The Neonatal Colon: An Anatomic Approach to Plain Films

PAUL K. KLEINMAN,”2 PATRICIA WINCHESTER,’ MORTON A. MEYERS,’

AND GERALD ABBOTT’

An appreciation of haustral anatomy as well as the The taeniae serve as longitudinal cables upon which
anatomic relationships of the colon serve as the basis of the circular muscle fibers are fixed at right angles. The
plain film colon identification in the patient beyond in- colon is foreshortened by the taeniae, and contraction
fancy. An evaluation of the newborn colon in the normal of the circular muscle fibers produces plications run-
state and with low colonic obstruction indicates that these
ning perpendicular to the taenia. The result is the forma-
principles apply here as well. Newborns with suspected
tion of three haustral rows with septations produced by
intestinal obstruction should be studied in multiple pro-
interhaustral folds [3]. Lineback [1] noted characteristic
jections early in their clinical course. A search should
be made for haustrations and characteristic anatomic re- haustral sacculations in fetuses after 20 weeks of gesta-
lationships of the colon, as well as gas in the rectum. tion.
Although clear differentiation of large from small bowel The 270#{176}counterclockwise rotation of the colon is
obstruction may not always be possible, these principles completed after 10 weeks of gestation. By 20 weeks, the
should serve as a basis for a systematic approach to the ascending and descending portions become fixed in a
newborn abdominal plain film. netropenitoneal location; only occasionally does a short
mesentery persist [4]. At this time the colon is relatively
constant in its relationships to adjacent anatomic struc-
Introduction
tunes. Although further growth of the colon and mesen-
In cases of suspected intestinal obstruction in the new-
teny occurs and descent of the cecum may continue into
born or infant, the ability to differentiate colon from
infancy, the basic anatomic relationships of the colon
small bowel on the plain film is crucial in limiting the dif-
persist into adult life. Thus at as early as 20 weeks of
ferential diagnosis. It is generally assumed that plain gestation, both the intrinsic pattern and the anatomic
film identification of the colon in the newborn, in the relationships of the colon are established.
absence of gas in the rectum, is unreliable if not impos-
sible. In the older child or adult, the colon is clearly nec-
ognizable by distinctive haustral folds and its relation-
ship to other anatomic structures. We have confirmed Radiologic Observations
that haustral folds are well developed at birth, and since Unequivocal evidence of gas in the colon is provided
the course and relationships of the colon vary little be- by the presence of gas-filled bowel in the immediate pre-
tween infants and adults, specific identification of the sacnal region. This is best appreciated on the prone or
large intestine is possible on the plain film when appre- inverted abdominal film, since gas rises to the most dis-
ciable intraluminal gas is present. Analysis of the plain tal portion of the colon [5]. When rectal gas is absent in
film in cases of distal colonic obstruction in the newborn cases of suspected newborn intestinal obstruction, fur-
allows definite localization of the obstruction to the then attempts to localize gas on the plain film are often
colon in a significant number of cases. abandoned.
Colonic haustnations were demonstrated in 81 of 105
neonates in barium enema studies by Henderson and
Embryolog ic and Structural Considerations
Bniant [6]. Figure 1 demonstrates the findings at autopsy
Haustral structure and development were extensively in a newborn infant. Prominent haustrations are evident
studied by Lineback in the 1 92Os [1 , 2]. Meyers et al. [3] in the transverse colon and, to a lesser extent, in the de-
recently reviewed haustral anatomy, correlating it with scending colon. Figure 2 shows a striking haustral pat-
the radiographic appearance. These studies form the tern in a newborn after barium enema. In the older pa-
basis of an understanding of the muscular organization tient, haustral folds may be mistaken for the semicircular
of the colon. folds of the small bowel. This does not ordinarily pre-
The colon is thrown into haustral sacculations by the sent a problem in the newborn, since distinct small
abbreviated length and contraction of three distinct bowel folds are rarely demonstrated even following a
bands of longitudinal muscle, the taeniae coli. The tae- barium meal [7, 8].
niae form as condensations of muscle bundles within With the appearance on barium enema studies in
the outer longitudinal layer and are present in the hu- mind, a search on the plain film will often reveal gas-
man fetus after 12 weeks of gestation (150 mm) [1, 2]. filled loops of bowel demonstrating a distinct haustral

