Segmental jejunal necrotizing enterocolitis mimicking malrotation with midgut volvulus in a term newborn with abnormal prenatal bowel sonography: A case report

Necrotizing enterocolitis (NEC) is uncommon in term infants and rarely presents within hours of birth, when bilious vomiting more often reflects malrotation with midgut volvulus or intestinal atresia. A male infant was born by cesarean section at 38 weeks of gestation (3230 g). Prenatal ultrasound at approximately 34 weeks had shown a dilated, aperistaltic bowel segment with a whirlpool-like configuration and polyhydramnios. Bilious vomiting began 2 hours after birth, followed by upper abdominal distension, rectal bleeding, and failure to pass meconium. On day 3, an upper gastrointestinal contrast study showed a tapered obstruction just beyond the duodenum with an indeterminate duodenojejunal junction; radiography and ultrasound showed pneumatosis intestinalis without portal venous gas, and color Doppler ultrasound showed the superior mesenteric vein wrapping around the superior mesenteric artery. Malrotation with midgut volvulus was diagnosed. At laparotomy, rotation was normal and there was no volvulus; a 4-cm necrotic jejunal segment enveloped by fibrinous and fibrous adhesions was resected, and a Bishop–Koop enterostomy was created. Histopathology showed hemorrhagic mucosal necrosis, subserosal pneumatosis, inflammation, bacterial colonies, vascular thrombi, and granulation tissue, consistent with NEC. At 5 months, the infant was thriving. A whirlpool sign, even with the superior mesenteric vein wrapping around the artery, may occur without malrotation when a necrotic jejunal segment tethers adjacent loops. Segmental NEC can present within hours of birth in a term newborn, and the prenatal and subacute histopathological findings suggest that the intestinal injury may begin before birth.