0:01

So here we have an infant who is seven days old,

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is a premature infant

0:05

and there is clinical concern for an abdominal abnormality.

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So this supine portable abdomen radiograph demonstrates a

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opal tooth that, uh, terminates in the gastric body.

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Um, I'm gonna zoom in.

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So you can see this very abnormal

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gas in an abnormal location.

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So I think necrotizing enteritis can be a challenging

0:26

diagnosis, uh,

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or rather pneumatosis intestinal can be

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a challenging diagnosis.

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But once you start to see these loosen lines start to kind

0:35

of coalesce and form these lines at the periphery of a loop

0:39

of bowel, you can be confident

0:40

that this is pneumatosis intestinal.

0:42

So, um, this is a diagnosis of medical, um,

0:46

necrotizing enteritis because we have pneumatosis intestinal

0:49

and it's pretty extensive.

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Um, we'll just zoom out and make sure.

0:54

Um, we will look for portal venous gas

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and then we'll look for any supine evidence

0:58

of pneumoperitoneum.

0:59

Um, this abnormal lo

1:01

of gas here looks like this could be gas in the main portal

1:04

Vein, um,

1:06

this patient does have a left lateral decubitus view.

1:10

Um, to help us be confident

1:11

that there is no pneumoperitoneum so concerned, uh,

1:15

we have pneumatosis intestinal compatible

1:17

with necrotizing enterocolitis.

1:19

We have a concern for possible portal venous gas,

1:23

but we don't have evidence

1:24

of pneumoperitoneum on the left lateral

1:26

decubitus radiograph.

1:29

So this patient already had a diagnosis on x-ray

1:32

of medical necrotizing enterocolitis,

1:34

but clinically they were concerned

1:36

that this was gonna be surgical NEC.

1:38

So they asked us to go onto ultrasound to look

1:40

for any complex fluid collections.

1:42

So this is an unfortunate great example of

1:46

what necrotizing intra colitis looks like at ultrasound.

1:49

So, um, the first thing that I'll point out is, uh, the

1:53

pneumatosis intestinalis that we diagnose at

1:56

x-ray is indeed confirmed sonographic.

2:00

So we have these genic foci in the um, uh,

2:05

non-dependent wall of this loop of bowel.

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We also can see that there is portal venous gas.

2:11

So that's these genic foci here at the porta hetus.

2:15

Um, we'll keep going. We can see that there.

2:17

Um, so this is a loop of bowel

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where we see little tiny bubbles of, uh, gas within the wall

2:22

of, of this loop of bowel.

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We do have intraluminal gas blocking our view

2:27

of the dependent aspect of those bowel loops.

2:30

So we'll keep going and see if we can see any loop of loops

2:33

of bowel where we can see not only the non-dependent wall,

2:35

but we can see the dependent wall of the bowel as well.

2:39

Um, and here we can see, um,

2:41

we don't have bowel gas within the aluminum obscuring the

2:45

dependent, uh, loop of bowel.

2:46

So we have these genic foci not only in the anterior aspect

2:50

of this loop of bowel, but we can see that there's um, uh,

2:54

foci of gas within the dependent aspect of this,

2:57

this loop of bowel here as well.

2:59

This is just academic heterogeneous contact within the

3:01

lumen of that loop of bowel.

3:02

So pneumatosis intestinal is definitely

3:05

confirmed in this infant.

3:07

Um, uh, here's another great example

3:10

of pneumatosis intestinalis at ultrasound.

3:12

So we have these academic foci anteriorly

3:15

and within the wall posteriorly of this loop of bowel here.

3:19

So, um, definitely pneumatosis intestinalis, um,

3:23

on this ultrasound image.

3:24

So their question of is this perforated NEC?

3:27

We'll have to see. Do we see any complex fluid collections?

3:30

So far I'm seeing a ton of pneumatosis intestinalis,

3:33

but no focal fluid collections,

3:35

no complex fluid collections.

3:38

Um, and I don't see any peritoneal stripe signs.

3:40

This just looks like simple ascites to me.

3:43

Um, over here in this right side of the abdomen.

3:47

So let's go to our cine so we can be confident

3:49

that we don't see any, um, uh, pneumoperitoneum

3:54

or focal fluid collections.

3:56

So here is where the stenographer is

3:57

mowing the lawn, if you will.

3:59

So we take our probe on gray scale,

4:01

transverse linear high frequency images with superficial,

4:04

um, detailed settings.

4:06

We're going superior to inferior.

4:08

I'm gonna let this play again.

4:10

Um, I look anterior to the liver looking

4:12

for any pneumoperitoneum.

4:13

I do see some simple as ascites inferior to the liver,

4:16

but I don't see any peritoneal stripe signs.

4:19

I lose a lot of the abdomen because of biogas obscuration.

4:22

This is urinary bladder.

4:23

I don't see any focal fluid collections.

4:26

This is a syne of the left side of the abdomen, kind

4:28

of in a similar, similar um, technique,

4:31

but looking at the leftward aspect

4:33

of the patient, here's left kidney.

4:35

We see crazy pneumatosis intestinalis,

4:37

but I don't see any focal fluid.

4:39

I don't see a peritoneal stripe sign to make me think

4:41

that there's pneumoperitoneum.

4:43

I'll let that play one more time

4:45

'cause I do see some simple ascites in the lower pelvis at

4:50

the end of this, um, sene

4:54

here, this little triangle of fluid just

4:57

above the urinary bladder,

4:58

but it doesn't look particularly complex or septated.

5:01

It just looks like, um,

5:03

simple free fluids mean let's find a midline view.

5:07

Oh, let's see if we can see that portal.

5:08

Venous gas, actually, for better.

5:11

Yeah, so, um, this is that fruit pulp appearance

5:13

of portal venous gas.

5:14

You can see centrally in the liver.

5:16

These genic foci of portal venous gas.

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Um, I don't see frank like large mobile,

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uh, gas bubbles Moving through this, um, portal vein.

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Typically what we wanna do is we'll put our spectral gate

5:32

over the main portal vein.

5:34

And when you have portal venous gas, it is this classic, um,

5:37

spectral doppler blip as the air bubbles go by,

5:40

which I don't think was done in this case.

5:41

But we de we definitely have portal venous gas within,

5:44

within the parenchyma itself of this, um, liver.

5:49

Let's find the midline together

5:53

so we don't have midline, um, transverse

5:56

Cinematic images to help us, uh,

5:58

look at the central aspect of the abdomen,

6:01

but we could see a, a good deal

6:02

of the abdomen on the right-sided

6:04

and left-sided transverse syns.

6:06

Um, so we won't send our sonographer back upstairs to,

6:09

to image this, to image this baby.

6:11

Um, and we will say, uh,

6:13

we have confirmed the radiographic findings

6:16

of just medical NEC.

6:17

No evidence of perforation at this time.