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Alimentary tract of infant showing intestinal necrosis, pneumatosis intestinalis, and perforation site (arrow). Autopsy.

Closeup of intestine of infant showing necrosis and pneumatosis intestinalis. Autopsy.

Gross pathology of neonatal necrotizing enterocolitis. Autopsy of infant showing abdominal distension, intestinal necrosis and hemorrhage, and peritonitis due to perforation.

Necrotizing enterocolitis (NEC) is a medical condition primarily seen in premature infants,^[1] where portions of the bowel undergo necrosis (tissue death). It occurs postnatally (i.e. it is not seen in stillborn infants)^[2] and is the second most common cause of mortality in premature infants,^[3] causing 342 deaths in the United States in 2012, down from 386 in 2011.^[4]

Signs and symptoms

The condition is typically seen in premature infants, and the timing of its onset is generally inversely proportional to the gestational age of the baby at birth (i.e. the earlier a baby is born, the later signs of NEC are typically seen).^[5] Initial symptoms include feeding intolerance, increased gastric residuals, abdominal distension and bloody stools. Symptoms may progress rapidly to abdominal discoloration with intestinal perforation and peritonitis and systemic hypotension requiring intensive medical support.

Diagnosis

The diagnosis is usually suspected clinically but often requires the aid of diagnostic imaging modalities, most commonly radiography. Specific radiographic signs of NEC are associated with specific Bell's stages of the disease:^[2]

Bell's stage 1/Suspected disease:

Mild systemic disease (apnoea, bradycardia, temperature instability)
Mild intestinal signs (abdominal distention, gastric residuals, bloody stools)
Non-specific or normal radiological signs

Bell's stage 2/Definite disease:

Mild to moderate systemic signs
Additional intestinal signs (absent bowel sounds, abdominal tenderness)
Specific radiologic signs (pneumatosis intestinalis or portal venous air)
Laboratory changes (metabolic acidosis, thrombocytopaenia)

Bell's stage 3/Advanced disease:

Severe systemic illness (hypotension)
Additional intestinal signs (striking abdominal distention, peritonitis)
Severe radiologic signs (pneumoperitoneum)
Additional laboratory changes (metabolic and respiratory acidosis, disseminated intravascular coagulation)

More recently ultrasonography has proven to be useful as it may detect signs and complications of NEC before they are evident on radiographs, specifically in cases that involve a paucity of bowel gas, a gasless abdomen, or a sentinel loop.^[6] Diagnosis is ultimately made in 5–10% of very low-birth-weight infants (<1,500g).^[7]

Treatment

Treatment consists primarily of supportive care including providing bowel rest by stopping enteral feeds, gastric decompression with intermittent suction, fluid repletion to correct electrolyte abnormalities and third-space losses, support for blood pressure, parenteral nutrition,^[8] and prompt antibiotic therapy. Monitoring is clinical, although serial supine and right lateral decubitus abdominal x-rays should be performed every six hours. Where the disease is not halted through medical treatment alone, or when the bowel perforates, immediate emergency surgery to resect the dead bowel is generally required, although abdominal drains may be placed in very unstable infants as a temporizing measure. Surgery may require a colostomy, which may be able to be reversed at a later time. Some children may suffer from short bowel syndrome if extensive portions of the bowel had to be removed.

Prevention

Once a child is born prematurely, thought must be given to decreasing the risk for developing NEC. Toward that aim, the methods of providing hyperalimentation and oral feeds are both important. In a 2012 policy statement, the American Academy of Pediatrics recommended feeding preterm infants human milk, finding "significant short- and long-term beneficial effects," including reducing the rate of NEC by a factor of two or more. ^[9]

A study by researchers in Peoria, IL, published in Pediatrics in 2008, demonstrated that using a higher rate of lipid (fats and/or oils) infusion for very low birth weight infants in the first week of life resulted in zero infants developing NEC in the experimental group, compared with 14% with NEC in the control group. (They started the experimental group at 2 g/kg/d of 20% IVFE and increased within two days to 3 g/kg/d; Amino acids were started at 3 g/kg/d and increased to 3.5.)^[10]

Neonatologists at the University of Iowa reported on the importance of providing small amounts of trophic oral feeds of human milk starting as soon as possible, while the infant is being primarily fed intravenously, in order to prime the immature gut to mature and become ready to receive greater oral intake.^[11] Human milk from a milk bank or donor can be used if mother's milk is unavailable. The gut mucosal cells do not get enough nourishment from arterial blood supply to stay healthy, especially in very premature infants, where the blood supply is limited due to immature development of the capillaries, so nutrients from the lumen of the gut are needed.

