NECROTIZING ENTEROCOLITIS

Atan Baas SinuhajiDepartment of Childhealth,School of Medicine,University of North SumateraMedanNECROTIZING ENTEROCOLITISAffects 0.5 to 1 per 1000 live birthsIncidence 3-10% in infants < 1500 gIncidence 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 feedingNecrotising Enterocolitis (NEC)

NECROTIZING ENTEROCOLITISAn Acute Intestinal Necrosis Syndrome Resulting From Complex Interaction : = Gut Ischemia = Poor Mucosal Integrity = Microbial Infection = Enteral Nutrition MUCOSAL INJURY

INTESTINAL PERFORATIONLoss of barrier functionImmaturityMucosal disruptionBacterial translocationMacromolecular absorptionMucosal damageNECMilk feedsIschaemiaToxinsBacterial overgrowthVirusesenterocytGoblet cellnucleusBacteriaMucusors

6bacterial factorsimmunological factorsepithelial factorsbacterial factorsimmunological factorsepithelial factorsBacterialEpithelialImmunological factorsENTERAL FEEDING 1.PROVIDES SUBSTRATE FOR PROLIFERATION OF ENTERAL PATHOGENS 2.HYPEROSMOLAR FORMULA MUCOSAL DAMAGE 3.LACK OF IMMUNOPROTECTIVE FACTORS 4.AGGRESSIVE ENTERAL FEEDING 5.BREASTFEEDING LOWERS THE RISK OF NECUsually occurs in the first two weeks of life Child is lethargic and apathetic with vomiting and increasing abdominal distensionBloody diarrhoea is a late featureProgression may be rapid from to mild to severe after 72 hours Abdominal examination may show peritonitis or a mass

Necrotising Enterocolitis (NEC)Clinical features

9Abdominal x-ray may showDistended bowel with mucosa edemaIntramural gas ( = pneumatosis intestinalis )Portal venous gas or free intraperitoneal gasAbdominal x-ray

AA

Abdominal x-ray

TreatmentA. 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 Medical1.Preventing futher injury a. Cessation of feeding b. Decompression c. IntraVenous Fluid Drip ( IVFD )2.Supportive a. Respiration status b. Coagulation profile c. Electrolyte and Acid base balance d. Antibiotics

PREVENTION1. EXCLUSIVELY BREAST-FED2. MINIMAL ENTERAL FEEDS FOLLOWED BY JUDICIOUS VOLUME ADVANCEMENT 3. PROBIOTIC