Paula
W. Brill,
MD
#{149} Steven
R. Olson,
MD
#{149} Patricia
Neonatal Necrotizing Air in Morison Pouch’
N
Six newborn infants with necrotizing enterocolitis (NEC) were noted to have air confined to Monison pouch as an early sign of pneumoperitoneum. Air in Morison pouch appears as a triangular lucency in the right upper quadrant. Extraluminal air in this location is easily mistaken for air within a loop of bowel if its characteristic appearance is not specifically sought. Review of the literature revealed no reported cases of NEC in which air in Morison pouch was mentioned. The authors’ observation of six patients suggests that air in Monison pouch may be more common than previously recognized. Air in Morison pouch has the same significance as more obvious signs of pneumoperitoneum, and its detection is an indication for surgery. Index
terms:
newborn, tines,
Colitis,
cysts.
73.78
infants
Radiology
children,
1990;
#{149} Intes-
7933.71
#{149} Ultrasound
a
(US),
70.1298
174:469-471
MD
Enterocolitis:
ECROTIZING
enterocolitis
is a serious
#{149} Infants,
70.1298
pouch,
791.71
and
75.267
tract,
#{149} Morison
Pneumopenitoneum. in
74.267,
gastrointestinal
Winchester,
and
(NEC)
frequent
dison-
den of the gastrointestinal tract in patients in the neonatal intensive care unit (NICU) (1-3). Medical therapy suffices in most cases. Bowel penforation occurs in 12%-32% of cases (4) and is an absolute indication for sungical intervention, without which the mortality is almost 100% (5). Intnapenitoneal air confined to Monison pouch is an early sign of pneurnoperitoneum and can be necognized on supine abdominal radiographs (6-8). It is seen projected oven a portion of the liver and is usually also seen on chest radiographs (Fig 1). The highly characteristic appearance of air in Monison pouch has been likened to the renaissance headgear worn by the doge of Venice (7) (Fig 2). The literature on NEC has not referred to this finding. We describe six patients with NEC in which air in Monison pouch was the initial sign of pneumopenitoneurn. Five cases were surgically proved; one of the surgical cases had sonographic correlation.
PATIENTS Between 201
AND April
patients
METHODS
1982
admitted
and to the
February New
1989, York
Hospital NICU were diagnosed as having NEC. Six of these patients had the chanactenistic radiographic findings of air in Monison pouch as the first or only sign of pneumopenitoneum. performed in
The
patients
were
birth weight, time time of appearance pouch, radiographic in Monison pouch, graphic
I
From
York 68th
St.
1989;
,.
Department
New
York,
revision
received
dress
the
of Radiology.
Hospital-Cornell
reprint
Center,
10021.
Received
requested
October
RSNA,
NY
Medical September
2; accepted
requests
1990
October
to P.W.B.
New 525 July 6; revision 10.
Ad-
findings,
Sonognaphy was of the six patients.
one
analyzed
regarding
of diagnosis of NEC, of air in Monison characteristics of aim subsequent radioand
clinical
course.
RESULTS
detected on supine abdominal radiographs within 3 days of the clinical diagnosis of NEC. In all patients, this was the only initial sign of intrapenitoneal air. Pneumatosis intestinalis was noted in four of the six patients before the appearance of air in Monison pouch (Fig 3). In the other two patients, NEC was clinically apparent, although pneumatosis intestinalis was not detected on abdominal radiographs before on concurrent with the development of air in Monison pouch (Fig 4). Abdominal radiographs obtained at the same time in the supine and left lateral decubitus positions were available in four patients. The charactenistic collection of air in Monison pouch on the supine radiograph remained confined there on the left batenal decubitus view (Fig 5). In one patient, an abdominal sonognam showed a gas-containing collection in Morison pouch (Fig 6). Five patients underwent surgery, and perforation was documented in each. Immediately before surgery, left lateral decubitus nadiographs showed extension of free air lateral to the liver in three patients and extraluminal air confined to Monison pouch in two patients. The patient who died without undergoing an operation had air confined to Monison pouch. The sites of perforation in the patients who underwent surgery were the terminal ileum (n = 4) and the ascending and transverse colon (n 1). Permission for autopsy was not granted in the sixth patient, who died without undergoing surgery. Two of the patients who underwent surgery died: one in the penioperative period, secondary to new perfo-
E 24.
