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Roberts AG, Younge N, Greenberg RG. Neonatal Necrotizing Enterocolitis: An Update on Pathophysiology, Treatment, and Prevention. Paediatr Drugs 2024; 26:259-275. [PMID: 38564081 DOI: 10.1007/s40272-024-00626-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/04/2024]
Abstract
Necrotizing enterocolitis (NEC) is a life-threatening disease predominantly affecting premature and very low birth weight infants resulting in inflammation and necrosis of the small bowel and colon and potentially leading to sepsis, peritonitis, perforation, and death. Numerous research efforts have been made to better understand, treat, and prevent NEC. This review explores a variety of factors involved in the pathogenesis of NEC (prematurity, low birth weight, lack of human breast milk exposure, alterations to the microbiota, maternal and environmental factors, and intestinal ischemia) and reports treatment modalities surrounding NEC, including pain medications and common antibiotic combinations, the rationale for these combinations, and recent antibiotic stewardship approaches surrounding NEC treatment. This review also highlights the effect of early antibiotic exposure, infections, proton pump inhibitors (PPIs), and H2 receptor antagonists on the microbiota and how these risk factors can increase the chances of NEC. Finally, modern prevention strategies including the use of human breast milk and standardized feeding regimens are discussed, as well as promising new preventative and treatment options for NEC including probiotics and stem cell therapy.
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2
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Hosokawa T, Tanami Y, Sato Y, Nomura K, Oguma E. Association between the dynamic movement of hyperechoic foci and patients'/sonographic outcomes among pediatric patients with portal venous gas following a cardiac event. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023. [PMID: 37262363 DOI: 10.1002/jcu.23496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/12/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To demonstrate the association between the dynamic movements of hyperechoic foci in portal venous gas (PVG) and patients'/sonographic outcomes after congenital heart disease or cardiac events. METHODS Thirty-one pediatric patients requiring management of congenital heart diseases or cardiac events who had PVG on ultrasound were included in this retrospective study. The patient outcome was prognosis: dead or alive. The sonographic outcome was recovery from PVG, measured as days from PVG detection to when it diminished on ultrasound. The following sonographic findings of hyperechoic foci in PVG were compared between patients: detection within the mesenteric vein, having to-and-fro movements within the intrahepatic portal vein, distribution (left segment or both left and right segments) and shape (line or punctate) in the liver, and detection within the portal and hepatic veins. Comparisons were made using Fisher's exact/Mann-Whitney U test. RESULTS Four patients died without having recovered from PVG. A significant difference was observed in terms of the to-and-fro movement (with/without to-and-fro movement in dead vs. alive patients: 3/1 vs. 1/26, respectively; P = 0.003). Furthermore, a significant difference in sonographic outcomes was observed regarding patients with/without hyperechoic foci within the mesenteric vein (days with vs. without this finding: 2.0 ± 1.24(1-5) vs.1 ± 0(1), respectively; P = 0.011). CONCLUSIONS In our small limited cohort, when PVG was visualized on ultrasound, close evaluation of the dynamic movement of hyperechoic foci, especially their to-and-fro movement within the intrahepatic portal vein and detection of hyperechoic foci within the mesenteric vein, were useful in predicting patients' outcomes and the time to PVG diminishment.
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Affiliation(s)
- Takahiro Hosokawa
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yutaka Tanami
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Yumiko Sato
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
| | - Koji Nomura
- Department of Cardiovascular Surgery, Saitama Children's Medical Center, Saitama, Japan
| | - Eiji Oguma
- Department of Radiology, Saitama Children's Medical Center, Saitama, Japan
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Abstract
Necrotizing enterocolitis is a severe gastrointestinal disease of the infant. It most commonly targets those that are born prematurely. NEC has been associated with initiation of feeds and in most cases, it can be managed with antibiotics and bowel rest. However, in up to half of the cases, intestinal perforation, peritonitis, and failure of medical treatment will require surgical intervention. The following review will discuss the surgical approach to managing NEC, based on an updated review of practice patterns and recently published literature.
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The effect of single ventricle congenital heart disease on recurrence risk of pneumatosis intestinalis in neonates. Pediatr Surg Int 2022; 38:1399-1404. [PMID: 35852591 DOI: 10.1007/s00383-022-05171-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/06/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Congenital heart disease (CHD) is a risk factor for the development of pneumatosis intestinalis (PI). Patients with single ventricle physiology (SVP) may be at higher risk of developing PI secondary to variations in systemic blood flow which affect bowel perfusion when compared to patients with biventricular physiology (BVP). We hypothesized that patients with SVP would have increased risk of recurrent PI. METHODS A retrospective review was done from 10/2014 through 05/2020 with patients that met the following criteria: CHD, radiographic evidence of PI, and less than 1 year of age. Groups were divided based on ventricular physiology. Primary outcome was radiographic recurrence of PI and secondary outcomes were average antibiotic duration, NPO duration, median length of stay, need for GI operation, and death from PI. RESULTS A total of 51 patients were included, 34 with SVP and 17 with BVP. 26.47% of SVP had recurrence of PI whereas no BVP experienced a recurrence of PI. There was no significant difference in any of the secondary outcomes. CONCLUSION Our data suggest that patients with SVP are more likely to have recurrence of radiographic PI. We may need to consider patients with SVP that get PI as their own separate group.
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Chen J, Zhong W, Hou L, Lin T, Lyv J, Tian Y, Ma Z, He Q, Zhong W. Predictive factors for rapid progression in preterm neonates with necrotizing enterocolitis. Front Pediatr 2022; 10:970998. [PMID: 36699309 PMCID: PMC9869057 DOI: 10.3389/fped.2022.970998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a devastating gastrointestinal emergency with significant mortality and morbidity rates. A subset of patients progressed rapidly and underwent surgical intervention within a short period. This study aimed to establish a model to predict the rapid progression of NEC in preterm neonates. METHODS A retrospective study was conducted to review neonates with NEC between December 2015 and April 2019 at the Guangzhou Women and Children's Medical Center. Rapidly progressive NEC was defined as the need for surgical intervention or death within 48 h of NEC onset. Patients were divided into two groups: rapidly progressive NEC (RP-NEC) and non-rapidly progressive NEC (nRP-NEC). Data on demographics, perinatal characteristics, examination variables, and radiographic findings at onset were collected. RESULTS A total of 216 preterm neonates with NEC were included in the study, of which 64 had RP-NEC and 152 had nRP-NEC. The mortality rates of patients with RP-NEC and nRP-NEC were 32.8% and 3.28%, respectively. Male sex (p-value, adjusted odds ratio [95% confidence interval]: 0.002, 3.43 [1.57, 7.53]), portal venous gas (0.000, 8.82 [3.73, 20.89]), neutrophils <2.0 × 109/L (0.005, 4.44 [1.59, 12.43]), pH <7.3 (7.2 ≤ pH < 7.3) (0.041, 2.95 [1.05, 8.31]), and pH <7.2 (0.000, 11.95 [2.97, 48.12]) at NEC onset were identified as independent risk factors for RP-NEC. An established model that included the four risk factors presented an area under the curve of 0.801 with 83% specificity and 66% sensitivity. CONCLUSION Among preterm neonates with NEC, a significantly higher mortality rate was observed in those with rapid progression. It is recommended that close surveillance be performed in these patients, and we are confident that our established model can efficiently predict this rapid progression course.
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Affiliation(s)
- Jiale Chen
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Weitao Zhong
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Longlong Hou
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Tulian Lin
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Junjian Lyv
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yan Tian
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Zuyi Ma
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Qiuming He
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wei Zhong
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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6
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Cho A, Ko D, Youn J, Yang HB, Kim HY. Characteristics of Surgical Necrotizing Enterocolitis: Is It Different from Medical Necrotizing Enterocolitis? A Single-Center Retrospective Study. CHILDREN 2021; 8:children8121148. [PMID: 34943344 PMCID: PMC8700107 DOI: 10.3390/children8121148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/16/2021] [Accepted: 12/04/2021] [Indexed: 11/16/2022]
Abstract
(1) Background: Necrotizing enterocolitis (NEC) is one of the leading causes of death in newborns despite improvements in the care of critically ill neonates. Approximately 50–70% of the cases are managed by medical therapy. However, the remaining patients require surgical intervention. The purpose of our study was to analyze the factors associated with patients requiring surgical treatment compared to patients requiring only medical treatment; (2) Method: Patients diagnosed with necrotizing enterocolitis over a period of 14 years (January 2003–December 2016) in a single tertiary referral children’s hospital were retrospectively enrolled. Demographics and clinical data were collected through the medical record and were analyzed using Pearson’s χ2 test, t-tests, and linear regression; (3) Results: A total of 189 NEC patients were analyzed. In the surgical NEC group, gestational age was lower (p = 0.018), body weight at birth was lower (p = 0.034), comorbidity with respiratory distress syndrome (RDS) was higher (p = 0.005), the days of antibiotic use were greater (p = 0.014), the percentage of breast milk feeding was lower (p = 0.001), and the length of hospital stay was longer (p < 0.000). The in-hospital mortality between the two groups was not significantly different (p = 0.196). In multivariate logistic analysis, breast milk feeding remained less associated with surgical NEC (OR = 0.366, 95% CI: 0.164–0.817), whereas the length of hospital stay was more associated with surgical NEC (OR = 1.010, 95% CI: 1.001–1.019); (4) Conclusion: Comparing medical and surgical NEC, a significantly lower percentage of surgical NEC patients were fed breast milk and their hospital stays were longer.
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Affiliation(s)
- Ara Cho
- Department of Surgery, Division of Pediatric Surgery, Seoul National University Hospital, 101 Daehakro, Chongno-gu, Seoul 03080, Korea; (A.C.); (D.K.); (J.Y.)
| | - Dayoung Ko
- Department of Surgery, Division of Pediatric Surgery, Seoul National University Hospital, 101 Daehakro, Chongno-gu, Seoul 03080, Korea; (A.C.); (D.K.); (J.Y.)
| | - JoongKee Youn
- Department of Surgery, Division of Pediatric Surgery, Seoul National University Hospital, 101 Daehakro, Chongno-gu, Seoul 03080, Korea; (A.C.); (D.K.); (J.Y.)
| | - Hee-Beom Yang
- Department of Surgery, Division of Pediatric Surgery, Seoul National University Bundang Hospital, 82, Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si 13620, Korea;
| | - Hyun-Young Kim
- Department of Surgery, Division of Pediatric Surgery, Seoul National University Hospital, 101 Daehakro, Chongno-gu, Seoul 03080, Korea; (A.C.); (D.K.); (J.Y.)
