Necrotizing enterocolitis (NEC) in a premature neonate is managed surgically when conservative measures fail. Which finding on abdominal X-ray is an absolute indication for surgery in NEC?

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

Explanation

Pneumoperitoneum (free air under the diaphragm) in NEC indicates intestinal perforation and is the only absolute surgical indication. It necessitates immediate laparotomy or bedside peritoneal drainage in extremely low-birth-weight (ELBW) infants. Pneumatosis intestinalis (intramural gas) and portal venous gas are Bell Stage II–III radiological signs confirming NEC but are not absolute surgical indications in isolation — they trigger intensive medical management and close monitoring. A fixed dilated loop persisting >24–48 hours suggests gangrenous bowel and is a relative surgical indication. The NEST trial and others compare primary peritoneal drainage vs laparotomy for ELBW infants.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.