Necrotizing Enterocolitis

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Case Presentation. LS is a ex 26 weeker from a twin gestation delivered by emergency caesarean section when mother presented to the ER with cord prolapseBirth weight 680 gApgars 9/9 at birth, Neopuff in delivery roomS/p surfactantDx w/ Staph Epidermidis sepsis and meningitisFeeds began on DOL 4.

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Necrotizing Enterocolitis

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1. Necrotizing Enterocolitis Pediatric Surgery Conference Shalini Arora July 15th, 2005

2. Case Presentation LS is a ex 26 weeker from a twin gestation delivered by emergency caesarean section when mother presented to the ER with cord prolapse Birth weight 680 g Apgars 9/9 at birth, Neopuff in delivery room S/p surfactant Dx w/ Staph Epidermidis sepsis and meningitis Feeds began on DOL 4

3. On DOL 28 began having episodes of bradycardias and desaturation, intolerance of tube feeds and abdominal distention Abdominal radiograph suspicious for pneumatosis intestinalis in RLQ Over the next five days had worsening clinical status w/ thrombocytopenia, increased ventilatory support, worsening abdominal distention

4. Operative Findings Distended loops small bowel Necrotic terminal ileum and right colon extending to mid-distal transverse colon Underwent an extended Right hemicolectomy w/ ileostomy and mucous fistula

5. POD #10 Significantly improved clinically Remains intubated Awaiting bowel function, NPO w/ GI decompression, IV antibiotics Pathology consistent with necrotizing enterocolitis

6. Epidemiology Most common GI emergency in newborns Incidence 3 per 1000 live births Incidence is 30 per 1000 live births for low birth weight neonates 90% are premature Incidence is 7% in newborns <1500 g Race: blacks > non-Hispanic whites

7. Question You are in the NICU taking care of a premature infant when the nurse says she thinks the baby has NEC. What are some of the signs and symptoms that should make one suspicious for NEC?

8. Question What tests should you order?

9. Physiologic signs Temperature instability Apnea Episodes of Bradycardias & Desaturation Lethargy Acidosis Thrombocytopenia Physical signs Feeding intolerance Increased gastric residuals Abdominal distention Occult blood/ Hematochezia Peritonitis Discoloration of abdominal wall Abdominal mass

10. Further workup WBC <1500 indicates poor prognosis Worsening thrombocytopenia Acidosis Hyponatremia, Na <130 Sepsis evaluation Paracentesis in infants w/ severe ascites/peritonitis, if positive indicates perforation Radiographs in supine, left lateral decub or crosstable position

11. Radiographic Signs

12. Bell’s Classification of NEC Stage I- Temperature instability, apnea, B’s & D’s, feeding intolerance, bilious emesis, Mild ileus Stage II- Metabolic acidosis, thrombocytopenia, Bloody stools, moderate distention, pneumatosis intestinalis, fixed loops of bowel Stage III- Neutropenia, DIC, cardiovascular collapse, peritonitis, discoloration, pneumoperitoneum, portal venous gas

13. Pathogenesis Cause is uncertain Likely multifactorial- intestinal ischemia and infection central to process Enteral feeding also considered an etiology-90% occur after starting feeds Immature gut and immune system Inflammatory mediators

14. Clinical risk factors Preterm infants- incidence inversely related to gestational age Incidence and severity higher in neonates with smaller birth weights Associated with congenital heart disease- hypoplastic left heart, truncus arteriosus Umbilical Artery cath not supported as a risk factor

15. Pathology Most common site of involvement is the terminal ileum followed by the colon Disease can involve single or multiple segments of bowel Pan-necrosis in 19%, mortality 100%

16. Question How do you manage an infant w/ NEC?

17. Treatment Initial treatment is non-operative with decompression via orogastric tube to low continuous suction Prevent hypovolemia-diminish ischemia Intravenous nutrition Broad spectrum antibiotics Serial physical exams, radiographs q 6-8 hours, serial platelet count

18. Surgical Management Absolute indications -Pneumoperitoneum Relative indications are fixed Loops bowel, abdominal wall erythema, positive paracentesis, failure to improve, progressive thrombocytopenia, Portal vein gas

19. Peritoneal drainage-performed at bedside w/ local anesthesia. Percutaneous drains placed usually in RLQ. Majority still need laparotomy. For infants <1000g OR-Minimal resection of obviously necrotic bowel, w/ stoma formation and second look in 36-48bhours if needed

20. Complications Sepsis, meningitis, abscess formation DIC Hypotention, shock Respiratory failure

21. Outcomes Mortality 20-40% Long-term complication - intestinal strictures in 9-36%, most common location colonic, but ileum and jejunum may be involved; And short bowel syndrome in 9% of those who undergo surgery Neurodevelopmental delay Psychomotor retardation

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