WIDI - P4) Gastrointestinal complications in a preterm infant following enteral feeding

P4) Gastrointestinal complications in a preterm infant following enteral feeding

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a pediatric patient with abdominal pain.
Review the DDx considerations in a pediatric patient with abdominal pain.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a pediatric patient with abdominal pain.

History

A 5-week-old baby born at 29 weeks gestational age was admitted to the neonatal ICU for prematurity and respiratory distress syndrome. As of two days ago, his feeds have been progressively increased and are now exclusively enteral. However, over the 24 hours, he has developed increased irritability, bilious vomiting, abdominal distension, and bloody stools.

Physical Exam

BP: 71/48 mmHg, HR 155 bpm, RR 42 bpm, Temp 98F rectally, O2 saturation 96%. Abdomen distended, firm, and tender to palpation.

Labs

WBC: 22,000 cells/uL (ref: 5,000-21,000cells/uL); Lactic acid: 4.2 mmol/L (ref: 0.3-2.2mmol/L); Na: 128 mEq/L (ref: 136-145 mEq/L); K: 2.8 mEq/L (ref 4-6.2 mEq/L); Cl: 95 mEq/L (ref 95-105mEq/L)

Provisional Diagnosis

Select the Dx you believe is most appropriate

Gastroenteritis

Necrotizing enterocolitis

Meconium aspiration

Milk protein intolerance

The premature infant, who presents with worsening abdominal distension and tenderness, leukocytosis, and lactic acidosis after recently starting enteral feeding, is most likely suffering from necrotizing enterocolitis.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

This case necessitates urgent evaluation and management due to the risk of bowel ischemia and sepsis associated with necrotizing enterocolitis.

First Imaging Study

What is the first imaging study you will order?

Abdominal ultrasound

Abdominal X-Ray

Abdominal CT with oral contrast

Abdominal CT without contrast

An abdominal X-ray if a quickly obtainable imaging modality that minimizes radiation exposure.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Xray Case

The bowel loops are distended

Yes

There is diffuse abdominal loop distension.

This child has a foreign body in the abdomen.

Yes

No foreign bodies are present. An NG tube is appropriately positioned. The other lines represent EKG leads.

There is evidence of pneumatosis

Yes

The presence of air along the bowel walls and portal venous gas indicates pneumatosis.

There is free air

Yes

Free air is not evident in this view; however, a left lateral decubitus X-ray would provide a better assessment.

View Report

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Second Imaging Study

What is the next imaging study you will order?

Abdominal CT w/ oral contrast

Abdominal CT w/o contrast

Abdominal ultrasound

None

No further imaging is needed as the clinical presentation and X-ray is strongly consistent with the diagnosis.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Infectious enteritis

Necrotizing enterocolitis

Spontaneous bowel perforation

Milk protein intolerance

The patient’s clinical presentation and imaging findings are consistent with necrotizing enterocolitis.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

This patient requires urgent evaluation and management due to the risk of bowel ischemia and sepsis associated with necrotizing enterocolitis.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a 5-week-old baby born at 29 weeks gestational age, now presenting with necrotizing enterocolitis following the initiation of enteral feedings. The feedings should be discontinued, and the patient should be started on IV fluids to correct their metabolic abnormalities resulting from vomiting. Broad-spectrum antibiotics should be administered, and gastric decompression should be continued. Pediatric surgery should be consulted for further evaluation and management.

Lessons Learned:
- A sudden change in feeding intolerance is a common presenting symptom of necrotizing enterocolitis.
- Otherwise, patients may be present with abdominal distention, bilious vomiting, and bloody stools are common presenting symptoms.
- Abdominal radiography is the primary imaging modality for identifying necrotizing enterocolitis and its sequelae, such as pneumoperitoneum.
- Key radiographic findings include pneumatosis intestinalis, which presents as linear or bubbly lucencies along the bowel wall, and portal venous gas, which appears as branching, tubular lucencies extending to the liver periphery.
- Serial abdominal radiographs can help monitor the response to medical management, disease progression, and the need for surgical intervention.
- Serious complications following NEC may include extensive bowel ischemia and sepsis.

Socioeconomic Factors: Advanced maternal age, long maternal working hours, and high emotional stress have all been associated with an increased risk for premature birth and, consequently, a higher risk for necrotizing enterocolitis.

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