Pediatr Radiol (2013) 43:318329 DOI 10.

1007/s00247-012-2573-1

REVIEW

A pattern-based approach to bowel obstruction in the newborn

Charles M. Maxfield & Brett H. Bartz & Jennifer L. Shaffer

Received: 22 June 2012 / Revised: 21 October 2012 / Accepted: 29 October 2012 / Published online: 12 December 2012 # Springer-Verlag Berlin Heidelberg 2012

Abstract Intestinal obstruction is common in newborns, and the radiologist plays a critical role in the care of these children. Diagnosing and managing the potentially obstructed newborn can be challenging, especially given the myriad underlying pathologies that range from benign to acutely life-threatening. A familiarity with the most common diagnoses is essential, but equally important to the radiologist is a systematic approach to management of the child in this setting. We propose an approach based on the recognition of eight radiographic patterns, five upper gastrointestinal examination (UGI) patterns and four contrast enema patterns. Recognition of these patterns directs further imaging when necessary and allows triage of children who can be managed medically, those requiring elective or urgent surgery and those requiring emergent surgery. Keywords Newborn . Neonatal . Obstruction . Gastrointestinal

include surgical and non-surgical causes ranging from the benign and nearly universal gastroesophageal reflux (GER) to life-threatening midgut volvulus [1]. In between the benign and the life-threatening are myriad etiologies of vomiting that produce different patterns on abdominal radiographs, contrasted upper gastrointestinal examination (UGI), and contrast enema. A familiarity with these patterns allows triage of cases that can be managed medically, those requiring elective surgery and those requiring emergent surgery. We present a pattern-based approach to the workup and management of the vomiting newborn. Through identification of eight patterns on abdominal radiograph, five patterns on UGI and four patterns on contrast enema, the radiologist can competently and confidently manage this common and potentially life-threatening clinical presentation.

Clinical presentation Introduction The radiologist plays a crucial role in the diagnosis and management of the vomiting newborn. This common and potentially life-threatening presentation is not limited to childrens hospitals. All radiologists must be familiar with the workup and management of potential bowel obstruction in the newborn. Etiologies of vomiting in the newborn
CME activity This article has been selected as the CME activity for the current month. Please visit the Society for Pediatric Radiology Web site at www.pedrad.org on the Education page and follow the instructions to complete this CME activity. C. M. Maxfield (*) : B. H. Bartz : J. L. Shaffer Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710, USA e-mail: charles.maxfield@duke.edu

Vomiting newborns sometimes present with additional signs and symptoms, such as feeding intolerance, abdominal distension, failure to pass meconium and peritoneal signs [2]. The symptoms do not reliably discriminate the causes of vomiting, although they can provide clues to the underlying etiology. Vomiting typically presents earlier with proximal obstructions than it does with more distal obstructions [3]. Duodenal atresia, for example, typically presents with the first feeding. The various causes of duodenal stenosis, whether intrinsic or extrinsic, present at more variable times, depending on the degree of stenosis. Distal obstructions (ileal and colonic) progress over the first 2448 h of life, often with more abdominal distension [2]. Midgut volvulus presents more variably, 50% during the first week and 60% by the end of the first month [2], often with a sudden onset of bilious vomiting after initially tolerating feeds.

