Clin. Radiol. (1978) 29, 295-301 NECROTISING ENTERO-COLITIS FOLLOWING UMBILICAL VEIN CATHETERISATION* K. J. SHAH and J. J. CORKERY
The Children's Hospital, Birmingham Fifteen cases of neonatal necrotising entero-colitis (NEC) following umbilical vein catheterisation are reported. Their clinical and radiological features are briefly described and the proper course of a catheter through the umbilical vein-ductus venosus-inferior vena cava segment is demonstrated. The significance of real-position of the catheter and its association with NEC is discussed. It is suggested that the abdominal radiographs be taken in the anteroposterior and lateral projections with a portable X-ray machine to check the position of the radio-opaque catheter prior to the commencement of transfusion or infusion.
The number of neonates showing various abdominal symptoms and signs are given in Table 3. Four out of 15 patients passed blood per rectum. Most of these ill babies also had respiratory and metabolic problems, temperature instability and dehydration, and some had septicaemia. Three patients had successful conservative management while the remaining 12 needed surgery. Eleven out of 15 survived, i.e. a 27% mortality rate. Table 4 lists the range of pathological findings in the resected bowel specimen or the post-mortem examinations. Four out of 12 cases showed thrombosis of small peripheral mesenteric vessels but no major vessel was MATERIAL found to be occluded by a thrombus or an embolus. Clinical features. - Between 1970 and 1974, 15 Colon was most frequently affected and in four cases of NEC following UV catheterisation were seen patients it was involved in its entirety. at the Birmingham Children's Hospital. Ten had exchange transfusions for rhesus incompatibility and five had UV infusions (Table 1, 2). Seven infants of the exchange transfusion group were born by normal RADIOLOGY vertex delivery and one by caesarian section. The Abdominal distension present in all 15 patients mode of delivery was not recorded in the remaining was due to dilated loops of bowel with gas/fluid two. All the mothers in this group were multiparous levels, ascites and/or pneumoperitoneum (Table 5). and were rhesus negative with raised antibodies Of the 12 patients with distended loops of bowel, during the pregnancy. In each case the serum seven had features of mechanical intestinal obstrucbilirubin levels were raised and the Coombs' test was tion and five had ileus due to peritonitis: Pneumatosis positive. Of the UV infusion group three were born intestinalis (Fig. 1) was seen in 33% of the cases. It by normal vertex delivery and two by caesarian section. In case 3 the mother was known to suffer from was not as extensive in all cases as illustrated in Fig. 1, diabetes mellitus while patient number 4 had idio- but was confined to flexures of the colon. Intrapathic hypoglycaemia and the blood sugar level hepatic gas in the portal vein radicles and the thumbprinting effect due to intramural haematomata recorded at the time was 13 rag% (0.72 mmol/litre). There was a time interval of 12 72 h after the pro- (Fig. 2) were separately seen in two patients. Three cedure when symptoms and signs were first noticed. showed frank pneumo-peritoneum while at laparotomy perforations were observed in 12 cases (Table * Based on paper read by K.J.S. at 3rd Congress of Euro- 6). This discrepancy can be explained by the operative pean Associationof Radiology,Edinburgh, 1975. Correspondence to Dr K. J. Shah, Department of Diag- findings of small perforations which had sealed off nostic Radiology, The Children's Hospital, Ladywood by a localised inflammatory process so that gas had Middleway, Birmingham B16 8ET. not freely escaped into the peritoneal cavity. Necrotising entero-colitis (NEC) in neonates is a very serious and potentially fatal condition if not diagnosed early and managed correctly. The condition has been recognised for 86 years (Genersich, 1891; Berdon et al., 1964; Masters et al., 1973; Santulli et al., 1975) but it is still not fully understood (British Medical Journal, 1970). NEC following umbilical vein (UV) catheterisation procedures has been reported previously (Corkery et al., 1968, Orme and Eades 1968; Livaditis et aI., 1974). We wish to draw attention to some radiological aspects of this condition.