A Cochrane review published in April 2014 has established that supplementation of probiotics enterally prevents severe NEC as well as all-cause mortality in preterm infants."^[12]

Increasing amounts of milk by 30 to 35 ml/kg is safe in infant who are born weighting very little or are premature.^[13] Not beginning feeding an infant by mouth for more than 4 days does not appear to have protective benefits.^[14]

Prognosis

Typical recovery from NEC if medical, non-surgical treatment succeeds, includes 10–14 days or more without oral intake and then demonstrated ability to resume feedings and gain weight. Recovery from NEC alone may be compromised by co-morbid conditions that frequently accompany prematurity. Long-term complications of medical NEC include bowel obstruction and anemia.

Despite a significant mortality risk, long-term prognosis for infants undergoing NEC surgery is improving, with survival rates of 70–80%. "Surgical NEC" survivors are at-risk for complications including short bowel syndrome and neurodevelopmental disability.

References

^ Sodhi C, Richardson W, Gribar S, Hackam DJ (2008). "The development of animal models for the study of necrotizing enterocolitis". Dis Model Mech 1 (2-3): 94–8. doi:10.1242/dmm.000315. PMC 2562191. PMID 19048070.
^ ^a ^b Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet. 2006 Oct 7;368(9543):1271–83.
^ Panigrahi, P (2006). "Necrotizing enterocolitis: a practical guide to its prevention and management.". Paediatric drugs 8 (3): 151–65. doi:10.2165/00148581-200608030-00002. PMID 16774295.
^ "Deaths: Preliminary Data for 2012" (PDF). National Vital Statistics Reports 63 (9): 85. December 2014.
^ Yee, Wendy H.; Soraisham, Amuchou Singh; Shah, Vibhuti S.; Aziz, Khalid; Yoon, Woojin; Lee, Shoo K.; Canadian Neonatal Network (1 February 2012). "Incidence and Timing of Presentation of Necrotizing Enterocolitis in Preterm Infants". Pediatrics 129: e298–e304. doi:10.1542/peds.2011-2022. Retrieved 2013-07-25.
^ Muchantef K, Epelman M, Darge K, Kirpalani H, Laje P, Anupindi SA. Sonographic and radiographic imaging features of the neonate with necrotizing enterocolitis: correlating findings with outcomes. Pediatr Radiol. 2013 Jun 15.
^ Marino, Bradley S.; Fine, Katie S. (1 December 2008). Blueprints Pediatrics. Lippincott Williams & Wilkins. ISBN 978-0-7817-8251-7.
^ Heird, WC; Gomez, MR (June 1994). "Total parenteral nutrition in necrotizing enterocolitis.". Clinics in perinatology 21 (2): 389–409. PMID 8070233.
^ American Academy of Pediatrics, Section on Breastfeeding (2012). "Breastfeeding and the Use of Human Milk". Pediatrics 129 (3): e827–e841. doi:10.1542/peds.2011-3552. PMID 22371471. Retrieved 2013-07-25. Meta-analyses of 4 randomized clinical trials performed over the period 1983 to 2005 support the conclusion that feeding preterm infants human milk is associated with a significant reduction (58%) in the incidence of NEC. A more recent study of preterm infants fed an exclusive human milk diet compared with those fed human milk supplemented with cow-milk-based infant formula products noted a 77% reduction in NEC.
^ Drenckpohl D, McConnell C, Gaffney S, Niehaus M, Macwan KS (October 2008). "Randomized trial of very low birth weight infants receiving higher rates of infusion of intravenous fat emulsions during the first week of life". Pediatrics 122 (4): 743–51. doi:10.1542/peds.2007-2282. PMID 18829797.
^ Ziegler EE, Carlson SJ (March 2009). "Early nutrition of very low birth weight infants". J. Matern. Fetal. Neonatal. Med. 22 (3): 191–7. doi:10.1080/14767050802630169. PMID 19330702.
^ AlFaleh K, Anabrees J (2014). "Probiotics for prevention of necrotizing enterocolitis in preterm infants". Cochrane Database Syst Rev (4): CD005496. doi:10.1002/14651858.CD005496.pub4.
^ Morgan, J; Young, L; McGuire, W (2 December 2014). "Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants.". The Cochrane database of systematic reviews 12: CD001241. doi:10.1002/14651858.CD001241.pub5. PMID 25452221.
^ Morgan, J; Young, L; McGuire, W (1 December 2014). "Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants.". The Cochrane database of systematic reviews 12: CD001970. doi:10.1002/14651858.CD001970.pub5. PMID 25436902.