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The bilious or non-bilious character of the vomiting is not a reliable discriminator for the presence of midgut volvulus. Most neonates with bilious emesis do not, in fact, have midgut volvulus [2]. The presence of bile simply reflects that the obstruction is below the ampulla of Vater. For instance, the vomiting in 70% of cases of duodenal atresia is bilious [3], and in distal (ileal and colonic) obstructions bilious vomiting [4] typically develops over hours to days. Meconium passage can provide additional clues to diagnosis. Normal newborns pass meconium in the first 24 h of life. Non-passage of meconium suggests a complete distal obstruction. Infants with Hirschsprung disease or functional obstructions might pass small amounts of meconium [5]. Similarly, the surgeons physical exam is not always a reliable discriminator. Even in cases of midgut volvulus, the abdomen is typically soft and non-tender until ischemia develops [2]. These relatively benign symptoms and physical exam findings prior to the onset of catastrophic bowel infarction justify a high index of suspicion and explain the central importance of the radiologist in managing the vomiting infant. With near-universal utilization of prenatal US screening, many congenital bowel obstructions are detected in utero [6]. Duodenal atresia, as manifested by a fluid-filled double bubble plus polyhydramnios, is more reliably detected than duodenal stenosis, malrotation and distal obstructions [7]. Pitfalls in the diagnosis of congenital obstructions are well documented and necessitate a post-natal imaging workup before surgery is contemplated [6].

Double bubble (Fig. 1) The true double bubbletwo upper abdominal gas bubbles, one on each side of the midline, and no distal gascan be considered diagnostic of duodenal atresia (Fig. 2) [9]. A UGI is unnecessary, both because this pattern is highly specific for duodenal atresia and because contrast (barium or iodinated) will not characterize the abnormality any better than does air. Because the obstruction caused by duodenal atresia is already long-standing at birth, the proximal duodenum is markedly dilated. This is in contradistinction to midgut volvulus, an acute obstruction that does not distend the duodenum significantly. The treatment for duodenal atresia is elective surgical repair. The critical question, however, is whether this pattern warrants any concern for midgut volvulus, which would necessitate emergent, rather than elective, surgery. There is considerable debate in the literature concerning whether midgut volvulus needs to be excluded in the setting of a newborn with a double bubble, because of concern that midgut volvulus could either produce a double bubble pattern [10] or complicate duodenal atresia [11]. Some believe such concern is unwarranted [12, 13]. What is undeniable is that if air is not passing distal to the duodenum, neither will contrast material; a UGI would not rule out malrotation. The single bubble (Fig. 1) The true single bubble, with no gas beyond a distended stomach, is characteristic of gastric (antral or pyloric) atresia [14]. It is important to note, however, that gastric atresia is exceedingly uncommon. More often, this pattern is characterized by a stomach that is partially decompressed by vomiting or a nasogastric tube, with no gas distally. In such cases, the pattern must be considered incompletely characterized. Frequently, a subsequent radiograph will reveal better distension. If not, the pattern might be fully characterized by a portable radiograph obtained following insufflation of the stomach with approximately 1020 ml of air through the nasogastric tube. One of three patterns will then become manifest, two of which establish diagnoses and obviate UGI evaluation: (1) a single bubble with distal gas (discussed below), which should prompt an emergent UGI; (2) a true double bubble, diagnostic of duodenal atresia, an indication for elective surgery (Fig. 3); (3) a true single bubble, distended and without any distal gas, a finding indicative of a complete gastric outlet obstruction, such as the rare gastric atresia. Triple bubble (Fig. 1) If confidently identified, this pattern is indicative of jejunal atresia [15], with dilation of the stomach,

Eight patterns on radiographs: definitions The postnatal imaging workup of the vomiting infant often begins with an abdominal radiograph. We propose that recognition of the eight patterns on the frontal supine abdominal radiograph shown in Fig. 1 helps narrow the differential diagnosis and, more important, triage the neonate with bowel obstruction to the next phase of management either additional imaging or admission to the medical or surgical team for treatment.

Significance of the eight patterns and associated management Normal (Fig. 1) A normal abdominal radiograph might seem reassuring in this setting until one realizes that many cases of midgut volvulus present with a normal abdominal radiograph [8]. If the vomiting is bilious or if there is another reason to suspect malrotation with midgut volvulus, the workup should proceed to UGI.