T a b l e 1 - NEC - 10 cases of exchange transfusion
Birth weight (g)
P~riod of gestation (weeks)
ET after birth * (h )
Onset of S and S? (h )
1 2 3 4 5 6 7 8 9 10
M M F F F F F F F F
2030 2300 2620 2300 2950 3OOO 2200 3000 2400 3000
36 37 38 38 40 39 35 40 36 40
12 22 Immediately Immediately 24 8 5 12 12 24
36 48 24 24 48 36 29 58 48 ? 10th day
* Time interval when exchange transfusion after birth was carried out. "~Time interval of onset of symptoms and signs after the procedure.
T a b l e 2 - NEC - five cases of umbilical vein infusion
Birth weight (g)
Period of gestation (weeks)
Respiratory difficulties Convulsion and irritability Hypoglycaemia Hypoglycaemia Respiratory distress and acidosis
3 4 5
M M M
5000 3005 NR
35 40 36
Onset orS and S ~ Duration (h )
1 7 72
20% Fructose 10% Dextrose D/Saline + 8.7% Na HCO 3
24h 12h 5th day
NR -~ Not recorded. *Time interval of onset of symptoms and signs after the procedure.
In m o s t cases initial plain r a d i o g r a p h y i n d i c a t e d t h e diagnosis a n d a c o n t r a s t e n e m a was n o t n e c e s s a r y at this stage. Later, h o w e v e r , a c o n t r a s t e n e m a using s o d i u m d i a t r i z o a t e ( H y p a q u e 25%) was h e l p f u l in t h e f u r t h e r surgical m a n a g e m e n t o f six p a t i e n t s . | n t e s t i n a l o b s t r u c t i o n at t h e o u t s e t m a y be due to s p a s m a n d o e d e m a (Fig. 3a, b ) ; w h e n t h e y have s u b s i d e d f i b r o u s strictures m a y r e m a i n . In t w o cases i n t r a p e r i t o n e a l abscess a n d i n t e s t i n a l fistulae were d e m o n s t r a t e d .
In all 15 p a t i e n t s t h e U V c a t h e t e r s h a d b e e n i n t r o d u c e d b l i n d l y a n d t h e i r p o s i t i o n s were n o t localised radiologically. In m o s t cases t h e c a t h e t e r s were withd r a w n p r i o r t o t h e p a t i e n t ' s a d m i s s i o n t o this h o s p i t a l so t h a t a r e t r o s p e c t i v e localisation h a s n o t b e e n possible; h o w e v e r , in t h r e e i n s t a n c e s it was possible t o ascertain t h e p o s i t i o n o f the c a t h e t e r as seen o n c h e s t or a b d o m i n a l r a d i o g r a p h s t a k e n at t h e r e f e r r i n g h o s p i t a l . In t w o cases t h e c a t h e t e r tip was in t h e right p o r t a l vein (Figs. 4, 5) while in t h e t h i r d it was in t h e left u p p e r p u l m o n a r y vein; t h e c a t h e t e r h a d passed
T a b l e 3 - N E C - a b d o m i n a l s y m p t o m s and signs
T a b l e 4 - Pathology (resected bowel or post-mortem speci-
m en) Abdominal distension Abdominal tenderness Vomiting bite stained Constipation Blood per rectum Abdominal mass (abscess) Diarrhoea
15 9 9 8 4 2 1
Ulcers Infarcts - mucosal to full thickness of bowel wall Perforations Peritonitis Pneumatosis intestinalis Congested vessels and inflammatory infiltrate in vessel walls
NECROTISING ENTERO-COLITIS FOLLOWING UMBILICAL VEIN CATHETERISATION Table 5 - NEC - radiological features Number
Abdominal distention (a) Distended loops of bowel with gas/fluid levels Obstruction 7 Ileus (peritonitis) 5
(b) Ascites (c) Pneumo-peritoneum Pneumatosis intestinalis Thumb-printing Abscess and fistula Intrahepatic gas
the mid-sagital line at T12 level before entering the ductus venosus (DV) (Fig. 7a). In the lateral projection the catheter describes a characteristic curve (Fig. 7b). The point of direction change in the curve marks the DV inlet. DISCUSSION
4 3 5 1 2 1
