NECROTIZING

ENTEROCOLITIS

Janice Nicklay Catalan M.D.

 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…….

PRIMARY INFECTIOUS AGENTS
Bacteria, Bacterial toxin, Virus, Fungus
MUCOSAL INJURY
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage)
Platelet activating factor (PAF)
Tumor necrosis factor (TNF)
Leukotriene C4, Interleukin 1; 6
CIRCULATORY INSTABILITY
Hypoxic-ischemic event
Polycythemia
ENTERAL FEEDINGS
Hypertonic formula or medication
Malabsorption, gaseous distention
H2 gas production, Endotoxin
production
 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: Age at diagnosis:

< 30 wks 20 days

31-33 wks 11 days
> 34 wks 5.5 days
Full term 3 days

*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
 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
 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
 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
 TREATMENT
• Stop enteral feeds
– re-start or increase IVF
• Nasogastric decompression
– low intermittent suction
• Antibiotics
– Amp/Gent; Vanc/Cefotaxime
– Clindamycin
• suspected or proven perforation
 TREATMENT
• Surgical Consult
– suspected or proven NEC
– indications for surgery:
• portal venous gas; pneumoperitoneum
• clinical deterioration
– despite medical management
• positive paracentesis
• fixed intestinal loop on serial x-rays
• erythema of abdominal wall
 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