Necrotizing enterocolitis is a disease of the intestine that occurs primarily in premature infants. The exact causes have not yet been clearly determined. Although treatment of the disease is achieving greater and greater success, it continues to occur frequently and in quite a few cases leads to death.
What is necrotizing enterocolitis?
By necrotizing enterocolitis, physicians mean a severe intestinal disease that occurs mainly in premature infants. It involves an infection associated with impaired blood flow to the intestinal wall. The tissue becomes necrotic and changes. Putrefactive gases become trapped and, in the worst cases, intestinal contents leak into the abdominal cavity. Affected newborns present with a distended abdomen, can no longer tolerate food, and may vomit bloody bile. Statistics indicate that necrotizing enterocolitis still affects one in 10 premature infants. Although medical advances are increasing, the mortality rate for premature infants is still 5-10%, depending on birth weight and the infant’s general condition, as well as the stage at which the disease is detected.
Causes
The exact causes of necrotizing enterocolitis have not yet been determined. Medical researchers have been able to identify numerous risk factors or circumstances that appear to favor the disease. However, it could not be determined whether some factors have a major influence on the development of the disease or not. Possible triggers of necrotizing enterocolitis include pre-existing conditions such as certain heart defects (for example, aortic isthmic stenosis, a narrowing of the aorta). However, conditions such as volume-deficiency shock, in which there is a decrease in the amount of blood in the vessels due to a severe loss of fluid, or respiratory distress syndrome, a lung dysfunction in newborns, are also thought to promote the development of necrotizing enterocolitis. This also applies to hypoglycemia, hypothermia, low blood pressure, or even insertion of a catheter through the umbilical vessels.
Symptoms, complaints, and signs
Usually, the disease begins insidiously. Its progression is classified according to different stages. In stage I, the first signs appear in the form of unstable body temperature, a bloated abdomen that is sensitive to touch, and refusal of food. In addition, respiratory arrests occur repeatedly. The child looks pale, his facial color becomes grayish and he is sleepy. Bloody stools may occur. In stage II, the general condition deteriorates even more. The child hardly responds to painful stimuli and the body cools down, especially arms and legs feel cold. Respiratory arrests become more frequent and the heartbeat slows. Vomiting of bilious gastric juice occurs and the amount of blood in the stool increases. If the child becomes unresponsive, he or she must be ventilated. This condition can rapidly worsen and progress to stage III. The intestinal tissue dies, causing its contents to flow into the abdominal cavity and causing life-threatening peritonitis. There is a risk of sepsis. The abdomen is then severely tense, reddish spots form on the flanks, and water retention occurs. In most cases, these stages occur one after the other. However, it is also possible for the disease to worsen dramatically from stage I to stage III within a few hours.
Diagnosis and progression
Necrotizing enterocolitis can still be diagnosed in the clinic by the attending physicians. First, a general physical examination of the premature infant takes place, along with a comprehensive blood test. In addition, imaging techniques provide information about clear symptoms such as thickened intestinal walls and dilated intestinal loops. Often, gas bubbles can also be detected. If the bowel wall is already perforated, leaked air in the abdominal cavity can also be detected. An ultrasound can similarly provide definitive evidence of the presence of necrotizing enterocolitis. If necrotizing enterocolitis remains untreated or is detected too late, the perforations in the intestinal wall just described will occur. This can allow intestinal contents to enter the abdominal cavity, which leads to sepsis and can have a fatal outcome.
Complications
In the worst case, this disease can lead to the death of the affected person. Especially the parents and the relatives can react to this with psychological upsets and sometimes need psychological treatment. As a rule, those affected by this disease suffer from various complaints in the region of the stomach and intestines. There is a bloody bowel movement and further more often vomiting. A bloated abdomen and insufficient bowel movements can also occur and further reduce the patient’s quality of life. In many cases, patients with this disease also suffer from a very pale skin color and circulatory problems. Likewise, if left untreated, it can lead to peritonitis, which in the worst case can be fatal. As a rule, this disease can be treated with the help of antibiotics. Complications do not occur. However, those affected are still dependent on surgical interventions or on the removal of the intestine and thus receive an artificial bowel outlet. This leads to considerable restrictions in the patient’s everyday life. If treatment is successful, the life expectancy of the affected person is usually not reduced.
When should one go to the doctor?
