NECROTIZING ENTEROCOLITIS

1

• NECROTIZING ENTEROCOLITIS
• PRESENTED BY
• 
  ANSU ANN
• 
  (NICU)

2

• ANTHROPOMETRIC MEASUREMENT
• weight 650 gms
• Length 31 cm
• Height 22cm
• APGAR 1/1, 6/5, 7/15
• Type of delivery LSCS

3

• HISTORY
• Mother is 29y/o, G2_P1_, having uncontrolled
  PET, received (Labetalol, MgSO4, Ehydralazine and
  one dose of Dexamethasone), with gestational age
  of 29wks who undergone emergency CS due to PET
  and fetal distress.

4

• PHYSICAL EXAMINATION
• INTEGUMENTARY skin are edematous and pinkish in
  color warm to touch
• CVS no heart murmur S1 S2 present, maintaining
  normal range of heart rate and BP, decreased
  peripheral perfusion
• RESP with O2 support of mechanical ventilator
  due to respiratory failure.
• GIT Increased abdominal girth, visible
  intestinal loops, abdominal distension, decreased
  bowel sounds, palpable abdominal mass, erythema
  of abdominal walls.
• GUT passing urine and stool (color of stool
  dark greenish).
• MS () movement of extremities

5

• INTRODUCTION
• Necrotizing enterocolitis NEC is the most
  common gastrointestinal emergency in the
  premature infant, an important cause of neonatal
  morbidity and mortality. NEC affects apparently
  healthy premature infant who have no other
  medical problems or those who have recovered from
  their initial respiratory disease, look well and
  are feeding and growing.
•  
• INCIDENCE
• Although NEC is most commonly observed in
  premature infant, 10 of affected patients are
  born term. Between 0.3 and 2.4 infants/ 1000
  birth and between 7-11 (range 3-22 in
  individual nursery data) among infants of less
  than 1500g male and female are equally affected.
  NEC mortality varies between 9-28

6

• ANATOMY AND PHYSIOLOGY OF INTESTINE

7

• The intestines are a long, continuous tube
  running from the stomach to the anus. Most
  absorption of nutrients and water happen in the
  intestines. The intestines include the small
  intestine, large intestine, and rectum.
• The small intestine (small bowel) is about 20
  feet long and about an inch in diameter. Its job
  is to absorb most of the nutrients from what we
  eat and drink. Velvety tissue lines the small
  intestine, which is divided into the duodenum,
  jejunum, and ileum.
• The large intestine (colon or large bowel) is
  about 5 feet long and about 3 inches in diameter.
  The colon absorbs water from wastes, creating
  stool. As stool enters the rectum, nerves there
  create the urge to defecate.

8

• DEFINITION
• NEC is the death of the intestinal tissue occurs
  when the lining of the intestinal wall dies and
  tissues falls off.
•  

9

• ETIOLOGY (CAUSES)
• NEC occurs when the lining of the intestinal wall
  and tissues falls off.
• Cause (unknown)
• Bacteria in the intestine
• Infant is already ill or premature
• Prolonged hospitalization

10

• RISK FACTORS
• Premature infants
• Infant who are fed by concentrated formulas
• Infant who received blood exchange transfusion
•  

11

• SIGNS AND SYMPTOMS
• It may occur suddenly or slowly.
• Abdominal distention
• Feeding intolerance
• Blood in the stool
• Lethargy
• Diarrhea
• Temperature instability
• Vomiting
• Prior to any specific signs and symptoms, we can
  observe the activity level of the infant and
  temperature instability.
• Speed of progression of the diseases quite
  variable, in some cases onset is sudden little
  warning signs and is followed by severe apnea
  which require intubation, persistent metabolic
  acidosis, hypotension requires bolus of
  intravascular therapy.

12

• PATHOPHYSIOLOGY
• Infectious agent Klebsiella, E. Coli,
  Clostridia, Coagulus negative Staphylococcus,
• Coronavirus 
• Enteral Elementation NEC occurs mostly infect
  infants, 90

13

• DIAGNOSIS
• Radiology The abdominal X-ray is the best
  diagnostic tool in the evaluation of NEC.
  Pneumatosis intestinalis (air the bowel wall),
  when present.

