NECROTIZING

ENTEROCOLITIS

By : Irwan Subekti

NECROTIZING
ENTEROCOLITIS
Epidemiology:
Paling sering terjadi pada bayi prematur
kegawatan GI
Penyebab utama bedah emergensi pada neonatus
Kebanyakan incidence: 1-5% di NICU
Paling sering terjadi pada bayi prematur BBLSR
10% of all cases occur in term infants

NECROTIZING
ENTEROCOLITIS
Epidemiology:
10x sangat mungkin terjadi pada bayi yang
telah diberi makanan
males = females
blacks > whites
mortality rate: 25-30%
50% dari pasien mengalami gejala sisa jangka
lama

Data of 14 Full-Term Infants with NEC

FROM: Necrotizing Enterocolitis in Full-Term Infants: CaseControl Study and Review of the Literature
Ayala Maayan-Metzger, Amir Itzchak, Ram Mazkereth and Jacob Kuint

NECROTIZING
ENTEROCOLITIS
Pathology:
Area yang paling sering terlibat: terminal ileum
and proximal colon
MAKROSKOPIS:
Usus mengalami dilatasi tak beraturan dengan
perdarahan/area ischemic pada frank necrosis
focal or diffuse

MICROSCOPIC:
mucosal edema, hemorrhage and ulceration

NECROTIZING
ENTEROCOLITIS
MICROSCOPIC:
Inflamasi minimal selama fase akut
Meningkat selama revaskularisasi
Jaringan granulasi dan fibrosis berkembang
Pembentukan striktur
Microthrombi di arteriol mesenterika dan
venula

PRIMARY INFECTIOUS AGENTS

Bacteria, Bacterial toxin, Virus, Fungus

CIRCULATORY INSTABILITY
Hypoxic-ischemic event
Polycythemia
UNKNOWN CAUSE

MUCOSAL INJURY
INFLAMMATORY MEDIATORS
Inflammatory cells (macrophage)
Platelet activating factor (PAF)
Tumor necrosis factor (TNF)
Leukotriene C4, Interleukin 1; 6

ENTERAL FEEDINGS
Hypertonic formula or medication
Malabsorption, gaseous distention
H2 gas production, Endotoxin
production

RISK FACTORS

Infectious Agents:
usually occurs in
clustered epidemics
normal intestinal flora

primary risk factor

90%
of
cases
are
premature infants
immature gastrointestinal
system

Prematurity:

mucosal barrier
poor motility

immature
response
impaired
dynamics

immune
circulatory

Circulatory Instability:
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

E. coli
Klebsiella spp.
Pseudomonas spp.
Clostridium difficile
Staph. Epi
Viruses

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

RISK FACTORS

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

Enteral Feedings:
immature mucosal function
malabsorption

breast milk may have a

protective effect

IGA
macrophages, lymphocytes
complement components
lysozyme, lactoferrin
acetylhydrolase

CLINICAL PRESENTATION
Gestational age:
< 30 wks
31-33 wks
> 34 wks
Full term

Age at diagnosis:
20 days
11 days
5.5 days
3 days

*Time of onset is inversely related to gestational age/birthweight

CLINICAL PRESENTATION
Gastrointestinal:

Systemic

Feeding intolerance
Abdominal distention
Abdominal tenderness
Emesis
Occult/gross blood in stool
Abdominal mass
Erythema of abdominal wall

Lethargy
Apnea/respiratory distress
Temperature instability
Hypotension
Acidosis
Glucose instability
DIC
Positive blood cultures

Sudden Onset:
Full term or preterm infants
Acute catastrophic
deterioration
Respiratory decompensation
Shock/acidosis
Marked abdominal
distension
Positive blood culture

Insidious Onset:
Usually preterm
Evolves during 1-2 days
Feeding intolerance
Change in stool pattern
Intermittent abdominal
distention
Occult blood in stools

BELL STAGING CRITERIA

Modified Bell's Staging Criteria for Necrotizing Entercolitis

RADIOLOGICAL FINDINGS

Pneumatosis Intestinalis

hydrogen gas within

the bowel wall

extension of
pneumatosis intestinalis
into the portal venous
circulation

product of bacterial
metabolism

a. linear streaking
pattern

linear branching
lucencies overlying
the liver and extending
to the periphery
associated with severe
disease and high
mortality

more diagnostic

b. bubbly pattern
appears like retained
meconium
less specific

Portal Venous Gas

Pneumoperitoneum
free air in the peritoneal
cavity secondary to
perforation
falciform ligament may be
outlined

football sign

surgical emergency

LABORATORY FINDINGS
CBC
neutropenia/elevated
WBC
thrombocytopenia

Acidosis
metabolic

Hyperkalemia
increased secondary to
release from necrotic
tissue

DIC
Positive cultures

blood
CSF
urine
stool

PROGNOSIS
Tergantung pada tingkat keparahan penyakit
Terkait dengan komplikasi akhir
Striktur
Sindrom usus pendek
Malabsorpsi
Fistula
Abses

MOST COMMON

CASE
o BY DB, 30 hari, laki-laki, MRS tgl 7-11-2013. by
dilahirkan spontan, presentasi kepala, ketuban warna
kuning, langsung menangis. Uk : 32 minggu, BBl : 1700
gram, PB : 45 cm
o Klien di rawat di ruang bayi RSU K selama 5 hari lalu
di pulangkan.
o Bayi kuning saat umur 13 hari kemudian di bawa ke
bidan dan langsung di pulangkan dengan obat puyer
o Tgl 7-11-2011 klien di bawa ke RS X langsung ke IGD
dengan keluhan mencret sejak 3 hari SMRS >3x/hari
sedikit-sedikit darah (-) lendir (-) warna kuning
o Perut membesar sejak 1hari SMRS, pada pemeriksaan
fisik didapatkan hipertimpani, perut cembung,
o Kembung pada bayi sejak 1minggu SMRS
o Saat pengkajian : KU mencret dan perut membesar

CASE
Kesadaran :somnolen
GCS

:456

TD____/____mmhg

RR = 20x/mnt

N; 112x/menit

BB= 2,7 kg

Suhu 37,5C

TB= - cm

PENUNJANG
1.foto otot polos perut : terdapat gambaran
akumulasi gas di
usus.
2.Laboratorium
Tanggal 8 Nopember 2011
Lekosit
: 8500 / ul (N = 3500-10000)
Hb
: 8,0 gr/dl (N = 11,0-16,5)
Hematokrit : 22,6 % (N = 35-50)
Trombosit : 232000 /ul (N = 150000-390000)
GDS
: 361 mg/dl (N = >200)
Ureum
: 11,7 mg/dl (N = 10-50)
Albumin
: 3,33 gr/dl (N = 3,5-5,5)

 Stop enteral feeds

TREATMENT

re-start or increase IVF

Nasogastric decompression
low intermittent suction

Antibiotics
Amp/Gent; Vanc/Cefotaxime
Clindamycin
suspected or proven
perforation

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

TUGAS
Berdasarkan ilustrasi kasus di atas
buatlah ASKEP dan temukan masalah
keperawatan yang dapat muncul
Lakukan analisis terhadap kasus tersebut

TERIMAKASIH