Practical Imaging Approach to Bowel

Obstruction in Neonates: A Review and Update

Janet R. Reid, MD

he newborn with intestinal obstruction can elicit unease

in many radiologists and neonatologists. The clinical
presentation may be nonspecific, with bilious or nonbilious
vomiting, abdominal distension, and often failure to pass
meconium evident. The etiology of neonatal intestinal obstruction could lie anywhere from esophagus to anus. Some
disorders, such as malrotation with midgut volvulus, are lifethreatening and require prompt decision-making, whereas
others, such as duodenal atresia, which often have a similar
clinical presentation, may be managed semielectively. This is
one scenario in which the application of a logical approach,
radiology, provides the most definitive information. The
overarching goal of this article is to provide a helpful and
practical imaging strategy for evaluating newborn intestinal
obstruction and to review the myriad causes as well as their
characteristic imaging features.

Imaging Strategy
The 3-step approach is based on the abdominal radiographic
findings in neonates with suspected intestinal obstruction.
First, initial review should rule out ominous signs, such as
pneumoperitoneum (Fig. 1), intestinal pneumatosis, or portal venous gas (Fig. 2), because these children require emergency surgical assessment. Second, one should look for classic signs, such as the following: a nasogastric tube lodged in
proximal pouch in esophageal atresia, a double bubble in
duodenal atresia, bubbly gas within the chest in congenital
diaphragmatic hernia, a triple bubble or large featureless
loop in jejunal atresia, and a soap bubble pattern within the
right lower quadrant in meconium ileus. The third step involves deciding whether the bowel gas pattern is most consistent with a high or low intestinal obstruction pattern.1 The
high intestinal obstruction pattern shows few scattered airfilled loops in the upper abdomen, whereas the low intestinal
obstruction pattern demonstrates many (3) dilated gas-

Section of Pediatric Radiology, Childrens Hospital Cleveland Clinic, Cleveland, OH.

Address reprint requests to Janet R. Reid, MD, Section of Pediatric Radiology, Childrens Hospital Cleveland Clinic, 9500 Euclid Avenue, Mail
Code Hb6, Cleveland, OH 44195. E-mail: reidj@ccf.org

0037-198X/12/$-see front matter 2012 Elsevier Inc. All rights reserved.

doi:10.1053/j.ro.2011.07.003

filled loops (Figs. 3 and 4). It is important to recognize that

caution should be taken when interpreting intestinal obstruction pattern on the abdominal radiograph. For an example, assessment of the abdominal radiograph too early after
delivery may misrepresent the obstruction as high because
the gas has not yet made its way through unobstructed loops
after birth. In addition, one must not attempt to differentiate
small from large bowel in the newborn because loops are
relatively featureless and do not lie in anatomically predictable locations. Once designated as high or low intestinal obstruction, further imaging studies, such as barium upper gastrointestinal (GI) study or water-soluble contrast enema, can
be obtained for a definitive diagnosis.

Imaging Technique
High intestinal obstruction may be attributable to esophageal
atresia with or without fistula, duodenal atresia, malrotation
with or without midgut volvulus, or jejunal atresia. Air may
be injected through the nasogastric tube as negative contrast, which further defines the level of intestinal obstruction.
An upper GI study for high intestinal obstruction is performed immediately, whereby the newborn is given contrast
barium through bottle or nasogastric tube. The neonate is
imaged in the right lateral decubitus or semiprone position,
and images are taken to demonstrate a normal duodenal Csweep (a duodenal course of back, down, anterior and up on the
oblique lateral projection). Once the barium filled duodenal
C-sweep is demonstrated, frontal supine images are obtained to
show the duodenojejunal junction coursing to the left of the L1
pedicle at the same level of the first portion of the duodenum to
confirm normal bowel rotation. At the end of the study, the
residual barium is withdrawn from the stomach through the
tube to prevent aspiration of refluxed contrast.
Low intestinal obstruction is most commonly attributable
to ileal atresia, meconium ileus, Hirschsprung disease, small
left colon syndrome, colonic atresia, or imperforate anus.
These cases can be definitively diagnosed with enema and a
slightly hyperosmolar water-soluble contrast. The study is
performed by placing a small caliber (8F) flexible Foley-type
catheter in the distal rectum just beyond the anal verge and
taping it well at the perineum. With the infant in left lateral
21