- Correspondence: ; Tel.: +82-2-2072-2478
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Yuan K, Chen QQ, Zhu YL, Luo F. Hepatic portal venous gas without definite clinical manifestations of necrotizing enterocolitis in a 3-day-old full-term neonate: A case report. World J Clin Cases 2021; 9:9269-9275. [PMID: 34786413 PMCID: PMC8567523 DOI: 10.12998/wjcc.v9.i30.9269] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 06/20/2021] [Accepted: 08/30/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Neonatal hepatic portal venous gas (HPVG) is associated with a high risk of necrotizing enterocolitis (NEC) and was previously believed to be associated with an increased risk of surgery.
CASE SUMMARY A 3-day-old full-term male infant was admitted to the pediatrics department after presenting with “low blood glucose for 10 min”. Hypoglycemia was corrected by intravenous glucose administration and oral breast milk. On the 3rd d after admission, an ultrasound examination showed gas accumulation in the hepatic portal vein; this increased on the next day. Abdominal vertical radiograph showed intestinal pneumatosis. Routine blood examination showed that the total number of white blood cells was normal, but neutrophilia was related to age. There was a significant increase in C-reactive protein (CRP). The child was diagnosed with neonatal NEC (early-stage). With nil per os, rehydration, parenteral nutritional support, and anti-infection treatment with no sodium, his hepatic portal vein pneumatosis resolved. In addition, routine blood examination and CRP examination showed significant improvement and his symptoms resolved. The patient was given timely refeeding and gradually transitioned to full milk feeding and was subsequently discharged. Follow-up examination after discharge showed that the general condition of the patient was stable.
CONCLUSION The presence of HPVG in neonates indicates early NEC. Early active anti-infective treatment is effective in treating NEC, minimizes the risk of severe NEC, and reduces the need for surgery. The findings of this study imply that early examination of the liver by ultrasound in a sick neonate can help with the early diagnosis of conditions such as NEC.
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Affiliation(s)
- Ke Yuan
- Department of Pediatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Qing-Qing Chen
- Department of Pediatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Yi-Lin Zhu
- Department of Pediatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
| | - Fang Luo
- Department of Pediatrics, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, Zhejiang Province, China
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Syed MK, Al Faqeeh AA, Saeed N, Almas T, Khedro T, Niaz MA, Kanawati MA, Hussain S, Mohammad H, Alshaikh L, Alshaikh L, Abdulhadi A, Alshamlan A, Syed S, Mohamed HKH. Surgical Versus Medical Management of Necrotizing Enterocolitis With and Without Intestinal Perforation: A Retrospective Chart Review. Cureus 2021; 13:e15722. [PMID: 34295576 PMCID: PMC8290905 DOI: 10.7759/cureus.15722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/05/2022] Open
Abstract
Background Necrotizing enterocolitis (NEC) is a debilitating disease that predominantly afflicts premature neonates, although it can also affect term neonates. The clinical features of the ailment vary widely and range from transient feed intolerance to life-threatening complications such as septicemia and disseminated intravascular coagulation. While surgery is usually only reserved for severe cases, such as those presenting with intestinal perforation, the role of surgical management in cases of NEC without perforation remains elusive. Methods A retrospective chart review of patients, three years in duration, was conducted and studied confirmed cases of NEC. The clinical presentations studied included cases of NEC with pneumatosis intestinalis, fixed bowel loop, pneumoperitoneum, and abdominal wall erythema. The patients were divided with regards to their intestinal perforation status and with pertinence to the treatment modality employed (medical or surgical). The results in either group were eventually analyzed in terms of the overall survival rate. Results A total of 48 patients were included in the study, of which 79.16% presented without perforation and 20.83% with perforation. Of the study participants included, 26 were females and 22 were males. Pertinently, no gender predominance was appreciated. In patients without perforation, medical management was noted to boast a lower mortality rate when compared with surgical intervention (15.6% vs 50.0%, respectively). In patients with perforation, the overall mortality was noted to hover at 50.0%, which was higher than that encountered in the non-perforation group. Conclusion In patients with NEC without perforation, surgical treatment confers no comparative therapeutic advantage when compared with medical management alone. Conservative management with broad-spectrum antibiotics including metronidazole yields equally favorable outcomes in such cases.
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Affiliation(s)
| | | | - Noman Saeed
- Neonatology, King Fahad Hospital, Al Baha, SAU
| | - Talal Almas
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Tarek Khedro
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Muhammad Ali Niaz
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - M Ali Kanawati
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Salman Hussain
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Hussain Mohammad
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Lamees Alshaikh
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | - Lina Alshaikh
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
| | | | | | - Saifullah Syed
- Internal Medicine, Royal College of Surgeons in Ireland, Dublin, IRL
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Chen CC, Chen Y, Zhang YX, Chen ZH, Yang K. Case Report: A Rare Condition of Abdominal Pain: Chemotherapy Induced Portal Vein Pneumatosis Mimicking the Bowel Necrosis. Front Surg 2021; 8:620908. [PMID: 33693027 PMCID: PMC7938891 DOI: 10.3389/fsurg.2021.620908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/05/2021] [Indexed: 02/05/2023] Open
Abstract
Portal vein pneumatosis is the presence of air in the portal venous system, which is one of the classic radiologic features of bowel ischemia or necrosis. However, there are several other morbidities that can have portal vein pneumatosis as a complication. This is a case of a 44-year-old man who suffered from severe abdominal pain after chemotherapy for soft tissue sarcoma of his left hip. The physical signs, laboratory findings, as well as the portal venous pneumatosis sign of the CT scan strongly indicated the probability of bowel necrosis and subjected the treatment decision of the patient finally to laparotomy. However, nothing abnormal except a segment of swollen small intestine was detected. Caution should be kept in mind when encountering a patient with suspected bowel necrosis following chemotherapy since several chemotherapeutic agents could cause portal vein pneumatosis. Diagnostic laparoscopy might be a better option for such cases.
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Affiliation(s)
- Chong-Cheng Chen
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Chen
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yue-Xin Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ze-Hua Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Kun Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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Knudsen KBK, Thorup J, Thymann T, Strandby R, Nerup N, Achiam MP, Lauritsen T, Svendsen LB, Buelund L, Sangild PT, Ifaoui IBR. Laparoscopy to Assist Surgical Decisions Related to Necrotizing Enterocolitis in Preterm Neonates. J Laparoendosc Adv Surg Tech A 2019; 30:64-69. [PMID: 31874058 DOI: 10.1089/lap.2018.0180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Aim of the Study: Necrotizing enterocolitis (NEC) is a devastating intestinal disease that mainly affects preterm infants. Despite advancements in neonatal care, mortality of NEC remains high and controversies exist regarding the most appropriate time for surgical intervention and challenging of diagnosing NEC. Using a pig model of NEC, we aimed to examine if laparoscopy is feasible for diagnosis of NEC. Methods: Preterm caesarean-delivered piglets (n = 42) were fed with increasing amounts of infant formula up to 5 days to induce NEC. On days 3-5, we examined the intestine by laparoscopy under general anesthesia. The bowel was examined by tilting the pigs from supine position to the left and right side. Macroscopic NEC lesions were identified and graded according to a macroscopic scoring system, then a laparotomy was performed to rule out any organ injury and missed NEC lesions. Results: Visible NEC lesions (scores 4-6) were found in 26% (11/42) of the piglets. A positive predictive value of 100% was found for laparoscopy as a diagnostic marker of NEC in both colon and the small intestine. One piglet had a higher NEC score in the small intestine found at laparotomy, than at laparoscopy, resulting in a sensitivity of 67%, and a specificity of 100% for the small intestine. Conversely, both the sensitivity and specificity for colon was 100%. Acceptable levels of agreement was found, with minimal proportional bias in both colon and the small intestine for laparoscopy and laparotomy. Ultrasound examination had a lower sensitivity of 67% and specificity of 63%. All piglets were respiratory and circulatory stable during the procedure. Conclusions: In preterm piglets, laparoscopy is a feasible tool to diagnose NEC with a high positive predictive value and a high specificity.
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Affiliation(s)
- Kristine Bach Korsholm Knudsen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark
| | - Jorgen Thorup
- Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Thymann
- Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Rune Strandby
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Nikolaj Nerup
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Michael Patrick Achiam
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Torsten Lauritsen
- Department of Anesthesiology, The Juliane Marie Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Lars Bo Svendsen
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Buelund
- Section of Diagnostic Imaging, Department of Veterinary Clinical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Torp Sangild
- Section for Comparative Pediatrics and Nutrition, IVH, University of Copenhagen, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Inge Botker Rasmussen Ifaoui
- Department of Surgical Gastroenterology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Pediatric Surgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Hirose R, Kai H, Inatomi K, Iwanaka T, Morishima N, Ikeda M, Masaki R, Iwasaki A. Portal venous gas in intestinal malrotation with mild midgut volvulus. Surg Case Rep 2019; 5:141. [PMID: 31520296 PMCID: PMC6744531 DOI: 10.1186/s40792-019-0700-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/30/2019] [Indexed: 12/02/2022] Open
Abstract
Background Portal venous gas has been considered as a radiological sign requiring urgent operative intervention; however, the reports concerning portal venous gas associated with favorable outcome are recently increasing. Case presentation We describe a 9-month-old boy with acute onset high fever and vomiting. The ultrasonography demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein. Contrast-enhanced CT, performed 1 h later from echography, revealed a whirlpool sign suggesting an intestinal malrotation with midgut volvulus, but with no signs of residual intrahepatic gas. Operative findings showed a mild volvulus with neither congestion nor ischemic change of the twisted bowel. Detorsion and Ladd’s procedure were completed laparoscopically. Conclusions Transient portal venous gas bubbles may be generated even in the mild intestinal volvulus with no bowel ischemia. Ultrasonography can be a sensitive detector to visualize such small amounts of gas. Electronic supplementary material The online version of this article (10.1186/s40792-019-0700-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ryuichiro Hirose
- Department of General Thoracic, Breast, and Pediatric Surgery, Fukuoka University, 7-45-1, Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan.
