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Necrotizing enterocolitis

Last updated: October 23, 2020

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Necrotizing enterocolitis (NEC) is a dangerous hemorrhagic inflammation of the intestinal wall that most often affects premature infants. Typical symptoms include abdominal distension, gastric retention, tenderness, rectal bleeding, and visible intestinal loops lacking peristalsis. A radiographic finding of gas within the wall of the intestine (pneumatosis intestinalis) confirms the suspected diagnosis. Conservative management of the condition involves parenteral nutrition and antibiotics. In the case of advanced NEC and intestinal perforation, however, surgery is necessary.

References:[1][2][3]

Epidemiological data refers to the US, unless otherwise specified.

  • The causes of necrotizing enterocolitis are not fully understood but multiple factors contribute to the development of the condition.

References:[4][5][6][7]

Bell staging criteria
Stage Diagnosis Symptoms
Stage I
  • Suspected NEC
  • Lethargy, distended and shiny abdomen, gastric retention, vomiting, diarrhea, rectal bleeding
Stage II
  • Proven NEC
  • Stage I symptoms + abdominal tenderness, visible intestinal loops lacking peristalsis
Stage III
  • Advanced NEC

References:[8][9]

Laboratory tests

Imaging

References:[9][10][11][12][13]

Differential diagnoses of necrotizing enterocolitis
Features NEC Spontaneous intestinal perforation

Intestinal obstruction

Infectious enteritis Allergy to cow's milk
Symptoms
  • Distended abdomen
  • Abdominal pain
  • Vomiting
  • Crepitus
  • Abdominal pain
  • Vomiting
  • Bloody stools
  • Rectal bleeding
Other findings
  • First week after birth
  • Independent of feeding
  • Cow's milk-specific IgE

References:[14][15]

The differential diagnoses listed here are not exhaustive.

Treatment should be initiated promptly when NEC is suspected to prevent complications such as perforation, peritonitis, and sepsis.

References:[16][17]

References:[17]

We list the most important complications. The selection is not exhaustive.

Mortality rate: approx. 10–30%

References:[18][19]

Breast milk has a protective effect

  1. Llanos AR, Moss ME, Pinzòn MC, Dye T, Sinkin RA, Kendig JW. Epidemiology of neonatal necrotising enterocolitis: a population-based study. Paediatr Perinat Epidemiol. 2002; 16 (4): p.342-349. doi: 10.1046/j.1365-3016.2002.00445.x . | Open in Read by QxMD
  2. Yee WH, Soraisham AS, Shah VS et al. Incidence and timing of presentation of necrotizing enterocolitis in preterm infants. Pediatrics. 2012; 129 (2): p.e298-304. doi: 10.1542/peds.2011-2022 . | Open in Read by QxMD
  3. Epelman M, Daneman A, Navarro OM et al. Necrotizing enterocolitis: review of state-of-the-art imaging findings with pathologic correlation. Radiographics. 2007; 27 (2): p.285-305. doi: 10.1148/rg.272055098 . | Open in Read by QxMD
  4. Understanding the susceptibility of the premature infant to necrotizing enterocolitis (NEC). http://www.nature.com/pr/journal/v63/n2/full/pr200824a.html. Updated: February 1, 2008. Accessed: March 7, 2017.
  5. Buescher ES. Host defense mechanisms of human milk and their relations to enteric infections and necrotizing enterocolitis. Clin Perinatol. 1994; 21 (2): p.247-262.
  6. Mapping the New World of Necrotizing Enterocolitis (NEC): Review and Opinion. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3666872/pdf/nihms435179.pdf. Updated: January 1, 2012. Accessed: March 7, 2017.
  7. Clark DA, Miller MJ. Intraluminal pathogenesis of necrotizing enterocolitis. J Pediatr. 1990; 117 (1 Pt 2): p.S64-67.
  8. Neonatal necrotizing enterocolitis. Therapeutic decisions based upon clinical staging. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1396409/. Updated: January 1, 1978. Accessed: March 7, 2017.
  9. Neu J. Necrotizing enterocolitis: the search for a unifying pathogenic theory leading to prevention. Pediatr Clin North Am. 1996; 43 (2): p.409-432.
  10. Epelman M, Daneman A, Navarro OM, et al. Necrotizing enterocolitis: review of state-of-the-art imaging findings with pathologic correlation. Radiographics. 2007; 27 (2): p.285-305. doi: 10.1148/rg.272055098 . | Open in Read by QxMD
  11. Christensen RD, Yoder BA, Baer VL, Snow GL, Butler A. Early-Onset Neutropenia in Small-for-Gestational-Age Infants. Pediatrics. 2015; 136 (5): p.e1259-1267. doi: 10.1542/peds.2015-1638 . | Open in Read by QxMD
  12. Kenton AB, O'donovan D, Cass DL, et al. Severe thrombocytopenia predicts outcome in neonates with necrotizing enterocolitis. J Perinatol. 2006; 25 (1): p.14-20. doi: 10.1038/sj.jp.7211180 . | Open in Read by QxMD
  13. Intramural Bowel Gas. https://radiopaedia.org/articles/intramural-bowel-gas. Updated: January 1, 2018. Accessed: February 15, 2018.
  14. Schanler RJ. Clinical features and diagnosis of necrotizing enterocolitis in newborns. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-necrotizing-enterocolitis-in-newborns?source=search_result&search=necrotizing%20enterocolitis&selectedTitle=2~150.Last updated: February 18, 2016. Accessed: March 7, 2017.
  15. Gordon PV, Swanson JR, Attridge JT, Clark R. Emerging trends in acquired neonatal intestinal disease: is it time to abandon Bell's criteria?. J Perinatol. 2007; 27 (11): p.661-671. doi: 10.1038/sj.jp.7211782 . | Open in Read by QxMD
  16. Solomkin JS, Mazuski JE, Bradley JS, et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clin Infect Dis. 2010; 50 (2): p.133-164. doi: 10.1086/649554 . | Open in Read by QxMD
  17. Schanler RJ. Management of Necrotizing Enterocolitis in Newborns. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/management-of-necrotizing-enterocolitis-in-newborns.Last updated: May 9, 2017. Accessed: February 18, 2018.
  18. Horwitz JR, Lally KP, Cheu HW, Vazquez WD, Grosfeld JL, Ziegler MM. Complications after surgical intervention for necrotizing enterocolitis: a multicenter review. J Pediatr Surg. 1995; 30 (7): p.994-999.
  19. Neonatal necrotizing enterocolitis: a retrospective and multicentric review of 331 cases. https://www.ncbi.nlm.nih.gov/pubmed?term=8086688. Updated: April 1, 1994. Accessed: March 7, 2017.
  20. Neu J. Necrotizing enterocolitis: the search for a unifying pathogenic theory leading to prevention. Pediatr Clin North Am. 1996; 43 (2): p.409-432.