J.R. Reid

22

Figure 3 Newborn with bilious vomiting. Left lateral decubitus radiograph shows a paucity of bowel gas with a few air fluid levels
(arrows), consistent with high intestinal obstruction.
Figure 1 Newborn with respiratory distress and abdominal distension. Supine abdominal radiograph shows massive free air (arrows).

Imaging Findings
decubitus position, contrast is slowly infused by gravity drip
as images are taken during the initial filling phase of the
rectosigmoid colon. Contrast is then followed through the
colon to the level of obstruction or refluxed into terminal and
distal ileum for meconium ileus. Care must be taken to avoid
rectal stimulation, and it is unwise to inflate a rectal balloon
because of potential rectal perforation.

Figure 2 Newborn with in utero midgut volvulus. Supine radiograph

of the right upper quadrant is windowed and cropped to enhance
detection of portal venous gas (arrows) and pneumatosis intestinalis
(arrowheads).

General Diagnostic Considerations

High intestinal obstructions are often suspected prenatally
and diagnosed readily by newborn examination or radiography. All causes for low intestinal obstruction, except imperforate anus, should be definitively diagnosed at enema. The 2
most common ileal causes for low intestinal obstruction in
neonates, meconium ileus and ileal atresia, will show a mi-

Figure 4 Newborn with abdominal distension. Supine radiograph

shows multiple dilated bowel loops throughout the abdomen and
extending to below the umbilicus, consistent with low intestinal
obstruction pattern.

Imaging bowel obstruction in neonates

Figure 5 Premature newborn with esophageal atresia who was ventilated with failure of the nasogastric tube to pass. Supine chest
radiograph shows the endotracheal tube (white arrow) and the nasogastric tube (black arrow), terminating in a blind-ending upper
esophageal pouch. Note air in the stomach (arrowheads) implies a
distal fistula to the tracheobronchial tree.

23

Figure 6 Newborn with esophageal atresia who presented with failure to pass the nasogastric tube. Supine abdominal radiograph
shows a proximal esophageal pouch (arrow) and gasless abdomen
indicating the rare absence of a distal fistula in esophageal atresia.

High Intestinal Obstruction

tric tube in the newborn (Fig. 5). Subtypes of EA include

atresia with fistula to the proximal esophageal pouch, fistula
to the distal pouch, fistula to neither or to both, and finally
the intact esophagus with an oblique fistula to the trachea
(H or N-type).4
The abdominal radiograph typically shows a gasless abdomen for EA without fistula (Fig. 6). Otherwise, the abdominal radiograph will most often be normal, because
the most common type of EA allows air to bypass the
atretic esophagus through a distal fistula to the trachea.
Preoperative imaging includes radiographs of the chest
and abdomen. Air may be injected into the proximal
pouch as negative contrast. The introduction of positive
contrast is potentially dangerous because of the risk of
aspiration or extravasation into the tracheobronchial tree.
There will always be some degree of tracheomalacia in
patients with EA. Postoperatively, an esophagram can be
safely performed with the use of near iso-osmolar watersoluble contrast with evaluate the caliber of the anastomosis and exclude postoperative leak and residual or new
fistula (Fig. 7).