| | - Hiroki Kai
- Department of General Thoracic, Breast, and Pediatric Surgery, Fukuoka University, 7-45-1, Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Kaori Inatomi
- Department of General Thoracic, Breast, and Pediatric Surgery, Fukuoka University, 7-45-1, Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Tsuyoshi Iwanaka
- Department of General Thoracic, Breast, and Pediatric Surgery, Fukuoka University, 7-45-1, Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
| | - Naomi Morishima
- Division of Pediatrics, Fukuoka Central Hospital, 2-6-11, Yakuin Chuo-ku, Fukuoka, 810-0022, Japan
| | - Momotoshi Ikeda
- Division of Radiological Technologist, Fukuoka Central Hospital, 2-6-11, Yakuin Chuo-ku, Fukuoka, 810-0022, Japan
| | - Reiko Masaki
- Division of Radiological Technologist, Fukuoka Central Hospital, 2-6-11, Yakuin Chuo-ku, Fukuoka, 810-0022, Japan
| | - Akinori Iwasaki
- Department of General Thoracic, Breast, and Pediatric Surgery, Fukuoka University, 7-45-1, Nanakuma Jonan-ku, Fukuoka, 814-0180, Japan
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12
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Diminished DEFA6 Expression in Paneth Cells Is Associated with Necrotizing Enterocolitis. Gastroenterol Res Pract 2018; 2018:7345426. [PMID: 30420878 PMCID: PMC6215571 DOI: 10.1155/2018/7345426] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 08/28/2018] [Indexed: 01/05/2023] Open
Abstract
Background Necrotizing enterocolitis (NEC) is the most common gastrointestinal disorder in premature infants with a high morbidity and mortality. Paneth cell dysfunction has been suggested to be involved in the pathogenesis of NEC. Defensin alpha-6 (DEFA6) is a specific marker for Paneth cells acting as part of the innate immunity in the human intestines. The aim of this study was to investigate the expression of DEFA6 in infants with NEC. Materials and Methods Infants who underwent bowel resection for NEC at level III NICU in Sweden between August 2004 and September 2013 were eligible for the study. Macroscopically vital tissues were selected for histopathological evaluation. All infants in the control group underwent laparotomy and had ileostomy due to dysmotility, and samples were taken from the site of the stoma. DEFA6 expression was studied by immunohistochemistry. Digital image analysis was used for an objective and precise description of the samples. Results A total of 12 infants were included in the study, eight with NEC and four controls. The tissue samples were taken from the colon (n = 1), jejunum (n = 1), and ileum (n = 10). Both the NEC and control groups consisted of extremely premature and term infants (control group: 25-40 gestational weeks, NEC group: 23-39 gestational weeks). The postnatal age at the time of surgery varied in both groups (control group: 4-47 days, NEC group: 4-50 days). DEFA6 expression in the NEC group was significantly lower than that in the control group and did not correlate with gestational age. Conclusion The diminished DEFA6 expression in Paneth cells associated with NEC in this study supports the hypothesis that alpha-defensins are involved in the pathophysiology of NEC. Future studies are needed to elucidate the role of alpha-defensins in NEC aiming at finding preventive and therapeutic strategies against NEC.
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Palleri E, Aghamn I, Bexelius TS, Bartocci M, Wester T. The effect of gestational age on clinical and radiological presentation of necrotizing enterocolitis. J Pediatr Surg 2018; 53:1660-1664. [PMID: 29079313 DOI: 10.1016/j.jpedsurg.2017.09.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 09/16/2017] [Accepted: 09/17/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND/PURPOSE To test the hypothesis that clinical and radiological features of necrotizing enterocolitis vary with gestational age in all neonates with NEC and in subgroup of surgically treated patients. METHODS This was a retrospective study case series. NEC cases treated in Stockholm County from 2009 to 2014 were identified in the National Quality Register. Patients were included in the study if they had a verified NEC diagnosis and they were divided into 2 groups according to the gestational age. RESULTS A total of 89 patients were included. Of these 60 (67.4%) neonates had a gestational age <28 and 29 (32.6%) infants ≥28weeks. Surgical NEC patients were 57 (64%). Pneumatosis intestinalis at the abdominal radiographs was noted significantly more often in neonates born at ≥28weeks of gestation (86.2%) compared to extremely preterm newborns (60.0%). Neonates born at ≥28weeks of gestation presented more often bloody stools (58.6%) compared to extremely preterm newborns (20.0%). In surgical NEC patients gasless abdomen was detected in 35.6% of the neonates born <28weeks compared to 6.7% of the more mature neonates. CONCLUSIONS Extremely preterm neonates with NEC show less specific clinical and radiological signs of NEC compared to more mature neonates. This suggests that Bell's classification is not adequate for the diagnosis and staging of NEC in extremely preterm neonates. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Elena Palleri
- Department of Women and Children's Health, Karolinska Institute, Elevhemmet, H2:00, Karolinska University Hospital, 17176, Stockholm, Sweden; Department of Neonatology, Astrid Lindgren Children's Hospital, 17176, Stockholm, Sweden.
| | - Ida Aghamn
- Department of Advanced Pediatric In-home care, Astrid Lindgren Children's Hospital, 17176, Stockholm, Sweden
| | - Tomas S Bexelius
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, 17177, Stockholm, Sweden
| | - Marco Bartocci
- Department of Women and Children's Health, Karolinska Institute, Elevhemmet, H2:00, Karolinska University Hospital, 17176, Stockholm, Sweden; Department of Neonatology, Astrid Lindgren Children's Hospital, 17176, Stockholm, Sweden
| | - Tomas Wester
- Department of Women and Children's Health, Karolinska Institute, Elevhemmet, H2:00, Karolinska University Hospital, 17176, Stockholm, Sweden; Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, 17176, Stockholm, Sweden
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14
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Dos Santos IGG, Mezzacappa MA, Alvares BR. Radiological findings associated with the death of newborns with necrotizing enterocolitis. Radiol Bras 2018; 51:166-171. [PMID: 29991838 PMCID: PMC6034718 DOI: 10.1590/0100-3984.2017.0040] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective The aim of this study was to identify radiological and clinical risk factors
for death in newborns with necrotizing enterocolitis. Materials and Methods This was a retrospective cohort study, based on radiological examinations and
medical charts of 66 infants with necrotizing enterocolitis, as confirmed by
a finding of intestinal pneumatosis (stage IIA, according to modified Bell’s
staging criteria). Radiological and clinical variables were evaluated. Results Of the 66 infants evaluated, 14 (21.2%) presented pneumatosis in the large
and small bowel; 7 (10.6%) presented air in the portal system; and 12
(18.2%) died. Bivariate analysis revealed that the following variables were
associated with death: bowel perforation; pneumatosis in the large and small
bowel; air in the portal system; earlier gestational age; longer time on
mechanical ventilation before the identification of pneumatosis; and longer
time on mechanical ventilation before discharge or death. In the
multivariate regression, the following variables remained as predictors of
death: pneumatosis in the large and small intestines (odds ratio [OR] =
12.4; 95% confidence interval [95% CI] = 1.2-127.4; p =
0.035), perforation (OR = 23.2; 95% CI = 2.2-246.7; p =
0.009), and air in the portal system (OR = 69.7; 95% CI = 4.3-[not
calculated]; p = 0.003). Conclusion The set of factors most strongly associated with death in infants with
necrotizing enterocolitis comprised extensive pneumatosis, pneumoperitoneum,
and air in the portal system. Our findings confirm the importance of
radiological imaging in the diagnosis and monitoring of necrotizing
enterocolitis.
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Affiliation(s)
| | - Maria Aparecida Mezzacappa
- PhD, Professor in the Department of Pediatrics at the Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
| | - Beatriz Regina Alvares
- PhD, Professor in the Department of Radiology at the Faculdade de Ciências Médicas da Universidade Estadual de Campinas (FCM-Unicamp), Campinas, SP, Brazil
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15
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The role of imaging in the management of necrotising enterocolitis: a multispecialist survey and a review of the literature. Eur Radiol 2018; 28:3621-3631. [PMID: 29582131 PMCID: PMC6096607 DOI: 10.1007/s00330-018-5362-x] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/26/2018] [Accepted: 01/30/2018] [Indexed: 01/04/2023]
Abstract
Objectives To investigate current practices and perceptions of imaging in necrotising enterocolitis (NEC) according to involved specialists, put them in the context of current literature, and identify needs for further investigation. Methods Two hundred two neonatologists, paediatric surgeons, and radiologists answered a web-based questionnaire about imaging in NEC at their hospitals. The results were descriptively analysed, using proportion estimates with 95% confidence intervals. Results There was over 90% agreement on the value of imaging for confirmation of the diagnosis, surveillance, and guidance in decisions on surgery as well as on abdominal radiography as the first-choice modality and the most important radiographic signs. More variation was observed regarding some indications for surgery and the use of some ultrasonographic signs. Fifty-eight per cent stated that ultrasound was used for NEC at their hospital. Examination frequency, often once daily or more but with considerable variations, and projections used in AR were usually decided individually rather than according to fixed schedules. Predicting the need of surgery was regarded more important than formal staging. Conclusion Despite great agreement on the purposes of imaging in NEC and the most important radiographic signs of the disease, there was considerable diversity in routines, especially regarding examination frequency and the use of ultrasound. Apart from continuing validation of ultrasound, important objectives for future studies include definition of the supplementary roles of both imaging modalities in relation to other diagnostic parameters and evaluation of various imaging routines in relation to timing of surgery, complications, and mortality rate. Key Points • Imaging is an indispensable tool in the management of necrotising enterocolitis • Predicting the need of surgery is regarded more important than formal staging • There is great consensus on important signs of NEC on abdominal radiography • There is more uncertainty regarding the role of ultrasound • Individualised management is preferred over standardised diagnostic algorithms Electronic supplementary material The online version of this article (10.1007/s00330-018-5362-x) contains supplementary material, which is available to authorized users.
