NECROTIZING ENTEROCOLITIS

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ecrotising enterocolitis is the most common gastro-intestinal disorder and is a surgical emergency in neonates. Mortality rates exceedingly more than 50% in premature babies or those whose weight is less than 1500 grams.

NEC (Necrotising Enterocolitis) occurs in three groups of babies –

1.    Term babies with risk factors

2.    Preterm babies (immaturity of the gut)

3.    Babies with IUGR (Intra-Uterine-Growth-Retardation)

4.    Any other food given other than breast milk for the baby

5.    Ischaemia to the gut

Basically, what happens in NEC is, due to ischaemia, there occurs a decrease in blood supply to the gut, this leads to necrosis and increase in air accumulation inside the gut. This causes excessive filling of the gut with the air leading to bloating of the gut. This condition is called as Pneumatosis intestinalis. This leads to distention of the abdomen and bleeding with the gut bacteria to migrate to peritoneum and cause infection there.

If this air leaks out it leads to –

1.    Pneumoperitoneum

2.    Pneumatosis portalis (air in portal system)

3.    Peritonitis (bacterial infection of the peritoneum)


 


Images showing Pneumatosis intestinalis (air bubbles seen)

 

 Signs and symptoms –

1.    Apnoea

2.    Lethargy

3.    Shock (in advanced stages)

4.    Decreased peripheral perfusion

5.    Cardiovascular collapse

6.    Increased abdominal girth

7.    Visible intestinal loops

8.    Distention of abdomen with decreased abdominal sounds

9.    Palpable abdominal mass

10.  Acidosis

11.  Hyponatraemia

12.  Thrombocytopaenia

Differential diagnosis –

1.    Hirschprung disease

2.    Meningitis

3.    UTI

4.    Malrotation

5.    Volvulus

6.    Septicaemia

Bell’s staging for NEC –

1.    Stage I – bleeding, abdominal distention, decreased bowel sounds.

Ia – occult bleeding in stools

Ib – Gross bleeding in stools

2.    Stage II – Definite NEC, where air enters the bowel.

IIa – pneumatosis intestinalis

IIb – pneumatosis portalis

Triad of NEC seen – Acidosis + hyponatraemia + thrombocytopaenia

3.    Stage III – Advanced stage of NEC

IIIa – peritonitis, ascites

IIIb – pneumoperitoneum

Treatment –

1.    Upto stage IIIa – keep the child NBM, i.e. nil by mouth and start broad spectrum antibiotics.

2.    Stage IIIb – If baby is unstable – peritoneal drainage, if baby is stable and can be taken to OT – Laparotomy.

Prevention –

1.    Antenatal steroids

2.    Minimal Enteral Nutrition.

 


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