Esophageal Atresia
Esophageal atresia (EA) results from abnormal tracheoesophageal cleavage during development.3 There may be an associated fistula. The incidence of EA is 1 in 3000 births, with an
equal incidence in males and female infants.3 The VACTERL
(ie, vertebral, anal atresia, cardiac, tracheoesophageal fistula,
renal and limb anomalies) association may be found in up to
50% of cases.3 Although sometimes suspected from prenatal
ultrasound findings of microgastria or polyhydramnios, the
classic clinical history of EA is failure of passage of an orogas-

Duodenal Atresia
Duodenal atresia (DA) results from lack of canalization of the
periampullary segment of the foregut early in gestation.5 The
incidence is 1 in 6-10,000 live births with no gender predilection.5 The classic clinical presentation of DA is bilious
emesis and radiographic double bubble (dilated stomach
and proximal duodenum). However, in reality, many are diagnosed prenatally by the ultrasound double bubble sign
and polyhydramnios (Figs. 8 and 9).6 Duodenal atresia is
associated with biliary and other anomalies in 50% of cases.7

crocolon (ie, an unused colon) from failure of meconium to

pass through the level of obstruction. In ileal atresia, there
will be an abrupt cutoff between decompressed ileum and the
dilated loop above, whereas in meconium ileus, there will be
multiple filling defects in the progressively distended distal
ileum as contrast is advanced above the obstruction. The
filling defects represent the thick, impacted, tar-like succus
entericus, typical for meconium ileus. The 2 most common
colonic causes for low intestinal obstruction also have characteristic features on enema. Neonatal small left colon syndrome shows a normal caliber rectum, larger than the sigmoid (a normal rectosigmoid index), and a small caliber
descending colon with abrupt transition to normal caliber at
the splenic flexure. Hirschsprung disease shows the opposite
finding, with a recto-sigmoid index below 1 and a transition
to normal caliber most often at the distal sigmoid with distended loops above the obstruction. Finally, the rarest of
causes, colonic atresia, will also show microcolon with an
abrupt cutoff at the site of bowel atresia.2

24
As many as one-third of patients with DA have trisomy 21,
yet only 15% of fetuses with trisomy 21 have DA.3 Other
associations include preduodenal portal vein, which is rarely
the primary cause of obstruction in these infants, and annular
pancreas in 20%.3 Duodenal atresia/stenosis may also be seen
with VACTERL association. Imaging includes a supine abdominal radiograph in the stable newborn with nonbilious
vomiting. Air may be injected as negative contrast with exclude duodenal stenosis over atresia.8 Rarely, malrotation
with midgut volvulus may present with high intestinal obstruction pattern on abdominal radiographs and mimic DA.9
With this clinical concern, an upper GI study is performed
with the use of single contrast barium. If high-grade obstruction is demonstrated with upper GI study, then urgent laparotomy is indicated to exclude malrotation with midgut volvulus. Ultrasound or magnetic resonance imaging (MRI) is of
limited value in defining the anatomy before surgical correction for DA. With duodenal stenosis, an upper GI study is
performed with barium to better define the anatomy and
distinguish between web (which rarely shows a windsock
deformity in the newborn), stenosis, annular pancreas and
atresia with Y-connection of the common bile/pancreatic
duct beyond the ampulla of Vater (Fig. 10).
Malrotation and Midgut Volvulus
Intestinal malrotation represents embryologic nonrotation
or lack of complete 270 of foregut rotation around the
superior mesenteric artery (SMA) pedicle. In this condi-

Figure 7 Two-month-old infant after surgical repair of esophageal

atresia. Lateral image from iso-osmolar water-soluble swallow
shows the mild short segment narrowing (white arrow) at the surgical anastomosis and a recurrent fistula (black arrows) between the
esophagus and trachea at the carina.

J.R. Reid

Figure 8 Newborn with trisomy 21 and duodenal atresia. Supine

abdominal radiograph shows the classic double bubble of duodenal atresia with dilation of the stomach (asterisk) and first portion of
the duodenum (arrow).

tion, the mesentery is narrow-based, and the small bowel

is therefore prone to rotate around its axis, resulting in
midgut volvulus in a substantial number of patients.10 The
incidence of midgut volvulus is 1 in 500 live births and
almost always presents in the first year of life with 80%
presenting in the newborn period.11 Affected patients

Figure 9 Prenatal ultrasound of fetus with duodenal atresia shows a

double bubble with dilation of the stomach (arrow) and duodenum (asterisk).

