Necrotizing Enterocolitis

Necrotizing Enterocolitis also known as NEC is a condition most commonly found in babies having a premature birth. The disease is characterized by the tissue death (necrosis) of the bowels or intestinal tract in infants. However the disease develops after the baby has been born, it is not found in stillborn children. Due to a tremendous amounts of deaths in infants occurring due to it, it is now ranked as the second most common factor/disease responsible for the mortality of infants born prematurely. Taking a look at some statistics now, this disease was responsible for 472 infant deaths in the United States in year 2010 and took 386 tiny lives in 2011.

Hematochezia and Necrotizing Enterocolitis

Necrotizing enterocolitis, a common gastrointestinal problem in infants is also a major cause of Hematochezia in infants. Hematochezia (passing of blood in stool from the rectum) in infants basically results from swallowing the mother’s blood at the time of delivery, however it may also be an initial indicator of Necrotizing enterocolitis. According to research the condition is more prevalent in babies who are fed concentrated formula milk. It causes the intestinal lining to reduce its production of mucous. Mucous is an essential lubricating agent in bowel movement and without it the intestinal lining becomes dry and eventually falls off resulting in necrosis.

Signs and Symptoms of NEC

The onset of Necrotizing enterocolitis occurs primarily during the first 3-4 weeks of the baby’s birth. In some cases, symptoms may present themselves as early as 1-3 days, the latest cases reported have been babies who are almost a month old. The gestational age of the baby’s birth has been reported to be inversely proportional to the onset of the disease.

Some initial symptoms are:

• Severe vomiting
• Development of diarrhea
• Delays in emptying of the gastrointestinal tract
• Distention/ Tenderness in the abdominal region
• Onset of Ileus
• Hematochezia i.e. passing of blood in the stool
• Feeding intolerance and problems
• Lethargy and lack of active energy
• Instability in the body’s temperature

Advanced stages may include:

• Erythema of the intestinal/ abdominal walls
• Cardiovascular failure
• Respiratory and circulatory failure
• Visible and palpable development of abdominal masses which sometimes may take the shape of intestinal loops

Diagnosis of NEC

The diagnosis is usually done on suspect basis, if there are concerns of NEC being present you can obtain laboratory tests or radiography tests to support your diagnosis

Laboratory studies may include

• WBC count
• Platelet count
• Hemoglobin and Hematocrit levels; Extensive blood loss due to Hematochezia results in decreased levels of hematocrit and increased levels of hemoglobin production
• A negative blood culture test may result

Abdominal Radiography findings may include

• Abnormal patterns of gas production
• Dilated bowel loops may be present
• The bowel walls may have a thickened appearance
• If there is an absence or scarcity of intestinal gas then it may be sure sign of Necrotizing enterocolitis.

Bell’s stages of NEC are associated with radiographic results;

1. Stage 1; The disease is suspected only

• Mild systemic indications of the disease such as fluctuating body temperature
• Mild gastrointestinal indications such as mild abdominal distention or blood in the stools
• No specific results from radiology

2. Stage 2 ; The disease is definitely present

• The systemic signs might be slightly more aggravated than the mild ones
• Tenderness in the abdominal region and there might be an absence of bowel sounds
• Specific results from radiology such as pneumatosis intestinalis

3. Stage 3 ; The disease is in advanced stages and requires specific medical attention

• Severe abdominal distresses such as hypotension and peritonitis
• Acidosis( both metabolic and respiratory)
• Intravascular coagulation

Abdominal Ultrasonography is the best method for recognition of the disease, the best thing about it is that it is noninvasive and is an excellent method for identification of any ascites if they may be present. A gasless abdomen or the presence of intestinal loops are common indicators which can be identified using ultrasonography.

Treatment of NEC

General treatment methods include:

• Putting a stop to enteral feedings ; the baby should be fed with intervals
• Nasogastric decompression will need to be performed in some cases which involves the insertion of a tube into the gastric/alimentary canal and removal of gases through it.
• Administration of antibiotics is usually done for the Bell’s stages of the disease
• Administration of IV fluids and the baby should be totally fed on parenteral nutrition
• For advanced stages of the disease, cardiovascular or respiratory support must be provided, Ventilator support may be considered
• In extreme cases, surgical intervention may become necessary.

The surgical procedure involves the removal of any dead tissue that might be present in the bowel. A colostomy or ileostomy may need to be performed. After a period of 3-4 weeks it would be safer to reconnect the bowels after all signs of infection have vanished and the intestinal tract is healed.

Preventive Measures

Surely prevention is better than cure and this disease can be prevented too.  This can be done through hyper alimentation and oral feeds both. According to research, practices of feeding of human milk in preterm infants should be adopted. This would decrease the chance of NEC developing in the babies. Infants should be fed with milk containing high lipid and fat content. Pediatric Research shows that adopting this method for very low birth infants resulted in no infants developing NEC. Mother’s milk is the best choice of feed, but if it’s not available, milk from a donor milk bank can also be utilized.

Prognosis

Surgical intervention usually develops in some kind of complication. These may include Intestinal perforation or stricture, sepsis or the onset of infection. Some bad cases may result in Peritonitis. It usually takes about 10-14 days to recuperate from surgery. Long term effects such as bowel obstruction or lack of blood may also occur. Short bowel Syndrome may be a long term complication as well. But despite all these negative factors rates of survival in infants undergoing surgery have improved by 70-80% and the mortality rate is dropping from the 1 in 4 deaths in infants suffering from NEC.

References

https://emedicine.medscape.com/article/977956-overview

https://www.nlm.nih.gov/medlineplus/ency/article/001148.htm