A Preterm Neonate with Abdominal Distension (Questions)

A preterm (31 weeks +3 days), appropriate for gestational age (1.5 kg), male baby was born out of nonconsanguineous marriage to a 37-year-old fifth gravida mother with previous two first trimester abortions, by emergency lower segment cesarean section (LSCS) in view of previous two LSCS in preterm labor. The mother was noted to be hypothyroid in the first trimester and received thyroxine for the same. Antenatal scans were normal with no Doppler abnormalities. History of preterm premature rupture of membranes was present for 12 hours before delivery. There was no history of maternal fever or foul smelling liquor. The neonate cried immediately at birth with an Apgar score of 8 and 9 at 1 and 5 minutes of life. The neonate had respiratory distress at birth and was given delivery room continuous positive airway pressure (CPAP). Baby was started on bubble CPAP on admission to the intensive care unit. His respiratory rate (RR) was 58/minute, heart rate (HR) 160/minute, right upper limb saturation of 95% with 30% FiO2, capillary refill time (CRT) of 2 seconds, and Silverman Anderson score of 5/10 which gradually improved with CPAP. X-ray taken on day 1 is represented in Image 1.Image 1Neonate was initially started on intravenous (IV) fluids. Feeds were started with expressed breast milk at 4 hours of life (HOL) at 20 mL/kg/day. At 24 HOL, the baby was noticed to have visible abdominal distension and bilious orogastric aspirate. The neonate had RR of 64/minute, HR of 154/minute SpO2 of 96% on CPAP 5 cm, and 21% FiO2 with CRT of 2 seconds and per abdomen examination revealed no tenderness or organomegaly with sluggish bowel sounds. He was kept nil per orally and orogastric (OG) tube was kept open. Intravenous antibiotics Piperacillin-Tazobactam and Amikacin were added for gram negative and anaerobic coverage after sending sepsis screen and blood culture. Supine X-ray abdomen of the neonate at 24 HOL (white arrow showing orogastric tube) is shown in Image 2. Blood investigations done showed hemoglobin 19 g/dL, total count 7450/mm3 with 36% neutrophils and 49% lymphocytes, platelets 2.5 lakhs/mm3, C-reactive protein of 1.9 mg/L, serum calcium 7.8 mg/dL, sodium 135 mEq/dL, and potassium 4.8 mEq/dL.Image 2Pediatric surgery consultation was sought. As per their advice, rectal stimulation was given and baby passed meconium for the first time at 40 HOL. However, baby had progressive abdominal distension, despite keeping nil per oral for 24 hours. A repeat X-ray abdomen in the erect and supine position was taken at 50 HOL, which is shown in Image 3 (erect) and Image 4 (supine), respectively.Image 3Image 4Questions: What is depicted by white arrows depicted in Image 3? Name the sign depicted by green arrows in the same image What is the classical sign depicted in Image 4 by white arrows? Green arrow, blue arrows and red arrows represent which named signs, respectively, and represent which intra-abdominal structures? What is the clinical diagnosis as per Images 3 and 4? What is the further line of management in such a case? What can be the possible causes of the same in this case? Answers to the questions may be mailed by readers at the following E-mail: [email protected]. The answers of the questions along with the name and affiliation of the sender of the first correct response will be published in the subsequent issue of IPCaRes, in the section of Clinical Quiz (Answers).Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal patient identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.