Necrotizing Enterocolitis Clinical Presentation

  • Author: Shelley C Springer, MD, MBA, MSc, JD, FAAP; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Jan 24, 2012
 

History

The clinical presentation of necrotizing enterocolitis (NEC) includes nonspecific aspects of the history, such as vomiting, diarrhea, feeding intolerance and high gastric residuals following feedings. More specific GI tract symptoms include abdominal distention and frank or occult blood in the stools.

With disease progression, abdominal tenderness, abdominal wall edema, erythema, crepitans, or palpable bowel loops indicating a fixed and dilated loop of bowel may develop. Systemic signs, such as apnea, bradycardia, lethargy, labile body temperature, hypoglycemia, and shock, are indicators of physiologic instability.

Epidemiologic studies demonstrate that demographics, risk factors, patient characteristics, and clinical course differ significantly between term and preterm infants with NEC.

Term baby

Compared with a preterm infant, a term baby with NEC presents at a younger age, with a reported median age of onset that ranges from 1-3 days of life in the immediate postnatal period but that may appear as late as age 1 month.

The term neonate who is immediately affected postnatally is usually systemically ill with other predisposing conditions, such as birth asphyxia, respiratory distress, congenital heart disease, or metabolic abnormalities, or has a history of abnormal fetal growth pattern.

Maternal risk factors that reduce fetal gut blood flow, such as placental insufficiency from acute disease (eg, pregnancy-induced hypertension), chronic disease (eg, diabetes), or maternal cocaine abuse, can increase the baby's risk for developing NEC.

Specific signs and symptoms that may be part of the history include bilious vomiting or gastric aspirates, abdominal distention, passage of blood per rectum, abdominal radiographs that reveal dilated loops of bowel, pneumatosis intestinalis, free abdominal air, and other signs of systemic infection, including shock and acidosis.

Premature baby

Premature babies are at risk for developing necrotizing enterocolitis for several weeks after birth, with the age of onset inversely related to gestational age at birth.

Premature infants with patent ductus arteriosus are at higher risk for developing NEC earlier in life, particularly if they are treated with indomethacin for pharmacologic closure. However, patients with persistent patent ductus arteriosus who ultimately required surgical ligation were found to have a higher NEC-associated mortality rate than did patients whose patent ductus arteriosus was successfully closed without surgery.

Patients are typically advancing on enteral feedings or may have achieved full-volume feeds when symptoms develop.

Increased incidence in the posttransfusion period has been reported in otherwise healthy premature babies who are feeding enterally and undergo blood transfusion for asymptomatic anemia of prematurity.

Presenting symptoms may include subtle signs of feeding intolerance that progress over several hours to a day, subtle systemic signs that may be reported enigmatically by the nursing staff as "acting different," and, in advanced disease, a fulminant systemic collapse and consumption coagulopathy.

Symptoms of feeding intolerance can include abdominal distention/tenderness, delayed gastric emptying as evidenced by increasing gastric residuals, and, occasionally, vomiting.

Systemic symptoms can insidiously progress to include nonspecific signs and symptoms, such as increased apnea and bradycardia, lethargy, and temperature instability, among the primary manifestation(s).

Patients with fulminant NEC present with profound apnea, rapid cardiovascular and hemodynamic collapse, and shock.

The baby's feeding history can help increase the index of suspicion for early NEC. Babies who are breastfed have a lower incidence of NEC than do formula-fed babies.

Rapid advancement of formula feeding has been associated with an increased risk of NEC.[18] However, multiple subsequent studies have failed to substantiate this finding.

Next

Physical Examination

The pertinent physical findings in patients who develop necrotizing enterocolitis (NEC) can be primarily GI, primarily systemic, indolent, fulminant, or any combination of these. A high index of clinical suspicion is essential to minimize potentially significant morbidity or mortality.

