necrotizing enterocolitis
DESCRIPTION
prepared from clohorty some slides were taken from dr. Padmesh Vadakepat presentationTRANSCRIPT
Necrotizing enterocolitis
- DrRaghavendra Babu S
DNB year II
JLNHampRC
Necrotizing Enterocolitis 1048766an acquired neonatal acute intestinal necrosis of unknown etiology1048766NEC is neither a uniform nor a well-defined disease entity
Acquired neonatal intestinal diseases (ANIDs)
Wider umbrella includes different pathologies affecting gastrointestinal tract in preterm and term infants Some which do lead to the common final pathology of NEC and some which do not1048766Includes1048766NEC1048766SIP (isolated spontaneous intestinal perforation)1048766Viral enteritis of infancy1048766Cowrsquos milk protein allergy
Epidemiology
Incidence 03-24 1000 live births2-5 of all NICU admissions5-10 of VLBW infants Over 90 of cases occur in preterm babiesAbout 10 occur in term newborns essentially limited to those that have some underlying illness or condition requiring NICU admission Sex race geography climate has no role in
determining the incidence of NEC Prematurity is the single greatest risk factor
Intestinal ischemia (injury)
Enteral nutrition Pathogenic
organisms
Risk Factors for NEC - Triad
Risk factors influencing NEC prediposition
bull Prematurity inflamatory propensity of the immature gut Decreases intestinal barrier function Decreased gut motility and abberent vascular regulation
bull Enteral feeding Aggressive advancement of feeding Non human milk feeding
bull Abnormal bacterial colonization Prolonged emperical antibiotic therapy Decreased commensal flora Increased pathogenic bacteria
Maternal cocaine abuse ndash 25 times increases risk
Risk Factors in Term Babies
Limited to those that have some underlying illness or condition requiring NICU admission
bull Congenital Heart Diseasebull Intrauterine growth restrictionbull Polycythemiabull Hypoxic-ischemic events
bull The mean gestational age of infants with NEC is 30 to 32 weeks and the infants generally are weight appropriate for gestational age
bull Postnatal age at onset is inversely related to birth weight and gestational age with mean age at onset of 12 days
PRIMARY INFECTIOUS AGENTS
Bacteria Bacterial toxin Virus Fungus
CIRCULATORY INSTABILITY
Hypoxic-ischemic event Polycythemia
MUCOSAL INJURY
ENTERAL FEEDINGS
Hypertonic formula or medication Malabsorption gaseous distention H2 gas production Endotoxin production
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4 Interleukin 1 6
pathogenesis
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Necrotizing Enterocolitis 1048766an acquired neonatal acute intestinal necrosis of unknown etiology1048766NEC is neither a uniform nor a well-defined disease entity
Acquired neonatal intestinal diseases (ANIDs)
Wider umbrella includes different pathologies affecting gastrointestinal tract in preterm and term infants Some which do lead to the common final pathology of NEC and some which do not1048766Includes1048766NEC1048766SIP (isolated spontaneous intestinal perforation)1048766Viral enteritis of infancy1048766Cowrsquos milk protein allergy
Epidemiology
Incidence 03-24 1000 live births2-5 of all NICU admissions5-10 of VLBW infants Over 90 of cases occur in preterm babiesAbout 10 occur in term newborns essentially limited to those that have some underlying illness or condition requiring NICU admission Sex race geography climate has no role in
determining the incidence of NEC Prematurity is the single greatest risk factor
Intestinal ischemia (injury)
Enteral nutrition Pathogenic
organisms
Risk Factors for NEC - Triad
Risk factors influencing NEC prediposition
bull Prematurity inflamatory propensity of the immature gut Decreases intestinal barrier function Decreased gut motility and abberent vascular regulation
bull Enteral feeding Aggressive advancement of feeding Non human milk feeding
bull Abnormal bacterial colonization Prolonged emperical antibiotic therapy Decreased commensal flora Increased pathogenic bacteria
Maternal cocaine abuse ndash 25 times increases risk
Risk Factors in Term Babies
Limited to those that have some underlying illness or condition requiring NICU admission
bull Congenital Heart Diseasebull Intrauterine growth restrictionbull Polycythemiabull Hypoxic-ischemic events
bull The mean gestational age of infants with NEC is 30 to 32 weeks and the infants generally are weight appropriate for gestational age
bull Postnatal age at onset is inversely related to birth weight and gestational age with mean age at onset of 12 days
PRIMARY INFECTIOUS AGENTS
Bacteria Bacterial toxin Virus Fungus
CIRCULATORY INSTABILITY
Hypoxic-ischemic event Polycythemia
MUCOSAL INJURY
ENTERAL FEEDINGS
Hypertonic formula or medication Malabsorption gaseous distention H2 gas production Endotoxin production
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4 Interleukin 1 6
pathogenesis
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Epidemiology
Incidence 03-24 1000 live births2-5 of all NICU admissions5-10 of VLBW infants Over 90 of cases occur in preterm babiesAbout 10 occur in term newborns essentially limited to those that have some underlying illness or condition requiring NICU admission Sex race geography climate has no role in
