Adhesive small bowel obstruction in a 3-year-old child with history of necrotizing enterocolitis: a case report

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Abstract
Background and objectives: Adhesive small bowel obstruction (ASBO) is a serious complication following abdominal surgery in children, yet its presenting symptoms often mimic non-surgical conditions such as viral mesenteric adenitis and functional constipation. This diagnostic challenge is particularly acute in young children with a history of neonatal intestinal surgery who cannot reliably communicate their symptoms. This case report describes a former extreme preterm infant with surgical history of necrotizing enterocolitis (NEC) who presented with acute abdominal pain and was found to have complete mechanical small bowel obstruction due to postoperative adhesions. The objective is to highlight the diagnostic pitfalls in this population and to describe an unusual postoperative course complicated by three concurrent infections. Case presentation: A 3-year-7-month-old former preterm girl (23 weeks gestation) with a history of necrotizing enterocolitis (NEC) requiring jejunal resection and stoma closure presented with one day of colicky abdominal pain, vomiting, and constipation. Initial ultrasound showed reactive mesenteric lymph nodes and fecal loading, suggesting mesenteric adenitis and constipation. However, given her surgical history, she was admitted for observation. Abdominal x-ray revealed small bowel dilatation with air-fluid levels, and contrast-enhanced CT confirmed complete mechanical small bowel obstruction with pneumatosis intestinalis. She underwent emergent laparotomy, which revealed extensive adhesive bands causing obstruction without volvulus, and adhesiolysis was performed without complication. On postoperative day 17, she developed a one-day fever. Workup revealed three concurrent infections: ESBL-producing Escherichia coli urinary tract infection, adenovirus, and Entamoeba histolytica/dispar. She was treated with intravenous meropenem and metronidazole and recovered fully. Conclusion: Children with prior intestinal surgery can present with acute abdominal pain that mimics non-surgical conditions such as mesenteric adenitis and constipation while having a complete adhesive small bowel obstruction requiring emergent surgery. Normal or equivocal ultrasound findings do not exclude this diagnosis, and a low threshold for CT is essential. Postoperative fever in such patients warrants a broad infectious workup, as multiple concurrent pathogens may coexist.

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