Necrotizing Enterocolitis: A Surgical Emergency
Jocelyn Oleshansky MPA, PA-C Department of Surgery Surgical Hospitalist Disclosures
• Sponsorship or Commercial Support: This CNE activity received no sponsorships or commercial support.
•Non-Endorsement of Products: Approved provider status of Texas Children’s Hospital refers only to the continuing nursing education activity and does not imply a real or implied endorsement by Texas Children’s Hospital, the American Nurses Credentialing Center (ANCC) or the Texas Nurses Association (TNA) of any commercial product, service, or company referred to or displayed in conjunction with this activity, nor any company subsidizing costs related to this activity.
•Off-label Product Use: This CNE activity does not include any information about off-label use of any product for a purpose other than that for which it is approved by the U.S. Food and Drug Administration.
Page 1
Page 1 xxx00.#####.ppt 10/24/19 1:42:23 PM Objectives
A. Understand the pathophysiology of necrotizing enterocolitis (NEC)
B. Be able to explain and identify the signs and symptoms of NEC
C. Discuss medical treatment options for NEC
D. Identify the surgical patient
E. Understand the complications of NEC Case Presentation •Ex 32 weeker, spent 2 weeks in OSH NICU for feeding and growing
• Presented to EC at 4 weeks with non-bloody diarrhea ~ 10 episodes x 4 days with decreased PO intake
•Admitted for fluid resuscitation, monitoring electrolytes and ad lib feeding
Page 3
Page 3 xxx00.#####.ppt 10/24/19 1:42:24 PM Initial Physical Exam
•Vitals: Physical Exam: - BP 100/59 General: thin, tired - HR 141 Head: fontanelles slightly sunken - T 98.5F (36.9C) – rectal CV/Pulm: no respiratory distress, CTAB, RRR, good cap refill - RR 44 Abdomen: BS appreciated, soft, non- - SpO2 100% on RA distended, non-tender Neuro: tired, but wakes to cry
Page 4
Page 4 xxx00.#####.ppt 10/24/19 1:42:24 PM Two days after admission
•Bedside nurse concerned with appearance of infant and that he had not eaten in ~ 4 hours
•MD to bedside: exam was unremarkable besides child appearing pale with BG 275
• (9/3) “Approximately 20 minutes after I left the room, RN noted blood in his diaper with a rectal temp of 93F. On exam, belly distended. Grunting with respirations which was new. KUB ordered. BCx ordered. Called NICU MD on call ... She came to evaluate immediately. KUB c/w NEC. Transferred to NICU.”
Page 5
Page 5 xxx00.#####.ppt 10/24/19 1:42:25 PM CHAB
Page 6
Page 6 xxx00.#####.ppt 10/24/19 1:42:25 PM Defining Necrotizing Enterocolitis
“ …result of mucosal compromise in the presence of pathogenic bacteria … in a susceptible host. This leads to bowel injury and an inflammatory cascade.” – Pediatric Surgery NaT
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Page 7 xxx00.#####.ppt 10/24/19 1:42:26 PM Pathophysiology of NEC
•Genetic predisposition •Abnormal microbial colonization or dysbiosis •Intestinal immaturity -E.coli, Klebsiella, Enterobacter sp., Motility - Staphylococcus sp., -Absorption, digestion, and Clostridium sp. circulatory regulation •Exaggerated inflammatory -Mucosal physical barriers response (i.e. decreased gastric acid production) -Factors such as: TLR4, PAF, interleukin-8, COX- 2, PGE2
Page 8
Page 8 xxx00.#####.ppt 10/24/19 1:42:27 PM Pathophysiology continued
Open Closed
Page 9
Page 9 xxx00.#####.ppt 10/24/19 1:42:27 PM Risk Factors
Necrotizing enterocolitis is primarily a disease of prematurity
*Prematurity •Enteral feedings in preterm infants •Maternal eclampsia •Hypothermia •Hypoxia (congenital heart and lung disease) •Use of indomethacin and steroids •Neonatal sepsis •Gastrointestinal disease (i.e. gastroschisis)
Page 10
Page 10 xxx00.#####.ppt 10/24/19 1:42:28 PM Benefits of Breastfeeding
•Human breast milk includes antimicrobial and anti- inflammatory factors -Secretory immunoglobulins -Cytokines -Lactoferrin -Lysozymes -Growth factors
Page 11
Page 11 xxx00.#####.ppt 10/24/19 1:42:28 PM Just for fun
Is any one brave enough to shout out signs and symptoms that come to mind when you hear necrotizing enterocolitis?
Page 12
Page 12 xxx00.#####.ppt 10/24/19 1:42:29 PM Signs and symptoms
• Vital signs: •Temperature instability
•Bradycardia
•Apnea
• Hypotension
Page 13
Page 13 xxx00.#####.ppt 10/24/19 1:42:29 PM Signs and Symptoms continued
•Physical Exam: -Lethargy, and irritability -Abdominal distention and tenderness -Abdominal wall erythema/bruising - +/- Rectal bleeding - Feeding intolerance •Increased gastric residuals
Page 14
Page 14 xxx00.#####.ppt 10/24/19 1:42:30 PM Priority Nursing Assessment for the Prevention of NEC
Page 15
Page 15 xxx00.#####.ppt 10/24/19 1:42:30 PM Just for fun
What diagnosis should you think of first in an infant experiencing bilious emesis?