determining the incidence of NEC Prematurity is the single greatest risk factor
Intestinal ischemia (injury)
Enteral nutrition Pathogenic
organisms
Risk Factors for NEC - Triad
Risk factors influencing NEC prediposition
bull Prematurity inflamatory propensity of the immature gut Decreases intestinal barrier function Decreased gut motility and abberent vascular regulation
bull Enteral feeding Aggressive advancement of feeding Non human milk feeding
bull Abnormal bacterial colonization Prolonged emperical antibiotic therapy Decreased commensal flora Increased pathogenic bacteria
Maternal cocaine abuse ndash 25 times increases risk
Risk Factors in Term Babies
Limited to those that have some underlying illness or condition requiring NICU admission
bull Congenital Heart Diseasebull Intrauterine growth restrictionbull Polycythemiabull Hypoxic-ischemic events
bull The mean gestational age of infants with NEC is 30 to 32 weeks and the infants generally are weight appropriate for gestational age
bull Postnatal age at onset is inversely related to birth weight and gestational age with mean age at onset of 12 days
PRIMARY INFECTIOUS AGENTS
Bacteria Bacterial toxin Virus Fungus
CIRCULATORY INSTABILITY
Hypoxic-ischemic event Polycythemia
MUCOSAL INJURY
ENTERAL FEEDINGS
Hypertonic formula or medication Malabsorption gaseous distention H2 gas production Endotoxin production
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4 Interleukin 1 6
pathogenesis
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Intestinal ischemia (injury)
Enteral nutrition Pathogenic
organisms
Risk Factors for NEC - Triad
Risk factors influencing NEC prediposition
bull Prematurity inflamatory propensity of the immature gut Decreases intestinal barrier function Decreased gut motility and abberent vascular regulation
bull Enteral feeding Aggressive advancement of feeding Non human milk feeding
bull Abnormal bacterial colonization Prolonged emperical antibiotic therapy Decreased commensal flora Increased pathogenic bacteria
Maternal cocaine abuse ndash 25 times increases risk
Risk Factors in Term Babies
Limited to those that have some underlying illness or condition requiring NICU admission
bull Congenital Heart Diseasebull Intrauterine growth restrictionbull Polycythemiabull Hypoxic-ischemic events
bull The mean gestational age of infants with NEC is 30 to 32 weeks and the infants generally are weight appropriate for gestational age
bull Postnatal age at onset is inversely related to birth weight and gestational age with mean age at onset of 12 days
PRIMARY INFECTIOUS AGENTS
Bacteria Bacterial toxin Virus Fungus
CIRCULATORY INSTABILITY
Hypoxic-ischemic event Polycythemia
MUCOSAL INJURY
ENTERAL FEEDINGS
Hypertonic formula or medication Malabsorption gaseous distention H2 gas production Endotoxin production
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4 Interleukin 1 6
pathogenesis
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Risk factors influencing NEC prediposition
bull Prematurity inflamatory propensity of the immature gut Decreases intestinal barrier function Decreased gut motility and abberent vascular regulation
bull Enteral feeding Aggressive advancement of feeding Non human milk feeding
bull Abnormal bacterial colonization Prolonged emperical antibiotic therapy Decreased commensal flora Increased pathogenic bacteria
Maternal cocaine abuse ndash 25 times increases risk
Risk Factors in Term Babies
Limited to those that have some underlying illness or condition requiring NICU admission
bull Congenital Heart Diseasebull Intrauterine growth restrictionbull Polycythemiabull Hypoxic-ischemic events
bull The mean gestational age of infants with NEC is 30 to 32 weeks and the infants generally are weight appropriate for gestational age
bull Postnatal age at onset is inversely related to birth weight and gestational age with mean age at onset of 12 days
PRIMARY INFECTIOUS AGENTS
Bacteria Bacterial toxin Virus Fungus
CIRCULATORY INSTABILITY
Hypoxic-ischemic event Polycythemia
MUCOSAL INJURY
ENTERAL FEEDINGS
Hypertonic formula or medication Malabsorption gaseous distention H2 gas production Endotoxin production
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4 Interleukin 1 6
pathogenesis
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Risk Factors in Term Babies
Limited to those that have some underlying illness or condition requiring NICU admission
bull Congenital Heart Diseasebull Intrauterine growth restrictionbull Polycythemiabull Hypoxic-ischemic events
bull The mean gestational age of infants with NEC is 30 to 32 weeks and the infants generally are weight appropriate for gestational age
bull Postnatal age at onset is inversely related to birth weight and gestational age with mean age at onset of 12 days
PRIMARY INFECTIOUS AGENTS
Bacteria Bacterial toxin Virus Fungus
CIRCULATORY INSTABILITY
Hypoxic-ischemic event Polycythemia
MUCOSAL INJURY
ENTERAL FEEDINGS
