Necrotizing enterocolitis (NEC) is a rare but life-threatening diagnosis in infants presenting with bilious emesis, abdominal distension, or bloody stools. Ultrasonography has been advocated as an alternative initial imaging modality to abdominal radiography, and may be superior in the evaluation of NEC. We describe the use of point-of-care ultrasound (PoCUS) in the evaluation of suspected NEC in the emergency department (ED) when the ability to obtain immediate abdominal x-ray (AXR) was delayed due to pandemic conditions.

A pre-term infant with history of bowel resection presented with non-bilious emesis, bloody stools, and slight abdominal distension. Evaluation with PoCUS identified pneumatosis intestinalis and pneumoperitoneum, which were confirmed on subsequent AXR. Pneumatosis intestinalis in a neonate is highly suggestive of NEC, but seen by itself, can be associated with milk protein allergy and Food Protein Induced Enterocolitis syndrome (FPIES). Pneumoperitoneum is considered an indication for operative intervention for NEC. The infant was re-admitted to the NICU for suspected NEC.

NEC is a rare, but potentially surgical diagnosis in infants as can be FPIES, but not milk protein allergy. NEC can be identifiable using PoCUS to search for a constellation of findings that include pneumatosis intestinalis, pneumoperitoneum, free peritoneal fluid, and portal venous gas. These findings have been previously described in the PoCUS literature for other diseases, but not for a case of suspected NEC presenting to the ED.