Worsening enterocolitis in neonates: diagnosis by CT examination of urine after enteral administration of iohexol

The Duke Abdominal Assessment Scale: initial experience

Plain abdominal radiographs are the current standard imaging modality of choice in the evaluation of patients with clinically suspected necrotizing enterocolitis. The time interval between radiographic exams varies with the severity of disease and may range from every 6 h to every 24 h. Radiographs are often also obtained at any point of acute clinical deterioration. Evaluation of the abdominal radiographic series is critical as the findings may alter patient management and can be an indication for surgical intervention. For these reasons, it is essential that the radiographic findings are communicated to the referring neonatologist in a clear and consistent manner. Inherent variability and lack of consistency in radiology reporting makes it difficult for the referring clinician to incorporate radiographic reports into his/her treatment algorithm. Assigning abdominal radiographic findings in necrotizing enterocolitis to a numerical scale that increases as the disease progresses provides objective terminology in lieu of subjective descriptors and may facilitate communication to our clinical colleagues. With this task in mind, the Duke Abdominal Assessment Scale was created as a 10-point numerical scale of plain film bowel gas pattern findings designed to reflect progressive disease and increased certainty of the diagnosis of necrotizing enterocolitis.

Radiographic predictors of disease severity in neonates and infants with necrotizing enterocolitis

OBJECTIVE

The objective of our study was to validate a radiographic scale, the Duke abdominal assessment scale (DAAS), as a tool for predicting the severity of disease in neonates and infants with suspected necrotizing enterocolitis (NEC).

MATERIALS AND METHODS

Study group patients (n = 43) underwent at least two two-view abdominal radiographic series within 48 hours of surgical intervention for suspected NEC complications. Control group patients (n = 86) were patients with suspected NEC who did not undergo surgery for suspected NEC complications. DAAS scores were assigned by two pediatric radiologists with 20 and 6 years' experience.

RESULTS

The initial radiographs of 26 of 43 (60.5%) patients in the study group showed fixed bowel loops (10/43, 23.3%), highly probable or definite pneumatosis (9/43, 20.9%), or portal venous gas (7/43, 16.3%). These findings had progressed to pneumoperitoneum on the follow-up series in 20 (46.5%) study group patients. Among the control group, three patients (3.5%) had highly probable or definite pneumatosis, and none had fixed bowel loops, portal venous gas, or pneumoperitoneum. Patients with higher DAAS scores were more likely to undergo surgical intervention than patients with lower scores (odds ratio, 1.69; 95% CI, 1.40-2.03). A receiver operating characteristic curve analysis showed good overall performance (c statistic = 0.83) for predicting eventual surgical intervention in the study group with higher DAAS scores.

CONCLUSION

The DAAS provides a standardized 10-point radiographic scale that increases with disease severity when using need for surgical intervention as a surrogate for severe NEC. For every 1-point increase in the DAAS score, patients were statistically significantly more likely to have severe disease as measured by need for surgical intervention.

Peritoneography in the assessment of peritoneal cerebrospinal fluid absorption potential for distal ventriculoperitoneal shunt catheter placement: technical case report

OBJECTIVE AND IMPORTANCE

Distal ventriculoperitoneal shunt failure has been associated with absorption failure secondary to previous peritonitis. This assumption has caused surgeons to seek alternate sites for distal catheter placement. We propose that the absorptive potential of the peritoneal cavity should be assessed before that site is discounted for catheter placement.

CLINICAL PRESENTATION

The case of a 14-month-old male patient is presented, demonstrating multiple ventriculoperitoneal shunt placement procedures and a diagnostic dilemma with respect to distal shunt placement. Peritoneography was performed to demonstrate peritoneal fluid absorption, allowing subsequent placement of a new distal shunt catheter with good clinical results.

TECHNIQUE

Using aseptic technique, a 24-gauge spinal needle was inserted in the midline of the abdomen and water-soluble contrast material was instilled. Delayed radiographs delineated peritoneal adhesions and demonstrated renal excretion of the contrast material, confirming peritoneal absorption.

CONCLUSION

The peritoneal cavity remains the site of choice for distal shunt catheter placement. If failure of peritoneal cerebrospinal fluid absorption is suspected as a cause of shunt failure, then peritoneography with water-soluble contrast material may be safely used to demonstrate the adequacy of fluid absorption before a secondary site is chosen.