Necrotising Enterocolotis Flashcards
Define
Disorder characterised by ischaemic necrosis of the intestinal mucosa, which is associated with severe inflammation and invasion of enteric gas forming organisms and dissection of gas into the bowel wall and portal venous system.
Most common surgical emergency in newborn babies:
1. premature babies
2. LBW and PDA
3 in 10,000 (7% of those premature get NEC)
20% morbidity and mortality
Leads to serious intestinal injury after combination vascular, mucosal, toxic and other insults to an immature gut
Causes
This is a serious illness where the incidence increases with increasing prematurity
Typically seen in the first few weeks of life
- The bowel in the preterm infant is vulnerable to ischaemic injury and bacterial invasion
- It is associated with bacterial infection of the ischaemic bowel wall
- Main cause is unknown and thought to be a combination of many factors – thought to lead to a combination of poor blood flow and infection of the intestines – often begins after starting enteral feeding
Preterm infants fed with cow’s milk formula are MORE likely to develop this condition than those feeding only on breast milk.
Supplementing milk feeds with prebiotics and probiotics may be beneficial.
Presentation
EARLY Signs and Clinical features:
- Sudden feed intolerance
- Vomiting (may be bile stained)
- Distended abdomen
- Diarrhoea
- Fresh blood in stool (sometimes)
- Bilious gastric aspirate
Other non-specific systemic findings:
* Apnoea
* Respiratory failure
* Lethargy
* Temperature instability
* Hypotension resulting from septic shock
* The infant may rapidly develop shock and require mechanical ventilation because of abdominal distension and pain
Investigations
Investigations
Bloods: FBC, WCC, platelets
Blood culture
Characteristic X-ray features:
1. Distended loops of bowel- usually consistent with ileus
2. Thickening of bowel wall (oedema + inflammation)
3. Intramural gas (gas bubbles in the small bowel wall)
4. Gas in portal venous tract (transient sign of bacterial gas entering portal system)
5. Pneumoperitoneum (due to bowel perforation)
6. Air both inside and outside the bowel wall (Rigler sign)
7. Air outlining the falciform ligament (Football sign)
May do abdominal USS
Management
Supportive care
* Stop oral feeding
* Gastric decompression using intermittent NG suction
Total parenteral nutrition
* Fluid replacement
* Cardiorespiratory support- mechanical ventilation with circulatory support
Broad-spectrum antibiotics to cover both aerobic and anaerobic organisms
* IV Cefotaxime and vancomycin
* Often IV ampicillin, gentamicin + metronidazole for 10-14 days
Surgery if bowel perforation or with severe necrosis- peritoneal drainage and laparotomy
Complication
Acute complications:
* Infection- sepsis, meningitis, peritonitis, abscess formation
* DIC
* Cardiorespiratory complications- hypotension, shock, respiratory failure
* Metabolic- hypoglycaemia, metabolic acidosis
The long-term sequelae include:
* Development of strictures
* Malabsorption if extensive bowel resection is necessary (short bowel syndrome)
* Intestinal failure
* Recurrent NEC
* Adhesion ileus
* Greater risk of poor neurodevelopmental outcome
