Question 1 of 10

    Necrotizing Enterocolitis

    Necrotizing enterocolitis 202[1]

    Neonatal necrotizing enterocolitis (NEC) is a destructive non-specific inflammatory bowel disease of preterm infants and continues to be a significant clinical problem of the neonatal period. It affects nearly 10% of infants with a mass less than 1500 g and has more than 50% of mortality rates depending on the severity of illness. In spite of the fact that necrotizing enterocolitis is most common in premature infants, it may rarely occur in term newborns.

    Necrotizing Enterocolitis is triggered by the following process: infectious.

    Presentation

    Presentation of necrotising enterocolitis has a broad spectrum of severity, from fulminant to insidious or asymptomatic forms at first. However, milder forms are more frequent in growing premature infants [8]. A decrease of gastric retention and feeding tolerance is a common early symptom of the disease. It is known that the level of glutamine and arginine have decreased for at least 10 days before clinical verification of NEC [6]. These amino acids are essential components for gastrointestinal muscle cells but it is still unclear if they can be considered as markers of the disease or part of pathogenesis.

    Initial signs can involve one or more of the next:

    • Meteorism: The increase of feeding intolerance and abdominal distension are initial clinical symptoms of NEC [8]. Meteorism caused by the accumulating of gas, that builds up in the intestine. Consequently, continued abdominal distension may compromise the bowel's wall perfusion. 
    • Visible to naked eye intestinal loops
    • Bilious vomiting
    • Stool change (bloody mucoid)
    • Decrease of peristaltic sounds
    • Erythema of the abdomen wall
    • Ascites

    Nonspecific systemic signs can include:

    The clinical presentation and recognize of NEC are based on well-defined staging criteria [9] [10] [11]. It consists of the severity of systemic, intestinal symptoms and radiographic findings.

    Bell Stage I - suspected necrotising enterocolitis (NEC)

    • Systemic: general signs such as fiber, inactivity, apnoea, bradycardia.
    • Gastrointestinal tract (GIT): gastric residuals, positive fecal occult blood test.
    • Abdominal X-ray (AXR): without pathological finding or nonspecific changes.

    Stage IB diagnosis is equivalent to IA, with the addition of the bloody stool.

    Bell stage II - definite disease

    Stage IIA - definite and mild NEC:

    • Systemic: Nonspecific signs.
    • GIT: Abdominal wall tenderness or abdominal distension, absent peristaltic sounds, blood in the stool.
    • AXR: Ileus, focal pneumatosis of intestine.

    Stage IIB - definite and moderate NEC:

    • Systemic: Moderate acidosis, thrombocytopenia.
    • GIT: Abdominal wall edema, tenderness, intestinal mass as a palpation symptoms.
    • AXR: Extensive pneumatosis of the intestine, early ascites. Radiographs note a portal venous gas.

    Bell stage III - advanced disease

    Stage IIIA - advanced NEC:

    Stage IIIB - advanced NEC:

    • Systemic: Drop of vital signs, shock, electrolyte imbalance.
    • GIT and AXR: Signs of perforation.
    • Stage IIIB use for the severely ill newborn with perforated bowel observed on X-rays in addition to the IIIA findings.

