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PubMed2002

An outbreak of necrotizing enterocolitis associated with a novel clostridium species in a neonatal intensive care unit.

An outbreak of necrotizing enterocolitis (NEC) occurred in 6 neonates within a 2-month period. Blood cultures from 3 of these neonates grew the same strain of what appears to be a novel clostridial species for which the name "Clostridium neonatale" has been proposed. A point-prevalence survey that used rectal swabs was performed in our intensive-care and intermediate-care nurseries, and it indicated that 20.8% of neonates carried this same "C. neonatale" strain despite having no evidence of NEC. In conclusion, we describe an outbreak of NEC associated with the novel species, and we suggest that, in larger neonates, carriage of this type of Clostridium species may be a necessary step in the multistage pathogenesis of NEC.

Clostridium↗
PubMed1994

Problems of ileostomy in necrotizing enterocolitis.

Exteriorization of the intestine and resection of the gangrenous bowel are major therapeutic regimens for necrotizing enterocolitis (NEC). Ileostomy associated complications are well known, therefore the time of ileostomy closure is a matter for discussion. Between 1975 and 1992, 84 patients with NEC were treated surgically. Ileostomies were performed in 37 children (44%). Of these 37 neonates, 9 (7M, 2F) died. In the remaining 28 patients (16M, 12F) with a mean gestational age of 35.8 weeks and a mean birth weight of 2412 g, ileostomies were performed between the 2nd and 11th days after birth. On average, the stomies were in function for 91 days, and within this period the average weekly weight gain was 153 g. Nineteen patients of this group did not show any problems attributable to the ileostomy. In 9 patients (32%) complications occurred, requiring a preplanned closure of the stoma. Postinflammatory strictures of bowel were diagnosed in 9 patients and resection of the stenotic intestine was performed at the same time as stoma closure. In conclusion, an appropriate weight gain can be achieved in patients with an ileostomy with an adequate feeding regimen. In otherwise uncomplicated cases, ileostomy closure can be delayed by up to 10 weeks when simultaneous surgical correction of additional intestinal strictures is possible. In one-third of patients with an ileostomy, however, complications may occur and urge a preplanned closure of the stoma.

Enterocolitis, Pseudomembranous↗
PubMed1975

Neonatal necrotizing enterocolitis. Occurrence secondary to thrombosis of abdominal aorta following umbilical arterial catheterization.

A patient had neonatal necrotizing enterocolitis (NNE), secondary to aortic thrombosis following umbilical arterial catheterization. The thrombus occluded the ostium of the inferior mesenteric artery. A review of cases reported in the literature with complications following umbilical arterial catheterization revealed four instances of NNE or NNE-like lesions due to thrombosis of the abdominal aorta or one of its major branches. Thrombosis of the aorta, with occlusion of one or more of its major abdominal branches following umbilical arterial catheterization, should be considered as a potential etiologic factor in certain cases of NNE.

Adult↗
PubMed1983

Necrotizing enterocolitis--a 5-year experience.

With the increased survival of very-low-birth-weight neonates, necrotizing enterocolitis (NEC) represents one of the most frequent life-threatening conditions for this population. NEC was diagnosed on 24 occasions during a 5-year period (1977-81) at the Neonatal Intensive Care Unit, Kaplan Hospital, Rehovot. These 24 NEC cases, confirmed by radiological, surgical or pathological findings, were analyzed in a retrospective study. The mean weight was 1,450 g and the mean gestational age 32 weeks. Only one of the affected infants was a full-term newborn. The mean age at onset of symptoms was 9.8 days. In one case, NEC developed before feedings were started. The infectious agents--most frequently gram-negative rods--were isolated from the most seriously ill babies. Cultures from blood and gastric aspirate were positive in 10 of the 12 fatal cases. No bacteria were isolated from the blood among the survivors. Rotavirus, the only viral particle detected, was diagnosed in the bloody stools of two of the infants who recovered completely. Prophylactic therapy with oral kanamycin, administered to all premature infants weighing less than 1,500 g born over a 3-year period, did not appear to have a preventive influence. The overall mortality was 50%, with no sequelae observed among survivors. The high incidence of positive cultures among fatal cases suggests that overwhelming infection played a fundamental role in the outcome.

