N.E.

C
Necrotizing Enterocolitis
(Enterokolitis Nekrotikans)

Pembimbing:
dr. Hartaniah Sadikin, Sp.A

Presentasi oleh:
Patrick Hiskia Hasiholan Situmeang
 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/assets http://go2.wordpress.com/?
id=725X1342&site=usebrains.wordpress.com&url=http%3A
/images/krames/85061.jpg %2F%2Fusebrains.files.wordpress.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
Bell’s Staging
oleh Walsh dan
Kliegmann
• 3 stadium
1. Suspected NEC
http://knol.google.com/k/-/-/Mpv6w2
2. Proven / _G/cMzxJA/fig%202.jpg
Definite NEC
3. Advanced /
Severe NEC
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
• Relatif:
– Perubahan warna dinding perut yang progresif
– Looping dan dilatasi usus serta pneumatosis
intestinalis bermakna pada foto polos
– Portal Vein Gas
 Surgery

Peritoneal Drainage Laparatomy

• VLBW - Severe NEC • Gangren - Sepsis

• Tidak ada • penentuan:
kemajuan klinis • Reseksi dan
selama 12 – 24 enterostomi
jam  laparatomi • 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
– Laktoferin-laktoperoksidase Bakterisid
– 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 digestable-
oligosaccharides):
– FOS (Fructo-Oligosaccharides)
– TOS (Transgalacto-Oligosaccharides)
– 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.