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Criss CN, Selewski DT, Sunkara B, Gish JS, Hsieh L, Mcleod JS, Robertson JO, Matusko N, Gadepalli SK. Acute kidney injury in necrotizing enterocolitis predicts mortality. Pediatr Nephrol 2018; 33:503-510. [PMID: 28983789 DOI: 10.1007/s00467-017-3809-y] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/01/2017] [Accepted: 09/08/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND Morbidity and mortality with necrotizing enterocolitis (NEC) remains a significant challenge. Acute kidney injury (AKI) has been shown to worsen survival in critically ill neonates. To our knowledge, this study is the first to evaluate the prevalence of AKI and its impact on outcomes in neonatal NEC. METHODS We carried out a single-center retrospective chart review of all neonates treated for NEC between 2003 and 2015 (N = 181). AKI is defined as a rise in serum creatinine (SCr) from a previous trough according to neonatal modified KDIGO criteria (stage 1 = SCr rise 0.3 mg/dL or SCr 150 < 200%, stage 2 = SCr rise 200 < 300%, stage 3 = SCr rise ≥300%, SCr 2.5 mg/dL or dialysis). Primary outcome was in-hospital mortality and secondary outcomes were hospital length of stay (LOS) and need for and type of surgery. RESULTS Acute kidney injury occurred in 98 neonates (54%), with 39 stage 1 (22%), 31 stage 2 (18%), and 28 stage 3 (16%), including 5 requiring dialysis. Non-AKI and AKI groups were not statistically different in age, weight, Bell's NEC criteria, and medication exposure (vasopressors, vancomycin, gentamicin, or diuretic). Neonates with AKI had higher mortality (44% vs 25.6%, p = 0.008) and a higher chance of death (HR 2.4, CI 1.2-4.8, p = 0.009), but the effect on LOS on survivors did not reach statistical significance (79 days, interquartile range [IQR] 30-104 vs 54 days, IQR 30-92, p = 0.09). Overall, 48 (27.9%) patients required surgical intervention. CONCLUSIONS This study shows that AKI not only occurs in over half of patients with NEC, but that it is also associated with more than a two-fold higher mortality, highlighting the importance of early recognition and potentially early intervention for AKI.
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Affiliation(s)
- Cory N Criss
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - David T Selewski
- Department of Pediatrics & Communicable Disease, Division of Pediatric Nephrology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
| | - Bipin Sunkara
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Joshua S Gish
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Lily Hsieh
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Jennifer S Mcleod
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Jason O Robertson
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
| | - Niki Matusko
- Department of General Surgery, Michigan Medicine, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Department of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA
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Narumoto S, Sakamoto S, Uchida H, Sasaki K, Shigeta T, Fukuda A, Nosaka S, Irie R, Yoshioka T, Kasahara M. Necrotizing enterocolitis in the setting of milk allergy after pediatric living donor liver transplantation. Pediatr Transplant 2018; 22. [PMID: 29218832 DOI: 10.1111/petr.13096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2017] [Indexed: 01/25/2023]
Abstract
NEC is an idiopathic intestinal mucosal injury that may progress to transmural bowel necrosis without mesenteric ischemia. NEC usually affects 7- to 10-day-old neonates following enteral feeding. A 10-month-old girl with no history of laparotomy underwent LDLT for acute liver failure. After starting enteral feeding on postoperative day 5, she developed abdominal distention. Diffuse PVG and PI were detected by radiologic modalities. Exploratory laparotomy revealed patchy necrosis of the intestine without perforation. The microscopic findings of a resected specimen revealed transmural coagulative necrosis with multiple small thromboses compatible with neonatal NEC features, and eosinophil infiltration was also observed. Subsequently, after the resumption of enteral feeding with cow's milk, she developed severe diarrhea, the symptoms of which were eliminated after the administration of cow's milk was stopped. These clinical and pathological findings support the speculation that NEC might have been induced by a CMA. Food allergies, which can be induced by immunosuppressive agents, should be considered as a potential cause of NEC in the setting of pediatric liver transplantation.
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Affiliation(s)
- Soichi Narumoto
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Hajime Uchida
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Kengo Sasaki
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Takanobu Shigeta
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Shunsuke Nosaka
- Department of Radiology, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Rie Irie
- Department of Clinical Pathology, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Takako Yoshioka
- Department of Clinical Pathology, National Center for Child Health and Development, Setagaya, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Setagaya, Tokyo, Japan
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18
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Cuna AC, Reddy N, Robinson AL, Chan SS. Bowel ultrasound for predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis. Pediatr Radiol 2018; 48:658-666. [PMID: 29260286 PMCID: PMC5895673 DOI: 10.1007/s00247-017-4056-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/31/2017] [Accepted: 12/06/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Necrotizing enterocolitis (NEC) is a devastating inflammatory disease of the intestinal tract that represents a significant source of morbidity and mortality in preterm infants. Imaging of the abdomen is valuable for timely diagnosis and close monitoring of disease progression in NEC. Bowel ultrasound (US) is increasingly being recognized as an important imaging tool for evaluating NEC that provides additional detail than plain abdominal radiographs. OBJECTIVE To identify bowel US findings associated with surgical management or death in infants with NEC. MATERIALS AND METHODS We searched Embase, PubMed, and the Cumulative Index to Nursing and Allied Health Literature for studies investigating the association between bowel US findings and surgical management or death in NEC. Selected articles were evaluated for quality of study methodology using the Newcastle-Ottawa Scale, and aggregate statistics for odds ratio (OR) and 95% confidence interval were calculated. RESULTS Of 521 articles reviewed, 11 articles comprising 748 infants were evaluated for quality. Nine of the studies were retrospective and from single-center experiences. Pooled analysis showed that focal fluid collections (OR 17.9, 3.1-103.3), complex ascites (OR 11.3, 4.2-30.0), absent peristalsis (OR 10.7, 1.7-69.0), pneumoperitoneum (OR 9.6, 1.7-56.3), bowel wall echogenicity (OR 8.6, 3.4-21.5), bowel wall thinning (OR 7.11.6-32.3), absent perfusion (OR 7.0, 2.1-23.8), bowel wall thickening (OR 3.9, 2.4-6.1) and dilated bowel (OR 3.5, 1.8-6.8) were associated with surgery or death in NEC. In contrast, portal venous gas (OR 3.0, 0.8-10.6), pneumatosis intestinalis (OR 2.1, 0.9-5.1), increased bowel perfusion (OR 2.6, 0.6-11.1) and simple ascites (OR 0.54, 0.1-2.5) were not associated with surgery or death. CONCLUSION This meta-analysis identified several bowel US findings that are associated and not associated with surgery or death in NEC. Bowel US may be useful for early identification of high-risk infants with NEC who may benefit from more aggressive treatment, including surgery. Future studies are needed to determine whether the addition of bowel US in NEC evaluation would improve outcomes.
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MESH Headings
- Enterocolitis, Necrotizing/diagnostic imaging
- Enterocolitis, Necrotizing/pathology
- Enterocolitis, Necrotizing/surgery
- Humans
- Infant
- Infant, Newborn
- Infant, Newborn, Diseases/diagnosis
- Infant, Newborn, Diseases/pathology
- Infant, Newborn, Diseases/surgery
- Predictive Value of Tests
- Ultrasonography/methods
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Affiliation(s)
- Alain C Cuna
- Department of Pediatrics, Division of Neonatology, Children's Mercy Kansas City, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Nidhi Reddy
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Amie L Robinson
- Department of Radiology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA
| | - Sherwin S Chan
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.
- Department of Radiology, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO, 64108, USA.
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Esposito F, Mamone R, Di Serafino M, Mercogliano C, Vitale V, Vallone G, Oresta P. Diagnostic imaging features of necrotizing enterocolitis: a narrative review. Quant Imaging Med Surg 2017; 7:336-344. [PMID: 28812000 DOI: 10.21037/qims.2017.03.01] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Necrotizing enterocolitis (NEC) is an inflammatory process, characterized by intestinal necrosis of variable extension, leading to perforation, generalized peritonitis and death. The classical pathogenetic theory focuses on mucosal damage related to a stress induced intestinal ischemia leading to mucosal injury and bacterial colonization of the wall. A more recent hypothesis emphasizes the role of immaturity of gastrointestinal and immune system, particularly of the premature, responsible of bowel wall vulnerability and suffering. NEC is the most common gastrointestinal emergency in the newborn, with a higher incidence in the preterm; improvement of neonatal resuscitation techniques enables the survival of premature of very low birth weight (VLBW) with prolongation of hospital stay for perinatal and neonatal care and a higher risk of NEC. Clinical presentation of NEC in newborn ranges from mild forms with moderate gastrointestinal tract disorder and that can heal spontaneously, to very serious forms with fulminant course characterized by perforation, peritonitis, sepsis, disseminated intravascular coagulation (DIC) and shock. Imaging modality in the diagnosis of NEC is historically represented by the plain-film abdominal radiographs which can be performed every 6 hours because of the rapid evolution that may occur in the patient's clinical condition. However ultrasound (US), in recent years, is playing an increasingly important role in the evaluation of early stages of the disease as it provides images in real time of the abdominal structures being able to assess the presence and validity of peristalsis of the bowel loops, detect the thickness of the intestinal wall and the presence of minimal amounts of fluid in the peritoneal cavity. In this paper we review the pathogenesis, clinical presentation and imaging of NEC with a particular attention to the emergent role of US in the diagnosis of the disease.