    Skin
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  • urogenital
    Oliguria
    • Signs of deterioration are apnea, pallor, hyperbilirubinemia, oliguria, abdominal tenderness, and erythema and edema of the anterior abdominal wall or palpable masses, with eventual respiratory failure leading to death.[medical-dictionary.thefreedictionary.com]
    • […] focal pneumatosis IIB: Moderate NEC Mild acidosis and thrombocytopenia Abdominal wall edema and tenderness palpable mass Extensive pneumatosis, early ascites PVG IIIA: Advanced NEC Respiratory and Meatbolic acidosis, Mechanical ventilation, hypotension, oliguria[jpediatricsreview.com]
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  • Ears
    Hearing Impairment
    • Patient Outcomes Following NEC Patient Outcomes Intestinal strictures Bowel resection and/or Short Bowel Syndrome Intestinal failure secondary to short bowel syndrome Neurodevelopmental deficits Visual and hearing impairments Cognitive impairment Psychomotor[jpediatricsreview.com]
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  • hematological
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  • cardiovascular
    Tachycardia
    • Cardiac exam demonstrates tachycardia and no murmurs.[hawaii.edu]
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  • gastrointestinal
    Vomiting
    • Initial symptoms of NEC can include vomiting food and possibly bile from the stomach, a distended or abnormally large belly, diarrhea, and blood in the stool.[aboutkidshealth.ca]
    • […] damage to the intestinal tract, causing death of intestinal tissue . [1] [2] The condition most often occurs in premature newborns, but it may also occur in term or near-term babies. [2] Signs and symptoms may include abdominal distension, bloody stools, vomiting[rarediseases.info.nih.gov]
    • Typically, the neonate exhibits lethargy, vomiting, distended abdomen, signs of intestinal bleeding, and absence of bowel sounds.[medical-dictionary.thefreedictionary.com]
    • Bloody mucoid stool and bilious vomiting.[patient.info]
    • Symptoms of NEC usually develop in the first 2 weeks and may include the following: Bloating or swelling in the tummy Poor tolerance to feedings Frequent vomiting (possibly green in color) Bloody stool (bowel movements) Redness or abnormal color to the[my.clevelandclinic.org]
    Abdominal Distension
    • On physical examination the patient appears lethargic and abdominal distension is appreciated.[medbullets.com]
    • distension, bloody stools, vomiting bile-stained fluid, and pneumatosis intestinalis (gas in the bowel wall) identified on abdominal x-ray .[rarediseases.info.nih.gov]
    • Examination Abdominal distension with increasing gastric aspirates.[patient.info]
    • Clinical symptoms found in cases of necrotizing enterocolitis are feeding intolerance, increased, abdominal distension and bloody stools.[sonoworld.com]
    • Autopsy of infant showing abdominal distension, intestinal necrosis and hemorrhage, and peritonitis due to perforation.[en.wikipedia.org]
    Diarrhea
    • Initial symptoms of NEC can include vomiting food and possibly bile from the stomach, a distended or abnormally large belly, diarrhea, and blood in the stool.[aboutkidshealth.ca]
    • The most common of these include failure to suckle or nurse, fever, depression, severe colic, and diarrhea.[thehorse.com]
    • Other signs are bloating, a red an tender abdomen, diarrhea, and listlessness.[columbiadoctors.org]
    • Infants in a nursery where an outbreak has occurred Infants who have received blood exchange transfusions or have been seriously ill Symptoms Symptoms may come on slowly or suddenly, and may include: Abdominal bloating Blood in the stool Diarrhea Feeding[ufhealth.org]
    • The symptoms of NEC often include the following: swelling or bloating of the abdomen discoloration of the abdomen bloody stool diarrhea poor feeding vomiting Your baby may also show symptoms of an infection, such as: apnea, or disrupted breathing a fever[healthline.com]
    Intestinal Disease
    • It is a devastating intestinal disease that primarily affects preemies.[necsociety.org]
    • You are here Steven J McElroy MD Peer Review Status: Internally Peered Review Definition Neonatal necrotizing enterocolitis (NEC) is an inflammatory intestinal disease of newborn infants.[uichildrens.org]
    • Although most strains don’t cause intestinal disease, there are two types that do so in foals.[thehorse.com]
    • One of these diseases is necrotizing enterocolitis (nek-roh-TIE-zing en-ter-oh-coh-LIE-tis), the most common and serious intestinal disease among preemies.[kidshealth.org]