Hypertonic formula or medication Malabsorption gaseous distention H2 gas production Endotoxin production
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4 Interleukin 1 6
pathogenesis
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
PRIMARY INFECTIOUS AGENTS
Bacteria Bacterial toxin Virus Fungus
CIRCULATORY INSTABILITY
Hypoxic-ischemic event Polycythemia
MUCOSAL INJURY
ENTERAL FEEDINGS
Hypertonic formula or medication Malabsorption gaseous distention H2 gas production Endotoxin production
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4 Interleukin 1 6
pathogenesis
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
pathogenesis
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Microbiologic Flora and Infection
Several organisms have been accused but non has been proven to be causativendash Enterobacteriaceaendash Enterobactersakazakiindash Coagulase-negative staphylococci SIPndash Closrtidium perfringensndash Candida species SIPndash Cytomegalovirusndash Torovirusndash HIVndash Mucormycosis
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Cytokines and Inflammatory Mediators
ndash Platelet Activating Factor (PAF)ndash Tumor Necrosis Factor (TNF)ndash High-mobility group box 1 protein (HMGB 1)ndash Interferon-gamma (INF-gamma)ndash Interleukins (ILs)ndash Matrix metalloproteinases(MMPs)
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Clinical Presentation
bull Course of the diseaseFulminant presentation
Slow paroxysmal presentationbull The onset of NEC usually occurs in the 1st 2 weeks of
life (with a mean age at onset of 12 days) but can be as late as 3 months of age in VLBW infants
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull The 1st signs of impending disease may be
-Nonspecific including lethargy and temperature instability or
-Related to gastrointestinal pathology such as abdominal distention and gastric retention
bull Obvious bloody stools are seen in 25 of patients
The spectrum of illness is broad and ranges from
-Mild disease with only guaiac-positive stools to
-Severe illness with bowel perforation peritonitis systemic inflammatory response syndrome shock and death
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull Abdominal (enteric) signsndash Distensionndash Tendernessndash Gastric aspirate
vomitingndash Ileusndash Abdominal wall
erythema indurationndash Ascitesndash Abdominal massndash Bloody stool
bull Systemic signs ndash Respiratory distress
apnea bradycardiandash Lethargy irritabilityndash Temp instabilityndash Poor feedingndash Hypotensionndash Acidosisndash Oligureandash Bleeding diathesis
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Laboratory featuresbull No lab test is specific for NECbull The most common triad
ndash Thrombocytopeniandash Persistent metabolic acidosisndash Severe refractory hyponatremia
Serial measurements of CRP ndash diagnostic and prognostic
bull uarrWBC darrWBC darrPMNbull Hyperkalemiabull Stool reducing substances occult blood
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Blood studies
Thrombocytopenia
COMMON TRIAD
OF SIGNS
Persistent Severe Refractory
Hyponatremia Metabolic Acidosis
HAT
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Radiology studies
bull Abdominal X-raybull Abnormal gas pattern ileusbull Bowel wall edemabull Pneumatosis intestinalisbull Fixed position loopbull Intra hepatic-portal venous gas ( in the absence of
UVC)bull Pneumoperitonium - left lateral decubitus or cross-
table lateral views
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull Intestinal perforation bull Abdominal Xray in NEC demonstrates marked distention and massive
pneumoperitoneum
Free air below the anterior abdominal wall
NEC
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull Abdominal ultrasoundndash Thick-walled loops of bowel with hypomotilityndash Intraperitonealfluid is often presentndash Intramural gas can be identified in early-stage NEC ndash In the presence of pneumatosisintestinalis gas is
identified in the portal venous circulation within the liver
ndash Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull Differential diagnosis of NEC bull Specific infections (systemic or intestinal)- Pneumonia
Sepsis
bull Gastrointestinal obstruction volvulus malrotation
bull Isolated intestinal perforation
bull Severe Inherited Metabolic disorders (eg galactosemia with Escherichia coli sepsis)
bull Feeding intolerance
bull Severe allergic colitis
bull Idiopathic focal intestinal perforation can occur spontaneously or after the early use of postnatal steroids and indomethacin
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull MODIFIED BELLrsquoS STAGING OF NEC Based on
1 Systemic Signs
2 Intestinal Signs
3 Radiological Signs
Classified into
I Suspected
II Definite
A (Mildly ill)
B (Moderately ill)
III Advanced
A (Severely illbowel intact)
B (Severely illbowel perforated)
SIR
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull TREATMENTbull Rapid initiation of therapy is required for suspected as well
as proven NEC cases
bull There is no definitive treatment for established NEC and therapy is directed at supportive care and preventing further injury with
