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PubMed1990

Necrotizing enterocolitis in term neonates.

Necrotizing enterocolitis (NEC) is usually a disease of premature infants, but occasionally it affects the term neonate. A 5-year review of NEC at Children's Hospital and Medical Center identified the unique features of this disease in the term neonate. Eighty-one patients with NEC were treated between January 1984 and May 1989. Ten full-term neonates with gestational age greater than 38 weeks were identified for study. Charts were reviewed for recognized risk factors, clinical course, surgical intervention, and outcome. Ninety percent had a birth weight greater than or equal to 2.7 kg, and all were above 2.1 kg. NEC developed early in this group, with onset of disease in the first 48 hours of life in 50% of the group and within the first 4 days of life in 90%. The recognized risk factors of asphyxia, hypoglycemia, polycythemia, and respiratory distress were absent in 60%. Seven of 10 patients required exploratory laparotomy, whereas 3 of 10 required only medical treatment. Indications for operation were perforation in three patients, peritonitis in three patients, and mass in one patient. All patients requiring operations had severe colonic disease, with perforation of the colon in five of seven and full-thickness necrosis without perforation in two of seven. Two patients required total abdominal colectomy. Only one patient with perforated meconium ileus and associated NEC had small bowel involvement. This patient was the only mortality of the group. Subsequent intestinal continuity was restored in all surviving patients with no late complications. Two patients required resection of additional NEC strictures prior to reanastomosis. Of the three medically treated patients, none required subsequent operation for colonic stricture. Our experience indicates that the presentation, clinical course, and operative findings in full-term neonates with NEC differ from those encountered in the premature infant with NEC.

Birth Weight↗
PubMed1979

Epidemiologic and bacteriologic evaluation of neonatal necrotizing enterocolitis.

The incidence of necrotizing enterocolitis (NEC) in our neonatal unit has varied from 4.7% to zero to 4.4% during three time periods. Simultaneously, significant changes have occurred in the spectrum of bacterial species in the gastrointestinal tract of unaffected infants in the same unit. During the first period of increased attack rate, 82% of gastric and 88% of fecal Enterobacteriaceae were E. coli and K. pneumoniae. When the attack rate decreased the frequencies were 11% (gastric) and 47% (fecal), and P. mirabilis was retrieved with increased frequency. The return of E. coli and K. pneumoniae as the dominant organisms was associated with an increase in NEC. Infants with NEC, compared with controls, had a statistically significant increased frequency of retrieval of E. coli and K. pneumoniae from gastric and fecal samplings. The data suggest an active role for certain enteric bacteria in the pathogenesis of NEC.

Enterocolitis, Pseudomembranous↗
PubMed1983

An outbreak of rotavirus-associated neonatal necrotizing enterocolitis.

An outbreak of necrotizing enterocolitis and hemorrhagic gastroenteritis occurred in two nurseries during 25 days in August 1982. Eleven of the 40 patients in these nurseries during that time developed disease (attack rate 27.5%). In seven of the 10 patients with gastrointestinal disease, stool samples tested for human rotavirus were positive by ELISA, whereas in 20 unaffected infants, no stools tested demonstrated HRV (P = 0.0001). Eleven staff members had serologic evidence of recent HRV infection. Comparison of risk factors traditionally associated with the development of NEC between the affected and unaffected infants revealed no significant differences. Rotavirus infection was the only finding that was highly correlated with this epidemic.

Cross Infection↗
PubMed1996

[Increasing frequency and diagnostic difficulties in intestinal stenosis after necrotizing enterocolitis].

BACKGROUND: Stenosis after necrotizing enterocolitis (NEC) has increased from 15 to 57% over the last 10 years in our unit. The aim of this study is to point out the difficulty of diagnosis and treatment, and search for factors explaining this increase. PATIENTS AND METHODS: From 1986 to 1991, 42 newborns had NEC, followed by intestinal strictures in 19 of them (57% of the 33 survivors). Data from these 19 patients were compared with those of the 14 without intestinal strictures. The 33 survivors were also compared with those of an earlier study including 25 NEC seen from 1979 to 1986. RESULTS: After medical treatment (n = 12), intestinal stenosis led to occlusion after three weeks, was located to both small and large intestine and was short and tight. After surgical treatment (n = 7), stenosis was shown by opacification before digestive anastomosis (n = 5) or revealed by occlusion (n = 2); it stayed on the colon, was long or multiple, requiring extensive resections. No difference could be found between data from patients with or without stenosis. Although newborns were actually more premature, the risk of stenosis was more frequent when newborns of same gestational ages and/or weights were compared. CONCLUSIONS: Intestinal stenosis is a frequent complication after NEC; its diagnosis is often difficult and requires extensive digestive resections. No clinical or therapeutic factor could be found to explain the actual increase in frequency.