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Fig. 1 The eight radiographic patterns. a Normal. Gas is distributed uniformly throughout non-dilated stomach and bowel. The L1 interpedicular distance can be used as an internal standard for the upper limits of normal for bowel distension. b The double bubble. This pattern consists of two large rounded lucencies (bubbles) in the upper abdomen, with no distal gas. The left-side bubble is larger and more superiorly located. The right-side bubble is slightly smaller but clearly distended, with its epicenter to the right of the spine. c The single bubble. Gas is limited to the stomach. The stomach may be distended or may be decompressed by an enteric tube or vomiting. The key to recognizing this pattern is the absence of any gas distal to the stomach. d Triple bubble. There are three lucencies in the upper abdomen. The third bubble is dilated and is often oriented horizontally. There is no gas distal to the three large bubbles, which rarely extend below the

level of the iliac crests. To assign this pattern with confidence, the third gas bubble must be contiguous with the more superior bubbles. e Single bubble with distal gas. Gas is present in the stomach, which is sometimes distended. There is also a small amount of gas distal to the stomach in a limited number of decompressed bowel loops. f Double bubble with distal gas. This pattern implies the presence of gas distal to an otherwise classic double bubble pattern. Distal gas is variable in amount, but distal loops are typically decompressed. g Diffusely dilated loops. In this pattern, dilated, non-separated bowel loops fill the distended abdomen and extend into the pelvis. h Dilated, scattered bowel loops. This pattern is characterized by bowel loops that are mildly dilated but noncontiguous, featureless in appearance and scattered randomly throughout the abdomen and pelvis

duodenum and a jejunal bowel loop just proximal to the atretic segment (Fig. 4). One might argue that the confident recognition of this pattern obviates UGI examination, but if all three loops are not distended, this pattern is easily confused with other radiographic patterns that necessitate UGI to exclude malrotation and midgut volvulus. Many surgeons also request a contrast enema to exclude an additional colonic atresia (which would change surgery) or meconium ileus (which might obviate surgery). A search for additional atresias is reasonable because jejunal atresia is thought to be most often secondary to a vascular insult [16], which can cause more than a single atresia. This is in contradistinction to duodenal atresia, which is thought to

be caused by failure of recanalization [3] and is therefore typically an isolated atresia. Single bubble with distal gas (Fig. 1) Gastric distention out of proportion to non-distended distal bowel loops is a very common and typically benign finding at any age, including the neonatal period. However, in the setting of bilious vomiting, this pattern must be considered as ominous, as it is well described in association with midgut volvulus [8]. Even though midgut volvulus obstructs distal to the gastric outlet, the obstruction is too acute to dilate the duodenum appreciably, and so the pattern frequently suggests

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Fig. 2 Double bubble in a newborn boy intolerant of first feed. Abdominal radiograph demonstrates dilated stomach and duodenum with no distal gas. Elective surgery was performed without additional imaging and confirmed duodenal atresia

Fig. 4 Triple bubble in a newborn girl who had abnormal prenatal US. Initial radiograph demonstrates three rounded upper abdominal lucencies and no distal gas. Elective surgery confirmed jejunal atresia

a gastric outlet obstruction. This pattern should trigger UGI examination in this clinical setting. Double bubble with distal gas (Fig. 1) Whether one is dealing with a single or double bubble, the presence of even a tiny amount of distal gas is a critical finding that alters the differential diagnosis and necessities UGI examination. In the setting of the double-bubble pattern, the identification of distal gas (Fig. 5) virtually excludes duodenal atresia (exception being the rare case of the bifid common bile duct inserting above and below the atretic segment) [17] and widens the differential diagnosis to include midgut volvulus, along with duodenal stenosis/web.
Fig. 3 Duodenal atresia initially presenting as a single bubble. a Initial abdominal radiograph obtained after newborn girl vomited first feed demonstrates no air distal to a decompressed stomach. b The subsequent radiograph demonstrates gaseous distension of stomach and distended duodenum, with no distal gas. Notice the nasogastric tube had migrated out of the stomach, allowing the distension, and demonstration of the classic double bubble pattern

