Characteristic Radiological findings in Preterm Infants with Missed Intestinal Perforation

BACKGROUND: Pneumoperitoneum on radiological imaging is typical in intestinal perforation in necrotizing enterocolitis [NEC]. However, it is not seen in all cases and intestinal perforation is missed on occasions. We present a series of preterm infants with characteristic x-ray findings that on exploration revealed missed intestinal perforation. METHODS: Retrospective review of neonates with intra-operative diagnosis of intestinal perforation which was missed on x-ray abdomen over a period of 6 months is being presented here. RESULTS: Three neonates born at 24 (24-30) weeks of gestation were identified. PDA was noted in all 3 patients and they required ventilator and inotropic support. Feeds were commenced at 5 (2-7) days of life. All three patients were treated for NEC. Surgical opinion was sought in view of localized gas shadow in a fixed position seen on repeated x-rays in all three patients. All three patients had laparotomy and small bowel resection with ileostomy formation at a mean age of 26 (24-46) days. Intra-operatively, small bowel perforation and adjacent pseudocysts filled with air and intestinal contents were noted in all 3 patients. Post-operatively full feeds were established in all patients. CONCLUSION: In premature infants with NEC, intestinal perforation can be missed on occasions. Our patients interestingly, developed characteristic abdominal x-ray findings that in our experience should prompt for surgical intervention.