GI signs can include any or all of the following:

  • Increased abdominal girth
  • Visible intestinal loops
  • Obvious abdominal distention and decreased bowel sounds
  • Change in stool pattern
  • Hematochezia
  • Palpable abdominal mass
  • Erythema of the abdominal wall

Systemic signs can include any of the following:

  • Respiratory failure
  • Decreased peripheral perfusion
  • Circulatory collapse

With insidious onset, the clinical signs may be mild, whereas patients with fulminant disease can present with severe clinical abnormalities.

If abdominal signs are present, surgical consultation may be advisable. Disease progression ranges from indolent to fulminant, and early and expeditious involvement of surgical colleagues can be helpful, especially if appropriate surgical care requires transfer to another facility.

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Contributor Information and Disclosures
Author

Shelley C Springer, MD, MBA, MSc, JD, FAAP  Clinical Instructor, Department of Pediatrics, University of Vermont College of Medicine; Clinical Instructor, Department of Pediatrics, University of Wisconsin School of Medicine and Public Health; Neonatologist, Pediatrix Medical Group; Assistant Clinical Professor, Department of Pediatrics, University of North Texas Science Center; Assistant Clinical Professor, Department of Pediatrics, Texas A&M Health Science Center College of Medicine

Shelley C Springer, MD, MBA, MSc, JD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Coauthor(s)

David J Annibale, MD  Professor of Pediatrics, Director of Neonatology, Director of Fellowship Training Program in Neonatal-Perinatal Medicine, Department of Pediatrics, Medical University of South Carolina

David J Annibale, MD, is a member of the following medical societies: American Academy of Pediatrics and National Perinatal Association

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Robert S Bloss, MD Clinical Associate Professor of Surgery and Pediatrics, University of Texas Medical School; Clinical Assistant Professor, Department of Surgery, Baylor College of Medicine; Consulting Staff, Houston Pediatric Surgeons

Robert S Bloss, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Southwestern Surgical Congress, and Texas Pediatric Society

Disclosure: Nothing to disclose.

Li Ern Chen, MD Fellow, Pediatric Surgery, Children's Hospital of Wisconsin, Medical College of Wisconsin

Li Ern Chen, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, and Sigma Xi

Disclosure: Nothing to disclose.

David A Clark, MD Chairman, Professor, Department of Pediatrics, Albany Medical College

David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Diana Farmer, MD Associate Professor, Departments of Clinical Surgery, Pediatrics, Obstetrics, Gynecology and Reproductive Services, Division of Pediatric Surgery and the Fetal Treatment Center, University of California at San Francisco

Diana Farmer, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, and American Pediatric Surgical Association

Disclosure: Nothing to disclose.

Philip Glick, MD, MBA Professor, Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Finance and Development, Department of Surgery, State University of New York at Buffalo

Philip Glick, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, Central Surgical Association, Federation of American Societies for Experimental Biology, Medical Society of the State of New York, Phi Beta Kappa, Physicians for Social Responsibility, Royal College of Surgeons of England, Sigma Xi, Society for Pediatric Research, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, and Society of University Surgeons

Disclosure: Nothing to disclose.

Andre Hebra, MD Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina

Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association

Disclosure: Nothing to disclose.

Oussama Itani, MD, FAAP, FACN Clinical Associate Professor of Pediatrics and Human Development, Michigan State University; Medical Director, Department of Neonatology, Borgess Medical Center

Oussama Itani, MD, FAAP, FACN is a member of the following medical societies: American Academy of Pediatrics, American College of Nutrition, American College of Physician Executives, and American Heart Association

Disclosure: Nothing to disclose.

Robert K Minkes, MD, PhD Professor of Surgery, University of Texas Southwestern; Chief of Surgical Services, Children's Medical Center of Dallas-Legacy

Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Tapash K Palit, MD Assistant Professor of Surgery, Louisiana State University Health Sciences Center, New Orleans

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine

Disclosure: Nothing to disclose.

References

  1. Scmid O, Quaiser K. Uer eine besondere schwere verlaufende Form von enteritis beim saugling. Oesterr Z Kinderh. 1953;8:114.

