Magnetic Resonance Imaging of Intestinal Necrosis in Preterm Infants
Elia F. Maalouf, MRCP*; Andrew Fagbemi, MRCP*; Philip J. Duggan, MRCP*;
Subramanyam Jayanthi, MRCS‡; Serena J. Counsell, DCR§; Helen J. Lewis, DCR§;
Alison M. Fletcher, DCR§; Kokila Lakhoo, FRCS‡; and A. David Edwards, FRCP*
ABSTRACT. Background and Objective. Noninvasive
diagnosis of intestinal necrosis is important in planning
surgery in preterm infants with necrotizing enterocolitis
(NEC). We aimed to assess the potential of magnetic
resonance imaging (MRI) for the diagnosis of intestinal
necrosis.
Study Participants and Methods. Abdominal MRI
scans were performed in a group of preterm infants with
suspected NEC and compared with surgical findings and
to MRI results in a group of control infants. In addition,
MRI was performed in 2 preterm infants with suspected
NEC who did not require surgery.
Results. Six infants with a median birth weight of
1220 g (range, 760-1770 g) and median gestational age at
birth of 30 weeks (range, 28 –34 weeks) were studied at a
median postnatal age of 10 days (range, 4 –19 days). Four
infants had a bubble-like appearance in part of the in-
testinal wall, intramural gas, and an abnormal fluid level
within bowel lumen. At surgery, NEC was found in 5
infants and sigmoid volvulus in 1. The site of the bubble-
like appearance corresponded to the site of intestinal
necrosis at surgery. Four control infants with a median
birth weight of 1500 g (range, 730-2130 g) and a median
gestational age of 31 weeks (range, 26 –36 weeks) had
abdominal MRI at a median postnatal age of 8 days
(range, 4 –70 days). None of the above findings were seen
in any control infant. The bubble-like appearance was
not seen in the 2 infants with suspected NEC who did not
require surgery.
Conclusion. Abdominal MRI allows the noninvasive
diagnosis of bowel necrosis. This may aid the timing of
surgical intervention in preterm infants with a clinical
diagnosis of NEC. Pediatrics 2000;105:510 –514; gangrene,
ischemia, MRI, necrotizing enterocolitis.
ABBREVIATIONS. NEC, necrotizing enterocolitis; MRI, magnetic
resonance imaging; GA, gestational age; T1, longitudinal relax-
ation time; T2, transverse relaxation time; CT, computed tomog-
raphy; CSE, conventional spin echo; FSE, fast spin echo.
N
ecrotizing enterocolitis (NEC) is the most
common surgical emergency in preterm in-
fants. It is generally believed to be secondary
to several underlying factors including: intestinal in-
From the Departments of *Paediatrics and ‡Surgery and Gastroenterology;
and §Robert Steiner Magnetic Resonance Unit and Medical Research Coun-
cil Clinical Science Centre, Imperial College School of Medicine, Hammer-
smith Hospital, London, England.
Received for publication Feb 22, 1999; accepted Jun 15, 1999.
Reprint requests to (A.D.E.) Department of Paediatrics, Imperial College
School of Medicine, Hammersmith Hospital Campus, Du Cane Road, Lon-
don W12 ONN, England. E-mail: david.edwards@ic.uc.uk.
PEDIATRICS (ISSN 0031 4005). Copyright © 2000 by the American Acad-
emy of Pediatrics.
510 PEDIATRICS Vol. 105 No. 3 March 2000
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jury, usually ischemic; bacterial colonization of the