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Affiliation(s)
- Francesco Esposito
- Department of Radiology, Santobono-Pausilipon Children Hospital, Naples; Italy
| | - Rosanna Mamone
- Department of Radiology, Santobono-Pausilipon Children Hospital, Naples; Italy
| | - Marco Di Serafino
- Department of Emergency Radiology, San Carlo Hospital, Potenza; Italy
| | | | - Valerio Vitale
- Department of Imaging and Radiation therapy, Azienda Socio-Sanitaria Territoriale di Lecco, A. Manzoni Hospital, Lecco, Italy
| | - Gianfranco Vallone
- Department of Radiology, Section of Pediatric Diagnostics, University Hospital "Federico II", Naples, Italy
| | - Patrizia Oresta
- Department of Radiology, Santobono-Pausilipon Children Hospital, Naples; Italy
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Robinson JR, Rellinger EJ, Hatch LD, Weitkamp JH, Speck KE, Danko M, Blakely ML. Surgical necrotizing enterocolitis. Semin Perinatol 2017; 41:70-79. [PMID: 27836422 PMCID: PMC5777619 DOI: 10.1053/j.semperi.2016.09.020] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Although currently available data are variable, it appears that the incidence of surgical necrotizing enterocolitis (NEC) has not decreased significantly over the past decade. Pneumoperitoneum and clinical deterioration despite maximal medical therapy remain the most common indications for operative treatment. Robust studies linking outcomes with specific indications for operation are lacking. Promising biomarkers for severe NEC include fecal calprotectin and S100A12; serum fatty acid-binding protein; and urine biomarkers. Recent advances in ultrasonography make this imaging modality more useful in identifying surgical NEC and near-infrared spectroscopy (NIRS) is being actively studied. Another fairly recent finding is that regionalization of care for infants with NEC likely improves outcomes. The neurodevelopmental outcomes after surgical treatment are known to be poor. A randomized trial near completion will provide robust data regarding neurodevelopmental outcomes after laparotomy versus drainage as the initial operative treatment for severe NEC.
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Affiliation(s)
- Jamie R. Robinson
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Eric J. Rellinger
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - L. Dupree Hatch
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Joern-Hendrik Weitkamp
- Division of Neonatology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - K. Elizabeth Speck
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Melissa Danko
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Martin L. Blakely
- Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, TN,Correspondence to: Department of Pediatric Surgery, Vanderbilt University Medical Center, 2200 Children’s Way, Suite 7100, Nashville, TN 37232-2730. (M.L. Blakely)
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21
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Wang L, Li Y, Liu J. Diagnostic value and disease evaluation significance of abdominal ultrasound inspection for neonatal necrotizing enterocolitis. Pak J Med Sci 2016; 32:1251-1256. [PMID: 27882031 PMCID: PMC5103143 DOI: 10.12669/pjms.325.10413] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 08/04/2016] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To summarize abdominal plain X-rays and ultrasound characteristics of 144 cases of Neonatal Necrotizing Enterocolitis (NEC) and to analyze diagnostic value and disease evaluation significance of abdominal ultrasound inspection for NEC. METHODS Clinical data of 144 NEC patients were retrospectively analyzed from February 2014 to December 2015. The patients were divided into suspected NEC group (N=74) and confirmed NEC group (N=70) according to amended Bell-NEC classification and diagnostic criteria. Meanwhile, we divided them into internal medicine treatment group (N=95) and surgery/death group (N=49) according to clinical prognosis and took records of their clinical manifestations, laboratory inspection results and abdominal plain X-rays and ultrasound characteristics. RESULTS For confirmed NEC group, the detection rate of portal venous gas (PVG) and dilatation of intestine by abdominal ultrasound was obviously higher than by plain X-rays (P<0.05). Abdominal ultrasound inspection revealed that the incidence rate of dilatation of intestine, bowel wall thickening and ascites (acoustic transmission difference) of the surgery/death group was higher than that of the internal medicine treatment group by comparing risk ratio (RR) and 95% confidence interval (CI) of RR; the difference was statistically significant (P<0.05). The abdominal plain X-rays inspection only showed the result that dilatation of intestine and free intraperitoneal air was more often found in the surgery/death group (P<0.05). CONCLUSION Compared with abdominal plain X-rays, abdominal ultrasound has certain clinical value and offers more advantages in some aspects; therefore, it can be considered as the reference index in prediction of clinical prognosis.
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Affiliation(s)
- Li Wang
- Li Wang, Department of Special Inspection, Binzhou People’s Hospital, Shandong 256610, China
| | - Yinghui Li
- Yinghui Li, Department of Health Examination, Binzhou People’s Hospital, Shandong 256610, China
| | - Jian Liu
- Jian Liu, Department of Special Inspection, Binzhou People’s Hospital, Shandong 256610, China
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22
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He Y, Zhong Y, Yu J, Cheng C, Wang Z, Li L. Ultrasonography and radiography findings predicted the need for surgery in patients with necrotising enterocolitis without pneumoperitoneum. Acta Paediatr 2016; 105:e151-5. [PMID: 26676409 DOI: 10.1111/apa.13315] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2015] [Revised: 11/02/2015] [Accepted: 12/11/2015] [Indexed: 11/28/2022]
Abstract
AIM The timing of surgical intervention in patients with necrotising enterocolitis (NEC) without pneumoperitoneum remains unclear. This study aimed to identify the predictors associated with surgical intervention in such patients and to assess how effective imaging reports were as an aid to surgical decision-making. METHODS We collected clinical data, laboratory investigations and imaging findings on NEC patients without pneumoperitoneum. A critical imaging report was defined as persistent dilation of bowel loops and evidence of portal venous gas on radiography and thickening of the bowel wall, absent peristalsis and evidence of echogenic-free fluid on sonography. Independent predictors of surgical NEC were identified using multivariate logistic regression analysis. Sensitivity and specificity analyses were performed for the imaging findings, and receiver operator characteristic curve analysis was used to evaluate the predictive accuracy. RESULTS Of the 238 neonates studied, 54 (22.69%) required surgical intervention. The multivariate logistic regression analysis showed that abdominal erythema, C-reactive protein levels and the critical imaging report were independent predictors of the need for surgical intervention. The critical imaging report was the most powerful predictor of surgical NEC. CONCLUSION Both ultrasonography and radiography findings proved helpful in predicting the need for surgery in NEC without pneumoperitoneum.
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Affiliation(s)
- Yu He
- Department of Neonatology; Children's Hospital; Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Paediatrics; Chongqing China
- Ministry of Education Key Laboratory of Child Development and Disorder; Children's Hospital; Chongqing Medical University; Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders; Chongqing China
| | - Ying Zhong
- Department of Neonatology; The Children's Hospital Zhejiang University School of Medicine; Chongqing China
| | - Jialin Yu
- Department of Neonatology; Children's Hospital; Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Paediatrics; Chongqing China
- Ministry of Education Key Laboratory of Child Development and Disorder; Children's Hospital; Chongqing Medical University; Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders; Chongqing China
| | - Chen Cheng
- Department of Neonatology; Children's Hospital; Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Paediatrics; Chongqing China
- Ministry of Education Key Laboratory of Child Development and Disorder; Children's Hospital; Chongqing Medical University; Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders; Chongqing China
| | - Zhengli Wang
- Department of Neonatology; Children's Hospital; Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Paediatrics; Chongqing China
- Ministry of Education Key Laboratory of Child Development and Disorder; Children's Hospital; Chongqing Medical University; Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders; Chongqing China
| | - Luquan Li
- Department of Neonatology; Children's Hospital; Chongqing Medical University; Chongqing China
- Chongqing Key Laboratory of Paediatrics; Chongqing China
- Ministry of Education Key Laboratory of Child Development and Disorder; Children's Hospital; Chongqing Medical University; Chongqing China
- China International Science and Technology Cooperation Base of Child Development and Critical Disorders; Chongqing China
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Necrotizing enterocolitis: a clinical review on diagnostic biomarkers and the role of the intestinal microbiota. Inflamm Bowel Dis 2015; 21:436-44. [PMID: 25268636 DOI: 10.1097/mib.0000000000000184] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Necrotizing enterocolitis (NEC) remains one of the most frequent gastrointestinal diseases in the neonatal intensive care unit, with a continuing unacceptable high mortality and morbidity rates. Up to 20% to 40% of infants with NEC will need surgical intervention at some point. Although the exact pathophysiology is not yet elucidated, prematurity, use of formula feeding, and an altered intestinal microbiota are supposed to induce an inflammatory response of the immature intestine. The clinical picture of NEC has been well described. However, an early diagnosis and differentiation against sepsis is challenging. Besides, it is difficult to timely identify NEC cases that will deteriorate and need surgical intervention. This may interfere with the most optimal treatment of infants with NEC. In this review, we discuss the pathogenesis, diagnosis, and treatment of NEC with a focus on the role of microbiota in the development of NEC. An overview of different clinical prediction models and biomarkers is given. Some of these are promising tools for accurate diagnosis of NEC and selection of appropriate therapy.
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Mistry KA, Sood D, Chadha V, Bhoil R, Sharma S. In Response to the Article “Usefulness of Ultrasound Examinations in the Diagnostics of Necrotizing Enterocolitis”. Pol J Radiol, 2015; 80: 1-9. Pol J Radiol 2015; 80:382-3. [PMID: 26379806 PMCID: PMC4551167 DOI: 10.12659/pjr.894761] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Accepted: 06/19/2015] [Indexed: 11/09/2022] Open
Affiliation(s)
- Kewal A. Mistry
- Department of Radiology, Dr. Rajendra Prasad Government Medical College, Kangra, India
| | - Dinesh Sood
- Department of Radiology, Dr. Rajendra Prasad Government Medical College, Kangra, India
| | - Veenal Chadha
- Department of Community Medicine, Dr. Rajendra Prasad Government Medical College, Kangra, India
| | - Rohit Bhoil
- Department of Radiology, Indira Gandhi Medical College, Shimla, India
| | - Sarthak Sharma
- Department of Radiology, Dr. Rajendra Prasad Government Medical College, Kangra, India
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Garbi-Goutel A, Brévaut-Malaty V, Panuel M, Michel F, Merrot T, Gire C. Prognostic value of abdominal sonography in necrotizing enterocolitis of premature infants born before 33 weeks gestational age. J Pediatr Surg 2014; 49:508-13. [PMID: 24726102 DOI: 10.1016/j.jpedsurg.2013.11.057] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 10/01/2013] [Accepted: 11/12/2013] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the prognostic value of abdominal sonography in necrotizing enterocolitis (NEC) in preterm infants with a gestational age less than 33 weeks of gestation, using surgery and/or death as the primary outcome and stenosis as the secondary outcome. METHODS A retrospective study of 95 premature infants (mean gestational age: 28.6 weeks), presenting with NEC between January 2009 and November 2011 and who underwent plain abdominal radiography and sonography, was performed. In uni- and multivariate analyses, radiographic and sonographic findings were correlated with complications ('surgery and/or death' and 'stenosis'). RESULTS Sonographic findings of free intraperitoneal air (odd ratio [OR]=8.0; IC, 1.4-44.2), free abdominal fluid (OR 3.5; IC 1.3-9.4), portal venous gas (OR 3.9; IC, 1.2-12.9), and bowel wall thickening (OR 2.8; IC,1.1-7.2) were significantly associated with surgery and/or death. Intramural gas was significantly correlated (OR=11.8; IC, 1.5-95.8) with intestinal stenosis following NEC. None of the radiographic findings were associated with complications. CONCLUSION Abdominal sonography is a reliable tool for the prognostic assessment of NEC in preterm infants.
