Necrotising enterocolitis (NEC) is a serious gastrointestinal disease that primarily affects premature neonates. Diagnosis can be challenging, as early symptoms such as abdominal distension, feeding intolerance, and lethargy are non-specific. Abdominal radiography is traditionally the first-line imaging modality; however, radiographic findings may lag behind clinical deterioration. Bowel ultrasound is increasingly recognised as a valuable adjunct in the evaluation of suspected NEC.
Ultrasound has demonstrated higher sensitivity than abdominal radiography, particularly in early disease. It enables direct assessment of bowel wall thickness, peristalsis, perfusion, free fluid, and highly specific findings such as pneumatosis intestinalis and portal venous gas. Doppler imaging plays an important role in evaluating bowel perfusion and may help identify more severe disease as well as other clinically relevant abdominal pathology.
NEC can also occur in term or near term infants with congenital heart disease (CHD). Although the clinical presentation may appear similar between these vulnerable populations, the underlying pathogenesis differs. This presentation aims to: increase sonographer confidence in recognising NEC; differentiate pathogenesis, with a particular focus on cardiac patients; discuss relevant anatomy; review sonographic technique; and highlight key ultrasound findings.

Introduction: Neonates with bilious vomiting are typically investigated for midgut malrotation and volvulus. Recent publications have successfully demonstrated the transition to ultrasound from the traditional upper gastrointestinal (GI) study in the initial investigation for midgut malrotation and volvulus.
Method: In collaboration with the paediatric surgical and newborn services teams at our tertiary institution, we transitioned to a management pathway using ultrasound as the initial investigation for a neonate with suspected midgut malrotation and volvulus. The ultrasound assessment included two important components; (i) assessment of the mesenteric vessels orientation and (ii) following the course of the duodenum from the pylorus to the duodenojejunal flexure with the use of sterile water, thus ensuring a normal retroperitoneal course of the third part of the duodenum (D3). Abnormal or inconclusive ultrasound findings were investigated further with an upper GI study.
Results: In the 18 months post transition, ultrasound results and patient outcomes at our institution were consistent with published literature, resulting in a 90% reduction in the use of upper GI studies. Some of the challenges of the transition at our institution included developing sonographer expertise to ensure adequate afterhours coverage, building confidence in the collaborating teams and the utility of assessment in moderate or extreme preterm neonates.
Conclusion: Transition to ultrasound can be achieved with a clearly established management pathway and appropriate development of sonographer expertise to ensure adequate assessment.
Take home message: Transition to ultrasound as the first diagnostic test for midgut malrotation can be done safely and effectively.

Elastography has emerged as a key non‑invasive tool for assessing liver fibrosis and monitoring chronic liver disease in children. While paediatric cirrhosis remains uncommon, early and accurate detection of fibrosis is essential, as timely treatment can stabilise or even reverse disease progression. This presentation reviews the role of ultrasound‑based elastography— including point shear‑wave elastography (pSWE), and two‑dimensional shear‑wave elastography (2D‑SWE). Elastography techniques provide quantitative measures of liver stiffness that correlate with fibrosis stage, with reported sensitivities for detecting significant fibrosis (≥F2) ranging from 81–95%, depending on modality. In addition to fibrosis staging, elastography assists in differentiating biliary atresia from other causes of neonatal cholestasis, monitoring inflammatory activity in autoimmune hepatitis, and assessing hepatic congestion in conditions such as Fontan physiology. Important limitations include age‑dependent normal values, technical variability between vendors, and confounders such as inflammation, steatosis, and congestion. Despite these challenges, elastography is now central to routine follow‑up, risk stratification for portal hypertension, and treatment response assessment in children with chronic liver disease. This session will highlight current evidence, practical considerations, and emerging applications of elastography in paediatric hepatology.