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necrotizing enterocolitis

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necrotizing enterocolitis

  1. 1. Necrotizing enterocolitis Alan Mathew Skaria TSMU
  2. 2. Overview Necrotizing enterocolitis is the necrosis(death) of intestinal tissue. It primarily affects premature infants or sick newborns. "Necrotizing" means the death of tissue, "entero" refers to the small intestine, "colo" to the large intestine, and "itis" means inflammation.
  3. 3. Necrotizing Enterocolitis • One of the most serious GI diseases of neonates, especially preterm infants. • NEC involves infection and inflammation that causes destruction of the bowel (intestine) or part of the bowel • Intestinal necrosis that can involve all layers of the bowel. • Most commonly involves the ileum and colon but can occur anywhere.
  4. 4. Epidemiology • Most common GI emergency in newborns • Incidence 3 per 1000 live births • Incidence is 30 per 1000 live births for low birth weight neonates • 90% are premature • Incidence is 7% in newborns <1500 g • Race: blacks > non-Hispanic whites
  5. 5. Risk Factors • Prematurity (<34 weeks) • Low birth weight (<1500g) – Occurs in 2-10% of neonates <1500g • Enteral feeding of premature infants – Hypertonic formula/enteral meds – Breast milk protective compared to formula – Rate of feeds and timing of initiation of feeds don’t change rates of NEC • Term infant with pre-existing illness
  6. 6. Causes: • The exact cause of NEC is unknown • These premature infants have immature bowels, weakened by too little oxygen or blood flow. So when feedings are started, the added stress of food moving through the intestine allows bacteria normally found in the intestine to invade and damage the wall of the intestinal tissues. The damage may affect only a short segment of the intestine or can progress quickly to involve a much larger portion.
  7. 7. Pathogenesis: • A combination of risk factors predispose pts to NEC • An insult begins the process • Progression is due to stasis, bacterial overgrowth, vascular factors • May resolve, or may progress to perforation intenstine with gas bubbles in the intestinal wall and portions of the intestine that is frankly necrotic
  8. 8. CIRCULATORY INSTABILITY PRIMARY INFECTIOUS AGENTS Hypoxic-ischemic event Bacteria, Bacterial toxin, Virus, Polycythemia Fungus MUCOSAL INJURY INFLAMMATORY MEDIATORS Inflammatory cells ENTERAL FEEDINGS (macrophage) Platelet activating Hypertonic formula or factor (PAF) Tumor necrosis medication Malabsorption, factor (TNF) Leukotriene C4, gaseous distention H2 gas Interleukin 1; 6 production, Endotoxin
  9. 9. Symptoms *Abdominal distention *Blood in the stool *Diarrhea *Feeding intolerance *Lethargy *Temperature instability *Vomiting
  10. 10. Physiologic signs Physical signs • Temperature • Feeding intolerance instability • Increased gastric residuals • Apnea • Abdominal distention • Episodes of • Occult blood/ Hematochezia Bradycardias & • Peritonitis Desaturation • Discoloration of abdominal • Lethargy wall • Acidosis • Abdominal mass • Thrombocytopenia
  11. 11. Severe Abdominal Distension
  12. 12. Tests & diagnosis *Abdominal x-ray *Stool for occult blood test *Elevated white blood cell count in a CBC *Thrombocytopenia (low platelet count) *Lactic acidosis
  13. 13. Radiographic presentation • X-ray – Pneumatosis(gas cysts in the bowel wall) – Dilated loops of bowel – Portal air – Free air (if perforated) • Lateral decub is particularly helpful • Ultrasound – Good for bedside demonstration of ascites – May show portal air more clearly than KUB
  14. 14. Radiographic Signs
  15. 15. Alimentary tract of infant showing intestinal necrosis, pneumatosis intestinalis, and perforation site (arrow).
  16. 16. Modified Bell Staging for NEC Stage & Systemic Signs Abdominal Signs Radiographic Signs Severity Stage Ia Temp changes, apnea, Distension, gastric Normal, or intestinal Suspected NEC bradycardia, lethargy retention, emesis, heme dilation positive stool Mild ileus Stage Ib Same as Ia Ia + grossly bloody Same as Ia Suspected NEC stool Stage IIa Same as Ia Ib + absent bowel Intestinal dilation, Definite Mild NEC sounds +/- abdominal ileus, pneumatosis tenderness intestinalis Stage IIb Ia + mild metabolic IIa + definite IIa + ascites Definite Moderate NEC acidosis, tenderness, +/- abd thrombocytopenia cellulitis, RLQ mass Stage IIIa IIb, but more severe, + IIb + peritonitis, Same as IIb Advanced, Severe NEC combined respiratory & marked distension and Bowel Intact metabolic acidosis, tenderness neutropenia, & DIC Stage IIIb Same as IIb Same as IIIa IIIa + Advanced Severe NEC pneumoperitoneum Bowel Perforated Adapted from sources showing Bell Staging
  17. 17. Prevention • Encourage breast feeding – Breast fed babies have lower incidence than formula fed • No evidence shows that late initiation of enteral feeding or slow rate of feeding makes any difference • Maintain high level of suspicion – Feeding babies with NEC worsens the disease
  18. 18. Treatment •In an infant suspected of having necrotizing enterocolitis, feedings are stopped and gas is relieved from the bowel by inserting a small tube into the stomach. •Intravenous fluid replaces formula or breast milk. •Antibiotic therapy is started. •The infant's condition is monitored with abdominal x-rays, blood tests, and blood gases. •Surgery will be needed if there is a hole in the intestines or peritonitis (inflammation of the abdominal wall). •The dead bowel tissue is removed and a colostomy or ileostomy is performed. •The bowel is then reconnected several weeks or months later when the infection and inflammation have healed.
  19. 19. Complications *Intestinal perforation *Intestinal stricture *Peritonitis *Sepsis
  20. 20. Prognosis •Depends on the severity of the illness •Necrotizing enterocolitis is a serious disease with a death rate approaching 25%. Early, aggressive treatment helps improve the outcome. •Most infants who develop NEC recover fully and do not have further feeding problems. •In some cases, scarring and narrowing of the bowel may occur and can cause future intestinal obstruction or blockage. •Another residual problem may be malabsorption (the inability of the bowel to absorb nutrients normally). This is more common in children who required surgery for NEC and had part of their intestine removed.
  21. 21. THANK YOU!!!!

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