Snapshot A 1-month-old boy is brought to the emergency department by his mother due to vomiting after feeds and blood in stool. The patient was born to a 28-year-old woman at 28 weeks gestation. His weight was 989 grams at the time of delivery and had a 5-minute APGAR score of 6. On physical examination the patient appears lethargic and abdominal distension is appreciated. An abdominal radiograph is shown. Introduction Clinical definition acute neonatal intestinal necrosis Epidemiology Incidence 0.1% of all live births Demographics more common in males Risk factors infants born ≤ 35 weeks gestation especially with a birth weight < 1000 g early-onset neonatal sepsis mechanical ventilation 5-minute APGAR < 7 ETIOLOGY Pathogenesis although the pathogenesis is unclear, it is believed to be due to an exaggerated inflammatory response to some sort of insult (e.g., enteral feeds in a premature infant) that injures immature intestinal epithelial cells Associated conditions prematurity Presentation Symptoms feeding intolerance (e.g., emesis) lethargy apnea dyspnea may require ventilatory support Physical exam abdominal distension blood in stool Imaging Radiography view abdominal in the supine position indication abdominal radiagraphy is used to confirm the diagnosis of suspected necrotizing enterocolitis findings findings suggestive of necrotizing enterocolitis include pneumatosis intestinalis (hallmark of the disease) hepatobiliary gas pneumoperitoneum Studies Labs complete blood count (CBC) thrombocytopenia is often found and can suggest worsening disease progression if they are declining serum chemistry blood culture Diagnostic criteria the diagnosis is based on abdominal radiographic findings (e.g., pneumatosis intestinalis) and characteristic clinical findings such as abdominal distention rectal bleeding (the bleeding can be occult or grossly present) Differential Spontaneous intestinal perforation Infectious enteritis Treatment Conservative supportive care indication this is the initial medical management of patients with necrotizing enterocolitis modalities intravenous fluid administration discontinuation of enteral feeds total parenteral nutrition (TPN) Medical intravenous broad-spectrum antibiotics indication administered after appropriate samples are obtained for culture modalities an example of medications used for necrotizing include ampicillin, gentamicin, and metronidazole Operative abdominal surgery indication an absolute indication for abdominal surgey is intestinal perforation technique exploratory laparotomy with bowel resection primary peritoneal drainage Complications Bowel perforation Disseminated intravascular coagulation Infectious complications (e.g., peritonitis) Prognosis 15-30% overall mortality and increased mortality with prematurity low birth weight