Enterocolitis, Pseudomembranous↗
PubMed1982

Age at onset of necrotizing enterocolitis. Risk factors in small infants.

We compared the features of 45 infants with early-onset necrotizing enterocolitis (NEC) (in the first ten days of life) and 41 infants with late-onset NEC (after the tenth day of life); all weighed 1,500 g or less at birth. Infants with late-onset NEC were smaller at birth and had younger gestational ages than infants with early-onset illness. No significant differences between the two groups, however, were found in sex or race distribution, mean one- and five-minute Apgar scores, or in the relative frequency of occurrence of 30 maternal and neonatal risk factors. Intravenous alimentation was administered significantly more frequently to infants with late-onset NEC. Birth weight-specific weekly attack rates for NEC declined dramatically when infants reached the equivalent of 35 to 36 weeks' gestational age. We hypothesize that the timing of noxious events in relation to gut maturity may explain these observations.

Age Factors↗
PubMed1978

The radiology of neonatal necrotizing enterocolitis (NEC). A review of 47 cases and the literature.

The radiological findings in 47 neonates with necrotizing enterocolitis (NEC) are reviewed. The presence of nonspecific, generalized bowel dilatation is stressed as being an important sign in early diagnosis and the progress of the distribution of the dilated loops is important in evaluating progress of the disease process. It is thus the key to the radiology of NEC. Intramural gas and portal venous gas are not always related to the severity of the disease and their disappearance is not always related to clinical improvement. These signs are therefore poor prognostic indicators. Important radiological indications for surgery besides free intraperitoneal gas and free fluid include: 1. diminished bowel gas with asymmetric loops, and 2. persistent dilated loops. Because of the number of colonic strictures seen at our hospital we advise routine barium enemas (several weeks after the acute phase) in all infants who have had NEC. Following bowel resection contrast studies of both distal and proximal remaining bowel are essential to exclude further stricture formation prior to final reanastomosis.

Enterocolitis, Pseudomembranous↗
PubMed1991

Peri-cholecystic hyper-echogenicities in necrotizing enterocolitis: a specific sonographic sign?

The authors report a new sonographic pattern found in association with neonatal necrotizing enterocolitis in 5 newborns: hyperechogenicities around the gallbladder. The pattern probably corresponds to extension of the disease to the perivesicular space. The most probable hypothesis for that extension is diffusion by contiguity through the lesser sac and/or the right gutter. The hyperechogenicities could be related to the foamy infiltrate typical of NEC. Air within the pericholecystic vascular system similar to portal air could be another (less probable) explanation.

Enterocolitis, Pseudomembranous↗
PubMed1986

Per anal balloon dilatation of a post-necrotizing enterocolitis stricture of the sigmoid colon.

Per anal balloon dilatation of a sigmoid colon stricture caused by necrotizing enterocolitis allowed identification of a more proximal lesion which would otherwise have gone radiographically undetected. Repeated dilatations at two weeks and four weeks following the initial dilatation of the stricture resulted in relief of the stricture and obviated the need for surgical treatment of this lesion.

Angioplasty, Balloon↗
PubMed1990

A 13-year experience with peritoneal drainage under local anesthesia for necrotizing enterocolitis perforation.

Between 1974 and 1986, inclusive, over 400 newborns with clinical, radiological, and/or pathological evidence of necrotizing enterocolitis (NEC) were treated at the Hospital for Sick Children, Toronto, Ontario. Within this group were 37 babies who had a bowel perforation that was treated with peritoneal drainage under local anesthesia. Eighty-eight percent of the 41 weighed less than 1,500 g and 65% weighed less than 1,000 g; during the same time 40 other neonates (9% of the total) with perforated NEC had laparotomies. Twelve neonates (32%) required only drainage with complete recovery of their intestinal tracts. The remaining 25 (68%) fell into one of three groups: (1) nine (24%) had rapid downhill course, sepsis, and death without laparotomy; (2) nine (24%) had rapid downhill course, sepsis, and laparotomy (five deaths); (3) seven (20%) had slow development of bowel obstruction requiring operation (two deaths). The overall survival rate was 56%. These results continue to indicate that this method is effective in temporizing 88% of the small and/or very ill babies with a NEC perforation. However, an added bonus is that 32% of these newborns treated in this fashion had complete resolution of their disease.

