Original Article: Gastroenterology
Cutoffs and Characteristics of Abnormal Bowel
Dilatation in Pediatric Short Bowel Syndrome
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Oona Nieminen, MD, *Maria Hukkinen, MD, PhD, †Reetta Kivisaari, MD, PhD,
*
*
Annika Mutanen, MD, PhD, ‡Laura Merras-Salmio, MD, PhD, and *§Mikko P. Pakarinen, MD, PhD
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ABSTRACT
Objectives: Although excessive intestinal dilatation associates with wors-
ened outcomes in pediatric short bowel syndrome (SBS), little is known
about the natural history and definition of pathological dilatation. We
addressed fore-, mid-, and hind-gut dilatation in children with SBS, who
had not undergone autologous intestinal reconstructive (AIR) surgery, in
relation to controls.
Methods: SBS children without history of AIR surgery (n = 59) and age-
matched controls without any disclosed intestinal pathology (n = 140) were
included. Maximum diameter of duodenum, small bowel (SB), and colon
were measured in each intestinal contrast series during 2002 to 2020 and
expressed as diameter ratio (DR) to L5 vertebrae height. Predictive ability
of DR for weaning off parenteral nutrition (PN) was analyzed with Cox
proportional hazards regression models using multiple cutoffs.
Results: Duodenum (DDR), SB (SBDR), and colon (CDR) DR were 53%,
183%, and 23% higher in SBS patients compared to controls (P < 0.01 for
all). The maximal DDR and SBDR measured during follow-up is associated
with current PN dependence and young age. DDR correlated with SBDR
(r = 0.586, P < 0.01). Patients with maximal DDR less than 1.5, which was
also the 99th percentile for controls, were 2.5-fold more likely to wean off
PN (P = 0.005), whereas SBDR and CDR were not predictive for PN dura-
tion.
Conclusions: All segments of remaining bowel, especially SB, dilate above
normal levels in children with SBS. In SBS children without AIR surgery,
PN dependence and young age is associated with duodenal and small intes-
tinal dilatation, while duodenal dilatation also predicted prolonged PN.
Key Words: diameter ratio, enteral autonomy, intestinal failure
(JPGN 2023;77: 720–725)
I
ntestinal failure (IF) is defined as reduced intestinal capacity
for absorption, requiring long-term parenteral nutrition (PN) to
maintain sufficient nutrition and growth (1,2). Short bowel syn-
drome (SBS) due to extensive bowel resection is the most common
reason for IF (3). Children with SBS possess significant adaptive
capacity to bowel resection, and they have better chances of reach-
ing enteral autonomy compared to adults (4). After resection, the
Received April 21, 2023; accepted August 26, 2023.
From the *Department of Pediatric Surgery, Pediatric Liver and Gut
Research Group, Pediatric Research Center, Helsinki University Hos-
pital and University of Helsinki, Helsinki, Finland, the †Department of
Pediatric Radiology, Medical Imaging Center, Helsinki University Hos-
pital and University of Helsinki, Helsinki, Finland, the ‡Department of
Pediatric Gastroenterology, Helsinki University Hospital and University
of Helsinki, Helsinki, Finland, and the §Department of Women’s and
Children’s Health, Karolinska Institute, Stockholm, Sweden.
Address correspondence and reprint requests to Oona Nieminen, MD,
Helsinki University Hospital, New Children’s Hospital, PO BOX 281,
00029 Helsinki, Finland (e-mail: oona.nieminen@fimnet.fi).
720
What Is Known
• In short bowel syndrome (SBS) remaining bowel
undergoes structural changes.
• Dilatation of remaining intestine associates with
prolonged parenteral nutrition (PN) dependence.
• Remaining small intestinal length is the major deter-
minant of enteral autonomy.
What Is New
• All segments of remaining bowel dilate to abnormal
levels in children with SBS.
• The degree of duodenal and small bowel dilatation
is greatest in young PN dependent patients with
SBS.
