ANGELES,
produces
stricture
However, tion
colon. On
the
Department
roent-
dilatation. was placed
feedings
were
on
anti-
discontinued.
unchanged. was seen
Extenin the IA). Be-
of the entire colon (Fig. the discrepancy between the clinical of the infant and the roentgenogram, study was ordered. A Hypaque enema
condition a colon
(Fig.
condiA
showed pneumatosis ofthe descending
was no bowel the infant
oral
in normal
distention.
clinical condition was pneumatosis intestinalis of
iB)
matosis
confirmed
the
presence
of the
pneu-
intestinalis.
On
Day
residual were
3,
and
cause
formation
remained
of the abdomen in the distribution
distribution
6, there
was
pneumatosis
only
and
the
a small
amount
intestinalis,
and
Oral
feedings
negative.
hematest
sumed,
infant
was
the
of
stools
were
discharged
re-
25 days
later. CASE
infant
PF
II.
born
Spontaneous by
OF CASES
of Radiology,
M.D.
abdominal
There Day
The sive
CASE I. PF 328-02-83 is a 1,680 gram female born following a 36 week gestation. The pregnancy was complicated by ruptured membranes i6 days prior to spontaneous vaginal delivery in an outside hospital. Apgars of 7 were obtained at I and minutes. From
the infant
biotics,
fistula resulting in bowel obstruction. This also requires surgery. Finally, there is a third group of patients who have comparatively mild clinical signs and symptoms related to the gastrointestinal tract. These infants demonstrate the radiographic findings of necrotizing enterocolitis except for pneumoperitoneum and do well with medical management. Cases which belong in this group have been alluded to in previous reports.”5’6 The case histories and radiographic findings of 7 cases which can be placed in this latter group will be presented. Because of the clinical course of these infants, we have referred to the disease process in this group as the benign form of necrotizing enterocolitis, representing one end of a spectrum.
*
MIKITY,
without
genogram intestinalis
internal
REPORT
VICTOR
Transient respiratory distress was present on admission 2 hours after birth. There was no radiographic evidence of hyaline membrane disease. An umbilical arterial catheter was inserted on Day o and remained in place for 36 hours. An umbilical venous catheter was placed for a shorter period. On Day 2, blood-streaked stools were noted.
HE radiographic findings in neonatal necrotizing enterocolitis have been previously described.2’3’7 These include bowel dilatation, pneumatosis intestinalis, portal venous gas and pneumoperitoneum. The typical case will have necrosis of a segment or segments of bowel resulting in perforation. Surgery is then usually considered mandatory. A small series of cases has been described in which infants with necrotizing enterocolitis and pneumoperitoneum were treated 9 Those who survived later required surgery for stricture formation. There is a smaller group of patients who do not perforate, but have delayed manifestations.”3’8 In this group, vascular compromise
and
CALIFORNIA
T
or
ENTEROCOLITIS*
Los Angeles County-USC
vaginal
a
is a 1,640 34 week
delivery
hemorrhage,
maternal
was
gram
male
gestation. complicated
probably of 6 were
due
to
abruptio placentae. Apgars obtained at i and 5 minutes. The infant had mild transient respiratory distress, treated by oxygen. Chest roentgenograms showed no evidence of hyaline membrane disease. An umbilical arterial catheter was placed on Day 0 and removed 48 hours later. On Day 2, blood-tinged stools were passed, and gastric residual was noted. The clinical condition otherwise remained normal. Oral feedings were discontinued, and the infant was placed
on
antibiotics.
gram showed of bowel and Medical
30!
332-47-60
following
Center,
An abdominal
roentgeno-
slight dilatation of multiple questionable pneumatosis Los Angeles,
California.
loops intesti-
John
Downloaded from www.ajronline.org by 113.160.225.166 on 06/21/16 from IP address 113.160.225.166. Copyright ARRS. For personal use only; all rights reserved
302
and
Mikity
FEBRUARY,
Extensive pneumatosis intestinalis in the distribution of the entire defects in the Hypaque enema examination produced by the collections
FIG.
colon. (B) Irregular of intramural gas.
I. (A)
nalis
on the
right
roentgenogram in On
side (Fig.
demonstrated
a linear
the
rectum.
Day
3,
ofthe abdomen. A lateral obtained 8 hours later collection of intramural
CASE
111.
a normal
Pl’
336-I
intestinal
gas
1-82
is
a
pattern
remained on Day negative. later.
1,290
gram
I .
