Necrotizing EnterocolitisPresentation and DiagnosisNecrotizing Enterocolitis (NEC) may include a distended abdomen, green/yellow vomiting, blood in the stools, inability to tolerate feeds, and early signs of blood stream infection. The typical patient is in the intensive care unit, is premature, has other medical problems, and has recently been fed. Blood pressure or lung problems, lethargy, unstable temperature, low heart rate, and/or breathing difficulties may be observed. The white blood cell count may be high or low. A low platelet count is frequently observed. The ability of the blood to clot may be reduced. Onset of this disease rarely occurs in the first few days of life. An X-ray showing pneumatosis intestinalis (air in the wall of the intestine) is the hallmark of NEC. Other X-ray signs of NEC include the presence of air in the portal vein leading to the liver, enlarged, non-moving loops of small intestine, and evidence of fluid (ascites) around the loops of the intestine. An inside the abdomen, but outside of the small intestine may be indicative of a hole in the intestine. However, NEC may be present even in the absence of all of these X-ray signs. The clinical setting combined with physical examination and X-ray findings should be used to established the diagnosis. TreatmentApproximately 80% of patients may be managed without an operation by giving fluid into the bloodstream, nasogastric (NG) suction tube and administration of antibiotics. Operation is performed when on of the following are seen: 1) continuing or progressive signs of body-wide infection, 2) X-ray evidence of perforation, or 3) progressive worsening on physical exam, such as development of an increasingly distended abdomen, a mass in the abdomen, and/or redness of the abdominal wall. Worsening heart or lung function, often in conjunction with falling platelet counts, are signs of progressive infection. A 50% reduction in platelet count after initiation of treatment for NEC is a strong indication of continuing infection and need for an operation. The goal of the operation is to remove dead or dying intestine. In almost all cases, the ends of the intestine are brought out onto the abdominal wall rather than being joined together. If remaining intestinal length is of concern, questionable areas of the intestines may be left in and a second operation 24 hours later to examine these areas may be required. Occasionally, all of the intestine will be dead. Further intervention in these cases is not indicated. One alternative in the small premature newborn with NEC and evidence of a perforation of (hole in) the intestine is the placement of a drain into the abdomen via an incision in the right lower abdomen. If continued clinical deterioration is observed, then a larger operation may be indicated. In a few patients with a short area of the intestine that is sick, the affected portion of the intestine can be removed and the two ends put back together. When the intestine is brought out onto the abdominal wall, the two ends can be generally rejoined 4-6 weeks later. An X-ray with dye injection of the downstream intestine should be performed prior to putting the two ends back together. Results and complicationsSurvival in the patient with NEC is approximately 60-70%. Death is generally related to widespread infection and prematurity. Frequently observed complications from the operation include fistula (connection between the intestine and the skin) formation, and death of the intestine where it is brought out of the skin. More intestine may die which may require another operation in an occasional patient. Long term problems are usually associated with the development of intestinal strictures (narrowing) in 11-25% of patients. Strictures occur most often in the colon with the second most site in the terminal ileum (last part of the small intestine). Those patients with a inadequate intestinal length may develop short gut syndrome with complications related to inability to tolerate feeds and need for long term hyperalimentation (food by vein). Suggested readings authored by the University of Michigan, Section of Pediatric Surgery
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