Birth Weight↗
PubMed1987

Comparison of two antibiotic regimens for neonatal necrotizing enterocolitis.

Treatment of neonatal necrotizing enterocolitis (NEC) regularly includes broad-spectrum antibiotics but there has been no comparative study of alternative regimens. We have studied 90 infants with definite NEC; 46 cases in 1982-3 were treated with ampicillin and gentamicin, while 44 cases in 1984-5 received cefotaxime and vancomycin. Groups were well matched and managed uniformly. Infants greater than or equal to 2200 g birthweight did well with either regimen. Smaller infants given cefotaxime and vancomycin had a lower risk of culture-positive peritonitis (P = 0.01), and as a result, were less likely to die (P = 0.048) or develop thrombocytopenia (P = 0.004). The better outcome might be explained by the greater suppression by cefotaxime and vancomycin of the gut flora of treated patients (P less than 0.001). Both regimens were well-tolerated. Our data suggest that carefully chosen antibiotic regimens can improve the outcome of NEC.

Ampicillin↗
PubMed1990

Risk factors for late-onset necrotizing enterocolitis.

The etiology of necrotizing enterocolitis (NEC) is unknown. We conducted a retrospective, case-controlled study of 23 infants hospitalized during a five-year period who developed NEC after the 11th day of life (late-onset NEC). We evaluated 58 different factors among the case and control populations to determine if there were any statistically significant differences between the two populations. Our data showed a statistically significant association between the occurrence of NEC and the use of ventilatory support (both mechanical ventilation and nasopharyngeal continuous positive airway pressure (NPCPAP)), the transpyloric (TP) feeding route and the addition of glucose polymers to feeds.

Case-Control Studies↗
PubMed1989

Necrotizing enterocolitis of the neonate.

Necrotizing enterocolitis is the most common gastrointestinal emergency in the newborn. The syndrome strikes premature infants during the first 2 weeks of life. Abdominal distention, lethargy, and feeding intolerance are early signs of NEC that may progress to gastrointestinal bleeding and hemodynamic instability. The radiographic hallmark of NEC is pneumatosis intestinalis (air in the bowel wall). The ileum and colon are the usual sites of crepitant intestinal necrosis, leading frequently to perforation. In spite of appropriate medical therapy, about half of the infants with NEC develop intestinal gangrene or perforation and require surgery, consisting of bowel resection and enterostomy formation. The most common late complication, intestinal stricture, occurs in 15 to 35 per cent of recovered infants. Overall mortality from NEC ranges from 20 to 40 per cent. The etiology of NEC is poorly understood and is considered to be multifactorial, related to ischemia, bacterial colonization, and formula feedings in a susceptible infant. Future progress in the treatment of NEC may be achieved by earlier detection of necrosis, modification of gastrointestinal flora, or by bolstering the deficient gastrointestinal immune mechanisms of the premature neonate.

Enterocolitis, Pseudomembranous↗
PubMed1977

The surgical management of neonatal necrotizing enterocolitis.

Twelve infants with necrotizing enterocolitis were treated surgically in the 2 year period from 1973 to 1974. Resection of gangrenous intestine and proximal enterostomy was preferred in 11 patients. There were four deaths: two were grossly premature infants, one died from electrolyte disturbances related to the proximal enterostomy, and one was an apparent cot death. Intravenous nutrition was used routinely in all cases in the postoperative period. The problems of recommencement of enteral feeding and ileostomy dysfunction are discussed briefly.

Enterocolitis, Pseudomembranous↗
PubMed1994

The role of the circulation in the pathogenesis of necrotizing enterocolitis.

Early descriptions of necrotizing enterocolitis (NEC) proposed gut ischemia as a primary factor in pathogenesis. Subsequent laboratory and clinical investigations have failed to support these theories, relegating most to positions of historical significance. Presently, the role of the circulation in the pathogenesis of NEC is unclear; however, several lines of ongoing investigation have begun to provide novel insight into the means by which circulatory aberration may initiate or contribute to the development of bowel necrosis.

Animals↗
PubMed1993

Neonatal necrotizing enterocolitis an epidemiological study.