4.
male
infant born following a 29 week gestation. The pregnancy was complicated by premature rupture of the membranes 3 days prior to onset of labor. Following vaginal delivery at in outside hospital, the infant had an episode of apnea, treated by positive pressure with mask and bag. Apgar scores were not obtained. The amniotic fluid was described as being mucopurulent. On admission to the nursery approximately i hour after delivery, respiratory grunting and hypothermia were noted. The infant was treated with
positive intravenous
course
of
transfusions An umbilical level of the
pressure
by mask
and
bag, placed
8 day Blood were given for a low hematocrit. arterial catheter was passed to the right common iliac artery and was fluids,
antibiotics
1975
and
for
started
on
amnionitis.
an
filling
maintained in place for less than 24 hours. Chest roentgenograms revealed nodular densities in the lower lungs consistent with mild hyaline membrane disease.
2)
was present. The clinical condition good and oral feedings were resumed By Day 7, the stools were hematest The infant was discharged 22 days
on
Victor
___
_.s_
gas
A. Richmond
the
The
respiratory
Oral
feedings
infant
distress were
developed
gastric residual large amount roentgenograms through
Day
testinal sent
resolved
begun
on
during
Day
abdominal
Day
2. However,
distention
with
and on one occasion vomited of greenish fluid. Abdominal over a 3 day period (Day 3)
showed
dilatation.
This
a nonspecific
adynamic
slight
was
generalized
thought ileus
a i
in-
to repregrade feedings
or a low
meconium blockage s-ndrome. Oral were discontinued for a 6 hour period on Day 3. The distention improved, and the oral feedings were resumed and tolerated well. In subsequent days, the infant fed well by gavage and gained weight. On Day 12, blood-tinged stools were passed. The abdomen remained soft and nondistended, and no vomiting or gastric residual was observed. Oral feedings were discontinued, and the infant was placed on antibiotics. An abdominal roentgenogram
tosis
scending dilatation.
intestinalis
and By
(I’ig.
3)
in
the
sigmoid Day
15,
demonstrated distribution
colon, without the pneumatosis
pneum of
a-
the debowel intes-
VOL.
No.
123,
Form
Benign
2
Enterocolitis
Necrotizing
of
303
had resolved. The clinical condition during this period was unremarkable. Oral feedings were resumed and by Day 20, the stools had become hematest negative. The infant was discharged at 8 weeks of age.
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tinalis
PF 346-62-69
is an 1,140 gram male following a 28 week gestation. Dewas by version extraction of a double breech presentation under general anApgars of 2 and s were obtained at i
CASE
IV.
infant
born
livery
footling esthesia.
and
minutes.
mask
for transient
cyanosis.
and
arterial catheters
were
admission
fant
had
the chest
mild
was
tachypnea
venous
4. Transfusions
given
on Days
crit.
The 8.
arterial
On
Day
However,
was
pressure
nal
distention,
and
A roentgenogram
was oral
normal.
The
oxygen
and
cent by
catheter
mask
was
of packed
there
by
venous
placed shortly after At this time the inand some retractions,
2.5 per
5 and catheter
oxygen
Umbilical
and
red
on
blood
only
a grossly
slight
feedings
of the
cells
bloody
abdomiwere
abdomen
FIG.
3. Case ni. Pneumatosis tribution of the descending
toler-
(Fig.
4)
demonstrated small and
slight to large bowel
pneumatosis
in
unchanged.
gastric
residual
and
served. biotics
Stools were
were begun,
in
4.
the
moderate
An
Case
the
colon. 13, the clinical status
were
findings
FIG.
Linear of intramural gas in the rectum.
moderate loops
intestinalis
the entire On Day
discontinued.
2.
intestinalis in the (usand sigmoid colon.
bag.
removed
6 for a low hematowas removed on
the infant passed
12,
stool. ated.
with
positive
umbilical
Day were Day
received
roentgenogram
treated
intermittent
The
infant
to the nursery.
but
infant
The
Iv.
distribution
dilatation of and extensive distribution
skin
hematest
and
radiologic
and
by Day
However,
poor
color
abdominal
feedings roen
15,
were
positive.
oral
of
obAnti-
were
tgenogra
Extensive pneumatosis intestinalis of the entire colon. Slight
dilatation
of the intestinal
loops.
m
to
John
304
A. Richmond
and
Victor On
Mikity
Day
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the
,
distention,
FEBRUARY,
infant
vomiting,
developed
and
1975
abdominal
lethargy.
Stools
were
initially blood-tinged and then hematest positive. An abdominal roentgenogram (Fig. c) demonstrated moderate dilatation of multiple loops of bowel with extensive pneumatosis intestinalis
and
portal
venous
gas.
