Introduction
Necrotizing enterocolitis refers to extensive necrosis of the intestine of multi-factorial origin.
It may ultimately result in intestinal perforation.
It commonly affects the terminal ileum and proximal colon but it may involve the entire length of the gut.
Predisposing Factors
Prematurity and very low birth weight, early infant formula feeding, intra-uterine growth restriction, polycythaemia, septicaemia, umbilical catheterization, congenital heart diseases can predispose to it.
Symptoms and clinical features of necrotizing enterocolitis
Grading
This is different from the Bell’s classification but it involves clinical, laboratory and radiologic features.
This grading is useful for prognostication and management planning.
A. Grade 1 (Better Prognosis)
- Feed intolerance
- Abdominal distension
- Bilious vomiting or gastric aspirate
- Haematochezia or malaena
- Systemic illness – lethargy
- Hypotonia
- Apne – plain abdominal X-Ray shows gaseous bowel distension or presence of gas within the bowel wall (pneumatosis intestinalis).
B. Grade 2 (Worse Prognosis)
In addition to features of Grade 1, cases also have:
- Abdominal tenderness and rigidity (evidence of perforation)
- abnormal or spontaneous bleeding,
- Shock
- Leucopenia
- Thrombocytopaenia
- Pneumomediastinum or portal vein gas.
Investigations.
- Full blood count
- Plain abdominal X-Ray.
- Random Blood Glucose
- Serum electrolytes, urea and creatinine
- Blood culture
Management of necrotizing enterocolitis
The baby should be put on Nil per Os (NPO) while Total Parenteral Nutrition (TPN) is instituted.
In the alternative, intravenous fluid therapy can be used to meet the maintenance fluid, caloric and electrolyte requirements.
Abdominal girth should be monitored as progressive increment may indicate intestinal perforation.
Insert a nasogastric tube to decompress the stomach and for regular aspiration.
Antibiotics are administered
intravenously: a triple regimen of
- cephalosporin (ceftriaxone, cefotaxime or ceftazidime-100mg/kg/day),
- gentamicin 5mg/kg/day (or kanamycin) and
- metronidazole 7mg/kg 8 hourly.
Serial plain abdominal X-Ray (supine and right lateral) is useful in monitoring the progress of the disease.
Thrombocytopaenia and deranged coagulation profile should be corrected with the appropriate blood product available.
Shock is managed using crystalloids or colloids and inotropes.
Urinary output must be monitored to confirm the success of anti-shock therapy.
If diagnosis is confirmed (with X-Ray findings), antibiotics and nil per os are continued for 7-10 days but if diagnosis remains unconfirmed and baby recovers quickly, gradual oral feeds may be reintroduced after 48 hours while antibiotic therapy continues for 5 days.
Surgery is indicated by
- clinical deterioration
- intestinal perforation
Follow-up Care should anticipate strictures presenting with intestinal obstruction.