Necrotizing enterocolitis (NEC) was diagnosed in 77 infants among 2200 admissions to the NICU during the period January 1986 to September 1990. The incidence was 0.5% of all live births and 3.5% of NICU admissions. Majority (57.1%) had Stage I of the disease while 23.4% had Stage II and 19.5% had Stage III of the disease. The average birth weight of the babies was 1650 +/- 577 g and gestational age 33.3 +/- 2.6 weeks. Majority (53.2%) were very low birth weight (VLBW) babies. Incidence was significantly more (5.7% vs 0.25%, p < 0.001) in VLBW infants and in preterm infants of gestational age less than 32 weeks (5.2% vs 0.09%, p < 0.001). Multiple risk factors were present in these babies while 8 babies did not have any risk factor. Risk of developing NEC was significantly more if infants had any of these risk factor (p < 0.001). Incidence of severe birth asphyxia was more in Stage I cases (35.7% vs 10.3%, p < 0.05). The age at presentation was 4.9 +/- 4.8 days and majority (96%) presented during the first 14 days. The overall survival was 61% and was 70.5, 77.8 and 13.3% in Stages I, II and III, respectively. VLBW and preterm infants had a higher mortality.

Age Factors↗
PubMed1993

Neonatal necrotizing enterocolitis: a clinical study.

Necrotizing enterocolitis was found in 77 infants over a 5 year period. Diagnosis of NEC was established on 4.9 + 4.8 days in babies with birth weight of 1667 + 577 grams and the gestational age of 33.3 + 2.6 weeks. Definite disease occurred in 33 (42.9%) babies while there was strong suspicion in another 44 (57.1%) babies. Prefeed gastric residue (98.7%), abdominal distension (97.3%), lethargy (78.7%), hypotonia (60%) and jaundice (48%) were the main presenting features. However, blood in stools and abdominal wall erythema were found in 38.7% babies. About one third of infants had a positive blood culture. Pneumatosis intestinalis was present in 83.9% of babies and pneumoperitoneum was seen in 35.5% of neonates with NEC. Ileo-ceco-colic region was the commonest site of involvement. Overall survival was 61% and survival with Stage III was only 13%. Birth weight less than 1500 g, gestational age less than 32 weeks, erythema of the abdominal wall, intra-abdominal mass, portal venous gas in abdominal X-ray and Gram negative septicemia were associated with higher mortality.

Age of Onset↗
PubMed2006

Laparoscopy as an adjunct to peritoneal drainage in perforated necrotizing enterocolitis.

Intestinal perforation in very low birth weight infants with necrotizing enterocolitis has a high morbidity and mortality. We report the use of laparoscopy on day 30 of life in the treatment of a very low birth weight infant (900 g) with perforated necrotizing enterocolitis. The question of laparotomy versus peritoneal drain is ongoing. Laparoscopy may have a major role to play in the answer to this debate. The versatility of laparoscopy enables good visualization of the bowel and organs: a drain can be placed in a port site if there is no fecal contamination and a more conservative approach is warranted, or a conversion to a laparotomy can be undertaken if there are obvious feces or necrotic bowel. We feel that laparoscopy in the initial evaluation of necrotizing enterocolitis is invaluable, and can avoid potentially unnecessary surgery in an already extremely unwell infant.

Combined Modality Therapy↗
PubMed2006

Doppler flow velocimetry in the superior mesenteric artery on the first day of life in preterm infants and the risk of neonatal necrotizing enterocolitis.

OBJECTIVE: The purpose of this work was to relate Doppler indices of splanchnic perfusion and vascular resistance to the risk of developing necrotizing enterocolitis. METHODS: We conducted a prospective cohort study with analysis of Doppler flow velocity waveforms of splanchnic vessels on the first day of life. Clinical management and diagnosis of necrotizing enterocolitis were performed blind to the Doppler results in a tertiary NICU on 64 eligible preterm neonates admitted for intensive care. We measured necrotizing enterocolitis using an objective diagnostic classification. RESULTS: When adjusted for gestational age at birth, the following indices of the Doppler flow velocity wave form in the superior mesenteric artery were significantly predictive of the risk of necrotizing enterocolitis: end-diastolic velocity, mean velocity, and pulsatility index. The association between necrotizing enterocolitis and Doppler velocimetry indicative of high vascular resistance was independent of a range of other factors and comorbidities (race, mode of delivery, umbilical arterial catheter, growth restriction, patent ductus arteriosus, jaundice, respiratory distress syndrome, mechanical ventilation, and hypotension). CONCLUSIONS: We concluded that neonates with high resistance patterns of blood flow velocity in the superior mesenteric artery on the first day of life are at increased risk of developing necrotizing enterocolitis.

Enterocolitis, Necrotizing↗
PubMed2005

Spontaneous liver hemorrhage during laparotomy for necrotizing enterocolitis: a potential role for recombinant factor VIIa.

Necrotizing enterocolitis remains a serious condition in very low birth weight infants, particularly in those infants who require surgery. Perioperative hemorrhage is a potentially fatal complication in this population. We describe our experience in 4 premature infants with necrotizing enterocolitis who received recombinant factor VIIa to manage life-threatening intraoperative hemorrhage.

