A. Antibiotics should be given.
B. May present with Pneumatosis Intestinalis.
C. Principal indication of surgery is Necrotic Intestine.
D. All of the above.
Ans:D. All of the above.
- Typically occurs in the second to third week of life in premature, formula-fed infants, is characterized by variable damage to the intestinal tract, ranging from mucosal injury to full-thickness necrosis and perforation.
- NEC affects close to 10% of infants who weigh less than 1500 g, with mortality rates of 50% or more depending on severity, but may also occur in term and near-term babies.
Presentation may be subtle and can include 1 or more of the following:
- Delayed gastric emptying
- Abdominal distention, abdominal tenderness, or both
- Ileus/decreased bowel sounds
- Abdominal wall erythema (advanced stages)
Systemic signs can include any of the following:
- Respiratory failure
- Decreased peripheral perfusion
- Circulatory collapse.
- Radiographic features
- Plain radiograph
- Supine abdominal x-rays are the mainstay of diagnosis. If NEC is suspected clinically, or there is concern on supine films, then an additional cross-table lateral or left-lateral decubitus film should be obtained :
- dilated bowel loops (often asymmetrical in distribution)
- loss of the normal polygonal gas shape
- bowel wall oedema with thumb printing
- pneumatosis intestinalis (intramural gas)
- portal venous gas
- pneumoperitoneum secondary to perforation
- air on both sides of the bowel (Rigler sign)
- air outlining the falciform ligament (football sign)
- bowel wall thickening
- alteration of vascular state
- hypervascular (viable but engorged in early stage)
- hypovascular (infarcted in later stage)
intramural gas manifesting as hyperechoic foci within the bowel wall
free fluid, especially with echogenic debris, is suspicious for perforation
- Grossly, the affected segment of the bowel is dilated, necrotic, haemorrhagic and friable. Bowel wall may contain bubbles of air (pneumatosis intestinalis).
- Microscopically: initial changes are confined to mucosa and show oedema, haemorrhage and coagulative necrosis.
- A pseudomembrane composed of necrotic epithelium, fibrin and inflammatory cells may develop.
- As the ischaemic process extends to the subjacent layers, muscle layer is also involved and may lead to perforation and peritonitis.
- The initial course of treatment consists of the following:
- Stop enteral feedings
- Perform nasogastric decompression
- Initiate broad-spectrum antibiotics (eg, ampicillin, gentamicin, and clindamycin or metronidazole).
- The principal indication for operative intervention in NEC is perforated or necrotic intestine, which is most compellingly predicted by pneumoperitoneum. Other indications include the following:
- Erythema in the abdominal wall
- Gas in the portal vein
- Positive paracentesis
- Clinical deterioration