The
infant
was
placed on antibiotics, and oral feedings were discontinued. By Day 5, the intestinal dilatation persisted, but the pneumatosis intestinalis and portal venous gas had resolved. Blood transfusions were given because of a drop in hematocrit from 49 per cent on Day o to 33 per cent on Day s. The clinical condition improved, and by Day 8 the intestinal gas pattern was normal. Stools became hematest negative on Day . The infant was discharged at 9 weeks of age.
CASE infant
gram female week gestation. A vaginal delivery followed artificial of amniotic membranes for low grade
normal rupture
RH Case v. Dilated lections of intramural
FIG.
.
showed
no
intestinalis On Day
bowel
intestinal gas, and
dilatation,
loops, bubbly colportal venous gas. but
pneumatosis
was again seen in the entire colon. i6, the stools became hematest nega-
tive, and there was incomplete resolution of the pneumatosis intestinalis. Transfusions of packed red blood cells were given as the hematocrit had dropped from 39 on day 9 to 27 on Day 15. Oral feedings were resumed on Day 19. An abdominal roentgenogram on Day 23 showed a normal intestinal gas pattern. The infant was discharged at 2 months of age. PU 350-60-18 infant born following spontaneous rupture CASE
prior
is a
V.
to delivery.
tion
Delivery
a of
30
1,480
week
female
gestation
membranes was
gram
by
24
cesarean
and
hours sec-
for breech presentation. Apgars of 2 and 6 were obtained at i and s minutes. The infant required positive pressure resuscitation with mask and bag and subsequently, 6o per cent oxygen by hood for respiratory distress during the first 3 days. There was no radiologic evidence of hyaline membrane disease. Umbilical venous and arterial catheters were placed on Day 0 and removed within 4$ hours and 72 hours,
respectively.
1l’
VI.
born
351-94-31
sensitization.
tanied
at
is
a 2,470
a 37
following
Apgars
of
s minutes.
8 and
9 were
ob-
given by mask and hood for transient respiratory distress. A chest roentgenogram was normal. An umbilical arterial catheter was placed on Day o and was removed on Day 2, because of vascular insufficiency to the left leg. This subsequently resolved. On Day 3, the infant developed abdominal distention and passed a blood-streaked stool. Abdominal roentgenograms (Fig. 6, A and B) revealed slight dilatation ofbowel loops, pneumatosis
I
and
intestinalis
Oxygen
on
the
right
abdomen, was
were
and portal venous placed on antibiotics, discontinued.
was
gas. and
side
of the
The oral
infant feedings
By Day , the abdomen was soft; the stools were hematest positive. Transfusion of packed red blood cells was given because of a drop in hematocrit from 38 per cent on Day 3 to 3 I per cent on Day . An abdominal roentgenogram revealed a normal intestinal gas pattern except for slight dilatation of some loops. On Day #{231}, a normal gas pattern was present. Oral feedings were resumed on Day 6, and the stools became hem atest negative on Day . The patient was discharged at is days of age.
CASE infant
VII.
born
P1
is a
357-48-30
following
a
30
week
I,740
gram
gestation.
male
The
VOL.
123,
No.
Form
Benign
2
of Necrotizing
Enterocolitis
305
Downloaded from www.ajronline.org by 113.160.225.166 on 06/21/16 from IP address 113.160.225.166. Copyright ARRS. For personal use only; all rights reserved
pregnancy was vaginal bleeding
complicated by an episode of and maternal fever 12 hours prior to delivery. Delivery was by cesarean section for placenta previa and transverse lie. Apgars of 8 and 10 were obtained at I and s minutes. The infant had no respiratory distress, and a chest roentgenogram was normal. An umbilical arterial catheter was passed and remained in place for 5 days. On Day 2, the infant developed abdominal distention and lethargy. Hematest positive stools were passed. An abdominal roentgeno-
gram (Fig. pneumatosis
7) demonstrated bowel dilatation, intestinalis involving the stomach
and intestinal domen, and
loops portal
on the right side of the abvenous gas. Oral feedings
Slight collections
Case
7.
FIG.
dilatation of intestinal loops, of intramural gas involving
VII.
curvilinear
the stomach and intestinal of the abdomen, and portal
were
discontinued,
and
loops
on
venous
the
the
right
side
gas.
infant
was
placed
on antibiotics.
The
following
day,
unremarkable
was
On Day
4, the
distended,
ative. present sumed
infant
and
the
for
was stools
gas pattern
slight
more
normal intestinal on Day 5, and oral on Day 6. The patient
dilatation.
active
became
A
days
28
the intestinal
except
and
hematest
less neg-
gas pattern was feedings were rewas discharged at
of age. In the 7 cases
Gomment.
presented,
all of the
infants
were premature by weight and gestation. Only i infant (Case ru) had hyaline membrane disease, and this was clinically mild. With the Cases
FIG. 6. Case
vi.
