NECROTIZING ENTEROCOLITIS

Atan Baas Sinuhaji

Sub Division of Pediatrics Gastroentero-Hepatology
Department of Childhealth,School of
Medicine,University of Sumatera Utara
Medan
 NECROTIZING ENTEROCOLITIS

PATCHY SEGMENTAL

ILEUM & COLON JEJUNUM

PREMATURE CHILD & ADULT

INTERACTION :GUT ISCHEMIA,

TOXIN C.PERFRINGENS
INFECTION,POOR MUCOSAL INTEGRITY,
ENTERAL FEEDING

“NECROTIZING ENTEROCOLITIS” NECROTIZING JEJUNITIS

( PIG BEL )
Necrotising Enterocolitis (NEC)

•Affects 0.5 to 1 per 1000 live births

•Incidence 3-10% in infants < 1500 g
•Incidence increase with decreasing birthweigh and
gestational age
•Usually affects terminal ileum and colon to a
variable extent
•NEC rarely occus before the initiation of enteral
feeding
 Incidence of NEC related to gestational age
no IUGR IUGR

10
8
6
%
4
2
0
26 27 28 29 30 31 32 33 34 35 36 >37

gestational age
 NECROTIZING ENTEROCOLITIS
An Acute Intestinal Necrosis Syndrome Resulting From
Complex Interaction :
= Gut Ischemia
= Poor Mucosal Integrity
= Microbial Infection
= Enteral Nutrition

MUCOSAL INJURY

INTESTINAL PERFORATION
Immaturity Ischaemia

Milk feeds
Loss of barrier function

Mucosal disruption

Bacterial translocation Toxins

Bacterial overgrowth
Macromolecular absorption
Viruses

Mucosal damage NEC

 ors
Bacteria

Mucus

enterocyt
Goblet cell
nucleus
 NEC

MUCOSAL INJURY

INVASION PREDISPOSITION

=Infection =Gut Immaturity

=Feeding
=Ischemia
 ABDOMINAL DISTENTION

DIARRHOEA CIRCULATORY DISTURBANCE

MALABSORPTION MUCOSAL INJURY

NEC
 ENTERAL FEEDING

1.PROVIDES SUBSTRATE FOR PROLIFERATION OF

ENTERAL PATHOGENS
2.HYPEROSMOLAR FORMULA MUCOSAL DAMAGE
3.LACK OF IMMUNOPROTECTIVE FACTORS
4.AGGRESSIVE ENTERAL FEEDING
5.BREASTFEEDING LOWERS THE RISK OF NEC
Necrotising Enterocolitis (NEC)
Clinical features

•Usually occurs in the first two weeks of life

•Child is lethargic and apathetic with vomiting and increasing
abdominal distension
•Bloody diarrhoea is a late feature
•Progression may be rapid from to mild to severe after 72 hours
•Abdominal examination may show peritonitis or a mass
Abdominal x-ray may show

 Distended bowel with mucosa edema

 Intramural gas ( = pneumatosis intestinalis )
 Portal venous gas or free intraperitoneal gas
Abdominal x-ray
AA
Abdominal x-ray
Treatment

 A. Medical No definitive treatment

 B. Surgical
1. Perforation
2.Fixed dilated loop on serial x-ray
3.Abdominal wall cellulitis
4.Progressive deterioration despite maximal medical
support
Medical
 1.Preventing futher injury
a. Cessation of feeding
b. Decompression
c. IntraVenous Fluid Drip ( IVFD )
 2.Supportive
a. Respiration status
b. Coagulation profile
c. Electrolyte and Acid base balance
d. Antibiotics
 Bell staging (Bell et al 1978) Feeding strategy
Stage I: - feeding intolerance Day 0-2: - no enteral feeding
- abdominal distention Day 3-5: - minimal enteral feeding
- vomiting Day 5- : - 24 x 1 ml/kg
- blood with stools

Stage II: - like stage I and Day 0-5: - no enteral feeding

- pneumatosis intestinalis or Day 6-8: - minimal enteral feeding
- gas in portal vein Day 9- : - 24 x 1 ml/kg

Stage III:- like stage II and

Day 0-10: - no enteral feeding
- septic shock
Day 11-13: - minimal enteral feeding
- generalized pneumatosis
Day 14- : - 24 x 1 ml/kg
- free air in peritoneum
PREVENTION
1. EXCLUSIVELY BREAST-FED
2. MINIMAL ENTERAL FEEDS FOLLOWED BY
JUDICIOUS VOLUME ADVANCEMENT
3. PROBIOTIC