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NECROTIZING ENTEROCOLITIS Dr.Padmesh, Dept of Pediatrics, Dr.SMCSI Medical College, Karakonam, India.

Necrotizing Entero Colitis.. Dr.Padmesh

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NEC, Necrotizing enterocolitis

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Page 1: Necrotizing Entero Colitis..  Dr.Padmesh

NECROTIZING ENTEROCOLITIS

Dr.Padmesh, Dept of Pediatrics, Dr.SMCSI Medical College, Karakonam, India.

Page 2: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V Introduction:

NEC is the most common life-threatening emergency of the gastrointestinal tract in the newborn.

Various degrees of mucosal or transmural necrosis of the intestine occurs.

The incidence of NEC is 1–5% of infants in NICU. Although rare, the disease does occur in term

infants (10%)

Birth weight

Incidence, Fatality

Gestational age

Page 3: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V ETIOLOGY:

Etiology of NEC is unclear; May be multifactorial.

Prematurity is the single greatest risk factor.

Infants exposed to cocaine have a 2.5 times increased risk of developing NEC.

The mean gestational age of infants with NEC is 30 to 32 weeks, and the infants generally are weight appropriate for gestational age.

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Dr.Padmesh. V

PATHOLOGY AND PATHOGENESIS:

Intestinal ischemia (injury)

Enteral nutrition Pathogenic

(metabolic substrate) organisms

Risk Factors for NEC - Triad

Page 5: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V PATHOLOGY AND PATHOGENESIS:

Distal part of the ileum

Involved most frequently

Proximal segment of colon

In fatal cases, gangrene may extend from the stomach to the rectum.

NEC probably results from an interaction between loss of mucosal integrity due to factors like ischemia, infection, inflammation,

and the host's response to that injury like circulatory, immunologic, inflammatory responses resulting in necrosis of the affected area.

Page 6: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V PATHOLOGY AND PATHOGENESIS: contd..

Various bacterial and viral agents, including Escherichia coli, Klebsiella, Clostridium perfringens, Staphylococcus epidermidis, and rotavirus, have been recovered from cultures.

However, in most situations, no pathogen is identified.

NEC rarely occurs before the initiation of enteral feeding and is much less common in infants fed human milk.

Aggressive enteral feeding may predispose to the development of NEC.

Coagulation necrosis is the characteristic histologic finding of intestinal specimens.

Page 7: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

CLINICAL MANIFESTATIONS: Onset can be insidious or rapid.

The onset of NEC usually occurs in the 1st 2 weeks of life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants.

The postnatal age at onset is inversely related to birth weight and gestational age.

It is unusual for the disease to progress from mild to severe after 72 hr.

Page 8: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V CLINICAL MANIFESTATIONS:

The 1st signs of impending disease may be

-Nonspecific including lethargy and temperature instability

or

-Related to gastrointestinal pathology such as abdominal

distention and gastric retention.

Obvious bloody stools are seen in 25% of patients.

The spectrum of illness is broad and ranges from

-Mild disease with only guaiac-positive stools to

-Severe illness with bowel perforation, peritonitis, systemic

inflammatory response syndrome, shock, and death.

Page 9: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V CLINICAL MANIFESTATIONS:

Page 10: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V MODIFIED BELL’S STAGING OF NEC:

Based on:

1. Systemic Signs

2. Intestinal Signs

3. Radiological Signs

Classified into:

I. Suspected:

A

B

II. Definite :

A (Mildly ill) ,

B (Moderately ill)

III. Advanced:

A (Severely ill,bowel intact),

B (Severely ill,bowel perforated)

SIR

Page 11: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

ModifiedBell’sStaging

Page 12: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

ModifiedBell’sStaging

Page 13: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

ModifiedBell’sStaging

Page 14: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

ModifiedBell’sStaging

Ampicillin,Gentamycin

Ampicillin,Gentamycin,Clindamycin

Ampicillin,Gentamycin,Clindamycin

Page 15: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V CLINICAL MANIFESTATIONS:

Page 16: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

A simpler classification…

Page 17: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V DIAGNOSIS:

Very high index of suspicion.

