Plain Roentgenography in Diagnosing Neonatal Gastrointestinal Emergencies

Plain radiography is universally available and a low-cost investigation that helps pediatricians and pediatric surgeons in the early diagnosis of various gastrointestinal (GI) anomalies and emergency conditions. It has several advantages: lack of potential complications of contrast agents such as aspiration (oral), dehydration (rectal), or hypersensitivity reactions (intravenous); not a time-consuming procedure, such as ultrasonography or magnetic resonance imaging, thus avoiding the need for the patient to lie still for a prolonged time. Here we describe some common surgical GI emergencies including esophageal atresia [Images 1-3], gastric volvulus [Image 4a and b], pyloric atresia [Image 5], duodenal atresia [Image 6], jejunal atresia [Image 7], ileal atresia [Image 8], pneumoperitoneum [Images 9-11], necrotizing pneumonitis [Image 12], anorectal malformation [Image 13] and pouch colon [Image 14], through a series of images, for easy learning of pediatricians.Image 1: Chest X-ray of a male newborn (birth weight 1800 g) with esophageal atresia and distal trachea-esophageal fistula (TEF). Orogastric tube is seen to coil at 3rd thoracic vertebral level (T3). The air-contrast is seen in the upper pouch suggesting that the upper pouch is ending at T3. The gas pattern in the abdomen appears normal suggesting the presence of distal TEF and the absence of intestinal atresia. Cardiac shadow, lung fields, and bones (ribs and vertebrae) are normal. Posterolateral thoracotomy was done to ligate the fistula and achieve a tension-free primary anastomosisImage 2: Babygram of a female newborn female (birth weight 1350 g). The air-contrast upper pouch ends at T2 level. The normal gas pattern in the abdomen suggests distal trachea-esophageal fistula. Thirteen pairs of ribs are encountered suggesting a high possibility of long-gap esophageal atresia. The fistula was ligated through standard right posterolateral thoracotomy. Primary anastomosis could not be achieved in this patientImage 3: Babygram of a male newborn male (birth weight 1200 g) with pure esophageal atresia. The air-contrast upper pouch ends at T3. The abdomen is gasless signifying the absence of distal tracheaesophageal fistula. The heart, lung fields, and bones are normal. The patient was managed by diverting esophagostomy and feeding gastrostomy and was planned for esophageal replacement using a gastric conduit laterImage 4: A 2-day-old baby was referred to us with complaints of excessive salivary secretions and inability to pass an oro-gastric tube, the latter could not be inserted beyond 17 cm from the gums (c.f. 10 cm from the lips for esophageal atresia). Chest X-ray-both anterior-posterior (a) and lateral (b) views show infant feeding tube stuck at T7 level, retrocardiac gas shadow, and absence of gastric bubble in the abdomen. The patient was diagnosed as having a hiatus hernia with gastric volvulus. On laparotomy, a paraesophageal hiatus hernia with mesenteric-axial gastric volvulus was found. The stomach was reduced into the abdomen, hiatus hernia repaired and Stamm’s gastrostomy doneImage 5: Plain X-ray abdomen (erect) of a 3-day-old male baby with “single-bubble” and nonvisualization of distal gases. A large single bubble in the location of the stomach is suspicious of obstruction at the level of the gastric pylorus. The differential diagnosis considered was pyloric atresia/pyloric web. The baby was operated through the right upper abdomen transverse incision and found to have pyloric atresia. The patient underwent gastroduodenostomyImage 6: (a) X-ray abdomen of a 5-day-old baby with Down’s facies showing “double-bubble” sign with absent distal gas shadow suggesting duodenal atresia. The child underwent upper transverse laparotomy with Kimura’s diamond-shaped duodeno-duodenostomy, (b) Oral air contrast study done in a 7-day-old baby with projectile nonbilious vomiting. The double bubble sign became prominent which was earlier not appreciated in a plain X-ray. Thus, doing an air contrast study enabled us to decipher the double bubble sign and plan the patient for surgery. The neonate was found to have duodenal web for which she underwent duodenal web excisionImage 7: A 10-day-old female newborn presented with history of bilious vomiting, intolerance to feed, and abdominal distension. A plain X-ray abdomen showed a few large air-fluid levels suggestive of dilated jejunal loops. Laparotomy revealed jejunal atresia for which resection of dilated jejunal loops and jejuno-jejunal end-to-back anastomosis was doneImage 8: A 5-day-old male newborn presented with a history of abdominal distension and bilious vomiting. A plain erect X-ray abdomen of the patient revealed multiple air-fluid levels. The child underwent laparotomy with resection of dilated ileal loop and end-to-back anastomosisImage 9: Erect X-ray abdomen of a 5-day-old male newborn with nonpassage of meconium since birth and progressive gross abdominal distension and severe shock. Air is seen under the bilateral dome of the diaphragms. The child was found to have descending colon perforation with pancolitis. A proximal stoma was made with the repair of distal perforation. Biopsy from peritoneal reflection confirmed Hirschsprung’s disease with enterocolitis and perforation in a proximal ganglionic segmentImage 10: Rigler Sign: Plain X-ray abdomen of a neonate showing air both inside and outside the bowel lumen, due to accumulation of free air all around the bowel loops, suggestive of pneumoperitoneumImage 11: Football sign: Large oval translucency seen occupying almost the whole of the abdomen in a shape of American football, suggestive of pneumoperitoneumImage 12: A 15-day-old premature baby who was top-fed, developed abdominal distension, and erythema of the abdomen with severe septic shock. The plain X-ray abdomen showed pneumatosis intestinalis with portal vein gas. The patient was taken for exploration and found to have gangrene of the entire bowel. The abdomen was closed and the parents prognosticatedImage 13: (a) A 2-day-old male newborn presented with abdominal distension and absent anal opening. A cross-table prone lateral (CTPL) film was taken which revealed gas shadow below pubococcygeous line suggestive of “low anorectal malformation” (ARM). The patient underwent anoplasty, (b) A 3-day-old boy with an absent anal opening presented to our emergency with history of meconuria. A CTPL film showing rectal gas shadow above PC line suggestive of high ARM. The patient underwent high divided sigmoid colostomyImage 14: X-ray abdomen of a 2-day-old newborn with absent anal opening showing large air-filled distended colon occupying more than half of abdomen diameter suggestive of pouch colonCONCLUSION A pediatrician might come across various neonatal GI emergencies which require urgent surgical intervention. The best tool to reach an initial diagnosis is a thorough history and clinical examination. In this modern era of advanced imaging technologies, the role of plain X-ray is also invaluable and cannot be belittled to arrive at a diagnosis and plan a life-saving urgent intervention. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.