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Affiliation(s)
- Aurélie Garbi-Goutel
- Service de médecine néonatale, unité de soins intensifs néonatale, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Chemin des Bourrellys, 13015 Marseille Cedex 20, France.
| | - Véronique Brévaut-Malaty
- Service de médecine néonatale, unité de soins intensifs néonatale, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Chemin des Bourrellys, 13015 Marseille Cedex 20, France
| | - Michel Panuel
- Département d'imagerie médicale, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Chemin des Bourrellys, 13015 Marseille Cedex 20, France
| | - Fabrice Michel
- Service d'anesthésie et de réanimation pédiatrique, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Marseille, France
| | - Thierry Merrot
- Service de chirurgie pédiatrique, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Chemin des Bourrellys, 13015 Marseille Cedex 20, France
| | - Catherine Gire
- Service de médecine néonatale, unité de soins intensifs néonatale, Hôpital Nord, Assistance Publique-Hôpitaux de Marseille, Université de la Méditerranée, Chemin des Bourrellys, 13015 Marseille Cedex 20, France
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Abstract
Neonatal sepsis continues to be a common and significant health care burden, especially in very-low-birth-weight infants (VLBW <1500 g). Though intrapartum antibiotic prophylaxis has decreased the incidence of early-onset group B streptococcal infection dramatically, it still remains a major cause of neonatal sepsis. Moreover, some studies among VLBW preterm infants have shown an increase in early-onset sepsis caused by Escherichia coli. As the signs and symptoms of neonatal sepsis are nonspecific, early diagnosis and prompt treatment remains a challenge. There have been a myriad of studies on various diagnostic markers like hematological indices, acute phase reactants, C-reactive protein, procalcitonin, cytokines, and cell surface markers among others. Nonetheless, further research is needed to identify a biomarker with high diagnostic accuracy and validity. Some of the newer markers like inter α inhibitor proteins have shown promising results thereby potentially aiding in early detection of neonates with sepsis. In order to decrease the widespread, prolonged use of unnecessary antibiotics and improve the outcome of the infants with sepsis, reliable identification of sepsis at an earlier stage is paramount.
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Affiliation(s)
- Birju A Shah
- Instructor of Pediatrics; Neonatal-Perinatal Medicine; Warren Alpert Medical School of Brown University; Women & Infants Hospital of Rhode Island; Providence, RI USA
| | - James F Padbury
- Pediatrician-in-Chief, Professor of Pediatrics; Warren Alpert Medical School of Brown University; Women & Infants Hospital of Rhode Island; Providence, RI USA
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Abstract
Necrotising enterocolitis is a serious disorder in preterm infants with a mortality of up to 60%. Therefore, early and precise diagnosis and rapid initiation of proper treatment are essential. Clinically suspected diagnosis is usually confirmed by typical findings on plain abdominal radiograph, for example, pneumatosis intestinalis, portal venous gas and, in case of intestinal perforation, pneumoperitoneum. Recently, there has been growing evidence that with real-time ultrasound, intramural air and portal gas can be better detected than with x-ray. Furthermore, ultrasound is able to assess the bowel wall directly and detect bowel wall thickening or thinning, reduced peristalsis or disturbed bowel wall perfusion. Intra-abdominal fluid, both intraluminal or extraluminal is also visible. However, data regarding the diagnostic validity and prognostic value of abdominal ultrasound are limited and often focused on a single finding rather than a combination of them. Additionally, until now, ultrasound findings seem to have little influence on therapeutic decisions. Therefore, the value of abdominal ultrasound in the diagnosis of necrotising enterocolitis has to be determined by further studies until its use can be generally recommended.
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Affiliation(s)
- Bettina Bohnhorst
- Department of Pediatric Pulmonology, Allergology and Neonatology, Hannover Medical School, Germany.
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29
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Abstract
Necrotizing enterocolitis (NEC) primarily affects premature infants. It is less common in term and late preterm infants. The age of onset is inversely related to the postmenstrual age at birth. In term infants, NEC is commonly associated with congenital heart diseases. NEC has also been associated with other anomalies. More than 85% of all NEC cases occur in very low birth weight infants or in very premature infants. Despite incremental advances in our understanding of the clinical presentation and pathophysiology of NEC, universal prevention of this disease continues to elude us even in the twenty-first century.
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MESH Headings
- Age of Onset
- Disease Management
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/epidemiology
- Enterocolitis, Necrotizing/therapy
- Humans
- Infant, Newborn
- Infant, Premature/physiology
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/epidemiology
- Infant, Premature, Diseases/therapy
- Intestinal Perforation/diagnosis
- Intestines/diagnostic imaging
- Intestines/microbiology
- Intestines/physiopathology
- Pneumoperitoneum/diagnosis
- Prevalence
- Radiography
- Risk
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Affiliation(s)
- Renu Sharma
- Division of Neonatology, Department of Pediatrics, University of Florida College of Medicine at Jacksonville, 655 West 8th Street, Jacksonville, FL 32209, USA.
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30
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Tooke L, Alexander A, Horn A. Extensive portal venous gas without obvious pneumatosis intestinalis in a preterm infant with necrotizing enterocolitis. J Pediatr Surg 2012; 47:1463-5. [PMID: 22813817 DOI: 10.1016/j.jpedsurg.2012.03.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Revised: 03/20/2012] [Accepted: 03/24/2012] [Indexed: 11/24/2022]
Abstract
Portal venous gas is one of the classic radiologic features of necrotizing enterocolitis and is an uncommon isolated finding because it is most commonly seen in conjunction with pneumatosis intestinalis. In this case study, we present a preterm neonate with necrotizing enterocolitis who had extensive portal venous gas without obvious pneumatosis intestinalis.
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Affiliation(s)
- Lloyd Tooke
- Neonatal Department, Groote Schuur Hospital, University of Cape Town, 7925 South Africa.
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31
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Tritou I, Megremis S, Stefanaki E, Goumenakis M, Sfakianaki E. Sonographic detection of transient gas in the portal vein in an infant following abdominal surgery: a possible sign of adhesive small bowel obstruction. JOURNAL OF CLINICAL ULTRASOUND : JCU 2012; 40:306-309. [PMID: 21953368 DOI: 10.1002/jcu.20879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 08/16/2011] [Indexed: 05/31/2023]
Abstract
We present a case of sonographically detected transient gas in the portal vein in a 4.5-month-old infant who had a history of two consecutive jejunectomies due to jejunal stenoses and was admitted to our hospital with clinical and laboratory findings consistent with a subacute small bowel obstruction and dehydration. Sonography excluded other pathologies and the patient was treated conservatively with success. The presence of gas in the portal vein could be a sign of an underlying mechanical obstacle, as another episode of small bowel obstruction 1 month later required surgical treatment of adhesive intestinal obstruction.
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Affiliation(s)
- Ioanna Tritou
- 1st Department of Radiology, Venizelio General Hospital, Knossos Avenue, 71409 Heraklion, Crete, Greece.
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Could clinical scores guide the surgical treatment of necrotizing enterocolitis? Pediatr Surg Int 2012; 28:271-6. [PMID: 22002167 DOI: 10.1007/s00383-011-3016-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2011] [Indexed: 12/20/2022]
Abstract
PURPOSE Test the diagnostic reliability of the score for neonatal acute physiology-perinatal extension-II (SNAPPE-II) and the metabolic derangement acuity score (MDAS) as predictors of surgery in patients with necrotizing enterocolitis (NEC). METHODS The SNAPPE-II and the MDAS were applied to 99 patients with NEC. Both the scores were calculated at the moment of diagnosis (T(0)) and when surgical assessment was required (T(1)). The main outcome was the need of surgical revision. Comparison between models was made through their receiver operator characteristics (ROC) curves. RESULTS Thirty-five patients required surgical treatment (group A) and 64 responded to medical therapy (group B). Median SNAPPE-II was 22 versus 5 for group A (U test 621, p = 0.002) at T(0); and 22 versus 10 for group A (U test 487, p = 0.01) at T(1). Measuring the value of the SNAPPE-II as a predictor of surgery, the ROC curve was 0.69 (CI 95%, 0.57-0.80) at T(0) and 0.67 (CI 95%, 0.55-0.80) at T(1). Median MDAS were 2 for both groups A and B at T(0) (U test 890.5, p = 0.113) and 2 versus 1.5 for group A at T(1) (U test 570, p = 0.043). The ROC curve for MDAS was 0.59 (CI 95%, 0.47-0.71) at T(0) and 0.64 (CI 95%, 0.52-0.77) at T(1). CONCLUSIONS The diagnostic performance of the SNAPPE-II offers mild results in the moment of the diagnosis of NEC, and at T(1). The MDAS is non significant at T(0) and obtains moderate results at T(1). These results do not encourage using the SNAPPE-II and the MDAS as definite tools to decide for surgical treatment of the patients affected by NEC.
