Necrotizing enterocolitis

What is necrotizing enterocolitis?

Necrotizing enterocolitis (abbreviated NEC) refers to a severe intestinal inflammation that is mainly seen in premature infants. Usually diagnosed between the 2nd and 4th week of life, NEC affects infants with a birth weight below 1500 grams. A similar presentation of NEC may also develop in older children or adults, however, only a small number of such cases have been reported worldwide. NEC is a medical emergency and is fatal in about 10 to 40% of cases, even with intensive treatment resources.

How and why does NEK develop?

The precise cause of necrotizing enterocolitis is still not fully understood. It is clear that in premature infants the inflammation of the intestinal wall results from an dysbiosis of gut bacteria. Under normal circumstances, the human gut tract is predominantly colonized by good bacteria which help digestion. In NEC, bad pathogenic bacteria become prevalent leading to intestinal inflammation. As the immune system of newborns, particularly premature babies, is not yet fully developed, they are not able to eradicate the bad bacteria from the gut, even though the body initiates an inflammatory response. The result is a severe and persistent illness which poses an enormous burden on the premature infant's system.

How is NEC diagnosed?

It can be challenging to diagnose NEC, in particular during its early stages, because the symptoms of the disease can be quite vague at first. There may be an inflated, tender abdomen along with bloody stools that may indicate NEC in a newborn. Also general symptoms, including weakness, refusal to feed and difficulty breathing are symptoms that call for closer examination. X-ray imaging of a patient with NEC can demonstrate pneumatosis intestinalis, which is air accumulation within the intestinal wall. However, this is generally considered a specific symptom that occurs later on and may not be found in every affected child. Pneumatosis hepatis is an accumulation of gases in the large blood vessels of the liver, is another specific symptom of NEC, but is also not obvious until later in the course of the disease.

How is necrotizing enterocolitis treated?

In the beginning, treatment of NEC is directed towards stabilization of the circulatory system. As part of this, the patient is provided with a nasal gastric tube and fed with a special diet, and is intubated for respiratory support. Furthermore, a broad spectrum antibiotic therapy is given to patients to cover as many bacteria species in the intestine as possible. About half of all patients will also require surgery to have necrotic segments of the intestine removed. Additionally, drainage tubes can be inserted as part of the surgery to help remove stool and inflammatory fluids from the intestines to promote healing. Details of the surgical procedure are based on the extent of the disease as well as the overall health status of the patient.

Prognosis and potential long-term consequences

Mortality rates of necrotizing enterocolitis lie between 10% and 40% and vary according to multiple factors, including the age of the child and the point in time of diagnosis. Potential late complications include inflammation of surgical site, scarring of the intestinal walls, and bowel stricture. Besides, recurrence of NEC occurs in about 5-10% of cases during the first five months after the therapy. Over the long term, the altered intestinal structure may result in digestive disorders and poor absorption of nutrients by the intestine. In many cases, there are further deficits in the physical development.

Which doctors and clinics are specialists?

Any child with suspected NEC should first be referred to the pediatric GP. Generally, once NEC has been confirmed, the child is admitted immediately to a hospital where treatment is continued in the neonatal intensive care unit by pediatricians and pediatric surgeons.

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