Necrotizing Enterocolitis: Diagnosis and Management

by Kevin Pei, MD

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    00:01 Here's an abdominal x-ray.

    00:03 In this x-ray, the baby is lying supine on the back.

    00:07 Note the distended loops of intestines.

    00:11 Here's another view.

    00:13 This is what we call commonly a babygram.

    00:16 You see the entire baby on the x-ray.

    00:18 And again, note, there are multiple loops of dilated bowel.

    00:22 How do we manage these patients with NEC (or necrotizing enterocolitis)? Initially, it's mostly medical.

    00:29 If this is bottle-feed or feeds, in general, induced, we discontinue feeds and make the patient NPO (nothing by mouth).

    00:38 Sometimes, the baby requires NG tube and bowel rest.

    00:43 We initiate broad-spectrum antibiotics, covering broadly for gram-negative rods and anaerobic organisms.

    00:52 And because the nutrition to the baby is of utmost importance and we can't right away use the bowel, you should consider TPN on these patients.

    01:04 However, if the patient is clinically deteriorating, has hemodynamic instability, those are indications for surgery.

    01:14 Pneumoperitoneum suggests that there was a perforation or ischemic bowel.

    01:19 Any pneumoperitoneum requires exploratory laparotomy.

    01:24 And as I mentioned, if the baby has progressive clinical deterioration, as evidenced by septic shock or hypotension, that may also warrant surgery.

    01:35 Now, if you're presented with this scenario, again, pneumoperitoneum, signs of perforation or progressive clinical deterioration, the next step of management should be should be surgery.

    01:49 I’d like to pose a question to you.

    01:51 What if your patient has continued hypotension and is progressively lethargic? What would you do? I’ll give you a second to think about this.

    02:02 That's right.

    02:03 Absolutely take the patient to the operating room.

    02:05 Don't stop at radiology.

    02:07 Don't get any workup.

    02:08 These patients require exploratory laparotomy.

    02:15 Now, let's review some very important clinical pearls and high-yield information for your examination.

    02:20 Remember, you need to have a high index of suspicion if your newborn is not tolerating feeds and has clinical deterioration.

    02:28 Don't wait for late signs such as septic shock or abdominal wall erythema to diagnose necrotizing enterocolitis.

    02:37 For your examination, remember that the next step of management is not surgery.

    02:43 It's usually to start with medical management and supportive care.

    02:47 However, as a reminder, if the scenario changes and the patient has clinical deterioration, or you suspect that there's ischemic bowel, by all means, take the patient to the operating room for an exploratory laparotomy.

    03:02 Thank you very much for joining me on this discussion of necrotizing enterocolitis.

    About the Lecture

    The lecture Necrotizing Enterocolitis: Diagnosis and Management by Kevin Pei, MD is from the course Special Surgery.

    Included Quiz Questions

    1. Pneumoperitoneum detected by abdominal imaging
    2. Preterm infants with a gestational age <32 weeks
    3. Dilated loops of bowel detected by abdominal imaging
    4. Laboratory evaluation showing thrombocytosis and eosinophilia
    5. Patients who cannot tolerate oral intake
    1. Intravenous corticosteroids
    2. Broad-spectrum antibiotics
    3. Bowel rest
    4. Fluid replacement
    5. Total parenteral nutrition

    Author of lecture Necrotizing Enterocolitis: Diagnosis and Management

     Kevin Pei, MD

    Kevin Pei, MD

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