Imaging bowel obstruction in neonates

Figure 10 Infant with duodenal web who presented with feeding intolerance. Upper gastrointestinal (UGI) study shows a dilated second portion of the duodenum containing a curvilinear filling defect (arrows).

present with bilious vomiting, often with no other signs or

symptoms. Although only 38% of newborns with bilious
emesis will have midgut volvulus, this condition is a surgical emergency and mandates immediate imaging evaluation for a correct diagnosis to prevent potential bowel

Figure 11 Infant with malrotation who presented with bilious emesis.

UGI supine image demonstrates a duodenojejunal junction that is too
low and too far to the right (arrow). The normal duodenojejunal junction (asterisk) is to the left of the L1 pedicle at the same level as the first
portion of the duodenum, often crossing the greater curvature of the
stomach.

25

Figure 12 Newborn with midgut volvulus who presented with bilious vomiting. Doppler ultrasound showed reversal of the SMA/
SMV (not shown) and the classic whirlpool of the SMA at the site
of midgut volvulus (arrows). (Color version of figure is available
online.)

ischemia/infarction and inevitable short gut syndrome

that occurs with delay in diagnosis.11
Malrotation is almost always present with heterotaxy syndromes,12 congenital diaphragmatic hernia, omphalocele,
and gastroschisis. It is seen with greater frequency in patients
with biliary atresia. An upper GI study is performed with
barium through bottle or nasogastric tube. Malrotation is
present if there is failure of the following: normal course of
duodenal C sweep on the oblique lateral projection and duodenojejunal junction to the left of the L1 pedicle and at the
level of the first portion of the duodenum (Fig. 11). Highgrade intestinal obstruction from midgut volvulus will lead to
a pattern that may mimic duodenal atresia; however, the
duodenum is not as distended because of the shorter duration of obstruction in cases of midgut volvulus. In experienced hands, ultrasound has been used to identify the retroperitoneal position of the third portion of the duodenum to
exclude malrotation.13 Ultrasound with Doppler may demonstrate superior mesenteric vein (SMV) to the left of SMA on
transverse imaging and the whirlpool sign for malrotation
with midgut volvulus (Fig. 12).14 These signs have been described on computed tomography and MRI as well.
Jejunal Atresia
Jejunal atresia results from ischemic insult to the developing
jejunum.3 Rare familial forms of jejunal atresia include the
apple-peel small bowel syndrome and multiple intestinal
atresias.15 The incidence of isolated jejunal atresia is between
1 in 3-5000 live births and has been associated with prenatal
amniocentesis with methylene blue injection into the amniotic sac.3,16 Affected patients present with increasing abdom-

26

Figure 13 Newborn infant with jejunal atresia who presented with

emesis and abdominal distension. Frontal supine radiograph shows
a markedly dilated featureless midabdominal loop (arrows) typical
for proximal intestinal (jejunal) atresia.

inal distension and feeding intolerance but are often not

acutely ill. Abdominal radiographs show a paucity of bowel
gas with dilated loops in the upper abdomen and sometimes
the triple bubble sign (dilated stomach, duodenum and
proximal jejunum). Often the jejunum is impressively dilated
and featureless coursing across the upper abdomen (Fig. 13).
Upper GI with positive contrast is rarely necessary in patients
with classic clinical presentation and characteristic abdominal radiographic findings of jejunal atresia. A water-soluble
contrast enema is helpful to exclude microcolon, which
would suggest the presence of additional atresias in the ileum
(Fig. 14).1

Low Intestinal Obstruction

Ileal Atresia
Ileal atresia results from a local ischemic event to the developing ileum.3 The incidence is approximately 1 in 3000
live births.3 Ileal atresia is most often isolated but can lead
to perforation and meconium peritonitis. Radiographs of
the abdomen in neonates with ileal atresia usually show
multiple dilated, air-filled loops throughout the abdomen
consistent with a low intestinal obstruction (Fig. 15). A
water-soluble contrast enema is necessary for making a
definitive diagnosis in almost all cases. Ileal atresia will
demonstrate a microcolon (unused colon) on enema leaving only one other condition, meconium ileus, in the differential diagnosis (Fig. 16). Gentle persistence with the
enema will lead to the blind-ending loop at the level of
atresia in patients with ileal atresia. Prenatal ultrasound in

