necrotising enterocolitis.doc

8/9/2019 Necrotising Enterocolitis.doc

1/5

Necrotising Enterocolitis (NEC)Post your experience

See others (3 there) First described over a century ago necrotising enterocolitis (NEC) is now the most commongastrointestinal emergency occurring in neonates !t is an ac"uired disorder with a mortality ashigh as #$% (&$' % in in ants less than $$ g* $'+$% in in ants over +#$$ g) Prematurity andlow birthweight are the most important ris, actors -his is particularly poignant because.

!t mainly a ects premature in ants who having survived a di icult neonatal period thencon ront a disease with high morbidity and mortality

/ith obstetric advances more very low birth weight in ants survive the neonatal periodincreasing the population at ris, o NEC

NEC is rare in term babies as a whole* but these account or &$% o cases !n term babies theinitiating events are di erent and it it o ten associated with underlying disorders 0espite a loto research over many years the aetiology remains elusive !t involves serious intestinal in1ury

ollowing a combination o vascular* mucosal* toxic* and possibly other insults to a relativelyimmature gut & 0iagnosis and treatment remain very di icult and challenging +

Epidemiology 2 -he most re"uent gastrointestinal emergency in neonates 3 Few population or multicentre studies but re"uency ranges rom &% to #% o neonatal

intensive care unit (N!C2) admissions !ncidence o $ # to # patients per &$$$ live births !ncidence and mortality increase in inverse proportion to birthweight and gestational

age + nly one study has reported a decline in the rate o disease in very low birth weight

(456/) in ants &$% o NEC occurs in ull term in ants !n ull term in ants NEC is usually associated with predisposing or underlying disorders.

o Perinatal asphyxiao Polycythaemiao 7espiratory distresso Congenital anomalies ( myelomeningocoele * congenital heart disease)

-here is no consistent association between gender and rates o NEC 8owever male 456/ babies have a higher mortality 9ortality is higher in blac, in ants with NEC (even when matching or birthweight and

other characteristics) :verage yearly in ant death rate rom NEC has been reported as &+ deaths per

&$$*$$$ live births :n estimated +$' $% o in ants with NEC undergo surgery ;#% o NEC occurs a ter enteral eeds have been introduced 8uman mil, is protective with a three to ten' old reduction in NEC (compared to

ormula ed) No identi ied sex


2/5

Pathophysiology 2 -he aetiology is un,nown and the pathophysiology poorly understood Premature in ants are atris, because o immaturity o .

Gastrointestinal motility Slower motility also occurs in etal hypoxia and perinatalasphyxia

Digestive ability !mpaired ability to digest and absorb nutrients may contribute to

intestinal in1ury Circulatory regulation 8ypoxic'ischaemic in1ury may play a part ne hypothesis is

that there is re lex diversion o blood supply away rom gut and towards heart andbrain (the diving re lex) and that this together with other actors ( eeding andbacteria) might lead to intestinal hypoxia

Intestinal barrier function ! this is immature* or reduced* bacteria are able topenetrate the mucosal barrier and cause in lammation more easily !mmature gobletcells and an immature mucin layer may lead to increased permeability and breaching o the intestinal epithelial barrier !mmature paneth cells and biochemical de ences mayalso reduce de enses (less able to secrete antimicrobial peptides)

Immune defence : series o events contribute to the in lammatory responsecharacterising NEC (mucosal oedema* coagulation necrosis* haemorrhage) 4ariousin lammatory mediators are implicated in what may be an exaggerated response by

immature intestinal cells :nother hypothesis is that an inade"uate immune responseallows bacterial overgrowth Either excessive or hypoactive immune responses maythere ore be implicated in the pathogenesis

ther contributory actors include. 8ypoxic'ischaemic in1ury Formula eeding and ormula composition (human mil, is protective) Colonisation by pathological bacteria

NEC does not occur in utero Colonisation o the gut with either commensal or pathogenicbacteria may a ect maturation o the innate immune system (pattern recognition receptorsand microbial'associated molecular patterns) 8yperactive in lammation in in ants caused by

inade"uate or altered colonisation o the gut may cause de iciencies in dampening obacterially mediated in lammatory pathwaysNote also that.

Polycythaemia* drugs* cardiac de ects* exchange trans usions* 70S may contribute tothe hypoxic'ischaemic in1ury

6lood cultures are positive in +$'3$% o cases re lecting the reduced de ense tobacterial invasion ( E. coli, Klebsiella spp., Salmonella spp., S. epidermidis )

Several groups have shown that upregulation o nitric oxide plays an integral role in thedevelopment o epithelial in1ury in NEC #

Clinical presentationnset usually 3'&$ days (extremes & to ;$ days) a ter birth :ge at presentation is inversely

related to gestational age at birth (that is ull term in ants with NEC present in the irst ewdays) Early signs are non'speci ic and sepsis may be suspected be ore NEC !t may be benign orcatastrophic and since &;=> a system o staging has been used (see box) ?*=