14

• Laboratory evaluation Common laboratory
  abnormalities include thrombocytopenia,
  leukocytosis, electrolytes imbalance, metabolic
  acidosis, hypoxia or hyper apnea therefore one
  should carefully monitor the complete blood
  count, electrolytes and blood gases. Blood
  culture should be obtained before antibiotics are
  started.
• Bell (clinical staging)
• Stage 1 Suspect Infant with suggestive
  clinical signs but X-ray non-diognostic.
• Stage 2 Definite Infant w/ pneumatosis
  intestinalis (11A mildly ill, 11B moderately
  ill (acidosis, thrombocytopenia or ascites))
• Stage 3 Advanced (111A critically w/
  impending perforation, 111B critical w/ proven
  perforation)

15

• TREATMENT
• Early bowel decompression by effective
  nasogastric tube suctioning.
• Prompt intravenous spectrum antibiotic therapy
  (usually include Ampicillin, an aminoglycoside,
  and anaerobic bacterial coverage such as
  clindamycin).
• Maintain volemia/ mesenteric perfusion,
  intravascular volume supplement is required to
  maintain mesenteric perfusion and to avoid
  worsening intestinal injury.
• Except in the milder cases, because of the
  respiratory failure and worsening acidosis,
  intubation mechanical ventilation is often
  necessary.
• Pain control is essential in this extremely
  painful disease, a fentanyl drip is often used at
  2-4 mcg/kg/hr.

16

• Early parenteral nutrition w/ adequate protein/
  calories/ lipid is essential in order to provide
  substrate for the bowel to heal.
• Surgical option include laparotomy w/ resection
  and enterostomy or peritonial drain placement,
  allowing abdominal decompression.

17

• COMPLICATION
• NEC complication include inadequate nutrition w/
  failure to thrive, electrolytes and nutrient
  losses, complication due to prolonged total
  parenteral nutrition and central venous catheters
  (infections, thrombus), intestinal surgical
  complications (intestinal stricture in 25-35 of
  NEC survivors, complication related to the
  stoma,..) and short bowel syndrome.

18

• PROGNOSIS
• NEC mortality ranges from reported 9-28 and is
  due to refractory shock.
• HEALTH TEACHING 
• Encourage all mothers to initially provide
  breast milk for their preterm
• Educate all staff about clinical signs of NEC and
  increase awareness
• Evaluate any untoward GI findings(abdominal
  distension , feeding intolerance

19

• 
  CONCLUSION
• True reduction in the incidence of NEC likely to
  depend on limiting preterm
• birth.Health care providers having close
  contact with infant play vital role in
  recognition and management of this potentially
  debilitating disease.
•  
• REFERENCES
• Sodhi C, Richardson W, Gribar S, Hackam DJ
  (2008). "The development of animal models for the
  study of necrotizing
  enterocolitis". Dis Model Mech 1 (2-3) 948.
  doi10.1242/dmm.000315. PMC 2562191.
  PMID 19048070. http//dmm.biologists.org/cgi/pmidl
  ookup?viewlongpmid19048070.
• Skelley, Tao Le, Vikas Bhushan, Nathan William.
  First aid for the USMLE step 2 CK (8th ed. ed.).
  New York McGraw-Hill Medical. pp. 369-370.
  ISBN 9780071761376.
• Marino, Bradley S. Fine, Katie S. (1 December
  2008). Blueprints Pediatrics. Lippincott Williams
  Wilkins. ISBN 978-0-7817-8251-7.
  http//books.google.com/books?idoqpSRIOcd8MC.
• Hunter CJ, Upperman JS, Ford HR, Camerini V
  (February 2008). "Understanding the
  susceptibility of the premature infant to
  necrotizing enterocolitis (NEC)". Pediatric
  Research 63 (2) 11723. doi10.1203/PDR.0b013e318
  15ed64c. PMID 18091350.
•