Pediatr Radiol (2013) 43:318–329
DOI 10.1007/s00247-012-2573-1
REVIEW
A pattern-based approach to bowel obstruction
in the newborn
Charles M. Maxfield & Brett H. Bartz & Jennifer L. Shaffer
Received: 22 June 2012 / Revised: 21 October 2012 / Accepted: 29 October 2012 / Published online: 12 December 2012
# Springer-Verlag Berlin Heidelberg 2012
Abstract Intestinal obstruction is common in newborns,
and the radiologist plays a critical role in the care of these
children. Diagnosing and managing the potentially
obstructed newborn can be challenging, especially given
the myriad underlying pathologies that range from benign
to acutely life-threatening. A familiarity with the most com-
mon diagnoses is essential, but equally important to the
radiologist is a systematic approach to management of the
child in this setting. We propose an approach based on the
recognition of eight radiographic patterns, five upper gas-
trointestinal examination (UGI) patterns and four contrast
enema patterns. Recognition of these patterns directs further
imaging when necessary and allows triage of children who
can be managed medically, those requiring elective or ur-
gent surgery and those requiring emergent surgery.
Keywords Newborn . Neonatal . Obstruction .
Gastrointestinal
Introduction
The radiologist plays a crucial role in the diagnosis and
management of the vomiting newborn. This common and
potentially life-threatening presentation is not limited to
children’s hospitals. All radiologists must be familiar with
the workup and management of potential bowel obstruction
in the newborn. Etiologies of vomiting in the newborn
CME activity This article has been selected as the CME activity for
the current month. Please visit the Society for Pediatric Radiology Web
site at www.pedrad.org on the Education page and follow the
instructions to complete this CME activity.
C. M. Maxfield (*) : B. H. Bartz : J. L. Shaffer
Department of Radiology, Duke University Medical Center,
Box 3808, Durham, NC 27710, USA
e-mail: charles.maxfield@duke.edu
include surgical and non-surgical causes ranging from the
benign and nearly universal gastroesophageal reflux (GER)
to life-threatening midgut volvulus [1]. In between the be-
nign and the life-threatening are myriad etiologies of vomit-
ing that produce different patterns on abdominal
radiographs, contrasted upper gastrointestinal examination
(UGI), and contrast enema. A familiarity with these patterns
allows triage of cases that can be managed medically, those
requiring elective surgery and those requiring emergent
surgery.
We present a pattern-based approach to the workup and
management of the vomiting newborn. Through identifica-
tion of eight patterns on abdominal radiograph, five patterns
on UGI and four patterns on contrast enema, the radiologist
can competently and confidently manage this common and
potentially life-threatening clinical presentation.
Clinical presentation
Vomiting newborns sometimes present with additional signs
and symptoms, such as feeding intolerance, abdominal disten-
sion, failure to pass meconium and peritoneal signs [2]. The
symptoms do not reliably discriminate the causes of vomiting,
although they can provide clues to the underlying etiology.
Vomiting typically presents earlier with proximal
obstructions than it does with more distal obstructions [3].
Duodenal atresia, for example, typically presents with the
first feeding. The various causes of duodenal stenosis,
whether intrinsic or extrinsic, present at more variable times,
depending on the degree of stenosis. Distal obstructions
(ileal and colonic) progress over the first 24–48 h of life,
often with more abdominal distension [2]. Midgut volvulus
presents more variably, 50% during the first week and 60%
by the end of the first month [2], often with a sudden onset
of bilious vomiting after initially tolerating feeds.
Pediatr Radiol (2013) 43:318–329
The bilious or non-bilious character of the vomiting is not
a reliable discriminator for the presence of midgut volvulus.
Most neonates with bilious emesis do not, in fact, have
midgut volvulus [2]. The presence of bile simply reflects
that the obstruction is below the ampulla of Vater. For
instance, the vomiting in 70% of cases of duodenal atresia
is bilious [3], and in distal (ileal and colonic) obstructions
bilious vomiting [4] typically develops over hours to days.
Meconium passage can provide additional clues to diag-
nosis. Normal newborns pass meconium in the first 24 h of
life. Non-passage of meconium suggests a complete distal
obstruction. Infants with Hirschsprung disease or functional
obstructions might pass small amounts of meconium [5].
Similarly, the surgeon’s physical exam is not always a
reliable discriminator. Even in cases of midgut volvulus, the
abdomen is typically soft and non-tender until ischemia devel-
ops [2]. These relatively benign symptoms and physical exam
findings prior to the onset of catastrophic bowel infarction
justify a high index of suspicion and explain the central
importance of the radiologist in managing the vomiting infant.
With near-universal utilization of prenatal US screening,
many congenital bowel obstructions are detected in utero
[6]. Duodenal atresia, as manifested by a fluid-filled double
bubble plus polyhydramnios, is more reliably detected than
duodenal stenosis, malrotation and distal obstructions [7].
Pitfalls in the diagnosis of congenital obstructions are well
documented and necessitate a post-natal imaging workup
before surgery is contemplated [6].
Eight patterns on radiographs: definitions
The postnatal imaging workup of the vomiting infant often
begins with an abdominal radiograph. We propose that
recognition of the eight patterns on the frontal supine ab-
dominal radiograph shown in Fig. 1 helps narrow the dif-
ferential diagnosis and, more important, triage the neonate
with bowel obstruction to the next phase of management—
either additional imaging or admission to the medical or
surgical team for treatment.
Significance of the eight patterns and associated
management
Normal (Fig. 1)
A normal abdominal radiograph might seem reassuring in
this setting until one realizes that many cases of midgut
