NECROTIZIN

G Mutiyas nadia ulfa G99172120

ENTEROCOLI
Aditia Nurmalita S.
Arfan Surya A.
Jemmy Haryadi Sima
G99172023
G99181011
G991903025

TIS Ina Agustin

Luthfi Adijay L.
Fadhila Khairunnisa
G99172089
G991904035
G99172072
Yulia Anggraeni G99181070
• Necrotizing enterocolitis is the most
common serious surgical emergency in
NICU.

• NEC occurs in 2- 5 % of all NICU admission

and 5-10% of VLBW infants.
 ETIOLOGY
• It is probably multifactorial . There are several
associated factors including:
• Prematurity
• Rapid advances in feeding of ELBW infants.
• Asphyxia
• PDA
• Umbilical artery cath. Tip at or above the mesenteric
artery.
• Indomethacin / ibuprofen
• Aminophylline
• Polycythemia
• Hypothermia
 PATHOGENESIS
Preterm baby
Low cardiac
Perinatal output
hypoxia Hypovolemia Hypothermia
(shock) Blood loss
Septicemia
Exchange
Umbilical vessel transfusion
Diving reflex
catheterization
(mesenteric
vasospasm)
Vasospasm
thrombo- embolic
phenomena
Reduced
intestinal
perfusion
Bacterial invasion
Type and amount
Ischemic mucosal injury
of feeds
Direct mucosal damage
Toxins Hyperosmolar
(neuraminidase) feeds
Intestinal stasis
 CLINICAL FINDINGS
• Feeding residuals ( coffee ground aspirates)
• Abdominal distension
• Constipation
• Blood in the stool
• Erythema of abdominal wall ( when peritonitis is present)
• Lethargy or other non-specific signs of infection

* Data from PGIMER shows that the peak age for NEC in
preterm infants is from end of the 1st week of life to the 2nd
week
 STAGING
• A staging devised by Bell and letter modified by Walsh
AND Kleighman is useful for therapeutic decisions .
Stage Systemic Intestinal signs Radiologica Rx
sign l signs
Ia suspected Temp. Elevated pre Normal or NBM,
NEC instability, lavage residual, intestinal antibiotics
apnea, mild abdominal dilatation, for 3 days
bradycardia distension , mild ileus
, lethargy emesis , guaiac
positive stool
Ib suspected --do-- Bright red blood Do Do
NEC from rectum
Stage Systemic sign Intestinal Radiological Rx
signs signs
II a definite Temperature Absent bowel Intestinal NBM ,
NEC , instability, sounds , dilatation, antibiotics
mildly ill apnea, abdominal ileus, for 7-10
bradycardia, tenderness pneumatosis days
lethargy intestinalis(
small gas
bubble in
bowel loops)
II b definite Do plus mild Do plus Same as II a NBM,
NEC metabolic definite plus portal antibiotic
moderately acidosis abdominal vein gas +/- for 14 days ,
ill tenderness ascites NaHCO3
+/- for acidosis
abdominal
cellulitis or
right lower
quadrant
mass
Plain abdominal x-ray on the left showed pneumatosis intestinalis (large arrow), a specific
characteristic finding in necrotizing enterocolitis (NEC). X ray on the right is a follow-up
film which showed free air indicating the perforation of the bowel (small arrow)
Stage Systemic Intestinal Radiological Rx
sign signs signs
III a advanced Same as II b Same as Same as IIB plus Same plus
NEC severely plus above plus definite ascites more fluid
ill , bowel hypotension, signs of abd.
intact bradycardia, generalized Paracentesis
apnea, peritonitis, Inotropic
combined marked agents,
respiratory and tenderness ventilation
metabolic and distension
acidosis, DIC, of abdomen
neutropenia

III b advanced Same as III a Same as III a Same as II b plus Same +

NEC severely pneumoperitonium abdominal
ill , bowel surgery
perforated
 ..

