N.E.

C
Necrotizing Enterocolitis
(Enterokolitis Nekrotikans)

Definisi
Necrotizing
kematian jaringan

Entero
saluran pencernaan (usus halus)

Colli
saluran pencernaan (usus besar)

-itis
peradangan

Definisi
Kegawatan (emergencies) abdomen pada bayi baru lahir (bayi prematur) 1 2 minggu pertama kehidupan Ditandai dengan peradangan pada saluran cerna (usus halus dan usus besar) sampai dengan kematian jaringan (nekrotisasi) akibat berbagai faktor

http://kidshealth.org/parent/medi cal/digestive/nec.html

Anatomi Saluran Cerna

http://www.mountnittany.org/ass ets/images/krames/85061.jpg

http://go2.wordpress.com/?id=725X1342&site=usebrains.wo rdpress.com&url=http%3A%2F%2Fusebrains.files.word press.com%2F2008%2F11%2Fclip-image002.jpg

Anatomi Saluran Cerna

http://www.lighterliving.com/uploads/images/intestinaldiagram.jpg

Saluran Cerna Bayi Prematur

IgA, Limfosit T Respon Antibodi Permeabilitas membran epitel GI Motilitas GI Lapisan Mucin tipis dan permeabel

McElroy, Steven M.D.:Neonatal NEC pp 34.Vanderbilt University.Vanderbilt Children Hospital.April 2008

Predileksi NEC

Ileum terminalis - caecum

http://medimages.healthopedia.com/ large/necrotizing-enterocolitis.jpg

Epidemiologi

http://knol.google.com/k/-/-/Mpv6w2_G/cMzxJA/fig%201.jpg

Faktor Resiko

Carol Rees Parish, R.D.: NUTRITION ISSUES IN GASTROENTEROLOGY, SERIES #59, Practical Gastroenterology, February 2008

Patofisiologi

Faktor Defensive Usus

http://neoreviews.aappublications.org Jesse, Nathan M.D.;Necrotizing Enterocolitis: relationship to innate immunity, Clinical features, and Strategies for Prevention

aq

http://knol.google.com/k/-/-/Mpv6w2_G/cMzxJA/fig%208.jpg

Diagnosis NEC
Modifikasi kriteria Bells Staging oleh Walsh dan Kliegmann 3 stadium

1. Suspected NEC 2. Proven / Definite NEC 3. Advanced / Severe NEC

http://knol.google.com/k/-//Mpv6w2_G/cMzxJA/fig%202.jpg

Diagnosis NEC

Stadium I Suspected NEC

Faktor faktor resiko untuk terjadinya stress perinatal Instabilitas suhu tubuh, disertai keadaan letargi, apnoe, bradikardia

Gejala saluran pencernaan, bayi malas makan, meningkatnya residu saluran pencernaan, emesis, distensi abdomen ringan, tes darah samar feces positif
Gambaran radiologis densitas ringan, dilatasi lumen usus

 Gambaran Radiologis

Normal

Dilatasi lumen

Stadium II Proven NEC

Gejala seperti stadium I, tetapi:
Distensi abdomen lebih berat Bising usus menghilang Perdarahan lewat tinja lebih jelas (gross bleeding) Asidosis metabolik ringan Radiologis:
pneumatosis intestinalis portal vein gas tanda tanda ascites

Stadium III Advanced NEC

Gejala 2 stadium sebelumnya ditambah:
tanda tanda shock (septic), peritonitis generalisata, eritema pada abdomen Radiologis
pneumoperitoneum

Pneumoperitoneum (football sign)

Tatalaksana
Puasa (NPO) dan oksigenasi adekuat Selang hidung-lambung (NGT) Infus untuk cairan dan nutrisi cukup Antibiotik Pemeriksaan serial foto polos abdomen

Tatalaksana
Nutrisi

Antibiotik
Clindamycin 15 40 mg/kg/hari terbagi 3-4x; Gentamycin 2,5 mg/kg/x, 1-2x/hari Metronidazole 7,5 15 mg/kg/hari

II A

II B

III A

III B

Indikasi Pembedahan
Absolut:
Perforasi pneumoperitoneum Perburukan gejala klinis dengan terapi maksimal Obstruksi intestinal Sepsis Jaringan nekrotik striktura
Perubahan warna dinding perut yang progresif Looping dan dilatasi usus serta pneumatosis intestinalis bermakna pada foto polos Portal Vein Gas