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Ting YJ, Chan KL, Wong SCM, Chim S, Wong KY. Gastric pneumatosis in a premature neonate. AJP Rep 2011; 1:11-4. [PMID: 23705077 PMCID: PMC3653539 DOI: 10.1055/s-0030-1271218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Accepted: 11/03/2010] [Indexed: 01/04/2023] Open
Abstract
Gastric pneumatosis is extremely rare during infancy. It has been reported in association with necrotizing enterocolitis or congenital abnormalities such as pyloric stenosis. Here, we report a case of gastric pneumatosis in a premature neonate on synchronized nasal intermittent positive pressure ventilation. No pneumatosis was noted in the rest of the bowel or esophagus. There could have been mild damage in the gastric mucosa, either related to the placement of the feeding tube or secondary to the use of indomethacin or both. The condition was further aggravated by noninvasive ventilation. An increase in intragastric pressure resulted in the submucosal dissection of air followed by the development of gastric pneumatosis. Conservative management strategies, including the use of a nasogastric tube for decompression and the withholding of feeding, successfully managed the gastric pneumatosis in our patient. An uneventful recovery was made after conservative management. Prompt recognition and evaluation of this condition were essential for making the diagnosis.
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Affiliation(s)
- Yuk Joseph Ting
- Department of Paediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong
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Puiman PJ, Burger-Van Paassen N, Schaart MW, De Bruijn ACJM, De Krijger RR, Tibboel D, Van Goudoever JB, Renes IB. Paneth cell hyperplasia and metaplasia in necrotizing enterocolitis. Pediatr Res 2011; 69:217-23. [PMID: 21372757 DOI: 10.1203/pdr.0b013e3182092a9a] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Paneth cell dysfunction has been suggested in necrotizing enterocolitis (NEC). The aim of this study was to i) study Paneth cell presence, protein expression, and developmental changes in preterm infants with NEC and ii) determine Paneth cell products and antimicrobial capacity in ileostomy outflow fluid. Intestinal tissue from NEC patients (n = 55), preterm control infants (n = 22), and term controls (n = 7) was obtained during surgical resection and at stoma closure after recovery. Paneth cell abundance and protein expression were analyzed by immunohistochemistry. RNA levels of Paneth cell proteins were determined by real-time quantitative RT-PCR. In ileostomy outflow fluid, Paneth cell products were quantified, and antimicrobial activity was measured in vitro. In acute NEC, Paneth cell abundance in small intestinal tissue was not significantly different from preterm controls. After recovery from NEC, Paneth cell hyperplasia was observed in the small intestine concomitant with elevated human alpha-defensin 5 mRNA levels. In the colon, metaplastic Paneth cells were observed. Ileostomy fluid contained Paneth cell proteins and inhibited bacterial growth. In conjunction, these data suggest an important role of Paneth cells and their products in various phases of NEC.
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Affiliation(s)
- Patrycja J Puiman
- Department of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam 3015 GJ, The Netherlands
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Tepas JJ, Leaphart CL, Plumley D, Sharma R, Celso BG, Pieper P, Quilty J, Esquivia-Lee V. Trajectory of metabolic derangement in infants with necrotizing enterocolitis should drive timing and technique of surgical intervention. J Am Coll Surg 2010; 210:847-52, 852-4. [PMID: 20421063 DOI: 10.1016/j.jamcollsurg.2010.01.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 01/05/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Seven clinical metrics of metabolic derangement (MD7) have improved the timing of surgical intervention in infants with necrotizing enterocolitis (NEC). We compared surgical NEC outcomes based on MD7 at our center (unit S) with a similar center (unit B) that based its intervention on abdominal radiograph. STUDY DESIGN Premature infants undergoing surgical care for NEC were evaluated. MD7 included positive blood culture, acidosis, bandemia, hyponatremia, thrombocytopenia, hypotension, and neutropenia. Surgical recommendations were stratified as observation or intervention. Good outcomes included full enteric feeding by discharge and poor outcomes were death or dependence on parenteral nutrition. For unit S and unit B, the frequency, median, and mode of MD7 component per case were determined for observation and intervention. Mann-Whitney U test and Wilcoxon matched pairs were used to compare positive MD7 frequency for observation with intervention. Institutional mortality was compared and metabolic severity of unit cohorts was evaluated by incidence of MD7 in each. RESULTS From March 2005 to July 2008, forty-one infants at unit S underwent 62 surgical evaluations. Observation was elected in 38 (median 1 MD7 per case, mode 0). Operative intervention occurred in 24 (median 4 MD7 per case, mode 4). Proportional MD7 difference between observation and intervention was significant (p = 0.018, U = 6). From February 2007 to December 2008, sixty-five unit B infants received 81 evaluations, recommending 37 observations (median 2 MD7 per case, mode 2), and 44 interventions (median 3 MD7 per case, mode 3). MD7 proportions between observation and intervention were not significant (p = 0.318, U = 16). Poor outcomes rates for unit S and unit B infants were 24% and 66%, respectively (p = 0.0001). Severity of MD7 did not differ between institutions (p = 0.53, U = 19). CONCLUSIONS These data demonstrate variability in surgical approach to NEC. The MD7 panel describes the trajectory of metabolic derangement, defines more timely surgical intervention, and demonstrates that waiting for free air is too late.
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MESH Headings
- Acidosis/diagnosis
- Acidosis/etiology
- Cohort Studies
- Enterocolitis, Necrotizing/diagnosis
- Enterocolitis, Necrotizing/metabolism
- Enterocolitis, Necrotizing/surgery
- Humans
- Hyponatremia/diagnosis
- Hyponatremia/etiology
- Hypotension/diagnosis
- Hypotension/etiology
- Infant, Newborn
- Infant, Premature
- Infant, Premature, Diseases/diagnosis
- Infant, Premature, Diseases/metabolism
- Infant, Premature, Diseases/surgery
- Neutropenia/diagnosis
- Neutropenia/etiology
- Predictive Value of Tests
- Retrospective Studies
- Risk Assessment
- Severity of Illness Index
- Thrombocytopenia/diagnosis
- Thrombocytopenia/etiology
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Affiliation(s)
- Joseph J Tepas
- Department of Surgery, University of Florida College of Medicine, Jacksonville, FL 32209, USA.
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36
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Abboud B, El Hachem J, Yazbeck T, Doumit C, Hechtman HB. Hepatic portal venous gas: Physiopathology, etiology, prognosis and treatment. World J Gastroenterol 2009; 15:3585-90. [PMID: 19653334 PMCID: PMC2721230 DOI: 10.3748/wjg.15.3585] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatic portal venous gas (HPVG), an ominous radiologic sign, is associated in some cases with a severe underlying abdominal disease requiring urgent operative intervention. HPVG has been reported with increasing frequency in medical literature and usually accompanies severe or lethal conditions. The diagnosis of HPVG is usually made by plain abdominal radiography, sonography, color Doppler flow imaging or computed tomography (CT) scan. Currently, the increased use of CT scan and ultrasound in the inpatient setting allows early and highly sensitive detection of such severe illnesses and also the recognition of an increasing number of benign and non-life threatening causes of HPVG. HPVG is not by itself a surgical indication and the treatment depends mainly on the underlying disease. The prognosis is related to the pathology itself and is not influenced by the presence of HPVG. Based on a review of the literature, we discuss in this paper the pathophysiology, risk factors, radiographic findings, management, and prognosis of pathologies associated with HPVG.
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de Souza JCK, Fraga JC. Is mortality rate influenced by the site of involvement in neonates undergoing laparotomy for necrotizing enterocolitis? J Pediatr Surg 2009; 44:1534-9. [PMID: 19635301 DOI: 10.1016/j.jpedsurg.2008.12.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2008] [Revised: 12/13/2008] [Accepted: 12/17/2008] [Indexed: 11/19/2022]
Abstract
PURPOSE The aim of the study was to evaluate the effect of disease site on the mortality rate of newborns with necrotizing enterocolitis (NEC) undergoing exploratory laparotomy. METHODS The study used prospective cohort of 141 consecutive newborns with NEC who underwent laparotomy from November 1991 to December 2005. RESULTS One hundred nineteen (84.4%) newborns were premature. Small for gestational age was observed in 57 (40.4%). Sixty-eight (48.2%) infants died. Bivariate analysis revealed that involvement of the jejunum and ileum was associated with high mortality rates (20 deaths; 76.9%; odds ratio [OR], 20; 95% confidence interval [CI], 4.6-96.3; P < .001) and that coinvolvement of the jejunum was associated with greater disease extent. After controlling for individual variables, logistic regression showed that the mortality associated with jejunum and ileum involvement (OR, 0.61; 95% CI, 0.06-6.14; P = .68) did not differ from that associated with large bowel involvement (OR, 2.91; 95% CI, 0.81-10.50; P = .10). When the jejunum was involved with the disease, the percentage of involvement of the entire intestine was 72%, and the mortality rate was 85.1%. When the other bowel segments were involved, the global percentage of disease extent ranged from 42% to 49%, and the mortality rate from 51.9% to 71.8%. After multivariable adjustment disease site, jejunal involvement appeared to be only a surrogate marker of disease extent. CONCLUSIONS The NEC-related mortality in newborns undergoing laparotomy was not influenced by disease site (small or large bowel). However, jejunum coinvolvement was a marker of greater disease extent and therefore of poor prognosis.
