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and distention and persistent thrombocytopenia and acidosis. Exploratory
laparotomy is often indicated in this group to identify and remove the necrotic
segment.
Clinical Considerations
Clinical Recognition. The signs associated with NEC are often nonspecific and
can include hematochezia, emesis or feeding intolerance, abdominal distention,
lethargy, and apnea and bradycardia. In advanced disease, there is also
tachycardia, abdominal tenderness with discoloration, respiratory failure, and
shock. Laboratory analysis may reveal neutropenia, thrombocytopenia, metabolic
acidosis, and/or hyponatremia.
Triage Considerations. Neonates with suspected NEC should be triaged urgently
as the disease can progress rapidly to respiratory failure and shock.
Clinical Assessment. The most common presenting sign in the neonate is emesis.
The examination may reveal a distended abdomen; however signs of peritonitis
or shock are often late findings and may not be present. The diagnosis is made by
the identification of pneumatosis intestinalis, portal venous gas, or
pneumoperitoneum on abdominal radiograph ( Fig. 96.40 ). In mild cases, plain
radiographs may reveal signs of ileus but no evidence of pneumatosis; in these
cases, portal venous gas may be appreciated by US.
Management. There is no specific treatment for NEC other than supportive
therapy. Bowel rest is indicated, with gastric decompression. Fluid resuscitation
is often required, and in advanced disease, may also require blood pressure
support. Due to the mucosal injury and bacterial translocation of intestinal flora,
broad-spectrum antibiotics are indicated. Blood cultures should be drawn prior to
the initiation of antibiotics, and will be positive in approximately one-third of
cases. Two-view radiographs of the abdomen are indicated to detect pneumatosis
and/or pneumoperitoneum. Laboratory evaluation should include blood cultures,
complete blood count, basic metabolic profile, blood gas, and, in severe cases
accompanied by disseminated intravascular coagulation, coagulation studies.
Surgical intervention is warranted if there is evidence of intestinal perforation or
if there is worsening of clinical symptoms that suggest a necrotic segment. Bowel

necrosis is often accompanied by persistent thrombocytopenia and acidosis, with
systemic signs of respiratory failure and shock.