Ultimately, the vomiting infant with a double bubble needs surgery, whether there is distal gas or not. It is the radiologists role to assist the surgeon in determining whether the surgery is elective/urgent or emergent. This is determined with the help of UGI. Diffusely dilated loops (Fig. 1) It can be impossible to distinguish colon from small bowel in infants, particularly when the bowel is distended. The appearance of multiple (four or more) dilated (wider than the L1 interpedicular distance) loops of bowel throughout the abdomen and extending into the pelvis (Fig. 6) is suggestive of a low obstruction, typically at the level of the ileum or colon. Contrast enema is indicated to evaluate

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suggests meconium ileus [18]. Alternatively, multiple dilated loops with a single disproportionately distended loop of bowel suggest a distal atresia, often colonic [4]. These clues do not obviate a contrast enema, however. If the infant with this radiographic pattern is very ill with bilious vomiting and peritoneal signs, midgut volvulus should be considered. In this rare case, the diffuse dilation is not secondary to obstruction but rather to an ileus secondary to ischemia or infarction [19]. It is therefore important in this setting that a normal contrast enema be followed immediately by UGI to exclude midgut volvulus. Dilated, scattered bowel loops (Fig. 1) Whether encountered in the infant, the older child or the adult, this pattern can be recognized by the experienced radiologist as that of a sick belly (Fig. 7). The loops are dilated but noncontiguous, featureless in appearance, and scattered randomly throughout the abdomen and pelvis. This pattern can be seen with distal obstruction (such as complicated meconium ileus), proximal obstruction (midgut volvulus) and in utero bowel perforation. The radiologist should be prepared to perform UGI and contrast enema before surgery.

Fig. 5 Double bubble with distal gas. This infant boy had vomited since birth, prompting this abdominal radiograph, which demonstrates two rounded upper abdominal lucencies, with additional gas in nondilated distal small bowel loops. UGI (not shown) demonstrated a partial duodenal obstruction and normally positioned DJJ. A duodenal web was found at surgery 1 month later

further. A contrast enema is usually diagnostic and can be therapeutic in the case of meconium ileus. Radiographs demonstrating this pattern sometimes provide additional clues to a specific diagnosis. For instance, a soap bubble appearance, or absence of air-fluid levels,

Five UGI patterns At least four and as many as six of the eight radiographic patterns presented should prompt UGI as the next examination

Fig. 6 Pattern of diffusely dilated loops. This girl, born at 24 weeks gestational age, had become progressively distended over the first 72 h after birth. The abdominal radiograph demonstrates diffusely dilated bowel caused by a functional obstruction of prematurity

Fig. 7 Pattern of dilated scattered bowel loops on abdominal radiograph obtained in a 1-day-old girl with bilious vomiting. Based on physical exam findings, the girl was taken directly to surgery, where midgut volvulus was found

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in the workup of the vomiting newborn. Clearly, the most immediate goal of the UGI examination is to exclude malrotation with midgut volvulus. The radiologist must be aware of the various appearances of malrotation and midgut volvulus but otherwise should not approach the UGI examination feeling the necessity to make a specific diagnosis. Rather, the radiologists goal in performance of the UGI in this setting should be to categorize the vomiting infant into one of three groups, based on clinical management: (1) those requiring emergent surgery, (2) those requiring elective surgery and (3) those who can be treated non-surgically. We propose that the recognition of the following five patterns on the UGI series narrows the differential diagnosis and allows assignment into one of the three management paths (Fig. 8).

possible non-surgical causes [20], the more common causes being gastroesophageal reflux and sepsis. Malposition of the duodenojejunal junction (Fig. 8) Given malposition of the duodenojejunal junction (DJJ) in a vomiting infant (Fig. 9), one must assume that the vomiting is from intermittent midgut volvulus. While that is not always the case, and should not necessarily be assumed in the older child or in the absence of vomiting, this finding is an indication for emergent surgery in the infant with bilious vomiting. We acknowledge that the differentiation between a malpositioned and a normally positioned DJJ can be subtle, particularly in the setting of ileus or distal bowel obstruction, which can displace the normal DJJ because of ligamentous laxity and result in a false-positive UGI [21]. We refer the reader to excellent reviews of this topic [22]. Corkscrew duodenum (Fig. 8)

Significance of each of the five UGI patterns Normal (Fig. 8) A normal UGI excludes structural causes of vomiting. Vomiting is presumed secondary to any of the large number of This pattern (Fig. 10) is diagnostic of midgut volvulus and requires emergent surgery with detorsion and Ladd procedure [23].

