Updated: 4/7/2017

Necrotizing Enterocolitis

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Snapshot
  • A 26-day-old boy presents to the pediatrician due to increased irritability and episodes of vomiting after feeding. He also reports that the patient appears lethargic. Obstetric history is significant for a spontaneous vaginal delivery at 29 weeks gestation and weight of 1005 grams at birth. He was born to a 32-year-old mother. On physical examination, there is abdominal distension. Laboratory testing is significant for heme-positive stool and thrombocytopenia. An abdominal radiograph is shown.
Introduction
  • Clinical definition
    • acute neonatal intestinal necrosis
  • Epidemiology
    • incidence
      • 0.1% of all live births
    • demographics
      • more common in males
    • risk factors
      • infants born ≤ 35 weeks gestation especially with
        • a birth weight < 1000 g
      • early-onset neonatal sepsis
      • mechanical ventilation
      • 5-minute APGAR < 7
  • Pathogenesis
    • although the pathogenesis is unclear, it is believed to be due to an exaggerated inflammatory response to some sort of insult (e.g., enteral feeds in a premature infant) that injures
      • immature intestinal epithelial cells
  • Associated conditions
    • prematurity
  • Prognosis
    • 15-30% overall mortality and increased mortality with
      • prematurity
      • low birth weight
Presentation
  • Symptoms
    • feeding intolerance (e.g., emesis)
    • lethargy
    • apnea
    • dyspnea
      • may require ventilatory support
  • Physical exam
    • abdominal distension
    • blood in stool
Imaging
  • Radiography
    • view
      • abdominal in the supine position
    • indication
      • abdominal radiagraphy is used to confirm the diagnosis of suspected necrotizing enterocolitis
    • findings
      • findings suggestive of necrotizing enterocolitis include
        • pneumatosis intestinalis (hallmark of the disease) 
        • hepatobiliary gas
        • pneumoperitoneum
Studies
  • Labs
    • complete blood count (CBC)
      • thrombocytopenia is often found and can suggest
        • worsening disease progression if they are declining
    • serum chemistry
    • blood culture
  • Diagnostic criteria
    • the diagnosis is based on abdominal radiographic findings (e.g., pneumatosis intestinalis) and characteristic clinical findings such as
      • abdominal distention
      • rectal bleeding (the bleeding can be occult or grossly present)
Differential
  • Spontaneous intestinal perforation
  • Infectious enteritis
Treatment
  • Medical
    • intravenous broad-spectrum antibiotics
      • indication
        • administered after appropriate samples are obtained for culture
      • modalities
        • an example of medications used for necrotizing include
          • ampicillin, gentamicin, and metronidazole
  • Operative
    • abdominal surgery
      • indication
        • an absolute indication for abdominal surgey is intestinal perforation
      • technique
        • exploratory laparotomy with bowel resection
        • primary peritoneal drainage
Complications
  • Bowel perforation
  • Disseminated intravascular coagulation
  • Infectious complications (e.g., peritonitis)
 

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