    • More recently, the terminology of acquired neonatal intestinal diseases (ANIDs) was introduced by Gordon et al. to further classify NEC into subgroups based on associated clinical factors: these include NEC in term infants, NEC associated with red blood[rarediseases.org]
    Decreased Bowel Sounds
    • bowel sounds Imaging findings Acute disease most commonly affects the terminal ileum Plain film of the abdomen remains method in which disease is diagnosed most often Findings include Dilated loops of bowel Thickened bowel walls Fixed and dilated loop[learningradiology.com]
    • . - Decreased bowel sounds. - Blood in the stool. - Redness or abnormal coloring of the abdomen. - Lethargy. - Vomiting. - Fever. - Apnea (pauses in breathing). - Slowed heart rate.[abc.go.com]
    • Decreased bowel sounds with erythema of the abdomen.[patient.info]
    • Early in the disease process, neonates can exhibit signs of feeding intolerance with vomiting, increased gastric aspirates, bile-tinged (green) gastric aspirates, or decreased bowel sounds with abdominal distention and tenderness.[rarediseases.org]
    Bilious Vomiting
    • The baby may have lethargy, poor feeding, bilious vomiting, distended abdomen and blood in stools.[childrens.memorialhermann.org]
    • Bloody mucoid stool and bilious vomiting.[patient.info]
    • Symptoms Abdominal distention (78 to 98 percent), lethargy, gross or occult blood in stool (79 to 86 percent), increased gastric residuals ( 70 percent), temperature instability, bilious vomiting ( 70 percent), Apnea/Bradycardia.[phoenixchildrens.org]
    • Today she presents with abdominal distention and bilious vomiting.[hawaii.edu]
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  • neurologic
    Lethargy
    • Affected infants occasionally have temperature instability, lethargy, or other findings of sepsis. [2] [2] The exact cause of NEC is unknown.[rarediseases.info.nih.gov]
    • […] of NEC usually develop in the first 2 weeks and may include the following: Bloating or swelling in the tummy Poor tolerance to feedings Frequent vomiting (possibly green in color) Bloody stool (bowel movements) Redness or abnormal color to the tummy Lethargy[my.clevelandclinic.org]
    • However, symptoms might include: A swollen and / or tender stomach Skin over stomach looks red Bloody bowel movements Little or no interest in feeding Green colored vomit or drainage Signs of infection, such as lethargy or long pauses in breathing (apnea[cincinnatichildrens.org]
    • Sepsis may be manifested by lethargy, temperature instability, increased apneic spells, and metabolic acidosis.[merckmanuals.com]
    • Typically, the neonate exhibits lethargy, vomiting, distended abdomen, signs of intestinal bleeding, and absence of bowel sounds.[medical-dictionary.thefreedictionary.com]
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  • Entire body system
    Fever
    • The most common of these include failure to suckle or nurse, fever, depression, severe colic, and diarrhea.[thehorse.com]
    • […] the first 2 weeks and may include the following: Bloating or swelling in the tummy Poor tolerance to feedings Frequent vomiting (possibly green in color) Bloody stool (bowel movements) Redness or abnormal color to the tummy Lethargy (lack of energy) Fever[my.clevelandclinic.org]
    • Affected infants present within two weeks of birth with abdominal swelling and bloating, as well as poor feeding tolerance, fever and lethargy.[news-medical.net]
    • The symptoms of NEC often include the following: swelling or bloating of the abdomen discoloration of the abdomen bloody stool diarrhea poor feeding vomiting Your baby may also show symptoms of an infection, such as: apnea, or disrupted breathing a fever[healthline.com]
    Disability
    • Morbidities associated with the condition include recurrent NEC, intestinal strictures, and failure as well as disabilities with regards to neurodevelopment.[news-medical.net]
    • "Surgical NEC" survivors are at risk for complications including short bowel syndrome and neurodevelopmental disability .[en.wikipedia.org]
    Coarctation of the Aorta
    • Coarctation of the aorta .[patient.info]
    • ., intestinal volvulus, hypoplastic left heart syndrome, critical coarctation of the aorta); omphalitis; isolated intestinal perforation (IIP); and in term infants, milk protein intolerance.[clinicaladvisor.com]
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  • Fetus
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  • Workup