• Duodenal diameter ratio to fifth lumbar verte-
bra height >1.5 strongly predicts prolonged PN
dependence
remaining bowel undergoes structural changes to compensate the
loss of absorptive surface, including increase in width and length
(4–9). Anatomical factors improving the likelihood of weaning off
PN include remaining small bowel (SB) length over 40–50 cm,
intact ileocecal valve (ICV), and preserved colon (5,6,10–12). In
children with SBS, excessive bowel dilatation associates with pro-
longed PN dependence and worsened outcomes (9). It is thought
bowel dilatation impairs motility and promotes bacterial over-
growth (BO), predisposing to bowel derived bloodstream infections
and IF-associated liver disease (13–15). Symptomatic bowel dilata-
tion is commonly treated with autologous intestinal reconstructive
(AIR) surgery, designed to reduce harmful dilatation while simul-
taneously increasing SB length and thereby improving bowel func-
tion and outcomes (5,12,15,16). However, correct patient selection
for AIR surgery remains challenging as cutoff for abnormal harm-
ful bowel dilatation remains unclear (17).
Sources of Funding: This study was supported by research grants from the
Sigrid Jusélius Foundation (MPP), the Finnish Pediatric Research Foun-
dation (MPP), and Helsinki University Hospital Fund (MPP).
The authors report no conflicts of interest.
Supplemental digital content is available for this article. Direct URL cita-
tions appear in the printed text, and links to the digital files are provided
in the HTML text of this article on the journal’s Web site (www.jpgn.
org).
Copyright © 2023 by European Society for European Society for Pediatric
Gastroenterology, Hepatology, and Nutrition and North American Soci-
ety for Pediatric Gastroenterology, Hepatology, and Nutrition.
DOI: 10.1097/MPG.0000000000003934
JPGN • Volume 77, Number 6, December 2023
 JPGN • Volume 77, Number 6, December 2023
Our previous study showed SB diameter more than twice
of lumbar vertebrae height associated with reduced probability of
weaning off PN and survival (9,18). However, that study included
patients who had undergone AIR surgery without normal controls,
and addressed only SB dilatation, while significance of duodenal
and colonic dilatation remains unclear (18). Here, by analyzing
duodenum, SB, and colon dilatation in relation to normal con-
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trols while excluding patients who had undergone AIR surgery, we
aimed to address natural history and define cutoffs for abnormal
bowel dilatation in pediatric SBS.
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METHODS
Patients
For this retrospective study, all patients with IF due to SBS
treated at our intestinal rehabilitation program during 2002 to 2020
(n = 98) were included. Patients with other etiology of IF such as
pseudo-obstruction and mucosal enteropathies were excluded. IF-
SBS was defined as SB resection over 50% of age-adjusted ref-
erence values or PN duration over 2 consecutive months (19,20).
We excluded SBS patients who had undergone any type of AIRs
prior or post contrast series (n = 31) and those who had no contrast
series available for analysis (n = 8), leaving in total 59 patients for
inclusion.
SBS patients underwent intestinal contrast series to investi-
gate dysmotility or BO, to rule out intestinal obstruction, or as part
of the follow-up program every 6–24 months in patients receiving
PN or recently weaned off PN. Medical records were reviewed for
SBS etiology, remaining intestinal anatomy, gestational age, birth
weight, duration of PN, presence of ICV, and operative treatment.
Remaining intestinal length were expressed as absolute values and
percentage of age-adjusted reference values (19). Our previously
described management protocol for SBS, was refined in 2009,
whereafter continuous tube feeding has been avoided while favor-
ing ad libitum oral feeding according to individual tolerance (21).
Controls
After reviewing all contrast SB series performed in Chil-
dren’s Hospital Helsinki during 2012–2020, we retrospectively
identified 174 controls who had undergone contrast series to rule
out intestinal obstruction or malrotation. Their contrast series were
considered normal by pediatric radiologists. They had not under-
gone any abdominal operations, and clinical investigations and
follow-up had not revealed any gastrointestinal pathology. Controls
were matched by age and gender at contrast series to the SBS study
group, leaving 140 controls to be included in the analysis. Each
control had undergone one contrast series examination.
