Necrotizing enterocolitis

Background

• Abbreviation: NEC
• Intestinal necrosis in previously well infant
• Typically presents in 1st week of life, with case reports to 6 months in children that are chronically ill.
• Predominantly affects preemies; 10-15% occurs in full-term patients
• Bacterial overgrowth in bowel, translocation of bacteria into bowel wall, subsequent bacterial endotoxin and gas production

Clinical Features

• Poor feeding, lethargy, abdominal distention/tenderness
• Sepsis, pneumoperitoneum

Differential Diagnosis

Pediatric Abdominal Pain

0–3 Months Old

• Emergent
  • Necrotizing Enterocolitis
  • Volvulus
  • Testicular torsion
  • Inguinal hernia
    • Incarcerated hernia
  • Trauma
  • Pyloric stenosis
  • Toxic megacolon
  • Hirschsprung's Disease
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Colic

3 mo–3 y old

• Emergent
  • Intussusception
  • Testicular Torsion
  • Trauma
  • Volvulus
  • Appendicitis
  • Toxic megacolon
  • Vaso-occlusive crisis
• Nonemergent
  • Acute Gastroenteritis
  • Constipation
  • Urinary tract infection
  • Henoch-Schonlein purpura

3 y old–adolescence

• Emergent
  • Appendicitis
  • DKA
  • Vaso-occlusive crisis
  • Toxic ingestion
  • Testicular Torsion
  • Ovarian Torsion
  • Ectopic Pregnancy
  • Trauma
  • Toxic megacolon
  • Inflammatory bowel disease
  • Gastric ulcer disease
  • Ovarian cyst
  • Pregnancy
  • Pancreatitis
  • Cholecystitis
  • Intussusception (to age 6)
• Nonemergent
  • Constipation
  • Acute Gastroenteritis
  • Nonspecific viral syndrome
  • Streptococcus pharyngitis
  • Urinary tract infection
  • Pneumonia
  • Renal Stone
  • Henoch-Schonlein purpura
  • Inflammatory bowel disease
  • Vulvovaginitis

Evaluation

Neonate with necrotizing enterocolitis.

Left: KUB with pneumatosis intestinalis (large arrow) a specific finding in necrotizing enterocolitis. Right: follow-up film showing free air indicating bowel perforation (small arrow).

Work-Up

• CBC
• Chem
• Sepsis evaluation
• Coags
• Stool +/- heme positive

Radiography

• Pneumatosis on XR is hallmark
  • Get KUB in supine position and left lat decubitus
• Ultrasound
  • Pseudo-kidney sign - bowel wall with hyperechoic center and hypoechoic rim
  • Assess for gas bubbles in liver and portal veins

Management

1. NPO
2. Aggressive IV hydration
3. Ampicillin + gentamicin + clindamycin
4. Surgery consult

Disposition

• Admit

See Also

• Abdominal pain (peds)