Six newborn infants (birth weight, 880-3,240 g) were clinically diagnosed as having NEC at 2-10 days of age. Air in the Monison pouch was
Abbreviations: tis,
NICU
NEC =
neonatal
necrotizing intensive
care
enterocoliunit.
469
nations, and the second, from liver disease.
months
later
DISCUSSION
Mo
Attention has been focused on the early radiographic findings of NEC (9) and on findings that may be considened highly suggestive of imminent perforation (10-12). The ultimate goal is timely operative intervention to decrease morbidity and mortality. Indications for surgical intervention have been described (12). The one radiologic finding that almost always prompts surgical intervention is that of pneumopenitoneurn (2,4). Radiographic findings of perforation may be present even before clinical signs.
Free
intrapenitoneal
pine radiograph finding, and been described These include line of normal
air on the
su-
may be a subtle numerous signs have to aid in its detection. the football sign, outpenitoneal ligaments (inverted V sign, fabcifonm ligament sign, or urachus sign), visualization of air on both sides of the bowel wall (Rigber sign), triangle sign when air accumulates in a space where three loops of bowel adjoin each other or two loops of bowel adjoin a viscus or abdominal wall, air in the lesser pentoneal sac, air in the scrotum, parahepatic air, the cupola sign when air is trapped below the central tendon of the diaphragm (13-15), on the lucent liven sign (16). A less well-known sign of free intrapenitoneab air is air within Monison pouch (posterior hepatonenal space). This was described by Mann et al (6) in six of 157 patients with known perforated peptic ulcers. Subsequently, Hajdu and deLacey (7) reported three cases of extraintestinal collection of gas in Monison pouch. One of the cases involved an 8-month-old infant with a ruptured appendix. They likened the characteristic shape of air within Monison pouch to the peaked cap with a sloped front worn by the doge of Venice (Fig 2). Therefore, they proposed that it be called the “doge’s cap sign.” In a more recent study of patients with documented pneumoperitoneum (8), the most common finding on supine abdominal radiographs to indicate intrapenitoneal air was air in the night upper quadrant of the abdomen. Approximately onehalf of these cases involved air in Monison pouch alone or in combination with subhepatic free air or free air anterior to the liver. Monison pouch (posterior hepatonenal space) is an intrapenitoneal ne470
#{149} Radiology
Figure ration contents cavity,
1. Diagram shows that after perfoof bowel there is spillage of bowel and bowel gas into the peritonea! which follows the preferred route
along
the right
son
pamacolic
gutter
into
Figure 2 Reproduction of Doge Giovanni Mocenigo by Gentile Be!lini. (Reprinted, with permission, from the Fnick Collection, New York.)
Momi-
pouch.
Figure
4. characteristic
Figure
3
Supine
veals pneurnatosis Momison pouch
cess and The the cated
abdominal intestinalis (arrow).
radiograph and
air
mein
bounded anteriorly by the liven posteriorly by the right kidney. inferior coronary ligament forms roof of Morison pouch and is loat the level of the right 11th nib (17). It has previously been demonstrated that in a supine patient, fluid within the general penitoneal cavity will seek the dependent pelvic cavity. As determined with penitoneal reflections and respiratory-induced abdominal pressure gradients, the fluid in the pelvis will ascend preferentialby along the right paracolic gutter. The fluid then seeks the dependent recess of Monison pouch. The fluid may then extend laterally around the inferior aspect of the liver into the subhepatic space (18). We propose that with perforation of bowel in a patient with NEC, the highly irnitating bowel contents escape with bowel gas into the penitoneal cavity.