  2. Berdon WE. Necrotizing enterocolitis in the premature infant. Radiology. 1964;83:879.

  3. Hunter, CJ, Camerini V, Boyle A, et al. Bacterial Flora Enhance Intestinal Injury and Inflammation in the Rat Pup Model of Necrotizing Enterocolitis [dissertation/master's thesis]. Presented at PAS 2007, Toronto: Childrens hospital Los Angeles, CA; 2007.

  4. Hoyos AB. Reduced incidence of necrotizing enterocolitis associated with enteral administration of Lactobacillus acidophilus and Bifidobacterium infantis to neonates in an intensive care unit. Int J Infect Dis. 1999;3(4):197-202. [Medline].

  5. Alfaleh K, Anabrees J, Bassler D. Probiotics Reduce the Risk of Necrotizing Enterocolitis in Preterm Infants: A Meta-Analysis. Neonatology. Aug 25 2009;97(2):93-99. [Medline].

  6. Pickard SS, Feinstein JA, Popat RA, Huang L, Dutta S. Short- and long-term outcomes of necrotizing enterocolitis in infants with congenital heart disease. Pediatrics. May 2009;123(5):e901-6. [Medline]. [Full Text].

  7. Moya FR, Eguchi H, Zhao B, et al. Platelet-activating factor acetylhydrolase in term and preterm human milk: a preliminary report. J Pediatr Gastroenterol Nutr. Aug 1994;19(2):236-9. [Medline].

  8. Book LS, Herbst JJ, Atherton SO, Jung AL. Necrotizing enterocolitis in low-birth-weight infants fed an elemental formula. J Pediatr. Oct 1975;87(4):602-5. [Medline].

  9. Bhandari V, Bizzarro MJ, Shetty A, Zhong X, Page GP, Zhang H, et al. Familial and genetic susceptibility to major neonatal morbidities in preterm twins. Pediatrics. Jun 2006;117(6):1901-6. [Medline].

  10. Moonen RM, Paulussen AD, Souren NY, Kessels AG, Rubio-Gozalbo ME, Villamor E. Carbamoyl phosphate synthetase polymorphisms as a risk factor for necrotizing enterocolitis. Pediatr Res. Aug 2007;62(2):188-90. [Medline].

  11. Treszl A, Heninger E, Kalman A, Schuler A, Tulassay T, Vasarhelyi B. Lower prevalence of IL-4 receptor alpha-chain gene G variant in very-low-birth-weight infants with necrotizing enterocolitis. J Pediatr Surg. Sep 2003;38(9):1374-8. [Medline].

  12. Young C, Sharma R, Handfield M, Mai V, Neu J. Biomarkers for Infants at Risk for Necrotizing Enterocolitis: Clues to Prevention?. Pediatr Res. Jan 28 2009;[Medline].

  13. Terrin G, Passariello A, De Curtis M, et al. Ranitidine is Associated With Infections, Necrotizing Enterocolitis, and Fatal Outcome in Newborns. Pediatrics. Jan 2012;129(1):e40-5. [Medline].

  14. Kawase Y, Ishii T, Arai H, Uga N. Gastrointestinal perforation in very low-birthweight infants. Pediatr Int. Dec 2006;48(6):599-603. [Medline].

  15. Kovacs L, Papageorgiou, A. Incidence, Predisposing Factors and Outcome of NEC in Infants < 32 Weeks' Gestation [dissertation/master's thesis]. Presented at PAS 2007, Toronto: SMBD-Jewish General Hospital, McGill University, Montreal; 2007.

  16. Wiswell TE, Robertson CF, Jones TA, Tuttle DJ. Necrotizing enterocolitis in full-term infants. A case-control study. Am J Dis Child. May 1988;142(5):532-5. [Medline].

  17. Brotschi B, Baenziger O, Frey B, Bucher HU, Ersch J. Early enteral feeding in conservatively managed stage II necrotizing enterocolitis is associated with a reduced risk of catheter-related sepsis. J Perinat Med. Aug 13 2009;[Medline].