    Laboratory workup

    Despite the blood lab tests have low specificity, blood cultures, blood gas, full blood count (FBC) and biochemical tests should be taken for the support to the diagnosis. Moreover, thrombocytopenia, neutropenia, coagulopathy, acidosis may indicate the severity of NEC.

    • Complete blood count: A complete blood count (CBC), with standard differential to estimate the white blood cell (WBC), hematocrit, and platelet volume, is regularly repeated every 6 hours if the patient's dynamic status is declining. Leukopenia is more common than a leukocytosis. This fact caused by massive sequestration of neutrophils in the peritoneal liquid [5].
    • Serum chemistries: Electrolyte disorders are nonspecific finding, however, it may be suggestive of NEC. The hyponatremia, hypoglycemia, and metabolic acidosis are commonly seen in babies with NEC.
    • Coagulation studies: These tests are necessary, especially in cases with thrombocytopenia or gastrointestinal bleeding. Moreover, disseminated intravascular coagulation is a common finding in babies with severe NEC.
    • Bacteriological tests of the stool, blood, urine, or spinal fluid. Despite the fact that a direct relationship between a specific microbe and NEC is still unclear, the presence of bacteria can be critical for the NEC development [12] [13] [7].

    Imaging 

    • Diagnosis of NEC must be verified by abdominal radiograph (supine and erect) and should be done as soon as the NEC can be suspected. 
    • Early X-rays may be nonspecific and show only signs of ileus. Nevertheless, the dilated and fixed intestinal loop that give not change on repeated radiographs may recognize NEC. Other X-ray signs of NEC are intestinal pneumatosis and portal vein gas. Consequently, pneumoperitoneum indicates a perforation of bowel's wall and requires an urgent surgical intervention.
    • Ultrasonography (USG) is frequently used in the diagnosis of NEC. Typical findings on ultrasonography include the appearance of an intestinal wall with central echogenic locus and hypoechoic rim or pseudo-kidney sign. It may mean necrotic bowel and following perforation. Ultrasound can also be used for the detection of gas in the liver parenchyma or the portal venous system.

    Laboratory

    Serum
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  • Test Results

    Colonoscopy
    Colitis
    • Advertisement Colon non tumor Colitis (non-infectious) Necrotizing enterocolitis Author: Hanni Gulwani, M.D.[pathologyoutlines.com]
    • "Necrotizing" means damage and death of cells "Entero" refers to the intestine "Colitis" means inflammation of the colon (lower part of the intestine) Although NEC may develop in any newborn, most cases occur in premature babies and in up to 5 percent[stanfordchildrens.org]
    • "Colitis" means inflammation of the colon (lower part of the intestine).[luriechildrens.org]
    • ., volvulus, pyloric stenosis, ileal atresia, Hirschsprung's disease), neonatal appendicitis, spontaneous bowel perforation, and pseudomembranous colitis or ecchymotic colitis (1,5,9).[hawaii.edu]
    • In mouse models of colitis and NEC, TLR-4 knockout mice have reduced inflammatory infiltrates when compared with wild-type mice ( 84 ).[nature.com]
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  • Treatment

    Over than half of all premature infants reveal feeding intolerance during their hospital course, but at the same time less than 25% of those newborns have necrotizing enterocolitis (NEC). As with all neonatal clinical cases, the risks and benefits of different clinical approaches to NEC must be considered thoroughly.

    In over 75% of cases, conservative treatment without surgical intervention is sufficient. If NEC is suspected, feedings must be terminated immediately. Furthermore, the intestine should be decompressed. Decompression is necessary at the first indication of abdominal pathology. It may involve:

    • Large-bore catheter with multiple side perforations and a lumen to block vacuum attachment to the mucosa.
    • Install the catheter for low, continuous or intermittent suction.
    • If profuse amounts of intestinal or gastric secretions are eliminated, IV replacement with a physiological solution must be considered.

    Monitoring should involve complete blood count, platelet count, serum electrolyte every 12 hours. The serial abdominal X-rays should repeat at 6-hour intervals.

    The initial treatment consists of the next:

    • Stop enteral feedings
    • Make abdominal decompression
    • Broad-spectrum antibiotics. Systemic antibiotics should be begun immediately with a β-lactam antibiotic (eg, ampicillin, ticarcillin) and an aminoglycoside (amikacin). Antibiotic therapy should coverage anaerobic bacteria (clindamycin, metronidazole) and should continue at least 10 days.

    Bell stages IA and IB

    The infant is directed on an NPO diet with antibiotics for 3 days. IV fluids must be given and include total parenteral nutrition (TPN).

    Bell stages IIA and IIB

    Treatment must involve respiratory and cardiovascular support with fluid resuscitation, NPO, and a course of antibiotics for 14 days. Surgical consultation should be immediately considered. After stabilization, TPN should be given during all period of NPO diet.

    Bell stage IIIA

    Treatment must involve NPO for at least 14 days, fluid resuscitation, inotropic and ventilator support. Surgical consultation is necessary. TPN should be prolonged during the period of NPO diet.