External links

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1. 好中球減少性腸炎（盲腸炎） neutropenic enterocolitis typhlitis
2. 新生児における壊死性腸炎の臨床的特徴および診断 clinical features and diagnosis of necrotizing enterocolitis in newborns
3. 新生児における壊死性腸炎のマネージメント management of necrotizing enterocolitis in newborns
4. 新生児における壊死性腸炎の病理および病因 pathology and pathogenesis of necrotizing enterocolitis in newborns
5. 新生児における壊死性腸炎の予防 prevention of necrotizing enterocolitis in newborns

English Journal

Lactobacillus Reuteri for the prevention of necrotising enterocolitis in very low birthweight infants: a randomised controlled trial.

Oncel MY, Sari FN, Arayici S, Guzoglu N, Erdeve O, Uras N, Oguz SS, Dilmen U.Author information Division of Neonatology, Zekai Tahir Burak Maternity Teaching Hospital, , Ankara, Turkey.AbstractOBJECTIVE: To evaluate the effect of oral Lactobacillus reuteri (L reuteri) first on the incidence and severity of Necrotising enterocolitis (NEC) and second on sepsis.
Archives of disease in childhood. Fetal and neonatal edition.Arch Dis Child Fetal Neonatal Ed.2014 Mar;99(2):F110-5. doi: 10.1136/archdischild-2013-304745. Epub 2013 Dec 5.
OBJECTIVE: To evaluate the effect of oral Lactobacillus reuteri (L reuteri) first on the incidence and severity of Necrotising enterocolitis (NEC) and second on sepsis.DESIGN: Prospective randomised controlled study.SETTING: Tertiary neonatal intensive care unit.PATIENTS AND INTERVENTIONS: Preterm i
PMID 24309022

Early versus late enteral prophylactic iron supplementation in preterm very low birth weight infants: a randomised controlled trial.

Joy R, Krishnamurthy S, Bethou A, Rajappa M, Ananthanarayanan PH, Bhat BV.Author information Departments of Pediatrics and Biochemistry, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), , Pondicherry, India.AbstractOBJECTIVES: To evaluate whether preterm very low birth weight (VLBW) infants receiving early iron (EI) supplementation (2 mg/kg/day elemental iron) at 2 weeks postnatal age have improved serum ferritin levels compared with late iron (LI) supplementation at 6 weeks postnatal age.
Archives of disease in childhood. Fetal and neonatal edition.Arch Dis Child Fetal Neonatal Ed.2014 Mar;99(2):F105-9. doi: 10.1136/archdischild-2013-304650. Epub 2013 Dec 3.
OBJECTIVES: To evaluate whether preterm very low birth weight (VLBW) infants receiving early iron (EI) supplementation (2 mg/kg/day elemental iron) at 2 weeks postnatal age have improved serum ferritin levels compared with late iron (LI) supplementation at 6 weeks postnatal age.DESIGN: Single-blinde
PMID 24302687

Early regular versus late selective poractant treatment in preterm infants born between 25 and 30 gestational weeks: a prospective randomized multicenter study.

