Combining Abdominal Ultrasound and Radiography for Surgical Risk Prediction in Necrotising Enterocolitis: A Prospective Cohort Study

ObjectiveTo evaluate whether combining abdominal ultrasound with radiography improves diagnostic accuracy and surgical risk prediction in neonates with suspected necrotising enterocolitis (NEC) compared with radiography alone. Design, setting, patientsProspective cohort study conducted in two tertiary neonatal intensive care units. Sixty-seven neonates with suspected NEC underwent concurrent abdominal radiography and ultrasound assessments. Imaging studies were independently reviewed by masked investigators using pre-specified criteria to classify each study as reassuring or non-reassuring. Main outcome measuresThe primary outcome was the need for surgical intervention. Imaging data were analysed using unsupervised k-means clustering (k = 2); logistic regression - testing associations with surgery and Principal component analysis (PCA) - to identify imaging features most contributing to group separation. ResultsUltrasounds were reassuring in all cases subsequently diagnosed with non-NEC, i.e feeding intolerance, whereas most radiographs in this group were non-reassuring. Clustering based on radiographs alone did not significantly discriminate surgical risk (58.8% vs 39.4%; p = 0.11). Combined model (radiograph + ultrasound) produced two distinct clusters with significantly different surgical rates (78.3% vs 34.1%; OR 6.96, 95% CI 2.29-24.58). PCA highlighted complex ascites, absent peristalsis, and abnormal bowel perfusion as key discriminating features. ConclusionIn suspected NEC, combining ultrasound with radiography significantly improves surgical risk stratification compared with radiography alone. A reassuring ultrasound reliably identified infants with feeding intolerance, suggesting potential to reduce unnecessary transfers and treatments. Larger multicentre studies are needed to validate these findings and inform development of a unified multimodal imaging score for NEC diagnosis. Key messagesO_ST_ABSWhat is already known on this topicC_ST_ABSO_LINEC is an acquired intestinal disease mainly affecting preterm infants with the potential risk of serious life-long co-morbidities. C_LIO_LIPlain abdominal radiography remains the standard initial investigation for suspected NEC but provides limited information on bowel perfusion and viability. C_LIO_LIEmerging evidence supports the role of bowel ultrasound in NEC, in assessing bowel wall thickness, perfusion, peristalsis, and intra-abdominal fluid collections. C_LI What this study addsO_LIUsing a multi-modal imaging approach (combining ultrasound and radiography) improved surgical risk stratification in neonates with suspected NEC compared with using radiography alone. C_LIO_LIA reassuring ultrasound may identify benign conditions initially suspected as early NEC, supporting earlier de-escalation of care. C_LIO_LIThe study findings lay the foundation for a standardised imaging-based score combining radiograph and ultrasound findings in cases with suspected NEC, to better guide diagnosis and predict the need for surgical intervention. C_LI