NECROTIZING ENTEROCOLITIS

Atan Baas Sinuhaji

Department of Childhealth,School of Medicine,University of North Sumatera

Medan

•Affects 0.5 to 1 per 1000 live births

•Incidence 3-10% in infants < 1500 g

•Incidence increase with decreasing birthweigh and

Necrotising Enterocolitis (NEC)

•Incidence increase with decreasing birthweigh and gestational age

•Usually affects terminal ileum and colon to a variable extent

•NEC rarely occus before the initiation of enteral feeding

Incidence of NEC related to gestational age

6

8

10

%

no IUGR IUGR

0

2

4

26 27 28 29 30 31 32 33 34 35 36 >37

gestational age

%

NECROTIZING ENTEROCOLITIS

An Acute Intestinal Necrosis Syndrome Resulting From Complex Interaction :

= Gut Ischemia= Poor Mucosal Integrity= Microbial Infection= Enteral Nutrition= Enteral Nutrition

MUCOSAL INJURY

INTESTINAL PERFORATION

Loss of barrier function

Immaturity

Mucosal disruption

Milk feeds

Ischaemia

Bacterial translocation

Macromolecular absorption

Mucosal damage NEC

ToxinsBacterial overgrowth

Viruses

Bacteria

Mucus

ors

enterocyt

Goblet cell

nucleus

ENTERAL FEEDING

1.PROVIDES SUBSTRATE FOR PROLIFERATION OF ENTERAL PATHOGENS

2.HYPEROSMOLAR FORMULA MUCOSAL DAMAGE2.HYPEROSMOLAR FORMULA MUCOSAL DAMAGE

3.LACK OF IMMUNOPROTECTIVE FACTORS

4.AGGRESSIVE ENTERAL FEEDING

5.BREASTFEEDING LOWERS THE RISK OF NEC

•Usually occurs in the first two weeks of life

•Child is lethargic and apathetic with vomiting and increasing

abdominal distension

Necrotising Enterocolitis (NEC)Clinical features

abdominal distension

•Bloody diarrhoea is a late feature

•Progression may be rapid from to mild to severe after 72 hours

•Abdominal examination may show peritonitis or a mass

Abdominal x-ray may show

� Distended bowel with mucosa edema

� Intramural gas ( = pneumatosis intestinalis )� Intramural gas ( = pneumatosis intestinalis )

� Portal venous gas or free intraperitoneal gas

Abdominal x-ray

AA

Abdominal x-ray

Treatment

� A. Medical No definitive treatment

� B. Surgical

1. Perforation

2.Fixed dilated loop on serial x-ray

3.Abdominal wall cellulitis

4.Progressive deterioration despite maximal medical support

Medical

� 1.Preventing futher injurya. Cessation of feedingb. Decompressionc. IntraVenous Fluid Drip ( IVFD )c. IntraVenous Fluid Drip ( IVFD )

� 2.Supportivea. Respiration status b. Coagulation profilec. Electrolyte and Acid base balanced. Antibiotics

PREVENTION

1. EXCLUSIVELY BREAST-FED1. EXCLUSIVELY BREAST-FED

2. MINIMAL ENTERAL FEEDS FOLLOWED BY JUDICIOUS VOLUME ADVANCEMENT

3. PROBIOTIC