1. Plain abdominal x-rays : Pneumatosis intestinalis (air in the bowel wall) is

diagnostic; Portal venous gas is a sign of severe disease, and Pneumoperitoneum indicates a perforation.

2. Hepatic ultrasonography: May detect portal venous gas despite normal

abdominal Xray.

3. Analysis of stool for blood and carbohydrate

Carbohydrate malabsorption - positive stool Clinitest result, can be a frequent and early indicator of NEC.

Page 18: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V DIAGNOSIS: contd…

4. Blood studies:

Thrombocytopenia

COMMON TRIAD

OF SIGNS

Persistent Severe Refractory

Metabolic Acidosis Hyponatremia

HAT

Page 19: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

Hepatic portal venous gas

Pneumatosis

intestinalis

NEC

Page 20: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

Intestinal perforation.

Abdominal Xray in NEC demonstrates marked distention and massive pneumoperitoneum

Free air below the anterior abdominal wall.

NEC

Page 21: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

Differential diagnosis of NEC : Specific infections (systemic or intestinal)-

Pneumonia, Sepsis.

Gastrointestinal obstruction, volvulus, malrotation,

Isolated intestinal perforation.

Severe Inherited Metabolic disorders. (e.g., galactosemia with Escherichia coli sepsis)

Feeding intolerance

Severe allergic colitis

Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin.

Page 22: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V TREATMENT:

Rapid initiation of therapy is required for suspected as well as proven NEC cases.

There is no definitive treatment for established NEC and, therapy is directed at supportive care and preventing further injury with

-Cessation of feeding,

-Nasogastric decompression, and

-Administration of intravenous fluids.

Once blood has been drawn for culture, systemic antibiotics (with broad coverage for gram-positive, gram-negative, and anaerobic organisms) should be started immediately.

Page 23: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

TREATMENT: Contd.. Umbilical catheters if present should be removed.

Ventilation should be assisted as required.

Intravascular volume replacement with crystalloid or blood products.

Cardiovascular support with volume and/or inotropes.

Correction of hematologic, metabolic, and electrolyte abnormalities.

Careful attention to respiratory status, coagulation profile, and acid-base and electrolyte balance are important.

Page 24: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

MONITORING: Sequential anteroposterior and cross-table lateral

or lateral decubitus abdominal x-rays to detect intestinal perforation;

Serial determination of hematologic status,

Serial determination of electrolyte status, and

Serial determination of acid-base status.

Page 25: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

Indications for surgery : Absolute indications: Evidence of perforation on abdominal

roentgenograms (pneumoperitoneum) or Positive abdominal paracentesis (stool or organism

on Gram stain from peritoneal fluid).

Relative indications: Failure of medical management, Single fixed bowel loop on roentgenograms, Abdominal wall erythema, or A palpable mass.

Page 26: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

Ideally, surgery should be performed after intestinal necrosis develops, but before perforation and peritonitis occurs.

Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery. Peritoneal drainage is more successful in patients with isolated intestinal perforation.

Page 27: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V PROGNOSIS.:

Medical management fails in about 20–40% of patients with pneumatosis intestinalis at diagnosis; of these, 10–30% die.

Early postoperative complications : Wound infection, dehiscence, and stomal problems (prolapse, necrosis).

Later complications : Intestinal strictures develop at the site of the necrotizing lesion in about 10% of surgically or medically managed patients.

Page 28: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V PROGNOSIS….

After massive intestinal resection,

-Complications from postoperative NEC include short-bowel syndrome (malabsorption, growth failure, malnutrition),

Premature infants with NEC who require surgical

intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome.

The overall mortality is 9% to 28% regardless of surgical or medical intervention.

Page 29: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V PREVENTION:

Always better than cure! Newborns exclusively breast-fed have a reduced risk of

NEC.

Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants.

Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk.

Probiotic preparations have also decreased the incidence of NEC. . Induction of GI maturation.

Incidence of NEC is significantly reduced after prenatal steroid therapy.

Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation.

Page 30: Necrotizing Entero Colitis..  Dr.Padmesh

Dr.Padmesh. V

Thank you!