NEC
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Necrotizing enterocolitis (NEC) is a leading cause of emergency surgery in neonates, particularly preterm infants. It has an overall incidence of 1-5% in NICUs. The pathology involves necrosis of the bowel wall, typically in the terminal ileum and proximal colon. Risk factors include prematurity, enteral feedings, and circulatory instability. Clinically, NEC presents with feeding intolerance and abdominal distension, and can range from mild to severe with systemic involvement. Diagnosis is supported by radiographic findings like pneumatosis intestinalis. Treatment involves stopping feeds, antibiotics, and may require surgery for severe or perforated cases. Prognosis depends on severity, and survivors often
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NEC
- 1. Dr. Ufaque Batool Korai House Officer.
- 2. Ability to diagnose and treat the signs and symptoms of NEC Ability to evaluate radiographs for the classic findings of NEC List several long-term complications associated with NEC OBJECTIVES
- 3. Epidemiology: most commonly occurring gastrointestinal emergency in preterm infants leading cause of emergency surgery in neonates overall incidence: 1-5% in most NICU’s most common in VLBW preterm infants 10% of all cases occur in term infants NECROTIZING ENTEROCOLITIS
- 4. Epidemiology: 10x more likely to occur in infants who have been fed males = females blacks > whites mortality rate: 25-30% 50% of survivors experience long-term sequelae NECROTIZING ENTEROCOLITIS
- 5. Pathology: most commonly involved areas: terminal ileum and proximal colon GROSS: bowel appears irregularly dilated with hemorrhagic or ischemic areas of frank necrosis focal or diffuse MICROSCOPIC: mucosal edema, hemorrhage and ulceration NECROTIZING ENTEROCOLITIS
- 6. MICROSCOPIC: minimal inflammation during the acute phase increases during revascularization granulation tissue and fibrosis develop stricture formation microthrombi in mesenteric arterioles and venules NECROTIZING ENTEROCOLITIS
- 8. PRIMARY INFECTIOUS AGENTS Bacteria, Bacterial toxin, Virus, Fungus CIRCULATORY INSTABILITY Hypoxic-ischemic event Polycythemia MUCOSAL INJURY ENTERAL FEEDINGS Hypertonic formula or medication Malabsorption, gaseous distention H2 gas production, Endotoxin production INFLAMMATORY MEDIATORS Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4, Interleukin 1; 6
- 9. Prematurity: *primary risk factor 90% of cases are premature infants immature gastrointestinal system mucosal barrier poor motility immature immune response impaired circulatory dynamics RISK FACTORS
- 10. Infectious Agents: usually occurs in clustered epidemics normal intestinal flora E. coli Klebsiella spp. Pseudomonas spp. Clostridium difficile Staph. Epi Viruses RISK FACTORS
- 11. Inflammatory Mediators: involved in the development of intestinal injury and systemic side effects neutropenia, thrombocytopenia, acidosis, hypotension primary factors Tumor necrosis factor (TNF) Platelet activating factor (PAF) LTC4 Interleukin 1& 6 RISK FACTORS
- 12. Circulatory Instability: Hypoxic-ischemic injury poor blood flow to the mesenteric vessels local rebound hyperemia with re-perfusion production of O2 radicals Polycythemia increased viscosity causing decreased blood flow exchange transfusion RISK FACTORS
- 13. Enteral Feedings: > 90% of infants with NEC have been fed provides a source for H2 production hyperosmolar formula/medications aggressive feedings too much volume rate of increase >20cc/kg/day RISK FACTORS
- 14. Enteral Feedings: immature mucosal function malabsorption breast milk may have a protective effect IGA macrophages, lymphocytes complement components lysozyme, lactoferrin acetylhydrolase RISK FACTORS
- 15. Gestational age: < 30 wks 31-33 wks > 34 wks Full term Age at diagnosis: 20 days 11 days 5.5 days 3 days CLINICAL PRESENTATION *Time of onset is inversely related to gestational age/birthweight
- 16. Gastrointestinal: Feeding intolerance Abdominal distention Abdominal tenderness Emesis Occult/gross blood in stool Abdominal mass Erythema of abdominal wall Systemic Lethargy Apnea/respiratory distress Temperature instability Hypotension Acidosis Glucose instability DIC Positive blood cultures CLINICAL PRESENTATION
- 17. Sudden Onset: Full term or preterm infants Acute catastrophic deterioration Respiratory decompensation Shock/acidosis Marked abdominal distension Positive blood culture Insidious Onset: Usually preterm Evolves during 1-2 days Feeding intolerance Change in stool pattern Intermittent abdominal distention Occult blood in stools CLINICAL PRESENTATION
- 18. BELL STAGING CRITERIA STAGE CLINICAL X-RAY TREATMENT I. Suspect NEC Mild abdominal distention Poor feeding Emesis Mild ileus Medical Work up for Sepsis II. Definite NEC The above, plus Marked abdominal distention GI bleeding Significant Ileus Pneumatosis Intestinalis PVG Medical III. Advanced NEC The above, plus Unstable vital signs Septic Shock Pneumo- Peritoneum Surgical
- 19. Pneumatosis Intestinalis hydrogen gas within the bowel wall product of bacterial metabolism a. linear streaking pattern more diagnostic b. bubbly pattern appears like retained meconium less specific RADIOLOGICAL FINDINGS
- 20. Portal Venous Gas extension of pneumatosis intestinalis into the portal venous circulation linear branching lucencies overlying the liver and extending to the periphery associated with severe disease and high mortality RADIOLOGICAL FINDINGS
- 21. Pneumoperitoneum free air in the peritoneal cavity secondary to perforation falciform ligament may be outlined “football” sign surgical emergency RADIOLOGICAL FINDINGS
- 22. CBC neutropenia/elevated WBC thrombocytopenia Acidosis metabolic Hyperkalemia increased secondary to release from necrotic tissue LABORATORY FINDINGS
- 24. Stop enteral feeds re-start or increase IVF Nasogastric decompression low intermittent suction Antibiotics Amp/Gent; Vanc/Cefotaxime Clindamycin suspected or proven perforation TREATMENT
- 25. Surgical Consult suspected or proven NEC indications for surgery: portal venous gas; pneumoperitoneum clinical deterioration despite medical management positive paracentesis fixed intestinal loop on serial x-rays erythema of abdominal wall TREATMENT
- 26. Labs: q6-8hrs CBC, electrolytes, DIC panel, blood gases X-rays: q6-8hrs AP, left lateral decubitus or cross-table lateral Supportive Therapy fluids, blood products, pressors, mechanical ventilation TREATMENT
- 27. Depends on the severity of the illness Associated with late complications *strictures short-gut syndrome malabsorption fistulas abscess PROGNOSIS * MOST COMMON