volvulus present with a normal abdominal radiograph [8].
If the vomiting is bilious or if there is another reason to
suspect malrotation with midgut volvulus, the workup
should proceed to UGI.
319
Double bubble (Fig. 1)
The true double bubble—two upper abdominal gas bubbles,
one on each side of the midline, and no distal gas—can be
considered diagnostic of duodenal atresia (Fig. 2) [9]. A
UGI is unnecessary, both because this pattern is highly
specific for duodenal atresia and because contrast (barium
or iodinated) will not characterize the abnormality any better
than does air.
Because the obstruction caused by duodenal atresia is
already long-standing at birth, the proximal duodenum is
markedly dilated. This is in contradistinction to midgut
volvulus, an acute obstruction that does not distend the
duodenum significantly.
The treatment for duodenal atresia is elective surgical
repair. The critical question, however, is whether this pattern
warrants any concern for midgut volvulus, which would
necessitate emergent, rather than elective, surgery. There is
considerable debate in the literature concerning whether
midgut volvulus needs to be excluded in the setting of a
newborn with a double bubble, because of concern that
midgut volvulus could either produce a double bubble pat-
tern [10] or complicate duodenal atresia [11]. Some believe
such concern is unwarranted [12, 13]. What is undeniable is
that if air is not passing distal to the duodenum, neither will
contrast material; a UGI would not rule out malrotation.
The single bubble (Fig. 1)
The true single bubble, with no gas beyond a distended
stomach, is characteristic of gastric (antral or pyloric) atresia
[14]. It is important to note, however, that gastric atresia is
exceedingly uncommon. More often, this pattern is character-
ized by a stomach that is partially decompressed by vomiting
or a nasogastric tube, with no gas distally. In such cases, the
pattern must be considered incompletely characterized. Fre-
quently, a subsequent radiograph will reveal better distension.
If not, the pattern might be fully characterized by a portable
radiograph obtained following insufflation of the stomach
with approximately 10–20 ml of air through the nasogastric
tube. One of three patterns will then become manifest, two of
which establish diagnoses and obviate UGI evaluation: (1) a
single bubble with distal gas (discussed below), which should
prompt an emergent UGI; (2) a true double bubble, diagnostic
of duodenal atresia, an indication for elective surgery (Fig. 3);
(3) a true single bubble, distended and without any distal gas, a
finding indicative of a complete gastric outlet obstruction,
such as the rare gastric atresia.
Triple bubble (Fig. 1)
If confidently identified, this pattern is indicative of
jejunal atresia [15], with dilation of the stomach,
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Fig. 1 The eight radiographic patterns. a Normal. Gas is distributed
uniformly throughout non-dilated stomach and bowel. The L1 inter-
pedicular distance can be used as an internal standard for the upper
limits of normal for bowel distension. b The double bubble. This
pattern consists of two large rounded lucencies (bubbles) in the upper
abdomen, with no distal gas. The left-side bubble is larger and more
superiorly located. The right-side bubble is slightly smaller but clearly
distended, with its epicenter to the right of the spine. c The single
bubble. Gas is limited to the stomach. The stomach may be distended
or may be decompressed by an enteric tube or vomiting. The key to
recognizing this pattern is the absence of any gas distal to the stomach.
d Triple bubble. There are three lucencies in the upper abdomen. The
third bubble is dilated and is often oriented horizontally. There is no
gas distal to the three large bubbles, which rarely extend below the
duodenum and a jejunal bowel loop just proximal to the
atretic segment (Fig. 4). One might argue that the con-
fident recognition of this pattern obviates UGI examina-
tion, but if all three loops are not distended, this pattern
is easily confused with other radiographic patterns that
necessitate UGI to exclude malrotation and midgut
volvulus.
Many surgeons also request a contrast enema to exclude
an additional colonic atresia (which would change surgery)
or meconium ileus (which might obviate surgery). A search
for additional atresias is reasonable because jejunal atresia is
thought to be most often secondary to a vascular insult [16],
which can cause more than a single atresia. This is in
contradistinction to duodenal atresia, which is thought to
Pediatr Radiol (2013) 43:318–329
level of the iliac crests. To assign this pattern with confidence, the third
gas bubble must be contiguous with the more superior bubbles. e
Single bubble with distal gas. Gas is present in the stomach,
which is sometimes distended. There is also a small amount of
gas distal to the stomach in a limited number of decompressed
bowel loops. f Double bubble with distal gas. This pattern implies
the presence of gas distal to an otherwise classic double bubble
pattern. Distal gas is variable in amount, but distal loops are
typically decompressed. g Diffusely dilated loops. In this pattern,
dilated, non-separated bowel loops fill the distended abdomen and
extend into the pelvis. h Dilated, scattered bowel loops. This
pattern is characterized by bowel loops that are mildly dilated
but noncontiguous, featureless in appearance and scattered ran-
domly throughout the abdomen and pelvis
be caused by failure of recanalization [3] and is therefore
typically an isolated atresia.
Single bubble with distal gas (Fig. 1)
Gastric distention out of proportion to non-distended
distal bowel loops is a very common and typically
benign finding at any age, including the neonatal peri-
od. However, in the setting of bilious vomiting, this
pattern must be considered as ominous, as it is well
described in association with midgut volvulus [8]. Even
though midgut volvulus obstructs distal to the gastric
outlet, the obstruction is too acute to dilate the duode-
num appreciably, and so the pattern frequently suggests
Pediatr Radiol (2013) 43:318–329 321

