Necrotizing Enterocolitis

Barrie S. Rich, MD,* Stephen E. Dolgin, MD†

* Division
of Pediatric Surgery, Hofstra Northwell School of
Medicine, Cohen Children’s Medical Center, New Hyde Park,
NY
† Division
of Pediatric Surgery, Hofstra Northwell School of
Medicine, Lenox Hill Hospital, New York, NY
Introduction

• Life-threatening condition affecting neonates

• Most commonly affects premature newborns
• 1/3 – 1/2 require surgical intervention
• Risk of long-term consequences is high
• Important to gain familiarity with common and consequential
conditions
Epidemiology and Pathogenesis
• Timing varies inversely with age
• Premature: ~4th week after birth
• Term (10% of NEC cases)
• Lower birth weight, higher change of NEC
• Rare in neonates who haven’t been fed
• Other risk factors: peripartum events causing fetal distress and postnatal
events, including hypothermia, effects of congenital heart disease, and
sepsis
• Etiology of NEC: hypothesized to occur when ischemia to the intestines
afflicts an impaired or immature gut barrier exposed to infectious agents,
along with mediating cytokines or growth factors in a susceptible host
Diagnosis
• Imaging: anteroposterior (AP) and lateral abdominal radiographs of
the abdomen
• Pneumatosis intestinalis
• Portal venous gas are 2 such features
• Nonspecific gas-filled loops of bowel
• Pneumoperitoneum  indicative of intestinal perforation and one of the few
definite indicators for surgical intervention

• Ultrasonography and 3-dimensional imaging is of limited benefit.

Blue arrow: Portal venous gas

Red arrow: Pneumatosis

Red arrows outlining
“football sign” denote
pneumoperitoneum
Management
• Medical management
• Nil per os, parenteral nutrition
• Gastric decompression (orogastric tube)
• Intravenous fluid
• Intravenous broad-spectrum antibiotics
• Central venous access
• The use of vasopressors, transfusion of blood products, and mechanical ventilation
are often required
• Surgical intervention: up to 50%
• Pneumoperitoneum absolute indication
• Relative indications: abdominal wall edema or discoloration, portal venous gas,
extensive pneumatosis or fixed intestinal loops on radiographs, persistent
hemodynamic instability, or worsening acidosis or thrombocytopenia
• Surgical options: open surgery versus placement of a peritoneal drain
Outcome and Complications
• Overall survival for patients with NEC depends on severity and is
worse for the subset that requires surgical intervention.
• Surgically treated NEC patients have a mortality rate of approximately
35% vs approximately 20% in those treated with medical therapies.
• In medically treated patients, survival correlates with degree of
prematurity and weight.
• Approximately 50% of NEC survivors develop early postoperative
complications.
• Most common complications include wound infection, wound breakdown or
dehiscence, compartment syndrome, and complications secondary to stomas.
Intermediate and Long-term Consequences
• Intestinal stricture
• 20%
• Most common in the colon
• Can present with bilious emesis, distention, or diarrhea
• Contrast-enhanced studies to aid in diagnosis
• Short gut syndrome
• NEC most common cause of short gut syndrome
• Due to massive surgical resection leaving too short a length of intestine to meet the caloric
needs of the patient
• Degree of malabsorption is not always directly correlated with the amount of intestine that
has been resected, as NEC can result in damaged intestine, which leads to physiological short
gut syndrome
• Neurodevelopment consequences
• Developmental and behavioral problems are seen in those surgically treated, including
growth failure, motor delays, and cognitive delays
Prevention
• Maternal and donor breast milk reduce the incidence of NEC

• Probiotics: Studies show some benefit in reducing NEC; no clear

administration protocol exists

• Some data exist for lactoferrin with or without probiotics, but there is
no clear regimen in place