. I

-
A B
Figure 7(A.B). A: Abdominal plain x-ray obtamed in dorsal dccubitus v11th horizontal x-
rw; beam. Frco air
rnoverrent is observed antenor1y w1thm the abdominal cavny. B: Scheme demonstrating
the NN position· ing to be adopted for study in dorsal decubitus viith hortzootal beam to
demonstrate pneumopelitoneum (reference 16).
 LABORATORY FINDINGS
• Thrombocytopenia
• Hyponatremia
• Metabolic acidosis
• Evidence of DIC
• overt or occult blood in the stool
• Urine should be examined for hyphae and budding
yeast to rule out systemic candidiasis.
• Blood and stool culture are mandatory
 DIFFERENTIAL DIAGNOSIS
• infectious enterocolitis – diarrhea with blood in stool
• Candidemia –may mimic early features of NEC
• Sepsis and pneumonia may cause ileus without NEC.
• Gut immaturity
• Congenital intestinal obstruction
• Spontaneous intestinal obstruction
• Intussusception
• Dysentery
• Campylobacter diarrhea
 APPROACH TO CASE OF SUSPECTED NEC
Suspected NEC

NBM, continuous gastric aspiration, antibiotics, complete work up

for sepsis, platelet count, stool for occult blood, ABG, electrolytes,
AXR, remove umbilical cath.

Stage 3 disease

Yes

Pediatric Sx opinion and

abdominal paracentesis

Perforation No

Flank discharge

No Continue supportive
improvement care in all stages
in next 48h
Laparotomy
 MANAGEMENT
• General considerations
• Avoid or minimize factors which may contribute to bowel
ischemia.
• Maintain a high level of suspicion , when advancing
feedings in very low birth weights baby.
 MEDICAL MANAGEMENT
• Stop enteral feeds and oral medications
• Duration of NBM
• Stage 1 : 3 days
• Stage 2 : 7-10 days
• Stage 2b & 3 : 14 days
Keep the GIT decompressed using 8 -10 F NGT. Replace the
aspirate with N/2 saline with KCL every 8 hours.
• IV fluids
• Give normal maintenance for stage I and II
• In stage III , more than 200ml/kg/day may be required
due to 3rd space losses.
 OTHER MEASURES
• Maintain adequate tissue perfusion using
symapathomimetic agents. (dopamine 5-8
microgram/kg/min)
• Give plasma or blood transfusion as required
• Inj. Vit. K if bleeding or if not given in last 1 week
• Correct metabolic acidosis
• Start antibiotics as per culture report
• Duration of therapy
• Stage I : 3 days (depending on culture)
• Stage II : 7 to 10 days
• Stage III : 14 days
 MONITORING
• Aggressive monitoring forms a corner stone for successful
outcome
1. Clinical
• Abdominal girth
• Gastric aspirate – quantity and nature 1-2 hourly
• CRT, BP, RR, HR, and PaO2
2. Radiological
• Initially 8 hourly x-ray abdomen during the first 48 to 72 hours,
thereafter once daily.
3. Laboratory
• Hematocrit and blood glucose 8 hourly
• Serum Na+/ K+ : 12 hourly
• Platelet count and neutrophil count once initially and then 48
hrs. later
• ABG 12 hourly during the initial 48 to 72 hours
 SURGICAL MANAGEMENT
• Indications
• GI perforation
• Full thickness necrosis
• Peritonitis
• Features which suggestive perforation/ full thickness
necrosis are:
• Pneumoperitonium
• Positive abdominal paracentesis
• Portal venous gas on plain x-ray
• Abdominal wall erythema / induration
• Fixed loop on serial radiographs
• Supportive evidence:
• Abdominal tenderness
• Thrombocytopenia ( <1,00,000/ cu. Mm)
• Clinical deterioration
• Severe GI hemorrhage
 COMPLICATIONS
• Short term
• Irreversible shock
• Extensive bowel infraction
• secondary infection ( usually with enteric organism or
staph. )
• Long term
• Intestinal stricture and bowel obstruction
• Short bowel syndrome ( after bowel resection)
 PROGNOSIS
• It depends upon
• Severity of illness
• Amount of bowel removed
• Associated complications
 PREVENTION
• Delay enteral feeding in stressed preterm infants who
have suffered hypoxic ischemic episodes.
• Avoid rapid increases in the volume of feeds
• Treat polycythemia aggressively.
• Do not feed preterm with PDA
• Stop feeds with bilious aspirate or continuous large
gastric aspirates
• Do not feed during dopamine infusion
•
Prophylactic probiotics reduce severe NEC by 66%. 1
sachet 12 hourly for 21 days for all neonates weighing
<1250 gm at birth .
 REFERENCE
• Care Of Newborn – Meherban Singh
• PGI NICU HANDBOOK OF PROTOCOLS; 4th edition 2010
• Handbook of Neonatology ; Dr Hemant Jain
• Manual of newborn care ; 7th edi. John p. cloherty