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PubMed1986

Necrotizing enterocolitis: incidence, operative care, and outcome.

At Jefferson Davis Hospital, the incidence of necrotizing enterocolitis (NEC) was three per 1,000 live births, and 30 per 1,000 low birth weight births. The occurrence of NEC was sporadic and no epidemics occurred. NEC occurred most frequently in infants weighing between 750 and 1,500 g, and the smaller infant with NEC was more likely to require surgical intervention. As the survival of small birth weight infants improved over the 4 years of the study, the patient population developing NEC became smaller. The age at operation also increased in the period between 1982 and 1984. Those infants who developed NEC after 30 days of age typically had more extensive disease and a less favorable prognosis. In this series, 31% of infants with acute NEC required surgical intervention. An additional 11% of those infants treated nonoperatively eventually required surgical intervention for late sequelae of NEC. The overall survival of infants with NEC was 75%. While the survival of all infants operated for NEC was 68%, the survival for those with the acute syndrome was 63% and those operated on for late sequelae was 87%. Primary anastomosis in selected patients did not adversely affect mortality and simplified the postoperative care of these infants with severe complications. Indeed, enterostomy closure in an infant who had previously had NEC was an extensive procedure that carried significant risk. Our results indicated that the trained pediatric surgeon could predict at the operating table which infants could safely undergo resection and anastomosis and that, with experience, the percent undergoing primary anastomosis increased to approximately 50%.

Enterocolitis, Pseudomembranous↗
PubMed1990

The hidden mortality in surgically treated necrotizing enterocolitis: fungal sepsis.

From 1979 to 1986, 82 infants underwent surgical treatment for necrotizing enterocolitis (NEC), with 36 deaths. The records of 30 of the 36 infants who died were available for review. Fungal colonization and sepsis, the sites of infection, and timing of diagnosis and therapy were determined. Sixteen of 30 (53%) neonates had no evidence of fungus. Six (20%) were colonized with Candida species. Eight (27%) had fungal sepsis, with two of these eight found only at necropsy. Positive fungal blood cultures were a late finding. In only four of the six patients with positive blood cultures were the results known in time to initiate treatment with amphotericin B. Two of these four babies received less than 2 days of amphotericin B treatment prior to death. Fungal sepsis is a significant lethal factor in the surgical mortality of NEC. Vigorous efforts at earlier diagnosis are mandatory.

Enterocolitis, Pseudomembranous↗
PubMed1992

Sonographic findings in infants with suspected necrotizing enterocolitis.

During a three-year period, 27 infants with clinical signs of necrotizing enterocolitis (NEC) underwent ultrasonography; 22 of these infants also had abdominal radiographs within a few hours. Sonographically, portal venous gas (PVG) was seen in 10 and intestinal pneumatosis without PVG in 8 infants. Six children underwent laparotomy within 24 hours after ultrasonography and showed evidence of recent NEC. Three other children, laparotomized weeks later were found to have intestinal strictures as signs of previous NEC. None of the patients died from NEC. Nine infants without abnormal gas distribution did not develop overt NEC. With respect to PVG, sonography is able to support the tentative diagnosis of NEC prior to radiography. However, absence of PVG does not exclude NEC.

Enterocolitis, Pseudomembranous↗
PubMed1982

Necrotizing enterocolitis in the unfed infant.

From 1974 to 1981, 139 infants with neonatal necrotizing enterocolitis (NEC) were treated at our institution. Fourteen of these infants had not been fed prior to development of NEC. The unfed infants who developed intestinal necrosis had lower birth weights, were less mature, and had lower Apgar scores. The incidence of respiratory distress syndrome (RDS) and perinatal asphyxia were significantly higher in the entire unfed group. Unfed infants generally had longstanding indwelling umbilical artery catheters. Pneumatosis intestinalis was not often seen in unfed infants, even in those who developed intestinal necrosis and perforation. Anatomic location of the disease as determined at surgery was sometimes atypical. The pathologic lesion present in the intestine of the unfed infant suggested a primarily, if not purely, ischemic etiology.

Catheters, Indwelling↗
PubMed1983

Necrotizing enterocolitis in the asphyxiated full-term infant.