J.R. Reid

Figure 14 Newborn infant with maternal history of polyhydramnios

and jejunal atresia. Supine radiograph from a water-soluble enema
shows microcolon (white arrows) despite the classic massively dilated loop of bowel in the midabdomen (black arrowheads) of jejunal atresia. As simple jejunal atresia should not have microcolon, the
enema alerts the surgeon to more than one level of atresia, at both
the jejunal and ileal levels.

affected fetuses shows an abdomen full of moderately dilated anechoic loops showing hyperperistalsis (Fig. 17).
Meconium Ileus
Meconium ileus, which may be suspected prenatally, is a
result of thick succus entericus (secondary to lack of lubrication because of abnormal sodium-chloride pump) effectively
blocking the distal ileum during fetal and early neonatal life.
A patient with meconium ileus on contrast enema has cystic
fibrosis until proven otherwise. In contrast, only 15% of patients with cystic fibrosis will have meconium ileus.3 Prenatal
ultrasound typically shows dilated echogenic bowel, whereas
postnatal ultrasound demonstrates dilated loops of bowel
containing hyperechoic material with hypoperistalsis (Fig.
18).17 Recent study has shown that prenatal MRI may be a
promising imaging modality in differentiating between ileal
atresia and meconium ileus based on signal intensity of the
succus entericus on T2-weighted images. It has been reported that the signal intensity of succus entericus is very low
in atresia and intermediate in ileus on T2-weighted MR images.17 However, the differences in signal intensity throughout the small bowel on T1-weighted images must be interpreted with caution in attempting to determine levels of
bowel obstruction from prenatal MRI.18 The differential diagnosis for echogenic bowel on prenatal ultrasound includes
fetal systemic infection, chromosomal anomalies, and fetal
swallowing of blood early in gestation from occult placental
intra-amniotic hemorrhage. A majority of affected patients
have abdominal radiographs that are consistent with low in-

Imaging bowel obstruction in neonates

Figure 15 Newborn with abdominal distension. Supine radiograph

shows multiple dilated bowel loops (arrows) stacked throughout
the abdomen extending to below the umbilicus consistent with low
intestinal obstruction pattern.

testinal obstruction. A minority of cases may show a bubbly

gas pattern in the right abdomen similar to soap bubbles
appearance described by Neuhauser in 1946.19 Complications of meconium ileus include in utero perforation resulting in meconium pseudocyst (which may calcify) and small

Figure 16 Newborn with ileal atresia who presented with abdominal

distension. Image from water-soluble enema shows microcolon
(unused colon) with a blind end (arrow) at the ileal atresia with
massive dilation of upstream small bowel loops (arrowheads).

27

Figure 17 Prenatal ultrasound in a woman with polyhydramnios

shows a dilated midabdominal loop with mildly echogenic liquid
contents (asterisks) with decompressed distal loops (arrowheads).

bowel or pseudocyst volvulus. Microcalcifications are most

commonly intramural and not intraluminal in patients with
meconium ileus.20 Water-soluble enema is necessary to make
the diagnosis, but advancement of the contrast beyond the
level of obstruction is also therapeutic and will almost always
avoid surgical exploration. Enema shows extreme microcolon and multiple filling defects in the terminal ileum with
progressive dilation of the ileum upstream (Fig. 19). Multiple
therapeutic enemas (using hyperosmolar contrast diluted to

Figure 18 Prenatal ultrasound image shows echogenic bowel (arrows) in a fetus with meconium ileus.

