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 infectious processes.
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:
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)
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:
Stage IIB - definite and moderate NEC:
Bell stage III - advanced disease
Stage IIIA - advanced NEC:
Stage IIIB - advanced NEC:
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.
Imaging
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:
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:
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.
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:
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:
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.
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].
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.
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.
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:
Treatment
Treatment for a baby with necrotizing enterocolitis includes:
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:
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.