Five full term infants with necrotizing enterocolitis, confirmed histologically, presented in the first five days of life. All passed grossly bloody stools and three mucosal casts. Severe perinatal asphyxia with accompanying secondary hyperammonemia was present in all, and abnormal liver function studies were present in three. An awareness of the clinical characteristics of these infants may lead to their early identification and conservative management.

Ammonia↗
PubMed1991

Changing trends in necrotizing enterocolitis. Experience with 302 cases in two decades.

Three hundred two infants with necrotizing enterocolitis (NEC) were treated from 1972 to 1990. One hundred eighteen were treated medically while 184 infants required operation. Comparisons were made between two treatment periods, 1972 to 1982 (n = 176) and 1983 to 1990 (n = 126). Infants in the more recent era were of lower birth weight (1505 +/- 853 g versus 1645 +/- 836 g), earlier gestational age (30.4 +/- 4.7 weeks versus 32.4.5 weeks; [p less than 0.01]), had symptom onset at an older age (15.7 +/- 13.9 days versus 10.0 +/- 10.8 days; [p less than 0.001]), and a lower incidence of hyaline membrane disease (p less than 0.001). Fewer patients in the 1983 to 1990 group had acidosis (p less than 0.001) and severe oliguria (p less than 0.001). Operation was performed sooner after diagnosis in the second group (2.6 versus 3.8 days; [p less than 0.001]). Survival was unaffected by sex, maternal complications, or whether infants were inborn or transferred from other facilities. Improved survival (1983 to 1990) was observed in those infants between 24 to 27 weeks gestation (p less than 0.002) and those weighing less than 1000 g (p less than 0.001). Since 1983 portal vein air (PVA) on abdominal radiographs was used as an indicator for operation. Survival in infants with PVA has improved from 29% to 64% (p less than 0.02). Despite patients being more immature and weighing less, the overall survival rate improved from 58% (1972 to 1982) to 82% (1983 to 1990) (p less than 0.001). Operative survival rate improved from 51% to 75% (p less than 0.002). Long-term survival was 75% overall and 65% for surgical infants in the 1983 to 1990 group (p less than 0.05).

Birth Weight↗
PubMed1985

Enteric colonization in sporadic neonatal necrotizing enterocolitis.

Microflora of the gut was studied close to the onset of sporadic necrotizing enterocolitis (NEC) in neonates. Enteric flora in 25 babies with NEC differed from that in 23 matched controls. Bacteroides spp and lactobacilli were less common in babies with NEC compared with controls: 32 versus 61% (p = 0.03) and 12 versus 48% (p = 0.006), respectively. Clostridium perfringens was isolated from 40% of babies with NEC compared with 13% of controls (p = 0.03). It was present in 33% of babies with NEC aged less than 14 days but was not detected in control babies of the same age. The incidences of C. butyricum and C. difficile were similar in patients and controls. Colonization with C. perfringens in the absence of a protective barrier flora may be crucial in the pathogenesis of severe sudden onset NEC. Two potentially valuable marker factors to predict onset of this form of sporadic NEC are the use of fecal smears and estimation of fecal tryptic activity.

Bacteroides↗
PubMed1987

Necrotizing enterocolitis: a 15-year experience.

Eighty-seven infants (0.13% of livebirths) developed necrotizing enterocolitis (NEC) during a 15-year period at the Mercy Maternity Hospital, Melbourne. The disease was associated with 23 deaths, representing a mortality rate of 26.4% and comprising 2.6% of all neonatal deaths. The incidence of NEC increased from 0.07% of all livebirths for the years 1971-1974 to 0.25% for the 19-month period from January, 1984 to July, 1985. The mean age at onset was 9.9 days with an inverse relationship between birth-weight and age of onset of the disease. The mothers of the infants who developed NEC belonged to a significantly higher risk obstetric population; gestational diabetes was identified in 3 of 28 mothers (10.6%) having glucose tolerance tested, and 1 other patients was a known diabetic. Subnormal oestriol excretion was detected in 15 of 45 patients tested, treble the overall hospital incidence. Of the 87 infants, 26 (29.9%) were VLBW (birth-weight less than 1,500 g), 5 were term (5.7%) and 9 (10.3%) were small for gestational age. The mean gestational age was 34.7 weeks and mean birth-weight was 1,988 g. Sixty-seven (77%) infants received medical treatment alone and 20 (23%) also received surgical treatment. Sequelae which developed in survivors were colonic strictures (4), fistulas (2) and the short-gut syndrome (1).

