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.^[30]SIP is further distinguished by its earlier onset in babies of smaller birth weight and more extreme prematurity.^[31]Associations have been identified between SIP and indomethacin,^[30]dexamethasone,^[32]and systemic candidiasis.^[31]

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

Workup

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Media Gallery

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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Author

Shelley C Springer, JD, MD, MSc, MBA, FAAP Professor, University of Medicine and Health Sciences, St Kitts, West Indies; 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

Shelley C Springer, JD, MD, MSc, MBA, 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, Medical University of South Carolina College of Medicine; Director of Neonatology, Director of Fellowship Training Program in Neonatal-Perinatal Medicine, Department of Pediatrics, Division of Neonatology, MUSC Children's Hospital

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

Disclosure: Editorial staff for AAP NeoREVIEWS PLUS (includes reimbursement for meeting expecnses and $300 honorarium; Advisory meetings for the National Certification Corp. development of a QI certification test. (includes all expenses without honorarium) for: American Academy of Pediatrics, National Certification Corp.

Chief Editor

Muhammad Aslam, MD Professor of Pediatrics, University of California, Irvine, School of Medicine; Neonatologist, Division of Newborn Medicine, Department of Pediatrics, UC Irvine Medical Center

Muhammad Aslam, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Acknowledgements

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