a summary of disease process

1. NECROTIZING
ENTEROCOLITIS

2. CLINICAL FEATURES:
• The 1st signs of impending disease
(nonspecific):
• lethargy
• temperature instability
• GI pathology
• abdominal distention
• gastric retention.
• bloody stools → seen in 25% of
patients.

3. BELL STAGING CRITERIA
STAGE DIAGNOSIS SYMPTOMS
I Suspected Lethargy, distended and shiny abdomen, gastric retention, vomiting, diarrhea,
rectal bleeding
II Proven Stage I symptoms + abdominal tenderness, visible intestinal loops lacking
peristalsis
III Advanced Intestinal perforation, symptoms of sepsis, flank redness If left untreated: rapid
progression to disseminated intravascular coagulation (DIC) and shock

4. BELL STAGING CRITERIA (Modified)
SOURCE: PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES: Diagnostic evaluation of the neonate with established or
suspected necrotizing enterocolitis (NEC) - PEDIATRIC NEWBORN MEDICINE CLINICAL PRACTICE GUIDELINES (brighamandwomens.org)

5. DIAGNOSTICS:
• Complete blood count:
• Neutrophil counts < 1500/μL are associated with a poor prognosis.
• The degree of thrombocytopenia correlates with the severity of NEC.
• ↑ Inflammatory markers
• Check for signs of DIC
• Arterial blood gas analysis: Metabolic acidosis is associated with advanced NEC.
• Blood culture

6. DIAGNOSTICS:
• Abdominal radiography
• Pneumatosis intestinalis: bubbles of gas within the wall of the intestine
• Portal venous gas (pneumatosis hepatis)
• Increased intestinal wall thickness
• Dilated intestinal loops
• Air-fluid levels
• Pneumoperitoneum as a result of intestinal perforation
• Abdominal ultrasound
• Indication: Ultrasound may be helpful for diagnosing NEC when abdominal radiography is
inconclusive.
• Findings
• Pneumatosis intestinalis
• Portal venous gas
• Increased intestinal wall thickness
• Decreased intestinal wall perfusion

7. DIAGNOSIS
• ABDOMINAL PLAIN FILM
→ anterior-posterior and left lateral decubitus
views
 “ single most important test required to
make the diagnosis”
(Ginglen and Butki. 2022)
Findings: dilated loops of bowel, pneumatosis
intestinalis, and portal venous air are
diagnostic for necrotizing enterocolitis.

9. MANAGEMENT
• Rapid initiation of therapy is required for infants with suspected as
well as proven NEC
• Supportive care:
• Cessation of feeding
• Bowel decompression
• IV fluids and monitor fluid intake/output
• Monitor hemodynamics, coagulation profile, electrolytes, acid-base status

10. • Systemic antibiotics (with gram positive, gram negative, and
anaerobic coverage) after blood is drawn for cultures
• Usually given for 10-14 days
MANAGEMENT

11. • Indications for Surgery:
• Evidence of perforation on abdominal radiograph
• Abdominal paracentesis shows stool or organism on Gram stain
• Failure of medical management
• Single fixed bowel loop on X-ray
• Abdominal wall erythema
• Palpable mass
MANAGEMENT

12. PREVENTION
• most effective preventive strategy for NEC is the use of human milk.
• fortification is essential for preterm infants

13. References:
• Nelson Textbook of Pediatrics 21st edition
• Ginglen JG, Butki N. Necrotizing Enterocolitis. [Updated 2022 May 9]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK513357/
• Patel, Ravi & Denning, Patricia. (2015). Intestinal Microbiota and Its Relationship with Necrotizing
Enterocolitis. Pediatric research. 78. 10.1038/pr.2015.97.