(A)
Portal
venous
gas.
(B)
of intestinal loops. Pneumatosis nalis on the right side of the abdomen.
latation
Slight di-
intesti-
development i,
of
and
ii,
except
for
the
The
remaining
III
necrotizing were
presence
of
cases
were
enterocolitis,
clinically blood
more
in
normal, the
stools.
symptomatic
with abdominal distention, lethargy, gastric residual, and vomiting, in addition to bloody or hematest positive stools. Blood and stool cultures were negative for pathogenic organ isms in all of the infants. Cases i and III demonstrated pneumatosis intestinalis only. Cases ii and IV had bowel dilatation in addition to pneumatosis intestinalis.
John
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306
A. Richmond
and
Cases v, VI and VII demonstrated a combination of bowel dilatation, pneumatosis intestinalis, and portal venous gas.
Victor
Significant
From the cases presented, it can be seen that bowel dilatation, pneumatosis intestinalis, and portal venous gas may be present in the neonatal period without progression to significant bowel necrosis. Because the radiographic appearance seen in our series ofcases is that usually associated with neonatal necrotizing enterocolitis and because of the clinical signs and symptoms related to the gastrointestinal tract, we believe it is justified to consider this group in the category of necrotizing enterocolitis. In those infants in whom bowel dilatation is present with pneumatosis intestinalis and sometimes portal venous gas, a definite prognosis cannot always be made. The majority of these cases will develop significant bowel necrosis. Three of the cases presented are examples which did not progress to significant necrosis. It is evident that the presence of portal venous gas is not an indication for surgical intervention in necrotizing enterocolitis. This decision should be based on the presence of a pneumoperitoneum or clinical deterioration of the infant. In those infants in whom pneumatosis intestinalis is present without bowel dilatation, the most likely prognosis is that of the benign form of necrotizing enterocolitis. This statement is based on our experience 78 last
cases
of
are examples may certainly
necrotizing
Two which
3 years. in
be
enterocolitis
of the cases the benign
bowel
benign
necrosis
form
John
A. Richmond,
1200
North
of
does
not
necrotizing
occur entero-
Box
necrotizing
California
90033
REFERENCES I.
R.
BELL,
J. J.
S., GRAHAM, Roentgenologic
K.
tions
of
neonatal
W.
MIZRAHI,
Necrotizing Radiology, 3.
LLOYD,
and
83,
1964,
D. A., enterocyst
and
tizing
NUCLEAR
D. H., W. A. infant.
879-887.
Volume Publishers,
8, 479-486. P., IRU5C0TT,
D.
E.,
IEMPLETON,
J. H. Neonatal
MIDDLEMISS,
7. Radio!.,
8th.
enterocolitis.
2.
S. Intestinal stenosis as late complications enterocolitis. 7. Pediat.
CYWES,
formation
necrotizing
1973,
S.
Ari.
&
IHERAPY
X-ray Diagnosis. Year Book Medical pp. 15 18-1524.
and
of neonatal 5. MASTER, A. C.,
manifesta-
enterocolitis.
123-134.
112,
edition. Chicago,
Surg.,
STEVENSON,
E., GRossMAN, H., BAKER, A., BARLOW, 0., and BLANC, enterocoli tis in premature
J. Pediatric
CAFFEY,
Sixth Inc., 4.
RAD.
1971,
BERDON,
C. B., and and clinical necrotizing
ROENTGENOL.,
MED., 2.
1973,
necro46,
1063-1069.
6.
M.,
MISKIN,
wall 7.
8.
M.
A.
venous
7.,
1969,
R.,
and
enterocolitis
GENOL.,
RAD. 113,
B.
REILLY,
portal
tizing
of IHERAPY
J. Gas in intestinal system
in
infants.
129-134.
JO!, KASSNER,
infancy. &
E. G. NecroAM. NUCLEAR
J.
ROENTMED.,
283-296.
J. G.,
B. S., I’ELLER, M. R., changes following necrotizing enterocolitis in newborn. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1968, 103, 359-364.
RAiuxowITz,
and
9.
and
and
POCHACZEVSKV,
1971,
en-
terocolitis is nonspecific and may be seen in other entities in the neonatal period which produce bowel necrosis, such as mesenteric arterial or venous occlusion or intestinal volvulus.
Street
624
C’anad.
of
M.D.
