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High-Yield Facts

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  • Necrotizing enterocolitis (NEC) can occur in full-term newborns with existing medical conditions.

  • Vomiting in a newborn should be considered bilious if it shows a color other than white.

  • A newborn with vomiting, especially bilious emesis, should be evaluated for malrotation with midgut volvulus.

  • Any patient who has suspicion of malrotation with midgut volvulus should undergo an emergent upper GI contrast study with small bowel follow-through.

  • Patients with Hirschsprung's disease can present with chronic, progressive constipation and failure to thrive.

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Although an uncommon occurrence, the presentation of neonatal surgical emergencies after discharge from the newborn nursery are often life-threatening and require prompt evaluation, stabilization, and emergent referral to a pediatric surgeon. Three such conditions are necrotizing enterocolitis (NEC), malrotation with midgut volvulus, and Hirschsprung's disease.

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Necrotizing Enterocolitis

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Necrotizing enterocolitis (NEC) is the most common gastrointestinal emergency and the most common cause of intestinal perforation in the newborn period.1 It is usually a disease of preterm infants with low birth weight,2 although nearly 5% to 15% occur in term infants.24 Term infants are more likely than their preterm counterparts to have predisposing risk factors25 (Table 45-1). The vast majority of term infants with NEC have some underlying illness.5 Over 90% of full-term infants with NEC present within the first 4 days of life and the disease tends to advance more rapidly than in preterm infants.5 Mortality rates of infants with NEC have been reported between 12% and 30%.2,4 The diagnosis of NEC is based upon a three-stage classification system.6,7 Stage I is suspected disease; Stage II is definite disease; and Stage III is advanced disease (Table 45-2).

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TABLE 45-1   Risk Factors for Necrotizing Enterocolitis in Full-Term Infants 
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TABLE 45-2   Classification System for Necrotizing Enterocolitis 
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The development of NEC is multifactorial. Enteral intake in the presence of reduced blood flow and bacteria leads to mucosal inflammation and ulceration.8 A compromise in the intestinal mucosal barrier allows bacteria to spread, leading to intestinal perforation, necrosis, and the development of sepsis.9

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Signs and Symptoms

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A high index of suspicion should be maintained because clinical findings of early-stage disease ...

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