    Bell stage IIIB

    Surgical intervention includes primary peritoneal drainage (PPD at the bedside in the NICU), the laparoscopic resection of the affected intestinal segment with proximal enterostomy, distal mucous fistula. Surgical intervention is needed in approximately 25% of babies. With the resolution of peritonitis and sepsis, intestinal continuity may be renewed some weeks or months later.

    Prognosis

    Necrotizing enterocolitis is a dangerous condition. Nearly one every 4 affected infant dies. Therefore, only early and aggressive treatment can improve the outcome. Moreover, in surgically treated cases of NEC, the postoperative survival approaches to 95%, even if it must be considered that this improvement in treatment efficacy could be explained by the exclusion of the patients with pan-involvement forms of NEC. Necrotic process rises in the mucosa and may involve and affect the full width of the intestinal wall. It can lead to the dangerous complications such as pneumoperitoneum, perforation with following peritonitis, septic shock, and multiple organ dysfunction.

    Consequently, the most significant NEC complications include:

    Complications

    Fever
    • The most common of these include failure to suckle or nurse, fever, depression, severe colic, and diarrhea.[thehorse.com]
    • […] the first 2 weeks and may include the following: Bloating or swelling in the tummy Poor tolerance to feedings Frequent vomiting (possibly green in color) Bloody stool (bowel movements) Redness or abnormal color to the tummy Lethargy (lack of energy) Fever[my.clevelandclinic.org]
    • Affected infants present within two weeks of birth with abdominal swelling and bloating, as well as poor feeding tolerance, fever and lethargy.[news-medical.net]
    • The symptoms of NEC often include the following: swelling or bloating of the abdomen discoloration of the abdomen bloody stool diarrhea poor feeding vomiting Your baby may also show symptoms of an infection, such as: apnea, or disrupted breathing a fever[healthline.com]
    Patent Ductus Arteriosus
    • Infants with patent ductus arteriosus are at particularly high risk for developing NEC if pharmacologic closure is attempted.[emedicine.medscape.com]
    • Isabella was Rachael Erickson’s lung girl, she had a patent ductus arteriosus (pda) that closed, a chest tube inserted within the first 2 weeks, pneumonia and a run in with NEC.[nicuawareness.org]
    • Her early hospital course was remarkable for respiratory distress syndrome and patent ductus arteriosus.[hawaii.edu]
    • Patent ductus arteriosus is a risk factor in premature babies, especially if conservative closure using indometacin has been attempted.[patient.info]
    • Conditions, such as congenital heart disease, hemo-dynamically significant patent ductus arteriosus (PDA), and polycythemia, can precipitate a “steal phenomena” where blood is shunted away from less vital organs (e.g.- the gut) and make infants more vulnerable[jpediatricsreview.com]
    Colitis
    • Advertisement Colon non tumor Colitis (non-infectious) Necrotizing enterocolitis Author: Hanni Gulwani, M.D.[pathologyoutlines.com]
    • "Necrotizing" means damage and death of cells "Entero" refers to the intestine "Colitis" means inflammation of the colon (lower part of the intestine) Although NEC may develop in any newborn, most cases occur in premature babies and in up to 5 percent[stanfordchildrens.org]
    • "Colitis" means inflammation of the colon (lower part of the intestine).[luriechildrens.org]
    • ., volvulus, pyloric stenosis, ileal atresia, Hirschsprung's disease), neonatal appendicitis, spontaneous bowel perforation, and pseudomembranous colitis or ecchymotic colitis (1,5,9).[hawaii.edu]
    • In mouse models of colitis and NEC, TLR-4 knockout mice have reduced inflammatory infiltrates when compared with wild-type mice ( 84 ).[nature.com]
    Apnea
    • She is also having more apnea and bradycardia events.[hawaii.edu]
    • […] first 2 weeks and may include the following: Bloating or swelling in the tummy Poor tolerance to feedings Frequent vomiting (possibly green in color) Bloody stool (bowel movements) Redness or abnormal color to the tummy Lethargy (lack of energy) Fever Apnea[my.clevelandclinic.org]
    • However, symptoms might include: A swollen and / or tender stomach Skin over stomach looks red Bloody bowel movements Little or no interest in feeding Green colored vomit or drainage Signs of infection, such as lethargy or long pauses in breathing (apnea[cincinnatichildrens.org]
    • Symptoms Initial symptoms vary and may include feeding intolerance, abdominal distension, bloody stools, apnea, lethargy, temperature instability or hypoperfusion.[pediatrie.be]
    • To make matters more complex, early symptoms of NEC, such as apnea and rapid breathing, body temperature changes, and changes in blood sugar levels, are also similar to those of some respiratory and heart problems.[aboutkidshealth.ca]
    Anal Fissure
    • fissure , infectious enterocolitis , Hirschsprung disease [2] [3] Prevention Breast milk , probiotics . [2] Treatment Bowel rest , nasogastric tube , antibiotics , surgery [2] Prognosis Risk of death 25% [1] [ edit on Wikidata ] Necrotizing enterocolitis[en.wikipedia.org]
    Coarctation of the Aorta
    • Coarctation of the aorta .[patient.info]
    • ., intestinal volvulus, hypoplastic left heart syndrome, critical coarctation of the aorta); omphalitis; isolated intestinal perforation (IIP); and in term infants, milk protein intolerance.[clinicaladvisor.com]