Anesthesia, Local↗
PubMed1982

A prospective evaluation of intestinal stenosis following necrotizing enterocolitis.

In a retrospective study, we noted a 25% incidence of colonic stenosis following medical management of necrotizing enterocolitis (NEC). From March, 1980 to March, 1982, we performed routine contrast enemas to prospectively identify the incidence of colonic stenosis following medical management for NEC. Three to four weeks following recovery from the acute phase of NEC 28 infants were prospectively evaluated by contrast enema for post-NEC stenosis. Ten of the 28 infants had one or more sites of colonic stenosis (36%). Four infants were symptomatic when the contrast enema was performed and underwent colonic resection. Three of the six asymptomatic infants developed symptoms requiring surgery within 33 days following hospital discharge. Therefore, seven of the ten infants with post-NEC stenosis required segmental colectomy. Three patients with colonic stenosis have remained asymptomatic and are being followed on an outpatient basis. The weight gain in these three infants has been steady and has paralleled a normal growth curve. The data from this study demonstrate that: (1) the incidence of post-NEC colonic stenosis is 36%; (2) patients with colonic stenosis initially may not have symptoms but may become symptomatic after hospital discharge; (3) the sites of stenosis frequently are located in the left colon; and (4) normal weight gain can occur despite the presence of colonic stenosis. Because of the above findings, we recommend routine contrast enemas in all patients with NEC who have had successful medical management.

Barium Sulfate↗
PubMed1988

Resection with primary anastomosis for necrotizing enterocolitis: a contrasting view.

Resection with primary anastomosis is currently being advocated for treatment of infants with necrotizing enterocolitis. To determine whether our own data would support such an approach, we reviewed retrospectively our experience with this disease since 1974. Since that time, 173 infants have been admitted for treatment of advanced (surgical) disease in its acute phase, of whom 143 underwent resection for cure; the remainder either underwent laparotomy with decompression (3), laparotomy with drainage (3), laparotomy alone (14), died at operation (1), or could not be resuscitated sufficiently to withstand operation (9). Excluded were patients who underwent operative repair of late stricture (6), all of whom survived with no morbidity. Among those resected for cure, 27 infants were carefully selected by the operating surgeon for treatment by means of resection with primary anastomosis, based on the limited and apparently discrete nature of their disease; in three the procedure was combined with a decompressing enterostomy. In the majority of cases (14), the disease was found to involve multiple areas of intestine, but was limited to a particular anatomic region, usually distal ileum and/or ascending colon; in the remainder, it was due to discrete ileal or jejunal perforation or ulcer. Overall survival among those resected for cure was 65% (96/143). It was 48% (13/27) among those treated by means of resection with primary anastomosis but 72% (83/116) among those who underwent resection with enterostomy. However, if the early years of the series (1974 to 1976) are excluded, a time when resection with enterostomy had not yet become established as standard therapy, overall survival was 77% (77/100), 64% (9/14) among those anastomosed primarily.

Colon↗
PubMedDate not supplied

Risk factors for developing and dying from necrotizing enterocolitis.

