Gastrointestinal Disorders

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

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**25**

**Chapter 2**

**Abstract**

Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is the commonest inflammatory gastrointestinal disorder of newborn infants, occurring primarily in premature neonates. Presenting as a medical and surgical emergency, it is associated with significant morbidity and mortality. NEC is characterized by acute intestinal inflammation and necrosis with intramural dissection of gas, pathognomically appearing as pneumatosis intestinalis on radiography. The incidence and mortality, with an inverse relationship to maturation, range between 3–11% and 17–20% respectively. Mortality may be up to 50% in extremely premature infants who require surgery for intestinal perforation or gangrene. The exact etiopathogenesis is unknown. Over 90% of infants are premature and more than 98% are enterally fed. NEC presents with feeding intolerance and abdominal distension, which may rapidly progress to cardiorespiratory decompensation and death in severe cases. Intestinal dysbiosis and its functional and immunological immaturity are proposed to play roles in the pathogenesis. While exact triggers are undetermined, the disease is marked by an anomalous immunological response of enterocytes to inflammation, invoking cytokines and chemokines. NEC is treated with bowel rest, antibiotics, cardiorespiratory support, parenteral nutrition, and blood products transfusion. Approximately 30% of cases require surgery and a significant number of survivors suffer from neurological deficits, intestinal dysfunction, and

**Keywords:** necrotizing enterocolitis, preterm infants, pneumatosis intestinalis, intestinal gangrene, intestinal perforation, intestinal dysbiosis, short bowel syndrome, feeding intolerance, heme positive stools, abdominal distension,

Necrotizing enterocolitis (NEC) is an acquired, multifactorial and devastating gastrointestinal disease associated with high morbidity and mortality in preterm neonates. With an incidence of about 7% in infants with BW < 1500 g and mortality up to 30%, NEC presents as a medical and surgical emergency [1, 2]. It is characterized by ischemia, necrosis, and inflammation of bowel wall with invasion by gas-forming organisms and intramural dissection of gas, characteristically appearing as pneumatosis intestinalis in radiological and pathological studies. While exact etiology is undetermined, the pathogenesis is believed to be an anomalous innate immune response to an altered, less diverse intestinal microbiota by the highly immunoreactive enterocytes of premature infants, leading to inflammation and tissue necrosis [3, 4]. The clinical presentation can be severe with cardiorespiratory collapse, shock, and disseminated intravascular coagulopathy (DIC), escalating

*Rita Prasad Verma and Archana Kota*

post surgical short bowel syndrome.

cardiovascular decompensation

**1. Introduction**