Abdominal radiograph shows air collection in Monison
pouch overlying the right 11th rib (arrow) and notable absence of pneurnatosis intestinalis.
From this location, the inflammatory fluid and gas travel together along the preferred route described previously. When the air and inflammatory fluid collection reach Monison pouch, they may become loculated and remain confined there (Figs 1, 5). Alternatively, the air in Monison pouch will not become boculated and will be seen to rise above the lateral liver margin on a left lateral decubitus abdominal view. In adults with perforated viscus, the collection of air in Monison pouch may be more easily recognized than in infants because of the paucity of nearby gasfilled bowel in adults. In our six patients, air in Monison pouch was noted on supine abdominab radiographs. Its location in the right upper quadrant suggests that it might also be detected on supine chest radiognaphs that are frequently February
1990
4.
Rowe
MI.
Welch
KJ,
Necrotizing
Neill
JA Jr.
Judson
gery. 4th Publishers 5.
6.
MI,
rotizing
enterocolitis.
AJR
1976;
LS,
Kirsh
lE,
in
ulcer.
Arch
Hajdu
N, deLacey
Sung
Menuck
Figure
10.
5.
collection
(a) Supine is slightly
nal radiograph
abdominal lower than
confirms
that
radiograph expected.
reveals air (b) Corresponding
the air collection
in Monison left
is loculated
and
pouch (arrow). lateral decubitus
remains
The air abdomi-
confined
pouch.
Frey
EE,
Smith
Figure abscess
K
=
6.
Transverse sonogram reveals an collection in Monison pouch (arrow).
kidney.
5).
air
In
all
six
patients,
P. Whalen,
174
#{149} Number
2
for
authors
his
helpful
thank
Joseph
1.
rahi 2.
3.
WE, Grossman A,
Barlow
0,
H, Baker WA.
enterocolitis. Kliegman
AIR 1964; RM, Fanaroff
enterocolitis.
N Eng!
1093-1103. Bell RS,
Graham
Roentgenologic tions
17.
discussions.
Blanc
of neonatal 1971;
In:
DH,
Miz-
Smith
1983;
Cnit
imaging
Rev
JJ.
Acute
MA. ed.
abdo-
Burhenne
radiology.
HJ,
3rd
ed.
eds. St Lou-
radiological evaluation gas (pneumoperitoneum).
Radiol
Sci 1973;
JAMA Radiology
liver sign 1977;
of the
Dynamic and
New
York:
in the of 237:
abdomen:
basis. Philadelphia: 155-181. normal
of
4:61-85.
Pillani GP. Lucent a roentgenographic
abdomen:
in Harper
391-397.
The
pneumopenitoneum. 2218-2219. Whalen JP.
3rd
Abdominal
Philadelphia:
AR,
tract
im-
Philadelphia:
324-334. WL.
ed.
Margulis
Wind ES, newborn:
ed.
Gastrointestinal
Miller RE. intraperitoneal
my.
Radiol-
enterocolitis.
& Row, 1982; 391-396. Mindelzun RE, McCort
Meyers
in neoa new in-
Gastrointestinal
2nd
1982;
Jr. 2nd
In:
loop
Lea
radiology pathologic
& Feof the anato-
Springer-Verlag.
1988; 49-71.
83:879-887. AA. Necrotizing
J Med
CB,
Stevenson
and
clinical
necrotizing
EA
anatomical biger, 1976;
Necrotizing
Necrotizing
& Row,
Franken
CRC
Ra-
intervention?
in pediatrics.
is: Mosby,
16.
Winter-
perforation Pediatr
EA Jr. ed.
Alimentary
18.
Berdon
surgical
JC.
pediatrics.
15.
EA,
of bowel
126:201-204.
Leonidas
men.
References
AJR
Volume
The MD,
for
trauma.
14.
