logging in or signing up NECROTISING ENTEROCOLITIS maulikdr Download Post to : URL : Related Presentations : Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Uploaded from authorPOINT lite Insert YouTube videos in PowerPont slides with aS Desktop Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 189 Category: Entertainment License: All Rights Reserved Like it (0) Dislike it (0) Added: August 03, 2012 This Presentation is Public Favorites: 0 Presentation Description No description available. Comments Posting comment... Premium member Presentation Transcript PowerPoint Presentation: DR.MAULIK SHAH MD.(PED) ASST. PROF. – PEDIATRICS M.P.SHAH MEDICAL COLLEGE, JAMNAGAR. NECROTISING ENTEROCOLITISNECROTISING ENTEROCOLITIS: NECROTISING ENTEROCOLITIS Epidemiology: most common GI emergency in preterm infants. leading cause of emergency surgery in neonates. overall incidence: 1-5%. most common in VLBW preterm infants. 10% of all cases occur in term infants. a maulik shah presentationNECROTISING ENTEROCOLITIS: NECROTISING ENTEROCOLITIS Epidemiology: 10x more likely to occur in infants who have been fed. males = females blacks > whites. mortality rate: 25-30% 50% of survivors experience long-term sequelae a maulik shah presentationNECROTISING ENTEROCOLITIS: NECROTISING ENTEROCOLITIS Pathology: most commonly involved areas: terminal ileum and proximal colon a maulik shah presentationNECROTISING ENTEROCOLITIS: NECROTISING ENTEROCOLITIS GROSS: bowel appears irregularly dilated with hemorrhagic or ischemic areas of frank necrosis focal or diffuse per op a maulik shah presentationPowerPoint Presentation: Gross pathology- necrotising enterocolitis - postmortem a maulik shah presentationNECROTISING ENTEROCOLITIS: NECROTISING ENTEROCOLITIS MICROSCOPIC: mucosal edema, hemorrhage and ulceration a maulik shah presentationNECROTISING ENTEROCOLITIS: NECROTISING ENTEROCOLITIS minimal inflammation during the acute phase increases during revascularization granulation tissue and fibrosis develop stricture formation microthrombi in mesenteric arterioles and venules a maulik shah presentationETIO PATHOLOGY: ETIO PATHOLOGY a maulik shah presentation Prematurity : Prematurity primary risk factor 90% of cases are prematures . immature GI system mucosal barrier poor motility immature immune response impaired circulatory dynamics a maulik shah presentation PRIMARY INFECTIOUS AGENTS : PRIMARY INFECTIOUS AGENTS Bacteria Bacterial toxin Virus Fungus a maulik shah presentationInfectious Agents: Infectious Agents usually occurs in clustered epidemics normal intestinal flora E. coli Klebsiella spp. Pseudomonas spp. Clostridium difficile Staph. Epi Viruses a maulik shah presentation INFLAMMATORY MEDIATORS : INFLAMMATORY MEDIATORS Inflammatory cells (macrophage) Platelet activating factor (PAF) Tumor necrosis factor (TNF) Leukotriene C4 Interleukin 1; 6 a maulik shah presentationInflammatory Mediators: Inflammatory Mediators involved in the development of intestinal injury and systemic side effects neutropenia , thrombocytopenia, acidosis, hypotension primary factors Tumor necrosis factor (TNF) Platelet activating factor (PAF) LTC4 Interleukin 1& 6 a maulik shah presentationISCHEMIA: ISCHEMIA Hypoxic-ischemic injury poor blood flow to the mesenteric vessels local rebound hyperemia with re-perfusion production of O2 radicals Polycythemia increased viscosity causing decreased blood flow exchange transfusion Cyanotic congenital heart disease. Patent Ductus arteriosus Maternal pre- Eclampsia a maulik shah presentation ENTERAL FEEDINGS : ENTERAL FEEDINGS > 90% of infants with NEC have been fed provides a source for H2 production hyperosmolar formula/medications aggressive feedings too much volume rate of increase >20cc/kg/day a maulik shah presentationENTERAL FEEDINGS: ENTERAL FEEDINGS immature mucosal function Malabsorption breast milk may have a protective effect IGA macrophages, lymphocytes complement components lysozyme , lactoferrin acetylhydrolase a maulik shah presentationClinical Features: Clinical Features Gestational Age Age at Diagnosis < 30 wks 20 days 31-33 wks 11 days >34 wks 5.5 days Full term 3 days Time of onset is inversely related to gestational age/ birthweight a maulik shah presentation: G.I.T . Related…. Feeding intolerance Abdominal distention Abdominal tenderness Emesis Occult/gross blood in stool Abdominal mass Erythema of abdominal Clinical Features a maulik shah presentationClinical Features: Clinical Features Systemic Lethargy Apnea/respiratory distress Temperature instability Hypotension Acidosis Glucose instability DIC Positive blood cultures a maulik shah presentationClinical Features: Clinical Features Sudden onset – catastrophic Insiduous onset Indolent a maulik shah presentationClinical Features: Clinical Features Sudden onset Full term or preterm infants Acute catastrophic deterioration Respiratory decompensation Shock/acidosis Marked abdominal distension Positive blood culture Insiduous onset Usually preterm Evolves during 1-2 days