Necrotizing

Enterocolitis

Prof. Panchali Pal

Principal
Kothari Institute of Nursing
Kolkata
 Definition
• Necrotizing enterocolitis means necrosis (death) of intestinal tissue
• Necrotizing means death of the tissue
• Entero refers to small intestine
• Colo means large intestine
• Itis means inflammation
• Necrotizing enterocolitis (NEC), an inflammatory bowel necrosis of
infants, is the most common gastrointestinal emergency in preterm
neonates and a major cause of morbidity and mortality in neonatal
intensive care units throughout the world
 Incidence

• The incidence of NEC is estimated to be 1–3 per 1000 live

births, with more than 90% of all cases occurring in
preterm infants.
• NEC occurs in 7%–11% of all premature infants born with
very low birth weight (1500 g)
 Etiology

• Unknown, may be mutifactorial

• Immaturity of intestinal mucosa
• Intestinal ischemia/reperfusion
• Injury or infection
• Immature immune response.
 R is k fa c to r s

Premature infants (<32 All gestational age Late preterm and term
weeks) infant
Low birth weight (<1500gm) Formula feeding Congenital heart disease
Small for gestational age Hypoxia Chromosomal abnormalities
Anemia requiring packed cell Birth asphyxia Gastroschisis
transfusion IUGR Sepsis
Patent ductus arteriosus Polycythemia Hypoxic Ischemic encephalopathy
Formula feeding* Exchange transfusion Maternal preeclampsia
Umbilical lines Maternal gestational diabetes
Premature rupture of membrane Drugs- H2 blockers, broad spectrum
Maternal cocaine use antibiotics,Indomethacin and steroids in
Idiopathic combination

*Meta-analysis of 6 RCTs comparing formula feeds versus human milk in preterm

infants showed that preterm infants fed with formula had more than twice the
incidence of NEC
Pathogenesis
 Pathogenesis
• The actual spectrum of illness ranges from mild cases of feeding
intolerance and abdominal distension to severe cases characterized by
intestinal necrosis, perforation, and septic shock. NEC most commonly
involves terminal ileum and colon, although in severe cases the entire
small and large bowel may be affected.
• Predisposing factors in premature baby causes insult to intestinal tissue
• Mesenteric vasospasm occurs leading to reduced intestinal perfusion
• Eventually ischemic mucosal injury occurs with direct damage to the
mucosa.
 Clinical Features
• Nonspecific: Respiratory distress with increased episodes apnea/bradycardia,
temperature instability, glucose instability, lethargy or irritability with poor feeding,
hypotension, decreased peripheral perfusion, pallor, hypo/hyperglycemia
• Gastro-intestinal: Abdominal distension, Abdominal tenderness or redness, Feeding
residuals, often bilious , Absent bowel sounds, Gross or occult blood in stool, Bluish
discoloration of abdominal wall
• Others: Metabolic acidosis, Thrombocytopenia, Neutropenia, Increased or decreased
WBC, oliguria, bleeding diathesis
• The peak age of onset of NEC is end of 1st week of life to 2nd week
• Severe refractory hyponatremia, persistent metabolic acidosis and thrombocytopenia
forms the classic metabolic triad in NEC
Abdominal distension Necrosed bowel
 Diagnosis
Lab studies:
• Abnormal WBC, elevated CRP, Thrombocytopenia, electrolyte
imbalances
• Evidence of microorganism in blood/urine/stool culture
Radiologic studies:
• X-ray abdomen: Thickening of bowel wall, fixed dilated bowel loop,
pneumatosis intestinalis, portal venous gas, pneumoperitoneum
• Ultrasonography, paracentesis, histopathology
Pneumatosis intestinalis is pneumatosis of an intestine, that is, gas cysts in the
bowel wall.
Portal venous air is presence of air in portal vein and it’s branches
Pneumoperitoneum is presence of air or gas in the peritoneum
Staging of NEC: Modified Bell Staging
 Treatment
Medical management
• All neonates with suspect/established NEC should be kept nil per oral with continuous gastric
aspiration; volume-by volume replacement of aspirates should be done with N/2 saline.
• Total parenteral nutrition may be required, particularly in stage II/III NEC.
• Remove umbilical arterial or venous catheters, if any (to prevent on going mesenteric intestinal
ischemia).
• Appropriate respiratory support in form of CPAP or mechanical ventilation.
• Circulatory support: If there are features of shock, appropriate management with normal saline
bolus and inotropes with monitoring of arterial blood pressure.
• Metabolic derangements like acidosis and electrolyte imbalances should be corrected.
 Medical Management

• Blood cultures must be sent

• Broad spectrum antibiotics as per NICU protocol (with anaerobic cover) when there is evidence
of peritonitis or bowel perforation
• Pain control and minimal handling of the neonate are recommended
• Maintain hematocrit; arrange PRP and FFP if evidence of DIC
• Renal function monitoring: Monitor urine output, urea, creatinine, serum electrolytes and fluid
management as indicated
• Serial monitoring with abdominal X-rays and abdominal girth monitoring are recommended
• Consultation with a pediatric surgeon for further management
 Surgical Management

