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GOOD MORNING!!Tuesday, July 17, 2012
Symptoms
Acute /subacute Chronic
Localized Diffuse
Single Multiple
Static Progressive
Constant Intermittent
Single Episode Recurrent
Abrupt Gradual
Severe Mild
Painful Nonpainful
Bilious Nonbilious
Sharp/Stabbing Dull/Vague
Problem Characteristics
Ill-appearing/Toxic
Well-appearing/Non-toxic
Localized problem
Systemic problem
Acquired Congenital
New problem Recurrence of old problem
Semantic Qualifiers
Illness Script
Predisposing ConditionsAge, gender, preceding events (trauma, viral illness,
etc), medication use, past medical history (diagnoses, surgeries, etc)
Pathophysiological InsultWhat is physically happening in the body, organisms
involved, etc. Clinical Manifestations
Signs and symptoms Labs and imaging
NEC: Predisposing Conditions Prematurity (<34WGA) Weight < 1500g Enteral feedings
Congenital heart disease Hypoxic-ischemic event
~10% of cases occur in term infantsTypically have a preexisting illness: CHD, Sepsis,
Seizures, Hypoglycemia, Severe IUGR, Hypercoagulable state, Gastroschisis, Congenital HSV
NEC: Pathophysiology
Multiple contributing factors Ischemic necrosis of intestinal mucosa
InflammationInvasion of enteric gas forming organismsDissection of gas into the muscularis and
portal venous system
NEC: Clinical Manifestations**
Classic Symptoms Abdominal distension Increased gastric aspirates/emesis Heme-positive stoolsSystemic Symptoms Lethargy Temperature instability Increased As/Bs Respiratory failure Bacteremia (in 20-30%)
Diagnosis
For any patient with clinical findings suggestive of NEC prompt evaluation including: Abdominal radiographsLab studies
○ CBC, electrolytes, blood gas, +/-coags○ Stool analysis
Abdominal Radiographs Two views
SupineLeft lateral decubitus
or cross-table lateral
Q 8 to 12 hours
Early sign: persistently dilated bowel loops
Pneumatosis intestinalis**
Abdominal Radiographs
Football sign Portal venous gas
Abdominal Radiographs
FREE AIR!!
Labs CBC
Leukocytosis, bandemiaNeutropeniaThrombocytopenia
CoagsNot routine, but obtain if infant has thrombocytopenia or
bleeding (r/o DIC) Serum chemistries
Hyponatremia, hyperkalemia, increasing glucose levels, and metabolic acidosis suggest necrotic bowel or sepsis
Sepsis evaluationBlood cx, stool cx, CSF cx (if indicated)
Management**
Medical managementSupportive care
○ Bowel restStop feeds, Gastric decompression, TPN
○ Correction of hematologic and metabolic abnormalities
Antibiotic therapyClose lab and radiologic monitoring
Surgical consult1/3 of patients will need intervention
Antibiotic therapy Empiric regimens to provide coverage
for pathogens that cause late-onset bacteremia
Anaerobic coverage should be considered Especially if perforation or necrosis is
suspected Recommended regimens
Vanc + gent + clindaVanc + gent + metronidazoleVanc + gent + piperacillin-tazobactam
Complications**
AcuteInfectious
○ Sepsis, peritonitis, abscessDICHypotension, shock, resp. failure
LateStricture formation**If bowel resection necessary: short bowel
syndrome, FTT, hyperalimentation hepatitis
Status Epilepticus, Dr. McGuire
Noon Conference
Have a great day!!