Discusses Necrotising enterocolitis

1. Discuss the Pathology and
Management of Necrotising
Enterocolitis
Dr Aminu M Umar

2. Outline
• Introduction
• Pathogenesis
• Pathology
– Gross
– Microscopic
• Diagnosis
• Treatment
– Operative
– Non-operative
• Follow up
• Conclusion

3. Introduction
• Acquired inflammatory disease that affects
the gut of newborn infants
• A leading cause of infant morbidity and
mortality
• Most common newborn surgical emergency

4. Epidemiology
• Affects 5-10% of newborns
• Incidence varies widely with geographical
location
• Disease of
– Prematurity
– Low birth weight infants

5. Pathogenesis
• Feeding
• Infectious agent
• Intestinal injury
• Impaired gut barrier
• Pharmacological agents
• Cytokines and growth
factors

6. Pathogenesis

7. Pathology I
• Gross
– Peritoneal fluid-
• Brown/turbid
• Bloody
– Affected bowel
• Single vs. multiple
• Small bowel vs. large bowel
• NEC totalis

8. Pathology II
• Markedly distended
• Patchy areas of thinning
• Serosa
– red to grey
– Bland grey to white
– Fibrinoid exudate
• Subserosa- gas
• Mucosa- ulcerated

9. Pathology III

10. Pathology III

11. Pathology-Histology
• Enteric inflammation
– Mucosa- Bland/coagulation
necrosis
– Submucosa- oedema and
heamorrhage,
pneumatosis intestinalis
– Transmural necrosis- hyelin
oesinophilia, loss o cellular
detail
– Bacteria in lumen
• Resolution- epithelial
regeneration, granulation
tissue formation, early
fibrosis
• Mesenteric vessels-
thrombosed

12. Diagnosis
• Clinical features
– Non specific clinical findings- lethargy,
temperature instability, recurrent
bradycardia/apnoea
– Gastrointestinal symptoms- abdominal distension,
bleeding per rectum, gastric residues, vomiting,
diarrhoea

13. Diagnosis
• Features of
complications-
abdominal tenderness,
anterior abdominal wall
oedema/crepitus,
abdominal mass, scrotal
discolouration

14. Diagnosis
• Investigations
– FBC+ Diff
• Leuckopenia/leuckocytosi
s
• thrombocytopenia
– ABG
• Metabolic acidosis
– Stool analysis
• Occult blood and
reducing substances
– Breath hydrogen test
– Elevated Serum CRP,
Urinary I-FABP, faecal
calproctin
– Blood culture- E. Coli, K.
Pneumoniae, P. Mirabilis,
S. Aureus
– Stool culture- E. Coli, K.
Pneumoniae, P.
Aurigenosa
– Peritoneal culture-
Klebsiella spp, E. Coli

15. • Imaging
– Plain radiographs
• Nonspecific bowel distension, pneumatosis intestinalis,
portal venous gas, pneumoperitoneum, intraperitoneal
fluid, fixed bowel loops

19. – Ultrasound scan with Doppler imaging
• Abdominal fluid, hyperaemia, decreased blood flow to
the gut, pneumatosis intestinalis
– Contrast studies
– Magnetic resonance imaging

20. Differential diagnosis
• Sepsis
• Spontaneous intestinal perforation
• Jejunoileal atresia
• Meconium ileus
• Volvulus,
• Hirschsprung’s disease

21. Staging- Modified Bell’s Criteria

22. Staging- Modified Bell’s Criteria

23. Nonoperative management
• In the absence of intestinal necrosis or perforation
• Nil per oris
• Gastrointestinal decompression
• Intravenous fluid resuscitation
• Antibiotics
• Close clinical observation
– Frequent physical examination
• Serial investigation
– 2 view abdominal radiograph (every 6-8hrs)
– Serial serum platelets and leukocyte count and blood gasses
• Total parenteral nutrition

24. Operative treatment
• Goals
– To remove gangrenous bowel
– Preserve intestinal length

25. Operative treatment
Indications
• Absolute
– Pneumoperitoneum
• Relative
– Abdominal wall
erythema
– Palpable abdominal
mass
– Positive paracenthesis
– Fixed bowel loops
– Portal venous gas
– Clinical deterioration
despite maximal medical
therapy

26. Options for operative management
• Primary peritoneal drainage
• Laparotomy with
– Resection and enterostomy
– Resection with anastomosis
– ‘Clip and drop’
– ‘patch drain and drop’

27. Follow up/Complications
• Gastrointestinal
– Intestinal strictures
– Intestinal malabsorption and short gut syndrome
– Anastomotic ulceration
– Cholestatic liver disease
• Neurodevelopmental complications

28. Short Gut Syndrome

29. Summary of Treatment

30. Conclusion
• Despite extensive research into the
pathogenesis of necrotising enterocolitis, a
complete understanding remains elusive
• Identification of at risk population, close
monitoring and aggressive management
(including prompt surgical intervention) are
necessary for effective management

32. Thank you for listening