  18. McKeown RE, Marsh TD, Amarnath U, et al. Role of delayed feeding and of feeding increments in necrotizing enterocolitis. J Pediatr. Nov 1992;121(5 Pt 1):764-70. [Medline].

  19. Shorter NA, Liu JY, Mooney DP, Harmon BJ. Indomethacin-associated bowel perforations: a study of possible risk factors. J Pediatr Surg. Mar 1999;34(3):442-4. [Medline].

  20. Adderson EE, Pappin A, Pavia AT. Spontaneous intestinal perforation in premature infants: a distinct clinical entity associated with systemic candidiasis. J Pediatr Surg. Oct 1998;33(10):1463-7. [Medline].

  21. Stark AR, Carlo WA, Tyson JE, et al. Adverse effects of early dexamethasone in extremely-low-birth-weight infants. National Institute of Child Health and Human Development Neonatal Research Network. N Engl J Med. Jan 11 2001;344(2):95-101. [Medline].

  22. Deeg KH, Rupprecht T, Schmid E. Doppler sonographic detection of increased flow velocities in the celiac trunk and superior mesenteric artery in infants with necrotizing enterocolitis. Pediatr Radiol. 1993;23(8):578-82. [Medline].

  23. Pammi M, Abrams SA. Oral lactoferrin for the prevention of sepsis and necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. Oct 5 2011;CD007137. [Medline].

  24. Haque KN, Pammi M. Pentoxifylline for treatment of sepsis and necrotizing enterocolitis in neonates. Cochrane Database Syst Rev. Oct 5 2011;CD004205. [Medline].

  25. Vaughan WG, Grosfeld JL, West K, Scherer LR 3rd, Villamizar E, Rescorla FJ. Avoidance of stomas and delayed anastomosis for bowel necrosis: the 'clip and drop-back' technique. J Pediatr Surg. Apr 1996;31(4):542-5. [Medline].

  26. Martin LW, Neblett WW. Early operation with intestinal diversion for necrotizing enterocolitis. J Pediatr Surg. Jun 1981;16(3):252-5. [Medline].

  27. Ein SH, Marshall DG, Girvan D. Peritoneal drainage under local anesthesia for perforations from necrotizing enterocolitis. J Pediatr Surg. Dec 1977;12(6):963-7. [Medline].

  28. Moss RL, Dimmitt RA, Barnhart DC, Sylvester KG, Brown RL, Powell DM, et al. Laparotomy versus peritoneal drainage for necrotizing enterocolitis and perforation. N Engl J Med. May 25 2006;354(21):2225-34. [Medline].

  29. Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet. Dec 22-29 1990;336(8730):1519-23. [Medline].

  30. Eyal F, Sagi E, Arad I, Avital A. Necrotising enterocolitis in the very low birthweight infant: expressed breast milk feeding compared with parenteral feeding. Arch Dis Child. Apr 1982;57(4):274-6. [Medline].

  31. Berseth CL. Effect of early feeding on maturation of the preterm infant's small intestine. J Pediatr. Jun 1992;120(6):947-53. [Medline].

  32. Meetze WH, Valentine C, McGuigan JE, et al. Gastrointestinal priming prior to full enteral nutrition in very low birth weight infants. J Pediatr Gastroenterol Nutr. Aug 1992;15(2):163-70. [Medline].

  33. Rayyis SF, Ambalavanan N, Wright L, Carlo WA. Randomized trial of "slow" versus "fast" feed advancements on the incidence of necrotizing enterocolitis in very low birth weight infants. J Pediatr. Mar 1999;134(3):293-7. [Medline].

  34. Kennedy KA, Tyson JE, Chamnanvanakij S. Rapid versus slow rate of advancement of feedings for promoting growth and preventing necrotizing enterocolitis in parenterally fed low-birth-weight infants. Cochrane Database Syst Rev. 2000;(2):CD001241. [Medline].

