NECROTIZING

ENTEROCOLITIS

Reproduction System
2010
 OBJECTIVES
• Ability to diagnose and treat the signs and
symptoms of NEC

• Ability to evaluate radiographs for the

classic findings of NEC

• List several long-term complications

associated with NEC
 NECROTIZING
ENTEROCOLITIS
• Epidemiology:
– most commonly occurring gastrointestinal
emergency in preterm infants
– leading cause of emergency surgery in neonates
– overall incidence: 1-5% in most NICU’s
– most common in VLBW preterm infants
• 10% of all cases occur in term infants
 NECROTIZING
ENTEROCOLITIS
• Epidemiology:
– 10x more likely to occur in infants who have
been fed
– males = females
– blacks > whites
– mortality rate: 25-30%
– 50% of survivors experience long-term
sequelae
 NECROTIZING
ENTEROCOLITIS
• Pathology:
– most commonly involved areas: terminal ileum
and proximal colon
– GROSS:
• bowel appears irregularly dilated with hemorrhagic
or ischemic areas of frank necrosis
– focal or diffuse
– MICROSCOPIC:
• mucosal edema, hemorrhage and ulceration
 NECROTIZING
ENTEROCOLITIS
• MICROSCOPIC:
– minimal inflammation during the acute phase
• increases during revascularization
– granulation tissue and fibrosis develop
• stricture formation
– microthrombi in mesenteric arterioles and
venules
 NECROTIZING
ENTEROCOLITIS
• Pathophysiology:

UNKNOWN
CAUSE…….
From UpToDate online, Adapted from Kliegman, RM, Pediatr Res 1993; 34:701.
 RISK FACTORS
• Prematurity:
* primary risk factor
– 90% of cases are premature infants
– immature gastrointestinal system
• mucosal barrier
• poor motility
– immature immune response
– impaired circulatory dynamics
 RISK FACTORS
• Infectious Agents:
– usually occurs in clustered epidemics
– normal intestinal flora
• E. coli
• Klebsiella spp.
• Pseudomonas spp.
• Clostridium difficile
• Staph. Epi
• Viruses
 RISK FACTORS
• Inflammatory Mediators:
– involved in the development of intestinal injury
and systemic side effects
• neutropenia, thrombocytopenia, acidosis,
hypotension
– primary factors
• Tumor necrosis factor (TNF)
• Platelet activating factor (PAF)
• LTC4
• Interleukin 1& 6
 RISK FACTORS
• Circulatory Instability:
– Hypoxic-ischemic injury
• poor blood flow to the mesenteric vessels
• local rebound hyperemia with re-perfusion
• production of O2 radicals
– Polycythemia
• increased viscosity causing decreased blood flow
• exchange transfusion
 RISK FACTORS
• Enteral Feedings:
– > 90% of infants with NEC have been fed
– provides a source for H2 production
– hyperosmolar formula/medications
– aggressive feedings
• too much volume
• rate of increase
– >20cc/kg/day
 RISK FACTORS
• Enteral Feedings:
– immature mucosal function
• malabsorption
– breast milk may have a protective effect
• IGA
• macrophages, lymphocytes
• complement components
• lysozyme, lactoferrin
• acetylhydrolase
 CLINICAL PRESENTATION
Gestational
Age at diagnosis:
age:

2030
< days
wks
31-33
11 dayswks
> 34days
5.5 wks
3Full
daysterm

* Time of onset is inversely related to gestational age/birthweight

 CLINICAL PRESENTATION
Gastrointestinal: Systemic
Feeding intolerance Lethargy
Abdominal distention Apnea/respiratory distress
Abdominal tenderness Temperature instability
Emesis Hypotension
Occult/gross blood in stool Acidosis
Abdominal mass Glucose instability
Erythema of abdominal wall DIC
Positive blood cultures
 CLINICAL PRESENTATION
Sudden Onset:
Full term or preterm infants
Acute catastrophic deterioration
Respiratory decompensation
Shock/acidosis
Marked abdominal distension
Positive blood culture
Insidious Onset:
Usually preterm
Evolves during 1-2 days
Feeding intolerance
Change in stool pattern
Intermittent abdominal
distention
Occult blood in stools
 Modified Bell Staging for NEC
Stage & Systemic Signs Abdominal Signs Radiographic Signs
Severity
Stage Ia Temp changes, apnea, Distension, gastric Normal, or intestinal
Suspected NEC bradycardia, lethargy retention, emesis, heme dilation
positive stool Mild ileus

Stage Ib Same as Ia Ia + grossly bloody Same as Ia

Suspected NEC stool

Stage IIa Same as Ia Ib + absent bowel Intestinal dilation,

Definite Mild NEC sounds +/- abdominal ileus, pneumatosis
tenderness intestinalis

Stage IIb Ia + mild metabolic IIa + definite IIa + ascites

Definite Moderate NEC acidosis, tenderness, +/- abd
thrombocytopenia cellulitis, RLQ mass

