Critical Care Medicine

Gastrointestinal Emergencies: Necrotizing Enterocolitis (NEC)

Necrotizing Enterocolitis (NEC)

1. Description of the problem

NEC is characterized by ischemia and necrosis of the gastrointestinal tract and can lead to mortality and morbidity, including short bowel syndrome. It is most often found in premature infants and requires early recognition and treatment to prevent long segment bowel necrosis.

Clinical features

Most infants diagnosed with NEC are premature but are relatively healthy and feeding well prior to the development of NEC.

Feeding intolerance

Apnea/respiratory failure

Signs of sepsis

Abdominal distention


Lack of bowel sounds

Key management points

Early Identification - pneumatosis intestinalis and ileus on AXR

Early Treatment - antibiotics, cessation of oral feeding, possible surgical exploration

Serial abdominal X-rays

3. Diagnosis

The mainstay of NEC diagnosis remains abdominal radiography, although abdominal ultrasound may have some utility, especially with ultrasound expertise.

AXR - dilated bowel loops, ileus, pneumatosis intestinalis, pneumoperitoneum, fixed loops

While the diagnosis of NEC relies on radiographic evidence, laboratory evaluation may further suggest NEC. These findings include:

  • Metabolic acidosis

  • Low platelets

  • Low neutrophil count

  • Prolonged PT/PTT

  • High glucose

4. Specific Treatment

Medical Management

  • Fluid resuscitation and replacement of insensible losses

  • Bowel rest with NG suction

  • Total parenteral nutrition

  • Antibiotic coverage (see below)

  • Radiographic monitoring

Surgical Management

  • Laparotomy with resection of necrotic bowel and peritoneal drain placement

Drugs and dosages

Vancomycin, gentamicin, and clindamycin or metronidazole or piperacillin-tazobactam.

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