GI - Necrotisising Enterocolitis

Question 1

Defintion

Answer 1

Serious illness typically affecting premature neonates. It results necrosis of the intestines and can lead to multi-organ failure and death.

Question 2

Epidemiology

Answer 2

Prematurity
Low birthweight
Congenital anomalies: myelomeningocele, congenital heart disease

Question 3

Risk factors

Answer 3

Maternal illicit drug abuse
Maternal infection: HIV, chorioamnionitis
Placental abruption
Perinatal asphyxia
Neonatal shock and hypovolaemia
Formula milk ingestion: compared to breast milk
Blood transfusion

Question 4

Pathophysiology

Answer 4

Unknown

Question 5

Signs

Answer 5

Neonates in their first few weeks of life
Abdominal distension
Bloody mucoid stool
Decreased bowel sounds
Palpable abdominal mass
Ascites
Bradycardia
Shock: lethargy, respiratory distress, temparature instability

Question 6

Symptoms

Answer 6

Non-specific symptoms
Vomiting: bilious
Altered stool pattern

Question 7

Diagnosis

Answer 7

Primary investigations:
- FBC: thrombocytopenia and neutropenia in severe disease
- U + E’s: deranged electrolytes if dehydrated
- CRP: raised
- Blood gas: acidosis, raised lactate in severe disease
- Abdominal X-ray: bowel wall thickening, gas filled bowel loops, gaseous distension.

Investigations to consider
- bowel ultrasound:
= increased bowel wall thickness and echogenecity,
= free fluid collection,
= loss of bowel wall perfusion using Doppler.

Question 8

Stage 1

Answer 8

Systemic:
- Temperature instability,
- Lethargy,
- Bradycardia
GI:
- Occult blood in stool
Abdominal X-RAY:
- Normal/Non-specific change

Question 9

Stage 2a

Answer 9

Systemic:
- Temperature instability,
- lethargy,
- bradycardia
GI -
- Abdominal distention +/- tenderness,
- absent bowel sounds,
- frank blood in stools
Abdo X-RAY:
- Ileus,
- Focal pneumatosis intestinalis

Question 10

Stage 2b

Answer 10

Systemic:
- Mild acidosis,
- Thrombocytopenia
GI:
- Abdominal wall oedema,
- tenderness +/- abdominal mass
Abdo X-RAY:
- Extensive pneumatosis intestinalis,
- ascites +/- intrahepatic portal gas

Question 11

Stage 3a

Answer 11

Systemic:
- Severe acidosis,
- hypotension,
- reduced urine output,
- DIC
GI:
- Spreading oedema,
- erythema,
- induration of the abdomen
Abdo X-RAY:
- Prominant ascites +/- persistent sentinel bowel loop

Question 12

Stage 3b

Answer 12

Systemic:
- Deteriorating vital signs,
- Electrolyte imbalance
GI:
- Peritonitis
Abdo X-RAY:
- GI perforation

Question 13

Management

Answer 13

Stage 1:
- Conservative:
= Insert NGT
= IV fluids
= Parenteral nutrition
- Medical:
= IV antibiotics: triple therapy as per local guidelines
Analgesia: paracetamol +/- morphine

Stage 2 & 3:
- Conservative:
= Insert NGT
= Discuss with on-call surgical team
= Consider intubation and ventilation
- Medical:
= Correct electrolyte imbalances
= Analgesia: morphine infusion
= Parenteral nutrition
= IV antibiotics: triple therapy as per local guidelines
- Surgery:
= Laparotomy +/- bowel resection: 50% of neonates with advanced disease will require surgery

Question 14

Complications

Answer 14

Intestinal perforation
Post op short bowel syndrome
DIC
Sepsis and shock
Intestinal structures
Enterocolic fistulae
Abscess formation
Recurrence