Fig. 4 Triple bubble in a newborn girl who had abnormal prenatal US.
Fig. 2 Double bubble in a newborn boy intolerant of first feed.
Initial radiograph demonstrates three rounded upper abdominal lucen-
Abdominal radiograph demonstrates dilated stomach and duodenum
cies and no distal gas. Elective surgery confirmed jejunal atresia
with no distal gas. Elective surgery was performed without additional
imaging and confirmed duodenal atresia

a gastric outlet obstruction. This pattern should trigger
UGI examination in this clinical setting.
Double bubble with distal gas (Fig. 1)
Whether one is dealing with a single or double bubble, the
presence of even a tiny amount of distal gas is a critical
finding that alters the differential diagnosis and necessities
UGI examination.
In the setting of the double-bubble pattern, the identifi-
cation of distal gas (Fig. 5) virtually excludes duodenal
atresia (exception being the rare case of the bifid common
bile duct inserting above and below the atretic segment) [17]
and widens the differential diagnosis to include midgut
volvulus, along with duodenal stenosis/web.
Ultimately, the vomiting infant with a double bubble
needs surgery, whether there is distal gas or not. It is the
radiologist’s role to assist the surgeon in determining wheth-
er the surgery is elective/urgent or emergent. This is deter-
mined with the help of UGI.
Diffusely dilated loops (Fig. 1)
It can be impossible to distinguish colon from small bowel
in infants, particularly when the bowel is distended. The
appearance of multiple (four or more) dilated (wider than
the L1 interpedicular distance) loops of bowel throughout
the abdomen and extending into the pelvis (Fig. 6) is sug-
gestive of a low obstruction, typically at the level of the
ileum or colon. Contrast enema is indicated to evaluate

