Necrotizing

EnteroColitis
(NEC)
Necrotizing •
enterocolitis (NEC) is
one of the most
common
gastrointestinal
emergencies in the
.newborn infant
It is estimated to occur in 1 to 3 •
.per 1000 live births
More than 90 percent of cases •
occur in very low birth weight
(VLBW) infants (BW <1500 g) born
at <32 weeks gestation, and the
incidence of NEC decreases with
increasing gestational age (GA)
.and BW
The global incidence •
varies from 2 to 7
percent for VLBW
.infants
Term infants who •
develop NEC usually
have a preexisting
illness, such as
congenital heart disease
or sepsi
NEC primarily occurs in healthy, growing, •
.and feeding VLBW preterm infants
It presents with sudden changes in •
feeding tolerance (increase in gastric
residuals) with both nonspecific systemic
signs (eg, apnea, respiratory failure, poor
feeding, lethargy, or temperature
instability) and abdominal signs (eg,
abdominal distension, bilious gastric
retention and/or vomiting, tenderness,
.rectal bleeding, and diarrhea)
Physical findings may •
include abdominal wall
erythema, crepitus, and
induration. (See 'Clinical
presentation' above.)
A clinical diagnosis of NEC is based •
on the presence of the characteristic
clinical features of abdominal
distension, bilious vomiting or
gastric aspirate, and rectal bleeding
(hematochezia), and the abdominal
radiographic finding of pneumatosis
intestinalis, pneumoperitoneum, or
.sentinel loops (image 1)
A clinical diagnosis of NEC is based •
on the presence of the characteristic
clinical features of abdominal
distension, bilious vomiting or
gastric aspirate, and rectal bleeding
(hematochezia), and the abdominal
radiographic finding of pneumatosis
intestinalis, pneumoperitoneum, or
.sentinel loops (image 1)
The definite diagnosis of •
NEC is made from either
surgical or postmortem
intestinal specimens that
demonstrate the
histological findings of
inflammation, infarction,
.and necrosis
However, a pathologic •
diagnosis is not always
.possible
At times, radiographic findings •
may be equivocal and
treatment decision should be
based upon clinical suspicion
.and findings
The severity of NEC is● •
defined by the Bell staging
criteria, which stages NEC
based upon the severity of
clinical findings (table 1).
(See 'Severity of NEC:
Modified Bell staging
criteria' above.)
Results of laboratory● •
evaluation, including
blood studies and stool
analysis, are nonspecific,
but may be supportive of
.the diagnosis of NEC
In particular, low platelet count, •
metabolic acidosis, and a heme-
positive stool are associated with
.NEC
Once a diagnosis of NEC is made or •
suspected, a sepsis evaluation
should be performed as bacteremia
is a common concomitant finding in
infants with NEC. (See 'Laboratory
.evaluation' above
The differential diagnosis● •
of NEC includes other
conditions that cause
rectal bleeding,
abdominal distension, or
.intestinal perforation
These include •
spontaneous intestinal
perforation of the
newborn, infectious
enterocolitis, and the
usually benign diagnosis
.of anal fissure
NEC is usually differentiated from •
these conditions by its
characteristic clinical features
(healthy, growing, and feeding
VLBW preterm infants who
present with feeding intolerance
and evidence of rectal bleeding)
and abdominal radiographic
findings (eg, pneumatosis
intestinalis
The management of necrotizing● •
enterocolitis (NEC) depends upon
the severity of illness (table 1). Care
for the infant with (or suspected)
NEC is provided by a
multidisciplinary team, which
includes surgical consultation that
assists the neonatology team in the
evaluation and management of the
infant. (See 'Overview' above.)
Medical management● •
should be initiated promptly
when NEC is suspected and
in all infants with proven
.NEC
:It includes the following •
Supportive care – Supportive care• •
includes bowel rest with
discontinuation of enteral intake,
gastric decompression with
intermittent nasogastric suction,
initiation of parenteral nutrition,
correction of metabolic,
fluid/electrolyte, and hematologic
abnormalities, and stabilization of the
cardiac and respiratory function
Antibiotic therapy – After• •
obtaining appropriate
specimens for culture, we
recommend a course of
parenteral antibiotics that cover
a broad range of aerobic and
anaerobic intestinal bacteria
.(Grade 1C)
The empiric regimen •
should include coverage
for organisms causing
late-onset sepsis, because
20 to 30 percent of infants
with NEC have
.concomitant bacteremia
The chosen regimen •
should take into
consideration patterns of
resistance among gram-
negative enteric
organisms at the
individual institution
The clinical status is monitored to see if• •
the patient responds to medical
management, or if NEC continues to
progress and to determine if (and when)
surgical intervention is required.
Monitoring entails serial physical
examinations and abdominal
radiographs, and ongoing laboratory
testing (eg, white cell and platelet count,
and serum bicarbonate and glucose
measurements)
Surgical intervention is● •
required either when
intestinal perforation occurs
or when there is unremitting
clinical deterioration despite
medical management, which
suggests extensive and
.irreversible necrosis
Susceptibility – The risk of •
NEC increases with decreasing
gestational age and is greatest
in extremely preterm infants
(gestational age [GA] <28
weeks) due to the
immunologic and intestinal
.immaturity
Impairment of the physical, •
biochemical, and
immunologic barriers
decreases host resistance to
microbial dysbiosis and
mucosal injury, and
predisposes the preterm
infant to NEC
Risk factors and triggers• •
Risk factors for NEC include •
prolonged exposure to
antibiotics, non-human milk
feeding, and administration of
hyperosmolar agents or
medications that reduce gastric
acidity