Necrotising enterocolitis

Question 1

A premature infant presents with mild bleeding per rectum. What is your provisional diagnosis? Briefly outline your management. What problems are present in premature babies?

A 2-week old pre-term baby comes in with abdominal distension, inability to tolerate feeds, apnoeas, lethargy and a fluctuating temperature. How would you assess and manage?

Answer 1

Impression
concerned that this is necrotising enterocolitis, the most common gastrointestinal emergency in premature infants. Concerned this could lead to a perforation which could give rise to generalised peritonitis and septic shock.

DDx

• infectious: gastroenteritis (bacterial, viral), generalised sepsis with ileus, other focus of infection
• Obstructive: Hirschprung’s disease, intussusception, volvulus, meconium ileus
• intolerances: FPIES, CMPI (usually after first 6 weeks of life)

Goals

• targeted Hx/Ex/Ix, call for senior help and take A to E approach to assess for HD stability
• Transfer for definitive surgical intervention with resection of necrotic bowel segment

First conduct A to E to ensure HD stability before moving on with Hx/Ex/Ix to inform appropriate management

Question 2

NEC - History

Answer 2

History
- Bells severity criteria (suspected, confirmed, advanced [i.e. perf’d]). Complications of peritonitis, shock
- NEC: feeding intolerance/change in feeding habits,
- sx: distension, bloating, vomiting, bloody stools, diarrhoea, bilious vomiting
- non-specific: lethargy, irritability, poor feeding, temperature instability
Paeds Hx
- details of pregnancy, how premature, details of birth, any need for admission to NICU
- fam hx (Hirschprung’s disease),

Question 3

NEC - Examination

Answer 3

Examination

• General appearance + vitals: signs of toxicity and dehydration
• GIT examination: distension, tenderness

Question 4

NEC - Investigations

Answer 4

Investigations

• Bedside: VBG (lactate, pH), stool MCS
• Labs: FBC (neutropenia, low platelets), Coags (DIC if low platelets), UEC
• Imaging: Abdominal X-Ray, taken in supine + L later decubitus to see for free air/pneumoperitoneum if ?perforation. Looking for pneumoatosis intestinalis (stage 2)
• Abdo US if X-Ray is equivocal

Question 5

NEC - Management

Answer 5

Management
Supportive
- NBM for bowel rest
- TPN (bowel rest)
- NGT for gastric decompression and suck every 4 hrs
- IV fluid + electrolyte replacement for maintenance
- regular monitoring, abdo exams for ?perforation/progression (regular abdo exam every 2 hours)
- regular abdo X-Ray

Definitive

• Empirical antibiotics: check RCH guidelines but Gent, Amp, Metro
• Surgical intervention if failing to respond or signs of perforation
• laparotomy +/- resection of regions of necrosis
• peritoneal drainage of intra-abdominal fluid