Contrast SB Series
Contrast series were performed using either barium or
water-soluble, iso-osmolar iodixanol 270 mg/mL. Between 2002
and 2020, 59 included SBS patients underwent a total of 197 con-
trast series. Median number of contrast series was 2 (interquartile
range, IQR 2–4) per patient. Fluoroscopic images were stored to
reduce radiation dose. By confirming distribution of contrast mate-
rial throughout the intestine, mechanical intestinal occlusion was
ruled out.
Duodenum, SB, and Colon Diameter Ratio
(DR)
As described previously, the primary researcher in coopera-
tion with an experienced board-certified pediatric radiologist (RK)
analyzed each contrast series and recorded the maximum diameter
of duodenum, SB, and colon as well as height of the 5th lumbar
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Abnormal Bowel Dilatation in Pediatric SBS
vertebra, when the bowel segment and vertebra height were clearly
visible to record accurately (15). Caecum and sigma were excluded
as points of diameter measurements for colon. DR was calculated
for duodenum (DDR), SB (SBDR), and colon (CDR) by dividing
the absolute maximum diameter of each intestinal segment by the
5th lumbar vertebra height. For each patient, both first and greatest
(maximal) DR for duodenum, SB, and colon during follow-up were
analyzed.
Statistical Methods
Continuous data are expressed as median values and IQRs.
Categorical data are expressed as frequencies. Spearman rank
correlation was used to examine associations between variables.
Mann-Whitney U test was used to compare continuous variables
and Fisher exact test was used to compare frequencies between
subgroups. Linear regression was used to test the relationships
between DR and other variables, each bowel segment analyzed
separately.
Three different cutoff values for duodenum, SB, and colon
DR were assessed. First, the 99th percentiles of DDR, SBDR, and
CDR for controls were calculated. Second, the accuracy of the first
and maximal DR to predict PN dependence in SBS patients at the
time of contrast series was assessed by receiving operating char-
acteristic (ROC) curves and areas under ROC curves (AUROC).
Optimal cutoffs were defined by using the maximum sum of speci-
ficity and sensitivity.
The predictive value of the first and maximal DDR, SBDR,
and CDR and other variables of interest for weaning off PN were
tested by generating hazard ratios with 95% confidence intervals
(CI) with Cox proportional hazards regression models. For these
analyses duration of PN was calculated from the day of contrast
series to the day of weaning off PN or last recorded follow-up
day. All statistical analyses were performed using R version 4.0.5
(R Foundation for Statistical Computing, Vienna, Austria). P
value < 0.05 was set as the level of significance.
Ethics
The hospital ethical committee approved the study
protocol.
RESULTS
Patient Characteristics
Overall, 59 patients with IF-SBS without AIR surgery were
included. Their baseline characteristics are displayed in Table 1.
Most common reason for SBS was necrotizing enterocolitis (NEC)
(53%), and median remaining SB length was 50 (30–83) cm, cor-
responding to 33 (19–48) % of age-adjusted values (19) (Table 1).
At the time of the study 6 patients (10%) had an enterostomy, a jeju-
nostomy in all cases. Sex distribution (male gender 56% vs 52%)
and age in years at contrast series for maximal DDR [0.5 (0.1–
1.9) vs 0.7 (0.2–2.3)], SBDR [0.4 (0.1–1.6) vs 0.8 (0.2–3.1)], and
CDR [1.4 (0.4–3.2) vs 0.9 (0.3–3.5)] were comparable to healthy
controls.
All bowel segments were abnormally dilated
in SBS patients
First measured DDR, SBDR, and CDR was 48% (P < 0.01),
160% (P < 0.01), and 6% (P = 0.325) higher. Maximal DDR,
SBDR, and CDR was 53%, 183%, and 23% higher in SBS patients
compared to controls (P < 0.01 for all), respectively (Fig. 1). Among
SBS patients maximal DDR correlated with maximal SBDR (r =
0.586, P < 0.01), but neither DDR (r = −0.124, P = 0.649), nor
SBDR (r = −0.304, P = 0.271) correlated with maximal CDR.