Stage IIIa IIb, but more severe, + IIb + peritonitis, Same as IIb
Advanced, Severe NEC combined respiratory & marked distension and
Bowel Intact metabolic acidosis, tenderness
neutropenia, & DIC
Stage IIIb Same as IIb Same as IIIa IIIa +
Advanced Severe NEC pneumoperitoneum
Bowel Perforated

Adapted from sources showing Bell Staging

 BELL STAGING CRITERIA
STAGE CLINICAL X-RAY TREATMENT

I. Suspect Mild abdominal Mild ileus Medical

distention Work up for
NEC Poor feeding Sepsis
Emesis

II. Definite The above, plus Significant Medical

Marked abdominal Ileus
NEC distention Pneumatosis
GI bleeding Intestinalis
PVG

III. Advanced The above, plus Pneumo- Surgical

Unstable vital signs Peritoneum
NEC Septic Shock
 RADIOLOGICAL FINDINGS
• Pneumatosis Intestinalis
– hydrogen gas within the bowel wall
• product of bacterial metabolism
a. linear streaking pattern
• more diagnostic
b. bubbly pattern
• appears like retained meconium
• less specific
Abdominal Distension
Severe Abdominal Distension
Pneumatosis Intestinalis

Image from LearningRadiology.com

 RADIOLOGICAL FINDINGS

• Portal Venous Gas

– extension of pneumatosis intestinalis into the
portal venous circulation
• linear branching lucencies overlying the liver and
extending to the periphery
• associated with severe disease and high mortality
 RADIOLOGICAL FINDINGS

• Pneumoperitoneum
– free air in the peritoneal cavity secondary to
perforation
• falciform ligament may be outlined
– “football” sign
– surgical emergency
Pneumatosis Intestinalis

http://www.hawaii.edu/medicine/pediatrics/pemxray/v2c14.html
Pneumatosis & Dilated Loops

Pneumatosis

http://www.hawaii.edu/medicine/pediatrics/pemxray/v2c14.html
Dilated loops & Portal Air

Portal Air

Dilated
stomach &
loops of
bowel

http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/AXR/NEC/NECwithPortalGasAP1.jpg
 A Bad Case of NEC

Abdomin
Portal Air al free air

Pneumatosis

http://www.medicine.cmu.ac.th/dept/radiology/pedrad/case8ans.html
 LABORATORY FINDINGS
• CBC
– neutropenia/elevated WBC
– thrombocytopenia
• Acidosis
– metabolic
• Hyperkalemia
– increased secondary to release from necrotic
tissue
 LABORATORY FINDINGS
• DIC
• Positive cultures
– blood
– CSF
– urine
– stool
 Neonatal NEC Pathology

Pneumatosis

Necrosis

http://phil.cdc.gov/PHIL_Images/02051999/00023/20G0023_lores.jpg
 Prevention
• Encourage breast feeding
– Breast fed babies have lower incidence than
formula fed
• No evidence shows that late initiation of
enteral feeding or slow rate of feeding
makes any difference
• Maintain high level of suspicion
– Feeding babies with NEC worsens the disease
 TREATMENT
• Stop enteral feeds
– re-start or increase IVF
• Nasogastric decompression
– low intermittent suction
• Antibiotics
 Medical Treatment
• Stage Ia
– NPO x 3 days
• Stage Ib - IIb/IIIa
– NPO
– Broad spectrum antibiotics
• Cover Gram +, Gram - & Anaerobes
• Ib = 3 days, IIa = 7-10 d, IIb & up = 14 d
– Follow x-ray for resolution
• Resume enteral feeds 10-14 days after radiographic resolution
– May require paracentesis if IIIa
 Surgical Treatment
• Stage IIIa - IIIb
– Laparotomy
• Resection of necrotic bowel
• Ileostomy with mucous fistula
– Subsequent re-anastamosis
• May result in strictures requiring further surgery later
– Peritoneal drain
• Placement in NICU under local anesthetic
• Used when infant is too clinically unstable for surgery
• May help stabilize pt for subsequent surgery
 TREATMENT
• Labs: q6-8hrs
– CBC, electrolytes, DIC panel, blood gases
• X-rays: q6-8hrs
– AP, left lateral decubitus or cross-table lateral
• Supportive Therapy
– fluids, blood products, pressors, mechanical
ventilation
 PROGNOSIS
• Depends on the severity of the illness
• Associated with late complications
* strictures
– short-gut syndrome
– malabsorption
– fistulas
– abscess

* MOST COMMON
 Outcomes
• Mortality varies with birth weight:
– <1000 g = 40-100%
– <1500 g = 10-44%
– >2500 g = 0-20%
• Morbidity/Mortality vary with severity:
– Resection -> Short gut -> FTT, malabsorbtion
– Strictures -> further surgery in medical and surgical
NEC
– Prolonged NPO status on TPN -> cholestasis &
metabolic abnormalities