Relatif:

Surgery
Peritoneal Drainage Laparatomy

VLBW - Severe NEC Tidak ada kemajuan klinis selama 12 24 jam laparatomi

Gangren - Sepsis penentuan: Reseksi dan enterostomi Reseksi dan anastomosis primer Diverting jejunostomi

Komplikasi
Komplikasi penyakit dan tindakan:
Asidosis metabolik DIC Peritonitis Abses Striktura Short gut syndrome Neurodevelopmental delay (50% pasien)

Prognosis
Angka mortalitas 25 % Dapat pulih dan tidak mengalami gangguan pencernaan stadium dini terdiagnosis, tanpa komplikasi

Pencegahan
ASI untuk bayi bayi baru lahir Probiotik

Air Susu Ibu

Faktor anti infeksi
pH rendah
menghalangi pertumbuhan kuman colliform dan jamur

Meningkatkan kadar lisozym Bakterisid Laktoferin-laktoperoksidase Induksi imunitas enterik pasif

SIgA Sel T Sel B

Pengendalian flora usus (prebiotik-FOS,GOS)

Faktor osmolaritas
Hiposmolaritas ASI

Probiotik
Mikroorganisme hidup Saluran cerna manusia Jumlah cukup Bermanfaat

Probiotik
95% di ASI Muncul hari ke 7 homofermentasi

Prebiotik
NDO (non digestableoligosaccharides):
FOS (Fructo-Oligosaccharides) TOS (TransgalactoOligosaccharides) Lactulose

Daftar Pustaka
1. Avery, Gordon. B M.D., Ph.D. Neonatology: Pathophysiology and Management of the Newborn 3rd edition. pp 1220 1222:Section 47. Nutrition, Disorder of Nutrition. Fletcher, Anne B. Philadelphia: J. B. Lippincott Company.1987. 2. Bourlioux, Pierre et al. The Intestine and Its Microflora are Partners for the Protection of the Host: report on the Danone Symposium The Intelligent Intestine. Am Jou of Clinical Nutrition. 2002. Diunduh dari www.ajcn.org 3 Maret 2010. 3. Epelmann, Monica M. D. et al. Necrotizing Enterocolitis: Review of State-of-the-Art Imaging Findings with Pathologic Correlation. Radio Graphics Vol. 27:285 305. 2007. Diunduh dari: radiographics.rsna.org/content/27/2/285.full 3 Maret 2010. 4. Gomella, Tricia Lacy, M. Douglas Cunningham, Fabien Gabriel Eyal, Karin E. Zenk. Neonatology: Management, Procedures, On-call Problems, Diseases, and Drugs 5th edition. pp 482 487: Section 71. Necrotizing Enterocolitis and Spontaneous Intestinal Perforation.University of Michigan: Lange Medical Books.2004. 5. Hackam, David J M. D, Ph.D. Necrotizing Enterocolitis: A Leading Cause of Death and Disability in Newborn Children. Diunduh dari: http://knol.google.com/k/necrotizing-enterocolitis# 3 Maret 2010. 6. Henry Marion C. W M.D., R. Lawrence Moss, M.D. Surgical Therapy for Necrotizing Enterocolitis: Bringing Evidence to the Bedside. Diunduh dari: www.uftm.edu.br/discirped/textos/AVIdiscirped070102093945.pdf 4 Maret 2010 7. Jesse, Nathan and Josef Neu. Necrotizing Enterocolitis: Relationship to Innate Immunity, Clinical Features, and Strategies for Prevention. NeoReviews 2006;7;e143-e150. Diunduh dari: http://neoreviews.aappublications.org/cgi/content/full/neoreviews;7/3/e143 8. Reuters Health Information. SGA Preemies Face Excess Mortality from Lung Disease and Necrotizing Enterocolitis. Diunduh dari: http://www.medscape.com/viewarticle/709365. 3 Maret 2010. 9. Reuters Health Information. Human-Milk-Only Diet Lowers Necrotizing Enterocolitis Risk in Preemies. Diunduh dari: http://www.medscape.com/viewarticle/715321. 4 Maret 2010. 10. Springer, Shelley C M.D. Necrotizing Enterocolitis: Overview etc. Diunduh dari: http://emedicine.medscape.com/article/977956 3 Maret 2010.