Necrotising enterocolitis (NEC) is the most common gastrointestinal condition in premature neonates. It is characterised by inflammation, ischaemia, and permeability of the neonatal bowel wall to bacteria. It is potentially life threatening with significant associated morbidity.
NEC usually develops 2-3 days following birth, with 90% developing within the first 10 days of life 4. The incidence is inversely proportional to gestational age, with 90% occurring in premature infants. Its overall incidence is ~1 in 1000 births but is as high as 20% in low birth weight infants (<1500 grams) 5.
Presentation is often non-specific, and includes:
- poor feeding
- bile stained vomitus
- abdominal distension
- blood stained stools +/- explosive diarrhoea
- respiratory distress with acidosis
- features of generalised sepsis
- prematurity (50-80%) 4
- congenital heart disease
- perinatal asphyxia
- decreased umbilical flow in utero
NEC is usually idiopathic and multi-factorial. A combination of ischaemic and infective aetiology with added contributive factors such as immature immunity have been proposed 1. Although a partially infective aetiology has also been proposed, no causative organism has been isolated. Translocation of intestinal flora through immature mucosa has been postulated 5.
Inflammation starts from the mucosal surface and progresses to haemorrhagic and coagulative necrosis with the ensuing loss of mucosal integrity, transmural necrosis and perforation.
Supine abdominal x-rays are the mainstay of diagnosis. If NEC is suspected clinically, or there is concern on supine films, then an additional cross-table lateral or left-lateral decubitus film should be obtained 5:
- dilated bowel loops (often asymmetrical in distribution)
- loss of the normal polygonal gas shape
- bowel wall oedema with thumb printing
- pneumatosis intestinalis (intramural gas)
- portal venous gas
- pneumoperitoneum secondary to perforation
- bowel wall thickening
- alteration of vascular state
- hypervascular (viable but engorged in early stage)
- hypovascular (infarcted in later stage)
- intramural gas manifesting as hyperechoic foci within the bowel wall
- free fluid, especially with echogenic debris, is suspicious for perforation 5
Treatment and prognosis
NEC can be managed both medically and surgically and appropriate patient selection is essential in optimising outcome. A clinical staging system has been developed (see necrotising enterocolitis staging), with stage I and II receiving medical therapy and stage III undergoing surgery 8.
Medical management consists of supportive measures and cessation of oral feeding, along with broad spectrum antibiotics and gastric aspiration 7.
Surgery is usually reserved for patients with evidence of perforation, and entails resection of clearly necrotic bowel and the creation of a proximal enterostomy 5-6. Other relative indications for surgery include portal venous gas, a fixed dilated loop on serial x-rays and abdominal wall erythema 7. Re-anastomosis is usually delayed until the infant has completely recovered.
Despite therapy, mortality remains significant, ranging between 9 and 28% 5. Furthermore ~20% of surviving patients will go on to develop stricture. These are more commonly in the large bowel (80%) and may result in bowel obstruction weeks to months later 5, 8.
In the correct clinical scenario, the presence of gas within bowel wall has little differential.
Conditions worth keeping in mind include 8:
- 1. Epelman M, Daneman A, Navarro OM et-al. Necrotizing enterocolitis: review of state-of-the-art imaging findings with pathologic correlation. Radiographics. 27 (2): 285-305. doi:10.1148/rg.272055098 - Pubmed citation
- 2. Kosloske AM, Musemeche CA, Ball WS et-al. Necrotizing enterocolitis: value of radiographic findings to predict outcome. AJR Am J Roentgenol. 1988;151 (4): 771-4. AJR Am J Roentgenol (abstract) - Pubmed citation
- 3. Coursey CA, Hollingsworth CL, Wriston C et-al. Radiographic predictors of disease severity in neonates and infants with necrotizing enterocolitis. AJR Am J Roentgenol. 2009;193 (5): 1408-13. doi:10.2214/AJR.08.2306 - Pubmed citation
- 4. Dähnert W. Radiology review manual. Lippincott Williams & Wilkins. (2003) ISBN:0781738954. Read it at Google Books - Find it at Amazon
- 5. Devos AS, Blickman JG, Blickman JG. Radiological Imaging of the Digestive Tract in Infants and Children. Springer Verlag. (2007) ISBN:3540407332. Read it at Google Books - Find it at Amazon
- 6. Walker-Smith J, Murch S. Diseases of the small intestine in childhood. Informa HealthCare. (1999) ISBN:1901865037. Read it at Google Books - Find it at Amazon
- 7. Norton JA, Barie PS, Bollinger RR. Surgery, basic science and clinical evidence. Springer Verlag. (2008) ISBN:0387308008. Read it at Google Books - Find it at Amazon
- 8. Crocetti M, Barone MA, Oski FA. Oski's essential pediatrics. Lippincott Williams & Wilkins. (2004) ISBN:0781737702. Read it at Google Books - Find it at Amazon