gut; and the presence of high osmolality solutions,
usually formula milk, within the gut lumen. NEC
usually involves the ileum and the proximal colon,
but any part of the gastrointestinal tract may be
affected.1 The diagnosis of NEC is based on clinical
findings (abdominal distension, lethargy, gastroin-
testinal bleeding, abdominal wall erythema, and ac-
idosis) and plain abdominal radiographic criteria (di-
lated bowel loops, bowel-wall thickening, intramural
gas, and portal venous gas).
Despite appropriate medical treatment, surgical
intervention becomes necessary in 40% to 50% of
cases of NEC. The ideal timing for surgery is after the
development of intestinal necrosis but before the
development of intestinal perforation.1,2 Noninvasive
diagnosis of intestinal necrosis is difficult1,3 and no
test has a high sensitivity.2
Preliminary experience with animal models4 –7 sug-
gests that magnetic resonance imaging (MRI) may
have a role in the diagnosis of bowel ischemia. The
aim of this pilot study was therefore to describe
abdominal MRI findings in NEC and to assess the
potential role of MRI as a safe, noninvasive tool in
the diagnosis of intestinal necrosis.
STUDY PARTICIPANTS AND METHODS
Ethical approval for this study was given by the Hammersmith
Hospitals Research Ethics Committee and informed parental con-
sent was obtained in each case. Preterm infants who had clinical
and radiologic signs suggestive of NEC and who subsequently
underwent laparotomy were included in this study. The indica-
tions for surgical intervention were failure of medical treatment or
intestinal perforation. Abdominal MRI was obtained before and
after operation and compared with surgical findings. The severity
of NEC was staged using clinical signs and criteria on plain
abdominal radiographs (modified Bell criteria in which stage I is
suspect, stage II is definite, and stage III is advanced NEC).8 The
presence and the site of intestinal necrosis was determined at
laparotomy.
A control group of preterm infants of similar gestational age
(GA) and with no symptoms or signs suggestive of NEC were also
studied for comparison. In addition, MRI was performed in 2
infants with suspected NEC who responded to conservative med-
ical treatment and did not require surgery.
MRI Acquisition
Patients were scanned 2 to 3 hours before undergoing laparot-
omy and as soon as practical afterward. MRI was performed using
a 1-Tesla neonatal magnetic resonance system (Oxford Magnet
Technology, Oxford, UK/Picker, Cleveland, OH) located within
the neonatal intensive care unit. The magnet has a 380-mm bore
length, which allows good access to the infant for monitoring and
ventilation during scanning. Full intensive care and monitoring
were continued during scanning as previously described.9 Longi-
tudinal relaxation time (T1)-weighted CSE and transverse relax-
TABLE 1. Pulse Sequence Parameters
Pulse Sequence TR, TE/TEeff, Slice Number of NSA Phase Echo Train Interecho
ms ms Thickness, Slices Matrix Length Spacing
mm
T1-weighted CSE 600 20 4/5 12 2 192 – –
T2-weighted FSE 2430 96 4/5 9 4 256 16 16
T2-weighted FSE 3000 208 4/5 9 4 256 16 16
NSA indicates number of signal acquisitions; TR, repetition time; TE, echo time; TEeff, effective echo time.

