Neonatal Gastrointestinal Emergencies: A

Comprehensive Imaging Approach

Abstract
Neonatal gastrointestinal emergencies encompass a broad spectrum of conditions affecting the upper and
lower gastrointestinal tracts. Prompt diagnosis and treatment are crucial to minimize morbidity and
mortality. This article provides a detailed review of imaging modalities, including radiography, fluoroscopy,
ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI), highlighting their roles in
the diagnostic process. Key conditions such as esophageal atresia, pyloric stenosis, and Hirschsprung
disease are discussed with emphasis on their radiologic appearances and the appropriate imaging
techniques required for accurate diagnosis. This comprehensive approach aids clinicians in making timely
and informed decisions in the management of neonatal gastrointestinal emergencies.

Introduction
Neonatal gastrointestinal emergencies arise from various abnormalities that can occur anywhere along the
alimentary tract, from the esophagus to the colon. These emergencies can present with a range of
symptoms, from mild discomfort to life-threatening conditions requiring immediate intervention. Accurate
and prompt diagnosis is essential to reduce the risk of mortality and long-term morbidity. Imaging plays a
critical role in the diagnostic process, providing vital information that guides clinical decisions.

The primary imaging modalities used in the evaluation of neonatal gastrointestinal emergencies include
radiography, fluoroscopy, ultrasound, CT, and MRI. Each modality has specific indications and advantages,
and the choice of imaging technique is guided by the clinical presentation and suspected underlying
condition. This article provides a comprehensive overview of these imaging techniques and their
application in diagnosing common neonatal gastrointestinal emergencies.

Imaging Modalities and Techniques

Radiography
Radiography is often the first imaging modality employed in the assessment of neonates with suspected
gastrointestinal emergencies. A single supine anteroposterior (AP) view of the abdomen is usually the
initial examination. Additional views, such as left lateral decubitus or cross-table lateral, can help identify
ectopic air, air-fluid levels, and rectal gas.

Fluoroscopy
Fluoroscopy, including upper gastrointestinal series and contrast enema examinations, is critical for further
evaluation when initial radiographs are inconclusive. An upper gastrointestinal series is indicated for
abnormalities of the esophagus, stomach, or proximal small bowel, while a contrast enema is used for
evaluating the rectum, colon, or distal small bowel.

Ultrasound, CT, and MRI

Ultrasound is increasingly used, particularly for conditions like pyloric stenosis and necrotizing
enterocolitis. CT and MRI are typically reserved for problem-solving in complex cases due to their
limitations, such as the need for anesthesia and radiation exposure.

Upper Gastrointestinal Emergencies

In neonatal care, upper gastrointestinal emergencies require prompt and accurate imaging to guide
diagnosis and treatment. These conditions often present with specific radiographic signs that help
clinicians identify the underlying issue. The table below summarizes key upper gastrointestinal
emergencies, their initial imaging modalities, key findings, and further diagnostic techniques.

Initial Further
Imaging Key Imaging Imaging Diagnostic/Therapeutic
Condition Modality Findings Techniques Notes

Esophageal Radiography Gasless Bronchoscopy Prenatal diagnosis may

Atresia/Tracheoesophageal abdomen, include polyhydramnios.
Fistula inability to
pass NG tube

Pyloric Atresia Radiography "Single Prenatal Often associated with

bubble" sign ultrasound epidermolysis bullosa.

Hypertrophic Pyloric Ultrasound Thickened Gold standard for

Stenosis pyloric diagnosis, avoids
muscle, radiation.
elongated
channel

Duodenal Atresia Radiography "Double Diagnostic radiographs

bubble" sign often sufficient.

Duodenal Stenosis and Web Radiography Luminal Upper GI Upper GI series needed if
narrowing, series initial radiographs are
"windsock" inconclusive.
deformity

Malrotation Radiography Signs of Upper GI Urgent upper GI for

obstruction, series suspected midgut
abnormal volvulus.
bowel
positioning

Narrative for Upper Gastrointestinal Emergencies

Esophageal Atresia/Tracheoesophageal Fistula
Esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a common congenital anomaly
of the esophagus. It is often diagnosed prenatally if polyhydramnios is detected or postnatally when a
nasogastric tube cannot be passed into the stomach. Initial radiography will show a gasless abdomen if
there is no fistula. Bronchoscopy is essential for confirming the diagnosis and planning surgical repair.

Pyloric Atresia
Pyloric atresia is a rare condition where there is a complete obstruction of the pylorus, leading to a
distended stomach without distal gas, visible as a "single bubble" on radiography. This condition is often
associated with epidermolysis bullosa, and prenatal ultrasound can be helpful in identifying the anomaly.

Hypertrophic Pyloric Stenosis

Hypertrophic pyloric stenosis (HPS) involves the thickening of the pyloric muscle, leading to gastric outlet
obstruction. It typically presents with projectile vomiting in neonates. Ultrasound is the preferred
diagnostic tool, revealing a thickened pyloric muscle and an elongated pyloric channel. This avoids
radiation exposure compared to radiographic studies.
Duodenal Atresia
Duodenal atresia is characterized by a congenital closure of the duodenum, resulting in a "double bubble"
sign on radiography, which shows a distended stomach and proximal duodenum with no air beyond the
obstruction. This condition is often diagnosed through radiographs alone.

Duodenal Stenosis and Web

Duodenal stenosis and web present with luminal narrowing, which can be identified by radiography and
further confirmed through an upper gastrointestinal series if initial findings are inconclusive. The
"windsock" deformity is a characteristic finding.

Malrotation
Malrotation with midgut volvulus is a surgical emergency presenting with bilious emesis. Initial
radiographs may show signs of obstruction and abnormal bowel positioning. An urgent upper GI series is
critical to confirm malrotation and assess for volvulus, requiring immediate surgical intervention.