Franken
17:380-382.
1978;
Harper
of
as a
Radiology
Wexler HA. The persistent natal necrotizing enterocolitis:
aging
Morison
pouch was the first sign of intnaperitoneal air. The recognition of air in this location should lead to prompt surgical intervention before more obvious signs of pneurnopenitoneurn are evident. U Acknowledgment:
obtained in the NICU setting. In cases in which left lateral decubitus and supine views were done during the same time period, the air remained confined to Monison pouch in both positions and did not extend laterally to the liver. This boculation is presumably due to inflammatory membranes. A potential source of confusion is air within the duodenal
in
W,
quad-
enterocolitis
enterocolitis.
1987;
In: Franken
13.
upper
127:753-756. patterns
Analysis
in necrotizing
12.
1980;
roentgen
KA.
ogy
loop (7,8). noted in any of one patient in of air in Morion the supine a decubitus its location (Fig
appearBr J Ra-
Pneumoperito-
Necrotizing
early
dication
bulb or other intestinal This problem was not our six patients. In the whom a low position son pouch was noted abdominal radiograph, view helped confirm
PT.
of right
to prompt diagnosis. 130:367-370.
diol
1 1.
Rutherford
a characteristic radiographs.
AJR
MS.
meyer
to Monison
The
43:706-709.
features.
guide 1979;
JE. peptic
72:450-455.
C.
importance
infancy:
126:560-
perforated
1956;
L, Siemans
Kogutt
dinof nec-
J, Familaro
Eisen
roentgenogram
rant
b.
Medical
Changing patterns
neum:
a.
sun-
Book
RL.
566. Mann
0’-
Pediatric
JG, Siegle roentgenographic
diol 1970;
9.
eds.
In:
MM,
Chicago: Year 1986; 944-958.
Monison pouch: ance on abdominal 8.
Ravitch
Rabinowitz ica! and
The
7.
Rowe
ed.
enterocolitis.
CR,
1984;
310: JK.
manifestaenterocolitis.
112:123-134.
Radiology
#{149} 471
W. Brill,
MD
#{149} Steven
R. Olson,
MD
#{149} Patricia
Neonatal Necrotizing Air in Morison Pouch’
N
Six newborn infants with necrotizing enterocolitis (NEC) were noted to have air confined to Monison pouch as an early sign of pneumoperitoneum. Air in Morison pouch appears as a triangular lucency in the right upper quadrant. Extraluminal air in this location is easily mistaken for air within a loop of bowel if its characteristic appearance is not specifically sought. Review of the literature revealed no reported cases of NEC in which air in Morison pouch was mentioned. The authors’ observation of six patients suggests that air in Monison pouch may be more common than previously recognized. Air in Morison pouch has the same significance as more obvious signs of pneumoperitoneum, and its detection is an indication for surgery. Index
terms:
newborn, tines,
Colitis,
cysts.
73.78
infants
Radiology
children,
1990;
#{149} Intes-
7933.71
#{149} Ultrasound
a
(US),
70.1298
174:469-471
MD
Enterocolitis:
ECROTIZING
enterocolitis
is a serious
#{149} Infants,
70.1298
pouch,
791.71
and
75.267
tract,
#{149} Morison
Pneumopenitoneum. in
74.267,
gastrointestinal
Winchester,
and
(NEC)
frequent
dison-
den of the gastrointestinal tract in patients in the neonatal intensive care unit (NICU) (1-3). Medical therapy suffices in most cases. Bowel penforation occurs in 12%-32% of cases (4) and is an absolute indication for sungical intervention, without which the mortality is almost 100% (5). Intnapenitoneal air confined to Monison pouch is an early sign of pneurnoperitoneum and can be necognized on supine abdominal radiographs (6-8). It is seen projected oven a portion of the liver and is usually also seen on chest radiographs (Fig 1). The highly characteristic appearance of air in Monison pouch has been likened to the renaissance headgear worn by the doge of Venice (7) (Fig 2). The literature on NEC has not referred to this finding. We describe six patients with NEC in which air in Monison pouch was the initial sign of pneumopenitoneurn. Five cases were surgically proved; one of the surgical cases had sonographic correlation.