State
Los Angeles,
suggested.
appearance
the
Seven cases are presented which can be placed in this category. The radiographic findings in this group include bowel dilatation, pneumatosis intestinalis, and portal venous gas. A benign prognosis may be suggested when pneumatosis intestinalis is present without bowel dilatation.
in
presented prognosis
The etiology for the benign form of necrotizing enterocolitis is unknown but maybe related to transient intestinal hy-poxia. Finally, it should be mentioned that the radiographic
1975
colitis.
DISCUSSION
the
FEBRUARY,
SUMMARY
in
with
Mikity
KRASNA,
WOLF,
I. Colonic
W. D., and SHANNON, M. P. Necrotizing enterocolitis: medical approach to treatment. Canad. M. A. 7., 1973, zoS, 573-476.
REID,
No.
123,
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BENIGN
FORM
OF
JOHN
By
A.
NECROTIZING
RICHMOND, LOS
M.D., ANGELES,
produces
stricture
However, tion
colon. On
the
Department
roent-
dilatation. was placed
feedings
were
on
anti-
discontinued.
unchanged. was seen
Extenin the IA). Be-
of the entire colon (Fig. the discrepancy between the clinical of the infant and the roentgenogram, study was ordered. A Hypaque enema
condition a colon
(Fig.
condiA
showed pneumatosis ofthe descending
was no bowel the infant
oral
in normal
distention.
clinical condition was pneumatosis intestinalis of
iB)
matosis
confirmed
the
presence
of the
pneu-
intestinalis.
On
Day
residual were
3,
and
cause
formation
remained
of the abdomen in the distribution
distribution
6, there
was
pneumatosis
only
and
the
a small
amount
intestinalis,
and
Oral
feedings
negative.
hematest
sumed,
infant
was
the
of
stools
were
discharged
re-
25 days
later. CASE
infant
PF
II.
born
Spontaneous by
OF CASES
of Radiology,
M.D.
abdominal
There Day
The sive
CASE I. PF 328-02-83 is a 1,680 gram female born following a 36 week gestation. The pregnancy was complicated by ruptured membranes i6 days prior to spontaneous vaginal delivery in an outside hospital. Apgars of 7 were obtained at I and minutes. From
the infant
biotics,
fistula resulting in bowel obstruction. This also requires surgery. Finally, there is a third group of patients who have comparatively mild clinical signs and symptoms related to the gastrointestinal tract. These infants demonstrate the radiographic findings of necrotizing enterocolitis except for pneumoperitoneum and do well with medical management. Cases which belong in this group have been alluded to in previous reports.”5’6 The case histories and radiographic findings of 7 cases which can be placed in this latter group will be presented. Because of the clinical course of these infants, we have referred to the disease process in this group as the benign form of necrotizing enterocolitis, representing one end of a spectrum.
*
MIKITY,
without
genogram intestinalis
internal
REPORT
VICTOR
Transient respiratory distress was present on admission 2 hours after birth. There was no radiographic evidence of hyaline membrane disease. An umbilical arterial catheter was inserted on Day o and remained in place for 36 hours. An umbilical venous catheter was placed for a shorter period. On Day 2, blood-streaked stools were noted.
HE radiographic findings in neonatal necrotizing enterocolitis have been previously described.2’3’7 These include bowel dilatation, pneumatosis intestinalis, portal venous gas and pneumoperitoneum. The typical case will have necrosis of a segment or segments of bowel resulting in perforation. Surgery is then usually considered mandatory. A small series of cases has been described in which infants with necrotizing enterocolitis and pneumoperitoneum were treated 9 Those who survived later required surgery for stricture formation. There is a smaller group of patients who do not perforate, but have delayed manifestations.”3’8 In this group, vascular compromise
and
CALIFORNIA
T
or
ENTEROCOLITIS*
Los Angeles County-USC
vaginal
a
is a 1,640 34 week
delivery
hemorrhage,
maternal
was
gram
male
gestation. complicated
probably of 6 were
due
to
abruptio placentae. Apgars obtained at i and 5 minutes. The infant had mild transient respiratory distress, treated by oxygen. Chest roentgenograms showed no evidence of hyaline membrane disease. An umbilical arterial catheter was placed on Day 0 and removed 48 hours later. On Day 2, blood-tinged stools were passed, and gastric residual was noted. The clinical condition otherwise remained normal. Oral feedings were discontinued, and the infant was placed
on
antibiotics.
gram showed of bowel and Medical
30!
