NECROTIZING ENTEROCOLITIS (NEC): IS A GASTROINTESTINAL DISEASE THAT IS FOUND PRIMARILY IN PREMATURE INFANTS, ALTHOUGH IT CAN OCCUR IN FULL-TERM INFANTS AS WELL. AN INFECTION OR INFLAMMATION CAUSES THE DESTRUCTION OF ALL OR PART OF THE BOWEL (SMALL INTESTINE) OF THE BABY. THIS IS A SERIOUS CONDITION THAT REQUIRES CARE FROM YOUR BABY'S DOCTOR. ALMOST ALL BABIES AT RISK FOR NEC ARE ALREADY HOSPITALIZED IN A NEONATAL INTENSIVE CARE UNIT (NICU) AND UNDER CLOSE OBSERVATION DUE TO THEIR SMALL SIZE.MOST COMMON GASTROINTESTINAL MEDICAL AND/OR SURGICAL EMERGENCY OCCURRING IN NEONATES

CAUSES:

No exact cause is known for NEC. The bowel and intestine of a premature baby is not fully developed, and may not be able to handle the stress of food moving through them. A decrease in oxygen or blood flow to the intestines may cause damage, allowing bacteria to enter through the wall , leading to infection and inflammation. This can damage the strength of the intestinal tissue. If the bacteria remain long enough, they can make a hole in the wall of the intestine. NEC is most often found in premature, very low-birthweight babies.NEC usually occurs in the first two weeks of life, but can occur as late as three months of age.NEC usually occurs soon after you have started feeding your baby.

CLINICAL FEATURES:

If your baby experiences any of these symptoms, do not assume it is due to NEC. The symptoms of NEC are very similar to other, less serious, digestive conditions. Every baby experiences the symptoms of NEC differently. The symptoms may include:

Difficulty feeding Feedings stay in baby's stomach longer than

expected A sudden increase in bowel movements, or lack of

bowel movements Bowel movements may be bloody Baby doesn't pass a lot of gas Baby's belly may be bloated, tender to the touch,

or red Vomit may be greenish in color Baby shows general signs of infection, such as:

Initial symptoms may be subtle and can include the following Feeding intolerance Delayed gastric emptying Abdominal distention and/or tenderness Ileus/decreased bowel soundsStopping

breathing or difficulty breathing Low heart rate Sluggishness Vomiting Temperature instability Cool, clammy skin

Incidence and age at onset:

more common in premature infants But can also be seen in term babiesInversely related to birth weight and gestational ageTerm infants develop NEC earlier after birth than preemies Average age of onset occurs within first week of lifeAffected term neonates are usually systemically ill with other conditions such as birth asphyxia, respiratory distress or congenital heart diseasePremature babies are at risk for several weeks after birthBabies who are breastfed have a lower incidence of NEC than formula-fed babiesMor

Imaging findings:

Acute disease most commonly affects the terminal ileumPlain film of the abdomen remains method in which disease is diagnosed most oftenFindings include Dilated loops of bowelThickened bowel walls Fixed and dilated loop that persists is especially worrisomeAbsence of bowel gasPneumatosis intestinalis Pathognomonic of NEC in newborn Linear radiolucency parallels bowel lumen within bowel wallRepresents air that has entered from the lumen

How is NEC managed? Medical management consists of

stopping feeds, nasogastric drainage to suction (tube in baby’s stomach to "suck out" contents), 7-14 days of antibiotics and IV nutrition. Close monitoring of fluid status, electrolytes, coagulation and oxygen requirements are also necessary. 60-80% of babies with NEC are managed medically and symptoms resolve without surgery. Feedings postoperatively are started slowly.

What if surgery is needed? Surgery is necessary if medical management

fails or the bowel is perforated (torn). After opening the abdomen, the surgeon may find a swollen, purple bowel with areas of necrosed(dead) bowel. The usual areas involved are the terminal ileum, Cecum and right colon but the whole bowel may be involved. The goal is to remove only that bowel that is fully necrosed(dead) and to leave any marginal areas in the hope that they will survive. This may require an ostomy and/or another operation within 24-48 hours to evaluate any surviving bowel. The nutritional outcome is roughly based on the remaining intestinal length and the medical and surgical team will discuss this with you.

Distended and shiny abdomen

Editor :Abdul fatah abro Aga khan university hospital Karachi(N.I.C.U)