Dilmen U, Ozdemir R, Tatar Aksoy H, Uras N, Demirel N, Kırimi E, Erdeve O, Ozer E, Baş AY, Gürsoy T, Zenciroğlu A, Ovalı F, Oğuz SS.Author information Zekai Tahir Burak Maternity and Teaching Hospital, Neonatal Intensive Care Unit , Ankara , Turkey .AbstractAbstract Objective: Surfactant treatment in the early hours of life significantly decreases the rates of death and air leak, and increases survival without bronchopulmonary dysplasia (BPD) in preterm infants. We aimed to compare the impact of early surfactant (ES) administration to late selective (LS) treatment on neonatal outcomes in preterm infants. Methods: All preterm infants between 25 and 30 wks gestational age and who were not entubated in the delivery room and did not have any major congenital malformation or perinatal asphyxia were randomized to ES treatment (200 mg/kg Curosurf® administration in 1 hour after birth) or LS treatment (200 mg/kg Curosurf®administration in the first 6 h of life if needed). The patients were treated by nasal continuous positive airway pressure (nCPAP) treatment regardless of the surfactant requirement. Outcomes were the necessity of mechanical ventilation, nCPAP duration, the oxygen requirement duration, the rates of BPD, retinopathy of prematurity (ROP) and mortality, and the assesment of the following situations; (pneumothorax, patent ductus arteriosus (PDA), necrotizing enterocolitis (NEC), and intraventricular hemorrhage (IVH) ≥ grade III). Results: Among 159 infants enrolled in the study, 79 were randomized to ES and 80 to LS treatment groups. Thirty-five patients (44%) in the LS treatment group needed surfactant administration. Necessity of second dose surfactant administration was 8.9% in the ES treatment group. Although necessity of mechanical ventilation, nCPAP duration, oxygen need duration, rates of PDA, NEC, BPD, ROP stage >3 and mortality did not show a significant difference between groups, the ES treatment group had lower rates of pneumothorax and IVH≥ grade III when compared to the LS treatment group. Conclusions: ES treatment decreases IVH (≥ grade III) and pneumothorax rates but does not have any effect on BPD when compared to LS.
The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians.J Matern Fetal Neonatal Med.2014 Mar;27(4):411-5. doi: 10.3109/14767058.2013.818120. Epub 2013 Jul 30.
Abstract Objective: Surfactant treatment in the early hours of life significantly decreases the rates of death and air leak, and increases survival without bronchopulmonary dysplasia (BPD) in preterm infants. We aimed to compare the impact of early surfactant (ES) administration to late selective (L
PMID 23795582

Japanese Journal

T-tube ileostomy for intestinal perforation in extremely low birth weight neonates

RYGL M.,PYCHA K.,STRANAK Z.,SKABA R.,BRABEC R.,CUNAT V.,SNAJDAUF J.
Pediatric surgery international 23(7), 685-688, 2007-07-01
NAID 10027857633

Necrotising enterocolitis and localised intestinal perforation : different diseases or ends of a spectrum of pathology

BOSTON V. E.
Pediatric surgery international 22(6), 477-484, 2006-06-01
NAID 10027480682

Primary peritoneal drainage in necrotising enterocolitis : an 18-year experience

GOYAL A.,MANALANG L. R.,DONNELL S. C.,LLOYD D. A.
Pediatric surgery international 22(5), 449-452, 2006-05-01
NAID 10027480549

「壊死性腸炎」

Necrotizing enterocolitis
	Radiograph of an infant with necrotizing enterocolitis
Classification and external resources
Specialty	pediatrics
ICD-10	P77
ICD-9-CM	777.5
DiseasesDB	31774
MedlinePlus	001148
eMedicine	ped/2981 radio/469
MeSH	D020345

　　[★]

英: necrotizing enterocolitis、necrotising enterocolitis, necrotizing enteritis, NEC
ラ: enteritis necroticans

「necrotising」

　　[★]

adj.