332-47-60
following
Center,
An abdominal
roentgeno-
slight dilatation of multiple questionable pneumatosis Los Angeles,
California.
loops intesti-
John
Downloaded from www.ajronline.org by 113.160.225.166 on 06/21/16 from IP address 113.160.225.166. Copyright ARRS. For personal use only; all rights reserved
302
and
Mikity
FEBRUARY,
Extensive pneumatosis intestinalis in the distribution of the entire defects in the Hypaque enema examination produced by the collections
FIG.
colon. (B) Irregular of intramural gas.
I. (A)
nalis
on the
right
roentgenogram in On
side (Fig.
demonstrated
a linear
the
rectum.
Day
3,
ofthe abdomen. A lateral obtained 8 hours later collection of intramural
CASE
111.
a normal
Pl’
336-I
intestinal
gas
1-82
is
a
pattern
remained on Day negative. later.
1,290
gram
I .
4.
male
infant born following a 29 week gestation. The pregnancy was complicated by premature rupture of the membranes 3 days prior to onset of labor. Following vaginal delivery at in outside hospital, the infant had an episode of apnea, treated by positive pressure with mask and bag. Apgar scores were not obtained. The amniotic fluid was described as being mucopurulent. On admission to the nursery approximately i hour after delivery, respiratory grunting and hypothermia were noted. The infant was treated with
positive intravenous
course
of
transfusions An umbilical level of the
pressure
by mask
and
bag, placed
8 day Blood were given for a low hematocrit. arterial catheter was passed to the right common iliac artery and was fluids,
antibiotics
1975
and
for
started
on
amnionitis.
an
filling
maintained in place for less than 24 hours. Chest roentgenograms revealed nodular densities in the lower lungs consistent with mild hyaline membrane disease.
2)
was present. The clinical condition good and oral feedings were resumed By Day 7, the stools were hematest The infant was discharged 22 days
on
Victor
___
_.s_
gas
A. Richmond
the
The
respiratory
Oral
feedings
infant
distress were
developed
gastric residual large amount roentgenograms through
Day
testinal sent
resolved
begun
on
during
Day
abdominal
Day
2. However,
distention
with
and on one occasion vomited of greenish fluid. Abdominal over a 3 day period (Day 3)
showed
dilatation.
This
a nonspecific
adynamic
slight
was
generalized
thought ileus
a i
in-
to repregrade feedings
or a low
meconium blockage s-ndrome. Oral were discontinued for a 6 hour period on Day 3. The distention improved, and the oral feedings were resumed and tolerated well. In subsequent days, the infant fed well by gavage and gained weight. On Day 12, blood-tinged stools were passed. The abdomen remained soft and nondistended, and no vomiting or gastric residual was observed. Oral feedings were discontinued, and the infant was placed on antibiotics. An abdominal roentgenogram
tosis
scending dilatation.
intestinalis
and By
(I’ig.
3)
in
the
sigmoid Day
15,
demonstrated distribution
colon, without the pneumatosis
pneum of
a-
the debowel intes-
VOL.
No.
123,
Form
Benign
2
Enterocolitis
Necrotizing
of
303
had resolved. The clinical condition during this period was unremarkable. Oral feedings were resumed and by Day 20, the stools had become hematest negative. The infant was discharged at 8 weeks of age.
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tinalis
PF 346-62-69
is an 1,140 gram male following a 28 week gestation. Dewas by version extraction of a double breech presentation under general anApgars of 2 and s were obtained at i
CASE
IV.
infant
born
livery
footling esthesia.
and
minutes.
mask
for transient
cyanosis.
and
arterial catheters
were
admission
fant
had
the chest
mild
was
tachypnea
venous
4. Transfusions
given
on Days
crit.
The 8.
arterial
On
Day
However,
was
pressure
nal
distention,
and
A roentgenogram
was oral
normal.
The
oxygen
and
cent by
catheter
mask
was
of packed
there
by
venous
placed shortly after At this time the inand some retractions,
2.5 per
5 and catheter
oxygen
Umbilical
and
red
on
blood
only
a grossly
slight
feedings
of the
cells
bloody
abdomiwere
abdomen
FIG.
3. Case ni. Pneumatosis tribution of the descending
toler-
(Fig.
4)
demonstrated small and
slight to large bowel
pneumatosis
in
unchanged.
gastric
residual
and
served. biotics
Stools were
were begun,
in
4.
the
moderate
An
Case
the
colon. 13, the clinical status
were
findings
FIG.
Linear of intramural gas in the rectum.
moderate loops
intestinalis
the entire On Day
discontinued.