Lower Gastrointestinal Emergencies

Lower gastrointestinal emergencies in neonates can manifest through various imaging findings that are
crucial for accurate diagnosis and management. Conditions such as jejunoileal atresia and Hirschsprung
disease often require contrast studies for a definitive diagnosis. The table below provides an overview of
common lower gastrointestinal emergencies, their primary imaging modalities, key findings, and further
diagnostic techniques.

Initial Further
Imaging Key Imaging Imaging
Condition Modality Findings Techniques Diagnostic/Therapeutic Notes

Jejunoileal Radiography Multiple dilated Contrast Contrast enema helps exclude

Atresia bowel loops, air- enema colonic atresia.
fluid levels

Meconium Ileus Radiography "Soap bubble" Contrast Diagnostic and therapeutic;

appearance enema reveals small-caliber microcolon.

Meconium Radiography Diffuse peritoneal Ultrasound Typically does not require

Peritonitis calcifications contrast enema.

Colonic Atresia Radiography Multiple dilated Contrast Contrast enema identifies blind-
bowel loops, air- enema ending microcolon.
fluid levels

Functional Radiography Distal bowel Contrast Diagnostic and therapeutic;

Immaturity of obstruction enema clears meconium plugs.
the Colon pattern, meconium
plugs

Hirschsprung Radiography Distal bowel Contrast Contrast enema shows transition

Disease obstruction pattern enema, Rectal zone and altered rectosigmoid
biopsy ratio; biopsy confirms diagnosis.

Anorectal Radiography Imperforated anus, Contrast Pre-surgical evaluation of

Malformations distal bowel studies, anatomy and fistulas.
ending blindly Perineal
ultrasound
 Initial Further
Imaging Key Imaging Imaging
Condition Modality Findings Techniques Diagnostic/Therapeutic Notes

Bowel Ultrasound Layered Preferred modality due to

Duplication appearance of cyst characteristic layered
Cysts wall appearance.

Necrotizing Radiography Abnormal bowel Ultrasound Ultrasound evaluates bowel wall

Enterocolitis gas patterns, thickness, perfusion.
pneumatosis,
portal venous gas

Narrative for Lower Gastrointestinal Emergencies

Jejunoileal Atresia
Jejunoileal atresia results from in utero mesenteric ischemic events, leading to multiple dilated bowel loops
and air-fluid levels on radiography. A contrast enema is essential to exclude colonic atresia and to
determine the level of obstruction. This assists in surgical planning.

Meconium Ileus
Meconium ileus, often associated with cystic fibrosis, is characterized by the obstruction of the terminal
ileum by thick meconium. Radiographs show a "soap bubble" appearance due to the mixture of gas and
meconium. A contrast enema is both diagnostic and therapeutic, revealing a small-caliber microcolon and
aiding in clearing the obstruction.

Meconium Peritonitis
Meconium peritonitis occurs due to intrauterine bowel perforation, leading to peritoneal calcifications that
are visible on radiography. Ultrasound may further delineate the extent of calcifications and associated
findings. Typically, contrast enema is not required unless there is a need to evaluate the bowel anatomy.

Colonic Atresia
Colonic atresia is a rare cause of lower bowel obstruction, presenting with multiple dilated bowel loops
and air-fluid levels on radiography. A contrast enema is crucial for identifying a blind-ending microcolon
and confirming the diagnosis. It also helps to exclude Hirschsprung disease before surgical intervention.

Functional Immaturity of the Colon

Previously known as small left colon syndrome or meconium plug syndrome, this condition involves
transient colonic dysmotility. Radiographs show distal bowel obstruction with meconium plugs, and a
contrast enema is both diagnostic and therapeutic, clearing the plugs and confirming the diagnosis.

Hirschsprung Disease
Hirschsprung disease is caused by the absence of parasympathetic ganglia in the distal bowel, leading to
functional obstruction. Radiography typically shows a distal bowel obstruction pattern. A contrast enema
helps identify the transition zone and altered rectosigmoid ratio, while a rectal biopsy confirms the
absence of ganglion cells.

Anorectal Malformations
Anorectal malformations encompass a spectrum of congenital anomalies affecting the anus and distal
rectum. Radiographic and contrast studies are essential for delineating the anatomy and any associated
fistulas. Pre-surgical evaluation often includes perineal ultrasound.

Bowel Duplication Cysts

Bowel duplication cysts are rare congenital anomalies that present variably depending on their size and
location. Ultrasound is the preferred imaging modality due to its ability to demonstrate the characteristic
layered appearance of the cyst wall.
Necrotizing Enterocolitis
Necrotizing enterocolitis (NEC) is a serious condition characterized by inflammation and necrosis of the
bowel. Radiographic findings include abnormal bowel gas patterns, pneumatosis, and portal venous gas.
Ultrasound can further evaluate bowel wall thickness, perfusion, and the presence of free fluid or
abscesses.

Conclusion
Neonatal gastrointestinal emergencies require prompt and accurate diagnosis to minimize morbidity and
mortality. A comprehensive approach to imaging, utilizing radiography, fluoroscopy, ultrasound, CT, and
MRI, is essential for effective diagnosis and management. Understanding the radiologic appearances of
common conditions, such as esophageal atresia, pyloric stenosis, and Hirschsprung disease, allows
clinicians to make informed decisions and provide timely interventions. This article serves as a valuable
resource for clinicians involved in the care of neonates with gastrointestinal emergencies.

Citation
Stanescu, A. L., Liszewski, M. C., Lee, E. Y., & Phillips, G. S. (2017). Neonatal Gastrointestinal Emergencies:
Step-by-Step Approach. Radiologic Clinics of North America, 55(4), 717-739. doi:10.1016/j.rcl.2017.02.010.