Fig. 3 Duodenal atresia initially

presenting as a single bubble. a
Initial abdominal radiograph
obtained after newborn girl
vomited first feed demonstrates
no air distal to a decompressed
stomach. b The subsequent
radiograph demonstrates
gaseous distension of stomach
and distended duodenum, with
no distal gas. Notice the
nasogastric tube had migrated
out of the stomach, allowing the
distension, and demonstration of
the classic double bubble pattern
322
Fig. 5 Double bubble with distal gas. This infant boy had vomited
since birth, prompting this abdominal radiograph, which demonstrates
two rounded upper abdominal lucencies, with additional gas in non-
dilated distal small bowel loops. UGI (not shown) demonstrated a
partial duodenal obstruction and normally positioned DJJ. A duodenal
web was found at surgery 1 month later
further. A contrast enema is usually diagnostic and can be
therapeutic in the case of meconium ileus.
Radiographs demonstrating this pattern sometimes pro-
vide additional clues to a specific diagnosis. For instance, a
soap bubble appearance, or absence of air-fluid levels,
Fig. 6 Pattern of diffusely dilated loops. This girl, born at 24 weeks’
gestational age, had become progressively distended over the first 72 h
after birth. The abdominal radiograph demonstrates diffusely dilated
bowel caused by a functional obstruction of prematurity
Pediatr Radiol (2013) 43:318–329
suggests meconium ileus [18]. Alternatively, multiple dilat-
ed loops with a single disproportionately distended loop of
bowel suggest a distal atresia, often colonic [4]. These clues
do not obviate a contrast enema, however.
If the infant with this radiographic pattern is very ill with
bilious vomiting and peritoneal signs, midgut volvulus
should be considered. In this rare case, the diffuse dilation
is not secondary to obstruction but rather to an ileus sec-
ondary to ischemia or infarction [19]. It is therefore impor-
tant in this setting that a normal contrast enema be followed
immediately by UGI to exclude midgut volvulus.
Dilated, scattered bowel loops (Fig. 1)
Whether encountered in the infant, the older child or the adult,
this pattern can be recognized by the experienced radiologist
as that of a “sick belly” (Fig. 7). The loops are dilated but
noncontiguous, featureless in appearance, and scattered ran-
domly throughout the abdomen and pelvis. This pattern can be
seen with distal obstruction (such as complicated meconium
ileus), proximal obstruction (midgut volvulus) and in utero
bowel perforation. The radiologist should be prepared to
perform UGI and contrast enema before surgery.
Five UGI patterns
At least four and as many as six of the eight radiographic
patterns presented should prompt UGI as the next examination
Fig. 7 Pattern of dilated scattered bowel loops on abdominal radio-
graph obtained in a 1-day-old girl with bilious vomiting. Based on
physical exam findings, the girl was taken directly to surgery, where
midgut volvulus was found
Pediatr Radiol (2013) 43:318–329
in the workup of the vomiting newborn. Clearly, the most
immediate goal of the UGI examination is to exclude malro-
tation with midgut volvulus. The radiologist must be aware of
the various appearances of malrotation and midgut volvulus
but otherwise should not approach the UGI examination feel-
ing the necessity to make a specific diagnosis. Rather, the
radiologist’s goal in performance of the UGI in this setting
should be to categorize the vomiting infant into one of three
groups, based on clinical management: (1) those requiring
emergent surgery, (2) those requiring elective surgery and
(3) those who can be treated non-surgically.
We propose that the recognition of the following five
patterns on the UGI series narrows the differential diagnosis
and allows assignment into one of the three management
paths (Fig. 8).
Significance of each of the five UGI patterns
Normal (Fig. 8)
A normal UGI excludes structural causes of vomiting. Vom-
iting is presumed secondary to any of the large number of
Fig. 8 The five patterns on UGI. a Normal. A normal UGI demon-
strates prompt gastric emptying, a normal-caliber duodenum, and a
normally positioned DJJ. Normally, the duodenum crosses to the left of
the left vertebral body pedicle and rises to the level of the duodenal
bulb. On the lateral view, the duodenum remains retroperitoneal
throughout its course. The radiologist should use the lateral view to
ensure the entire duodenum remains posterior. b Malposition of the
DJJ. The duodenum fails to cross the midline and ascend to its normal
position in the left upper quadrant. There is no duodenal dilatation,
323
possible non-surgical causes [20], the more common causes
being gastroesophageal reflux and sepsis.
Malposition of the duodenojejunal junction (Fig. 8)
Given malposition of the duodenojejunal junction (DJJ) in a
vomiting infant (Fig. 9), one must assume that the vomiting
is from intermittent midgut volvulus. While that is not
always the case, and should not necessarily be assumed in
the older child or in the absence of vomiting, this finding is
an indication for emergent surgery in the infant with bilious
vomiting. We acknowledge that the differentiation between
a malpositioned and a normally positioned DJJ can be
subtle, particularly in the setting of ileus or distal bowel
obstruction, which can displace the normal DJJ because of
ligamentous laxity and result in a false-positive UGI [21].
We refer the reader to excellent reviews of this topic [22].
Corkscrew duodenum (Fig. 8)
This pattern (Fig. 10) is diagnostic of midgut volvulus
and requires emergent surgery with detorsion and Ladd
procedure [23].
narrowing or spiraling. c Corkscrew duodenum. The duodenum spirals
inferiorly without crossing to the left of the bony spine. d Complete
duodenal obstruction. Contrast material does not pass beyond the mid-
duodenum. Air, however, is seen in more distal bowel loops, ruling out
duodenal atresia. e Partial duodenal obstruction with normally
positioned DJJ. This pattern is assigned when a duodenal narrow-
ing (and typically, dilation proximally) is seen, but sufficient
contrast material is able to traverse the narrowing to document a
normally positioned DJJ
324 Pediatr Radiol (2013) 43:318–329