2.
intestinalis in the (usand sigmoid colon.
bag.
removed
6 for a low hematowas removed on
the infant passed
12,
stool. ated.
with
positive
umbilical
Day were Day
received
roentgenogram
treated
intermittent
The
infant
to the nursery.
but
infant
The
Iv.
distribution
dilatation of and extensive distribution
skin
hematest
and
radiologic
and
by Day
However,
poor
color
abdominal
feedings roen
15,
were
positive.
oral
of
obAnti-
were
tgenogra
Extensive pneumatosis intestinalis of the entire colon. Slight
dilatation
of the intestinal
loops.
m
to
John
304
A. Richmond
and
Victor On
Mikity
Day
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the
,
distention,
FEBRUARY,
infant
vomiting,
developed
and
1975
abdominal
lethargy.
Stools
were
initially blood-tinged and then hematest positive. An abdominal roentgenogram (Fig. c) demonstrated moderate dilatation of multiple loops of bowel with extensive pneumatosis intestinalis
and
portal
venous
gas.
The
infant
was
placed on antibiotics, and oral feedings were discontinued. By Day 5, the intestinal dilatation persisted, but the pneumatosis intestinalis and portal venous gas had resolved. Blood transfusions were given because of a drop in hematocrit from 49 per cent on Day o to 33 per cent on Day s. The clinical condition improved, and by Day 8 the intestinal gas pattern was normal. Stools became hematest negative on Day . The infant was discharged at 9 weeks of age.
CASE infant
gram female week gestation. A vaginal delivery followed artificial of amniotic membranes for low grade
normal rupture
RH Case v. Dilated lections of intramural
FIG.
.
showed
no
intestinalis On Day
bowel
intestinal gas, and
dilatation,
loops, bubbly colportal venous gas. but
pneumatosis
was again seen in the entire colon. i6, the stools became hematest nega-
tive, and there was incomplete resolution of the pneumatosis intestinalis. Transfusions of packed red blood cells were given as the hematocrit had dropped from 39 on day 9 to 27 on Day 15. Oral feedings were resumed on Day 19. An abdominal roentgenogram on Day 23 showed a normal intestinal gas pattern. The infant was discharged at 2 months of age. PU 350-60-18 infant born following spontaneous rupture CASE
prior
is a
V.
to delivery.
tion
Delivery
a of
30
1,480
week
female
gestation
membranes was
gram
by
24
cesarean
and
hours sec-
for breech presentation. Apgars of 2 and 6 were obtained at i and s minutes. The infant required positive pressure resuscitation with mask and bag and subsequently, 6o per cent oxygen by hood for respiratory distress during the first 3 days. There was no radiologic evidence of hyaline membrane disease. Umbilical venous and arterial catheters were placed on Day 0 and removed within 4$ hours and 72 hours,
respectively.
1l’
VI.
born
351-94-31
sensitization.
tanied
at
is
a 2,470
a 37
following
Apgars
of
s minutes.
8 and
9 were
ob-
given by mask and hood for transient respiratory distress. A chest roentgenogram was normal. An umbilical arterial catheter was placed on Day o and was removed on Day 2, because of vascular insufficiency to the left leg. This subsequently resolved. On Day 3, the infant developed abdominal distention and passed a blood-streaked stool. Abdominal roentgenograms (Fig. 6, A and B) revealed slight dilatation ofbowel loops, pneumatosis
I
and
intestinalis
Oxygen
on
the
right
abdomen, was
were
and portal venous placed on antibiotics, discontinued.
was
gas. and
side
of the
The oral
infant feedings
By Day , the abdomen was soft; the stools were hematest positive. Transfusion of packed red blood cells was given because of a drop in hematocrit from 38 per cent on Day 3 to 3 I per cent on Day . An abdominal roentgenogram revealed a normal intestinal gas pattern except for slight dilatation of some loops. On Day #{231}, a normal gas pattern was present. Oral feedings were resumed on Day 6, and the stools became hem atest negative on Day . The patient was discharged at is days of age.
CASE infant
VII.
born
P1
is a
357-48-30
following
a
30
week
I,740
gram
gestation.
male
The
VOL.
123,
No.
Form
Benign
2
of Necrotizing
Enterocolitis
305
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pregnancy was vaginal bleeding
complicated by an episode of and maternal fever 12 hours prior to delivery. Delivery was by cesarean section for placenta previa and transverse lie. Apgars of 8 and 10 were obtained at I and s minutes. The infant had no respiratory distress, and a chest roentgenogram was normal. An umbilical arterial catheter was passed and remained in place for 5 days. On Day 2, the infant developed abdominal distention and lethargy. Hematest positive stools were passed. An abdominal roentgeno-
gram (Fig. pneumatosis
7) demonstrated bowel dilatation, intestinalis involving the stomach
and intestinal domen, and
loops portal
on the right side of the abvenous gas. Oral feedings
Slight collections
Case
7.