A case-control study was performed to identify risk factors for developing and dying from necrotizing enterocolitis (NEC). Eighty-six infants observed at The Johns Hopkins Hospital who had clinical and/or pathological evidence of this disease during the past 10 years were studied. Birth weight matched autopsied control infants without NEC were also studied for comparison with the autopsied infants who died with NEC. Patients with NEC had a mean birth weight of 1,620 +/- 198 g, and those who died from NEC had even lower birth weights (1,418 +/- 109 g). The development of NEC was correlated with significantly higher frequencies of oral feeding (p less than 0.005) and septicemia (p less than 0.001). Death with NEC was correlated with earlier onset and more extensive disease (both p less than 0.05), hypotension (p less than 0.001), septicemia (p less than 0.001), persistent respiratory distress (p less than 0.05), a patent ductus arteriosus (p less than 0.05), and lower 5-min Apgar scores (p less than 0.05). These findings suggest that NEC is caused by overwhelming hypotensive/ischemic injury to the intestines in association with enterosepticemia. Intestinal immaturity and oral feedings appear to be important predisposing factors in this condition.

Apgar Score↗
PubMed1993

A fatal case of necrotizing enterocolitis in a neonate with polyagglutination of red blood cells.

An infant of 30 weeks gestation developed necrotizing enterocolitis (NEC) 8 days after birth and died 2 days later after a fulminating course. During her illness she received two blood transfusions, both of which produced sub-optimal rises in her haemoglobin and were associated with evidence of haemolysis. Retrospective analysis demonstrated T antigen (Tk) polyagglutination of the infant's red blood cells and donor plasma. Although bacterial cultures were negative throughout the course of the illness in this case, T antigen exposure is associated with certain anaerobic infections and with severity of NEC. Infants with NEC should be regularly screened for T antigen exposure and if this test is positive, plasma (immunoglobulin) containing infusions should be avoided.

Blood Component Transfusion↗
PubMed1994

Interdisciplinary treatment of necrotizing enterocolitis and spontaneous intestinal perforations in preterm infants.

From January 1986 to December 1992, 13 patients with necrotizing enterocolitis (NEC) (Grade II-III; Bell) were treated. The incidence was highest in the very immature infants with birth weight < 1000 g: 6/148 (4%). From onset, NEC was associated with clinical symptoms such as abdominal distension, bloody stools, retained gastric contents and septicemia. Indications of inflammation were seen in only 6 out of 13 patients at the time of diagnosis. No complications were seen in 10 patients during the acute phase. Two infants developed a bowel perforation and another one a gangrene. Immediate surgery was performed. In three other infants, elective surgery was performed because of colonic strictures. Twelve (92%) patients survived NEC. Five other VLBW infants developed spontaneous perforations of the bowel. The clinical presentation, laboratory and radiological findings differed greatly from those with NEC. Four infants survived. A primarily conservative therapeutic regime with close cooperation between the surgeon and pediatrician may be an alternative to early surgical intervention in NEC.

Enterocolitis, Pseudomembranous↗
PubMed1997

Gut hormone concentrations in preterm infants with necrotizing enterocolitis.

Blood levels of gastrin, neurotensin and vasoactive peptide (VIP) were estimated in 14 premature infants with necrotizing enterocolitis (NEC) and in 12 controls. In comparison to the control group, infants with NEC had (a) significantly lower gastrin levels both before [9.3 (7.8) versus 33.7 (27.1)] and after [52.4 (48.1) versus 100.8 (50.9)] the development of NEC; (b) significantly lower neurotensin levels only after the development of NEC [37.8 (10.4) versus 54.5 (20.6)1; and (c) no significant difference in VIP values [25.4 (9.7) versus 18.9 (9.9) and 24.5 (15.7) versus 26.1 (19.1)]. It is concluded that NEC can adversely affect gastrin and neurotensin concentrations in the blood.

Enterocolitis, Pseudomembranous↗
PubMed1981

Abdominal and hepatic uptake of 99mTc-pyrophosphate in neonatal necrotizing enterocolitis.