Fig. 9 Duodenojejunal malposition in a 3-day-old. UGI, performed

after a single episode of bilious vomiting, demonstrates an abnormal
duodenum that fails to cross the midline or ascend to the level of the
duodenal bulb. The infant was sent emergently to surgery, where
malrotation was confirmed. There was no midgut volvulus at the time
of surgery

Complete duodenal obstruction (Fig. 8)

Like the corkscrew duodenum, this pattern indicates the

need for emergent surgery. The appearance is strongly sug-
gestive of midgut volvulus, perhaps resulting from a tighter
twist than would produce the corkscrew pattern (Fig. 11).
Duodenal atresia can be excluded on the basis of air distal to
the duodenum and by the fact that the proximal duodenum is
not markedly dilated.

Fig. 11 Midgut volvulus in a 4-day-old girl. a Abdominal radiograph

demonstrates a mildly distended stomach, with gas seen distally in non-
dilated bowel (single bubble with distal gas). b Single image from UGI
examination demonstrates a complete obstruction to contrast agent at the
level of the proximal duodenum (arrow). The stomach is distended with
air. The girl was sent emergently to surgery with the presumptive diag-
nosis of midgut volvulus, which was confirmed at surgery

This pattern requires patience by the radiologist. Time must

be allowed for contrast agent to pass the mid-duodenum and
reach the DJJ. It is only with the failure of contrast agent to pass
that this pattern can be assigned. Recognition of this pattern
necessitates emergent surgery with the presumptive diagnosis
of midgut volvulus.