    Etiology

    In spite of the development of medical sciences, necrotising enterocolitis is still an idiopathic disease. The exact etiology is unknown. However, researchers suggest that an ischemic damage of the intestinal lining lead to increasing of bowels wall permeability and make the intestine more sensitive to microbial invasion. Often gram-positive and gram-negative bacteria, as well as fungi have been isolated from affected newborns, however, patients with NEC can have negative culture findings. This condition commonly develops in compromised and premature infants. Additionally, NEC is probable to occur while the newborn is still in the hospital.

    Groups with higher risk of NEC include:

    • Preterm infants
    • Babies with medical formula feeding
    • Infants who contact with outbreak of diseases 
    • Infants with blood exchange transfusions in anamnesis

    Causes

    Epidemiology

    The incidence of necrotising enterocolitis rangse from 1% to 7% of all neonatal intensive care unit (NICU). In other words, from one to three per thousand live births, and it befalls in males and females approximately equally [2]. Despite the varied mortality ranges from 4% to over 50%, newborns with mass fewer than 1000 g have the significant highest risk. [3] It decreases to 3.8 per 1000 newborns who weigh 1501-2500 g [4] [5].

    Different sources with epidemiologic studies report that risk factors, infants characteristics, and severe of disease differ between term and preterm babies with NEC. Although full-term infants may have a non-severe clinical course, these patients frequently have a compromised intestinal perfusion due to the polycythemia, birth asphyxia, transfusion, complications during pregnancy, or cardiovascular defects.

    Sex distribution
    Age distribution

    Pathophysiology

    One of the hypotheses indicates that the damage in NEC starts with a disturbance of the bowels mucosal barrier. This process causes bacterial migration across the epithelial layer. It begins the cascade of pathological excessive inflammatory reaction and the development of the clinical picture of necrotizing enterocolitis.

    According to animal model studies, irregardless the type of trigger, the consequent outcome is a massive inflammation of the intestinal wall tissues. The inflammatory mediators such as tumor necrosis factor (TNF), leukotrienes, platelet-activating factor (PAF), and others cytokines cause a severe alteration of tissues which can lead to intestinal damage including perforation [6].

    Prevention

    An effective intervention in the prevention of necrotising enterocolitis (NEC) is still natural feeding with human milk [6]. However, other interventions have an insufficient evidence base, and they are directed to reduce the various contributing factors in a sensitive organism. Probiotics (Bifidus infantis, Lactobacillus acidophilus) may help to prevent NEC, even if further studies to define optimal dosing and suitable strains are needed. Attempts to reduce the incidence of NEC may target infection prevention in the newborn nursery, increase of premature resistance, inhibition of inflammatory mediators, stimulation of GI tract maturation.

    Summary

    Necrotising enterocolitis (NEC) was described above one century ago, however, the term had been introduced by Rossier and Schmid in 1959. Now, it is the most frequent and serious gastrointestinal disorder among hospitalized neonates [1]. Necrotizing enterocolitis befalls commonly in the second and third week of preterm infant's life. This disorder can be characterized by different damage to the intestine, varying from mucosal inflammation to severe necrosis of all bowel's layers and perforation.