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Seo HJ, Jung YJ, Park SK, Choi SH, Lee JH, Kim MJ, Chang YS, Park WS. Rotavirus-associated neonatal necrotizing enterocolitis. KOREAN JOURNAL OF PEDIATRICS 2009. [DOI: 10.3345/kjp.2009.52.1.56] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hyun Joo Seo
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yu Jin Jung
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Kyung Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seo Hui Choi
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hyuk Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myo Jing Kim
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Sil Chang
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Won Soon Park
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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39
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Guner YS, Chokshi N, Petrosyan M, Upperman JS, Ford HR, Grikscheit TC. Necrotizing enterocolitis--bench to bedside: novel and emerging strategies. Semin Pediatr Surg 2008; 17:255-65. [PMID: 19019294 DOI: 10.1053/j.sempedsurg.2008.07.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Necrotizing enterocolitis (NEC) is a devastating illness that predominantly affects premature neonates. The mortality associated with this disease has changed very little during the last two decades. Neonates with NEC fall into two categories: those who respond to medical management alone and those who require surgical treatment. The disease distribution may be focal, multifocal, or panintestinal. Surgical treatment should therefore be based on disease presentation. Recent studies have added significant insight into our understanding of the pathogenesis of NEC. Several groups have shown that upregulation of nitric oxide plays an integral role in the development of epithelial injury in NEC. As a result, some treatment strategies have been aimed at abrogating the toxic effects of nitric oxide. In addition, several investigators have reported the cytoprotective effect of epidermal growth factor, which is found in high levels in breast milk, on the intestinal epithelium. Thus, fortification of infant formula with specific growth factors could soon become a preferred strategy to accelerate intestinal maturation in the premature neonate to prevent the development of NEC. One of the most devastating complications of NEC is the development of short bowel syndrome (SBS). The current treatment of SBS involves intestinal lengthening procedures or bowel transplantation. A novel emerging method for treating SBS involves the use of tissue-engineered intestine. In laboratory animals, tissue-engineered small intestine has been shown to be successful in treating intestinal failure. This article examines recent data regarding surgical treatment options for NEC as well as emerging treatment modalities.
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Affiliation(s)
- Yigit S Guner
- Department of Surgery, Childrens Hospital Los Angeles, and the Keck School of Medicine, University of Southern California, Los Angeles, California 90027, USA
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Lin PW, Nasr TR, Stoll BJ. Necrotizing enterocolitis: recent scientific advances in pathophysiology and prevention. Semin Perinatol 2008; 32:70-82. [PMID: 18346530 DOI: 10.1053/j.semperi.2008.01.004] [Citation(s) in RCA: 200] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Necrotizing enterocolitis (NEC) is a leading cause of morbidity and mortality among infants in the neonatal intensive care unit. Here we review the epidemiology and pathophysiology of NEC, with an emphasis on the latest research findings and potential areas for future research. NEC continues to be one of the most devastating and unpredictable diseases affecting premature infants. Despite decades of research, the pathogenesis of this disease remains unclear, and prevention and treatment strategies are limited. Hopefully, future studies aimed at understanding premature intestinal defenses, commensal or probiotic bacterial influences, and possible genetic predisposition will lead to the improvement of prevention and treatment strategies.
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Affiliation(s)
- Patricia W Lin
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.
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Blakely ML, Gupta H, Lally KP. Surgical management of necrotizing enterocolitis and isolated intestinal perforation in premature neonates. Semin Perinatol 2008; 32:122-6. [PMID: 18346536 DOI: 10.1053/j.semperi.2008.01.008] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Necrotizing enterocolitis (NEC) and isolated intestinal perforation (IP) are two relatively common disease conditions that require neonatal surgical therapy. The early mortality rate approaches 50%, and survivors frequently have growth and neurodevelopmental impairment. Much discussion has occurred regarding whether initial drain placement alone or laparotomy with resection of diseased intestine should be the initial surgical therapy. Several recent prospective studies have shown that the early mortality rate is likely not significantly different after either of these surgical approaches. Major morbidity, especially the likelihood for neurodevelopmental impairment, may be different in the two treatment groups. Further prospective trials are needed to further explore this question and are planned. Studies focusing on prevention of NEC and IP and also on improved medical treatment are needed to allow a major advance in the outcomes of infants with NEC and IP. As these studies are being performed, trials evaluating existing medical and surgical therapies are also needed.
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Affiliation(s)
- Martin L Blakely
- Division of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, TN, USA.
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Martins DL, Gonçalves A, Dabus GDC, Bustorff-Silva JM, Olímpio HO, Alvares BR, Sbragia L. Valor preditivo da distensão de alças intestinais em radiografias no prognóstico de enterocolite necrosante. Radiol Bras 2007. [DOI: 10.1590/s0100-39842007000500004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Avaliar o valor prognóstico da distensão de alças intestinais observada em radiografias na evolução e mortalidade de neonatos com enterocolite necrosante. MATERIAIS E MÉTODOS: Nas radiografias de abdome de 53 pacientes obtidas no momento da suspeita diagnóstica de enterocolite necrosante, foi realizada a medida do diâmetro da alça mais distendida (AD), assim como a distância entre a borda superior da primeira vértebra lombar e a borda inferior da segunda (L1-L2), a distância entre as bordas laterais dos pedículos da primeira vértebra lombar (L1), e foram estabelecidas as associações entre AD/L1-L2 e AD/L1. Esta medida foi considerada como possível determinante de potenciais complicações, intervenção cirúrgica e mortalidade. RESULTADOS: Os pacientes que necessitaram de tratamento cirúrgico, aqueles que tiveram complicações durante a evolução e aqueles que morreram da doença tiveram a relação entre AD e AD/L1-L2 maiores (p < 0,05). Os valores de AD/L1 e a localização da alça mais distendida não foram diferentes nos grupos com evolução desfavorável. CONCLUSÃO: Distensão de alça intestinal detectada em radiografias de abdome realizadas na admissão sugerem pior prognóstico em enterocolite necrosante. Outrossim, medidas do diâmetro da alça mais distendida nessas radiografias são um método simples e reprodutível que oferece informações diagnósticas e prognósticas.
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Dhillon T, Palmieri C, Sebire NJ, Lindsay I, Newlands ES, Schmid P, Savage PM, Frank J, Seckl MJ. Value of whole body 18FDG-PET to identify the active site of gestational trophoblastic neoplasia. J Perinatol 2007. [PMID: 17165434 DOI: 10.1038/sj.jp.7211598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate the usefulness of positron emission tomography with 18-fluorodeoxyglucose (18FDG-PET) in locating residual or relapsed gestational trophoblastic neoplasia (GTN). STUDY DESIGN The Charing Cross GTN database was screened, and 11 patients who had undergone 18FDG-PET were identified. A retrospective analysis was conducted to determine the value of this investigation as compared with other imaging modalities in clinical care. RESULTS All patients had elevated beta-human chorionic gonadotropin (beta-hCG) at the time of the investigation; none were false positive. In 7 patients the 18FDG-PET scans correctly confirmed the presence (4 of 7 cases) or absence (3 of 7 cases) of disease sites defined by other imaging investigations. In 2 patients positive PET-guided appropriate surgical resection of lung lesions that appeared of equivocal significance on computed tomography (CT) resulted in -hCG normalization. One patient had a pulmonary metastasis on CT not considered positive on 18FDG-PET (false negative). One patient with enlarged mediastinal lymph nodes on CT that were 18FDG-PET positive also had a vascular uterus on magnetic resonance imaging/Dopper ultrasound that was negative on PET (false negative). Hysterectomy led to hCG normalization and cure. The mediastinal lymph nodes were positive on CT and PET due to sarcoidosis (false positive). Patients with serum hCG levels <10 IU/L could have positive PET scans; that can contribute to patient care. CONCLUSION 18FDG-PET can aid in identifying residual disease sites in women relapsing from previously treated GTN. However, careful evaluation in combination with other imaging modalities is required to reduce the risk of false positive and negative results.
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Affiliation(s)
- Tony Dhillon
- Department of Medical Oncology, Charing Cross Hospital Campus of Imperial College, Fulham Palace Road, London W6 8RF, UK
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Abstract
Necrotising enterocolitis is one of the most common gastrointestinal emergencies in newborn infants. Here we review the epidemiology, clinical presentation, and pathophysiology of the disease, as well as strategies for diagnosis, management, and prevention. Necrotising enterocolitis is one of the most devastating and unpredictable diseases affecting premature infants. Despite decades of research, its pathogenesis remains unclear; diagnosis can be difficult; and treatment is challenging. We will need to improve our understanding of intestinal defences in premature infants, dietary and bacterial factors, and genetic effects that could predispose infants to necrotising enterocolitis before we can develop new strategies for prevention and treatment.
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Affiliation(s)
- Patricia W Lin
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA 30322, USA.
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Sharma R, Hudak ML, Tepas JJ, Wludyka PS, Marvin WJ, Bradshaw JA, Pieper P. Impact of gestational age on the clinical presentation and surgical outcome of necrotizing enterocolitis. J Perinatol 2006; 26:342-7. [PMID: 16724075 DOI: 10.1038/sj.jp.7211510] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE This investigation tests the hypothesis that the clinical presentation and the outcome of necrotizing enterocolitis (NEC) vary with gestational age (GA). METHODS All infants admitted to our center between October 1991 and September 2003 were evaluated weekly to identify confirmed cases of NEC. Based upon GA, these infants were divided into five groups: Extremely premature (EP, 23 to 26 weeks), very premature (VP, 27 to 29 weeks), moderately premature (MP, 30 to 34 weeks), near-term (NT, 35 to 36 weeks), and term (T, 37 to 42 weeks). RESULTS A total of 202 infants developed NEC. The most common sign of NEC among EP infants was ileus (77%), followed by abdominal distention (71%), emesis (58%), pneumoperitoneum (54%), fixed intestinal loop (52%), gasless abdomen (42%) and bloody stools (17%). Intramural gas was detected in 100% of T but was present in only 29% of EP infants (P < 0.0001). Similarly, portal venous gas was common in T but infrequent in the EP infants (47 vs 10%, P < 0.0001). Despite a higher peritoneal drain insertion rate (31 vs 5%, P < 0.001) and a higher mortality rate (33 vs 10%, P = 0.05) in EP compared to T infants, other clinical outcomes were not different. CONCLUSIONS The clinical presentation of NEC is different in EP compared to more mature infants; however, outcome among NEC survivors is similar across all GA. Reliance solely on observation of intramural or on portal venous gas in EP infants may lead to a delay or failure in the diagnosis.
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Affiliation(s)
- R Sharma
- Division of Neonatology, Department of Pediatrics, University of Florida, Jacksonville, FL 32209-6511, USA.
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