28

Figure 19 Newborn with bilious vomiting and abdominal distension. Image from water-soluble enema shows microcolon. There is
filling of the appendix and multiple filling defects are encountered
in the terminal ileum (arrow) without abrupt cutoff to suggest ileal
atresia. With persistence, there was filling of dilated meconiumfilled ileum beyond the level of obstruction (not shown); the enema
is both diagnostic and therapeutic in patients with meconium ileus.

twice that of serum osmolarity) are often necessary to completely evacuate the ileum.6
Hirschsprung Disease
Failure of craniocaudad migration of ganglion cells to the
submucosal (Meiners) and intermuscular (Auerbachs)
plexus of the distal large bowel results in failed relaxation of
the involved distal colonic segment of bowel with upstream
obstruction in Hirschsprung disease (HD). Histology will
show positive acetylcholinesterase staining and the presence
of thickened dysplastic nerves in the biopsy specimen.6
There is a 4:1 male-to-female ratio in HD.6 The disease involves a short segment of the rectosigmoid in 90% but can
involve longer segments proximal to this level in a continuous fashion.6 Ultrashort and longer-segment disease is less
common than short-segment HD. Total colonic HD is the
rarest form, with an equal incidence demonstrated in male
and female patients.6 HD has no racial predilection. However, total colonic disease is more common in white patients
and associated with trisomy 21 (in 2%-16%), hydronephrosis, and dysplastic kidneys.6 Total colonic HD may be part of
a systemic neurocristopathy with central hypoventilation
(Ondines curse) and multifocal neuroblastoma.21
Children with HD present with failure to pass meconium
within the first 24 hours of birth and progressive abdominal
distension. The most serious complication related to delay in
diagnosis is Hirschsprung enterocolitis, where there is transmural inflammatory ischemia and inflammation of the colon
prone to perforation. Imaging of HD begins with abdominal
radiographs that show a low intestinal obstruction pattern.

J.R. Reid

Figure 20 Newborn with abdominal distension and failure to pass

meconium. Supine cross-table lateral radiograph shows massive
pneumoperitoneum (asterisk) displacing the anterior abdominal
wall outward (arrows).

Hirschsprung enterocolitis will show markedly dilated bowel

and may show pneumatosis, free air and/or portal venous gas
(Fig. 20).
For evaluation of HD, an enema should be performed with
the use of water-soluble contrast. Characteristic enema findings for HD include narrow caliber rectum, rectosigmoid
index 1 (transverse diameter of the rectum greater than the
sigmoid on the lateral decubitus image taken as soon as the
rectosigmoid fills), a transition point, and serrations/contractions of the distal aganglionic colon (20%) (Fig. 21).6
Total colonic HD may appear normal on enema, or show
diffuse shortening or the rare diffuse microcolon.22 Delayed
emptying of contrast over 24 hours is not a specific sign, and
evacuation may be normal in HD.6 In newborns with HD, the
false-negative rate for transition point and abnormal rectosigmoid index is as high as 35%. With no other identifiable
cause for low intestinal obstruction, a rectal suction biopsy
must be performed to exclude HD.6 It is important to note
that the radiographic transition point does not correspond to
the surgical transition point. Diagnosis is confirmed with
surgical biopsy, and the surgeon must continue with biopsy
until the specimen reveals ganglion cells to determine the
surgical transition point.
Neonatal Small Left Colon Syndrome
Formerly known as meconium plug, this condition was frequently confused with the completely unrelated meconium ileus; therefore, the name has changed to reflect its radiographic
appearance. There is no gender or racial predilection.23 In 50%
of cases, there is a history of maternal diabetes, and a minority is

Imaging bowel obstruction in neonates

Figure 21 Three-week-old infant with HD who presented with progressive abdominal distension and failure to pass meconium at
birth. Lateral image from water-soluble enema shows an abnormal
rectosigmoid index where the rectum (white arrow) is narrower
than the sigmoid (black arrow) suspicious for Hirschsprung disease.
Rectal biopsy confirmed the diagnosis of HD.

associated with maternal magnesium sulfate administration for

pre-eclampsia.6 Often self-limited, neonatal small left colon syndrome appears to improve rapidly following water-soluble enema. The characteristic enema finding in neonates with small
left colon syndrome is normal caliber rectum and sigmoid with
a small caliber left colon (not as small as the microcolon of
meconium ileus or ileal atresia), with an abrupt transition to
normal caliber at the splenic flexure (Fig. 22). There is usually a
long continuous plug of meconium within the narrowed segment, hence the original name of meconium plug (Fig. 23).
Meconium plugs are seen in all other causes for low intestinal
obstruction; therefore, this is not a specific for small left colon
syndrome.

