Neonatal_NEC_Presentation pemaparan secara klinis

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1. Neonatal Necrotizing Enterocolitis Overview of NEC in Newborns dr. Nugra Daary Razsky Gunawna

2. Introduction • Necrotizing enterocolitis (NEC) is a life-threatening gastrointestinal emergency in newborns. • Characterized by ischemic necrosis of the intestinal mucosa. • Key Features: Severe inflammation, enteric gas formation, and gas dissection into the bowel wall.

3. Epidemiology • Affects 1 to 3 per 1000 live births. • 90% of cases occur in very low birth weight (VLBW) infants (<1500g) born <32 weeks gestation. • Risk Factors: Prematurity and low birth weight. Population-Based Studies : Incidence of 0.7 to 1.1 cases of NEC per 1000 live births. Occurrence rates: 3% to 7% in selected populations (Vermont Oxford Network: 6% to 7% in VLBW infants). New York Study : 8-year study: average annual incidence of 0.72 cases per 1000 live births. Highest incidence: infants weighing 750 to 1000 grams.

4. Risk Factors for NEC Low Birth Weight : -Significant risk factor across multiple studies. -Highest incidence in infants weighing <1000 grams. Gestational Age : -Lower gestational age = higher risk of NEC. -A U.S. study of NICUs found an NEC rate of 3% among infants of 23 to 34 weeks gestation. Canada Study : -6.6% incidence of stage 2 NEC in very low birth weight (VLBW) infants (<1500 grams).

5. Clinical Presentation • Preterm Infants: - Sudden feeding intolerance. - Nonspecific abdominal signs (distension, erythema). • Term Infants: - Often associated with underlying illness (e.g., congenital heart disease). Early Signs: - Feeding intolerance, abdominal distension, and blood in stools. -Lethargy, apnea, and bradycardia​(Ashcraft's Pediatric Su…). Progression: Can lead to shock, bowel perforation, and peritonitis.

6. Pathophysiology • Intestinal ischemia, bacterial colonization, and inflammatory response lead to bowel necrosis. • Gas Formation: Pneumatosis intestinalis (gas in bowel wall) is a hallmark sign.

7. Disruption of the intestinal barrier leads to bacterial translocation and an exaggerated inflammatory response​ Immature motility and digestion expose the intestinal lining to harmful substances and bacteria​ (Altered Gut Microbiota) Overproduction of nitric oxide (NO) and inflammatory mediators contributes to cell death Damage to Tight Junctions Genetic and Immunological Factors

8. Diagnosis • Clinical Signs: Abdominal distension, bilious vomiting, rectal bleeding. • Imaging: Abdominal radiography shows pneumatosis intestinalis and pneumoperitoneum.

9. Radiology Abdominal X-ray : Initial Imaging Modality : An abdominal X-ray is often the first imaging study performed in suspected cases of NEC due to its availability and speed. Key Findings : Pneumatosis Intestinalis : The presence of air within the bowel wall, which appears as linear radiolucencies outlining the intestinal loops. This is a hallmark sign of NEC. Portal Venous Gas : Gas in the portal venous system indicates severe disease and is associated with a higher risk of perforation. Free Air : Evidence of pneumoperitoneum (free air in the abdominal cavity) suggests bowel perforation, a critical complication of NEC.

10. Ultrasonography (US) : Supplemental Tool : While not the primary method, ultrasound can provide additional information, especially in evaluating bowel thickening and free fluid. Key Findings : Bowel Wall Thickening : A thickened bowel wall (greater than 3 mm) is a sign of inflammation and can suggest NEC. Fluid Collections : The presence of free fluid in the abdominal cavity may indicate perforation or severe disease.

11. Computed Tomography (CT) : Limited Use in Neonates : Although CT scans provide detailed images and can identify complications such as perforation or abscess formation, they are typically avoided in neonates due to radiation exposure. Findings : Similar to X-ray findings, CT can show pneumatosis intestinalis, bowel wall thickening, and portal venous gas.

12. Magnetic Resonance Imaging (MRI) : Experimental and Rarely Used : MRI can provide excellent soft tissue contrast without radiation exposure. However, its use in diagnosing NEC is still experimental and not widely adopted. Findings : May demonstrate bowel wall abnormalities and provide information on the extent of necrosis.

13. Bell Staging Criteria • Stage I: Suspected NEC with nonspecific symptoms. • Stage II: Proven NEC with signs such as abdominal tenderness and pneumatosis intestinalis on imaging. • Stage III: Advanced NEC with bowel perforation and systemic illness.

14. Laboratory Findings • Anemia, thrombocytopenia, metabolic acidosis, and positive blood cultures in 20% of cases. • Lab findings support diagnosis but are nonspecific.

15. Management • Medical Treatment: - NPO (nothing by mouth). - Broad-spectrum antibiotics. - Supportive care. • Surgical Intervention required if bowel perforation occurs or if no improvement with medical management.

16. Indications for Surgery Surgical intervention may be indicated in the following situations: Bowel Perforation : When there is evidence of perforation, indicated by pneumoperitoneum (air in the abdominal cavity) on imaging studies. Advanced NEC : When medical management fails, and there are signs of worsening clinical condition despite appropriate treatment. Severe Distention : If significant abdominal distention is present, causing respiratory compromise or hemodynamic instability. Persistent Clinical Deterioration : Signs of systemic infection, such as septic shock, that suggest bowel necrosis is progressing.

17. Surgical Procedures Resection of Necrotic Bowel : The primary surgical procedure is the resection of the affected segment of the intestine. This involves: Identification of Necrotic Segments : Surgeons assess the bowel for ischemic areas and necrosis. Resection : The necrotic bowel segment is excised. Anastomosis or Stoma Creation : If enough healthy bowel remains, an anastomosis (reconnection of the bowel ends) can be performed. If the remaining bowel is insufficient or the infant's condition is unstable, a stoma (e.g., ileostomy or colostomy) may be created temporarily.

18. Abdominal Drainage : In cases where significant intra-abdominal infection is present, placing a drain may be necessary to manage abscesses or to facilitate fluid removal. Fistula Management : Post-operative care may involve monitoring and managing enteric fistulas (abnormal connections between the intestine and skin or other organs), which can occur after bowel resection.

19. Prognosis and Mortality • Mortality rates: 15% to 30%, higher in extremely preterm infants. • Long-term complications include bowel strictures and neurodevelopmental impairment.

20. Prevention • Breastfeeding lowers the risk of NEC. • Careful feeding protocols in NICUs. • Use of probiotics in high-risk infants (controversial).

21. Conclusion • NEC is a serious neonatal condition, predominantly affecting preterm infants. • Early diagnosis and prompt treatment improve outcomes. • Ongoing research focuses on biomarkers and improved diagnostic techniques.