The earliest radiographic findings in NEC may be dilation of the small bowel. The pattern suggests mechanical or aganglionic obstruction, most frequently in the form of multiple dilated loops of small bowel, but sometimes as isolated loops. Air fluid levels often are observed in the erect position. Commonly, intestinal loops will appear separated and then progresses to pneumatosis intestinalis in about 30% of infants studied, and about one-third of those with pneumatosis intestinalis will also have gas within the portal venous system of the liver (1,2).
A common finding is thickened bowel wall, bubbly appearance of the intestinal contents, and loops of unequal size. Free air ultimately may be identified within the peritoneal cavity of many infants with NEC who are not successfully treated. The site of perforation often is walled off, and in some infants with gas under the diaphragm the intestinal wall may be intact. Ultrasonography is helpful for distinguishing fluid from air. Doppler study of the splanchnic arteries early in the course of NEC can help distinguish developing NEC from benign feeding intolerance in a mildly symptomatic baby (45).
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