PATIENTS Between 201
AND April
patients
METHODS
1982
admitted
and to the
February New
1989, York
Hospital NICU were diagnosed as having NEC. Six of these patients had the chanactenistic radiographic findings of air in Monison pouch as the first or only sign of pneumopenitoneum. performed in
The
patients
were
birth weight, time time of appearance pouch, radiographic in Monison pouch, graphic
I
From
York 68th
St.
1989;
,.
Department
New
York,
revision
received
dress
the
of Radiology.
Hospital-Cornell
reprint
Center,
10021.
Received
requested
October
RSNA,
NY
Medical September
2; accepted
requests
1990
October
to P.W.B.
New 525 July 6; revision 10.
Ad-
findings,
Sonognaphy was of the six patients.
one
analyzed
regarding
of diagnosis of NEC, of air in Monison characteristics of aim subsequent radioand
clinical
course.
RESULTS
detected on supine abdominal radiographs within 3 days of the clinical diagnosis of NEC. In all patients, this was the only initial sign of intrapenitoneal air. Pneumatosis intestinalis was noted in four of the six patients before the appearance of air in Monison pouch (Fig 3). In the other two patients, NEC was clinically apparent, although pneumatosis intestinalis was not detected on abdominal radiographs before on concurrent with the development of air in Monison pouch (Fig 4). Abdominal radiographs obtained at the same time in the supine and left lateral decubitus positions were available in four patients. The charactenistic collection of air in Monison pouch on the supine radiograph remained confined there on the left batenal decubitus view (Fig 5). In one patient, an abdominal sonognam showed a gas-containing collection in Morison pouch (Fig 6). Five patients underwent surgery, and perforation was documented in each. Immediately before surgery, left lateral decubitus nadiographs showed extension of free air lateral to the liver in three patients and extraluminal air confined to Monison pouch in two patients. The patient who died without undergoing an operation had air confined to Monison pouch. The sites of perforation in the patients who underwent surgery were the terminal ileum (n = 4) and the ascending and transverse colon (n 1). Permission for autopsy was not granted in the sixth patient, who died without undergoing surgery. Two of the patients who underwent surgery died: one in the penioperative period, secondary to new perfo-
E 24.
Six newborn infants (birth weight, 880-3,240 g) were clinically diagnosed as having NEC at 2-10 days of age. Air in the Monison pouch was
Abbreviations: tis,
NICU
NEC =
neonatal
necrotizing intensive
care
enterocoliunit.
469
nations, and the second, from liver disease.
months
later
DISCUSSION
Mo
Attention has been focused on the early radiographic findings of NEC (9) and on findings that may be considened highly suggestive of imminent perforation (10-12). The ultimate goal is timely operative intervention to decrease morbidity and mortality. Indications for surgical intervention have been described (12). The one radiologic finding that almost always prompts surgical intervention is that of pneumopenitoneurn (2,4). Radiographic findings of perforation may be present even before clinical signs.
