A 1500 g preterm neonate develops abdominal distension, bilious aspirates, and bloody stools on day 10. Abdominal X-ray shows pneumatosis intestinalis. The most specific radiological sign confirming advanced necrotising enterocolitis with intestinal perforation is:

• A Pneumatosis intestinalis
• B Portal venous gas
• C Fixed dilated bowel loop on serial films
• D Pneumoperitoneum ✓

Explanation

Pneumoperitoneum (free intraperitoneal air) is the definitive radiological sign of intestinal perforation in NEC and is an absolute indication for surgical intervention. Pneumatosis intestinalis (intramural gas) is diagnostic of NEC (Bell's stage II) but does not indicate perforation. Portal venous gas is an ominous sign reflecting advanced disease (Bell's stage III) but not necessarily perforation. A fixed dilated loop on serial films suggests ischemia but lacks specificity for perforation.

Reference: Ghai Essential Pediatrics, 10th ed.

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Written and medically reviewed by the StethoPrep medical team.