ation time (T2)-weighted FSE images in the coronal and transverse
planes were obtained in all infants. In addition, postcontrast T1-
weighted CSE images were obtained in the coronal and transverse
planes using intravenous dimeglumine gadopentetate (0.1 mmol/
kg) as a contrast agent. Control infants were scanned once without
the use of contrast agents. Infants with suspected NEC who did
not require surgery were scanned within 48 hours of developing
symptoms and signs suggestive of NEC. The sequence parameters
for T1-weighted CSE and T2-weighted FSE are summarized in
Table 1.
MRI Analysis
The images were analyzed before surgery, and results were
compared with findings at laparotomy. Abnormal features re-
corded were the presence or absence of bowel-wall thickening,
dilated bowel loops, intramural gas, abnormal fluid levels within
bowel lumen, mesenteric edema, and bubble-like appearance in
parts of the intestinal wall.
Bowel-wall thickening and bowel-loop dilatation were assessed
subjectively in comparison to control infants. Intramural gas ap-
peared as a line of low signal intensity within the bowel wall on
T1- and T2-weighted images. Fluid levels within bowel lumen had
low signal intensity on T1-weighted images and high signal in-
tensity on T2-weighted images. Mesenteric edema had high signal
intensity on T2-weighted images. Infants with a bubble-like ap-
pearance in parts of the intestinal wall had multiple small circular
low-signal intensity lesions within the bowel wall giving a char-
acteristic appearance on T2-weighted images. The site of bubble-
like appearance of bowel was compared with the site of bowel
necrosis observed at surgery with the help of detailed diagrams of
operative findings.
RESULTS
Six infants suspected of having NEC with a me-
dian birth weight of 1220 g (range, 760-1770 g) and a
median GA of 30 weeks (range, 28 –34 weeks) were
included in the study. Prelaparotomy MRI scans
were acquired at a median postnatal age of 10 days
(range, 4 –19 days) and postlaparotomy MRI scans
were acquired at a median of 8 days (range, 5–19
days) after surgery. Table 2 summarizes the clinical
details and the timing of the MRI scans in all cases.
Four control infants with a median birth weight of
1500 g (range, 730-2130 g) and a median GA of 31
weeks (range, 26 –36 weeks) were scanned at a me-
dian postnatal age of 8 days (range, 4 –70 days). Two
infants with a birth weight of 715 and 2006 g and a
GA of 25 and 36 weeks were scanned at a postnatal
age of 49 and 4 days, respectively.
Radiograph Findings
On plain abdominal radiography, all 6 infants who
underwent surgery had dilated bowel loops and in-
tramural gas; 5 had thickening of the bowel wall
(cases 1–5); 1 had air in the portal system (case 1);
and 2 had evidence of free intraperitoneal gas (cases
2 and 6). Plain radiographs were not obtained in the
control infants. The 2 infants with suspected NEC
who did not require surgery had generalized bowel
distension, dilated bowel loops, and intramural gas
on plain abdominal radiographs.
Surgical Findings
The diagnosis of NEC was surgically confirmed in
5 of these infants (cases 1–5) but sigmoid volvulus
with perforation was diagnosed intraoperatively in
the sixth (Fig 1) (case 6). Four of the infants with NEC
(cases 1– 4) had nonviable necrotic bowel and re-
quired bowel resection and exteriorization. Bowel
necrosis was subsequently confirmed on histologic
examination. The fifth infant with NEC (case 5) had
dusky but nonnecrotic bowel and did not require
bowel resection or exteriorization. The infant with
volvulus had healthy looking bowel. Table 2 sum-
marizes the surgical findings.
MRI Findings
Figure 2 summarizes pre- and postoperative MRI
findings in the 6 infants who required surgery. Pre-
operative MRI was less motion artifacted in all in-