721
 Nieminen et al JPGN • Volume 77, Number 6, December 2023

TABLE 1. Patient characteristics the time of contrast series, whereas first CDR correlated weakly
Number of patients 59 positively with age (r = 0.332, P = 0.04) (Figure 1, Supplemental
Number of contrast series/patient, median (IQR) 2 (2–4) Digital Content 1, http://links.lww.com/MPG/D301). Accordingly,
maximal DDR (r = −0.674, P < 0.01) and SBDR (r = −0.579, P <
Male gender, n (%) 33 (56%)
0.01) correlated negatively with age, while maximal CDR showed
Underlying diagnosis, n (%) no correlation with age (r = 0.213, P = 0.19) (Figure 2, Supplemen-
 Necrotizing enterocolitis 31 (53%) tal Digital Content 2, http://links.lww.com/MPG/D302).
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 Volvulus 10 (17%) In univariate linear regression, young age and PN depen-

dence at the time of contrast series were associated with both maxi-
 Atresia 8 (13%)
mal DDR and SBDR. Also, NEC etiology, gestational age, birth
 Hirschsprung disease 7 (12%) weight, and treatment before the year 2009 were associated with
 Gastroschisis 2 (3.3%) maximal SBDR. In multiple regression, PN dependence remained
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 Other (meconium peritonitis) 1 (1.7%) the only variable related with maximal DDR while both PN depen-
dence and NEC diagnosis were associated with maximal SBDR.
Gestational age, wk 31 (25–36)
Only small bowel atresia diagnosis is associated with maximal
Birth weight, g 1440 (743–2575) CDR (Table 2). In regression models for factors associated with
Enterostomy, n (%) 6 (10%) first DDR, SBDR, and CDR, young age, treatment before the year
Ileocecal valve preserved, n (%) 24 (40%) 2009, gestational age, birth weight, and PN dependence were asso-
ciated with SBDR (Table 1, Supplemental Digital Content 4, http://
SB length, cm 50 (30–83) links.lww.com/MPG/D304).
SB length, % of normal 33 (19–48)
Colon length, % of normal 100 (53–100) Cutoffs for Abnormal Dilatation
Duration of parenteral nutrition, mo 8.4 (3.9–15) According to 99th percentiles of control group, normal
DDR, SBDR, and CDR (cutoff 1) was 1.5, 2.1, and 3.8, respectively
Age at the latest recorded follow-up, y 5.7 (1.7–9.3) (Fig. 1). Based on AUROC analyses, optimal maximal DR cutoffs
Deceased, n (%) 4 (6.9%) for being off PN at the time of contrast series (cutoff 2) were 1.5
IQR = interquartile range; SB = small bowel. for DDR, 3.0 for SBDR, and 2.6 for CDR (Figure 3, Supplemental
Digital Content 3, http://links.lww.com/MPG/D303). When analyz-
ing similarly the first available contrast series for each patient, opti-
mal DR cutoffs (cutoff 3) were 1.4 for DDR, 1.3 for SBDR, and 2.5
for CDR (Figure 3, Supplemental Digital Content 3, http://links.
lww.com/MPG/D303).

Duodenal Dilatation Predicted Weaning

Off PN
The predictive value of DDR, SBDR, and CDR for weaning
off PN was analyzed with univariate Cox regression models accord-
ing to above defined cutoff values (Table 3). With cutoff 1.5, which
was both the 99th percentile of controls and the optimal thresh-
old of maximal DDR for current PN dependence, DDR predicted
subsequent weaning off PN. The likelihood of weaning off PN was
2.5-fold higher in patients with DDR < 1.5 compared to DDR ≥
1.5. SBDR and CDR were not predictive for PN duration with any
of the cutoffs. However, SBDR approached statistical significance
with cutoff 2.1 (Table 3). At the end of median 5.7 years follow-up,
only 1 patient remained on PN, while others had weaned off after
8.2 months (Table 1).

