0:00

This was a six day old infant who, uh, came to imaging

0:04

for an indication of endotracheal tube placement.

0:07

So they just wanted us to confirm that the, um,

0:09

support devices were all in the right position.

0:11

So endotracheal tube looks appropriate,

0:13

even though we have right upper lobe collapse in this

0:16

infant, the anter tube looks appropriately positioned,

0:19

projecting over the gastric body.

0:21

And then we have this umbilical venous catheter, which, um,

0:24

has a little bit of an undulating course, um, in the liver.

0:28

But the tip is projecting over

0:30

probably the high ductus noum level.

0:32

So just a little bit on the low lying side.

0:34

This is a urinary bladder catheter.

0:37

So this balgas pattern is abnormal, mostly

0:39

because we don't have a lot of bowel gas.

0:42

Um, so it's hard to say what's going on.

0:44

The loops of bowel that are air-filled are not

0:46

particularly dilated.

0:48

We don't have, um, pneumatosis, intestinalis.

0:51

I don't see portal venous gas,

0:52

and I certainly don't see any pneumoperitoneum on

0:55

this supine view.

0:58

So clinically this patient, um,

1:00

develop the clinician started to be concerned

1:02

that there was, um, some ab abnormality

1:05

of this patient's abdomen.

1:06

So they asked us to go to ultrasound next.

1:09

So on the first images were starting in the

1:11

right upper abdominal quadrant.

1:12

We do see that there is some abnormal, uh,

1:14

but simple looking ascites on these first images.

1:18

But then, um, as we're going more inferiorly into the

1:20

abdomen, we see this very large amount of multiloculated,

1:25

multi septated, very complex fluid in, uh,

1:28

it looks like we're in the right upper abdominal quadrant.

1:31

Um, here we're in the transverse plane,

1:33

midline upper abdomen.

1:34

We have this very large looking ated,

1:37

multi septated fluid collection in this, um,

1:40

in the abdomen of this infant.

1:42

So this is one where, let's just go to the CNAs

1:44

where we can see what the heck is going on.

1:46

Why is this here? So we're starting, uh, we have some,

1:51

uh, mi mislabeled images.

1:54

Don't judge the sonographer here.

1:55

It looks like I scan this patient where the, um,

1:58

transducer looks like it might be in the right, uh, abdomen,

2:00

but here it's labeled midline.

2:02

So we're going superior gray scale transverse, uh,

2:06

in superior to inferior.

2:07

We are in the right upper abdomen

2:09

because this is the, the liver.

2:11

So as we go superior to inferior number one,

2:13

we have some abdominal wall thickening,

2:15

which has been described in the setting

2:17

of necrotizing enteritis.

2:19

We have this very complex fluid, um, in the right abdomen

2:23

as we extend from the mid abdomen into the lower abdomen.

2:27

A huge amount

2:29

of debris containing mobile fluid in this right lower

2:32

abdominal quadrant extending into the midline upper pelvis.

2:36

This is urinary bladder here, so this is a large amount

2:39

of basically abscess, um, filling the, um,

2:43

abdominal cavity of this infant.

2:46

You're actually midline going superior to inferior.

2:49

Not only do we again demonstrate this multiloculated,

2:52

multi septated, uh, peri hepatic fluid, but look closely.

2:57

We have these bubbles of gas

2:59

At the, uh, superficial aspect of the abdominal cavity.

3:02

So this is frank pneumoperitoneum.

3:04

So multiloculated in tri abdominal abscess plus,

3:08

um, pneumoperitoneum.

3:09

On these images here, you can see there's even more gas.

3:12

So this is, uh, perforated, uh, bowel perforation

3:16

with large ated fluid collection

3:19

and frank pneumoperitoneum that we see on this ultrasound.

3:23

Let's look at the left upper abdominal quadrant just

3:26

to complete our, um, lawn mowing of, uh,

3:29

of ultrasound imaging of the abdomen.

3:32

And we're gonna get some, um, bowel gas obscuration from uh,

3:37

gas within the stomach,

3:38

but again, here is additional very complex genic,

3:42

multi septated fluid in the abdomen.

3:45

Um, we see part of spleen here as we extend inferiorly.

3:50

Tons of very abnormal, uh, uh, intraabdominal fluid.

3:55

So again, uh, bowel perforation that, um,

3:58

we can easily see on ultrasound.

4:00

But at x-ray, just like looks like a gas,

4:02

a mostly gas less abdomen,

4:04

I'm sure on follow-up radiographs.

4:06

If we got to view imaging, we would be able to see this, uh,

4:10

this new peritoneum on x-ray in addition to, on this,

4:13

this ultrasound, this unfortunate patient.