Abdominal 99mTc-pyrophosphate (99mTc-PYP) scans were obtained in 15 neonates: 12 with neonatal necrotizing enterocolitis (NEC), two with osteomyelitis, and one with myocarditis. Ten of the babies with NEC had at least one positive scan; of these 10 studies, seven (Group A) showed both diffuse abdominal uptake and localized hepatic activity, two (Group B) showed abdominal uptake and questionable hepatic uptake, and one (Group C) demonstrated diffuse abdominal uptake only. The other two babies with NEC had normal scans (Group D). Pneumatosis intestinalis was unquestionably present in two patients from Group A and one from Group B. Upon resolution of the clinical findings, all NEC patients had normal scans. A patient with myocarditis had hepatic uptake of 99mTC-PYP while the abdominal scan in the two infants with osteomyelitis was normal. These preliminary observations suggest that further study of a relationship between abdominal scan findings and the course of NEC is warranted.

Abdomen↗
PubMedDate not supplied

Necrotizing enterocolitis: feeding in endemic and epidemic periods.

Aggressive feeding practices are thought to increase the incidence of necrotizing enterocolitis (NEC). Detailed feeding histories of the 39 cases occurring between January 1, 1984 and May 31, 1985 were compared with matched controls. The study period included a cluster (epidemic) of 11 cases diagnosed within 1 month. Data were analyzed collectively and separately for endemic and epidemic cases. Collectively, cases had greater average daily intake volume, maximum daily intake volume, intake volume on the day prior to diagnosis, and maximum daily caloric intake (all p less than 0.05) than controls. The only recorded parameter that differed in endemic cases vs controls was intake the day prior to diagnosis. In contrast, epidemic cases were fed significantly more volume, more calories, and faster than controls: average intake volume (62.5 +/- 27.2 vs 37.4 +/- 18.0 ml/kg/day); maximum intake volume (118.5 +/- 33.5 vs 76.4 +/- 38.8 ml/kg/day); intake day prior to diagnosis (109.8 +/- 30.9 vs 63.8 +/- 43.1 ml/kg/day); maximum daily increment (42.6 +/- 16.7 vs 26.7 +/- 16.4 ml/kg); maximum caloric intake (126.1 +/- 44.6 vs 77.3 +/- 50.0) (all p less than 0.01). Five of the feeding parameters were significantly less for the epidemic controls than the endemic controls, suggesting a general slowing of feeding during the NEC epidemic. In summary, the data suggest feeding patterns may have an impact on NEC especially during epidemic periods.

Breast Feeding↗
PubMed1998

Enteric defensin expression in necrotizing enterocolitis.

Immaturity of local innate defenses has been suggested as a factor involved in the pathophysiology of necrotizing enterocolitis (NEC). The mRNA of enteric human defensins 5 (HD5) and 6 (HD6), antibiotic peptides expressed in Paneth cells of the small intestine, have significantly lower levels of expression in fetal life compared with the term newborn and adult. In the current study, intracellular HD5 was demonstrated by immunohistochemistry at 24 wk of gestation, but at low levels, consistent with findings at the mRNA level. These data suggest that the low level enteric defensin expression, characteristic of normal intestinal development, may contribute to the immaturity of local defense, which predisposes the premature infant to NEC. To test if levels of defensin expression are altered in NEC, specimens from six cases of patients with NEC and five control subjects (four patients with atresia and one with meconium ileus) were analyzed to determine HD5 and HD6 mRNA levels by in situ hybridization. Compared with the control group, the level of enteric defensin expression per Paneth cell assessed by image analysis was increased 3-fold in cases of NEC (p = 0.02, analysis of variance and covariance). In addition, the number of Paneth cells was increased 2-fold in the small intestinal crypts of NEC specimens compared with those of control subjects (p < 0.01, covariance analysis). In healthy tissue, peptide levels within Paneth cells paralleled mRNA levels through development. In tissue from infants with NEC, the steady state level of intracellular peptide was not increased in conjunction with the observed rise in defensin mRNA. A straightforward interpretation of this finding is that HD5 is actively secreted in this setting and the Paneth cells maintain a constant steady state level of intracellular peptide, but the possibility of translational regulation of peptide expression is also consistent with these data. The associations between NEC and enteric defensin expression reported here offer support for future studies to address the role of these endogenous host defense factors in the pathophysiology of this disease.

Adult↗