Management of Necrotizing Enterocolitis with Gastrointestinal Bleeding
The management of a neonate with necrotizing enterocolitis (NEC) and gastrointestinal bleeding requires immediate implementation of bowel rest, broad-spectrum antibiotics, fluid resuscitation, and nasogastric decompression, with surgical consultation for possible intervention if perforation or clinical deterioration occurs. 1
Initial Assessment and Stabilization
- Immediately discontinue all enteral feeds and implement complete bowel rest 1
- Insert nasogastric tube for bowel decompression to reduce abdominal distension 1
- Initiate fluid resuscitation to address hemodynamic instability and maintain adequate perfusion 1
- Monitor for signs of sepsis/septic shock and provide hemodynamic support as needed 1
- Obtain baseline laboratory studies including complete blood count, blood culture, electrolytes, and blood gas 1
- Perform abdominal radiographs (anteroposterior and lateral decubitus) to assess for pneumatosis intestinalis, portal venous gas, or pneumoperitoneum 2
Antibiotic Management
- Start broad-spectrum intravenous antibiotics immediately after obtaining blood cultures 1
- First-line antibiotic regimens include:
- Ampicillin + gentamicin + metronidazole OR
- Ampicillin + cefotaxime + metronidazole OR
- Meropenem as monotherapy 1
- For suspected MRSA or ampicillin-resistant enterococcal infection, substitute vancomycin for ampicillin 1
- For suspected fungal infection (particularly in extremely low birth weight infants), add fluconazole or amphotericin B 1
- Continue antibiotics for 7-14 days depending on clinical response and culture results 3
Management of Gastrointestinal Bleeding
- Closely monitor for ongoing blood loss and hemodynamic instability 2
- Obtain serial hemoglobin/hematocrit measurements to assess bleeding severity 1
- Consider blood transfusion for significant gastrointestinal bleeding causing anemia or hemodynamic compromise 4
- When blood transfusions are necessary, consider withholding enteral nutrition during and immediately after transfusion to reduce risk of transfusion-associated NEC (TANEC) 4
- Monitor platelet count and replace as needed, as thrombocytopenia is common in NEC 1
Surgical Management
- Urgent surgical consultation is required for all cases of NEC with gastrointestinal bleeding 1
- Immediate surgical intervention is indicated for:
- Pneumoperitoneum (indicating intestinal perforation)
- Clinical deterioration despite maximal medical therapy
- Fixed dilated intestinal loop on serial radiographs
- Abdominal wall erythema/discoloration 1
- Surgical options include:
- Laparotomy with resection of necrotic bowel and creation of ostomies
- Primary anastomosis in select cases
- Peritoneal drainage as a temporizing measure in extremely low birth weight infants 1
- Obtain intraoperative Gram stains and cultures to guide antimicrobial therapy 1
Ongoing Monitoring and Supportive Care
- Perform serial abdominal examinations to assess for worsening distension, tenderness, or discoloration 2
- Obtain serial abdominal radiographs every 6-12 hours to monitor disease progression 2
- Monitor for metabolic acidosis, which may indicate worsening intestinal ischemia 1
- Provide respiratory support as needed, as respiratory status may deteriorate with abdominal distension 3
- Monitor for multisystem organ dysfunction, which can develop rapidly in severe NEC 5
Nutritional Support
- Provide parenteral nutrition during the period of bowel rest 4
- Consider arginine supplementation in parenteral nutrition, as it may help prevent NEC progression 4
- Ensure adequate protein intake (3.5-4 g/kg/day) to support healing and prevent catabolism 4
- Monitor for parenteral nutrition-associated complications including cholestasis 4
- Reintroduction of enteral feeds should be delayed until clinical improvement is evident (typically 7-14 days) 3
Prevention Strategies for Future Cases
- Consider probiotic supplementation for prevention in preterm infants, particularly combinations of Lactobacillus spp. and Bifidobacterium spp., which have shown to reduce the risk of severe NEC and mortality 4
- Combinations of Lactobacillus spp. and Bifidobacterium spp. have demonstrated reduction in all-cause mortality (OR, 0.56,95% CI, 0.39–0.80) and severe NEC (OR, 0.35; 95% CI, 0.20–0.59) 4
- Human milk feeding should be prioritized when enteral nutrition is reintroduced 1
- Consider lactoferrin supplementation alone or in combination with Lactobacillus to reduce the incidence of late-onset sepsis 1
Prognosis and Follow-up
- Overall survival rate for NEC is approximately 95% unless NEC involves the entire bowel 1
- When NEC involves the entire bowel, mortality increases to 40-90% 1
- Monitor for development of intestinal strictures, which occur in 15-35% of recovered infants 6
- Long-term follow-up is essential to monitor for neurodevelopmental outcomes and growth 2
- Nonoperative management is successful in approximately 70% of cases 1