-Cessation of feeding
-Nasogastric decompression and
-Administration of intravenous fluids
bull Once blood has been drawn for culture systemic antibiotics (with broad coverage for gram-positive gram-negative and anaerobic organisms) should be started immediately
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull TREATMENT Contdbull Umbilical catheters if present should be removed
bull Ventilation should be assisted as required
bull Intravascular volume replacement with crystalloid or blood products
bull Cardiovascular support with volume andor inotropes
bull Correction of hematologic metabolic and electrolyte abnormalities
bull Careful attention to respiratory status coagulation profile and acid-base and electrolyte balance are important
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull MONITORING
bull Sequential abdominal grith measuremet
bull Sequential anteroposterior and cross-table lateral or lateral decubitus abdominal x-rays to detect intestinal perforation
bull Serial determination of hematologic status
bull Serial determination of electrolyte status and
bull Serial determination of acid-base status
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull Indications for surgery bull Absolute indicationsbull Evidence of perforation on abdominal roentgenograms
(pneumoperitoneum) or bull Positive abdominal paracentesis (stool or organism on
Gram stain from peritoneal fluid)
bull Relative indicationsbull Failure of medical management bull Single fixed bowel loop on roentgenograms bull Abdominal wall erythema or bull A palpable mass
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull Ideally surgery should be performed after intestinal necrosis develops but before perforation and peritonitis occurs
bull Peritoneal drainage may be helpful for patients with peritonitis who are too unstable to undergo surgery Peritoneal drainage is more successful in patients with isolated intestinal perforation
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Initial signs of possible NEC (bellrsquos stage I )
bullNPObullGI decompression- low constant sucton replace output with electrolytesbullCBC with differentials blood culture CRP SElectrolytesbullAbdominal radiographbullBegin antibiotics
Mild to Moderate (Bellrsquos stage II)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 5-10 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 days
Advanced (Bellrsquos Stage III)bullSerial abdominal radiographsbullBroad spectrum antibiotics for 7- 10 daysbullNPO for 10-14 days parentaral nutritionbullMonitor electrolytesbullSerial CBCs every 12h to 24h for 2-3 daysbullCo-mangement with paediatric surgeonbullHemodynamic supportbullMonitor coagulation abnormalities and correct Indications for surgery
bullIntestinal perforationbullFixed adynamic loop ndash necrotic gutbullSigns suggestive of necrotic gut ndashpersistent severe thrombocytopenia severe metabolic acidosis
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull PROGNOSIS
bull Medical management fails in about 20ndash40 of patients with pneumatosis intestinalis at diagnosis of these 10ndash30 die
bull Early postoperative complications Wound infection dehiscence and stomal problems (prolapse necrosis)
bull Later complications Intestinal strictures develop at the site of the necrotizing lesion in about 10 of surgically or medically managed patients
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull PROGNOSIShellip
bull After massive intestinal resection
-Complications from postoperative NEC include short-bowel syndrome (malabsorption growth failure malnutrition)
bull Premature infants with NEC who require surgical
intervention or who have concomitant bacteremia are at increased risk for adverse growth and neurodevelopmental outcome
bull The overall mortality is 9 to 28 regardless of surgical or medical intervention
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
bull PREVENTION bull Always better than curebull Newborns exclusively breast-fed have a reduced risk of NEC
bull Early initiation of aggressive feeding may increase the risk of NEC in VLBW infants
bull Gut stimulation protocol of minimal enteral feeds followed by judicious volume advancement may decrease the risk
bull Probiotic preparations have also decreased the incidence of NEC Induction of GI maturation
bull Incidence of NEC is significantly reduced after prenatal steroid therapy
bull Alteration of the immunologic status of the intestine using immunoglobulin A (IgA) and immunoglobulin G (IgG) supplementation
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-
Thank You
- Necrotizing enterocolitis
- Slide 2
- Slide 3
- Slide 4
- Risk factors influencing NEC prediposition
- Slide 6
- Slide 7
- pathogenesis
- Microbiologic Flora and Infection
- Cytokines and Inflammatory Mediators
- Clinical Presentation
- Slide 12
- Slide 13
- Slide 14
- Laboratory features
- Slide 16
- Radiology studies
- Slide 18
- Slide 19
- Slide 20
- Slide 21
- Slide 22
- Slide 23
- Slide 24
- Slide 25
- Slide 26
- Slide 27
- Slide 28
- Slide 29
- Slide 30
- Slide 31
- Slide 32
- Slide 33
- Slide 34
- Slide 35
-