Apgar Score↗
PubMed1994

Psychosocial and psychomotoric development of very low birthweight infants with necrotizing enterocolitis.

UNLABELLED: Twenty-six very low birthweight infants (VLBI) were treated for necrotizing enterocolitis (NEC). We investigated their consecutive health problems and psychosocial development. METHOD: One to 13 years after onset of NEC, follow-up studies were performed in 12 of the surviving children. Identical follow-up studies were performed in 6 VLBI who had been operated on for diseases other than NEC (control group). We used a detailed interview, a Denver test and a drawing test. RESULTS: Five children of the NEC group had major persistent health problems that impaired their psychomotoric and psychosocial development (including hearing impairment, concomitant strabismus, early onset bronchial asthma). Nine of 12 VLBI of the NEC group showed signs of reduced social contact, logopaedic problems and minimal partial skill reductions. CONCLUSION: We found similar results in both children who suffered from NEC and in a small control group of VLBI who had not suffered from NEC, therefore impaired psychomotoric and psychosocial development is probably due to prematurity.

Child↗
PubMed1977

Neonatal necrotizing enterocolitis: 2. Perinatal risk factors.

Forty-four infants were diagnosed as having necrotizing enterocolitis (NEC) during a 33 months' period; these represented 4% of all neonatal admissions. An increase in incidence was observed during this period, particularly in low-birth-weight infants weighing under 1,500 g. Perinatal risk factors occurring in infants preceding their onset of NEC are found also to be significantly more common in infants under 1,500 g compared with those between 1,500 and 2,499 g. When the incidence of these clinically associated conditions in infants with NEC are compared with the incidence in infants who did not have NEC in the same birth weight category, a difference can be demonstrated only in 4 out of the 23 analysed: prolonged rupture of membranes with amnionitis; birth asphyxia; hypertonic milk feeds; exchange transfusion. As NEC is possibly a disease of multifactorial aetiology, a multivariant analysis of the data is indicated to define the role of combined perinatal risk factors in the pathogenesis of this disease.

Asphyxia Neonatorum↗
PubMed1975

Acute necrotizing enterocolitis in infancy: a review of 64 cases.

Sixty-four cases of necrotizing enterocolitis are reviewed. The diagnosis was based on tissue examination in 57 and on the clinical syndrome, including pneumatosis, in 7. Three factors are important in the development of the disease: injury to the intestinal mucosa, bacteria, and feedings. The indications for surgical intervention are pneumoperitoneum, signs of peritonitis, and intestinal obstruction. The importance of stress in the etiology of the disease is confirmed by the high incidence of perinatal complications, particularly hypoxia. The mortality was high, but results are improving with the institution of early aggressive treatment.

Birth Weight↗
PubMed1989

[Frequency of neonatal necrotizing enterocolitis at a pediatric hospital].

A revision study of 322 cases of neonatal necrotizing enterocolitis (NEC) in a six year period at a pediatric hospital is presented. The frequency of NEC was 7.2% of the newborn (NB) admitted to the hospital. Fifty two percent corresponded to grade I on Bell's classification, 37% to grade II and 11% to grade III. Most of the cases were seen in at term newborn (51.3%) even though the proportional frequency in relation to the admissions was 38% in at term newborn and 62% in premature. The main clinical manifestations were abdominal distention, vomiting, and blood in feces. The frequency and intensity of other clinical signs as well as other signs as acidosis, anemia, hyponatremia and hypoprothrombinemia were directly proportional to the severity of the NEC. The radiological data of portal pneumatosis were more frequent in grade III NEC, and several cases of gastric pneumatosis were seen in the grade II NEC. Thirty four patients (10.6%) underwent surgery. The global mortality was 29.5% and in those who underwent surgery 79.4%.

Cross Infection↗
PubMed1980

Neonatal necrotizing enterocolitis associated with penicillin-resistant, toxigenic Clostridium butyricum.