  35. [Guideline] Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for necrotizing enterocolitis (NEC) among very low birth weight infants. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; 2007 Feb.

  36. Young TE, Mangum B. Neofax. Twenty-first edition. Montvale, NJ: Thomson Reuters; 2008.

  37. Alfaleh K, Bassler D. Probiotics for prevention of necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. Jan 23 2008;CD005496. [Medline].

  38. Bin-Nun A, Bromiker R, Wilschanski M, et al. Oral probiotics prevent necrotizing enterocolitis in very low birth weight neonates. J Pediatr. Aug 2005;147(2):192-6. [Medline].

  39. Carlson K, Schy RB, Jilling T, Lu J, Caplan MS. The Two Probiotic strains, L acidophilus and S thermophilus, down-regulate Toll-like Receptor 4 Expression in Enterocytes [dissertation/master's thesis]. Presented at PAS Toronto, 2007: Evanston Northwestern Hospital, IL; 2007.

  40. Dani C, Biadaioli R, Bertini G, Martelli E, Rubaltelli FF. Probiotics feeding in prevention of urinary tract infection, bacterial sepsis and necrotizing enterocolitis in preterm infants. A prospective double-blind study. Biol Neonate. Aug 2002;82(2):103-8. [Medline].

  41. Hammerman C, Bin-Nun A, Kaplan M. Germ warfare: probiotics in defense of the premature gut. Clin Perinatol. Sep 2004;31(3):489-500. [Medline].

  42. Lin HC, Su BH, Chen AC, et al. Oral probiotics reduce the incidence and severity of necrotizing enterocolitis in very low birth weight infants. Pediatrics. Jan 2005;115(1):1-4. [Medline].

  43. Millar M, Wilks M, Costeloe K. Probiotics for preterm infants?. Arch Dis Child Fetal Neonatal Ed. Sep 2003;88(5):F354-8. [Medline].

  44. Lin HC, Hsu CH, Chen HL, et al. Oral probiotics prevent necrotizing enterocolitis in very low birth weight preterm infants: a multicenter, randomized, controlled trial. Pediatrics. Oct 2008;122(4):693-700. [Medline].

  45. Alfaleh K, Anabrees J, Bassler D, Al-Kharfi T. Probiotics for prevention of necrotizing enterocolitis in preterm infants. Cochrane Database Syst Rev. Mar 16 2011;3:CD005496. [Medline].

 
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Normal (top) versus necrotic section of bowel. Photo courtesy of the Department of Pathology, Cornell University Medical College.
Pneumatosis intestinalis. Photo courtesy of Loren G Yamamoto, MD, MPH, Kapiolani Medical Center for Women & Children, University of Hawaii, with permission.
Pneumatosis intestinalis. Photo courtesy of Loren G Yamamoto, MD, MPH, Kapiolani Medical Center for Women & Children, University of Hawaii, with permission.
Pneumatosis intestinalis. Photo courtesy of Loren G Yamamoto, MD, MPH, Kapiolani Medical Center for Women & Children, University of Hawaii, with permission.
Pneumatosis intestinalis. Photo courtesy of Loren G Yamamoto, MD, MPH, Kapiolani Medical Center for Women & Children, University of Hawaii, with permission.
Pneumoperitoneum. Photo courtesy of the Department of Pathology, Cornell University Medical College.
Resected portion of necrotic bowel. Photo courtesy of the Department of Pathology, Cornell University Medical College.
Micrograph of mucosal section showing transmural necrosis. Photo courtesy of the Department of Pathology, Cornell University Medical College.
Histologic section of mucosal wall demonstrating pneumatosis. Photo courtesy of the Department of Pathology, Cornell University Medical College.
Histologic section of bowel mucosa showing regeneration of normal cellular architecture. Photo courtesy of the Department of Pathology, Cornell University Medical College.
Extensive pneumatosis intestinalis.
Necrotizing enterocolitis totalis. Pneumatosis intestinalis and multiple areas of perforation were seen.
Pneumatosis intestinalis.
 
 
 
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