Received April 26, 1976; accepted after revision July 16. 1976.
Presented at the annual meeting of the Radiological Society of North America. Chicago. December 1975.
1 Department of Radiology. New York Hospital-Cornell Medical Center, 525 East 68th Street. New York. New York 10021.
2 Present address: Department of Radiology. National Naval Medical Center, Bethesda, Maryland 20014. Address reprint requests to P. K. Kleinman.

Am J Roentgeno! 128:61-64, January 1977 61

 62 KLEINMAN ET AL.

Fig. 1.-Autopsy findings in 6-day-old infant. Transverse colon con- Fig. 3.-Plain film of newborn showing transverse colon (t) with
taming prominent haustrations closely parallels greater curvature of haustrations (arrows). d descending colon.
stomach (ST). Diaphragm has been deflected to show relationship of
radiographic (arrow) and anatomic (arrowhead) splenic flexures
to spleen (5). L Liver.

Fig. 2.-Abdominal film of newborn after barium enema showing very

prominent haustrations.
pattern (fig. 3). Because of changes in muscle tone and
varying degrees of distension, only a few haustral mark-
ings may be present, usually in the transverse colon.
Nevertheless, their identification indicates the presence Fig. 4.-Lateral projection after barium enema in newborn showing
of gas within the colon. anatomic (A) and radiographic (R) splenic flexures and prominent
haustrations (arrowheads). a ascending colon, d descending colon.
Identification of the colon on plain film can be further
enhanced if a gas-filled loop of bowel can be recognized (fig. 1 ). A single loop of bowel closely paralleling the
within a characteristic course and relationship to other entire gastric greaten curvature can be identified as the
abdominal structures [9]. The ascending and descending transverse colon (figs. 3 and 5). Identification of trans-
colon lie in a retropenitoneal location in most individ- verse colon in the absence of haustrations is not possible
uals; the remainder have a short mesentery. They can be when a redundant gastrocolic ligament is present, since
precisely located on lateral projection as posteriorly the colon will not lie in complete continuity with the
lying structures (fig. 4). greater curvature.
The transverse colon is closely related to the greaten There is constancy in the location of the anatomic
curvature of the stomach via the gastnocolic ligament splenic flexure. This portion of the colon is fixed poste-
 NEONATAL COLON 63

Fig. 5.-Abdominal film of premature infant showing gas-filled trans

verse colon paralleling gastric greater curvature. Radiographic (arrow)
and anatomic (arrowhead) splenic flexures evident. While haustrations
are not visible, anatomic relationships allow identification of gas-filled
loop as colon.

nionly at the phnenicocolic ligament [10], which forms the

);-j;;. ‘ .

support for the inferior edge of the spleen and also de- j-,’

marcates the transition from the mesentenic transverse

colon to the extrapenitoneal descending colon (figs. 4
and 5). On plain films (fig. 5), gas-filled colon may be
seen to extend from an anterosupenior location in the Fig. 6.-Abdominal film of newborn with Hirschsprung’s disease
left upper quadrant (radiographic splenic flexune) along showing dilated ascending and transverse colon with haustrations. Note
interhaustral folds (arrows)
the medial surface of the spleen to become fixed at the
phrenicocoiic ligament (anatomic splenic flexure). The
descending colon then extends retnopenitoneally to the
abdominal distension. With progressive distension and
mesentenic sigmoid (fig. 4).
atony of large and small bowel, confusing supenimposi-
tion of shadows occurs precluding evaluation. However,
Application
it is apparent that colonic gas can be identified in a sig-
To test the usefulness of these approaches to colon nificant number of patients with low colonic obstruction.
identification, a retrospective examination of plain ab-
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64 KLEINMAN ET AL.

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