    Presentation of NEC includes feeding intolerance, apathy, fever, in some cases obstruction of the intestine signs, tympanism, emesis, hematochezia, more frequent stools, apnea, and signs of intoxication. Diagnosis of the disease is based on clinical findings and needs to be confirmed by imaging studies. Therapy of NEC is essentially supportive and may include parenteral nutrition, antibiotics, isolation in cases of severe infection, and surgery if the indications are present.

    Patient Information

    Definition

    Necrotizing enterocolitis is a nonspecific inflammation of the bowels. It is most frequent in babies who are born early (preterm infants). Many newborns who have it alive and live normal lives. But if the condition becomes in severe form, it can cause critical damage to the intestine, which can be fatal.

    Causes

    The exact cause of NEC is unknown. There are hypotheses, however, that a decline in blood flow to the bowel blocks the bowel from producing mucus. The mucus protects the bowel's wall. Moreover, bacteria in the compromised intestine can be a cause. It may happen when a baby is born early or when there are difficulties during pregnancy or birth.

    Symptoms

    Symptoms depend on how critical the problem is. They may involve:

    Diagnosis

    The doctor will examine your baby's symptoms and may perform some tests, such as:

    • A radiograph of your newborn's abdomen. 
    • An analysis to check for blood in your baby's stool (fecal occult blood test).
    • Tests to verify bacteria in the stool, blood, urine, or spinal fluid.

    Treatment

    Treatment for a baby with necrotizing enterocolitis includes:

    • Halting normal feedings
    • Removing gas in the bowel by embedding a tube in the stomach
    • Intravenous solutions and antibiotic medicines
    • Monitoring the baby's condition with serial abdominal x-rays and blood tests.

    If your baby does not respond to a treatment or gets a hole in the bowels, he or she require surgical intervention. The surgeon will:

    • Remove dead bowel segment
    • Perform an ileostomy or colostomy

    Your baby will be able to leave the hospital when he or she is eating well and is not missing body mass.

    Prevention

    All infants should be fed only natural breast milk, and feedings should start with small volumes that are gradually increased agreeing to standards and protocols.

    Other symptoms

    Intermittent
    • Install the catheter for low, continuous or intermittent suction.[symptoma.com]
    • Orogastric Suction: A large bore suction catheter tube connected to low intermittent wall suction should be started initially and maintained until distention is resolved, pneumatosis is resolved, and output is less than 10 ml/Kg/day.[uichildrens.org]
    • Feedings must be stopped immediately if NEC is suspected, and the intestine should be decompressed with a double-lumen NGT attached to intermittent suction.[merckmanuals.com]
    • Treatment consists primarily of supportive care including providing bowel rest by stopping enteral feeds, gastric decompression with intermittent suction, fluid repletion to correct electrolyte abnormalities and third space losses, support for blood pressure[shortbowelfoundation.org]
    • […] a sentinel loop. [8] Diagnosis is ultimately made in 5–10% of very low-birth-weight infants ( [9] Treatment [ edit ] Treatment consists primarily of supportive care including providing bowel rest by stopping enteral feeds, gastric decompression with intermittent[en.wikipedia.org]
    Exchange Transfusion
    • Symptoms Poor feeding, bloating, decreased activity, vomiting of bili [1] Complications Short-gut syndrome , intestinal strictures , developmental delay [2] Causes Unclear [1] Risk factors Preterm birth , congenital heart disease , birth asphyxia , exchange[en.wikipedia.org]
    • Infants in a nursery where an outbreak has occurred Infants who have received blood exchange transfusions or have been seriously ill Tests may include: Abdominal x-ray Stool for occult blood test (guaiac) CBC (complete blood count) Electrolyte levels,[medlineplus.gov]
    • Infants in a nursery where an outbreak has occurred Infants who have received blood exchange transfusions or have been seriously ill Symptoms Symptoms may come on slowly or suddenly, and may include: Abdominal bloating Blood in the stool Diarrhea Feeding[ufhealth.org]
    • Intestinal ischemia may also result from low blood flow during an exchange transfusion, during sepsis, or from the use of hyperosmolar formulas.[merckmanuals.com]
    • See also enteritis . observations Significant predisposing factors for the condition include prematurity, hypovolemia, respiratory distress syndrome, sepsis, an indwelling umbilical catheter, exchange transfusion, and feeding with hyperosmolar or high-caloric[medical-dictionary.thefreedictionary.com]
    Electrolytes Abnormal
    • Treatment consists primarily of supportive care including providing bowel rest by stopping enteral feeds, gastric decompression with intermittent suction, fluid repletion to correct electrolyte abnormalities and third space losses, support for blood pressure[shortbowelfoundation.org]
    • abnormalities and third-space losses, support for blood pressure, parenteral nutrition , [10] and prompt antibiotic therapy.[en.wikipedia.org]
    • Medical Management The mainstay for management of NEC remains discontinuation of enteral feeds, initiation of broad-spectrum antibiotics, bowel decompression, and supportive therapies for hydration, nutrition, perfusion, and electrolyte abnormalities[jpediatricsreview.com]
    Dopamine
    • Dopamine may actually reduce the risk of NEC by increasing mesenteric blood flow. 3.[hawaii.edu]
    • Very ill babies may benefit from blood pressure support with vasopressors (eg, naloxone, dopamine).[patient.info]
    • Low doses of dopamine (2-3 mcg/kg/min) are often helpful to improve mesenteric perfusion. 4.[pediatrie.be]
    Slow Progression
    • The use of total parenteral nutrition with slow progression to enteral feeding rather than a rapid enteral feeding protocol may be one such measure.[hawaii.edu]

