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Post-necrotizing enterocolitis strictures presenting with sepsis or perforation: risk of clinical observation
G E Hartman1, G T Drugas, S J Shochat
1Department of Surgery, Stanford University Medical Center, CA 94305.
Insights
Infants surviving necrotizing enterocolitis (NEC) often develop intestinal strictures. Routine contrast enemas are recommended to identify at-risk infants and prevent life-threatening complications like sepsis or perforation.
Area of Science:
- Pediatric Surgery
- Neonatal Care
- Gastroenterology
Background:
- Necrotizing enterocolitis (NEC) survivors face a high risk of intestinal strictures.
- Delayed diagnosis of these strictures can lead to severe morbidity.
- Current practice often reserves contrast enemas for symptomatic patients.
Observation:
- Five infants (15%) developed symptomatic strictures post-NEC treatment.
- Routine contrast enemas were not performed in these cases.
- Four of these infants (80%) experienced life-threatening sepsis or perforation.
Findings:
- Two infants had complete colonic obstruction post-discharge, requiring emergency colostomy.
- Two hospitalized infants developed sepsis and cardiopulmonary distress.
- Complications arose weeks after initial oral feeding tolerance.
Implications:
- Clinical observation alone is insufficient for managing post-NEC strictures.
- Contrast enemas are crucial for identifying at-risk infants.
- Early diagnosis via contrast enema can prevent severe complications, especially for infants distant from surgical centers.
Abstract:
Intestinal stenosis or stricture occurs in approximately one third of medically treated infants surviving the acute phase of necrotizing enterocolitis (NEC). Identification of these lesions by the use of routine contrast enemas has been advocated as a means of decreasing potential morbidity from delayed diagnosis. However, the significant incidence of spontaneous resolution and reluctance to submit asymptomatic infants to contrast enema have led recent researchers to reserve these studies for patients developing symptoms of obstruction during a period of close observation. From July 1984 to July 1986, symptomatic strictures developed in five infants (15%) responding to medical management at our institution. Contrast enemas were not routinely performed and four (80%) of these patients presented with life-threatening sepsis or perforation associated with intestinal obstruction. Two infants developed complete colonic obstruction 4 and 6 weeks after discharge from the Intensive Care Nursery, having initially tolerated oral feedings. Both infants were critically ill due to perforation or sepsis and underwent emergency colostomy at community hospitals. Two other infants developed abdominal distension with sepsis and cardiopulmonary decompensation while remaining hospitalized for prematurity and pulmonary insufficiency. These patients became symptomatic 5 and 7 weeks after cautious refeeding while closely monitored in the Intensive Care Nursery. The occurrence of such life-threatening complications suggests that clinical observation alone is not adequate in the management of many of these infants. Contrast enemas should be performed to identify those patients at risk of such potential morbidity or mortality, especially those infants not residing near pediatric surgical facilities.