from the right to the left atrium via a patent foramen ovale and then into the pulmonary vein. To study the proper course of a catheter through the umbilical vein-ductus venosus-inferior vena cava segment as seen radiologically, attempts were made to catheterise fresh still-born foetuses. In only one o u t of six cases did a radio-opaque catheter (infant feeding tube size 8 Ft.) inserted blindly take the proper course and that at the second attempt (initially it passed into the left portal and splenic veins (Fig. 6)). When the UV catheter is properly positioned in the inferior vena cava (IVC), as seen in the anteroposterior projection, it gently curves to the right of
The clinical features and the radiological findings in NEC following UV catheterisation in these cases are similar to those described in other reported series (Mizrahi et aL, 1965, Santulli et al., 1975). Although the 27% mortality rate of this series is high it compares favourably with other reports. Pneumatosis intestinalis is an extremely valuable radiological sign of NEC but it should not be considered a prerequisite for diagnosis. Stevenson et al. (1971) reported a 97% incidence of pneumatosis intestinalis but it was seen in only 33% of our patients. Leonidas et aL (1976) and Rabinowitz and Siegle (1976) have shown that the sign is quite variable during the course of the illness. It needs to be emphasised that some patients without pneumatosis, or with minimal evidence of intramural gas, may have severe disease and ultimately succumb. The presence of intrahepatic gas may not necessarily suggest a bad prognosis as gas may have been introduced iatrogenically and, as illustrated, may lie around the catheter
Fig. l a , b - Extensive pneumatosis intestinals of the colon. (b) A magnified view of the right hypochondrial area show presence of intrahepatic gas in the portal vein radicles. 2~
CLINICAL RADIOLOGY Table 6 - Perforations of bowel (as seen at laparotomy) in 12 eases Colon Ileum Caecum Jejunum Stomach
7 3 2 1 1
a n d n o t spread p e r i p h e r a l l y i n t o t h e h e p a t i c radicles ( C a m p b e l l , 1971). T h e clinical a n d radiological features m a y n o t develop s i m u l t a n e o u s l y . In fact in some i n s t a n c e s diagnostic radiological changes o c c u r h o u r s b e f o r e the clinical features are m a n i f e s t e d ( R a b i n o w i t z and Siegle, 1976). T h e rad[ological d e t e c t i o n o f t h e d e v e l o p m e n t o f ascites m a y e x p l a i n clinical deteriorat i o n ; it m a y i n d i c a t e t h a t a p e r f o r a t i o n is i m m i n e n t or has already t a k e n place, even w h e n t h e r e is n o free p e r i t o n e a l gas. Ascites m a y also develop w i t h a simult a n e o u s d i s a p p e a r a n c e o f p n e u m a t o s i s i n t e s t i n a l i s or
Fig. 2 - A magnified view of the splenic flexure of the colon showing pneumatosis intestinalis (long arrow) and thumbprinting effect due to intramural haematomata (short arrows).
Fig. 3 - (a) Contrast enema performed simultaneously via the rectum and the ileostomy stoma reveal an obstruction at the splenic flexure (long arrow) and considerable spasm of the descending colon (short arrow). Also narrowed abnormal segment of the colon at the hepatic flexure. (b) A repeat examination two weeks later via ileostomy stoma shows relief of the obstruction and now residual narrowed areas at the hepatic and splenic flexures of the colon. They were resected and a further examination six months later did not reveal any new strictures.
UMBILICAL VEIN CATHETERISATION
Fig. 4a, b - A non-opaque catheter which has coiled up at the ductus venosus inlet (T12 level) and its tip lies in the right portal vein. In Fig. 4b the course of the same catheter is traced by black dots. Note findings seen on a chest radiograph.
Fig. 5 A n o t h e r case with malpositioned catheter in the right portal vein. Multiple small arrows indicate catheter position. Note presence o f gas around the catheter (a single large arrow) introduced iatrogenically.
