Necrotizing Enterocolitis Differential Diagnoses

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

Diagnostic Considerations

Necrotizing enterocolitis (NEC) is a clinical diagnosis that can be subtle at its onset. Early symptoms frequently mimic more common clinical conditions, such as poor gastric motility and benign feeding intolerance. Retrospective review of the earliest clinical signs once the diagnosis is apparent can seem misleadingly clear, even though the prospective assessment was much less straightforward. Laboratory and radiographic evidence can bolster a clinical impression of benign conditions.

Not infrequently, free air is noted on an abdominal radiograph of a premature infant, either as an incidental finding on imaging performed for other reasons or during an initial evaluation for abdominal pathology. Spontaneous intestinal perforation (SIP) can be distinguished from NEC by its lack of systemic involvement, absence of other clinical signs common to bowel perforation, and higher rate of survival.[19] SIP is further distinguished by its earlier onset in babies of smaller birth weight and more extreme prematurity.[20] Associations have been identified between SIP and indomethacin,[19] dexamethasone,[21] and systemic candidiasis.[20]

Conditions to consider in the differential diagnosis of NEC include the following:

  • Hypoplastic left heart syndrome
  • Intestinal malrotation
  • Intestinal volvulus
  • Bacterial meningitis
  • Neonatal sepsis
  • Omphalitis
  • Prematurity
  • Urinary tract infection
  • Volvulus

Differential Diagnoses

Proceed to Workup
 
 
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].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.