Necrotizing
Enterocolitis
Nouf abu-Hussein
Definition
It is difficult to define NEC
Necrotizing enterocolitis (NEC) is
an ischemic & inflammatory
necrosis of the bowel.
Incidence
Mainly in preterm infants with higher incidence in babies born at lower
gestational ages
with an incidence of (6–10%) in infants weighing <1500 g
It can occur in term infants (many have preexisting medical conditions)
Pathophysiology
Multifactorial theory with several risk factors (prematurity, formula feeds,
ischemia, bacterial colonization)
Mucosal damage
Pneumatosis intestinalis
Transmural necrosis or gangrene of bowel wall
Perforation & peritonitis
Risk factors
1. Prematurity
* most preterm infants develop NEC at age of 30-32 weeks (PMA) *
Immature mucosal barrier\enzymes & hormones
Imbalance between pro-and anti-inflammatory factors – impaired microcirculation
2. Microbial colonization
No single organism has been consistently associated with NEC
Blood culture are positive in only 20-30% of cases
The growth of noncommensal bacteria may result in endotoxic release, leading to mucosal damage
3. Enteral feeding
~ 95% of infants with NEC have received at least 1 enteral feed
Hyperosmolarity of formula may alter mucosal permeability + colonic fermentation produces fatty acids mucosal damage
* Breast milk significantly lowers risk of NEC *
Risk factors
4. Circulatory instability
During circulatory distress blood is diverted away from viscera\internal organs, this may lead to intestinal ischemia.
Reperfusion then may lead to bowel damage
5. Maternal cigarette smoking
Nicotin may affect fetal blood vessel development
6. Congenital heart disease
* Infants with symptomatic PDA are at higher risk for NEC *
7. Polycythemia & hyperviscosity syndrome
diminished perfusion & intestinal ischemia
8. Blood transfusion
about 25-35% cases of NEC occurring within 48 hours of transfusion
Clinical presentation of NEC in general
In term infants NEC occurs during 1st week because of underlying disease
Most infants who develop NEC are between 14-20 days of age or 30-32 weeks
postmenstrual age.
Clinical manifestations of NEC in
general
Early signs & symptoms:
Feeding intolerance\increased gastric residual\blood in stool
Specific abdominal signs:
Distension\tenderness\skin discoloration\emesis\bilious drainage PZ
Nonspecific signs:
Signs of sepsis like apnea\bradycardia\hypothermia\hyperthermia\hypotension\circulatory shock
Clinical course of NEC
Is variable
About 30% are mild and respond to medical treatment.
About 7% may have fulminant NEC NEC totalis septic shock severe
metabolic acidosis death
The modified Bell’s staging criteria is often used to classify NEC according to
clinical and radiographic presentations
Gross bloody stools
Diagnosis
High suspicion must be maintained !
1) Clinically Feeding
intolerance
Suspect any infant with
Blood in Abdominal
stool distension
2) Lab studies
Leukocytosis\ leukocytopenia, thrombocytopenia, increasing CRP, hyperkalemia, hypo-
and hypernatremia
Metabolic acidosis
Blood and stool cultures
PT\PTT and fibrinogen, fibrin, D-dimer (DIC in severe NEC)
Diagnosis
3) Imaging and other studies
- Flat X-ray
Pneumatosis intestinalis
Itrahepatic portal venous gas
- Lateral decubitus
Pneumoperitoneum
lateral x-ray series is indicated in pneumatosis
intestinalis every 6-8 hours because of perforation
risk
Stop if clinical improvement in 48-72 hours
pneumoperitone
um
diagnosis
3) Imaging and other studies
- Abdominal US
Detects gas bubbles in liver & portal venous system. Doppler helps detect
intestinal necrosis and perfusion
- Mesenteric oxygen saturation
This technique is still experimental
management
treat it as it is an acute abdomen with impending or septic peritonitis ! In order to prevent shock !
1) NPO & TPN
2) Replogle
3) Close monitoring
4) Monitor for gastrointestinal bleeding
5) Respiratory support
6) Circulatory support
7) Strict fluid intake & output monitoring (strict urine output to 1-3 cc\kg\h)
8) Lab monitoring daily
9) Antibiotic therapy
10)Monitoring for DIC
11)Serial imaging studies in 24-48 to detect perforation
12)Surgical consultation
Surgical management
A pneumoperitoneum is an absolute indication for surgical
intervention.
1)Exploratory laparotomy
Resecting necrotic segments.
Short bowel syndrome may occur, and it has a poor prognosis
2) Peritoneal drainage placement
prevention
1) Human milk ! Prevents NEC
2) Use of feeding protocol with initial period of trophic feeds
3) Probiotics also can prevent NEC by promoting gut colonization with
beneficial organisms
4) Avoidance of prolonged empiric antibiotic use
Complications
Recurrence of NEC may occur in about 5% of cases
Colonic strictures in 10-20% of cases (recurrent abdominal distension and
feeding intolerance)
Short bowel syndrome
TPN-associated liver disease
Prognosis
A. Infants with NEC have an overall mortality of 12.5%.
B. NEC with perforation is associated with mortality of 20–40%.
C. Infants with surgical NEC are at risk for significant growth delay and
adverse
neurodevelopmental outcomes.
Thanks !