FIGURE 1. A box plot displaying diameter ratio for duodenum,
small bowel, and colon in SBS patients and intestine healthy
controls. Outliers presented as dots. Solid horizontal line represents
99th percentile of control group DR (cutoff 1). Dashed horizontal
line represents cutoff 2 defined as maximum sum of sensitivity
and specificity in AUROC model assessing the predictive value of
maximal DR for PN dependence. AUROC = areas under receiving
operating characteristic curves; DR = diameter ratio; PN = paren-
teral nutrition; SBS = short bowel syndrome;
Duodenal and Small Intestinal Dilatation
Associated with PN and Young Age
Among SBS patients, first DDR (r = −0.480, P < 0.01) and
SBDR (r = −0.624, P < 0.01) correlated negatively with age at
DISCUSSION
Treatment of children with SBS aims at reaching enteral
autonomy to decrease PN-related morbidity and mortality (20,22).
We found that SBS patients have abnormally dilatated duodenum,
SB and colon compared to intestine healthy controls, with the
greatest dilatation seen in the remaining SB. In our patients, pre-
dictors for weaning off PN not only included remaining SB length
and presence of ICV, but also duodenum DR below 1.5. Our mul-
tiple cutoff determination methods suggested DDR exceeding 1.5
denotes abnormal dilatation while estimated cutoffs for SBDR and
CDR showed more variability.
The use of contrast series to measure bowel length and
width has been previously shown to correlate well with intraopera-
tive measurements (23). We have previously shown that standard-
ization of bowel width to lumbar vertebra height, which aims to
standardize intestinal width to the physical size of patients, more

722 www.jpgn.org
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TABLE 2. Maximal duodenum, small bowel, and colon diameter ratio in relation to different variables assessed with simple linear regression and multiple regression adjusted for
variables found significant in simple linear regression
Duodenum Small bowel Colon

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Simple regression Multiple regression Simple regression Multiple regression Simple regression

β (95% CI) P value β (95% CI) P value β (95% CI) P value β (95% CI) P value β (95% CI) P value
Age at contrast series −0.05 (−0.10 to 0.0) 0.036 −0.03 (−0.08 0.184 −0.10 (−0.19 to −0.02) 0.020 −0.02 (−0.11 0.693 0.01 (−0.07 to 0.08) 0.800
to 0.02) to 0.08)
Treatment before 0.04 (−0.46 to 0.54) 0.900 1.10 (0.26 to 2.00) 0.011 0.78 (−0.07 0.071 −0.26 (−0.92 to 0.39) 0.400
year 2009 to 1.67)
Gender 0.15 (−0.26 to 0.56) 0.500 0.11 (−0.60 to 0.82) 0.800 −0.05 (−0.57 to 0.48) 0.900
ICV 0.37 (−0.03 to 0.78) 0.067 −0.11 (−0.83 to 0.60) 0.800 −0.30 (−0.83 to 0.23) 0.300
SBA vs other 0.37 (−0.22 to 0.97) 0.200 0.45 (−0.57 to 1.50) 0.400 −0.78 (−1.40 to −0.13) 0.021
diagnosis
NEC vs other −0.07 (−0.48 to 0.33) 0.700 0.81 (0.14 to 1.50) 0.019 0.81 (0.38 to 0.010 0.35 (−0.15 to 0.86) 0.200
JPGN • Volume 77, Number 6, December 2023

diagnosis 2.00)
PN dependent at time 0.57 (0.14 to 0.99) 0.010 0.46 (0.01 to 0.045 1.20 (0.43 to 2.00) 0.003 1.20 (0.38 to 0.005 −0.19 (−0.69 to 0.32) 0.500
of contrast series 0.91) 2.00)
PN length in total 0.0 (−0.01 to 0.0) 0.400 0.0 (−0.01 to 0.0) 0.500 0.0 (0.0 to 0.01) 0.300
PN length at time of 0.0 (−0.01 to 0.0) 0.500 0.0 (−0.01 to 0.01) 0.400 0.01 (−0.01 to 0.02) 0.300
contrast series
Gestational age 0.0 (−0.04 to 0.03) >0.900 −0.07 (−0.13 to 0.01) 0.020 0.05 (−0.12 0.574 −0.04 (−0.09 to 0.01) 0.130
to 0.22)