:bdominal distension with increasing gastric aspirates 6loody mucoid stool and bilious vomiting 0ecreased bowel sounds with erythema o the abdomen Palpable abdominal mass or ascites :ssociated eatures are bradycardia* lethargy* shoc,* apnoea* respiratory distress*

temperature instability
http://www.patient.co.uk/doctor/#ref2http://www.patient.co.uk/doctor/#ref5http://www.patient.co.uk/doctor/#ref6http://www.patient.co.uk/doctor/#ref6http://www.patient.co.uk/doctor/#ref7http://www.patient.co.uk/doctor/#ref2http://www.patient.co.uk/doctor/#ref5http://www.patient.co.uk/doctor/#ref6http://www.patient.co.uk/doctor/#ref7


3/5

Differential diagnosis Sepsis 8aemorrhagic disease o the newborn Swallowed maternal blood 4olvulus

Investigations 6lood lab tests are non'speci ic* but cultures* ull blood count* blood gas and baseline

biochemistry should be ta,en and lend support to the diagnosiso Severe or persistent thrombocytopenia* neutropenia* coagulopathy or acidosis

indicate severe diseaseo Serial C'reactive protein may be use ul* with persistently high levels with

complications (stricture* abscess) 0iagnosis is con irmed on abdominal x'ray (supine and decubitus


4/5

N@ or @ tube to decompress the bowel with low intermittent orogastric suction !4 luids* -PN* and !4 antibiotics or &$'& days.

o :mpicillin


5/5

ral antibiotics Probiotics !mplementation o strict in ection'control measures to prevent aecal and oral spread

o organisms

Document references & /arrell 0* Cox -9* Firth 0* 6en E x ord -extboo, o 9edicine* th edition +$$

2P !S6N $&;>#+;;>>+ 5in P/* Stoll 6 G Necrotising enterocolitis 5ancet +$$? ct =G3?>(;# 3).&+=&'>3

HabstractI3 Pellegrini 9* 5agrasta N* @arcia @arcia C* et al G Neonatal necroti ing enterocolitis. a

ocus on Eur 7ev 9ed Pharmacol Sci +$$+ an'FebG?(&).&;'+# HabstractI5uig 9* 5ui J G Epidemiology o necroti ing enterocolitis''Part !!. 7is,s and susceptibilityo premature in ants during the sur actant era. a regional study Paediatr Child8ealth +$$# :prG &( ).&= '; HabstractI

# @uner KS* Cho,shi N* Petrosyan 9* et al G Necroti ing enterocolitis''bench to bedside.novel and emerging strategies Semin Pediatr Surg +$$> NovG&=( ).+##'?# HabstractI

? 6ell 9 G Neonatal necroti ing enterocolitis N Engl 9ed &;=> Feb +G+;>(#).+>&'+

= 6ell 9 * -ernberg 5* Feigin 70* et al G Neonatal necroti ing enterocolitis -herapeuticdecisions based upon clinical staging :nn Surg &;=> anG&>=(&).&'= HabstractI

> ,uyama 8* Jubota :* ue -* et al G : comparison o the clinical presentation andoutcome o ocal intestinal per oration and necroti ing enterocolitis in very'low'birth'weight neonates Pediatr Surg !nt +$$+ 0ecG&>(>).=$ '? Epub +$$+ 0ec &= HabstractI

; Neu * 9shvildad e 9* 9ai 4 G : roadmap or understanding and preventing necroti ingenterocolitis Curr @astroenterol 7ep +$$> ctG&$(#). #$'= HabstractI

&$ Koung C* Sharma 7* 8and ield 9* et al G 6iomar,ers or !n ants at 7is, or Necroti ingEnterocolitis. Clues to PreventionL Pediatr 7es +$$; an +> HabstractI

&& Nadler EP* 2pperman S* Ford 87 G Controversies in the management o necroti ingenterocolitis Surg !n ect (5archmt) +$$& SummerG+(+).&&3';G discussion &&;'+$HabstractI

&+ 6ur,itt 8@ and Muic, C7@ Essential Surgery 3rd edition Churchill 5ivingstone +$$+

&3 6erseth C5* 6is"uera :* Pa1e 42 G Prolonging small eeding volumes early in li edecreases the incidence o necroti ing enterocolitis in very low birth weight in antsPediatrics +$$3 9arG&&&(3).#+;'3 HabstractI

& Schurr P* Per,ins E9 G -he relationship between eeding and necroti ing enterocolitis invery low birth weight in ants Neonatal Netw +$$> Nov'0ecG+=(?).3;=' $= HabstractI

-hompson :9* 6i arro 9 G Necroti ing enterocolitis in newborns. pathogenesis*prevention and management 0rugs +$$>G?>(;).&++='3> HabstractI
http://www.patient.co.uk/doctor/#ref15http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17027734http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12608653http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15813870http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19019294http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=619275http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=413500http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12598969http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18799119http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19190533http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12594866http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12612232http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19065969http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18547133http://www.patient.co.uk/doctor/#ref15http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=17027734http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12608653http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=15813870http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19019294http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=619275http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=413500http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12598969http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18799119http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19190533http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12594866http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=12612232http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=19065969http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Abstract&list_uids=18547133

necrotising enterocolitis.doc

Documents