The cause of neonatal necrotizing enterocolitis (NEC) is unknown. An association between NEC and clostridial infection has been reported from several centers, but the organisms have not been extensively characterized. Clostridium butyricum was isolated from the peritoneal fluid and cerebrospinal fluid of a neonate with NEC. The organism was resistant to the penicillins, but sensitive to vancomycin. Toxin production was demonstrated. Although the role of clostridial toxins in the pathogenesis of NEC is unknown, clostridial toxins are well established as the causes of two other intestinal diseases (antibiotic-associated pseudomembranous colitis and pig-bel). Further investigation of the role of clostridia in the pathogenesis of NEC and of the use of oral, nonabsorbable antibiotics in the treatment of NEC is needed.

Bacterial Toxins↗
PubMed1995

[Necrotizing enterocolitis: a 10-year survey].

We reviewed the records of all infants with necrotizing enterocolitis (NEC) who had been diagnosed in "Teresa Herrera" Hospital in La Coruña between 1984 and 1994. We tried to determine the risk factors that could influence at the beginning of the disease, the clinic presentation, and the basic aspects of treatment. All cases of ECN with clinic-radiologic confirmation were examined (Bell stages II and III). With this approach, a general questionnaire containing records, clinical presentation, and treatment, was applied to all cases. In our revision, we found that neonate most at risk is that one with an average gestational age of 35 weeks, a mean weight of 2500 gr., with a laborious delivery and who was admitted in the neonatal intensive care unit for an important disease. The onset of NEC was more frequent in the first 15 days of life, and clinical and radiological features were used to confirm the disease. In 86% of the cases, oral feeding had begun. Surgery was needed in 36% of the cases, of which 86% suffered from gut perforation, terminal ileum being the most frequent localization. The general mortality was 12%. Only one of the operated patient died. We conclude that in the appearance of NEC there are a lot of influential factors, including perinatal stress, prematurity and a low birth weight. Clinical symptoms are haemodynamic instability, abdominal distension and bloody stools, obtaining confirmation through radiology in 87%. We consider the importance of early diagnosis and treatment and exhaustive observation by children's surgeon to indicate early surgery.

Birth Weight↗
PubMed1993

[Risk factors of necrotizing enterocolitis].

The purpose of the present study is to compare risk factors of necrotizing enterocolitis (NEC) between two group: group A, newborns with the disease and group B, newborns with other diseases different from NEC, in order to know if these risk factors are more frequent or not in the first group. We assessed the clinical records of all the patients hospitalized in the Neonatal Intensive Care Unit and Neonatology Service of the La Raza General Hospital between 1987 and 1991 with the diagnosis of NEC. They were compared with 65 clinical records chosen at random of patients hospitalized in the same Unit with other diagnosis at the same time, and who were discharged by improvement or deceased. In all of them were look for known risk factors for NEC generally accepted such as: prematurity, neonatal asphyxia, poliglobulia, cyanotic congenital heart disease, patent ductus arteriosus, respiratory distress syndrome, catheterization of umbilical vessels, early feeding of elevated formula increases, exchange exchange transfusion, hypoxic ischemic encephalopathy, infection, etc. Just 25 records of the possible 50 with the diagnosis of NEC full filled inclusion criteria. There were no statistically significant difference in weight, sex, mortality and known risk factors of NEC between both groups. Were concluded that NEC is a disease of unknown etiology that should be studied more thoroughly. The known risk factors must be avoided because the patient susceptibility probably play an important role.

Enterocolitis, Pseudomembranous↗
PubMed1994

Surgical procedures in colonic strictures after necrotizing enterocolitis.

Between 1982 and 1992, 22 patients were treated with colonic strictures in the course of necrotizing enterocolitis (NEC). Fourteen newborns in whom a primary enterostomy and, when necessary, resection of necrotic bowel was performed developed strictures in the diverted colon. The strictures were detected by colon contrast enema study performed on average 3 months after the first intervention. Eight additional children suffered from an ileus due to primary strictures after conservatively treated NEC, which was surgically managed by enterostomy. Closure of the enterostomy and resection of the stenotic part of the colon was performed thereafter in all 22 children as a single stage procedure. There was no insufficiency of the anastomosis nor any late stricture at follow-up 2.7 years after NEC in our patients. It is concluded therefore that reanastomosis of the enterostomy and resection of an intestinal stricture can be performed as a single stage procedure without any risk after an interval of 3 months between onset of acute NEC and reevaluation. During this interval, a close monitoring and an appropriate management of adequate supplement of electrolytes and bicarbonates is necessary. Most of our babies could be nursed at home and showed a good weight gain during this period, despite the enterostomy.

