NECROTIZING
ENTEROCOLITIS
(NEC)
Presenter : Tan Geok Eng
22/02/2023
Case Discussion
• Baby of A, currently day 18 OL (CGA), was prematurity at 30w5d, AGA,
with grade II RDS, born via SVD, requiring survanta x1 and ventilated
for 1/7, NCPAP for 1/7, oxygen blender for 6/7
• At day 18 OL (CGA), she developed desaturation and apneic,
tachycardic, required escalation from oxygen blender to NCPAP,
subsequently was intubated at day 20 OL due to frequent
desaturation episode and shallow breathing
• She achieved full feeding at day 10 OL (CGA)
Investigations
Management
Necrotizing Enterocolitis
• Necrotizing enterocollitis (NEC) is ischemic and
inflammatory necrosis of bowel primarily affecting
premature neonates after the initiation of enteral feeding
• Typically occur in 2nd to 3rd week of life
• Mortality ranges from 10% to 50%
• In severe cases involving perforation, peritonitis,
sepsis, mortality approaches 100%
• intestinal necrosis can involve all layer of the bowel
• most common involves the ileum and colon but can
occur anywhere
Epidemiology
• It is the most common intestinal emergency in preterm
infant
• Incidence of 1 to 3 per 1000 life birth
• Prematurity is the most significant risk factor
• 4-13% of infant weight <1500g (VLBW)
• Infrequent in term (<10%) whom have preexisting medical
conditions
Risk factors
• Prematurity (<34 weeks)
• Very low birth weight (<1500g)
• Enteral feeding of premature infant
• Breast milk is protective compared to formula
• IUGR with Reverse or absent end diastolic flow doppler
• Hypertonic formula / enteral medication
• Term infant with pre-existing illness
Prematurity
Immaturity of the gut
• Difference in blood flow autoregulation
• Weakened by too little oxygen or blood flow
• Decrease integrity of intestinal mucosa barrier
• Depressed mucosal enzymes and GIT hormones
• Suppressed intestinal host defence system
• Decreased coordination of intestinal motility
• There is inverse relationship between gestational age and
risk for developing NEC
• Imbalance between pro- and anti-inflammatory factors,
having increased activation and decreased inactivation of
specific mediators which link to NEC
• Inability to effectively regulate the intestinal microcirculation
Reversed or Absent End Diastolic
Flow (RAEDF)
• Abnormal fetal circulation shown by absent or reversed end diastolic
flow velocity in the fetal umbilical artery or aorta suggests
intrauterine fetal compromise due to fetal hypoxia / hypercarbia due
to placenta insufficiency
• Circulatory redistribution : decreased blood flow to the lung,
intestines, kidneys, skin, and muscle, with blood diverted to the brain,
myocardium and adrenals
• This reduction in visceral perfusion has been associated with an
increased risk of necrotizing enterocolitis, cerebral hemorrhage, and
neonatal morbidity
Pathogenesis
• Necrotizing enterocolitis is caused by bacterial invasion into
the intestinal wall. This leads to inflammation and cellular
destruction of the wall of the intestine causing intramural
gas accumulation (pneumatosis intestinalis)
• If unrecognized and untreated, may progress to transmural
necrosis or gangrene that leads to intestinal perforation
causing spillage of intestinal contents into the peritoneum
and resulting in peritonitis, sepsis and death
Symptoms Signs
• Feeding intolerence • Increase abdominal girth
• Increase gastric residual • Blood in stool
• Lethargy • Temperature instability
• Diarrhea , vomiting • Increased episodes of
apnea /bradycardia
• Systemic sign -> respiratory
failure, DIVC, circulatory
collapse (cyanosis,
unresponsiveness)
Physical examination
• Abdominal distension and tenderness
• Billous emesis
• Visible intestinal loops
• Erythema/ bluish abdominal wall (perforation)
• Reduce bowel sound
• Palpable abdominal mass
• Temperature instability
• Systemics ->respiratory failure, circulatory collapse, reduce peripheral
perfusion
Lab Investigation
• FBC
• Thrombocytopenia
• Leucocytosis / leucopenia
• Coagulopathy (evidence of DIC)
• Metabolic acidosis
• Electrolyte imbalance
• Hypo / hyperglycemia
• Occult blood in stool
Investigation
1. Serial AXR
Fixed / persistent dilated bowel loops
Air-fluid levels
Pneumatosis intestinalis (pathognomonic)
Hydrogen gas produced from pathogenic bacteria present between
the subserosal and muscularis layer of bowel wall
Intrahepatic venous gas
Pneumoperitoneum in bowel perforation
• Dilated bowel and thickened bowel wall • Soap bubble appearance
• Intrahepatic venous gas • pneumoperitoneum
Staging
Differentials
1. Septic ileus
2. Paralytic ileus
3. Premature bowel
4. Infectious enterocolitis – diarrhea with blood in stool
5. Intussusception / volvulus
6. Spontaneous intestinal obstruction
Management
1. Stop enteral feeds and oral medications
• Duration of NBM
• Stage 1 : 3 days
• Stage 2 : 7-10 days
• Stage 2b & 3 : 14 days
2. Gastrointestinal decompression with NG suction / free flow
3. Fluid and electrolyte replacement
4. Total parenteral nutrition
Management
1. Maintain adequate tissue perfusion and ventilation
• Inotropic supports
• Ventilation
2. Systemic broad-spectrum antibiotics
• 1st line : IV Ampicillin, IV Gentamicin, IV Metronidazole
• 2nd line : IV Tazocin, IV Amikacin
• Duration of therapy
• Stage 1 : 3 days (depending on culture)
• Stage 2 : 7-10 days
• Stage 3 : 14 days
Monitoring
1. Clinical
• Abdominal girth
• Gastric aspirate – quantity and nature 1-2 hourly
• CRT, BP, RR, HR, oximeter
2. Radiological
• Initially 8 hourly AXR during the first 48-72 hours, thereafter once daily
3. Laboratory
• Hematocrit and blood glucose 8 hourly
• Serum Na/K 12 hourly
• Platelet count and neutrophil count once initially then 48 hours later
• ABG 12 hourly during the initial 48 – 72 hours
Surgical management
• Indication:
• Rapid clinical deterioration despite on medical therapy
• Rapid onset and progression of pneumatosis, abdominal mass, intestinal
obstruction
• GI perforation / full thickness necrosis
• Pneumoperitoneum
• Portal venous gas
• Abdominal wall erythema
• Fixed loop on serial radiograph
• Surgical laparotomy with removal of frankly necrotic and nonviable bowel
COMPLICATIONS
• Short term
• Irreversible shock
• Extensive bowel infarction
• Secondary infection (enteric organism / staph.)
• Long term
• Intestinal stricture and bowel obstruction
• Short bowel syndrome (after bowel resection)
Reference
• Nelson, W., Kliegman, R., & Behrman, R. (2018). Nelson essentials of
pediatrics (5th ed.). Philadelphia: W.B. Saunders.
• Ginglen, J., & Butki, N. (2022). Necrotizing Enterocolitis. Retrieved 12
September 2022, from
https://www.ncbi.nlm.nih.gov/books/NBK513357/
• Feeding of Neonates with Umbilical Artery Doppler Abnormalities.
(2019). Retrieved 10 September 2022, from
https://www.newbornwhocc.org/2019_pdf/Feeding%20of%20Neonat
es%20with%20Umbilical%20Artery%20Doppler%20Abnormalities%20
%20%20-%
202019.pdf