Indications for Surgery

• Pneumoperitoneum (indicating bowel perforation)
• Presence of necrotic bowel (severe and persistent
metabolic acidosis and/or thrombocytopenia, persistent
fixed loop on serial x-rays with lack of response to medical
management)
 Surgical procedure

• Laparotomy: The standard operation is laparotomy with

resection of gangrenous bowel and enterostomy
formation. Surgery can be resection and proximal
jejunostomy or resection and primary anastomosis. The
principal surgical objectives of laparotomy in acute NEC
are to control sepsis and removal of gangrenous bowel
preserving as much bowel length as possible.
• Primary peritoneal drainage (PPD): Consider PPD in
ELBW neonates who are too unstable to undergo
laparotomy
 Prevention
• Antenatal steroids: Incidence of NEC is significantly reduced after
antenatal steroids given to pregnant women 7 with preterm labor or
premature rupture of membranes.
• Standardized enteral feeding: Minimal enteral nutrition and standard
feeding guidelines have proven benefit in 8 decreasing the incidence of
NEC.
• Human milk feeding: Newborns exclusively breastfed 4 have a reduced
risk of NEC.
• Probiotics: Meta-analysis of 30 RCTs and 14 observational studies show
a significant reduction in severe (stage II or 9 more) NEC with a
relative risk of 0.57 (95%CI 0.47-0.70). However, a recent large
multicenter trial with Bifidobacterium breve strain showed no reduction
 Prevention
• Lactoferrin: Supplementation of lactoferrin with or
without probiotics has been shown to reduce the
incidence of late-onset sepsis and NEC
• L-arginine: Arginine is a substrate for nitric oxide
production and may help in prevention of NEC
• Oral Immunogloulins
• Enteral antibiotics
 Nursing Management

Assessment
• History
• Physical examination
• Laboratory and radiologic investigations
• Clinical staging as per modified Bell’s criteria
 Nursing Management
Nursing Diagnosis
• Ineffective breathing pattern related to effect of metabolic acidosis as evidenced by respiratory
distress and apnea
• Ineffective tissue perfusion related to injury to abdominal mucosa as evidenced by abdominal
distension, bluish discoloration of abdominal wall, X ray findings of pneumatosis intestinalis
• Imbalanced nutrition less than body requirement related to immature intestinal mucosa evidenced
by poor feeding, feeding residuals
• Dysfunctional gastrointestinal motility related to immature intestinal mucosa and mucosal injury as
evidenced by absent bowel sound, gross or occult blood in stool
• Risk for electrolyte imbalance related reduced intestinal perfusion as evidenced by hyponatremia
• Risk for unstable blood glucose level related to mucosal injury as evidenced by hypo/hyperglycemia
 Nursing Management
• Acute pain related to surgical intervention as evidenced by
frequent crying and facial grimace
• Risk for fluid volume deficit related to blood loss
• Risk for infection related to surgical procedure
• Risk for impaired parenting related to long term
hospitalization
• Parental anxiety related outcome of disease as evidenced by
frequent questioning
 Nursing Management
Nursing intervention
Preoperative care
• Make patient NPO
• Monitor hemodynamic status, ABG 4-6 hrly
• Measure and record the abdominal girth 6 hrly
• Start maintenance IV fluids
• Start Gastric decompression
• Start antibiotics after blood culture as per stage of NEC
• Observe closely for deterioration
• Record bowel motion and test stool for occult blood
 Nursing Management
Nursing Intervention
Preoperative care
• Start fluid resuscitation to improve bowel perfusion (e.g., D5-Lactated
Ringer’s at 150 mL/kg per 24 h).
• Follow urine output closely; renal failure is common due to hypoperfusion
• Monitor arterial blood pressure and administer volume expanders and
dopamine
• Observe for hyperkalemia.
• Monitor for electrolyte imbalances
• Monitor intake out put
• Perform serial X ray Monitor blood glucose
 Nursing Management
Post operative care
• Continue total parental nutrition
• Keep NPO till further order
• Orogastic drainage:Place on free drainage. Aspirate every 4-6 hours and replace
fluid losses intravenously as prescribed (usually with 0.9% NaCl plus 10mmol
KCl/500ml). The colour, consistency and amount of gastric aspirates is recorded.
• Measure and record fluid balance accurately:-Urine output, 6-hourly total,
Urinalysis at each nappy change.
• Administer antibiotics (Vancomycin/ gentamicin)
• Monitor glucose, electrolytes and vital signs
• Observe stoma for color and drainage
• Resume feed slowly after 10-14 post op day
• Do not take rectal temperature
 Complications

• Intestinal stricture with bowel obstruction

• Short bowel syndrome
• Cholestasis, if prolonged dependence on TPN
• Peritonitis
• Intestinal perforation
• Sepsis