If premature infants show persistent or increasing abnormalities of behavior, there is usually cause for concern. Apathy, listlessness, or severe restlessness indicate health problems that should be investigated. If there is a refusal of food or fluids, severe weepiness, or insomnia, a physician is needed. Features of skin appearance, discoloration, or a dull skin texture need to be presented to a physician. If there are sensory disturbances, hypersensitivity to touch, or increased body temperature, a physician should be consulted. If there is severe bloating, blood in the stool or urine, and swelling, a workup is necessary. Vomiting, interruptions of breathing and disturbances of the heart rhythm must be presented to a doctor immediately. If water retention is noticed, the child does not respond appropriately to social interactions, or circulatory disturbances occur, medical attention is needed. If there are cold limbs, poor reflex response, and spotting, a physician must be consulted. Since the disease can end in the premature death of the patient if left untreated, a doctor should be consulted as soon as possible. If existing complaints increase in extent as well as intensity within a few hours, there is a need for action. In the event of an acute condition, an ambulance service should be alerted. At the same time, sufficient first aid measures should be initiated to ensure the infant’s survival.
Treatment and therapy
If necrotizing enterocolitis has been clearly diagnosed, gastrointestinal feeding must first be stopped. Meanwhile, the premature infant is provided with all necessary nutrients via infusions. In most cases, this measure must be carried out over a period of up to ten days. The disease itself is treated with antibiotics. The blood supply to the intestinal wall can also be supported or improved with medication. If perforation of the intestinal wall has already occurred, the affected parts of the intestine must be surgically removed. The earlier this operation is performed, the smaller the section to be removed. Temporarily, an artificial bowel outlet must be placed, which can be slowly replaced by normal bowel activity after about eight to ten days. If the disease is recognized early enough and treated appropriately, the prognosis for neonates with necrotizing enterocolitis is quite favorable.
Outlook and prognosis
The prognosis of the disease depends on how quickly the clinical picture of necrotizing enterocolitis and the resulting sepsis could be recognized. It also plays a major role in how timely adequate treatment was started. The chances of recovery for those affected always depend on the severity of the disease. If sepsis can be well controlled with the correct medication, the prognosis for the patient is not bad. If treated, only about 5 to 10 percent of affected newborns die. If untreated, about 10 to 30 percent die. If the necrosis has spread to larger sections of the intestine, the child quickly develops a short bowel syndrome. The intestine must be removed if it does not recover.The more intense the patient’s symptoms and the more advanced the disease, the more often surgery is necessary. However, there is always a risk that the removal of some intestinal segments may lead to the development of short bowel syndrome, which can result in malnutrition and diarrhea. On average, about ten percent of patients suffer from short bowel syndrome. Approximately ten percent of patients also suffer so-called strictures of the intestine in the further course of the disease. These then require urgent surgical intervention on the patient again.
Prevention
Prevention of necrotizing enterocolitis is not yet possible. Scientists are trying, among other things, to prevent premature infants from developing the disease by administering antibodies or prophylactic antibiotics. However, a proven preventive effect is not yet known. Close observation of the premature infant in the hospital is therefore the best and only way to date to recognize possible symptoms in good time and to initiate therapy. In this way, progression of the disease and a potentially fatal course can be prevented.
Follow-up
Follow-up of necrotizing enterocolitis is very limited. It depends on the type of treatment. With drug treatment, rehabilitation is less conflictive than after surgery. Further influence has the age of the child as well as the duration of the stay in the neonatological intensive care unit. Initially, follow-up care is completely inpatient. The child remains in the hospital until he or she can eat again and steadily gain weight. In some cases, infusions are used for this purpose. After discharge from the hospital, regular follow-up examinations are necessary. These initially take place at relatively short intervals. If the development is positive, they are then performed monthly, and later annually. It is important to rest and take care of the body during follow-up care in the patient’s own home. Physical exertion should be avoided. It is also important to observe whether there is vomiting, constipation, lack of bowel movements or anemia. In these cases, it is imperative to consult a physician. In some cases, continued use of antibiotics is necessary as follow-up care. Here, care must be taken to ensure that they are taken correctly. Necrotizing enterocolitis is a serious complication and can lead to long-term health problems.
Here’s what you can do yourself
Necrotizing enterocolitis is a threatening condition and therefore requires intensive medical care. Parents of the newborn therefore quickly feel relegated to the role of spectator and left alone with their fears. It is important for both partners to ask for emotional support at an early stage and to accept the help offered. Fears should be discussed openly with everyone involved. Any siblings should not be left out of the discussion. The sick newborn should be allowed to have contact with the parents as often as possible and, if possible, they should also take over nursing activities themselves. The professional nursing team is usually happy to accommodate this request. If, in the course of treatment, a section of intestine is removed and an artificial anus is created, the clinics usually offer appropriately trained staff to care for it. However, this so-called “anus praeter” is usually only a short-term solution. If a short bowel syndrome is imminent, the further feeding of the child and its individual needs should first be discussed with the attending physician. If necessary, an experienced nutritional therapist will then provide further advice. It is difficult to make general recommendations in this case, and the individuality of each patient must be given special consideration.