壊死性の

関: necrotic、necrotizing

[pmid19048070-1] Sodhi C, Richardson W, Gribar S, Hackam DJ (2008). "The development of animal models for the study of necrotizing enterocolitis". Dis Model Mech 1 (2-3): 94–8. doi:10.1242/dmm.000315. PMC 2562191. PMID 19048070.

[Lin-2] Lin PW, Stoll BJ. Necrotising enterocolitis. Lancet. 2006 Oct 7;368(9543):1271–83.

[Panigrahi-3] Panigrahi, P (2006). "Necrotizing enterocolitis: a practical guide to its prevention and management.". Paediatric drugs 8 (3): 151–65. doi:10.2165/00148581-200608030-00002. PMID 16774295.

[4] "Deaths: Preliminary Data for 2012" (PDF). National Vital Statistics Reports 63 (9): 85. December 2014.

[5] Yee, Wendy H.; Soraisham, Amuchou Singh; Shah, Vibhuti S.; Aziz, Khalid; Yoon, Woojin; Lee, Shoo K.; Canadian Neonatal Network (1 February 2012). "Incidence and Timing of Presentation of Necrotizing Enterocolitis in Preterm Infants". Pediatrics 129: e298–e304. doi:10.1542/peds.2011-2022. Retrieved 2013-07-25.

[Muchantef-6] Muchantef K, Epelman M, Darge K, Kirpalani H, Laje P, Anupindi SA. Sonographic and radiographic imaging features of the neonate with necrotizing enterocolitis: correlating findings with outcomes. Pediatr Radiol. 2013 Jun 15.

[7] Marino, Bradley S.; Fine, Katie S. (1 December 2008). Blueprints Pediatrics. Lippincott Williams & Wilkins. ISBN 978-0-7817-8251-7.

[Heird-8] Heird, WC; Gomez, MR (June 1994). "Total parenteral nutrition in necrotizing enterocolitis.". Clinics in perinatology 21 (2): 389–409. PMID 8070233.

[9] American Academy of Pediatrics, Section on Breastfeeding (2012). "Breastfeeding and the Use of Human Milk". Pediatrics 129 (3): e827–e841. doi:10.1542/peds.2011-3552. PMID 22371471. Retrieved 2013-07-25. Meta-analyses of 4 randomized clinical trials performed over the period 1983 to 2005 support the conclusion that feeding preterm infants human milk is associated with a significant reduction (58%) in the incidence of NEC. A more recent study of preterm infants fed an exclusive human milk diet compared with those fed human milk supplemented with cow-milk-based infant formula products noted a 77% reduction in NEC.

[10] Drenckpohl D, McConnell C, Gaffney S, Niehaus M, Macwan KS (October 2008). "Randomized trial of very low birth weight infants receiving higher rates of infusion of intravenous fat emulsions during the first week of life". Pediatrics 122 (4): 743–51. doi:10.1542/peds.2007-2282. PMID 18829797.

[11] Ziegler EE, Carlson SJ (March 2009). "Early nutrition of very low birth weight infants". J. Matern. Fetal. Neonatal. Med. 22 (3): 191–7. doi:10.1080/14767050802630169. PMID 19330702.

[12] AlFaleh K, Anabrees J (2014). "Probiotics for prevention of necrotizing enterocolitis in preterm infants". Cochrane Database Syst Rev (4): CD005496. doi:10.1002/14651858.CD005496.pub4.

[13] Morgan, J; Young, L; McGuire, W (2 December 2014). "Slow advancement of enteral feed volumes to prevent necrotising enterocolitis in very low birth weight infants.". The Cochrane database of systematic reviews 12: CD001241. doi:10.1002/14651858.CD001241.pub5. PMID 25452221.

[14] Morgan, J; Young, L; McGuire, W (1 December 2014). "Delayed introduction of progressive enteral feeds to prevent necrotising enterocolitis in very low birth weight infants.". The Cochrane database of systematic reviews 12: CD001970. doi:10.1002/14651858.CD001970.pub5. PMID 25436902.

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necrotising enterocolitis