Fig. 8 The five patterns on UGI. a Normal. A normal UGI demonstrates prompt gastric emptying, a normal-caliber duodenum, and a normally positioned DJJ. Normally, the duodenum crosses to the left of the left vertebral body pedicle and rises to the level of the duodenal bulb. On the lateral view, the duodenum remains retroperitoneal throughout its course. The radiologist should use the lateral view to ensure the entire duodenum remains posterior. b Malposition of the DJJ. The duodenum fails to cross the midline and ascend to its normal position in the left upper quadrant. There is no duodenal dilatation,

narrowing or spiraling. c Corkscrew duodenum. The duodenum spirals inferiorly without crossing to the left of the bony spine. d Complete duodenal obstruction. Contrast material does not pass beyond the midduodenum. Air, however, is seen in more distal bowel loops, ruling out duodenal atresia. e Partial duodenal obstruction with normally positioned DJJ. This pattern is assigned when a duodenal narrowing (and typically, dilation proximally) is seen, but sufficient contrast material is able to traverse the narrowing to document a normally positioned DJJ

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Fig. 9 Duodenojejunal malposition in a 3-day-old. UGI, performed after a single episode of bilious vomiting, demonstrates an abnormal duodenum that fails to cross the midline or ascend to the level of the duodenal bulb. The infant was sent emergently to surgery, where malrotation was confirmed. There was no midgut volvulus at the time of surgery

Complete duodenal obstruction (Fig. 8) Like the corkscrew duodenum, this pattern indicates the need for emergent surgery. The appearance is strongly suggestive of midgut volvulus, perhaps resulting from a tighter twist than would produce the corkscrew pattern (Fig. 11). Duodenal atresia can be excluded on the basis of air distal to the duodenum and by the fact that the proximal duodenum is not markedly dilated.
Fig. 11 Midgut volvulus in a 4-day-old girl. a Abdominal radiograph demonstrates a mildly distended stomach, with gas seen distally in nondilated bowel (single bubble with distal gas). b Single image from UGI examination demonstrates a complete obstruction to contrast agent at the level of the proximal duodenum (arrow). The stomach is distended with air. The girl was sent emergently to surgery with the presumptive diagnosis of midgut volvulus, which was confirmed at surgery

This pattern requires patience by the radiologist. Time must be allowed for contrast agent to pass the mid-duodenum and reach the DJJ. It is only with the failure of contrast agent to pass that this pattern can be assigned. Recognition of this pattern necessitates emergent surgery with the presumptive diagnosis of midgut volvulus. Partial duodenal obstruction with normally positioned DJJ (Fig. 8)
Fig. 10 Corkscrew duodenum in an infant girl who developed bilious vomiting at 2 days old. UGI demonstrates spiraling of the duodenum over the bony spine. Based on this finding, the girl was sent directly to surgery, where midgut volvulus was confirmed

A persistent duodenal narrowing demonstrated on UGI is typically a surgical lesion in a vomiting infant. The narrowing can be extrinsic (Ladd band, annular pancreas) or