Enterocolitis, Necrotizing↗
PubMed1986

T-cryptantigen exposure in neonatal necrotizing enterocolitis.

Sixty-two infants with necrotizing enterocolitis were prospectively evaluated for evidence of the Thomson-Friedenreich cryptantigen (TCA) on their red cell surfaces. The TCA is exposed when bacterially derived neuraminidase acts on the surface of the red cells, cleaving off the N-acetylneuraminic acid, which hides the antigen. Seventeen patients (27%) had red cell TCA exposure as demonstrated by agglutination of their red cells by peanut lectin. This test is a simple agglutination procedure, which can be easily performed and yields results in a matter of minutes. Patients with TCA exposure require surgery 76% of the time compared with 18% of the time of those who did not demonstrate this phenomenon, a highly significant difference (P less than .01). All patients strongly positive for TCA exposure had intestinal perforations found at laparotomy. Patients with TCA exposure had clostridia cultured from blood, peritoneal fluid, or stool in 88% of the cases. Isolation of Clostridium perfringens was highly associated with strong TCA exposure and advanced disease. Since naturally occurring anti-TCA is found in normal adult plasma, hemolysis was observed in TCA-exposed patients who received plasma-containing blood products. The presence of TCA exposure in babies with necrotizing enterocolitis had prognostic and therapeutic implications. It indicates the need for antibiotic coverage against anaerobic organisms, strict avoidance of plasma-containing blood products, and the use of washed blood products if the patient is to be transfused. It also alerts the surgeon to the possibility of early operative intervention.

Agglutination Tests↗
PubMed1979

Neonatal necrotizing enterocolitis: implications for an infectious disease.

There is a broad spectrum of presentations and severity of necrotizing enterocolitis. Because it may have several different causes, ncerotizing enterocolitis may be a syndrome rather than a specific disease. The triad of formula feeding, intestinal ischemia, and bacterial growth may be part of the pathogenesis of necrotizing enterocolitis. Bacteria are of central importance for the production of pneumatosis, a prerequisite of which is formula feeding. Bacteria may also contribute to the intestinal injury seen after ischemia. However, the disease in the low risk patient seen during an epidemic associated with a single organism is probably caused by a primary gastrointestinal infection. On the other hand, in the stressed newborn infant with mucosal injury the presence of the appropriate bacteria may be all that is needed to initiate the chain of events leading to necrotizing enterocolitis. Figure 2 illustrates the importance of bacteria in all the causes proposed to be involved in the pathogenesis of necrotizing enterocolitis. Whether bacteria are primary or secondary agents, necrotizing enterocolitis should always be approached therapeutically as an infectious disease.

Bacterial Infections↗
PubMed2001

Does exposure to magnesium sulfate in utero decrease the risk of necrotizing enterocolitis in premature infants?

BACKGROUND: The objective of this study is to assess whether antenatal exposure to magnesium sulfate may decrease the risk of necrotizing enterocolitis in preterm infants. METHODS: We have compared the rate of magnesium sulfate exposure before birth among 23 consecutive infants diagnosed with necrotizing enterocolitis with that of 46 controls matched by gestational age at delivery and gender. Relevant obstetric and neonatal variables were compared between the two groups using chi-square and Fisher's exact test for categorical data, and one-way analysis of variance for continuous variables, with a two-tailed p-value <0.05 considered significant. RESULTS: No significant differences were present between the two groups in mode of delivery (p=0.9), rate of Apgar score at five minutes below seven (p=0.4), prenatal exposure to indocin (p=0.5) or steroids (p=0.6), or neonatal administration of surfactant (p=0.1). Similar proportions of babies with necrotizing enterocolitis and controls were diagnosed with respiratory distress syndrome (p=0.5), intraventricular hemorrhage grades three or four (p=0.9), and sepsis (p=0.6). Babies with necrotizing enterocolitis had a significantly longer hospital stay (74.6+/-64.0 vs. 41.9+/-37.0 days, p=0.01) and intubation period (31.4+/-24.1 vs. 16.8+/-15.6 days, p=0.01) than controls. The rates of prenatal exposure to magnesium sulfate were similar in the necrotizing enterocolitis and control groups (30% vs. 39% respectively, p=0.4). Power analysis demonstrated that 385 babies would be required in each group to reach statistical significance (alpha=0.05, beta=80%). CONCLUSION: In this retrospective case-control study, maternal administration of magnesium sulfate prior to delivery does not appear to confer a significant protective effect for the neonatal occurrence of necrotizing enterocolitis.

Analysis of Variance↗