Birth weight 0.0 (0.0 to 0.0) 0.900 0.0 (0.0 to 0.0) 0.040 −0.0 (−0.0 0.618 0.0 (0.0 to 0.0) 0.200
to 0.0)
SB length (cm) 0.0 (0.0 to 0.01) 0.300 0.0 (−0.01 to 0.01) 0.600 0.0 (−0.01 to 0.0) 0.200
SB length (cm) as 0.16 (−0.13 to 0.45) 0.300 0.27 (−0.25 to 0.79) 0.300 −0.08 (−0.40 to 0.25) 0.600
categorical*
SB length (%) 0.01 (0.00 to 0.02) 0.044 0.01 (−0.0 to 0.073 0.01 (−0.01 to 0.02) 0.200 −0.01 (−0.02 to 0.0) 0.300
0.01)
SB length (%) as 0.11 (−0.23 to 0.45) 0.500 0.28 (−0.32 to 0.87) 0.400 −0.18 (−0.56 to 0.19) 0.300
categorical†
Colon length (%) 0.0 (0.0 to 0.01) 0.089 0.0 (−0.01 to 0.01) 0.600 −0.01 (−0.02 to 0.0) 0.300
Colon length (%) as 0.21 (−0.03 to 0.45) 0.089 0.03 (−0.40 to 0.45) >0.900 −0.03 (−0.45 to 0.38) 0.900
categorical‡
Endostomy −0.49 (−1.20 to 0.27) 0.200 −0.43 (−1.60 to 0.72) 0.500
β = unstandardized coefficient; CI = confidence interval; ICV = ileocecal valve; NEC = necrotizing enterocolitis; PN = parenteral nutrition; SB = small bowel; SBA = small bowel atresia. * SB length in
cm divided into 3 groups: <20 cm, between 20 and 40 cm, and ≥ 40 cm. † SB length in percentage of normal divided into 3 groups: <10%, between 10% and 25%, and ≥ 25%. ‡ Colon length in percentage
of normal divided into 3 groups: <50%, between 50% and 75%, and ≥75%.

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Abnormal Bowel Dilatation in Pediatric SBS
 Nieminen et al JPGN • Volume 77, Number 6, December 2023

TABLE 3. Univariate cox hazard ratios (HR) with 95% confidence preterm with a greater potential to intestinal adaptation, possibly
intervals (CI) for weaning off parenteral nutrition contributing to their tendency for both SB dilatation and reaching
intestinal autonomy (26,27). Indeed, we found NEC patients almost
Variable HR (95% CI) P value
twice more likely to wean off PN compared to other etiologies
ICV preserved 3.15 (1.61–6.14) <0.001 (25,28–30). The association between SB dilatation and treatment
NEC vs other etiology 1.90 (1.01–3.55) 0.046 era suggests spontaneous oral feeding ad libitum, instead of arti-
Gestational age 0.95 (0.90–1.00) 0.032
ficial tube feeding, may decrease the tendency for abnormal bowel
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dilatation (20).
Birth weight 1.00 (1.00–1.00) 0.026 There have been no previous attempts to set cutoff values for
SB 15%–30% Reference pathological bowel dilatation, while previous research has largely
SB under 15% 0.18 (0.02–1.43) 0.105 focused on SB dilatation (9,18). To our knowledge, this is the first
study analyzing the degree of bowel dilatation not only in SB but
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SB over 30% 3.26 (1.63–6.53) <0.001

also in duodenum and colon as well as the first to compare DR
Colon 50%–75% Reference values to intestine healthy controls and aiming to set DR cutoffs.
Colon under 50% 0.43 (0.14–1.29) 0.131 Interestingly, both of our cutoff determination methods suggested
Colon over 75% 1.34 (0.59–3.06) 0.488 DDR above 1.5 indicates abnormal dilatation strongly predicting
PN dependence. Instead, colon dilatation was less prominent in
DDR > 1.5* Reference
SBS and CDR did not associate with PN weaning rates. Although
DDR ≤ 1.5* 2.29 (1.19–4.41) 0.013 SB dilatation has been previously related with prolonged PN
DDR > 1.5† Reference dependence (18,31), the association only approached statistical sig-
DDR ≤ 1.5† 2.51 (1.31–4.81) 0.005 nificance here. Measuring DDR might be more accurate and repro-
ducible compared to SBDR, since duodenum is more delineated
DDR > 1.4‡ Reference
and easier to fill with contrast medium.