Anastomosis, Surgical↗
PubMed1993

Risk factors associated with fungal peritonitis in very low birth weight neonates with severe necrotizing enterocolitis: a case-control study.

Fungal peritonitis is uncommon in infants with severe necrotizing enterocolitis with intestinal perforation. In our institution we noted a significant (P < 0.01) increase in fungal peritonitis from 7% (3 of 45 cases of peritonitis) from January, 1980, to June, 1989, to 35% (8 of 23 cases of peritonitis) from July, 1989, to December, 1991. The mean birth weight of 11 infants with fungal peritonitis (946 +/- 70 g) (mean +/- SE) was significantly less (P = 0.008) than that of 57 infants with bacterial peritonitis (1282 +/- 52 g). In a case-control study to identify risk factors associated with fungal peritonitis, 11 infants with bacterial peritonitis were matched to the 11 infants with fungal peritonitis by age at bowel perforation and birth weight. Infants with fungal compared with bacterial peritonitis had significantly longer (P < 0.05): median duration of umbilical vessel catheterization before bowel perforation, 10 vs. 3 days, respectively; median duration of antibiotic therapy before bowel perforation, 23 vs. 14 days, respectively; and median duration of intubation, 13 vs. 5 days, respectively. Other potential risk factors that were not significant in this study included duration of central venous catheterization, total parenteral nutrition, intravenous lipid administration, aminoglycoside use, dexamethasone use or methyl xanthine therapy. In summary fungal peritonitis in neonates with necrotizing enteritis was significantly related to extremely low birth weight, prolonged umbilical vessel catheterization, prolonged exposure to antibiotics and prolonged intubation.

Bacterial Infections↗
PubMed2005

Necrotizing enterocolitis: assessment of bowel viability with color doppler US.

PURPOSE: To determine whether absence of bowel wall perfusion at color Doppler ultrasonography (US) is indicative of bowel necrosis in neonates with necrotizing enterocolitis (NEC). MATERIALS AND METHODS: This study was approved by the research ethics board, and informed consent was obtained. Sixty-two neonates enrolled in the prospective study underwent US of the bowel wall. Neonates were divided into two groups. Group A included 30 control subjects with gestational ages (GAs) ranging from 24 to 41 weeks. Group B included 32 neonates with GAs ranging from 24 to 40 weeks who were clinically proved to have or suspected of having NEC. All neonates in group B underwent abdominal radiography. Normative values were calculated in group A. In group B, the sensitivities and specificities of color Doppler US and abdominal radiography for detection of bowel necrosis were computed by using the modified Bell staging criteria for NEC as the reference standard. RESULTS: Two neonates were excluded from group B; thus, a total of 60 neonates were included in the study. In group A, bowel wall thickness ranged from 1.1 to 2.6 mm. Bowel wall perfusion was detected with color Doppler US in all 30 neonates. Color Doppler signals ranged from one to nine dots per square centimeter. Twenty-two of 30 neonates in group B received a diagnosis of NEC. Mild to moderate NEC was diagnosed in 12 neonates. Color Doppler US depicted an isolated segment of bowel-absent blood flow in two neonates; this finding was confirmed with laparotomy. In 10 neonates with severe NEC, color Doppler US depicted isolated or multiple segments of bowel with absent perfusion. Pneumoperitoneum was present in only four neonates. The remaining eight neonates at risk for NEC had no evidence of loops without perfusion at color Doppler US. The sensitivity of free air at abdominal radiography as a positive sign for severe NEC with necrotic bowel was 40% compared with the 100% sensitivity of absence of flow at color Doppler US (P = .03). CONCLUSION: Color Doppler US is more accurate than abdominal radiography in depicting bowel necrosis in NEC.

Enterocolitis, Necrotizing↗