29

Figure 22 Infant with small left colon syndrome and a diabetic mother;
the infant presented with feeding intolerance. Image from water-soluble enema shows normal rectal caliber with relative narrowing of the
sigmoid and distal descending colon (arrows) with abrupt transition to
normal caliber at the proximal to mid descending colon (arrowhead).

urinary bladder or urethra in boys and vagina in girls, for

a high or intermediate atresia. Low lesions have a perineal
cutaneous fistula. The diagnosis of imperforate anus is
usually made during the newborn physical examination,
where the anus is identified as a blind-ending pit, and the
child fails to pass meconium. Imaging plays an important

Colonic Atresia
Colonic atresia, like jejunal and ileal atresia, is thought to be
caused by a prenatal vascular event resulting in an ischemic
obliteration of the colonic lumen.6 There is no gender or
racial predilection.24 This is the rarest form of intestinal atresia and has no known associations.24 Newborns with colonic
atresia usually present with progressive abdominal distension and vomiting. Abdominal radiographs often show a
nonspecific, low intestinal obstruction pattern; however, in
some cases there is characteristic massive distension of the
cecum above a competent ileocecal valve. Water-soluble enema demonstrates a microcolon (unused colon) that terminates blindly at the point of atresia (Fig. 24).
Imperforate Anus
The incidence of imperforate anus is 1-4 in 5000 live
births and is equal in frequency in boys and girls.2 This
disorder is along the spectrum of cloacal malformation,
whereby there is a blind-ending rectum and a fistula to the

Figure 23 Large meconium plug evacuated during water-soluble enema for neonatal small left colon syndrome. (Color version of figure
is available online.)

J.R. Reid

30

Figure 25 Sagittal supine ultrasound image through the perineum in

a newborn with imperforate anus shows the distance (double arrowhead) between the skin surface and rectal pouch (). Symphysis
pubis (SP).
Figure 24 Newborn with colonic atresia who presented with low
intestinal obstruction pattern and increasing abdominal distension.
Image from water-soluble enema performed after barium UGI study
shows a short microcolon with abrupt termination (arrow) at the
mid transverse colon.

role in identifying the level of atresia and in excluding

associated tethered cord spectrum seen in 35%-39% of
cases.25,26 Ultrasound of the spine can be easily performed
without sedation in the newborn and is an excellent
screening tool. The level of the atresia was traditionally
determined through an inverted or prone radiograph
(forcing nondependent air to the distal most aspect of the
colon), but more recently, ultrasound has proven more
accurate in differentiating intermediate and high (supralevator) versus low (translevator) lesions with an accuracy
of 95% and a specificity of 86%.2,27 This distinction is
important in determining surgical approach. Ultrasound is
performed on the supine infants perineum by the use of a
sagittal approach, whereby the distance from the
perineum to the distal rectal pouch is measured. Distances
15 mm represent low lesions, and those greater represent intermediate and high lesions (Fig. 25).2 An important radiographic sign of rectourinary fistula in boys is the
presence of intraluminal calcifications (enteroliths) resulting from the admixture of urine and meconium; this can
be detected on prenatal ultrasound.28 Postnatal MRI is
most useful after surgical repair in evaluating the position
of the rectal pull through and integrity of the levator
sling.29

Conclusions
Many cases of newborn intestinal obstruction now arrive
with a preliminary diagnosis determined from prenatal ultra-

sound and/or MRI. For the remainder, a practical 3 step

approach based on the abdominal radiographic findings will
guide the radiologist to the appropriate subsequent imaging
test which will, in turn, lead to prompt and accurate diagnosis. Radiographs may show life-threatening signs or identify
classic features for high intestinal obstruction, with no need
for further imaging. The contrast enema leads to definitive
diagnosis in most cases of newborn low intestinal obstruction.

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