Necrotizing Enterocolitis for USMLE
90.9 هزار بار بازدید -
10 سال پیش
-
Necrotizing Enterocolitis is the most
Necrotizing Enterocolitis is the most common cause of GIT problems in preterm. It is a mucosal or even trans-mucosal necrosis which can often times cause perforation. Incidence and fatality increases with prematurity. Pathogenesis is related to three underlying factors.
First factor of necortizing enterocolitis is intestinal ischemia, enteral nutrition, and finally bacterial colonization. Enteral Nutrition of the preterm infant is still premature therefore there is decreased motility and function. Since it is not being absorbed there is increased amount of bacteria. Therefore aggressive enteral feeding of preterm infant can predispose to necrotizing enterocolitis. Therefore in preterm you don't want to overfeed them. Human milk tends to be better formula milk. Most likely becuase protective affects of IgA.
Bacterial growth in newborn with Necrotizing Entercolitis is due to immature barrier and immature immune system. Also the pH is still high and therefore it is difficult to tackle some of the bacteria. Common organisms are the coagulase nigative staph, e.coli, klebsiella, clostridium perfringens, rotavirus. Antibiotics for more than 5 days also increases likelihood.
Term infants don't get necrotizing entercolitis, but if they have congenital heart disease, perinatal asphyxia, respiratory condition, polycythemia can predispose to necrotizing enterocolitis. Indomethacin is associated with this because it causes contraction of splanchnic vasculature.
CLINICAL FINDINGS
Initially patient will be doing okay until the first or second week, however, it can be up to 30 days later. The greater the prematurity the later in gestational age will be seen. Presentation begins with decreasing feed tolerance, distention and vomiting and diarrhea. Diarrhea is generally bloody.
Pateitns with necrotizing entercolitis can develop sepsis, DIC, and perforation.
Management of Necrotizing entercolitis is to first do an abdominal x-ray to confirm the diagnosis. If pneumoperitoneum is suspected the patient needs to be left lateral decubitus position and you can see air in the abdomen. Pneumatosis intestinalis which is gas in the small intestines. There will also be dilated loops. Abdominal ultrasound will show the same picture, but there is also fluid collection and there will be bowel wall thickness. Hepatic ultrasound may show portal venous gas. Labs of necrotizing entercolitis can't confirm necrotizing entercolitis, but it can help rule out other causes and establish a baseline value. If there is severe neutropenia less than 1,500 than that is a poor prognostic sign. Coagulation is suspected DIC, and serum markers and electrolytes which can suggest necrosis and sepsis. Respiratory problems associated with Arterial Blood Gas. Sepsis workup is related to blood culture, stool culture, and CSF culture. Stool culture you may want to look for occult blood. Differential Diagnosis is obstruction, rotavirus, but this will be more clustered. Cow milk protein allergy. Spontaneous intestinal performation may mimic necrotizing entercolitis, however, there will be a bluish discoloration rather than reddish discoloration.
Management of necrotizing entercolitis is supportive. This includes bowel rest by giving TPN, Nasogastric suctioning, If there is Cardiovascular or respiratory issue than that also needs to be addressed. IV Fluids must correct for loss of fluids.
Anti-Biotics you need to go broad spectrum. Empirical treatment you have every hospital has its own protocol. Pediatric Surgeon needs to be invovled especially if there is any sign of perforation. They can't really handle surgery. Laparatory of necrotic bowel and resection, but this can lead to short bowel syndrome. Primary Peritoneal Drainage at bedside they can make a stab wound at McBurney's Point. Preferred if they are Extremely Low Birth Weight. Complications of necrotizing entercolitis can be divided into Acute and Chronic. Sepsis, DIC, CVS, Resp, Metabolic acidosis and hyoglycemia are the acute complications. Chronic complications may be strictures and worsening symptoms. If they undergo surgery there may be Short Bowel Syndrome and the infant can't absorb enough nutrients and they need to be on TPN. Generally, 50% have not sequelae, but mortality is between 20-40%. The more pre-term they are, then the higher the mortality.
