Acute abdominal processes (necrotizing enterocolitis) of newborns

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4. Acute abdominal processes (necrotizing enterocolitis) of newborns

Necrotizing enterocolitis (NEC) is a medical condition where a portion of the bowel dies.

Symptoms

The condition is typically seen in premature infants, and the timing of its onset is generally inversely proportional to the gestational age of the baby at birth (i.e., the earlier a baby is born, the later signs of NEC are typically seen).

Initial symptoms include feeding intolerance and failure to thrive, increased gastric residuals, abdominal distension and bloody stools. Symptoms may progress rapidly to abdominal discoloration with intestinal perforation and peritonitis and systemic hypotension requiring intensive medical support.

Causes

The exact cause is unclear. Risk factors include congenital heart disease, birth asphyxia, exchange transfusion, and premature rupture of membranes.

Diagnosis

The diagnosis is usually suspected clinically but often requires the aid of diagnostic imaging modalities, most commonly radiography. Specific radiographic signs of NEC are associated with specific Bell's stages of the disease:

· Bell's stage 1 (suspected disease):

o Mild systemic disease (apnea, lethargy, slowed heart rate, temperature instability)

o Mild intestinal signs (abdominal distention, increased gastric residuals, bloody stools)

o Non-specific or normal radiological signs

· Bell's stage 2 (definite disease):

o Mild to moderate systemic signs

o Additional intestinal signs (absent bowel sounds, abdominal tenderness)

o Specific radiologic signs (pneumatosis intestinalis or portal venous gas

o Laboratory changes (metabolic acidosis, too few platelets in the bloodstream)

· Bell's stage 3 (advanced disease):

o Severe systemic illness (low blood pressure)

o Additional intestinal signs (striking abdominal distention, peritonitis)

o Severe radiologic signs (pneumoperitoneum)

o Additional laboratory changes (metabolic and respiratory acidosis, disseminated intravascular coagulation)

Ultrasonography has proven to be useful as it may detect signs and complications of NEC before they are evident on radiographs, specifically in cases that involve a paucity of bowel gas, a gasless abdomen, or a sentinel loop. Diagnosis is ultimately made in 5–10% of very low-birth-weight infants (<1,500g).

Treatment

Treatment consists primarily of supportive care including providing bowel rest by stopping enteral feeds, gastric decompression with intermittent suction, fluid repletion to correct electrolyte abnormalities and third-space losses, support for blood pressure, parenteral nutrition,[18] and prompt antibiotic therapy.

Monitoring is clinical, although serial supine and left lateral decubitus abdominal X-rays should be performed every six hours.

As an infant recovers from NEC, feeds are gradually introduced. "Trophic feeds" or low-volume feeds (<20 ml/kg/day) are usually initiated first. How and what to feed are determined by the extent of bowel involved, the need for surgical intervention and the infant's clinical appearance.

Where the disease is not halted through medical treatment alone, or when the bowel perforates, immediate emergency surgery to resect the dead bowel is generally required, although abdominal drains may be placed in very unstable infants as a temporizing measure. Surgery may require a colostomy, which may be able to be reversed at a later time. Some children may suffer from short bowel syndrome if extensive portions of the bowel had to be removed.

In the case of an infant whose bowel is left in discontinuity, the surgical creation of a mucous fistula or connection to the distal bowel may be helpful as this allows for re-feeding of ostomy output to the distal bowel. This re-feeding process is believed to improve bowel adaptation and aid in advancement of feeds.

Reference

Baskin, Laurence and Barry Kogan, John Duckett. Handbook of Pediatric Urology. Philadelphia: Lippincott-Raven; 1997.

Abnormalities of the Testicle and Scortum. Campbell-Walsh Urology. Wein, Kavoussi, Novick, Partin, Peters. 10th edition, vol. 1. 3582-3586.

"Necrotizing Enterocolitis – Pediatrics – Merck Manuals Professional Edition". Merck Manuals Professional Edition. February 2017. Retrieved 12 December 2017.

1. ^ a b c d e f g h i j k l m n Rich, BS; Dolgin, SE (December 2017). "Necrotizing Enterocolitis". Pediatrics in Review. 38(12): 552–559. doi:10.1542/pir.2017-0002. PMID 29196510.

2. ^ Crocetti, Michael; Barone, Michael A.; Oski, Frank A. (2004). Oski's Essential Pediatrics. Lippincott Williams & Wilkins. p. 59. ISBN 9780781737708.

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