DDR ≤ 1.4‡ 1.34 (0.71–2.54) 0.400 In SBS patients, bowel dilatation is considered to impair
SBDR > 2.1* Reference motility and increase the risk of BO, thus aggravating PN depen-
SBDR ≤ 2.1* 1.74 (0.88–3.43) 0.100 dency (32). Risk factors for BO include prolonged PN, short
remaining SB length, and gastroschisis as baseline diagnosis (33).
SBDR > 3.0† Reference As expected, remaining SB length and preserved ICV predicted
SBDR ≤ 3.0† 1.22 (0.66–2.25) 0.500 weaning off PN (29,30,34,35).
SBDR > 1.3‡ Reference Yet, ICV and remaining SB or colon length were not associ-
SBDR ≤ 1.3‡ 1.26 (0.58–2.75) 0.600 ated with dilatation of any bowel segment, although missing ICV
has been reported to predispose to small intestinal re-dilatation
CDR > 3.8* Reference after serial transverse enteroplasty (36).
CDR ≤ 3.8* 1.25 (0.30–5.27) 0.760 Limitations of this study include a relatively small sample
CDR > 2.6† Reference size of 59 patients. Due to the retrospective study design, clinical
CDR ≤ 2.6† 0.57 (0.28–1.17) 0.130
information was not systematically recorded and available at the
time of contrast series. Though only one measured DR per patient
CDR > 2.5‡ Reference was chosen for analysis, not all contrast series could be used since
CDR ≤ 2.5‡ 0.63 (0.29–1.35) 0.230 occasionally no reliable measurements of both bowel width and L5
AUROC = areas under receiving operating characteristic curves; CDR = vertebrae height from the same contrast series could be obtained.
colon diameter ratio; CI = confidence interval; DDR = duodenum diameter Additionally, using a double-blind assessment of contrast series
ratio; DRs = diameter ratios; HR = hazard ratio; ICV = ileocecal valve; NEC could have potentially increased the accuracy of the taken mea-
= necrotizing enterocolitis; PN = parenteral nutrition; SB = small bowel; surements. Though, the bowel width was systematically measured
SBDR = small bowel diameter ratio. *Cutoff based on 99th percentile of from the widest part and the vertebrae height measured consistently
control DRs. †Optimal AUROC cutoff for PN dependence using maximal from the 5th vertebrae. Furthermore, the use of magnetic resonance
DR. ‡Optimal AUROC cutoff for PN dependence using first DR. imaging (MRI) in prospective studies can have the potential to pro-
vide more accurate bowel width measurements but is not as readily
reliably reflects the degree of bowel dilatation compared to absolute available as contrast series.
bowel width (18). Since the most symptomatic patients are likely to
undergo more contrast series examinations than others, we decided
to analyze the maximal DR and the first measured DR for each CONCLUSIONS
patient. In addition, patients who had undergone AIR surgery at In conclusion bowel dilatation in duodenum measured as
any time during follow-up were excluded in order to avoid the con- ratio from bowel width and L5 vertebrae associated with longer
founding effects of surgery on PN weaning rates. This allowed us PN dependence in children with SBS, while colon dilatation had
to concentrate on natural history of bowel dilatation in SBS. The no effect on PN dependence. SBS etiology impacts SB dilatation
first DR measured during follow-up could theoretically be a useful and NEC patients were more likely to wean off PN. Additional
predictor of subsequent PN weaning potential. However, in contrast research is needed to assess optimal cutoff values for AIR surgery
to maximal DR values, the first measured DR of any bowel segment and mechanisms underlining bowel dilatation in different parts of
proved to have no prognostic value. the intestine.
Young age and PN dependence at the time of contrast series
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