A. Duodenal atresia B. Necrotizing enterocolitis C. Malrotation with volvulus
Page 16
Page 16 xxx00.#####.ppt 10/24/19 1:42:31 PM Just for fun
What diagnosis should you think of first in an infant experiencing bilious emesis?
A. Duodenal atresia B. Necrotizing enterocolitis C. Malrotation with volvulus
Page 17
Page 17 xxx00.#####.ppt 10/24/19 1:42:31 PM Lab findings
• Abnormally high or low WBC • Evidence of DIC with left shift • Metabolic acidosis •Elevated CRP • +/- Gram negative blood •Thrombocytopenia cultures - Important to be trended
•High or low blood glucose
•Electrolyte imbalances
Page 18
Page 18 xxx00.#####.ppt 10/24/19 1:42:32 PM Radiologic findings
• Non-specific bowel dilatation • Thickening of bowel wall • Fixed, dilated loop (unchanged on > 1 radiograph) • Pneumatosis intestinalis • Portal venous gas • Pneumoperitoneum
Page 19
Page 19 xxx00.#####.ppt 10/24/19 1:42:32 PM Just for fun
Which radiologic finding is pathognomonic for necrotizing enterocolitis?
A. Fixed, dilated loop of bowel
B. Pneumatosis intestinalis
C. Pneumoperitoneum
Page 20
Page 20 xxx00.#####.ppt 10/24/19 1:42:32 PM Just for fun
Which radiologic finding is pathognomonic for necrotizing enterocolitis?
A. Fixed, dilated loop of bowel
B. Pneumatosis intestinalis
C. Pneumoperitoneum
Page 21
Page 21 xxx00.#####.ppt 10/24/19 1:42:33 PM Fixed Loop of Bowel
Page 22
Page 22 xxx00.#####.ppt 10/24/19 1:42:33 PM Pneumatosis Intestinalis
Page 23
Page 23 xxx00.#####.ppt 10/24/19 1:42:34 PM Portal Venous Gas Pneumoperitoneum
Page 24
Page 24 xxx00.#####.ppt 10/24/19 1:42:34 PM Modified Bell’s Criteria
Page 25
Page 25 xxx00.#####.ppt 10/24/19 1:42:35 PM Medical Treatment
•Bowel rest
•Sump orogastric decompression
•IV fluid resuscitation
•TPN/IL
•Broad spectrum antibiotics (triple antibiotic therapy) -Antibiotic therapy 10-14 days
Page 26
Page 26 xxx00.#####.ppt 10/24/19 1:42:36 PM Indications for Surgery
•Absolute indication: pneumoperitoneum
•Relative indications: 1. Abdominal wall cellulitis and edema 2. Persistent dilated, fixed loop of bowel on x-ray 3. Clinical deterioration i.e. hemodynamic instability, increasing ventilatory support, worsening laboratory abnormalities
Page 27
Page 27 xxx00.#####.ppt 10/24/19 1:42:36 PM Surgery
First Surgery Second Surgery
Page 28
Page 28 xxx00.#####.ppt 10/24/19 1:42:36 PM Just for fun
What is the most common location of intestine to be affected by NEC?
A. Duodenum B. Ileocecum C. Sigmoid colon
Page 29
Page 29 xxx00.#####.ppt 10/24/19 1:42:37 PM Just for fun
What is the most common location of intestine to be affected by NEC?
