TEXAS PEDIATRIC SURGICAL ASSOCIATES (832) 325-7234

NECROTIZING ENTEROCOLITIS
What is Necrotizing Enterocolitis (NEC)? Necrotizing enterocolitis (NEC) affects mainly premature babies. It is the most common surgical emergency in newborns. NEC accounts for 15% of deaths in premature babies weighing less than 1500 grams. Overall death from those babies with NEC is 25%. What causes NEC? No single factor has been established as the cause of NEC. It is now thought that NEC is the result of a combination of several factors. The two consistent findings are prematurity and feedings. The premature intestine reacts abnormally and develops an acute inflammatory response to feedings leading to intestinal necrosis (death). Some postnatal issues including heart abnormalities, obstruction of circulation in the bowel, infection or gastroschisis are also associated with NEC. In the premature infant, NEC usually occurs a week to ten days after the initiation of feedings. In the term baby, NEC occurs within one to four days of life if feeding is started on day one. The risk of NEC is less with later gestational age. Very few unfed infants develop NEC. One theory which connects feeding to bowel mucosa damage involves the overgrowth of bacteria when provided with a carbohydrate source. The digestion of the lactose in formula by premature infant is incomplete and the residual ferments (has a chemical change) that encourages growth of bacteria that cause inflammation. What are the signs and symptoms of NEC? NEC is difficult to diagnose. The baby may have lethargy, poor feeding, bilious vomiting, distended abdomen and blood in stools. Physical examination may show the baby to have abdominal tenderness, periumbilical darkening or erythema (redness, or a fixed loop of bowel that can be felt. How is NEC diagnosed? Abdominal X-rays are done frequently if NEC is suspected. These films will show the neonatal team if there are any fixed or distended loops of bowel that may indicate an ileus (obstruction). Pneumatosis intestinalis (air in the bowel wall) can be seen early in NEC and can resolve over a number of hours. Pneumoperitoneum (air in the abdomen) is an indicator for immediate surgery. Air in the abdomen shows that the bowel has perforated (torn). Diagram of normal intestines and colon,

showing location of ileocecal valve How is NEC managed? Medical management consists of stopping feeds, nasogastric drainage to suction (tube in babys stomach to "suck out" contents), 7-14 days of antibiotics and IV nutrition. Close monitoring of fluid status, electrolytes, coagulation and oxygen requirements are also necessary. 60-80% of babies with NEC are managed medically and symptoms resolve without surgery. Feedings postoperatively are started slowly. What if surgery is needed? Surgery is necessary if medical management fails or the bowel is perforated (torn). After opening the abdomen, the surgeon may find a swollen, purple bowel with areas of necrosed (dead) bowel. The usual areas involved are the terminal ileum, cecum and right colon but the whole bowel may be involved. The goal is to remove only that bowel that is fully necrosed (dead) and to leave any marginal areas in the hope that they will survive. This may require an ostomy and/or another operation within 24-48 hours to evaluate any surviving bowel. The nutritional outcome is roughly based on the remaining intestinal length and the medical and surgical team will discuss this with you. A note to parents Having a baby with NEC is confusing and frightening. Feeding your child is a basic bonding parental experience and a child that cant be fed probably makes you feel helpless and frustrated. We know that soul searching is inevitable with questions like "What did we do wrong?" The frustration and anxiety are increased with the realization that there is nothing to do but "wait and watch". Your nurse and any other members of the team are here to help you. Ask questions. We are here to support you through this difficult time.

NEC Definition Return to top

Necrotizing enterocolitis is an acquired disease, primarily in premature infants or sick newborns, in which intestinal tissue dies. Causes, incidence, and risk factors Return to top

In necrotizing enterocolitis, the lining of the intestinal wall dies and the tissue sloughs off. The cause for this disorder is unknown, but it is thought that a decreased blood flow to the bowel keeps the bowel from producing the normal protective mucus. Bacteria in the intestine may also be a cause. At risk are small, premature infants, infants who are fed concentrated formulas, infants in a nursery where an outbreak has occurred (suggesting an infectious cause), and infants who have received blood exchange transfusions.

Symptoms Return to top

Abdominal distention Vomiting and feeding intolerance Blood in the stool (visible or microscopic) Lethargy Temperature instability Diarrhea Return to top

Signs and tests

Abdominal x-ray Stool for occult blood test (guaiac) Elevated white blood cell count in a CBC Thrombocytopenia (low platelet count) Lactic acidosis

Treatment Return to top In an infant suspected of having necrotizing enterocolitis, feedings are stopped and gas is relieved from the bowel by inserting a small tube into the stomach. Intravenous fluid replaces formula or breast milk. Antibiotic therapy is started. The infant's condition is monitored with abdominal x-rays, blood tests, and blood gases. If intestinal perforation (hole) or peritonitis (inflammation of the abdominal wall) develops, surgery is indicated. The dead bowel tissue is removed and a colostomy or ileostomy is performed. The bowel is then reconnected several weeks or months later when the infection and inflammation have healed. Expectations (prognosis) Return to top

Necrotizing enterocolitis is a serious disease with a death rate approaching 25%. The outcome is improved by aggressive, early treatment. Complications

Return to top

Intestinal perforation Sepsis Peritonitis Intestinal stricture (a narrow area that may lead to bowel obstruction)

Calling your health care provider Return to top This disorder usually develops in an infant that is already ill or premature, and most often develops while the infant is still in the hospital. If any symptoms of necrotizing enterocolitis develop, especially in an infant that has recently been hospitalized for illness

or prematurity, go to the emergency room or call the local emergency number (such as 911). Update Date: 8/2/2005