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Fig. 12 Partial duodenal obstruction with normal DJJ in a 3-week-old girl with congenital heart disease had persistent non-bilious vomiting. Single image from UGI, with contrast injected through an enteric tube placed in the proximal duodenum, demonstrates a focal narrowing of the descending duodenum (arrow). Contrast agent passes distally to document normal position of the DJJ (arrowhead), allowing elective surgery. At surgery, an annular pancreas narrowed the descending duodenum

intrinsic (duodenal web, duodenal stenosis) to the duodenum [24]. It is not always possibleor necessary for the UGI to distinguish the cause of the partial obstruction. It is important only that the UGI distinguish malrotation (with Ladd band or midgut volvulus) from the other causes of partial duodenal obstruction. This is best done by patiently waiting for contrast agent to pass through the stenotic area and document the position of the DJJ. If a normally positioned DJJ can be documented (Fig. 12), malrotation is excluded and surgery can be performed electively rather than emergently, at a time when the child can be optimally prepared for surgery. If a normal DJJ position cannot be documented, then emergent surgery is indicated.

Fig. 14 Meconium ileus in an infant with microcolon who presented with vomiting, abdominal distension and failure to pass meconium. Note caliber of colon is less than the height of an upper lumbar vertebral body. Contrast material is refluxed from a microcolon into terminal ileal loops (arrows) outlining multiple filling defects indicative of meconium ileus. Obstruction was successfully relieved with contrast enema. Note also reflux into the appendix (arrowhead)

Four patterns on contrast enema The radiographic pattern of multiple, diffusely dilated bowel loops in the setting of a newborn who is vomiting and has not passed meconium suggests a low bowel obstruction and should prompt a contrast enema. The radiologist encounters one of four patterns in performance of a contrast enema in this setting. Each pattern offers a very limited differential diagnosis, which accounts for about 98% of cases, and allows appropriate management decisions, which might be surgical or nonsurgical (Fig. 13).

Fig. 13 The four patterns on contrast enema. a Microcolon. The entire colon is small in luminal diameter (less than the height of an upper lumbar vertebral body) and nondistensible. b Short microcolon. The colon is small or micro (as defined above) in caliber and its retrograde filling

terminates at some point short of the cecum. c Colonic caliber change. There is a demonstrable transition from small- or normal-caliber colon distally to more distended colon proximally. d Normal. The colon is of normal and uniform caliber throughout

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Fig. 15 Ileal atresia in an infant with microcolon who, like the infant in Fig. 14, presented with vomiting, abdominal distension and failure to pass meconium. Contrast material is refluxed into decompressed terminal ileum (arrows), which is devoid of meconium filling defects. No contrast material could be refluxed into more proximal ileum. Midileal atresia was confirmed at surgery

Fig. 17 Small left colon syndrome. Image shows colonic caliber change at the splenic flexure (arrows) characteristic of small left colon syndrome. Passage of plugs of meconium and abdominal decompression followed within hours of this contrast enema

Significance of the four contrast enema patterns Microcolon (Fig. 13) Normally, the developing fetal colon is stimulated by distension from meconium, sloughed cells and secreted fluid. A high-grade distal ileal obstruction prevents sufficient

bowel contents from reaching the colon, leaving it narrow and non-distensible, i.e. a microcolon [25]. The two most common causes of high-grade distal ileal obstruction leading to this pattern are meconium ileus and ileal atresia. Meconium ileus is a bowel obstruction caused by the inspissation of abnormal meconium in the distal ileum. Most children with meconium ileus have cystic fibrosis [26]. Ileal atresia is caused by intrauterine vascular insult with subsequent reabsorption [16].

Fig. 16 Short microcolon, diagnostic of colonic atresia. Single frontal image from contrast enema performed in a newborn with progressive abdominal distension over the first 2 days after birth. Contrast agent opacifies a small-caliber colon but could be refluxed no further proximal than splenic flexure (arrow)

Fig. 18 Hirschsprung disease. Image shows colonic caliber change in the proximal sigmoid colon (arrows) in a 5-day-old boy, demonstrated on a lateral view from a contrast enema. Rectal biopsy confirmed Hirschsprung disease

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Fig. 19 The algorithm for the diagnostic imaging workup of the newborn with potential bowel obstruction