Partial duodenal obstruction with normally positioned DJJ

Fig. 10 Corkscrew duodenum in an infant girl who developed bilious
vomiting at 2 days old. UGI demonstrates spiraling of the duodenum
over the bony spine. Based on this finding, the girl was sent directly to
surgery, where midgut volvulus was confirmed
(Fig. 8)
A persistent duodenal narrowing demonstrated on UGI is
typically a surgical lesion in a vomiting infant. The narrow-
ing can be extrinsic (Ladd band, annular pancreas) or
Pediatr Radiol (2013) 43:318–329
Fig. 12 Partial duodenal obstruction with normal DJJ in a 3-week-old
girl with congenital heart disease had persistent non-bilious vomiting.
Single image from UGI, with contrast injected through an enteric tube
placed in the proximal duodenum, demonstrates a focal narrowing of
the descending duodenum (arrow). Contrast agent passes distally to
document normal position of the DJJ (arrowhead), allowing elective
surgery. At surgery, an annular pancreas narrowed the descending
duodenum
intrinsic (duodenal web, duodenal stenosis) to the duo-
denum [24]. It is not always possible—or necessary—
for the UGI to distinguish the cause of the partial
obstruction. It is important only that the UGI distin-
guish malrotation (with Ladd band or midgut volvulus)
from the other causes of partial duodenal obstruction.
This is best done by patiently waiting for contrast agent
to pass through the stenotic area and document the
position of the DJJ.
If a normally positioned DJJ can be documented (Fig. 12),
malrotation is excluded and surgery can be performed elec-
tively rather than emergently, at a time when the child can be
optimally prepared for surgery. If a normal DJJ position
cannot be documented, then emergent surgery is indicated.
Fig. 13 The four patterns on contrast enema. a Microcolon. The entire
colon is small in luminal diameter (less than the height of an upper lumbar
vertebral body) and nondistensible. b Short microcolon. The colon is
small or “micro” (as defined above) in caliber and its retrograde filling
325
Fig. 14 Meconium ileus in an infant with microcolon who presented
with vomiting, abdominal distension and failure to pass meconium.
Note caliber of colon is less than the height of an upper lumbar
vertebral body. Contrast material is refluxed from a microcolon into
terminal ileal loops (arrows) outlining multiple filling defects indica-
tive of meconium ileus. Obstruction was successfully relieved with
contrast enema. Note also reflux into the appendix (arrowhead)
Four patterns on contrast enema
The radiographic pattern of multiple, diffusely dilated bowel
loops in the setting of a newborn who is vomiting and has
not passed meconium suggests a low bowel obstruction and
should prompt a contrast enema.
The radiologist encounters one of four patterns in perfor-
mance of a contrast enema in this setting. Each pattern offers
a very limited differential diagnosis, which accounts for
about 98% of cases, and allows appropriate management
decisions, which might be surgical or nonsurgical (Fig. 13).
terminates at some point short of the cecum. c Colonic caliber change.
There is a demonstrable transition from small- or normal-caliber colon
distally to more distended colon proximally. d Normal. The colon is of
normal and uniform caliber throughout
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Fig. 15 Ileal atresia in an infant with microcolon who, like the infant
in Fig. 14, presented with vomiting, abdominal distension and failure
to pass meconium. Contrast material is refluxed into decompressed
terminal ileum (arrows), which is devoid of meconium filling defects.
No contrast material could be refluxed into more proximal ileum. Mid-
ileal atresia was confirmed at surgery
Significance of the four contrast enema patterns
Microcolon (Fig. 13)
Normally, the developing fetal colon is stimulated by dis-
tension from meconium, sloughed cells and secreted fluid.
A high-grade distal ileal obstruction prevents sufficient
Fig. 16 Short microcolon, diagnostic of colonic atresia. Single frontal
image from contrast enema performed in a newborn with progressive
abdominal distension over the first 2 days after birth. Contrast agent
opacifies a small-caliber colon but could be refluxed no further prox-
imal than splenic flexure (arrow)
Pediatr Radiol (2013) 43:318–329
Fig. 17 Small left colon syndrome. Image shows colonic caliber
change at the splenic flexure (arrows) characteristic of small left colon
syndrome. Passage of plugs of meconium and abdominal decompres-
sion followed within hours of this contrast enema
bowel contents from reaching the colon, leaving it narrow
and non-distensible, i.e. a microcolon [25].
The two most common causes of high-grade distal ileal
obstruction leading to this pattern are meconium ileus and
ileal atresia. Meconium ileus is a bowel obstruction caused
by the inspissation of abnormal meconium in the distal
ileum. Most children with meconium ileus have cystic fi-
brosis [26]. Ileal atresia is caused by intrauterine vascular
