HDlive silhouette mode in antenatal diagnosis of jejunal atresia

Abstract

There have been numerous reports on the antenatal diagnosis of intestinal atresia using two-dimensional (2D) sonography1. HDlive and HDlive inversion mode are useful in the prenatal differentiation of meconium peritonitis from intestinal atresia2. To our knowledge, this is the first reported case of using HDlive silhouette mode in the antenatal diagnosis of jejunal atresia. A 22-year-old pregnant Japanese woman, gravida 2, para 1, was referred to our ultrasound clinic at 28 weeks of gestation because of suspected fetal intestinal dilatation. 2D sonography showed a single live cephalic fetus with biometry consistent with gestational age. The amniotic fluid index was 17.95 cm. At the upper region of the fetal abdomen, there were multiple cystic dilatations suggestive of dilated intestinal loops. HDlive imaging demonstrated clearly the inner wall of the stomach, connected to the duodenum by the clearly visualized pylorus which showed active peristalsis (Figure 1 and Videoclip S1). HDlive inversion mode confirmed the continuity between these structures and demonstrated active duodenal peristalsis (Figure 2 and Videoclip S2). The stomach appeared fully dilated with no peristalsis. HDlive silhouette mode (Voluson E10, GE Healthcare Japan, Tokyo, Japan) depicted the dilated stomach with no peristalsis, located behind the duodenum which showed active peristalsis (Figure 3 and Videoclip S3). The proximal part of the hypoplastic jejunum was identified clearly. A diagnosis of jejunal atresia was suggested. At 35 + 2 weeks' gestation, the patient was admitted because of threatened preterm labor and, at 36 + 2 weeks, a single 3002-g male neonate, 49 cm in length, was delivered vaginally. Apgar scores at 1 and 5 min were 8 and 9, respectively, with an umbilical artery pH of 7.382. Plain X-ray of the neonate showed a triple-bubble sign, and gastrograffin enema revealed a microcolon. Diagnosis of jejunal atresia was confirmed and resection with diamond-shaped anastomosis was performed 3 days after delivery. The neonate's subsequent course was uncomplicated. HDlive silhouette mode is a novel technology that demonstrates structures with vitreous-like clarity3, 4. Its capacity for visualization of inner structures resembles that of hologram technology4. In this case, HDlive silhouette mode showed a ventral panoramic view of the gastrointestinal tract (GIT). The dilated stomach was visualized clearly, even though it was located behind the dilated duodenum. The different anatomical parts of the duodenum, from the pylorus to the duodenojejunal junction, were visualized, in addition to the atretic proximal part of the jejunum. Assessment of spatial relationships between the stomach, duodenum and jejunum, and delineation of their outer contours enabled the location of the lesion to be determined. Moreover, propagation of peristaltic waves in different regions of the GIT was observed easily by the change in their caliber. The stomach showed weak peristalsis whereas the duodenum and jejunum contracted actively and the diagnosis of jejunal atresia was straightforward. Accurate evaluation of the inside and outer contour of the fetal GIT, peristaltic waves and the spatial relationship between different parts of the fetal GIT and surrounding structures represent the main advantages of using HDlive silhouette mode in the investigation of a fetus with suspected intestinal atresia. This work was supported by a Grant-in-Aid for Scientific Research on Innovative Areas ‘Constructive Developmental Science’ (No.24119004), and a Research Grant (No.25462561) from The Ministry of Education, Culture, Sports, Science and Technology, Japan. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.