The two can usually be distinguished by the contrast enema. If refluxed contrast reaches ileal loops containing multiple filling defects, a diagnosis of meconium ileus can be made (Fig. 14). If no reflux can be achieved beyond small-caliber ileum devoid of filling defects, then ileal atresia is the presumptive diagnosis (Fig. 15). This distinction is important because uncomplicated meconium ileus can be treated with contrast enemas [27] whereas ileal atresia requires surgery [4]. It should be noted that total colonic Hirschsprung disease can also produce a microcolon appearance [28]. This, however, is an uncommon presentation of an uncommon entity. Short microcolon (Fig. 13) Recognition of a short or incomplete microcolon (Fig. 16) allows a diagnosis of colonic atresia. The challenge is to be

confident that sufficient back pressure was achieved with the contrast enema such that the termination of the contrastfilled colon truly represents an atretic segment. Correlation with the abdominal radiograph often shows a massively dilated terminal loop just proximal to the atresia. Treatment is surgical [29]. Colonic caliber change (Fig. 13) A demonstrable transition from small- or normal-caliber colon distally to more dilated colon proximally narrows the differential diagnosis to two entities: Hirschsprung disease and small left colon syndrome (SLCS). Both are functional obstructions. Hirschsprung disease results from absence of ganglion cells that innervate the colon, and this disease must be treated surgically [30]. SLCS is caused by a functional immaturity of those ganglion cells, and it usually resolves after the contrast enema [31].

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Several imaging features distinguish these two entities. The location of the colonic caliber change is often helpful. SLCS is the presumptive diagnosis when the caliber transition is at the splenic flexure (Fig. 17), assuming that meconium evacuation and decompression follow the contrast enema within 2448 h. Hirschsprung disease is the likely diagnosis if the transition is elsewhere in the colon (Fig. 18), especially at the classic rectosigmoid level but even at the splenic flexure in a baby whose abdominal symptoms do not resolve after contrast enema. Other discriminators have been described [32]. SLCS might be favored over Hirschsprung disease when the rectum is more distensible or the caliber change more abrupt. A history of maternal diabetes or maternal treatment with magnesium sulfate for eclampsia might also suggest SLCS. Ultimately, questionable cases should undergo rectal biopsy to exclude Hirschsprung disease. Normal (Fig. 13) In the setting of a vomiting newborn with a distended abdomen and an abdominal radiograph suggesting low obstruction, a normal contrast enema should not necessarily be reassuring. The radiologists immediate concern should be for malrotation with midgut volvulus. It is very uncommon for midgut volvulus to produce a radiographic pattern suggesting low obstruction, but it is well described [33] and should be excluded with a UGI before the baby leaves the fluoroscopy suite. If midgut volvulus is excluded with the UGI, then Hirschsprung disease should be reconsidered. The contrast enema is interpreted as normal in about half of cases of total colonic Hirschsprung disease [34], but this is a rare entity. More frequently, a subtle caliber change is not appreciated in the case of classic low-segment Hirschsprung disease. It has been reported that Hirschsprung disease is missed on the initial contrast enema in 25% of cases [35]. Consideration should therefore be given to a rectal biopsy in this setting. This differential diagnosis includes a functional obstruction causing colonic dysmotility, often resulting from immaturity of the neuronal apparatus. This is most often seen in extremely premature infants [36].

familiar with the spectrum of imaging findings and common diagnoses and by using a systematic approach to imaging strategies, the radiologist can work with his or her surgical and neonatology colleagues to provide the best care to the neonate with bowel obstruction.
Conflicts of interest None.

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Conclusion We have proposed a simplified, pattern-based approach to serve as a framework for the practicing radiologist in the care and management of bowel obstruction in the neonate (Fig. 19). This is not presented as an all-inclusive review of the causes of newborn bowel obstruction, nor is it meant to imply that the recognition of patterns and assignment of diagnoses is always straightforward. But by becoming

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