Prevention of necrotizing entercolitis is breastfeeding and if they are Very Low Birth Weight then minimize enteral feeding, but there needs to be judicious volume advancement. Probiotics also has shown some benefits in treating necrotizing entercolitis.
First factor of necortizing enterocolitis is intestinal ischemia, enteral nutrition, and finally bacterial colonization. Enteral Nutrition of the preterm infant is still premature therefore there is decreased motility and function. Since it is not being absorbed there is increased amount of bacteria. Therefore aggressive enteral feeding of preterm infant can predispose to necrotizing enterocolitis. Therefore in preterm you don't want to overfeed them. Human milk tends to be better formula milk. Most likely becuase protective affects of IgA.
Bacterial growth in newborn with Necrotizing Entercolitis is due to immature barrier and immature immune system. Also the pH is still high and therefore it is difficult to tackle some of the bacteria. Common organisms are the coagulase nigative staph, e.coli, klebsiella, clostridium perfringens, rotavirus. Antibiotics for more than 5 days also increases likelihood.
Term infants don't get necrotizing entercolitis, but if they have congenital heart disease, perinatal asphyxia, respiratory condition, polycythemia can predispose to necrotizing enterocolitis. Indomethacin is associated with this because it causes contraction of splanchnic vasculature.
CLINICAL FINDINGS
Initially patient will be doing okay until the first or second week, however, it can be up to 30 days later. The greater the prematurity the later in gestational age will be seen. Presentation begins with decreasing feed tolerance, distention and vomiting and diarrhea. Diarrhea is generally bloody.
Pateitns with necrotizing entercolitis can develop sepsis, DIC, and perforation.
Management of Necrotizing entercolitis is to first do an abdominal x-ray to confirm the diagnosis. If pneumoperitoneum is suspected the patient needs to be left lateral decubitus position and you can see air in the abdomen. Pneumatosis intestinalis which is gas in the small intestines. There will also be dilated loops. Abdominal ultrasound will show the same picture, but there is also fluid collection and there will be bowel wall thickness. Hepatic ultrasound may show portal venous gas. Labs of necrotizing entercolitis can't confirm necrotizing entercolitis, but it can help rule out other causes and establish a baseline value. If there is severe neutropenia less than 1,500 than that is a poor prognostic sign. Coagulation is suspected DIC, and serum markers and electrolytes which can suggest necrosis and sepsis. Respiratory problems associated with Arterial Blood Gas. Sepsis workup is related to blood culture, stool culture, and CSF culture. Stool culture you may want to look for occult blood. Differential Diagnosis is obstruction, rotavirus, but this will be more clustered. Cow milk protein allergy. Spontaneous intestinal performation may mimic necrotizing entercolitis, however, there will be a bluish discoloration rather than reddish discoloration.
Management of necrotizing entercolitis is supportive. This includes bowel rest by giving TPN, Nasogastric suctioning, If there is Cardiovascular or respiratory issue than that also needs to be addressed. IV Fluids must correct for loss of fluids.
Anti-Biotics you need to go broad spectrum. Empirical treatment you have every hospital has its own protocol. Pediatric Surgeon needs to be invovled especially if there is any sign of perforation. They can't really handle surgery. Laparatory of necrotic bowel and resection, but this can lead to short bowel syndrome. Primary Peritoneal Drainage at bedside they can make a stab wound at McBurney's Point. Preferred if they are Extremely Low Birth Weight. Complications of necrotizing entercolitis can be divided into Acute and Chronic. Sepsis, DIC, CVS, Resp, Metabolic acidosis and hyoglycemia are the acute complications. Chronic complications may be strictures and worsening symptoms. If they undergo surgery there may be Short Bowel Syndrome and the infant can't absorb enough nutrients and they need to be on TPN. Generally, 50% have not sequelae, but mortality is between 20-40%. The more pre-term they are, then the higher the mortality.
Prevention of necrotizing entercolitis is breastfeeding and if they are Very Low Birth Weight then minimize enteral feeding, but there needs to be judicious volume advancement. Probiotics also has shown some benefits in treating necrotizing entercolitis.
10 سال پیش
در تاریخ 1393/12/13 منتشر شده
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