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Implementation of bowel ultrasound practice for the diagnosis and management of necrotising enterocolitis
Implementation of bowel ultrasound practice for the diagnosis and management of necrotising enterocolitis
REVIEWED BY | Madonna Burnett ASA SIG: Paediatric
REFERENCE | Authors: Karen M Alexander, Sherwin S Chan, Erin Opfer, Alain Cuna, Jason D Fraser, Shazia Sharif, Minesh Khashu Journal: BMJ Journals (ADC Fetal and Neonatal edition) Open Access: Yes
WHY THE STUDY WAS PERFORMED
Necrotising enterocolitis (NEC) is a serious inflammatory bowel disease with potentially devastating complications and is a leading cause of morbidity and mortality among premature infants. As bowel ultrasound (BUS) is a relatively new technique, there are some barriers which slow the implementation of these studies. These barriers include lack of education and training for sonographers, radiologists and clinicians and low case volume.
The aim of this paper is to provide a framework and a roadmap for work units to implement BUS in day-to-day practice for NEC diagnosis and management. It was written to highlight the advantages of BUS in the management of NEC and discuss the techniques used for this type of ultrasound study. It also aims to provide clear methods and examples to assist with implementation of the examination, interpretation of images and clear explanations of the clinical importance of the various findings on BUS for NEC.
WHAT THE PAPER LOOKED AT
The pathology and course of NEC was discussed and the potential to improve outcomes through timely management. Clinical examination and laboratory tests are not specific for the disease. Clinicians depend on abdominal X-rays (AXR) to aid in the diagnosis of NEC. However, AXRs have significant limitations in diagnosing NEC. Diagnosis of NEC can be made when pathognomonic signs such as portal venous gas and pneumatosis intestinalis are present.
The advantages of ultrasound over AXR are discussed. These include real-time assessment of peristalsis, vascular perfusion, bowel wall thickening/thinning/perforation, abdominal fluid, portal venous gas and pneumatosis.
BUS technique is discussed, including preparation (no preparation), equipment (both high and low frequency transducers for both superficial and deep imaging), and scanning technique. Different positioning is used to differentiate between pneumatosis and intraluminal gas. Colour Doppler is used to determine intestinal mural blood flows. Pneumoperitoneum, free fluid, bowel wall, bowel wall perfusion, pneumatosis and portal venous gas are all discussed at length. Limitations, including the fact that ultrasound is operator dependent, are discussed.
There are some excellent tables included in this article, which include: indications for ultrasound, representative protocol for sonographers and key findings and their relative clinical significance.
WHAT THE STUDY FOUND
BUS can be used to assess for and monitor NEC. Ultrasound can show early signs of NEC, as well as advanced signs of NEC, which include bowel wall thinning, absent bowel perfusion and absent peristalsis.
Implementation of bowel ultrasound practice for the diagnosis and management of necrotising enterocolitis continued
Although bowel ultrasound provides more information than AXR in the evaluation of NEC, its overall sensitivity and negative predictive value is still relatively low.
Implementation of BUS within a unit should include input from all aspects of the infant’s care. The whole multidisciplinary team should be involved.
RELEVANCE TO CLINICAL PRACTICE
BUS can be used as an adjunct to AXR. The ultrasound findings can assist in guiding clinicians whether aggressive treatment such as surgery is warranted or conservative treatment will suffice. Although ultrasound cannot definitively rule out NEC, it can provide reassurance that no findings suggestive of NEC are present. This is helpful when an abdominal X-ray is equivocal.
