GENERAL PERIOPERATIVE CONSIDERATIONS
Gastrointestinal emergencies are a frequent cause of hospitalization in children, and despite a wide range of etiologies, many of the principles in management are the same. Initial therapy should always include adequate resuscitation with establishment of stable IV access, IV fluid administration with isotonic solution such as Ringer's lactate, correction of electrolyte abnormalities, and consideration of a Foley catheter for careful monitoring of fluid shifts. Patients should be made NPO, and insertion of a nasogastric tube may be considered in cases of refractory vomiting or concern for an obstructive or ischemic process. Additionally, prompt administration of broad-spectrum IV antibiotics is often indicated when underlying infection or sepsis is suspected.
NECROTIZING ENTEROCOLITIS (NEC)
Necrotizing enterocolitis affects 5% to 10% of all infants admitted to the neonatal intensive care unit. Ninety percent of patients with NEC are also premature. Although the exact etiology is unknown, the hypothesized mechanisms include the presence of bacteria in an immature gut, inflammatory response, failure of the intestinal immunologic barrier, and resultant coagulation necrosis. Well-established risk factors include prematurity and low birth weight.
Signs and symptoms may range from mild and nonspecific to an acute abdomen with evidence of intestinal perforation.
Symptoms: Abdominal distention, gastric residuals, bloody stools, abdominal wall erythema, apnea, hemodynamic instability.
Labs: Leukocytosis or leukopenia, thrombocytopenia, elevated C-reactive protein (CRP), metabolic acidosis
Imaging (plain radiographs): Ileus gas pattern, pneumatosis, portal venous gas, pneumoperitoneum (Figure 64-1)
(a) Pneumatosis, (b) portal venous gas, (c and d) free air.
STAGING: MODIFIED BELL'S STAGING CRITERIA (TABLE 64-1)
Differential diagnosis – sepsis, medical ileus
Modified Bell's Staging Criteria
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Modified Bell's Staging Criteria
|Stage ||Classification ||Clinical Findings ||Radiographic Findings ||Gastrointestinal Symptoms |
|Ia ||Suspected ||Apnea, bradycardia, temperature instability ||Mild ileus ||Increased gastric residuals, mild distention, fecal occult blood |
|Ib ||Suspected ||Same as above ||Same as above ||Grossly bloody stools |
|IIa ||Definite, mild ||Same as above ||Ileus, intestinal dilation, focal pneumatosis ||Prominent distention, absent bowel sounds, grossly bloody stools |
|IIb ||Definite, moderate ||Thrombocytopenia, early metabolic acidosis ||Diffuse pneumatosis, ascites, portal vein gas ||Abdominal tenderness, abdominal wall edema |
|IIIa ||Advanced, severe ||Acidosis, oliguia, hypotension, coagulopathy ||Same as above, prominent bowel loops ||Worsening edema, erythema, palpable loops |
|IIIb ||Advanced, perforated bowel ||Shock, decompensation ||Pneumoperitoneum ||Bowel perforation |
Medical management (stage I–II): Bowel rest, gastric decompression, IV fluids and resuscitation, broad-spectrum antibiotics. Obtain blood and urine cultures prior to initiation of antibiotics. Follow with serial abdominal exams and radiographs. Clinical deterioration or failure to improve are indications for surgical management.
Surgical management (stage III): Laparotomy, resection of necrotic bowel, ...