FIG.
dilatation of intestinal loops, of intramural gas involving
VII.
curvilinear
the stomach and intestinal of the abdomen, and portal
were
discontinued,
and
loops
on
venous
the
the
right
side
gas.
infant
was
placed
on antibiotics.
The
following
day,
unremarkable
was
On Day
4, the
distended,
ative. present sumed
infant
and
the
for
was stools
gas pattern
slight
more
normal intestinal on Day 5, and oral on Day 6. The patient
dilatation.
active
became
A
days
28
the intestinal
except
and
hematest
less neg-
gas pattern was feedings were rewas discharged at
of age. In the 7 cases
Gomment.
presented,
all of the
infants
were premature by weight and gestation. Only i infant (Case ru) had hyaline membrane disease, and this was clinically mild. With the Cases
FIG. 6. Case
vi.
(A)
Portal
venous
gas.
(B)
of intestinal loops. Pneumatosis nalis on the right side of the abdomen.
latation
Slight di-
intesti-
development i,
of
and
ii,
except
for
the
The
remaining
III
necrotizing were
presence
of
cases
were
enterocolitis,
clinically blood
more
in
normal, the
stools.
symptomatic
with abdominal distention, lethargy, gastric residual, and vomiting, in addition to bloody or hematest positive stools. Blood and stool cultures were negative for pathogenic organ isms in all of the infants. Cases i and III demonstrated pneumatosis intestinalis only. Cases ii and IV had bowel dilatation in addition to pneumatosis intestinalis.
John
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306
A. Richmond
and
Cases v, VI and VII demonstrated a combination of bowel dilatation, pneumatosis intestinalis, and portal venous gas.
Victor
Significant
From the cases presented, it can be seen that bowel dilatation, pneumatosis intestinalis, and portal venous gas may be present in the neonatal period without progression to significant bowel necrosis. Because the radiographic appearance seen in our series ofcases is that usually associated with neonatal necrotizing enterocolitis and because of the clinical signs and symptoms related to the gastrointestinal tract, we believe it is justified to consider this group in the category of necrotizing enterocolitis. In those infants in whom bowel dilatation is present with pneumatosis intestinalis and sometimes portal venous gas, a definite prognosis cannot always be made. The majority of these cases will develop significant bowel necrosis. Three of the cases presented are examples which did not progress to significant necrosis. It is evident that the presence of portal venous gas is not an indication for surgical intervention in necrotizing enterocolitis. This decision should be based on the presence of a pneumoperitoneum or clinical deterioration of the infant. In those infants in whom pneumatosis intestinalis is present without bowel dilatation, the most likely prognosis is that of the benign form of necrotizing enterocolitis. This statement is based on our experience 78 last
cases
of
are examples may certainly
necrotizing
Two which
3 years. in
be
enterocolitis
of the cases the benign
bowel
benign
necrosis
form
John
A. Richmond,
1200
North
of
does
not
necrotizing
occur entero-
Box
necrotizing
California
90033
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R.
BELL,
J. J.
S., GRAHAM, Roentgenologic
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IEMPLETON,
J. H. Neonatal
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Ari.
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IHERAPY
X-ray Diagnosis. Year Book Medical pp. 15 18-1524.
and
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STEVENSON,
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JO!, KASSNER,
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E. G. NecroAM. NUCLEAR
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B. S., I’ELLER, M. R., changes following necrotizing enterocolitis in newborn. AM. J. ROENTGENOL., RAD. THERAPY & NUCLEAR MED., 1968, 103, 359-364.
RAiuxowITz,
and
9.
and
and
POCHACZEVSKV,
1971,
en-
terocolitis is nonspecific and may be seen in other entities in the neonatal period which produce bowel necrosis, such as mesenteric arterial or venous occlusion or intestinal volvulus.
Street
624
C’anad.
of
M.D.
State
Los Angeles,
suggested.
appearance
the
Seven cases are presented which can be placed in this category. The radiographic findings in this group include bowel dilatation, pneumatosis intestinalis, and portal venous gas. A benign prognosis may be suggested when pneumatosis intestinalis is present without bowel dilatation.
in
presented prognosis
The etiology for the benign form of necrotizing enterocolitis is unknown but maybe related to transient intestinal hy-poxia. Finally, it should be mentioned that the radiographic
1975
colitis.
DISCUSSION
the
FEBRUARY,
SUMMARY
in
with
Mikity
KRASNA,
WOLF,
I. Colonic
W. D., and SHANNON, M. P. Necrotizing enterocolitis: medical approach to treatment. Canad. M. A. 7., 1973, zoS, 573-476.
REID,
