Necrotizing Enterocolitis

1
Necrotizing Enterocolitis

• Presented by Dr Akram Saade
• Moderator Dr Yousef Abu Osba

2
History

• Ahmed is a newborn male baby , a product of
  caesarean section at 27 week gestational age
  due to antepartum hemorrhage on 28 July 2003 in a
  major hospital in Amman.

3
Cource in the referral hospital

• The baby was immediately admitted and treated as
  a case of
• -Respiratory Distress Syndrome.
• -Suspected Sepsis.

4
Course in the referral hospital

• Put on mechanical ventilator.
• Covered by Ampicillin and ceftazidime.
• Given Pentaglobin.
• Received 3 doses of surfactant.
• Received packed RBCs and plasma many times.

5
Course in the referral hospital

• Feeding started at the age of 10 days but 2
  days later the baby noticed to have abdominal
  distentionfollowed by bluish discoloration of
  the skin overlying the abdomen and scrotum.
• Feeding stopped.
• Metronidazole added.

6
The baby referred to our NICU

• At the age of 3 weeks as a case of
• Prematurity.
• Respiratory Distress Syndrome.
• Cholestatic Jaundice.
• Suspected Retroperitonial Hemorrhage.
• Suspected IntraventricularHemorrhage.

7
Course in our NICU

• The baby continued on mechanical
• ventilator with the following setup
• RR 15 PiP 12
• FiO2 100 PEEP 3
• with gradual weaning according
• to the respiratory status.
  

8
Examination

• Vital signs
• HR 140 bpm
• RR 40/min
• BP 75/39mmHg
• Temp 35.9 C

9
Examination

• Head and Neck
  
• Pale.
• No dysmorphic features.
• No cyanosis.
• Normal neck examination.

10
Examination

• Chest
• No deformities.
• Good air entry bilaterally.
• Normal vesicular breathing.
• No added sounds.

11
Examination

• Cardiovascular
• Normal 1st and 2nd heart sounds.
• No murmurs.
• Intact peripheral pulses.

12
Examination

• Abdomen
• Distention, abdominal girth23cm.
• Bluish discoloration of the skin overlying
• the abdomen.
• Palpated mass about 2cm in diameter
• just below the left costal margin.
• Bilateral inguinal hernia.
• Scrotal swelling with bluish discoloration
• of the overlying skin.

13
Investigation

• WBC14.9 x 10 9 N65 L25
• PCV36 PLT75x10 9
• Na132 meq/l K4 meq/l
• Ca8.5 mg/dl CRP48
• TSB8.1mg/dl Direct bilirubin3.5mg/dl
• ABGs pH7.45 PaO2186
• PaCO236 HCO324

14
Imaging

• Chest X-Ray
• Resolving respiratory distress syndrome.
• Abdominal Ultrasound
• Bilateral hydronephrosis ,Fluid collection.
• Head Ultrasound
  No hemorrhage.

Chest
15
Management

• NPO and NGT free drainage.
• Central line.
• IVFthat was changed according to blood glucose
  and electrlytes .
• Packed RBCs and Plasma.
• Metronidazole,Imipinem and Teicoplanin.
• Pentaglobin.
• Vitamin k.

16

• Necrotizing Enterocolitis suspected and
  abdominal erect and supine X-rays done and
  revealed
  Multiple air fluid levels with air under the
  diaphragm ,which suggested a perforated hollow
  viscus.

17
Pediatric surgeon consultation

• Peritoneal drainage performed, the drained
  peritoneal fluid was bloody, dirty
  and under pressure initially about
  50cc.
• Peritoneal lavage done with Cefotaxime and
  saline.

18

• Drain removed 5days later after clearing and
  decreasing in amount of the discharge.
• Follow up X-Rays revealed ---no air
  fluid levels
  -disappearance of air under the diaphragm.

19
Course in the hospital

• 10 days after admission
  Abdominal Ultrasound repeated and
  revealed
• disappearance of fluid collection.
• improvement of hydronephrosis.

20
Course in the hospital

• 2 weeks after admission
  -The general condition was significantly
  improved but unfortunately the condition
• deteriorated with development of metabolic
  and respiratory acidosis for which sepsis
  workup done that were all negative apart from
  growth of klebsiella from the ETT.
• Imipinem and Teicoplanin discontinued.
• Ceftazidime and Amikacin started.
• Fluconazole added.
• Pentaglobin given.

21
Course in the hospital

• In the last 3 days
• The patient developed cardiopulmonary
  compromise for which
  Dopamine and Dobutamine and NaHCO3 continuous
  infusion started . but the baby
  continued to have bradycardia and metabolic
  acidosis.

22
Course in the hospital

• Inspite of continuous intensive
  management ,the condition deteriorated
  and the patient resuscitated
  for 3 times
• Died on 3 AUGUST 2003.

23
Final Diagnosis

• Prematurity.
• Respiratory Distress Syndrome.
• Necrotizing Enterocolitis.
• Cholestatic Jaundice.