Fig. 6 - A malpositioned radio-opaque catheter in the left portal a n d splenic veins o f a still-born foetus. (At second a t t e m p t the catheter was correctly placed (Figs. 7a, b).).
Fig. 7 - (a) Antero-posterior (supine) view. A normal proper course of the catheter through the umbilical v e i n - d u c t u s v e n o s u s - i n f e r i o r vena cava segment. Tip o f the catheter is in the right atrium (position confirmed at autopsy). (b) Lateral view. A characteristic curve of the properly positioned catheter. Arrow points to the site o f the ductus venosus inlet.
intrahepatic gas (Leonidas et al., 1973). Our experience confirms that of others that any part of the gastrointestinal tract can be affected. It must also be emphasised that the radiology does not necessarily reflect the true state of the bowel, nor the full extent of the lesion. The UV ascends in the free border of the falciform ligament towards the porta hepatis where it enters the left portal vein. The DV usually originates in the left portal vein directly opposite but slightly above the UV outlet. The DV ascends along the visceral (posterior) surface of the liver and joins the left hepatic vein just before it enters the IVC. Normally the DV remains patent for 15-20 days after birth (Meyer and Lind, 1966) and it is commonly presumed by those who carry out these procedures that this ensures the passage of a catheter, introduced for 11 cm via the UV, into the IVC or right atrium. Occasionally the DV inlet lies to the right of the UV outlet or it may close or stenose soon after birth. In these circumstances it would clearly be impossible for the catheter to reach the IVC and its tip would lie in one of the portal vein branches. There have been various studies on the localisation of blindly introduced UV catheters. In Campbell's (1971) series
32 out of 98 neonates (33%) had malposition of the catheter while this was considerably higher in the reviews of Peck and Lowman (1967) and Rosen and Reich (1970) - approximately 90 and 93% respectively. Corkery et al. (1968) have shown how easy it is to flood the portal circulation in cadavers from a catheter inserted 5 cm in the UV and they argue that this happens in vivo in a restless baby when the central venous pressure is raised. Touloukian et al. (1973) have also demonstrated that 81% of UV infusion is shunted through the hepatic circulation rather than flowing directly through the DV into the IVC. They have also shown by experimental study on newborn piglets that considerable haemodynamic disturbance occurs in the portal circulation during exchange transfusion. This supports the common observation during such procedures that if the baby strains or cries, the pressure within the UV rises whereas during deep inspiration it falls. Various theories of the aetiology of NEC in neonates have been put forward (British Medical Journal, 1970). Recently formula feeding has also been incriminated (Barlow et al., 1974). In our experience the basic lesion in neonatal NEC associated with UV
N E C R O T I S I N G E N T E R O - C O L I T I S F O L L O W I N G UMBILICAL VEIN C A T H E T E R I S A T I O N catheterisation is an infarct. Rectal bleeding supports the c o n c e p t o f a vascular lesion. This could be due either to the h a e m o d y n a m i c changes in the splanchnic circulation o f infusion through a malpositioned catheter or related to the particular infusate. In the present series infusions o f blood, bicarbonate, dextrose and fructose were associated with the lesion. It seems most likely that a c o m b i n a t i o n o f a malpositioned catheter and an 'irritant' infusate are particularly dangerous. The foregoing discussion, and other reported series, stress the importance of correct catheter placement. The venous catheter tip should be in the IVC or even the right atrium. It can be localised by the use o f radio-opaque catheters which are visualised on abdominal radiographs w i t h o u t the administration o f any c o n t r a s t m e d i u m . As illustrated in this series the antero-posterior (supine) and lateral radiographs can be taken with minimal handling o f the patient on a portable X-ray machine. The lateral view is essential to determine the exact location o f the catheter tip, the i m p o r t a n c e o f which has also been emphasised by Campbell ( i 971) and Rosen and Reich (1970). The radiological localisation of the radio-opaque catheter seems a sensible r e q u i r e m e n t prior to the c o m m e n c e m e n t of transfusion or infusion but it is surprising that in this c o u n t r y it is rarely carried out.