Feeding intolerance Change in stool pattern Intermittent abdominal distention Occult blood in stools a maulik shah presentationBELL ‘S STAGING : BELL ‘S STAGING a maulik shah presentationDifferential diagnosis : Differential diagnosis Sepsis with ileus Bowel obstruction Volvulus Malrotation Spontaneous intestinal perforation Systemic candidiasis a maulik shah presentationRADIOLOGICAL FINDINGS: RADIOLOGICAL FINDINGS Pneumatosis Intestinalis hydrogen gas within the bowel wall product of bacterial metabolism a. linear streaking pattern more diagnostic b. bubbly pattern appears like retained meconium less specific a maulik shah presentationPowerPoint Presentation: Pneumatosis Intestinalis a maulik shah presentationPowerPoint Presentation: Bell stage 2 – pneumatosis intestinalis a maulik shah presentationRADIOLOGICAL FINDINGS: RADIOLOGICAL FINDINGS Pneumoperitoneum free air in the peritoneal cavity secondary to perforation falciform ligament may be outlined “football” sign surgical emergency a maulik shah presentationBell stage III -Pneumo peritonium: Bell stage III - Pneumo peritonium Pneumo peritonium Portal gas a maulik shah presentationBell stage III -Pneumo peritonium: Bell stage III - Pneumo peritonium a maulik shah presentationRADIOLOGICAL FINDINGS: RADIOLOGICAL FINDINGS Portal Venous Gas extension of pneumatosis intestinalis into the portal venous circulation linear branching lucencies overlying the liver and extending to the periphery associated with severe disease and high mortality a maulik shah presentationLABORATORY FINDINGS: LABORATORY FINDINGS CBC neutropenia /elevated WBC thrombocytopenia Acidosis metabolic Hyperkalemia increased secondary to release from necrotic tissue a maulik shah presentationLABORATORY FINDINGS: LABORATORY FINDINGS DIC Positive cultures blood CSF urine stool a maulik shah presentation MANAGEMENT : Medical Care : MANAGEMENT : Medical Care Bowel rest and nutrition: Cessation of enteral feeding. : usually 7- 10 days. Gastric decompression : large bore 8 -10F orogastric tube or Replogle catheter. Commencement of intravenous fluids Correction of electrolyte disturbances TPN a maulik shah presentation MANAGEMENT : Medical Care : MANAGEMENT : Medical Care Intravenous antibiotics: broad spectrum cefotaxime / vancomycin aminoglycoside +/- clindamycin / metronidazole a maulik shah presentation MANAGEMENT : Medical Care : MANAGEMENT : Medical Care Fluids and cardiovascular support: IVF : Increse total volume required- 150-180 ml./kg replace NG Aspirates with ½ NS or RL INOTROPES : Dopamine / dobutamine Platelet concentrate packed red cells Fresh Frozen Plasma. a maulik shah presentation MANAGEMENT : Medical Care : MANAGEMENT : Medical Care Respiratory support: Mechanical ventilation Correction of acidosis: ventilation + fluids +bicarbonate Analgesia: morphine / fentanyl Labs: q6-8hrs CBC, electrolytes, DIC panel, blood gases X-rays: q6-8hrs AP, left lateral decubitus or cross-table lateral a maulik shah presentation MANAGEMENT : Medical Care : MANAGEMENT : Medical Care Labs: q6-8hrs CBC, electrolytes, DIC panel, blood gases X-rays: q6-8hrs AP, left lateral decubitus or cross-table lateral Supportive Therapy fluids, blood products, pressors , mechanical ventilation a maulik shah presentation MANAGEMENT : Surgical Care : MANAGEMENT : Surgical Care Surgical Consult suspected or proven NEC indications for surgery: portal venous gas; pneumoperitoneum clinical deterioration despite medical management positive paracentesis fixed intestinal loop on serial x-rays erythema of abdominal wall a maulik shah presentation MANAGEMENT : Surgical Care : MANAGEMENT : Surgical Care 1. Laparotomy – Resection Enterostomy Mucosal fistula 2. Paritoneal Drainage. a maulik shah presentation Complications : Complications Intestinal strictures : 25-33%. , ileum / left side colon Contrast enema before re anastomosis Short-gut syndrome : Mal absorption syndrome Bowel obstruction Cholestasis Uncommon sequale : fistula, abscess, recurrent NEC, malabsorption , enterocyst formation a maulik shah presentation Complications : Complications Neurodevelopmental sequale Growth failure a maulik shah presentationPrevention of NEC (Evidence Based guidelines): Prevention of NEC (Evidence Based guidelines) Type of milk- Infants who received human milk were 4 times less likely to have confirmed NEC compared to infants who received formula. (McGuire 2003b [M], Schanler 1999 [A], Lucas 1990 [A], Gross 1983 [B], Tyson 1983 [B], Svenningsen 1982 [B]). a maulik shah presentationPowerPoint Presentation: Evidence-based support for efficacy Limited data to support efficacy Breast feeding Fluid restriction Trophic feeding Oral immunoglobulins Enteral administration of antibiotics Cautious advancement of feedings Antenatal steroids L- arginine supplementation Acidification of milk feeds Probiotics , prebiotics and postbiotics Polyunsaturated fatty acids Free radical scavengers a maulik shah presentation You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.