    Self-assessment

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    References

    1. Lahmiti S, Aboussad A. Neonatal Necrotizing Enterocolitis. Sci. World J. 2011;11:655-656.
    2. Coit AK. Necrotizing enterocolitis. J. Perinat. Neonatal Nurs. 1999;12(4):53-66; quiz 88-89.
    3. Stoll BJ. Epidemiology of necrotizing enterocolitis. Clin. Perinatol. 1994;21(2):205-218.
    4. Kosloske AM. Epidemiology of necrotizing enterocolitis. Acta Paediatr. Oslo Nor. 1992 Suppl. 1994;396:2-7.
    5. Chandler JC, Hebra A. Necrotizing enterocolitis in infants with very low birth weight. Semin. Pediatr. Surg. 2000;9(2):63-72.
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    • Bifidobacterial supplementation reduces the incidence of necrotizing enterocolitis in a neonatal rat model - R Thomson - Gastroenterology, 1999 - Elsevier
    • Acute necrotizing enterocolitis in infancy: a review of 64 cases - TV Santulli, JN Schullinger, WC Heird - Pediatrics, 1975 - Am Acad Pediatrics
    • Acute necrotizing enterocolitis in infancy: a review of 64 cases - TV Santulli, JN Schullinger, WC Heird - Pediatrics, 1975 - Am Acad Pediatrics
    • Acute abdominal complications of systemic lupus erythematosus and polyarteritis nodosa - TM Zizic, JN Classen, MB Stevens - The American journal of medicine, 1982 - Elsevier
    • Acute necrotizing enterocolitis in infancy: a review of 64 cases - TV Santulli, JN Schullinger, WC Heird - Pediatrics, 1975 - Am Acad Pediatrics
    • Antecedents of Bell stage III necrotizing enterocolitis - RD Christensen, SE Wiedmeier, VL Baer - Journal of , 2009 - nature.com
    • Acute necrotizing enterocolitis in infancy: a review of 64 cases - TV Santulli, JN Schullinger, WC Heird - Pediatrics, 1975 - Am Acad Pediatrics
    • 17: GASTROINTESTINAL BLEEDING - R Vairavanathan - THE ABCS OF EMERGENCY - emergencymedicine.utoronto.ca
    • A decreased incidence of necrotizing enterocolitis after prenatal glucocorticoid therapy - CR Bauer, JC Morrison, WK Poole, SB Korones - Pediatrics, 1984 - Am Acad Pediatrics
    • Changing trends in necrotizing enterocolitis. Experience with 302 cases in two decades. - JL Grosfeld, H Cheu, M Schlatter, KW West - Annals of , 1991 - ncbi.nlm.nih.gov
    • Acidosis and hepatic portal venous gas: indications for surgery in necrotizing enterocolitis - R Buras, P Guzzetta, G Avery, C Naulty - Pediatrics, 1986 - Am Acad Pediatrics

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