Free
intrapenitoneal
pine radiograph finding, and been described These include line of normal
air on the
su-
may be a subtle numerous signs have to aid in its detection. the football sign, outpenitoneal ligaments (inverted V sign, fabcifonm ligament sign, or urachus sign), visualization of air on both sides of the bowel wall (Rigber sign), triangle sign when air accumulates in a space where three loops of bowel adjoin each other or two loops of bowel adjoin a viscus or abdominal wall, air in the lesser pentoneal sac, air in the scrotum, parahepatic air, the cupola sign when air is trapped below the central tendon of the diaphragm (13-15), on the lucent liven sign (16). A less well-known sign of free intrapenitoneab air is air within Monison pouch (posterior hepatonenal space). This was described by Mann et al (6) in six of 157 patients with known perforated peptic ulcers. Subsequently, Hajdu and deLacey (7) reported three cases of extraintestinal collection of gas in Monison pouch. One of the cases involved an 8-month-old infant with a ruptured appendix. They likened the characteristic shape of air within Monison pouch to the peaked cap with a sloped front worn by the doge of Venice (Fig 2). Therefore, they proposed that it be called the “doge’s cap sign.” In a more recent study of patients with documented pneumoperitoneum (8), the most common finding on supine abdominal radiographs to indicate intrapenitoneal air was air in the night upper quadrant of the abdomen. Approximately onehalf of these cases involved air in Monison pouch alone or in combination with subhepatic free air or free air anterior to the liver. Monison pouch (posterior hepatonenal space) is an intrapenitoneal ne470
#{149} Radiology
Figure ration contents cavity,
1. Diagram shows that after perfoof bowel there is spillage of bowel and bowel gas into the peritonea! which follows the preferred route
along
the right
son
pamacolic
gutter
into
Figure 2 Reproduction of Doge Giovanni Mocenigo by Gentile Be!lini. (Reprinted, with permission, from the Fnick Collection, New York.)
Momi-
pouch.
Figure
4. characteristic
Figure
3
Supine
veals pneurnatosis Momison pouch
cess and The the cated
abdominal intestinalis (arrow).
radiograph and
air
mein
bounded anteriorly by the liven posteriorly by the right kidney. inferior coronary ligament forms roof of Morison pouch and is loat the level of the right 11th nib (17). It has previously been demonstrated that in a supine patient, fluid within the general penitoneal cavity will seek the dependent pelvic cavity. As determined with penitoneal reflections and respiratory-induced abdominal pressure gradients, the fluid in the pelvis will ascend preferentialby along the right paracolic gutter. The fluid then seeks the dependent recess of Monison pouch. The fluid may then extend laterally around the inferior aspect of the liver into the subhepatic space (18). We propose that with perforation of bowel in a patient with NEC, the highly irnitating bowel contents escape with bowel gas into the penitoneal cavity.
Abdominal radiograph shows air collection in Monison
pouch overlying the right 11th rib (arrow) and notable absence of pneurnatosis intestinalis.
From this location, the inflammatory fluid and gas travel together along the preferred route described previously. When the air and inflammatory fluid collection reach Monison pouch, they may become loculated and remain confined there (Figs 1, 5). Alternatively, the air in Monison pouch will not become boculated and will be seen to rise above the lateral liver margin on a left lateral decubitus abdominal view. In adults with perforated viscus, the collection of air in Monison pouch may be more easily recognized than in infants because of the paucity of nearby gasfilled bowel in adults. In our six patients, air in Monison pouch was noted on supine abdominab radiographs. Its location in the right upper quadrant suggests that it might also be detected on supine chest radiognaphs that are frequently February
1990
4.
Rowe
MI.
Welch
KJ,
Necrotizing
Neill
JA Jr.
Judson
gery. 4th Publishers 5.
6.
MI,
rotizing
enterocolitis.
AJR
1976;
LS,
Kirsh
lE,
in
ulcer.
Arch
Hajdu
N, deLacey
Sung
Menuck
Figure
10.
5.
collection
(a) Supine is slightly
nal radiograph
abdominal lower than
confirms
that
radiograph expected.
reveals air (b) Corresponding
the air collection
in Monison left
is loculated
and
pouch (arrow). lateral decubitus
remains
The air abdomi-
confined
pouch.
Frey
EE,
Smith
Figure abscess
K
=
6.
Transverse sonogram reveals an collection in Monison pouch (arrow).
kidney.
5).
air
In
all
six
patients,
P. Whalen,
174
#{149} Number
2
for
authors
his
helpful
thank
Joseph
1.
rahi 2.
3.