Acknowledgements. We are grateful to Dr A. H. Cameron for access to pathological material and to Mr A. Gourevitch ~br allowing two cases under his care to be included in this series. Our thanks to Dr R. Astley for his constant encouragement, to Medical Illustration Department for the Figures, and to Miss R. Mason for typing the manuscript. REFERENCES Barlow, B., Santulli, T. V., Heird, W. C., Pitt, J., Blanc, W. A. & Schullinger, J. N. (1974). An experimental study of acute neonatal enterocolitis the importance of breast milk. Journal of Pediatric Surgery, 9, 587-594. Berdon, W. E., Grossman, H., Baker, D. H., Mizrahi, A., Barlow, O. & Blanc, W. A. (1964). Necrotising enterocolitis in the premature infant. Radiology, 83, 879-887.
British Medical Journal (1970). Leading article, 3,121. Campbell, R. E. (1971). Roentgenological features of umbilical vascular catheterisation in the newborn. American Journal ofRoentgenology, 112, 68 76. Corkery, J. J., Dubowitz, V., Lister, J. & Moosa, A. (1968). Colonic perforations after exchange transfusion. British Medical Journal, 4, 345 349. Genersich, A. (1891). Bauchfellenentzundung beim neugeborenen in folge yon perforation des ileums. Archives Pathological Anatomy, 126,485-494. Leonidas, J. C., Hall, R. T. & Armoury, R. A. (1976). Critical evaluation of the roentgen signs of neonatal necrotizing enterocolitis. Annales de Radiologie, 19, 123-132. Leonidas, J. C., Krasna, 1. H., Fox, H. A. & Broder, M. S. (1973). Peritoneal fluid in necrotising enterocolitis: a radiological sign of clinical deterioration. Journal of Pediatrics, 82, 672 675. Lividatis, A., Wallgreen, G- & Faxelius, G. (1974). Necrotising enterocolitis after catheterisation of the umbilical vessels. Acta Paediatriea scandinavica, 63,277-282. Master, S. P., Truscott, D. E., Templeton, A. C. & Middlemiss, J. M. (1973). Neonatal necrotising enterocolitis. British Journal of Radiology, 46, 1063-1069. Meyer, W. W. & Lind, J. (1966). Ductus venosus and mechanism of its closure. Archives of Diseases of Childhood, 41,597-605. Mizrahi, A., Barlow, O., Berdon, W. E., Blanc, W. E. & Silverman, W. A. (1965). Necrotising enterocolitis in premature infants. Journal of Pediatrics, 66, 697-- 706. Orme, R. L. E. & Eades, S. M. (1968). Perforations of the bowel in the newborn as a complication of exchange transfusion. British Medical Journal, 4, 349-351. Peck, D. R. & Lowman, R. M. (1967). Roentgen aspects of umbilical vascular catheterisation in the newborn. Radiology, 89, 874 877. Rabinowitz, J. G. & Siegle, R. L. (1976). Changing clinical and roentgenographic patterns of necrotising enterocolitis. American Journal of Roentgenology, 126, 560 566. Rosen, M. S. & Reich, S. B. (1970). Umbilical venous catheterisation in the newborn. Identification of correct positioning. Radiology, 95,335~340. Santulli, T. V., Schullinger, J. N., Heird, W. C., Gongaware, R. D., Wigger, J., Barlow, B., Blanc, W. A. & Berdon,W. E. (1975). Acute necrotising enterocolitis in infancy: a review of 64 cases. Pediatrics, 55,376-387. Stevenson, J. K., Oliver, T. K., Graham, B., Bell, R. S. & Gould, V. E. (1971). Aggressive treatment of neonatal necrotising enterocolitis: 38 patients with 25 survivors. Journal of Pediatrics Surgery, % 28-35. Touloukian, R. J., Kadar, B. S. & Spencer, R. P. (1973). Gastro-intestinal complications of neonatal umbilical venous exchange transfusion: a clinical and experimental study. Pediatrics, 51, 36 43.