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Age: 6 weeks (born at 24 weeks)

Sex: Male

Indication: Direct hyperbilirubinemia

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Case #33


Findings

  • Gallbladder is visualized but is decompressed
  • Branching linear echogenic foci throughout the liver with a peripheral predominance
  • Liver is otherwise normal in size and appearance
  • No intrahepatic or extrahepatic biliary duct dilation
  • Increased right renal cortical echogenicity without hydronephrosis or focal mass
  • Echogenic, thickening bowel wall in the right upper quadrant
  • Visualized portions of the pancreas and aorta are normal in appearance


Diagnosis

Pneumatosis and portal venous gas

Sample Report

Branching linear echogenic foci throughout the liver with a peripheral predominance, concerning for portal venous gas. Thickened, echogenic bowel wall in the right upper quadrant, concerning for pneumatosis. Together, these findings are highly concerning for bowel ischemia. Recommend surgery consultation.

Gallbladder is visualized but is decompressed. These findings are not consistent with biliary atresia.

Liver is otherwise normal in size and appearance with no biliary duct dilation.

Increased right renal cortical echogenicity, which can be seen with medical renal disease. No hydronephrosis.


Discussion

  • It is important to look for signs of necrotizing enterocolitis in premature infants, which include pneumatosis, portal venous gas, and pneumoperitoneum
  • On ultrasound, both pneumatosis and portal venous gas appear as a linear array of speckled punctate foci, which may have corresponding ill-defined posterior acoustic shadowing (which is sometimes colloquially referred to as “dirty shadowing” in contrast to the more clearly defined shadowing associated with calcification)
  • Portal venous gas often has a linear branching appearance in the liver and is often best seen more peripherally in liver, in contrast to pneumobilia which is usually more pronounced centrally


Images

Multiple punctate and linear echogenic foci throughout the liver (red arrows), concerning for portal venous gas. Thickened, echogenic adjacent bowel wall (yellow arrow) with ill-defined posterior acoustic shadowing (blue arrows), concerning for pneumatosis.

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