WE, Grossman A,
Barlow
0,
H, Baker WA.
enterocolitis. Kliegman
AIR 1964; RM, Fanaroff
enterocolitis.
N Eng!
1093-1103. Bell RS,
Graham
Roentgenologic tions
17.
discussions.
Blanc
of neonatal 1971;
In:
DH,
Miz-
Smith
1983;
Cnit
imaging
Rev
JJ.
Acute
MA. ed.
abdo-
Burhenne
radiology.
HJ,
3rd
ed.
eds. St Lou-
radiological evaluation gas (pneumoperitoneum).
Radiol
Sci 1973;
JAMA Radiology
liver sign 1977;
of the
Dynamic and
New
York:
in the of 237:
abdomen:
basis. Philadelphia: 155-181. normal
of
4:61-85.
Pillani GP. Lucent a roentgenographic
abdomen:
in Harper
391-397.
The
pneumopenitoneum. 2218-2219. Whalen JP.
3rd
Abdominal
Philadelphia:
AR,
tract
im-
Philadelphia:
324-334. WL.
ed.
Margulis
Wind ES, newborn:
ed.
Gastrointestinal
Miller RE. intraperitoneal
my.
Radiol-
enterocolitis.
& Row, 1982; 391-396. Mindelzun RE, McCort
Meyers
in neoa new in-
Gastrointestinal
2nd
1982;
Jr. 2nd
In:
loop
Lea
radiology pathologic
& Feof the anato-
Springer-Verlag.
1988; 49-71.
83:879-887. AA. Necrotizing
J Med
CB,
Stevenson
and
clinical
necrotizing
EA
anatomical biger, 1976;
Necrotizing
Necrotizing
& Row,
Franken
CRC
Ra-
intervention?
in pediatrics.
is: Mosby,
16.
Winter-
perforation Pediatr
EA Jr. ed.
Alimentary
18.
Berdon
surgical
JC.
pediatrics.
15.
EA,
of bowel
126:201-204.
Leonidas
men.
References
AJR
Volume
The MD,
for
trauma.
14.
Franken
17:380-382.
1978;
Harper
of
as a
Radiology
Wexler HA. The persistent natal necrotizing enterocolitis:
aging
Morison
pouch was the first sign of intnaperitoneal air. The recognition of air in this location should lead to prompt surgical intervention before more obvious signs of pneurnopenitoneurn are evident. U Acknowledgment:
obtained in the NICU setting. In cases in which left lateral decubitus and supine views were done during the same time period, the air remained confined to Monison pouch in both positions and did not extend laterally to the liver. This boculation is presumably due to inflammatory membranes. A potential source of confusion is air within the duodenal
in
W,
quad-
enterocolitis
enterocolitis.
1987;
In: Franken
13.
upper
127:753-756. patterns
Analysis
in necrotizing
12.
1980;
roentgen
KA.
ogy
loop (7,8). noted in any of one patient in of air in Morion the supine a decubitus its location (Fig
appearBr J Ra-
Pneumoperito-
Necrotizing
early
dication
bulb or other intestinal This problem was not our six patients. In the whom a low position son pouch was noted abdominal radiograph, view helped confirm
PT.
of right
to prompt diagnosis. 130:367-370.
diol
1 1.
Rutherford
a characteristic radiographs.
AJR
MS.
meyer
to Monison
The
43:706-709.
features.
guide 1979;
JE. peptic
72:450-455.
C.
importance
infancy:
126:560-
perforated
1956;
L, Siemans
Kogutt
dinof nec-
J, Familaro
Eisen
roentgenogram
rant
b.
Medical
Changing patterns
neum:
a.
sun-
Book
RL.
566. Mann
0’-
Pediatric
JG, Siegle roentgenographic
diol 1970;
9.
eds.
In:
MM,
Chicago: Year 1986; 944-958.
Monison pouch: ance on abdominal 8.
Ravitch
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The
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CR,
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#{149} 471