TABLE 2. Clinical Details and Timing of MRI in Infants Who Required Surgery
Infant Birth GA, Sex Postnatal Age Postnatal Age Bell Operative Findings
Weight, Weeks at Pre-op at Post-op Stage8
g MRI, days MRI, days
1 1415 30 M 7 15 III NEC with necrosis of small and
large bowel. Bowel resection.
2 1058 29 F 15 24 III NEC with necrosis of small and
large bowel. Bowel resection.
3 760 33 F 4 23 III NEC with necrosis of small and
large bowel. Bowel resection.
4 1770 34 F 14 26 III NEC with necrosis of small and
large bowel. Bowel resection.
5 1038 28 M 7 12 III NEC with dusky large bowel.
Bowel viable, no resection.
6 1050 31 M 19 25 II Sigmoid volvulus with bands.
Bowel viable, no resection.
M indicates male; F, female.

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Fig 1. Infant with volvulus born at 31 weeks’ gestation and im-
aged at a postnatal age of 19 days (case 6). Transverse relaxation
time-weighted FSE (repetition time, 3000 ms; echo time, 208 ms)
transverse image showing dilated bowel loops but there is no
bubble-like appearance of the bowel wall and no abnormal fluid
level within bowel lumen.
fants with NEC compared with postoperative studies
and control infants’ MRI. All findings described were
seen on both transverse and coronal planes.
On preoperative MRI dilated bowel loops, mesen-
teric edema and thick bowel wall were present in all
6 infants. In addition to the above findings, the 4
infants who required bowel resection had an abnor-
mal fluid level within bowel lumen, intramural gas,
and a bubble-like appearance in parts of the intesti-
nal wall (Figs 3–5). The site of the bubble-like appear-
ance on MRI corresponded well to the site of intes-
tinal necrosis at surgery.
Postoperative MRI showed resolution of the ab-
normal fluid level within bowel lumen, the intramu-
ral gas, and the bubble-like appearance of the intes-
tine in all 4 infants with necrotic bowel. Infants
scanned between postoperative day 5 and day 9 still
Fig 2. Surgical diagnosis, preoperative and postoperative magnetic resonance imaging findings in infants who required surgery.
Abbreviations: MRI, magnetic resonance imaging; pre, preoperative MRI findings; post, postoperative MRI findings. W indicates present.
³ indicates absent.
512 MAGNETIC RESONANCE IMAGING OF NECROTIZING ENTEROCOLITIS
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had persistence of either bowel-wall thickening, mes-
enteric edema, and/or dilated bowel loops. The 2
infants scanned on postoperative days 12 and 19 did
not have any of the above findings. There was no
correlation between bowel wall enhancement on
postcontrast T1-weighted images and sites of bowel
necrosis.
MRI scans obtained in control infants showed mo-
tion artifact secondary to bowel peristalsis. These
infants did not have dilated bowel loops, bowel-wall
thickening, abnormal fluid levels within bowel lu-
men, mesenteric edema, or any of the other findings
described above.
MRI scans obtained in the 2 infants with suspected
NEC who did not require surgery showed dilated
and thickened bowel loops with mesenteric edema.
There was no fluid level seen within the bowel lu-
men, no intramural gas, and no bubble-like appear-
ance in any part of the intestine.
DISCUSSION
We have described the abdominal MRI findings in
a small group of preterm infants with clinical suspi-
cion of NEC who underwent surgery, compared
those to a group of control infants and to 2 infants
with NEC who were treated medically. We have
showed that the imaging appearances and in partic-
ular the sites of abnormality were closely related to
perioperative findings.
The noninvasive diagnosis of bowel necrosis,
which is the main indication for surgical intervention
in preterm infants with NEC in the absence of pneu-
moperitoneum, has proved to be difficult.1–3 Plain
abdominal radiographic features such as portal ve-
nous gas and fixed intestinal loops; and laboratory
markers such as white blood cell count, immature to
total neutrophil ratio, platelet count, and base excess
have all been used to assist in the timing of surgery
but none of these tests has a high sensitivity.2,3
Abdominal ultrasound scanning with Doppler has
been used to diagnose bowel necrosis without per-
foration but different reports give conflicting assess-
ments of its value in differentiating necrotic from
inflammatory bowel changes.10,11
Computed tomography (CT) findings of thickened
Fig 3. Infant with necrotizing enterocolitis born at 33 weeks’ gestation and imaged at a postnatal age of 4 days (case 3). A, coronal
transverse relaxation time-weighted fast spin echo (repetition time, 3000 ms; echo time, 208 ms) image showing the bubble-like
appearance in the intestinal wall (arrows). B, transverse relaxation time-weighted fast spin echo (repetition time, 3000 ms; echo time, 208
ms) image showing intramural gas (short arrow) and an abnormal fluid level within bowel lumen (long arrow).

Fig 4. Infant with necrotizing enterocolitis born at 30 weeks’ gestation and imaged at a postnatal age of 7 days (case 1). A, transverse
relaxation time-weighted fast spin echo (repetition time, 3000 ms; echo time, 208 ms) image showing a bubble-like appearance within
bowel wall (arrows). B, transverse relaxation time-weighted fast spin echo (repetition time, 3000 ms; echo time, 208 ms) image showing
mesenteric edema (long arrow) and thickened bowel wall (short arrow).

bowel wall with postcontrast enhancement, dilated
fluid filled bowel, intramural gas, and intramural
low attenuation zones have been described in adults
with bowel ischemia12–14 but the use of CT in preterm
infants with NEC has not yet been reported. A spe-
cific CT finding for bowel necrosis in adults is intes-
tinal pneumatosis which may be seen as cyst-like
collections of gas in the bowel mucosa.13 The appear-
ance of bubble-like collections of gas on CT have also
been described in adults with Fournier’s gangrene.15
The development of MRI in the abdomen has been
impeded by motion artifact secondary to both respi-
ratory and peristaltic motion. Infants with NEC or
sigmoid volvulus tend to have an ileus as part of
their illness and therefore the preoperative MRI ob-
tained from study infants showed very little motion
artifact.
MRI has been used in the diagnosis of early and
late intestinal ischemia in several animal models.4 –7
High signal intensity on T2-weighted and isointense
or slightly increased signal intensity on T1-weighted
images was reported early (within 45 minutes) after
an ischemic insult.5,6 High signal intensity on both
T1- and T2-weighted images was reported late (24