A. Duodenum B. Ileocecum C. Sigmoid colon
Page 30
Page 30 xxx00.#####.ppt 10/24/19 1:42:38 PM For Comparison
Page 31
Page 31 xxx00.#####.ppt 10/24/19 1:42:38 PM Complications
•Wound separation or dehiscence
•Stoma complications (stricture, necrosis, prolapse, and retraction)
•Intestinal strictures
•Intestinal failure associated liver disease
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Page 32 xxx00.#####.ppt 10/24/19 1:42:39 PM Wound Separation or dehiscence
• Definitions of the vocabulary • Diagnosed: Clinically • Treatment: depends (medical vs. surgical)
Page 33
Page 33 xxx00.#####.ppt 10/24/19 1:42:40 PM Stoma Complications
•Stricture - Diagnosed: clinically +/- imaging - Treatment: typically surgery is indicated
•Necrosis - Diagnosed: Clinically - Treatment: depends on the depth of the necrosis •Typically will slough off
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Page 34 xxx00.#####.ppt 10/24/19 1:42:40 PM Stoma Complications
•Prolapse - Diagnosed: clinically - Treatment: Depends on the severity of the prolapse
•Retraction - Diagnosed: clinically - Treatment: Depends on the severity of the retraction
Page 35
Page 35 xxx00.#####.ppt 10/24/19 1:42:41 PM Intestinal stricture
•Cause: result of fibrotic healing and scarring of an ischemic area
•Diagnosed: UGI with small bowel follow through
•Treatment: Surgical
Page 36
Page 36 xxx00.#####.ppt 10/24/19 1:42:41 PM Intestinal failure associated liver disease
•Diagnosed: trending bilirubin levels (> 2.0 mg/dL x 2 weeks)
•Causes: - Prolonged exposure to total parental nutrition - Extensive small bowel resections - lack of enteral feeding, which leads to reduced gut hormone secretion; reduction of bile flow and biliary stasis
•Treatment - Limit lipid use in TPN by using fish oil (Omegaven) - If able to start a feeding regimen, this has shown to decrease the rate by 40%
Page 37
Page 37 xxx00.#####.ppt 10/24/19 1:42:42 PM Short Bowel Syndrome
•Consequence of a large bowel resection
•Historically: if > 40 cm of bowel remaining, then can have eventual transition to oral feeds
•Actuality: depends on the health, function, and location, versus the absolute length of the remaining bowel
•Intestinal rehabilitation
Page 38
Page 38 xxx00.#####.ppt 10/24/19 1:42:42 PM Case presentation continued
Page 39
Page 39 xxx00.#####.ppt 10/24/19 1:42:43 PM Case presentation continued
(9/5) – Exploratory Laparotomy “Findings: Patchy necrotic bowel from ligament of Trietz to last 15cm of terminal ileum. Colon not involved.”
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Page 40 xxx00.#####.ppt 10/24/19 1:42:44 PM Case presentation continued
(9/7) – Second look exploratory laparotomy “Findings: Multiple areas of necrotic bowel. No perforation. 56cm resected, 59cm remaining.”
Page 41
Page 41 xxx00.#####.ppt 10/24/19 1:42:44 PM Case Conclusion
•Patient is 2 years old today -Consumes a regular diet and NOT ON TPN • lactose intolerance -Speech delay -Flagyl for 2 weeks/month
Page 42
Page 42 xxx00.#####.ppt 10/24/19 1:42:45 PM Future Considerations
•Use of probiotics -Mechanism: •Alter the composition of gut microbiota •Decrease the pro-inflammatory response •Decrease the permeability of the mucosa •Effects bacterial metabolites
Page 43
Page 43 xxx00.#####.ppt 10/24/19 1:42:45 PM Pathophysiology continued
Open Closed
Page 44
Page 44 xxx00.#####.ppt 10/24/19 1:42:46 PM Future considerations
•Use of probiotics *Not currently FDA approved in the US -Goal: promote the formation of a beneficial and protective intestinal microbiome -Concern: introducing live bacteria into a preemie gut could potentially cause bacteremia -Problems: since probiotics are not FDA regulated, finding standards to implement this regimen are difficult
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Page 45 xxx00.#####.ppt 10/24/19 1:42:47 PM References
• Agnoni, A MS, PA-C, C. Amendola MS, PA-C. (2017). Necrotizing enterocolitis: Current concepts in practice. Journal American Academy of Physician Assistants. 30(8), 16-21.
• Frothingham.S. Reviewed by Moyer, N. MD. (2018). Wound Dehiscense: When an Incision Reopens. Healthline. Retrieved from https://www.healthline.com/health/wound- dehiscence.
• Gregory, K. RN and DeForge, C. RN. (2011). Necrotizing enterocolitis in the premature infant. Adv Neonatal Care. 2011 Jun; 11(3): 155–166.
• Kelly, GA. (2006) Intestinal failure-associated liver disease: what do we know today? Gastroenterology. 2006 Feb;130(2 Suppl 1):S70-7.
• Neu, J. MD & Walker, W.A. MD. (2011). Medical Progress Necrotizing Enterocolitis. The New England Journal of Medicine, 364 (3).
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Page 46 xxx00.#####.ppt 10/24/19 1:42:47 PM References
• Olson, J. MD et al. (May 2019). Necrotizing Enterocolitis. Pediatric Surgery Library. Retrieved from https://www.pedsurglibrary.com/apsa/view/Pediatric-Surgery-NaT
• Patel, R. MD & Underwood, M. MD. (2018). Probiotics and necrotizing enterocolis. Seminars in Pediatric Surgery. 27(1), 39-46.
• Patel, R. MD & Underwood, M. MD. (2019, June). Probiotics and the Prevention of Necrotizing Enterocolitis, Sepsis and Death. NEC Symposium. Talk presented at 2019 of NEC Symposium, Ann Arbor, MI.
• Thakker, H. & Lakhoo, K. (2018). Necrotizing Enterocolitis. Paediatrics and Child Health, 28(5), p.227-230.
• Thakkar, H., & Lakhoo, K. (2016). The surgical management of necrotizing enterocolitis (NEC). Early Human Development. P25-28
• UCSF Children’s Hospital (2004). Necrotizing Enterocolitis, Intensive Care Nursery House Staff Manual. San Francisco, CA: UCSF Children’s Hospital at UCSF Medical Center
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Page 47 xxx00.#####.ppt 10/24/19 1:42:47 PM Questions