insult with subsequent reabsorption [16].
Fig. 18 Hirschsprung disease. Image shows colonic caliber change in
the proximal sigmoid colon (arrows) in a 5-day-old boy, demonstrated
on a lateral view from a contrast enema. Rectal biopsy confirmed
Hirschsprung disease
Pediatr Radiol (2013) 43:318–329
Fig. 19 The algorithm for the diagnostic imaging workup of the newborn with potential bowel obstruction
The two can usually be distinguished by the contrast
enema. If refluxed contrast reaches ileal loops containing
multiple filling defects, a diagnosis of meconium ileus can
be made (Fig. 14). If no reflux can be achieved beyond
small-caliber ileum devoid of filling defects, then ileal atre-
sia is the presumptive diagnosis (Fig. 15). This distinction is
important because uncomplicated meconium ileus can be
treated with contrast enemas [27] whereas ileal atresia
requires surgery [4].
It should be noted that total colonic Hirschsprung
disease can also produce a microcolon appearance
[28]. This, however, is an uncommon presentation of
an uncommon entity.
Short microcolon (Fig. 13)
Recognition of a short or incomplete microcolon (Fig. 16)
allows a diagnosis of colonic atresia. The challenge is to be
327
confident that sufficient back pressure was achieved with
the contrast enema such that the termination of the contrast-
filled colon truly represents an atretic segment. Correlation
with the abdominal radiograph often shows a massively
dilated terminal loop just proximal to the atresia. Treatment
is surgical [29].
Colonic caliber change (Fig. 13)
A demonstrable transition from small- or normal-caliber
colon distally to more dilated colon proximally narrows
the differential diagnosis to two entities: Hirschsprung dis-
ease and small left colon syndrome (SLCS). Both are func-
tional obstructions. Hirschsprung disease results from
absence of ganglion cells that innervate the colon, and this
disease must be treated surgically [30]. SLCS is caused by a
functional immaturity of those ganglion cells, and it usually
resolves after the contrast enema [31].
328
Several imaging features distinguish these two entities.
The location of the colonic caliber change is often helpful.
SLCS is the presumptive diagnosis when the caliber transi-
tion is at the splenic flexure (Fig. 17), assuming that meco-
nium evacuation and decompression follow the contrast
enema within 24–48 h. Hirschsprung disease is the likely
diagnosis if the transition is elsewhere in the colon (Fig. 18),
especially at the classic rectosigmoid level but even at the
splenic flexure in a baby whose abdominal symptoms do not
resolve after contrast enema.
Other discriminators have been described [32]. SLCS
might be favored over Hirschsprung disease when the rec-
tum is more distensible or the caliber change more abrupt. A
history of maternal diabetes or maternal treatment with
magnesium sulfate for eclampsia might also suggest SLCS.
Ultimately, questionable cases should undergo rectal biopsy
to exclude Hirschsprung disease.
Normal (Fig. 13)
In the setting of a vomiting newborn with a distended
abdomen and an abdominal radiograph suggesting low ob-
struction, a normal contrast enema should not necessarily be
reassuring. The radiologist’s immediate concern should be
for malrotation with midgut volvulus. It is very uncommon
for midgut volvulus to produce a radiographic pattern sug-
gesting low obstruction, but it is well described [33] and
should be excluded with a UGI before the baby leaves the
fluoroscopy suite.
If midgut volvulus is excluded with the UGI, then
Hirschsprung disease should be reconsidered. The contrast
enema is interpreted as normal in about half of cases of total
colonic Hirschsprung disease [34], but this is a rare entity.
More frequently, a subtle caliber change is not appreciated
in the case of classic low-segment Hirschsprung disease. It
has been reported that Hirschsprung disease is missed on the
initial contrast enema in 25% of cases [35]. Consideration
should therefore be given to a rectal biopsy in this setting.
This differential diagnosis includes a functional obstruc-
tion causing colonic dysmotility, often resulting from im-
maturity of the neuronal apparatus. This is most often seen
in extremely premature infants [36].
Conclusion
We have proposed a simplified, pattern-based approach to
serve as a framework for the practicing radiologist in the
care and management of bowel obstruction in the neonate
(Fig. 19). This is not presented as an all-inclusive review of
the causes of newborn bowel obstruction, nor is it meant to
imply that the recognition of patterns and assignment of
diagnoses is always straightforward. But by becoming
Pediatr Radiol (2013) 43:318–329
familiar with the spectrum of imaging findings and common
diagnoses and by using a systematic approach to imaging
strategies, the radiologist can work with his or her surgical
and neonatology colleagues to provide the best care to the
neonate with bowel obstruction.
Conflicts of interest None.
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