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Fig 5. Infant with necrotizing enterocolitis born at 34 weeks’ ges-
tation and imaged at a postnatal age of 14 days (case 4). A,
transverse relaxation time-weighted fast spin echo (repetition
time, 3000 ms; echo time, 208 ms) image showing a bubble-like
appearance of the intestinal wall (arrow).
hours) after an ischemic insult.4 Postcontrast enhance-
ment was reported to increase accuracy of diagnosis in
the early phase7 but not the late phase.4 All animal
models concentrated on measuring bowel wall signal
intensity. A bubble-like appearance in the bowel wall
was not reported. In our study there was no correlation
between signal intensity on pre- and postcontrast scans
and the site of necrotic bowel. The changes reported in
animal studies may represent a relatively early phase of
bowel ischemia compared with the in vivo progression
of bowel necrosis in preterm infants.
NEC in preterm infants is not only related to bowel
ischemia but several other factors including infection
and feeding pattern are believed to contribute to the
pathogenesis.1 The characteristic pathologic finding
in NEC is crepitant necrosis of the gut.1 The bubble-
like appearance seen on abdominal MRI in areas of
necrotic bowel may be explained by the presence of
gas bubbles within the bowel wall which gives the
pathologic characteristic of crepitance. The bubble-
like appearance has also been described on MRI in
cases of Fournier’s gangrene.16,17
Abdominal MRI features, which were constantly
associated with the surgical finding of bowel necro-
sis, were intramural gas, abnormal fluid level in
bowel lumen, and bubble-like appearance in parts of
the intestinal wall. The site of bubble-like appearance
in the bowel wall on MRI corresponded to the site of
necrotic bowel at surgery. The finding of bubble-like
appearance of bowel wall on abdominal MRI in as-
sociation with an abnormal fluid level in bowel lu-
men may therefore be diagnostic of bowel necrosis.
Mesenteric edema and thickening of bowel wall were
also seen in the case of NEC that did not have bowel
necrosis, in the 2 infants with NEC who did not
require surgery, and in the infant with volvulus.
Intramural gas can be seen on plain abdominal ra-
514 MAGNETIC RESONANCE IMAGING OF NECROTIZING ENTEROCOLITIS
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diographs in 85% of cases of NEC and is not indica-
tive of bowel necrosis.1 An abnormal fluid level
within bowel lumen has been described as a CT
finding in bowel ischemia in adults12–14 but is not a
specific sign of bowel necrosis.
CONCLUSION
In summary, dilatation of bowel loops, thickening of
bowel wall, and mesenteric edema are nonspecific MRI
findings and may be present in all infants with NEC.
The additional findings of fluid level within the bowel
lumen, intramural gas, and in particular bubble-like
appearance in parts of the intestinal wall on MRI are
highly suggestive of the presence of intestinal necrosis.
These results suggest that MRI is likely to be of
value in diagnosing intestinal necrosis and determin-
ing the need for surgical intervention. MRI may also
be of value in other intestinal conditions where gut
necrosis is a feature. We suggest that further studies
to determine the value of MRI in the diagnosis of
intestinal necrosis are warranted.
ACKNOWLEDGMENTS
This work was supported by Wellbeing, the Medical Research
Council, the Garfield Weston Foundation, Picker International,
and Oxford Magnet Technology.
We thank Professor G. M. Bydder for his support and his help
in interpreting the magnetic resonance images.
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 Magnetic Resonance Imaging of Intestinal Necrosis in Preterm Infants
Elia F. Maalouf, Andrew Fagbemi, Philip J. Duggan, Subramanyam Jayanthi,
MRCS?; Serena J. Counsell, Helen J. Lewis, Alison M. Fletcher, Kokila Lakhoo and
FRCS?; and A. David Edwards
Pediatrics 2000;105;510
DOI: 10.1542/peds.105.3.510

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2000 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
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 Magnetic Resonance Imaging of Intestinal Necrosis in Preterm Infants
Elia F. Maalouf, Andrew Fagbemi, Philip J. Duggan, Subramanyam Jayanthi,
MRCS?; Serena J. Counsell, Helen J. Lewis, Alison M. Fletcher, Kokila Lakhoo and
FRCS?; and A. David Edwards
Pediatrics 2000;105;510
DOI: 10.1542/peds.105.3.510

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/105/3/510

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2000 by the American Academy of Pediatrics. All rights reserved. Print ISSN:
.

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